DOI: 10.1542/peds.112.2.411 2003


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DOI: 10.1542/peds.112.2.411 2003

  1. 1. Resident Stress Revisited: A Senior Pediatric Resident’s Point of View Megan A. Moreno Pediatrics 2003;112;411-414 DOI: 10.1542/peds.112.2.411 The online version of this article, along with updated information and services, is located on the World Wide Web at: PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2003 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from by on October 20, 2010
  2. 2. As noted, if one only examines cadaveric-renal trans- M. Genetics of congenital deafness in the Palestinian population: mul- tiple connexin 26 alleles with shared origins in the Middle East. Hum plants, racial disparities are minimal. However, dis- Immunol. 2002;110:284 –289 parities are real for total transplants. 8. Swiatecka-Urban A, Garcia C, Feuerstein D, et al. Basilizimab induction Survival after transplant— of the organ and of the improves the outcome of renal transplants in children and adolescents. patient—is better in whites than in blacks. Kaplan- Pediatr Nephrol. 2001;16:693– 696 Meier 5-year patient survival rates in whites of all 9. Krensky AM. Immunologic tolerance. Pediatr Nephrol. 2001;16:675– 679 10. Hata Y, Cecka JM, Takemoto S, Ozawa M, Cho YW, Terasaki PI. Effects age groups are in excess of 90% (93% for those 0 – 4 of changes in the criteria for nationally shared kidney transplants for years old, 100% for those 5–9 years old, 98% for those HLA-matched patients. Transplantation. 1998;65:208 –212 10 –14 years old, and 97% for those 15–19 years old) 11. Greenstein SM, Delrio M, Ong E, et al. Plasmapheresis treatment for in contrast to 92% (0 – 4 years old), 73% (5–9 years recurrent focal sclerosis in pediatric renal allografts. Pediatr Nephrol. 2000;14:1061–1065 old), 98% (10 –14 years old), and 93% (15–19 years 12. USRDS. United States Renal Data System: 2000 Annual Data Report. Atlas old) for blacks. Organ survival in blacks is also lower of End-Stage Renal Disease in the United States. Minneapolis, MN: USRDS than in whites (40%– 62% in blacks vs 58%– 68% in Coordinating Center; 2000 whites) of the 4 age groups. Recurrence rates for focal segmental glomerulosclerosis and drug compliance issues may account for these differences. Another factor includes the increased degree of immunologic hypersensitization that makes matching for retrans- Resident Stress Revisited: A Senior plants using cadaveric kidneys especially problem- atic.3,12 Pediatric Resident’s Point of View Prejudice should always be viewed as a real issue in society and in the history of mankind. It is also ABBREVIATION. ACGME, Accreditation Council for Graduate very real in Israel and in the United States. However, Medical Education. racial prejudice is unlikely to influence the offering of renal transplants in children in either country. The RESIDENT STRESS REVISITED article by Drukker et al1 shows this in Israel and the I t has been 15 years since Dr Abraham Bergman1 US Renal Data System12 shows it in the United wrote his poignant essay for Pediatrics on resident States. One interesting fact is that in Israel patients stress. In some ways, it seems little has changed are divided by their religion and in the complex, in those 15 years in the area of resident stress. Many diverse and polyglot United States, this designation of the points raised in Dr Bergman’s article are still does not occur. relevant today. However, pediatric residents have The challenges for US pediatric nephrologists are recently entered a new era in pediatric education and to overcome genetic and histocompatibility factors, training led by the Accreditation Council for Gradu- to engage the community to enhance living-related ate Medical Education (ACGME).2 The ACGME has donor transplants, and to understand recurrent dis- established guidelines that limit the number of hours ease. Prejudice does not appear to be a barrier and a pediatric resident can work per shift, as well as per should never play a role in selection for transplanta- week. The guidelines set new standards for “compe- tion. tencies” in which residents should be trained as well Russell W. Chesney, MD as new ways that administrators must track and Robert J. Wyatt, MD evaluate residents’ progress. The ACGME expects Department of Pediatrics full compliance with these guidelines beginning July University of Tennessee Health Science Center 1, 2003. As residents look forward with anticipation LeBonheur Children’s Medical Center and hope to what changes these new guidelines will Memphis, TN 38103 bring, it seems an appropriate time to revisit Dr Bergman’s article and evaluate the past and current REFERENCES sources of resident stress. This commentary will con- 1. Drukker A, Feinstein S, Rinat C, Rotem-Braun A, Frishberg Y. Cadaver- sider which sources of stress described by Dr Berg- donor renal transplantation of children in Israel (1990 –2001): racial man are still relevant today, and whether the advent disparities in health care delivery? Pediatrics. 