Journal of Clinical Psychology in Medical Settings, Vol. 2, No. 3, 1995
The Clinical Psychologist as Program Consultant: When Is Enough Enough? Kathleen Sheridan 1
One of the most influential roles clinical psychologists play in health care settings is as consultant to medical colleagues. The psychologist consultant typically approaches either clinical or programmatic questions intending to tap both empirical research and clinical judgment perspectives in trying to answer them. This paper describes a specific "program consultation case," a not atypical consultation situation in which graduate medical education directors asked for advice about their residency training program. The purpose is to use this example to generate ideas and provoke discussion about such consultation processes and their usefulness in the health care training and service delivery world. The psychologist may be faced with questions that have meaningful implications beyond the specific consultation. What if the concerns being posed by this particular program are concerns which have been raised before, have been researched before, and have generated reasonable suggestions, conclusions, and strategies for improvement? And what if no one has paid attention, so that the questions are being raised again? When empirical and clinical data consistently combine to identify problems within health-related training or service delivery systems, and when suggestions or alternatives for their solutions have been presented and, also presumably, ignored, what does the clinical psychologist consultant do next? KEY WORDS: consultants; programmatic change in medical settings.
1Department of Psychology, University of Missouri-Columbia, 105 McAlester Hall, Columbia, Missouri 65211. 289
1068-9583/95/0900-0289507.50/0© 1995Plenum Publishing Corporation
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THE CONSULTATION CASE The Consultation Questions Directors of a pediatric residency program in a not-for-profit health care system serving a large, metropolitan populace wished to evaluate their training program. 2 While they viewed the program as thriving and highly sought after by prospective residents, the directors were concerned about the stresses they perceived. With continuing and dramatic increases in HIVinfected children, for instance, pediatric residents were more often facing patients and their families who were struggling with chronic and terminal illnesses. How were residents handling these issues, psychologically? In addition, residency classes were becoming more equally represented by women and men. As that shift occurred, directors noted that women residents also seemed to be dealing with more outside responsibilities than did their male counterparts. For instance, women residents appeared to shoulder more child care and household obligations. Were these women experiencing more stress than their male colleagues? Finally, directors had impressionistic data on graduates of their (and other statewide) programs over the past 5 years or so. Some pediatricians expressed disillusionment with their practices. Apparently, such disillusionment was not related to economic or managed care pressures nor to professional competencies, but reflected more elusive "this is not what I slaved for years to achieve" sentiments. Thus, directors wondered what, if anything, training programs had done to foster such reactions. The directors explicitly asked the consultants to tell them what was bothering their residents. Refreshingly, as well, they seemed to want to know what the program needed to do to become more responsive to and supportive of residents. The directors were also open to the idea that they could "do something" proactively in the program to help graduates enjoy their medical careers.
The Consultation Process At least one important group of informants, namely, the directors, thought their pediatric residency program was stressful. Not atypically, the consultation team decided to consult two other sources of information 2Key members of the consultation team included Robert L. MannieUo, M.D., Medical Director, Children's Hospital of Orange County, California; and Michelle Morgan and Elisa Vazquez, research assistants.
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about stress in pediatric residents. We reviewed the literature and we questioned residents, past and present. The Literature. Past researchers seemed never to have questioned the assumption that medical residencies are stressful. Rather, the literature over the last 10 years has focused on the sources of stress (Alexander, Monk, & Jonas, 1985; Badger, Chesebro, & Hartman, 1987; Evans, Tamburrino, Franco, & Seidman, 1986; Schwartz, Black, Goldstein, Jozefowicz, & Emmings, 1987; Taylor, Sinclair, & Wall, 1987; Urbach, Levenson, & Harbison, 1989) and how to measure such stress (Firth & Morrison, 1986; Kirsling, Kochar, & Chan, 1989; Lemkau, Purdy, Rafferty, & Rudisill, 1988; Revicki & May, 1983; Revicki, May, & Whitley, 1991; Simpson & Grant, 1991; Wolfgang, 1988a, b). And in some instances, authors have suggested how to cope with stress (Coombs, Perell, & Ruckh, 1990; Firth-Cozens & Morrison, 1989; Kumari & Sharma, 1990). Studies on sources of residency stress are the most common and represent both theory (Hoekelman, 1989) and quantitative data (Butterfield, 1988; Lee, 1987) to support conclusions. Explanations range from views of residency stress as a predictable cumulative result of years of exposure to the demands of medical education coupled with demographic and psychological characteristics of residents (Archer, Keever, Gordon, & Archer, 1991) to focus on work-related stressors (Bertram, Hershey, Opila, & Quirin, 1990). Nearly all data-based studies utilize self-report as their information medium. Some projects relied on or were parts of the developments of standardized questionnaires, including the Maslach Burnout Inventory (Lemkau et al., 1988), the Physician Stress Inventory (Revicki & May, 1983), and the Health Professions Stress Inventory (Wolfgang, 1988a, b). Some studies created questionnaires tailored for their specific programs (Alexander et aL, 1985; Taylor et al., 1987). Fewer studies added self-reports of moods; of those mood inventories used, the Profile of Mood States, the Beck Depression Inventory, and the Symptom Checklist-90-Revised were typical (Butterfield, 1988; Kirsling et al., 1989). As the consultants reviewed the results from this body of work, several characteristics emerged. First, most samples were relatively small (a 1992 study by Jex, Hughes, Storr, and Conrad represents an exception with approximately 1750 participants). Researchers tended to study individual residency programs and were dependent on the numbers of residents in those programs who agreed to participate. Most studies were able to attract participants in the beginning, middle, and end stages of their training. Some focused on particular residency specialties, e.g., internal medicine, while others combined specialties within a teaching hospital setting. Several studies recognized the potential for gender differences; at the same time, few
