Resident Stress and Impairment Darryl Y. Sue, M.D. July 2007

1. Resident Stress and ImpairmentDarryl Y. Sue, M.D.July 2007

2. Resources • Harbor-UCLA Committee on the Well-Being of Physicians • Ira Lesser, M.D. Extension 3137 • UCLA Mental Health Services for Physicians in Training • 310-206-8976

3. Stress and Impairment • What’s so stressful about residency? • Sources • Solutions • Can physicians be impaired? • Depression, substance abuse • Burnout--Are you talking about me? • Ways to help (Duty hour limits) • Does teaching/learning make me better?

4. Signs of stress and distress • Changes in personality • consistent sad, anxious or empty mood • mood swings • feelings of hopelessness, guilt, worthlessness • loss of interest or pleasure in activities • withdrawal, isolation, mistrust of others • financial recklessness • defensivess, anger, irritability UCLA Mental Health Service for Physicians in Training

5. Signs of stress and distress • Changes in performance • disrupted work habits • inconsistent productivity • cognitive errors • inability to concentrate or make decisions • missed or coming late for appointments, meetings • complaints from staff, patients, families UCLA Mental Health Service for Physicians in Training

6. Stress and Distress • Physical symptoms • fatigue, listlessness, drowsiness • changes in personal hygiene • change in appetite, with loss or gain • tremulousness or sweating • agitation, restlessness • self-diagnosed health concerns • use or suspected use of alcohol or drugs UCLA Mental Health Service for Physicians in Training

7. Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154

8. Internship: Will you get over it? • Cohort study of 61 residents who completed the Profile of Mood States (POMS) and the Interpersonal Reactivity Index (IRI) at six time-points during their internal medicine residency at a university-based program. Acad Med. 2005; 80:164–167.

9. Internship: Will you get over it? • Interns had lowest scores on 3 mood state subscales at baseline compared to later: • Depression–Dejection • Anger–Hostility • Fatigue–Inertia • Had highest score on Vigor–Activity • Scores peaked (or reached bottom) at mid-winter • Almost all were back to baseline by end of residency. Acad Med. 2005; 80:164–167.

10. Internship: Will you get over it? Acad Med. 2005; 80:164–167.

11. vigor-activity Acad Med. 2005; 80:164–167. depression-dejection anger-hostility

12. Internship: Will you get over it? • Conclusions • Internal medicine residency presents challenges resulting in common mood disturbances. • Although graduating residents appear to be better off than the population norms, some domains of their mood disturbances and empathy never fully recover from their internship year. Acad Med. 2005; 80:164–167.

13. Stresses in Training • Stress: situations or external forces that require a change in one’s behavior (adjusting to…) • Situations--”the Hospital” • Personal life--”the Family” • Professional life--”Medicine” Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154

14. Situational Stress • Characteristic of the environment • Related to work load (number and type of patients) • Responsibilities • Learning vs. work environment • “Your hospital is closing, but don’t worry…” • Time, time, time...

15. Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154

16. Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154

17. Reducing Situational Stress • Accept “non-physician” roles as needed (to accomplish MD role) • Develop understanding of qualitative assessment of patient “difficulty” • Set limits and use them • Foster a learning climate--Why?

18. Personal Stress • Family • strength and comfort • conflict and unhappiness • Financial burdens--loans, cost of living • Social dislocation • Isolation • Variable coping skills • Free time, free time, free time...

19. Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154

20. Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154

21. Reducing Personal Stress • Mandatory family and social activities • Support groups, formal/informal • Identify those at risk for isolation • Provide and encourage activities • Offer help with identification of stress and professional help • Develop coping skills--workshops?

22. Training StressA necessary evil? • Uncertainty • Lack of confidence • Future career opportunities (evaluation and performance) • Impetus for acquiring knowledge and skills • Graded responsibilities occur during training • When does your confidence return?

23. Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154

24. Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154

25. Reducing Professional Stress • Provide learning environment • Encourage teaching as a method of stress reduction • Recognize the student-physician conflict • Provide help with career planning--show end-results

26. Reducing Professional Stress • Define goals and responsibilities • Orient teachers (residents/faculty) • Teach residents to present well, teach effectively, critique articles • Encourage pride in the program and community • “Importance of faculty as role models cannot be overemphasized”

27. Other stresses... • “Marginal” residents • passed on from medical school • added stress of GME • “Mismatched” residents • wrong specialty for wrong reasons • “Disruptive” residents • OK academically, but interpersonal skills or coping strategies lacking Levey RE. Acad Med 2001; 76:142-150

28. Resident Impairment • “Response to an emotional problem prevents the physician from fulfilling professional or personal responsibilities.” • Highly like to be underreported during residency Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154