2003;112:341–344 of the ACGME guidelines will alleviate any of these 2. Furth SL, Garg PO, Neu AM, Hwang W, Fivush BA, Powe NR. Racial differences in access to the kidney transplant waiting list for children stressors for tomorrow’s pediatric house officer. and adolescents with end-stage renal disease. Pediatrics. 2000;106: 756 –761 GLOBAL CAUSES OF RESIDENT STRESS 3. Warady BA, Hebert D, Sullivan KE, Alexander SR, Tejani A. Renal Global causes of resident stress, as Dr Bergman transplantations, chronic dialysis and chronic renal insufficiency in explains, include the developmental milestones that children and adolescents. The 1995 annual report of the North Ameri- can Pediatric Renal Transplant Cooperative Study. Pediatr Nephrol. 1999; pediatric residents must face as adults learning to 13:404 – 417 balance their personal and professional lives. Dr 4. Epstein AM, Ayanian JZ. Racial disparities in medical care. N Engl Bergman lists the development of autonomy, indi- J Med. 2001;344:1471–1473 5. King TE. Racial disparities in clinical trials. N Engl J Med. 2002;346: 1400 –1402 Received for publication Nov 7, 2002; accepted Jan 24, 2003. 6. Zachary AA, Bias WB, Johnson A, Rose SM, Leffell MS. Antigen, allele, Address correspondence to Megan A. Moreno, MD, University of Wiscon- and haplotype frequencies report of the ASHI minority antigens sin-Madison, 3009 Stevens St, Madison, WI 53705. E-mail: ma.moreno@ workshops: part 1, African-Americans. Hum Immunol. 2001;62: 1127–1136 PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad- 7. Shahin H, Walsh T, Sobe T, Lynch E, King MC, Avraham KB, Kanaan emy of Pediatrics. COMMENTARIES 411 Downloaded from by on October 20, 2010
  3. 3. viduation from one’s parents, and wrestling with DIFFERENCES BETWEEN THEN AND NOW financial independence as global causes of resident In one of my favorite sections of Dr Bergman’s stress. These stressors are much the same today, as article he discusses modern teaching hospitals as every new physician must struggle with his/her new “strange worlds full of patients with incurable role and new identity of being a physician. The de- chronic illnesses whose care is difficult, frustrating, velopment of financial independence continues to be and never-ending.”1 I can find no better description a large source of stress for today’s debt-laden resi- for the patients I see on our pediatric wards every dents. The Future of Pediatric Education II Task day. The days of hospital wards full of “bread and Force report in 2000 illustrated a “progressively in- butter” pediatric problems such as failure to thrive, creasing debt burden among residents.”3 croup, or fever of unknown origin are long gone. It is doubtful that the ACGME guidelines will have They are replaced by patients who are co-managed an immediate effect on the developmental mile- by our pediatric residents along with numerous sub- stones that every new physician must face. Balancing specialty teams: gastrointestinal, transplant, renal, one’s own personal maturation in the face of career surgery. The skills of co-managing a patient among maturation will never be an easy task. Balancing several teams all invested in the fate of the patient one’s checkbook in the face of school loans that re- were not well-addressed in most residents’ medical quire payback will never be easy either. These devel- school experience. Pediatric residents often find opmental milestones must still be reached whether it themselves in uncharted waters, acting as middle- is within an 80-hour workweek or a 100-hour work- men trying to care for patients over whom they feel week. However, the initiation of an 80-hour work- they have no ultimate voice. The politics of these week may make these philosophical progressions patients are often more difficult than the medicine. occur within brains that are less clouded from fa- How will the ACGME guidelines affect this issue? tigue. As resident work hours decrease, some of One of the ACGME core competencies in which all these balancing act stressors may lessen. However, residents are supposed to receive training is “profes- residents will always struggle with setting a balance sionalism.” This competency includes the develop- between their personal and professional lives. ment of communication skills with other health care Dr Bergman’s article commented that faculty can professionals.2 I have not yet seen specific training have “only limited impact on some of the more guidelines or modules for these skills, and I wonder global causes of resident stress.”1 In this area, I re- how best they can be taught. Lectures, small group spectfully beg to differ with Dr Bergman. I feel that sessions, and role-playing may all contribute to a faculty can make a large difference to residents in resident’s professionalism training. However, Dr coping with these stressors. Faculty can serve as Mufson’s article in the Annals of Internal Medicine6 mentors for residents; they can provide advice and argues that “medical students and residents expect faculty to serve as