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studies were able to attract enough women resident participants to make such comparisons meaningful. Also, it was rarely clear from the reports whether or not participants were influenced by the fact that they were being asked questions about their training at the request of, or with the implicit/explicit consent of, the training program itself. Nearly all the studies acknowledge the limitations of self-report data, whether those self-report instruments were standardized or customized. What seems an interesting and probably unintended effect of this 10-to15-year industry of attempting to create, stabilize, and validate self-report items on residency stress is that now an item bank of about 100 to 200 solid questions is available for use! Researchers in this area also appear analytically practical and humble; not many seemed to need to elevate their work by imposing complex statistical techniques on data which are not worthy of such sophistication. Nevertheless, results across studies roughly combine to indicate that situational stressors or workload factors, particularly long hours and fat i g u e - a t least from what residents report--are the most frequent sources of stress in training programs. Other conclusions across studies are not so clear and also demand some degree of interpretation to be considered. It is one thing to conclude that, if most of the resident participants endorse "not enough time in the day" and "not enough sleep" as their biggest stressors, long hours and fatigue are really the reasons for their discomfort. Less clear are some other findings. Why, for instance, as has been found in some studies, is a particular year of 3- or 4-year residencies one in which residents seem to experience more stress (Revicki, Whitley, Gallery, & Allison, 1993)? As another example, if a gender difference does occur, it is that women residents report their experiences of stress more frequently than do their male counterparts (Toews, Lockyer, Dobson, & Brownell, 1993). Women also report more utilization of social support. Nothing strongly suggests that, in fact, women residents experience more stress than do men residents. Also, while most studies do find programs stressful, these studies also report that most residents do not experience the stresses to a degree severe enough to qualify as "psychological distress," depression, or anxiety. In fact, Toews and his associates (1993) compared residents with medical students and graduate students (M.Sc.~h.D. students); while all three groups reported elevated stress levels, the graduate students experienced more stress than the other two groups. The Residents. To begin gathering more information on the local situation, we wrote to 33 pediatric residents who had completed the training program in the past 5 years. We explained our project and presented them a list of stressors (compiled from the literature). We asked them to rate the stressors and also to add any others that they remembered as part of
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their training experience. We also asked them to list and rate the ways in which they dealt with such stressors when they were residents. Nineteen (57.6%) past residents responded, 10 men and 9 women. Based on their responses, we developed a rating scale with 40 items related to training program stressors and 28 items related to coping mechanisms. Each stressor item was rated on a 5-point scale from "not at all stressful" to "extremely stressful." Typical stressor items included "having work interfere with my primary intimate relationships," "not getting adequate feedback on a patient from my supervisor," and "having to deal with a difficult patient." Each coping strategy item was rated on a 5-point scale from "never used" to "very frequently used." Typical coping strategy items included "went to a movie," "prayed about it," and "went on as if nothing had happened." We then asked 23 current pediatric residents to complete the ratings. Nineteen (82.6%) chose to do so, 10 women and 9 men, roughly spread across the 3-year training program. We also asked 40 current internal medicine and emergency medicine residents to respond to the rating scales. Nine internal medicine and six emergency medicine residents responded (37.5%), 13 men and 2 women. The Results. From these small numbers, we began to compare some mean ratings among the past pediatric residents, the current pediatric residents, and the current internal and emergency medicine residents. Past residents rated as their five greatest stressors while in training having a patient die (M = 3.92), sharing difficult news about the patient to the family (M = 3.87), having so much to do that nothing is done well (M = 3.47), making mistakes (M = 3.42), and having no time for family and friends (M = 3.42). Current pediatric residents rated their five highest stressors as having no time for family and friends (M = 3.55), going without sleep for extended periods (M = 3.55), making mistakes (M = 3.53), having no time for personal activities (M = 3.42), and being on call excessively (M = 3.37). Similarly, current emergency and internal medicine residents listed as their five biggest stressors making mistakes ( M = 3.80), going without sleep for extended periods (M = 3.73), having no time for personal activities (M = 3.60), having so much to do that nothing is done well (M = 3.53), and having no time for family and friends (M = 3.33). How did they cope? Past pediatric residents talked with another resident (M = 4.11), took things one step at a time (M = 4.05), studied and worked harder in an attempt to gain more knowledge (M = 3.84), made a plan of action and followed it (M = 3.79), and spoke with a close friend or relative (M = 3.68). Current pediatric residents slept (M = 3.95); talked with another resident (M = 3.79), studied and worked harder in an attempt to gain more knowledge (M = 3.68), spoke with a close friend or relative
