Authors: Chaim B. Cohen
Roy S. Hwang
Many neurosurgeons involved in resident training read with concern the poignant article by Pranay Sinha regarding two recent suicides by residents in New York City.1 These two medical interns killed themselves within the first months of residency, and although we aren’t aware of the specifics preceding these events, their faculty and colleagues presumably must have been shocked and horrified and left wondering if they should have known, or what they could have done.
Physician psychosocial stressors and suicide are not new issues, and are not confined to residency training. Residents, however, are at increased risk for burnout and psychiatric morbidity as compared to their faculty due to a number of factors. Physician psychosocial stress has been related to high-demand, low-control situations that are extremely applicable to the residency situation.2 Furthermore, increased levels of distress have been noted among medical trainees when compared to early career physicians or non-medical controls.
Top Risks for Physician Distress
- Trainee status
- Concomitant depression
- Lack of constructive coping techniques
Have these stressors changed or increased over time? With the implementation of work hours and cultural changes within medicine, the stressors likely have changed, but to assert that they have increased is arguable. The difference may instead lie in the coping mechanisms available to the residents. Some insight into the real or perceived difference between coping mechanisms in past versus current residents may be gleaned from research into generational differences and their impact on medical training. The Society for Academic Emergency Medicine has conducted a study of the different generational types and their impact on residency training, noting that the current generation of residents, termed Millennials (born 1980-1999), are more collaborative and team-oriented and may have fewer internal reserves to deal with psychosocial or organizational stresses than Generation Xers (born 1964-1980), who tend to be more independent, self-sufficient, and flexible.3 This implies that some of our residents may need to be taught coping mechanisms, or would benefit from a collaborative rather than independent approach to them.
- Low level of control
- Conflict between commitments at work and at home
- Discord with coworkers
- Debt load
- Fear of litigation
- Poor patient outcomes
Through what avenues can we provide this training, and how can neurosurgical faculty, who most likely never received such training, provide it to others? The answer may lie in a combination of open, frank discussion, behavioral modeling, and utilization or initiation of institutional and other resources to deal with the problem. Much of the recent body of literature on physician psychosocial stress and burnout has centered on the concept of “resiliency,” focusing on efforts to prevent these issues before they happen. Resilience is practically defined as an ability to deal with stress in a constructive way and bounce back rather than becoming drained and burned out. It can be reflected in a resident’s clinical performance, attention to detail, and interaction with nurses, colleagues, and patients.
Ripp surveyed 145 first-year internal medicine residents at two internal medicine residency programs in New York. They looked at the Maslach Burnout Inventory (MBI) as well as the Epworth Sleepiness Scale, a tenitem personality inventory, as well as other characteristics such as social support and loan debt. Overall burnout was noted in 34% of residents in terms of the MBI scores. These results also showed an association with a lack of confidence, anxiety, and disorganization as a predictor of burnout (46% vs 27%, 51% vs 28%, and 60% vs 31%, p = 0.04, 0.01, 0.03). Neither sleep deprivation nor history of depression correlated with burnout. Therefore, careful attention to these personality traits should be identified early and addressed before problems arise.4
An increasing body of research has dealt with ways to increase resilience in physician populations. Zwack and colleagues interviewed 117 physicians across multiple specialties and found that successful techniques transcended specialty and included recreational activity and secondary fields of interest, continued contact with colleagues, family relationships, self-reflection and self-demarcation, proactive engagement with challenges, continuing education, spirituality, appreciation for positive aspects of life, and ritualized time-out periods, among others.5 Many of these activities, such as contact with colleagues and continuing education, are central to residency training already; however, techniques such as selfreflection may be neglected. The importance of self-awareness and recognition of maladaptive responses to stress as an initial step towards building more constructive stress responses has been noted.
Neurosurgery faculty, having been through rigorous neurosurgical training, are uniquely poised to discuss these issues from their own experiences, to recognize when such skills are lacking, and to redirect a resident in the clinic, wards, or operating room. Initiating open and frank discussions on these issues is possibly the most proactive way to deal with them on an individual level. Although the literature on these issues uses names that might sound “hokey” or “campfire,” the underlying lessons are valid and acceptable. Modeling and discussion of ideas such as avoiding a “Why me?” attitude, recognizing one’s luck at not being in our patients’ shoes, and taking constructive lessons from difficulty are useful in the individual mentorship paradigm of education that is common in neurosurgical training. Furthermore, encouraging such mentorship and communication between residents themselves encourages peer-level communication and reflection, which can be so important in the support systems of residents, as alluded to by Dr. Sinha at the end of his article. Skills in resilience are increasingly being taught to residents and medical students through such programs as Mayo Clinic’s “SMART” program (Stress Management and Resiliency Training). Some cases, particularly involving refractory problems or suspected psychiatric issues, require external assistance. A variety of institutional resources such as residency wellness directors, human resources programs, or wellness education programs may be available and can be recommended, or mandated, depending upon the situation. Particular institutions, including Mayo and Rochester, have their own innovative institutional resources (Table 1). A variety of proprietary services such as physician coaching and specialist consults are also available at a number of centers. Furthermore, any time suspicion arises that the issue is more than one of stress response or adaptation and may involve a psychiatric illness, prompt professional evaluation is required. The stressors and difficulties of residency training are a common experience for all neurosurgeons. Our newer generation of trainees may, due to generational differences, require more collaborative approaches in dealing with these struggles. We have our own experiences, and a growing body of literature, to help us provide for this need.
Table 1: Resources for residents and physicians.
Coping Mechanisms and Techniques
- Self-reflection and awareness
- Sharing experiences
- Setting limits
- Maintaining interest
- Supportive relationships
- Professional development
- Non-medical fields of interest
- Sinha P. Why do doctors commit suicide? New York Times. Sept 4, 2014. http://www.nytimes.com/2014/09/05/opinion/why-do-doctors-commit-suicide.html?_r=0.
- Von dem Knesebeck O, Klein J, Grosse Frie K, Blum K Siegrist J. Psychosocial stress among hospital doctors in surgical fields: results of a nationwide survey in Germany. Dtsch Artzebl Int. 2010;107(14):248-53.
- Mohr NM, Moreno-Walton L, Mills AM, Brunett PH, Promes SB. Generational influences in academic emergency medicine: teaching and learning, mentoring, and technology (part 1). Acad Emerg Med. 2011;18(2):190-199.
- Ripp J, Babyatsky M, Fallar R, et al. The incidence and predictors of job burnout in first-year internal medicine residents: a five-institution study. Acad Med. 2011;86(10):1304-10.
- Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med. 2013;88(3):382-9.