- Email: [email protected]
Factors associated with stress among emergency medicine residents
ORIGINAL CONTRIBUTION stress, residency
Factors Associated With Stress Among Emergency Medicine Residents A survey of members of the Emergency Medicine Residents Association was conducted to investigate the occupational stress and depression experienced by this group. The 488 respondents provided demographic reformation and completed measures of stress and depression. Multivariate analysis of variance revealed statistically significant differences in stress and depression by year of training (P < .00I), gender (P < .01), and marital status (P < .01). Univariate analyses of variance revealed overall differences in both stress and depression. Mean levels of stress and depression were higher for women residents, and unmarried residents reported more depressive symptomatology. The results indicate that women emergency medicine residents experience more stress and depression than men and that spouses can buffer some of the stress of residency training for men and women residents. No significant differences in stress or depression by year in training were revealed by univariate analysis of variance, which suggests that residents experience stress throughout the course of training. The similarities and differences in the occupational stress and depression experienced by emergency medicine residents in comparison with residents from other specialties suggest that additional study in emergency medicine is warranted. [Whitley TW, Gallery ME, Allison EJ Jr, Revicki DA: Factors associated with stress among emergency medicine residents. Ann Emerg Med November 1989;18:1157-1161.]
INTRODUCTION Occupational stress and resultant emotional disturbances such as depression among residents have been the subject of numerous investigations and commentaries in recent years. Investigators have been particularly interested in the impact of stress during the first year of residency training, 1~3 but other studies have demonstrated that residents experience substantial amounts of stress during ensuing years of training. 4-7 In addition, the special nature of the occupational stress experienced by women residents has received particular attention, 8 as has the effect of marriage on the stress of women residents 9 and residents in general, lo Studies of resident stress have been conducted in family medicineS,11,1~ internal medicine,13,14 pediatrics,4,15 and psychiatry, 16 but no studies of stress among emergency medicine residents have been reported in the emergency medicine literature. Residents surveyed by other investigators have indicated that rotations in emergency departments were highly stressful, 6 and depression has been observed following rotations on emergency medicineJ 7 These responses are not surprising in light of responses to Anwar's ~s survey predicting that the physical and mental stress encountered in the practice of emergency medicine would contribute to attrition from the specialty. Anwar's findings, in conjunction with concerns that maladaptive responses to stress during residency training may be reflected in future physician practices, S,12,19 suggested that an investigation of occupational stress and its emotional consequences might provide useful information. The purpose of this study was to assess the levels of occupational stress and depression experienced by emergency medicine residents as a function of year of residency training, gender, and marital status.
18:11 November 1989
Annals of Emergency Medicine
Theodore W Whitley, PhD* Greenville, North Carolina Michael E Gallery, PhDt Dallas, Texas E Jackson Allison Jr, MD/MPH, FACEP* Greenville, North Carolina Dennis A Revicki, PhD¢ Washington, DC From the Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina;* American College of Emergency Physicians, Dallas, Texas;t and Battelle Human Affairs Research Centers, Washington, DC.:~ Supported in part by the American College of Emergency Physicians. Presented at the Second International Conference on Emergency Medicine, Brisbane, Queensland, Australia, October 1988. Address for reprints: Theodore W Whitley, PhD, Department of Emergency Medicine, East Carolina School of Medicine, Brody 4W54, Greenville, NC 27858-4354.