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(M = 3.37), and confronted the source of stress (M = 3.21). Current internal and emergency medicine residents took things one step at a time (M = 3.93), slept (M = 3.47) and exercised alone (M = 3.47), talked with another resident (M = 3.27), and confronted the source of stress (M = 3.20). Interestingly striking consistency emerged among the past residents, the current pediatric residents, and the internal/emergency medicine group in the least endorsed stressor item--having fears about dying (M = 1.92, M = 1.84, and M = 1.53, respectively). Perhaps as striking was the consistency in the three least endorsed coping strategies: for past pediatric residents they were seeking professional help (M = 1.32), writing in a diary (M = 1.16), and taking sedatives or sleeping medication (M = 1.00). For current pediatric residents, they were writing in a diary (M = 1.21), seeking professional help (M = 1.16), and taking sedatives or sleeping medication (M = 1.05). For current internal and emergency medicine residents they were writing in a diary (M = 1.20), seeking professional help (M = 1.13), and taking sedatives or sleeping medication (M = 1.00).
Consultation Conclusions and Recommendations
Our consultation team knew this much: our information was not ground-breaking or earth-shattering, our methods were inelegant and imprecise, and our very small sample knew who was sponsoring the surveys and why. Yet our results seemed very familiar to what a decade or more of researchers had already discovered. Residents are overworked and tired and have no time for anything or anyone else. And they do not want to make mistakes. Having "eyeballed" means and ranges, we knew we were not going to get big standard deviations. Nor did there seem much difference between the current pediatric and the current internal/emergency medicine residents. Nor were there gender differences. Of course, given the context and visibility of the project, we were not surprised that participants did not endorse drug use as a coping mechanism; but was seeking professional help just as socially unacceptable? And (at the risk of too much interpreting) who had time to write in a diary? What did our small sample tell us that added to what the literature already suggested? What would we add by collecting more ratings from more residents? How would all this information be useful to the directors of the pediatric residency training program who wanted our advice in the first place?
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To be fair, our small attempt probably did add something to the field. We did ask about coping mechanisms and got a hint that talking with colleagues might be a valuable source of social support. What we could communicate to the training program directors were these statements. Residents feel tired and overworked. We would, of course, emphasize the limitations of our suggestions and answers because of the small numbers of participants, but we were unable to note any gender differences, or differences from year to year in the residency program, nor were we able to detect differences among pediatric, internal medicine, and emergency medicine residents. What we might convey with regard to what practicing pediatricians remembered as most stressful during training and what might be affecting their enjoyment of or disillusionment with their careers were having patients die and relating such news to their families. Since those items were not endorsed by current residents as highly stressful, we might also go so far as to speculate that the long hours and fatigue suffered by women and men in training may actually mask or interfere with the experience of other job stressors, such as dealing with death. In fact, Firth-Cozens and Morrison (1989) lend credibility to our speculation. Their work utilized open-ended descriptions of stressful situations by 173 British preregistration doctors (the equivalent of American junior house staff members). The most common stressor found was dealing with death. The authors note that their methodology contrasts with the more common questionnaire studies "which used predetermined categories from past literature and which find overwork to be the aspect of their jobs seen as most stressful" (p. 124). " . . .[C]onstant emphasis on overwork may be some form of defence against aspects of the job which cause even higher levels of anxiety" (p. 124). And what might we recommend? We could certainly suggest looking at the total hours of duty per week and consecutive hours on call for residents to see if reductions or more flexible scheduling were warranted. Interestingly, Cohen and his associates (1989) comment on the effects of the celebrated New York State regulations of residency work hours, "a shift from a virtual monastic existence of continuous work with no nights o f f . . . [to] working every third or fourth night" (p. 181). Unfortunately, as the authors note, the lighter work schedule also allowed residents to "moonlight" elsewhere--in effect, negating the attempts to alleviate long hours. We would also strongly recommend that the program create, encourage, and enhance opportunities--formal and informal--for residents to talk with one another about the psychological aspects of their training, the demands, the rewards, the uncertainties, and the responsibilities. Perhaps some support groups might extend to significant others in the residents'
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lives. Some discussions might be dedicated to communication problems with program directors and attending physicians.
