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Resident Stress Revisited: A Senior Pediatric Resident’s Point of View

2003; American Academy of Pediatrics; Volume: 112; Issue: 2 Linguagem: Inglês

10.1542/peds.112.2.411

1098-4275

Megan A. Moreno,

Adolescent and Pediatric Healthcare

It has been 15 years since Dr Abraham Bergman1 wrote his poignant essay for Pediatrics on resident stress. In some ways, it seems little has changed in those 15 years in the area of resident stress. Many of the points raised in Dr Bergman's article are still relevant today. However, pediatric residents have recently entered a new era in pediatric education and training led by the Accreditation Council for Graduate Medical Education (ACGME).2 The ACGME has established guidelines that limit the number of hours a pediatric resident can work per shift, as well as per week. The guidelines set new standards for "competencies" in which residents should be trained as well as new ways that administrators must track and evaluate residents' progress. The ACGME expects full compliance with these guidelines beginning July 1, 2003. As residents look forward with anticipation and hope to what changes these new guidelines will bring, it seems an appropriate time to revisit Dr Bergman's article and evaluate the past and current sources of resident stress. This commentary will consider which sources of stress described by Dr Bergman are still relevant today, and whether the advent of the ACGME guidelines will alleviate any of these stressors for tomorrow's pediatric house officer.Global causes of resident stress, as Dr Bergman explains, include the developmental milestones that pediatric residents must face as adults learning to balance their personal and professional lives. Dr Bergman lists the development of autonomy, individuation from one's parents, and wrestling with financial independence as global causes of resident stress. These stressors are much the same today, as every new physician must struggle with his/her new role and new identity of being a physician. The development of financial independence continues to be a large source of stress for today's debt-laden residents. The Future of Pediatric Education II Task Force report in 2000 illustrated a "progressively increasing debt burden among residents."3It is doubtful that the ACGME guidelines will have an immediate effect on the developmental milestones that every new physician must face. Balancing one's own personal maturation in the face of career maturation will never be an easy task. Balancing one's checkbook in the face of school loans that require payback will never be easy either. These developmental milestones must still be reached whether it is within an 80-hour workweek or a 100-hour workweek. However, the initiation of an 80-hour workweek may make these philosophical progressions occur within brains that are less clouded from fatigue. As resident work hours decrease, some of these balancing act stressors may lessen. However, residents will always struggle with setting a balance between their personal and professional lives.Dr Bergman's article commented that faculty can have "only limited impact on some of the more global causes of resident stress."1 In this area, I respectfully beg to differ with Dr Bergman. I feel that faculty can make a large difference to residents in coping with these stressors. Faculty can serve as mentors for residents; they can provide advice and encouragement to residents as they meet these challenges. Faculty can also serve as role models to residents, illustrating how they manage to balance their own work and personal lives.Dr Bergman discusses the adage that "patient needs invariably take precedence over family needs."1 This environment usually results in residents working long hours and sacrificing their home lives.Dr Bergman argues that residents cope with this sacrifice of their home lives by complaining or by bragging about their long work hours to their co-residents. As it was in 1988, today there is still a machismo among residents as to working long hours. Particularly horrendous shifts are talked about in a way that seems half-frustration, half-boastful. Despite this surface braggadocio persona, studies have shown that up to 30% of residents experience depression during their residencies.4 Other studies have shown that residents often harbor levels of anger and hostility that can effect their ability to deliver good patient care.5In this area of frustration it appears that the ACGME guidelines will have a profound effect. By limiting resident work hours there will be more time available for marriage, family, hobbies, academic pursuits, and, of course, sleep.In one of my favorite sections of Dr Bergman's article he discusses modern teaching hospitals as "strange worlds full of patients with incurable chronic illnesses whose care is difficult, frustrating, and never-ending."1 I can find no better description for the patients I see on our pediatric wards every day. The days of hospital wards full of "bread and butter" pediatric problems such as failure to thrive, croup, or fever of unknown origin are long gone. They are replaced by patients who are co-managed by our pediatric residents along with numerous subspecialty teams: gastrointestinal, transplant, renal, surgery. The skills of co-managing a patient among several teams all invested in the fate of the patient were not well-addressed in most residents' medical school experience. Pediatric residents often find themselves in uncharted waters, acting as middlemen trying to care for patients over whom they feel they have no ultimate voice. The politics of these patients are often more difficult than the medicine.How will the ACGME guidelines affect this issue? One of the ACGME core competencies in which all residents are supposed to receive training is "professionalism." This competency includes the development of communication skills with other health care professionals.2 I have not yet seen specific training guidelines or modules for these skills, and I wonder how best they can be taught. Lectures, small group sessions, and role-playing may all contribute to a resident's professionalism training. However, Dr Mufson's article in the Annals of Internal Medicine6 argues that "medical students and residents expect faculty to serve as role models for professionalism." I agree with Dr Mufson that attending physicians, and possibly fellows or senior residents, acting as positive role models in balancing the care of a multispecialty patient is likely the best training a resident can have.In this section of his article Dr Bergman also points out that "residents