1157/39
STRESS Whitley et al
MATERIALS A N D M E T H O D S A cross-sectional mail survey of members of the Emergency Medicine Residents Association (EMRA) was conducted during the fall of 1987. The survey questionnaire requested basic demographic information including gender, marital status, and year of residency training. Questionnaires returned by residents currently in the first, second, or third year of training were selected for analysis. Responses from fourth-year residents and fellows were not included in this study so that the results would be c o m p a r a b l e to those reported by other investigators. Occupational stress was measured by the Health Professional Stress Inventory (HPSI). A revision of the Physician Stress Inventory originally developed to assess the stress experienced by family physicians, ~o this latest version of the HPSI consists of 18 statements (Figure) dealing with perceived productivity at work, relationships with coworkers, and ability to disengage from work during off hours. Residents used a four-point Likert scale anchored by "Does not apply to me" at the low stress end and "Does apply to me" at the high stress end. With values 1 and 4 indicating low and high stress, respectively, HPSI scores can range from 18 to 72. The internal consistency reliability coefficient (Cronbach's alpha) for this study was 0.86. The C e n t e r for E p i d e m i o l o g i c Studies - Depression Scale (CES-D) was used to measure depression. 21 Designed for use in the general population, the CES-D consists of 20 statements describing emotions such as happiness and fear and behaviors such as eating or sleeping disturbances. Residents again used a fourpoint Likert scale to indicate the extent to which they had' experienced these emotions or behaviors during the past week. With 0 indicating rare or no occurrence of the emotion or behavior and 3 indicating that the emotions or behaviors had been experienced often, scores on the CES-D Scale can range from 0 to 60. The alpha coefficient was 0.91. Because a significant relationship between stress and depression was anticipated, a multivariate analysis of variance (MANOVA) was planned to determine whether there were any differences between mean HPSI and CES-D s c o r e s a n a l y z e d s i m u ] 40/1158
FIGURE. A b r i d g e d s t a t e m e n t s on the Health Professional Stress Inventory. taneously by year in training, gender, and m a r i t a l s t a t u s . A P e a r s o n product-moment correlation coefficient was calculated to confirm the relationship between stress and depression. Univariate analyses of variance were planned to permit identification of group differences following a statistically significant MANOVA. Because two residents did not complete the CES-D, the responses of 486 residents are reflected in these analyses. An alpha level of 0.05 was set as the criterion for statistical significance.
RESULTS The demographic characteristics of the residents used as independent variables in the MANOVA are shown (Table 1). The percentages of men and w o m e n in each of the three years were similar, as were the percentages of married and unmarried residents in their first two years of residency training. However, a lower percentage of third-year residents were married. Table 1 also shows that completed questionnaires were returned by 78 first-year residents, 163 second-year residents, and 247 third-year residents for a total of 488 respondents. EMRA m e m b e r s h i p was approximately 1,100 at the time this survey was conducted. Because the mailing list included some attending physicians, fourth-year residents, and fellows who were not included in this analysis, the response rate for this survey is conservatively estimated to be 50% to 55%, which is comparable to the 45.8% and 60% response rates reported by Taylor and colleagues 7 and Young, 22 respectively, for similar surveys. Data on year in residency t r a i n i n g were not available from EMRA records. The Pearson product-moment correlation between HPSI and CES-D scores of 0.67 (P < .0001) was of sufficient magnitude to warrant multivariate analysis. The MANOVA (Table 2) revealed statistically significant differences on each of the three independent variables: year of training, gender, and marital status. No statistically significant interactions a m o n g the independent variables were detected. Annals of Emergency Medicine
Decreased personal contribution Unrealized professional expectations Decreased productivity Colleagues failing to contribute Work interference with family life Stagnating professional growth and skills Difficulty disengaging at home Increased edginess Inadequate recognition Guilt about failing to understand patients More effort, but less accomplishment Being taken advantage of Frequent tardiness Avoiding others at work Increased arguments at home Increased daydreaming Different responsibilities than anticipated Support for contribution lacking Because the M A N O V A revealed statistically significant differences between mean scores on the HPSI and CES-D analyzed simultaneously, the results of univariate analyses of variance (Table 2) were examined. The u n i v a r i a t e analysis of HPSI scores revealed significantly different mean scores for men and women residents, while the analysis of CES-D scores demonstrated significantly different mean scores for both men and women residents and for married and unmarried residents. Comparison of the adjusted mean scores used in the M A N O V A (Table 3) s h o w e d that w o m e n residents reported higher levels of stress, and unmarried resid e n t s reported experiencing more symptoms of depression. The univariate analysis of variance on mean HPSI and CES-D scores by year in training did not reveal any statistically significant differences.