WHAT NEXT? We have no way of knowing whether the results of past program evaluations led to modifications in training programs. Coombs et al. (1990) called for stress prevention programs for trainees and practitioners, but was their call heard? In fact, we suspect that programs have not changed much, since the literature continues to indicate that long hours and fatigue are problematic in residencies. Perhaps one suggestion for "what next?" would be to survey residency training programs to see if any have incorporated stress prevention or stress management initiatives. Sadly, in our case, by the time we were ready to share our recomm e n d a t i o n s , the residency program changed directors. The new administration did not see stress as a particularly important issue for residents and declined to pursue the consultation further. As we knew at the outset, unforeseen changes in program administration are among those "not-so-obvious issues" consultants learn are always part of the process. But the entire experience led us to bring before our colleagues in medical settings this discussion. Why did we do all that we did? Should we have presented to the program directors, instead, a summary of all the research done before, commented on all the methodological shortcomings, and then said, "Look, training programs have been populated by tired, overworked residents for a long time. Are there educational benefits to long hours and fatigue? If so, we have not found them. Does patient care benefit? We do not think so, but to be fair, we also do not know if patient care suffers under the system-as-usual. Why do these conditions persist? Because this is the way it has always been. Indeed, such conditions are currently even more glorified, with the saga of overworked and tired emergency medicine residents claiming prime time television ratings!" When does the clinical psychologist as program consultant acknowledge that enough is enough? Medical residency training programs seem to be examples of institutional calcification. They will not change, no matter what the data suggest. We have other such examples in health care settings, some small, others more complex and multidetermined. In mental health, for instance, everyone knows (and the research data support) that inpatient psychiatric hospitalization for the majority of mentally ill patients is therapeutically no more valuable (but a lot more expensive) than outpatient treatment. Yet inpatient care continues to reign.
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This, then, is o u r question. H o w m u c h can we d o a n d how far can we go to affect a n d effect i n s t i t u t i o n a l a n d p r o g r a m m a t i c c h a n g e ? W e might s p e c u l a t e , f r o m o u r e x p e r i e n c e a n d from the literature, t h a t p e o p l e see t h e n e e d for c h a n g e b u t d o not p a r t i c u l a r l y wish to change. A t w h a t levels s h o u l d we c o n c e n t r a t e o u r efforts? In o u r e x a m p l e o f stress in resid e n t s , s h o u l d e f f o r t s b e d i r e c t e d at i n f l u e n c i n g at l e a s t o n e r e s i d e n c y p r o g r a m in o n e m e d i c a l s e t t i n g ? S h o u l d we c o n c e n t r a t e o u r efforts at h i g h e r a d m i n i s t r a t i v e a n d p o l i c y - m a k i n g levels, for instance, g r a d u a t e m e d i cal e d u c a t i o n a s s o c i a t i o n s r e g i o n a l l y a n d n a t i o n a l l y ? W e a r e o p e n to discussion.
REFERENCES Alexander, D. A., Monk, J. S., & Jonas, A. P. (1985). Occupational stress, personal, strain, and coping among residents and faculty members. Journal of Medical Education, 60(4), 830-839. Archer, L. R., Keever, R. R., Gordon, R. A., & Archer, R. P. (1991). The relationship between residents' characteristics, their stress experiences, and their psychosocial adjustment at one medical school. Academic Medicine, 66(5), 301-303. Badger, L. W., Chesebro, M. J., & Hartman, J. A. (1987). First year residency stress: Sources and mediators. Family Practice Research Journal 7(2), 104-113. Bertram, D. A., Hershey, C. O., Opila, D. A., & Quirin, O. (1990). A measure of physician mental work load in internal medicine ambulatory care clinics. Medical Care, 28(5), 458-467. Butterfield, P. S. (1988). The stress of residency: A review of the literature. Archives of Internal Medicine, 148, 1428-1435. Cohen, M. I., Dancis, J., Finberg, L., Hirschhorn, K., Katz, M., & Wasserman, E. (1989). Patient care, resident stress, and government regulation. AIDC, I43, 181-182. Coombs, R. H., Perell, K., & Ruckh, M. J. (1990). Primary prevention of emotional impairment among medical trainees. Academic Medicine, 65(9), 576-581. Evans, C. L., Tamburrino, M. B., Franco, K. N., & Seidman, P. A. (1986). Is internship really the worst? Journal of Psychiatric Education, 10(2), 113-119. Firth, J., & Morrison, L. (1986). What stresses health professionals.'?A coding system for their answers. British Jo,~rnal of Clinical Psychology, 25(4), 309-310. Firth-Cozens, J., & Morrison, L. A. (1989). Sources of stress and ways of coping in junior house staff. Stress Medicine, 5(2), 121-126. Hoekelman, R. A. (1989). Stress experienced during pediatric residency training. AJDC, 143, 177-180. Jex, S. M., Hughes, P., Storr, C., & Conrad, S. (I992). Relations among stressors, strains, and substance use among resident physicians. International Journal of the Addictions, 27(8), 979-994. Kirsling, R. A., Kochar, M. S., & Chan, C. H. (1989). An evaluation of mood states among first-year residents. Psychological Reports, 65(2), 355-366. Kumari, K., & Sharma, S. (1990). Social support, organizational role stress and well-being: A study of medicos. Psychological Studies, 35(3), 163-169. Lee, C. (1987). Professionals in medical settings: The research evidence in the 1980s. Journal of Organizational Behavior, 8(2), 195-213. Lemkau, J. P., Purdy, R. R., Rafferty, J. P., & Rudisill, J. R. (1988). Correlates of burnout among faculty practice residents. Journal of Medical Education, 63(9), 682-691.