29. Who is at risk…could be those with • Inappropriate dysphoria, depression, lack of self-worth (timing) • Loss of idealism--transfer of blame to patients • Social isolation • Persistent anger, frustration, hopelessness

30. Resident Impairment • One study: 30% of house officers completing internship identified as “depressed” • Another study: 29% in first year, 10% in last years • Higher in women, those with family history of depression Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154

31. Resident Impairment • In a study of 274 internal medicine programs, 55.5% granted leaves of absence because of “emotional impairment” to 0.9% of residents • 79% resumed training; 52% in internal medicine, 27% other field, 10% out of medicine, 2% committed suicide Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154

32. Alcohol and Substance Abuse • Historically high rate among physicians (>90% reported use in past month?) • AMA: 2.3-3.2% for alcoholism; 0.9%-2.0% for other substances; 0.9%-1.3% for psychiatric illness • Other studies--similar to matched controls

33. Alcohol and Substance Abuse • In residents, data limited, but 13-14% of residents could be classified as “alcoholics” • Hughes (1991, 1992) reported 60% response rate to questionaire of 15,814 3rd year residents--results show differences by specialty

34. Hughes et al. Am J Psychiatry 1992; 149:10

35. Self-Prescribing • Is self-prescription common among residents? • Anonymous mail survey of 4 internal medicine training programs • 316 (83%) of 381 residents responded Christie JD et al. JAMA 1998; 280:1253

36. Christie JD et al. JAMA 1998; 280:1253

37. Christie JD et al. JAMA 1998; 280:1253

38. Self-Prescribing • 244 residents (78%) used > 1 prescription medicine • 162 residents (52%) reported self-prescribing • 25% of medications, 42% of self-prescribed medications obtained from “sample cabinet” Christie JD et al. JAMA 1998; 280:1253

39. Self-Prescribing • 7% of all medications and 11% of self-prescribed medications obtained from pharmaceutical company representative Christie JD et al. JAMA 1998; 280:1253

40. Self-Prescribing • Self-prescription is common among resident physicians • “Although self-prescription is difficult to evaluate, the source of these medications and the lack of oversight of medication use raise questions about the practice.” Christie JD et al. JAMA 1998; 280:1253

41. Depression? • 12-month prevalence of depression in the general population 7.7% for men and 12.9% for women. • 1970-80s, 27%–30% of PGY-1s noted to be depressed. • In a 2002 survey of internal medicine trainees, 40% of female residents and 32% of male residents reported 4-5 symptoms of depression. Academic Psychiatry 2004; 28:221–225

42. Depression? • Substance abuse in physicians similar to general population (7%–15%) • 1991 survey among 3rd-year residents reported higher rates of alcohol and benzodiazepine use than the general population; 9.5% reporting unsupervised use of benzodiazepines. • The use of opiates and benzodiazepines correlated with the advent of controlled substance prescribing privileges. Academic Psychiatry 2004; 28:221–225

43. Resident Burnout--Who? Me? • 92-item questionnaire of 115 (76%) of IM residents at U Wash • Demographics • Work stress survey • Maslach Burnout Inventory (MBI) • Patient care practices • Substance abuse • Program features Shanafelt TD et al. Ann Intern Med 2002; 136:358-67.

44. Resident Burnout--Who? Me? • 76% returned questionnaires in February 2001 • Of these, 76% met criteria for “burnout”--by a high score on depersonalization or emotional exhaustion scale Shanafelt TD et al. Ann Intern Med 2002; 136:358-67.

45. In addition, burnt out residents more likely to have a break > 1 year between undergraduate and medical school (47% vs. 25%) Shanafelt TD et al. Ann Intern Med 2002; 136:358-67.

46. Shanafelt TD et al. Ann Intern Med 2002; 136:358-67.

47. Shanafelt TD et al. Ann Intern Med 2002; 136:358-67.

48. Reported Stresses • Inadequate sleep (41%) • Frequent shifts > 24 hours (40%) • Inadequate leisure time (42%) • Residents with burnout significantly more likely to report these stresses Shanafelt TD et al. Ann Intern Med 2002; 136:358-67.

49. Resident Burnout--Who? Me? • Response bias? • February? • No comparison to non-responders • Self-reporting of patient care practices • Current rotation or schedule? Shanafelt TD et al. Ann Intern Med 2002; 136:358-67.

50. Resident Burnout--Who? Me? • Resident burnout frequent • May affect quality of patient care (outcomes different?) • May desensitize physicians to patient-related factors • Is resident burnout a contributor to medical student specialty choice? Shanafelt TD et al. Ann Intern Med 2002; 136:358-67.