move ever-further from the bedside."1 It seems that little has changed in this area. Even with modern-day advances such as computerized medical records, computerized lab results, and computerized texts available at any hour of the day or night for resident perusal, residents still cannot find time to go talk to their patients. Residents often find themselves spending the workday obtaining numerical data, reporting that data to various teams, writing notes, and contacting numerous subspecialty teams to coordinate plans and tests. This type of day leaves little time for what residents went into pediatrics for: the patients. As the ACGME rules decrease residents' available hours of training, I fear for what these changes will do to patient contact, continuity, and doctor-patient relationships.Dr Bergman describes 2 main annoyances in his article: pagers and clerical work. Dr Bergman described pagers as an "unmitigated curse."1 Each time I am trying to get a quick soda to make up for a missed meal and my pager summons me even as I take the necessary minute or two to sneak away and slip my coins in the vending machine, I chortle as I think of his description of pagers. Dr Bergman encouraged programs to limit pagers to only a few necessary residents who could respond to the pager for emergencies only. But by now, pagers are a staple of the residents' work environment. They are practically a body part of today's resident. No longer for emergencies, they are a form of communication for anyone hoping to find the resident: nurses, other subspecialty teams, co-workers, and secretaries.The second annoyance discussed by Dr Bergman is the amount of clerical work involved in being a resident. Dr Bergman asked 2 ward interns to track their time during 2 days of work. In two 12-hour workdays the interns spent 4 to 5 hours a day on paperwork, scheduling, and contacting private physicians. Many of the calls involved the intern as "middleman," relaying information from one attending to another. Today, these clerical responsibilities have only worsened. A study on internal medicine residents in New York revealed that in a typical internal medicine resident's workday, 19% of one's time was spent doing activities that could be done by nurses, technicians, and support staff. Only 3.1% of time was spent seeing patients.7 In addition to the clerical responsibilities described by Bergman 15 years ago, interns now can find themselves attached to the phone for hours, sitting on hold with insurance companies while battling to get patients' hospital stays covered by their insurance.Where do residents and faculty go with this problem? The ACGME guidelines will limit the amount of time doing these jobs, but they will not eliminate the essentially noneducational work that these jobs involve. The solution to this problem was eloquently suggested by Dr Bergman 15 years ago, and I ardently support it now: hire clerical help. Over the last 15 years some programs have hired nurse managers or ward unit clerks to help with these daily duties. Others have not. For those that have not obtained clerical support for their residents, now is the time to do so. Have the support staff sit in on rounds and keep track of the clerical duties: phone calls to insurance companies, radiology orders, procedure scheduling, and seek their assistance with these aspects of patient care. Residents will soon have fewer hours they can spend in the hospital, clerical support staff can help make those residents' hours more meaningfully spent.Dr Bergman argues that "the single most important thing that faculty can do is to recognize the problem of stress in pediatric training programs and show the residents that we want to help them with it."1 Residents now move into a new era of training in which this statement will become evermore relevant. As the new ACGME guidelines go into effect and pediatric residents must go home post call, they will have less interaction with faculty. Residents may fear backlash from faculty because they "have" to go home post call, especially knowing that faculty endured residency back in the "unregulated days." Residents may fear being berated or disrespected by faculty for their own adherence to the ACGME rules. Now is the time that residents need faculty support and teaching more than ever.Now is also the time that faculty need support. For after the post call resident has gone home in the neonatal intensive care unit, it may very well be the neonatal intensive care unit attending who stays to complete the clinical duties. There are no guidelines available to send the attendings home when they become fatigued.I suspect that faculty are as nervous as residents about the changes that lie ahead and how they will affect patient care, resident learning, and work hours for all. Faculty may worry that their own clinical and clerical duties will increase after post call residents go home. Faculty may worry that their own fatigue may impede their ability to serve as good role models, or good teachers. On the other hand, faculty can look forward to teaching a new generation of residents, residents who will not yawn throughout their lectures, residents who will not complain of fatigue and balk at taking on another patient.Residents will still look up to faculty and seek qualities in them that they can emulate. Faculty can help residents embrace the changes ahead and make the most of their educational time in the hospital. Faculty can serve as mentors to residents and model different strategies of balancing patient care, research, teaching, and family. Faculty, as well as residents, have the opportunity to usher in a new era of medical training marked by humane hours, better patient care, and self-motivated learning.As the ACGME guidelines become standard residents will experience less stress in some areas: they will no longer work long 36-hour shifts, they will have mandated days off, and they will have more time for family. However, these new guidelines will also mean less time in which a resident can gain all the knowledge that a graduating senior resident must accrue to be a good pediatrician. To maximize residents' education they will need self-motivation to invest in their own reading and education while at home, supportive faculty who are dedicated to teaching, less time spent on clerical and other noneducational duties at work, and more time invested with their patients. Faculty can be of great assistance in this evolution by being supportive and understanding of residents' regulated work environment, and by providing excellent teaching and role modeling.I wish to thank Dr Abraham Bergman for his inspirational article.