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Revicki, D. A., & May, H. J. (1983). Development and validation of the Physician Stress Inventory. Faro@ Practice Research Journal, 2(4), 211-225. Revicki, D. A., May, H. J., & Whitley, T. W. (1991). Reliability and validity of the Work-Related Strain Inventory among health professionals. Behavioral Medicine, 17(3), 111-120. Revicki, D. A., Whitley, T. W., Gallery, M. E., & Allison, E. J. (1993). Impact of work environment characteristics on work-related stress and depression in emergency medicine residents: A longitudinal study. Journal of Community and Applied Social Psychology, 3(4), 273-284. Schwartz, A. J., Black, E. R., Goldstein, M. G., Jozefowicz, R. F., & Emmings, F. G. (1987). Levels and causes of stress among residents. Journal of Medical Education, 62(9), 744-753. Simpson, L. A., & Grant, L. (1991). Sources and magnitude of job stress among physicians. Journal of Behavioral Medicine, I4(1), 27-42. Taylor, A. D., Sinclair, A., & Wall, E. M. (1987). Sources of stress in postgraduate medical training. Journal of Medical Education, 62(5), 425-428. Toews, J. A., Lockyer, J. M., Dobson, D. J., & Brownell, A. K. (1993). Stress among residents, medical students, and graduate science (M.Sc./Ph.D.) students. Academic Medicine, 68(10, Suppl.), $46-$48. Urbach, J. R., Levenson, J. L., & Harrison, J. W. (1989). Perceptions of housestaff stress and dysfunction within the academic medical center. Psychiatric Quarterly, 60(4), 283-296. Wolfgang, A. P. (1988a). The Health Professions Stress Inventory. Psychological Reports, 62(1), 220-222. Wolfgang, A. P. (1988b). Job stress in the health professions: A study of physicians, nurses, and pharmacists. Behavioral Medicine, 14(1), 43-47.
The Clinical Psychologist as Program Consultant: When Is Enough Enough? Kathleen Sheridan 1
One of the most influential roles clinical psychologists play in health care settings is as consultant to medical colleagues. The psychologist consultant typically approaches either clinical or programmatic questions intending to tap both empirical research and clinical judgment perspectives in trying to answer them. This paper describes a specific "program consultation case," a not atypical consultation situation in which graduate medical education directors asked for advice about their residency training program. The purpose is to use this example to generate ideas and provoke discussion about such consultation processes and their usefulness in the health care training and service delivery world. The psychologist may be faced with questions that have meaningful implications beyond the specific consultation. What if the concerns being posed by this particular program are concerns which have been raised before, have been researched before, and have generated reasonable suggestions, conclusions, and strategies for improvement? And what if no one has paid attention, so that the questions are being raised again? When empirical and clinical data consistently combine to identify problems within health-related training or service delivery systems, and when suggestions or alternatives for their solutions have been presented and, also presumably, ignored, what does the clinical psychologist consultant do next? KEY WORDS: consultants; programmatic change in medical settings.
1Department of Psychology, University of Missouri-Columbia, 105 McAlester Hall, Columbia, Missouri 65211. 289
1068-9583/95/0900-0289507.50/0© 1995Plenum Publishing Corporation
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Sheridan
THE CONSULTATION CASE The Consultation Questions Directors of a pediatric residency program in a not-for-profit health care system serving a large, metropolitan populace wished to evaluate their training program. 2 While they viewed the program as thriving and highly sought after by prospective residents, the directors were concerned about the stresses they perceived. With continuing and dramatic increases in HIVinfected children, for instance, pediatric residents were more often facing patients and their families who were struggling with chronic and terminal illnesses. How were residents handling these issues, psychologically? In addition, residency classes were becoming more equally represented by women and men. As that shift occurred, directors noted that women residents also seemed to be dealing with more outside responsibilities than did their male counterparts. For instance, women residents appeared to shoulder more child care and household obligations. Were these women experiencing more stress than their male colleagues? Finally, directors had impressionistic data on graduates of their (and other statewide) programs over the past 5 years or so. Some pediatricians expressed disillusionment with their practices. Apparently, such disillusionment was not related to economic or managed care pressures nor to professional competencies, but reflected more elusive "this is not what I slaved for years to achieve" sentiments. Thus, directors wondered what, if anything, training programs had done to foster such reactions. The directors explicitly asked the consultants to tell them what was bothering their residents. Refreshingly, as well, they seemed to want to know what the program needed to do to become more responsive to and supportive of residents. The directors were also open to the idea that they could "do something" proactively in the program to help graduates enjoy their medical careers.