role models for professionalism.” encouragement to residents as they meet these chal- I agree with Dr Mufson that attending physicians, lenges. Faculty can also serve as role models to res- and possibly fellows or senior residents, acting as idents, illustrating how they manage to balance their positive role models in balancing the care of a mul- own work and personal lives. tispecialty patient is likely the best training a resident can have. MARRIAGE TO CAREERS In this section of his article Dr Bergman also points Dr Bergman discusses the adage that “patient out that “residents move ever-further from the bed- needs invariably take precedence over family side.”1 It seems that little has changed in this area. needs.”1 This environment usually results in resi- Even with modern-day advances such as computer- dents working long hours and sacrificing their home ized medical records, computerized lab results, and computerized texts available at any hour of the day lives. or night for resident perusal, residents still cannot Dr Bergman argues that residents cope with this find time to go talk to their patients. Residents often sacrifice of their home lives by complaining or by find themselves spending the workday obtaining nu- bragging about their long work hours to their co- merical data, reporting that data to various teams, residents. As it was in 1988, today there is still a writing notes, and contacting numerous subspecialty machismo among residents as to working long teams to coordinate plans and tests. This type of day hours. Particularly horrendous shifts are talked leaves little time for what residents went into pedi- about in a way that seems half-frustration, half- atrics for: the patients. As the ACGME rules decrease boastful. Despite this surface braggadocio persona, residents’ available hours of training, I fear for what studies have shown that up to 30% of residents ex- these changes will do to patient contact, continuity, perience depression during their residencies.4 Other and doctor-patient relationships. studies have shown that residents often harbor levels of anger and hostility that can effect their ability to deliver good patient care.5 ANNOYANCES In this area of frustration it appears that the Dr Bergman describes 2 main annoyances in his ACGME guidelines will have a profound effect. By article: pagers and clerical work. Dr Bergman de- limiting resident work hours there will be more time scribed pagers as an “unmitigated curse.”1 Each time available for marriage, family, hobbies, academic I am trying to get a quick soda to make up for a pursuits, and, of course, sleep. missed meal and my pager summons me even as I 412 COMMENTARIES Downloaded from by on October 20, 2010
  4. 4. take the necessary minute or two to sneak away and Residents may fear being berated or disrespected by slip my coins in the vending machine, I chortle as I faculty for their own adherence to the ACGME rules. think of his description of pagers. Dr Bergman en- Now is the time that residents need faculty support couraged programs to limit pagers to only a few and teaching more than ever. necessary residents who could respond to the pager Now is also the time that faculty need support. For for emergencies only. But by now, pagers are a staple after the post call resident has gone home in the of the residents’ work environment. They are practi- neonatal intensive care unit, it may very well be the cally a body part of today’s resident. No longer for neonatal intensive care unit attending who stays to emergencies, they are a form of communication for complete the clinical duties. There are no guidelines anyone hoping to find the resident: nurses, other available to send the attendings home when they subspecialty teams, co-workers, and secretaries. become fatigued. The second annoyance discussed by Dr Bergman is I suspect that faculty are as nervous as residents the amount of clerical work involved in being a about the changes that lie ahead and how they will resident. Dr Bergman asked 2 ward interns to track affect patient care, resident learning, and work hours their time during 2 days of work. In two 12-hour for all. Faculty may worry that their own clinical and workdays the interns spent 4 to 5 hours a day on clerical duties will increase after post call residents paperwork, scheduling, and contacting private phy- go home. Faculty may worry that their own fatigue sicians. Many of the calls involved the intern as “middleman,” relaying information from one attend- may impede their ability to serve as good role mod- ing to another. Today, these clerical responsibilities els, or good teachers. On the other hand, faculty can have only worsened. A study on internal medicine look forward to teaching a new generation of resi- residents in New York revealed that in a typical dents, residents who will not yawn throughout their internal medicine resident’s workday, 19% of one’s lectures, residents who will not complain of fatigue time was spent doing activities that could be done by and balk at taking on another