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Medical Teacher, Vol. 13, No. 1, 1991 89
Investigating stress levels of residents: a pilot study
STEVEN E. SAMUEL*, JANET S. LAWRENCEt, HARVEY J. SCHWARTZ", JEFFREY C. WE1SS.t & JOSEPH L. SELTZERS, Departments of *Psychiatry and Human Behaviour, fpaediatrics, and $ Anaesthesiology, JeJerson Medical College, Philadelphia
SUMMARY A pilot study of the levels of stress among residents was conducted in three departments in a university hospital prior to initiating a programme in stress manage- ment for residents.
The Beck Depression Inventory, which is a brief, standardized self-report measure of depression, was given to residents in anaesthesiology, paediatrics and psychiatry. Six additional questions were asked about the functioning of peers and services residents would like to have available. Of the 113 residents surveyed, 16% were experiencing a mild mood disturbance. The
researchers feel this is probably under-reported. Residents felt that about 15% of their colleagues were emotionally impaired; 10% may have a drug and/or alcohol problem; 12% were having marital problems.
Eighty per cent of all residents studied said that they would attend support groups if they existed. Approximately 60% thought coping skills/stress management seminars would be useful, and 30% of the paediatric and anaesthesiology residents (60% of the psychiatry residents) said they would use confidential indiviaual psychotherapy if it were available.
Recent attention is being directed towards developing a better understanding of the possible adverse effects medical education has upon physicians in training (Clark & Zeldow, 1988) and how medical schools may be more helpful to students as they progress through their training (Kahn & Schaeffer, 1981). One focus of concern has been the issue of how psychological stress contributes in both positive and negative ways to the medical education process. In light of recent findings, a corollary concern has been how medical institutions may help remedy the inherantly stressful experience of medical education (Aach et al., 1988; Samkoff & McDermott, 1989).
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90 Steven E. Samuel et al.
This is a report of a pilot study completed at a metropolitan university hospital which was designed to ascertain how serious is the problem of debilitating stress among residents, how residents evaluated their colleagues stress levels, and in what ways residents thought their stress might be remedied. The Beck Depression Inventory, a standardized measure of depression recently used in studies evaluating medical student stress (Clark & Zeldow, 1988) was given to each resident from the psychiatry, anaesthesia, and paediatric departments ( n = 113). In addition, each resident was asked to respond to six questions:
(1) What percentage of your colleagues do you feel are emotionally impaired? (2) What percentage of your colleagues do you feel have drug/alcohol problems? (3) What percentage of your colleagues do you feel have marital problems? (4) Would you use individual confidential psychotherapy if available? (5) Would you attend coping skilldstress management seminars if available? (6) Would you attend resident support groups if available?
Each resident received a letter from the Dean of the Medical School asking them to anonymously participate in the study. Residents’ responses were collected by the studies’ authors immediately upon completion.
Results
Of the 113 residents surveyed 16% received a Beck Depression Inventory score between 11 and 20 indicating they were experiencing a mild mood disturbance. One per cent of the residents sampled received a score greater than 20, indicating they were experiencing a moderate depression. The remaining 83% received a normal mood score of less than or equal to 10.
A two-way analysis of variance (ANOVA) showed that there were significant differences in Beck Depression Inventory scores by department, but not by year. The psychiatry department residents had the widest range of scores (0-24) and a mean Beck score of approximately 7. Anaesthesia residents had a range of 0-16 and a mean Beck score of approximately 4, while paediatric residents had a range of 0-19 and a mean Beck score of approximately 6.2.
Using a cut-off of 10, psychiatry residents were 2.2 times more likely to have an elevated Beck Depression Inventory score. Beck score and perception of colleagues as having emotional problems were correlated, but perceptions of colleagues as having marital or alcohol problems and Beck scores were not correlated.
When the residents’ answers to the six questions were evaluated, it was determined there was a tendency to report that peers were more emotionally distressed than oneself. This finding is opposite to that of the previous study completed at Cedar-Sinai (Davis, 1989) wherein residents felt that everyone else was coping well and only they themselves were distressed. In this study it was found that residents reported that they thought about 15% of their colleagues were emotionally impaired, and that approxi- mately 10% may have drug and or alcohol abuse problems.
Psychiatry residents estimated that approximately 16% of their colleagues were having marital problems. The other two resident groups estimated that approximately 12% of their colleagues were experiencing marital problems.
When asked what types of services they, themselves, might take advantage of approximately 30% of the paediatric and anaesthesiology residents said they would use
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Investigating stress levels of residents 9 1
confidential individual psychotherapy. Approximately 61 % of the psychiatry residents endorsed this option.
Sixty per cent of the first and second year paediatric residents and 60% of the second-year psychiatry residents felt coping skilldstress management seminars would be useful to them. Forty per cent of the third-year anaesthesia residents believed these types of groups would be helpful.
Resident support groups are distinguished by being less structured and lead by by other residents. Approximately 80% of all the residents stated that they would attend this type of group should it be offered.
Discussion
It may be concluded from a sample of 113 residents that 17% of these residents are experiencing stress of a mild to moderately disturbing nature. This finding is consis- tent with that of Clark & Zeldow (1988) who found that approximately 12% of their medical students demonstrated mild to moderate disturbances in mood at any given point during their medical school education.
This study determined that approximately 80% of the residents felt a peer-directed support group would be a useful addition to their training programme format. Approximately one-third of the anaesthesia and paediatric residents, and two-thirds of the psychiatry residents indicated they would seek individual psychotherapy should it become available in an affordable and confidential manner. It would certainly seem from these findings that some type of stress support service for residents would be helpful. In light of these findings we have recently started investigating ways to implement stress support services for residents at this institution.
It was noted that some residents within the anaesthesia and paediatric department demonstrated a response set which openly denied feelings of discomfort. The resear- chers observed that these residents appeared to simply read the first five items of the Beck Depression Inventory, learn the scoring pattern, and complete the remaining 16 items with a ‘0’ (signifying no distress) without reading these items. Several of these residents remarked later than they questioned the true confidentiality of their re- sponses. Others stated that they had learned it was best to always present themselves in a positive light for fear of a negative performance evaluation. Therefore, the stress levels for the anaesthesia and paediatric residents may well be under-reported.
Alternately, the finding that psychiatry residents were 2.2 times more likely to have an elevated Beck Depression Inventory score may be too high an estimation of their levels of stress. This may be understood, first, within the context of the above mentioned response set. Secondly, the psychiatry residents evidenced a considerably greater range of scores than the other residency group. Finally, unlike the other training programmes, residency training in psychiatry inherently encourages an open expression and examination of ones feelings, often within the context of individual psychotherapy. It was noted, in this light, that psychiatry residents in this study demonstrated a statistically significantly greater preference for confidential individual psychotherapy as the remediation for stress.
Learning to be a physician requires more than acquiring cognitive knowledge. It involves personal growth, the acquisition of professionalism, stamina, intellectual curiosity, a critical sense, and learning how to listen to and use ones self (Korsch, 1985). Hopefully, the opportunity for learning to manage the stress inherent in the
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92 Steven E. Samuel et al.
residency experience will be made available to residents towards their effecting optimal medical care for those in need.
We would welcome additional reports from colleagues who have considered or completed research in this area.
Correspondence: Steven E. Samuel, Department of Psychiatry and Human Behaviour, Jefferson Medical College, 1561 Thompson Building, 1 l th and Walnut Street, Phila- delphia PA 19107, USA.
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CLARK, D.C. & ZELDOW, P.B. (1988) Vicissitudes of Depressed Mood During Four Years of Medical
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