Transcript No Slide Title

Resident Stress and Impairment
Darryl Y. Sue, M.D.
July 2007
Resources
• Harbor-UCLA Committee on the WellBeing of Physicians
– Ira Lesser, M.D. Extension 3137
• UCLA Mental Health Services for
Physicians in Training
– 310-206-8976
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?
Signs of stress and distress
• Changes in personality
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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
Signs of stress and distress
• Changes in performance
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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
Stress and Distress
• Physical symptoms
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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
Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154
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.
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.
Internship: Will you get over it?
Acad Med. 2005; 80:164–167.
20
18
16
vigor-activity
14
12
T ens ion– A nxiety
D epres s ion– D ejec tion
A nger– H os tility
V igor– A c tivity
C onfus ion– Bewilderment
Fatigue– I nertia
10
8
6
Acad Med.
2005; 80:164–
167.
depression-dejection
anger-hostility
4
2
0
Start R1
M id R1
M id R1
E nd R1
E nd R3
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.
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
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...
Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154
Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154
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?
Personal Stress
• Family
– strength and comfort
– conflict and unhappiness
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Financial burdens--loans, cost of living
Social dislocation
Isolation
Variable coping skills
Free time, free time, free time...
Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154
Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154
Reducing Personal Stress
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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?
Training Stress
A 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?
Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154
Resident Services Committee, APDIM. Ann Intern Med 1988; 109:154
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
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”
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
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
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
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
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
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
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
Hughes et al. Am J Psychiatry 1992; 149:10
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
Christie JD et al. JAMA 1998; 280:1253
Christie JD et al. JAMA 1998; 280:1253
Self-Prescribing
• 244 residents (78%) used > 1
prescription medicine
• 162 residents (52%) reported selfprescribing
• 25% of medications, 42% of selfprescribed medications obtained from
“sample cabinet”
Christie JD et al. JAMA 1998; 280:1253
Self-Prescribing
• 7% of all medications and 11% of selfprescribed medications obtained from
pharmaceutical company
representative
Christie JD et al. JAMA 1998; 280:1253
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
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
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
Resident Burnout--Who? Me?
• 92-item questionnaire of 115 (76%) of
IM residents at U Wash
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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.
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.
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.
Shanafelt TD et al. Ann Intern Med 2002; 136:358-67.
Shanafelt TD et al. Ann Intern Med 2002; 136:358-67.
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.
Resident Burnout--Who? Me?
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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.
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.
Resident Burnout
• Does residency burnout residency
lead to dissatisfaction with eventual
specialty or practice choice?
• Could resident burnout affect the
individual’s medical education?
Burnout and Work Hours Limits
• Self-administered survey of IM residents in a
university-based program in Seattle.
• Part of survey identical to 2001, permitting
comparison of burnout, career satisfaction,
and depression before and after WHLs.
• 161 residents, 118 respondents (response
rate, 73%).
Arch Intern Med. 2005;165:2601-2606
Burnout and Work Hours Limits
• Measured resident well-being using Maslach
Burnout Inventory, a validated screen for
depression, and a previously described
questionnaire for career satisfaction.
• We developed questions about overall
agreement with implementation of WHLs and
effects on resident well-being, patient care,
and education.
Arch Intern Med. 2005;165:2601-2606
Burnout and Work Hours Limits
• Comparison with 2001 demonstrated:
– increase in proportion of residents satisfied with
their career (66% to 80%; P=.02)
– decrease in proportion meeting criteria for
emotional exhaustion (53% to 40%; P=.05).
• Slightly more residents reported a negative
effect of WHLs on patient care (37%) than
positive (29%) or neutral (34%) effect
Arch Intern Med. 2005;165:2601-2606
Burnout and Work Hours Limits
• More reported a negative effect on their
education (47%) than they did a positive
(32%) or a neutral (21%) effect.
• Overall, most residents (65%) approved of
WHLs.
Arch Intern Med. 2005;165:2601-2606
Improved resident
well-being
Some effects on
patient care
Negative effect on
resident education,
especially for R2/3?
Arch Intern Med.
2005;165:2601-2606
Burnout in Internal Medicine
• Evaluated rates of “burnout” in IM residents
before and after implementation of work-hour
restriction.
• U Colorado Health Science Center residents
were surveyed in 5/03 and 5/04.
Arch Intern Med. 2005;165:2595-2600
Burnout in Internal Medicine
• Maslach Burnout Inventory
– emotional exhaustion
– depersonalization
– personal accomplishment
• Primary Care Evaluation of Mental Disorders
depression screen
• Self-reported quality of care and education.
Arch Intern Med. 2005;165:2595-2600
Burnout in Internal Medicine
• Response rate 87% (121 of 139 residents)
and 74% (106 of 143 residents) in 2003 and
2004.
• Self-reported hours/week decreased from
74.6 to 67.1 (P=.003).
• In 2004, 13% fewer residents experienced
high emotional exhaustion (42% vs 29%;
P=.03).
Arch Intern Med. 2005;165:2595-2600
Burnout in Internal Medicine
• Trend toward fewer residents with high
depersonalization (61% vs 55%; P=.13) and
fewer residents with a positive depression
screen (51% vs 41%; P=.11).