The Consultation Process At least one important group of informants, namely, the directors, thought their pediatric residency program was stressful. Not atypically, the consultation team decided to consult two other sources of information 2Key members of the consultation team included Robert L. MannieUo, M.D., Medical Director, Children's Hospital of Orange County, California; and Michelle Morgan and Elisa Vazquez, research assistants.
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about stress in pediatric residents. We reviewed the literature and we questioned residents, past and present. The Literature. Past researchers seemed never to have questioned the assumption that medical residencies are stressful. Rather, the literature over the last 10 years has focused on the sources of stress (Alexander, Monk, & Jonas, 1985; Badger, Chesebro, & Hartman, 1987; Evans, Tamburrino, Franco, & Seidman, 1986; Schwartz, Black, Goldstein, Jozefowicz, & Emmings, 1987; Taylor, Sinclair, & Wall, 1987; Urbach, Levenson, & Harbison, 1989) and how to measure such stress (Firth & Morrison, 1986; Kirsling, Kochar, & Chan, 1989; Lemkau, Purdy, Rafferty, & Rudisill, 1988; Revicki & May, 1983; Revicki, May, & Whitley, 1991; Simpson & Grant, 1991; Wolfgang, 1988a, b). And in some instances, authors have suggested how to cope with stress (Coombs, Perell, & Ruckh, 1990; Firth-Cozens & Morrison, 1989; Kumari & Sharma, 1990). Studies on sources of residency stress are the most common and represent both theory (Hoekelman, 1989) and quantitative data (Butterfield, 1988; Lee, 1987) to support conclusions. Explanations range from views of residency stress as a predictable cumulative result of years of exposure to the demands of medical education coupled with demographic and psychological characteristics of residents (Archer, Keever, Gordon, & Archer, 1991) to focus on work-related stressors (Bertram, Hershey, Opila, & Quirin, 1990). Nearly all data-based studies utilize self-report as their information medium. Some projects relied on or were parts of the developments of standardized questionnaires, including the Maslach Burnout Inventory (Lemkau et al., 1988), the Physician Stress Inventory (Revicki & May, 1983), and the Health Professions Stress Inventory (Wolfgang, 1988a, b). Some studies created questionnaires tailored for their specific programs (Alexander et aL, 1985; Taylor et al., 1987). Fewer studies added self-reports of moods; of those mood inventories used, the Profile of Mood States, the Beck Depression Inventory, and the Symptom Checklist-90-Revised were typical (Butterfield, 1988; Kirsling et al., 1989). As the consultants reviewed the results from this body of work, several characteristics emerged. First, most samples were relatively small (a 1992 study by Jex, Hughes, Storr, and Conrad represents an exception with approximately 1750 participants). Researchers tended to study individual residency programs and were dependent on the numbers of residents in those programs who agreed to participate. Most studies were able to attract participants in the beginning, middle, and end stages of their training. Some focused on particular residency specialties, e.g., internal medicine, while others combined specialties within a teaching hospital setting. Several studies recognized the potential for gender differences; at the same time, few
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studies were able to attract enough women resident participants to make such comparisons meaningful. Also, it was rarely clear from the reports whether or not participants were influenced by the fact that they were being asked questions about their training at the request of, or with the implicit/explicit consent of, the training program itself. Nearly all the studies acknowledge the limitations of self-report data, whether those self-report instruments were standardized or customized. What seems an interesting and probably unintended effect of this 10-to15-year industry of attempting to create, stabilize, and validate self-report items on residency stress is that now an item bank of about 100 to 200 solid questions is available for use! Researchers in this area also appear analytically practical and humble; not many seemed to need to elevate their work by imposing complex statistical techniques on data which are not worthy of such sophistication. Nevertheless, results across studies roughly combine to indicate that situational stressors or workload factors, particularly long hours and fat i g u e - a t least from what residents report--are the most frequent sources of stress in training programs. Other conclusions across studies are not so clear and also demand some degree of interpretation to be considered. It is one thing to conclude that, if most of the resident participants endorse "not enough time in the day" and "not enough sleep" as their biggest stressors, long hours and fatigue are really the reasons for their discomfort. Less clear are some other findings. Why, for instance, as has been found in some studies, is a particular year of 3- or 4-year residencies one in which residents seem to experience more stress (Revicki, Whitley, Gallery, & Allison, 1993)? As another example, if a gender difference does occur, it is that women residents report their experiences of stress more frequently than do their male counterparts (Toews, Lockyer, Dobson, & Brownell, 1993). Women also report more utilization of social support. Nothing strongly suggests that, in fact, women residents experience more stress than do men residents. Also, while most studies do find programs stressful, these studies also report that most residents do not experience the stresses to a degree severe enough to qualify as "psychological distress," depression, or anxiety. In fact, Toews and his associates (1993) compared residents with medical students and graduate students (M.Sc.~h.D. students); while all three groups reported elevated stress levels, the graduate students experienced more stress than the other two groups. The Residents. To begin gathering more information on the local situation, we wrote to 33 pediatric residents who had completed the training program in the past 5 years. We explained our project and presented them a list of stressors (compiled from the literature). We asked them to rate the stressors and also to add any others that they remembered as part of