patient. nurses, technicians, and support staff. Only 3.1% of Residents will still look up to faculty and seek time was spent seeing patients.7 In addition to the qualities in them that they can emulate. Faculty can clerical responsibilities described by Bergman 15 help residents embrace the changes ahead and make years ago, interns now can find themselves attached the most of their educational time in the hospital. to the phone for hours, sitting on hold with insurance Faculty can serve as mentors to residents and model companies while battling to get patients’ hospital different strategies of balancing patient care, re- stays covered by their insurance. search, teaching, and family. Faculty, as well as res- Where do residents and faculty go with this prob- idents, have the opportunity to usher in a new era of lem? The ACGME guidelines will limit the amount medical training marked by humane hours, better of time doing these jobs, but they will not eliminate patient care, and self-motivated learning. the essentially noneducational work that these jobs involve. The solution to this problem was eloquently suggested by Dr Bergman 15 years ago, and I ar- TYING IT ALL TOGETHER dently support it now: hire clerical help. Over the last As the ACGME guidelines become standard resi- 15 years some programs have hired nurse managers dents will experience less stress in some areas: they or ward unit clerks to help with these daily duties. will no longer work long 36-hour shifts, they will Others have not. For those that have not obtained have mandated days off, and they will have more clerical support for their residents, now is the time to time for family. However, these new guidelines will do so. Have the support staff sit in on rounds and also mean less time in which a resident can gain all keep track of the clerical duties: phone calls to insur- the knowledge that a graduating senior resident ance companies, radiology orders, procedure sched- must accrue to be a good pediatrician. To maximize uling, and seek their assistance with these aspects of residents’ education they will need self-motivation to patient care. Residents will soon have fewer hours invest in their own reading and education while at they can spend in the hospital, clerical support staff home, supportive faculty who are dedicated to teach- can help make those residents’ hours more meaning- ing, less time spent on clerical and other noneduca- fully spent. tional duties at work, and more time invested with PALLIATIVE TREATMENT OF STRESS their patients. Faculty can be of great assistance in this evolution by being supportive and understand- Dr Bergman argues that “the single most impor- ing of residents’ regulated work environment, and tant thing that faculty can do is to recognize the by providing excellent teaching and role modeling. problem of stress in pediatric training programs and show the residents that we want to help them with Megan A. Moreno, MD it.”1 Residents now move into a new era of training Department of Pediatrics in which this statement will become evermore rele- University of Wisconsin-Madison vant. As the new ACGME guidelines go into effect Madison, WI 53705 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 ACKNOWLEDGMENT home post call, especially knowing that faculty en- I wish to thank Dr Abraham Bergman for his inspirational dured residency back in the “unregulated days.” article. COMMENTARIES 413 Downloaded from by on October 20, 2010
  5. 5. REFERENCES within the same program, most residents gain satis- 1. Bergman AB. Resident stress [special article]. Pediatrics. 1988;82:260 –263 faction from not having to perform a complete 2. ACGME. Program requirements for residency education. Available at: work-up on every patient who comes through the door. 3. The Future of Pediatric Education II (FOPE II) Task Force. The role of pediatric subspecialists. Pediatrics. 2000;105(suppl):185–189 WORK RULES 4. Valko RJ, Clayton PJ. Depression in the internship. Dis Nerv System. 1975;36:26 –29 I am less certain than Dr Moreno that the new 5. Uliana RL, Hubbell FA, Wyle FA, Gordon GH. Mood changes during work rules will significantly reduce resident stress. internship J Med Educ. 1984;59:118 –123 True, the most egregious rotations where residents 6. Mufson MA. Professionalism in medicine: the department chair’s per- spective on medical students and residents. Am J Med. 1997;103:253–255 are reduced to zombies will be curtailed. But the new 7. Knickman JR, Lipkin M Jr, Finkler SA, Thompson WG, Kiel J. The rules come with a price. In my program, elective time potential for using non-physicians to compensate for the reduced avail- has been scaled back to help cover “basic services.” ability of residents. Acad Med. 1992;67:429 – 438 Several senior residents say they would rather have more electives than shorter workweeks. “Shift work” lessons the opportunity to interact with families and follow the course of a child’s illness. With complex patients, the chances of errors are enhanced when More on Resident Stress responsibility