• Personal accomplishment and self-reported
quality of care did not significantly change
from 2003 to 2004.
Arch Intern Med. 2005;165:2595-2600
Arch Intern Med. 2005;165:2595-2600
Burnout in Internal Medicine
• Residents reported attending fewer
conferences per month (18.99 vs 15.56;
P=.01).
• Overall residency satisfaction decreased 6
mm on a 100-mm visual analogue score
(P=.02).
Arch Intern Med. 2005;165:2595-2600
Burnout in Internal Medicine
No significant changes between years (just one year)
for self-reported suboptimal patient care.
Arch Intern Med. 2005;165:2595-2600
Burnout in Internal Medicine
“Our prospective study shows that the change
in work hours had an inconsistent effect on our training
program. The longer-term effects on residents are
unknown.”
“Will
these residents provide better care as attending
physicians because they are less burned out, or
will the care suffer because of lack of education and
commitment to their patients?”
Arch Intern Med. 2005;165:2595-2600
Conference Attendance
• 1996-97 attendance for 81 residents
at UCLA-CHS
• Recorded attendance, other factors
• Compared to USMLE 2 and ABIM
• Factors correlated with attendance
FitzGerald JD, Wenger NS. Acad Med 2003; 78:84-89
FitzGerald JD, Wenger NS. Acad Med 2003; 78:84-89
odds ratio
3rd year residents had significantly lower attendance than 1st
or 2nd year residents
FitzGerald JD, Wenger NS. Acad Med 2003; 78:84-89
odds ratio
FitzGerald JD, Wenger NS. Acad Med 2003; 78:84-89
FitzGerald JD, Wenger NS. Acad Med 2003; 78:84-89
Residents’ Assistance Program
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Assessment
Short-term counseling
Followup services
Referral
Confidentiality
Educational and training components
Levey RE. Acad Med 2001; 76:142-150
Opinions about Work Hours
AMA “Question” Regarding Duty Hours--A good thing!
• “I feel more positive about the duty hour limits
every day. I have never seen resident
morale, attitude, mood, and camaraderie this
good. Participation in advocacy work is at an
all-time high. Residents are interested in
learning again, participation in AM report is
improved, they are looking up information on
the diseases of their patients.”
AMA “Question” Regarding Duty Hours--A guess about the future?
• “Even community practitioners are not looking kindly
at the new work hour limits. They are not looking
forward to hiring potential new partners who never—
not once in 36-84 months of "training"—learned how
to work a full day post-in-house-call. And there is no
escaping the fact that, because of reduced work
hours, much of the knowledge and skill that should
have been learned during training in some specialties
will have to be learned instead on the job, where the
structured learning and supervision so important for
high-quality medical education are virtually
nonexistent.”
AMA “Question” Regarding Duty Hours--An interesting answer!
• “Our rheumatology program has not had any
difficulty meeting the 80-hour limit, but the 4
days off a month has created a lot of suffering
among the attendings and fellows.”
2004 In-Training
Examination
Questionnaire
Am J Med. 2007 Jul;120:644-8.
2004 In-Training
Examination
Questionnaire
Am J Med. 2007 Jul;120:644-8.
Am J Med. 2007 Jul;120:644-8.
Program Directors’ Responses
• “Do you think the ACGME work hour regulations have
an adverse impact on your ability to educate your
residents?”
– 51% yes
• “If yes, which of the ACGME work hour regulations
has an adverse impact on your ability to educate your
residents?”
– 68% 24/6
– 38% 10 hours off between shifts regulations
– 31% 80-hour week.
Am J Med. 2007 Jul;120:644-8.
Residents’
perceptions of
attendings response
to duty hour
limitations.
Identifying those at risk...
• Work-related
– Incomplete patient evaluations
– Missing important results
• Emotional outbursts
– anger, depression, failure to interact
• Withdrawal from social milieu
• Overcompensation
• Suspected substance abuse
Profile of Suicide-Prone Physician
AMA Counsel of Scientific Affairs. JAMA 1987; 257:2950
Peer Help?
• Be aware of potential concerning
behaviors
• Provide constructive environment
• Team approach to problem solving
• Team approach to patient care
• Non-judgmental
• Self-participation as a role model
Can the Program help?
• Formal education and awareness
• Group meetings
• Informational meetings (rumor
control)
• Scheduling (meet requirements)
• Feedback to/from residents
• Educate faculty about stress
Can the resident help?
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Be a participant and contributor
Be realistic
Learn
“It’s not a job, it’s an adventure?”
Balance, balance, balance
Develop compatible career goals
Resources
• Harbor-UCLA Committee on the WellBeing of Physicians
– Ira Lesser, M.D. Extension 3137
• UCLA Mental Health Services for
Physicians in Training
– 310-206-8976
Med Educ.
2007;41:27380
Stress and Impairment
• Stress unavoidable part of training
• Can be minimized and coping
strategies developed
• Impairment not uncommon and must
be recognized
• Substance abuse, depression less
common than ”burnout,” affecting
patient care and education
Yao DC, Wright SM. J Gen Intern Med 2001; 16:486
Yao DC, Wright SM. J Gen Intern Med 2001; 16:486