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their training experience. We also asked them to list and rate the ways in which they dealt with such stressors when they were residents. Nineteen (57.6%) past residents responded, 10 men and 9 women. Based on their responses, we developed a rating scale with 40 items related to training program stressors and 28 items related to coping mechanisms. Each stressor item was rated on a 5-point scale from "not at all stressful" to "extremely stressful." Typical stressor items included "having work interfere with my primary intimate relationships," "not getting adequate feedback on a patient from my supervisor," and "having to deal with a difficult patient." Each coping strategy item was rated on a 5-point scale from "never used" to "very frequently used." Typical coping strategy items included "went to a movie," "prayed about it," and "went on as if nothing had happened." We then asked 23 current pediatric residents to complete the ratings. Nineteen (82.6%) chose to do so, 10 women and 9 men, roughly spread across the 3-year training program. We also asked 40 current internal medicine and emergency medicine residents to respond to the rating scales. Nine internal medicine and six emergency medicine residents responded (37.5%), 13 men and 2 women. The Results. From these small numbers, we began to compare some mean ratings among the past pediatric residents, the current pediatric residents, and the current internal and emergency medicine residents. Past residents rated as their five greatest stressors while in training having a patient die (M = 3.92), sharing difficult news about the patient to the family (M = 3.87), having so much to do that nothing is done well (M = 3.47), making mistakes (M = 3.42), and having no time for family and friends (M = 3.42). Current pediatric residents rated their five highest stressors as having no time for family and friends (M = 3.55), going without sleep for extended periods (M = 3.55), making mistakes (M = 3.53), having no time for personal activities (M = 3.42), and being on call excessively (M = 3.37). Similarly, current emergency and internal medicine residents listed as their five biggest stressors making mistakes ( M = 3.80), going without sleep for extended periods (M = 3.73), having no time for personal activities (M = 3.60), having so much to do that nothing is done well (M = 3.53), and having no time for family and friends (M = 3.33). How did they cope? Past pediatric residents talked with another resident (M = 4.11), took things one step at a time (M = 4.05), studied and worked harder in an attempt to gain more knowledge (M = 3.84), made a plan of action and followed it (M = 3.79), and spoke with a close friend or relative (M = 3.68). Current pediatric residents slept (M = 3.95); talked with another resident (M = 3.79), studied and worked harder in an attempt to gain more knowledge (M = 3.68), spoke with a close friend or relative
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(M = 3.37), and confronted the source of stress (M = 3.21). Current internal and emergency medicine residents took things one step at a time (M = 3.93), slept (M = 3.47) and exercised alone (M = 3.47), talked with another resident (M = 3.27), and confronted the source of stress (M = 3.20). Interestingly striking consistency emerged among the past residents, the current pediatric residents, and the internal/emergency medicine group in the least endorsed stressor item--having fears about dying (M = 1.92, M = 1.84, and M = 1.53, respectively). Perhaps as striking was the consistency in the three least endorsed coping strategies: for past pediatric residents they were seeking professional help (M = 1.32), writing in a diary (M = 1.16), and taking sedatives or sleeping medication (M = 1.00). For current pediatric residents, they were writing in a diary (M = 1.21), seeking professional help (M = 1.16), and taking sedatives or sleeping medication (M = 1.05). For current internal and emergency medicine residents they were writing in a diary (M = 1.20), seeking professional help (M = 1.13), and taking sedatives or sleeping medication (M = 1.00).
Consultation Conclusions and Recommendations
Our consultation team knew this much: our information was not ground-breaking or earth-shattering, our methods were inelegant and imprecise, and our very small sample knew who was sponsoring the surveys and why. Yet our results seemed very familiar to what a decade or more of researchers had already discovered. Residents are overworked and tired and have no time for anything or anyone else. And they do not want to make mistakes. Having "eyeballed" means and ranges, we knew we were not going to get big standard deviations. Nor did there seem much difference between the current pediatric and the current internal/emergency medicine residents. Nor were there gender differences. Of course, given the context and visibility of the project, we were not surprised that participants did not endorse drug use as a coping mechanism; but was seeking professional help just as socially unacceptable? And (at the risk of too much interpreting) who had time to write in a diary? What did our small sample tell us that added to what the literature already suggested? What would we add by collecting more ratings from more residents? How would all this information be useful to the directors of the pediatric residency training program who wanted our advice in the first place?
