Resident Physician Stress and Burnout Resident physicians are in the most stressful stage of their medical career. Normal stress may increase to the point where it becomes abnormal stress, which is thought to achieve a critical level at some point. This abnormal stress level can then lead to burnout; burnout can lead to impairment. Both professional and personal stresses make huge demands on the resident's time. Unfortunately, there are only 24 hours in a day, and as a resident physician that day includes very little, or no, free time. Learning medicine at this level requires a greater level of involvement in patient care and responsibility.

The daily actions of ordering medication, following outcomes of tests and communicating with patients and their families all fall upon the resident. The resident is still supervised by the attending physician. As during medical school, residents must learn to manage enormous amounts of information, new research, treatment protocols and processes of medical practice. This requires a great deal of study-time, as well as time in lecture, discussion groups, and journal clubs in order to learn their specialties. An additional demand occurs in residency. Residents become teachers for peers, attending physicians, and medical students.

The reasoning is that teaching often educates the teacher better than books or lectures. In many programs, residents provide substantial portions of medical student education during student's clinical years. Residents serve as on-site physicians, sometimes spending nights in the hospital "on call" for routine and emergency situations and for the admission and stabilization of patients. Traditionally, an on call assignment lasted about thirty-six consecutive hours in the hospital, and it was common for the resident to get little sleep. Things are slowly changing, and today's residents tend to have slightly short on call hours. Overall, a typical resident spends up to eighty hours a week in the hospital.

Time away from the hospital must be divided between learning and personal interests. During this time residents receive a stipend of about $28, 000 to $30, 000 dollars per year, an amount which increases slightly each year in the residency program. Debt is a considerable problem for residents. The debt among University of Colorado Health Science Center residents was anywhere from $65, 000 to $130, 000. All of these loans to be repaid create stressful budgeting problems for young physicians. Managing their personal lives becomes very difficult.

A June 1997 issue of Cortland Forum an article by Dr. Xenakis titled "Top Physicians Not Always Best Husbands and Dads" he notes: A major magazine annually lists top-rated physicians in the country. Generally, these are based on physician peer ratings and supplemented with information from patient surveys and physician-treatment patterns. While most physicians look forward to reading their names in the list, those not impressed with the survey are the physicians's poses. "We pay the price," said the non-physician husband of a Mid-western winner. "We do the chores, plan family and social activities, and arrange most other activities of daily living." According to an article written by Flora Skelly published in American Medical News, Male physicians are more prone to neglect their relationships and ignore warning signs of emerging problems in marriage.

"It's very common for men not to worry about their marriages unless the messages are coming pretty strongly from the partner or wife that there's a problem. They tend to rationalize: 'That's what it's like being married to a doctor. You can't have all this money and a happy marriage too.' " Female physicians, on the other hand, do not assume the same role as these male physicians. Women in general see themselves as the caretakers of their marriages. "Almost all women physicians have dual-career marriages.

On top of their responsibilities as physicians, they tend to expect themselves or are expected to bear the responsibility for being executive managers of their homes, lining up childcare, and so on." Physicians are subject to the same physical and mental illnesses as their patients. When physicians do have health problems, however, they tend to wait longer than their patients do to seek treatment. They may be especially reluctant to ask for help with psychosocial or psychiatric problems. David Ko sub states, "Reluctance to help themselves is due in part to the fact that physicians themselves have bought into the myths that so many of their patients subscribe to: that doctors are all-knowing and self-reliant, that they cannot fall from the pedestal that has been so carefully erected underneath them, that the doctor's personal and family life come second after the practice of medicine."Burnout is a cumulative process leading to emotional exhaustion and withdraw," says John-Henry Pfifferling, Ph. D.

, director of the Center for Professional Well-Being in Durham, N. C. The symptoms of burnout are as varied as the sufferers. Some people become angry, blowing up or growling at anyone who crosses their path, including other physicians. When asked to relate the most stressful position he had been in, one resident physician at University Hospital stated, "One time on call, there was a resident who was so tired and fed up with his pager going off, that he flushed the pager down the toilet.

He then turned around and went back to sleep." Some resort to blaming any annoyance, large or small, on external factors. Some become quiet, introverted and isolated, which can indicate the start of a serious depression. Others manifest burnout by under- or overeating or abusing alcohol or other mood-altering substances. My experience with physicians using mood-altering substances would be this last Halloween. I went to a resident physician's Halloween party and when I walked in, the majority of physicians were smoking marijuana.

I couldn't help but notice the irony. According to the Texas Medical Association, symptoms of burnout occur in four areas of the person's functioning: psychological-emotional, behavioral, physical, and spiritual. Psychological-emotional symptoms include being critical of others, an apathetic attitude, depersonalizing patients, feelings of low personal accomplishment, frustration with others, boredom, depression, anxiety, hopelessness, poor concentration, irritability, and feelings of alienation and isolation. Behavioral symptoms of burnout include abuse of chemicals, spending less time with patients, exhibiting tardiness and absenteeism, medication errors, poor record keeping, impersonal or stereotyped communications, sarcasm, and cynicism.

The physician often searches for relocation, is ineffective with patient care, misses deadlines and procrastinates, avoids interactions at home and work, and has frequent tearful or emotional outbursts. Physical symptoms of burnout include a rapid pulse, insomnia, fatigue, reduced resistance to infection, weakness and dizziness, memory problems, weight changes, hypertension, and head, back or muscle aches. Spiritual symptoms of burnout include doubt concerning one's value system or beliefs; drawing conclusions that a major change is necessary such as divorce, a new job, or relocation, and becoming angry or bitter at God and withdrawing from fellowship. Habit-forming agents such as alcohol or other substances along with psychiatric, physiologic, or behavioral disorders can cause impairment. Patient care must never be compromised because of a physician's judgement or skill is impaired.

Physicians significantly impaired for any reason must refrain from activities that may harm patients and should seek assistance in caring for their patients. The impaired physician, while undergoing therapy, is entitled to full confidentiality as in any other patient-physician relationship. To protect patients of the impaired physician, someone other than the physician of the impaired physician needs to monitor the impaired physician's fitness to work. Medical schools around the country are recognizing that young doctors need help with personal demands as they enter the roles as caregivers. The University of South Carolina School of Medicine launched a special final month called Capstone. Capstone month brings the senior class back together for a series of lectures on some nontraditional topics: physician burnout, the medical marriage, how to deal with the media, dressing for success and setting priorities in life.

This program implemented by USC should set an excellent example for other medical schools to follow. It is clear that something needs to be done to help physicians, and this is a great start!