for care is handed off. Dr Moreno is right to be concerned about the effect on faculty-resident relations. Because our incomes H ow flattering to have one’s article1 that was written in the past not only read by but are increasingly dependent on clinical practice, many commented on by a pediatric resident.2 Dr faculty are already forced to devote less time to Moreno is correct: little has happened in the past 15 resident teaching. If, as a result of the new work years to lessen resident stress. If anything, the situa- rules, faculty must take on more clinical and clerical tion is worse. Debts are greater and family stresses responsibilities, they will not be happy role models. are unabated. More women in pediatrics means That having been said, I do not really worry about more child care worries for some, and more anxiety faculty/resident relations. Despite grousing about about ticking biological clocks for others. Another changes that have made our jobs more complicated, concern is the uncertain primary care job market. most faculty members recognize that there is no Debts and family concerns deter many from embark- greater privilege in medicine than to be engaged in ing on subspecialty training. The haggard looks on teaching residents. our overworked gastroenterologists, nephrologists, COLLECTIVE ACTION and pulmonologists are not good selling points. The wards of tertiary care centers are even more As Dr Moreno notes, the unrewarding nonmedical bizarre. Patients have become virtual; rounds are tasks of inpatient residents have increased. At the often only a figure of speech. Teams sit in window- same time, after-hours nurse consultation phone less conference rooms and examine pulse oximetry lines have vastly improved the quality of lives for reports to determine whether or not a child is breath- pediatricians in major cities. Likewise, clinical care ing. Most of us went into medicine for the positive coordinators, usually nurses, who fetch and carry for feedback we get from interaction with patient fami- surgeons and medical subspecialists in large hospi- lies. “Running the numbers” does not do the trick. Dr tals, have substantially improved the lives of those Moreno puts it well: “Pediatric residents often find individuals. themselves in uncharted waters, acting as middle- Why no help for residents? Because residents do men trying to care for patients over whom they feel not know how to advocate for themselves. They are they have no ultimate voice. The politics of these flattered to be appointed to hospital committees, and patients are often more difficult than the medicine.” are easily bought off or, if necessary, waited out until Understandably, Dr Moreno writes almost exclu- they leave. In contrast to some of their parents who sively about life on the inpatient wards. Inpatient waved flags and shouted slogans in the 1960s and experiences are usually more intense and thus etched 1970s, current residents know little about collective more deeply into the minds of residents. But a salu- action. Academic departments and teaching hospi- tary development in resident education has been tals are well aware that their prestige points (and more and better experiences in ambulatory settings. rankings in US News and World Report), are highly There is usually a slower pace, fewer sleepless dependent on attracting good residents. But resi- nights, and a chance to interact with patients as an dents do not know how to leverage this potential individual physician instead of as part of a team. power. Large hospitals think nothing of spending Though there is considerable variation in continuity millions of dollars to purchase a new piece of equip- clinic experiences between programs, and even ment or a chunk of primary care practices. In com- parison, adding support staff for residents would be a piddling amount. Received for publication Mar 18, 2003; accepted Mar 18, 2003. Finally, the concept of resident stress should be Address correspondence to Abraham B. Bergman, MD, Harborview Med- placed in the context of what other jobs they could be ical Center, Box 359774, 325 Ninth Ave, Seattle, WA 98104. E-mail: doing. Most challenging jobs are stressful. Successful PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad- lawyers, teachers, accountants, stockbrokers, engi- emy of Pediatrics. neers, and politicians are stressed. However, few of 414 COMMENTARIES Downloaded from by on October 20, 2010
  6. 6. Resident Stress Revisited: A Senior Pediatric Resident’s Point of View Megan A. Moreno Pediatrics 2003;112;411-414 DOI: 10.1542/peds.112.2.411 Updated Information including high-resolution figures, can be found at: & Services References This article cites 6 articles, 1 of which you can access for free at: Citations This article has been cited by 2 HighWire-hosted articles: s Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Office Practice Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: Reprints Information about ordering reprints can be found online: Downloaded from by on October 20, 2010