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To be fair, our small attempt probably did add something to the field. We did ask about coping mechanisms and got a hint that talking with colleagues might be a valuable source of social support. What we could communicate to the training program directors were these statements. Residents feel tired and overworked. We would, of course, emphasize the limitations of our suggestions and answers because of the small numbers of participants, but we were unable to note any gender differences, or differences from year to year in the residency program, nor were we able to detect differences among pediatric, internal medicine, and emergency medicine residents. What we might convey with regard to what practicing pediatricians remembered as most stressful during training and what might be affecting their enjoyment of or disillusionment with their careers were having patients die and relating such news to their families. Since those items were not endorsed by current residents as highly stressful, we might also go so far as to speculate that the long hours and fatigue suffered by women and men in training may actually mask or interfere with the experience of other job stressors, such as dealing with death. In fact, Firth-Cozens and Morrison (1989) lend credibility to our speculation. Their work utilized open-ended descriptions of stressful situations by 173 British preregistration doctors (the equivalent of American junior house staff members). The most common stressor found was dealing with death. The authors note that their methodology contrasts with the more common questionnaire studies "which used predetermined categories from past literature and which find overwork to be the aspect of their jobs seen as most stressful" (p. 124). " . . .[C]onstant emphasis on overwork may be some form of defence against aspects of the job which cause even higher levels of anxiety" (p. 124). And what might we recommend? We could certainly suggest looking at the total hours of duty per week and consecutive hours on call for residents to see if reductions or more flexible scheduling were warranted. Interestingly, Cohen and his associates (1989) comment on the effects of the celebrated New York State regulations of residency work hours, "a shift from a virtual monastic existence of continuous work with no nights o f f . . . [to] working every third or fourth night" (p. 181). Unfortunately, as the authors note, the lighter work schedule also allowed residents to "moonlight" elsewhere--in effect, negating the attempts to alleviate long hours. We would also strongly recommend that the program create, encourage, and enhance opportunities--formal and informal--for residents to talk with one another about the psychological aspects of their training, the demands, the rewards, the uncertainties, and the responsibilities. Perhaps some support groups might extend to significant others in the residents'
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lives. Some discussions might be dedicated to communication problems with program directors and attending physicians.
WHAT NEXT? We have no way of knowing whether the results of past program evaluations led to modifications in training programs. Coombs et al. (1990) called for stress prevention programs for trainees and practitioners, but was their call heard? In fact, we suspect that programs have not changed much, since the literature continues to indicate that long hours and fatigue are problematic in residencies. Perhaps one suggestion for "what next?" would be to survey residency training programs to see if any have incorporated stress prevention or stress management initiatives. Sadly, in our case, by the time we were ready to share our recomm e n d a t i o n s , the residency program changed directors. The new administration did not see stress as a particularly important issue for residents and declined to pursue the consultation further. As we knew at the outset, unforeseen changes in program administration are among those "not-so-obvious issues" consultants learn are always part of the process. But the entire experience led us to bring before our colleagues in medical settings this discussion. Why did we do all that we did? Should we have presented to the program directors, instead, a summary of all the research done before, commented on all the methodological shortcomings, and then said, "Look, training programs have been populated by tired, overworked residents for a long time. Are there educational benefits to long hours and fatigue? If so, we have not found them. Does patient care benefit? We do not think so, but to be fair, we also do not know if patient care suffers under the system-as-usual. Why do these conditions persist? Because this is the way it has always been. Indeed, such conditions are currently even more glorified, with the saga of overworked and tired emergency medicine residents claiming prime time television ratings!" When does the clinical psychologist as program consultant acknowledge that enough is enough? Medical residency training programs seem to be examples of institutional calcification. They will not change, no matter what the data suggest. We have other such examples in health care settings, some small, others more complex and multidetermined. In mental health, for instance, everyone knows (and the research data support) that inpatient psychiatric hospitalization for the majority of mentally ill patients is therapeutically no more valuable (but a lot more expensive) than outpatient treatment. Yet inpatient care continues to reign.
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This, then, is o u r question. H o w m u c h can we d o a n d how far can we go to affect a n d effect i n s t i t u t i o n a l a n d p r o g r a m m a t i c c h a n g e ? W e might s p e c u l a t e , f r o m o u r e x p e r i e n c e a n d from the literature, t h a t p e o p l e see t h e n e e d for c h a n g e b u t d o not p a r t i c u l a r l y wish to change. A t w h a t levels s h o u l d we c o n c e n t r a t e o u r efforts? In o u r e x a m p l e o f stress in resid e n t s , s h o u l d e f f o r t s b e d i r e c t e d at i n f l u e n c i n g at l e a s t o n e r e s i d e n c y p r o g r a m in o n e m e d i c a l s e t t i n g ? S h o u l d we c o n c e n t r a t e o u r efforts at h i g h e r a d m i n i s t r a t i v e a n d p o l i c y - m a k i n g levels, for instance, g r a d u a t e m e d i cal e d u c a t i o n a s s o c i a t i o n s r e g i o n a l l y a n d n a t i o n a l l y ? W e a r e o p e n to discussion.
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