DISCUSSION Many factors contribute to the occupational stress experienced by residents. In a frequently cited review article, Small 23 i d e n t i f i e d sleep deprivation, excessive work loads, assumption of responsibility for patient care, continually changing work en18:11 November 1989
TABLE
1. Gender
and marital
1
status by year in residency training
Year in Residency 2
Training 3
Total
N
%
N
%
N
%
N
%
Gender Men Women
58 20
74.4 25.6
117 46
71.8 28.2
188 59
76.1 23.9
363 125
74.4 25.6
Marital Status Married Not married
43 35
55.1 44.9
97 66
59.5 40.5
138 109
44.1 55.9
278 210
57.0 43.0
TABLE Variable Year in Training HPSI CE$-D Gender HPSI CES-D
2. MANOVA
x 0.96
0.97
Marital Status 0.98 HPSI CES-D *Multivariate F, all others univariate. vironments, and competition with peers as sources of stress for residents. He noted further that while coping with stress has some benefit, resident stress may lead to episodic cognitive impairment, chronic anger, pervasive cynicism, family discord, depression, suicidal ideation, or substance abuse. Other specific outcomes of stress that have been identified include decreased sensitivity to patients,15 patient care of poor quality,Q24 poor professional attitudes,24 and reduced quality of personal life.12J5 Many of these sources of stress persist throughout residency training, and new sources of stress such as those accompanying the search for a joblo may surface during later years of training. Moreover, residents have expressed concern that undesirable behaviors and emotional responses acquired under the stress of residency training will persist into their careers.5J2J19 The results of this study demonstrate that residents in emergency 18:ll November1989
results P
df 4,960 2,481 2,481 2,480 1,481 1,481
F 4.87* 2.45 1.37 6.93* 5.28 13.79
c.001 NS NS <.Ol c.05 c.001
2,480 1,481 1,481
4.68* 0.09 5.96
c.01 NS c.05
medicine do experience occupational stress and depression. In particular, differences in stress and depression related to gender and marital status were detected. Before discussing these specific differences, it should be noted that in relation to the maxlmum possible score, mean HPSI scores do not indicate that residents experience extreme levels of occupational stress, regardless of their status on any independent variables. On the other hand, using a criterion score of 16,21 the actual mean CES-D score for women residents suggests clinically significant depressive symptomatology, and the mean for unmarried residents is close to the criterion. The relationship between the means and standard deviations indicating skewed distributions, coupled with the similarity between the means and the criterion, does not warrant the conclusion that women or unmarried residents suffer serious depression. However, the percentage of women (44.8%) and unmarried Annals
of Emergency
Medicine
(36.7%) residents with CES-D scores at or above the criterion does suggest a source of concern for both residents and faculty, particularly when compared with the percentages of first[28.7%), second- (21.5%), and thirdyear (10.3%) residents surveyed by Reuben19 whose CES-D scores were equal to or exceeded the same criterion. The significant differences in the levels of stress and depression reported by men and women residents were not surprising. Evidence has been provided8 that women residents experience more pressure in their social lives and have more difficulty achieving successful marriages, perhaps because of the conflict between career advancement requirements and more traditional family roles. In addition, Brashearlo notes that although both men and women firstyear residents who move to new geographic areas are subject to emotional distress attributable to leaving networks of established friendships and associations, women residents may realistically fear that their level of achievement may make establishment of affectional or marital relationships more difficult. New social networks may be difficult to establish because the adoption of personality traits expected in medicine such as assertiveness, dominance, independence, and ambitiousness may result in negative reactions from colleagues.z5 The effects of marriage during residency training appear to be varied. Although Schwartz and his colleague+ observed no relationship between resident stress and either gender or marital status, marriage has been associated with both stres+,ls and depression 26 in residents. Nevertheless, spouses have been identified as important sources of support for residents,g,lO and the results of this survey support this view. Specifically, while married and unmarried residents reported virtually identical levels of occupational stress, unmarried residents reported significantly greater levels of depressive symptomatology. The absence of a significant interaction between marital status and gender indicates that spouses serve to buffer some of the stresses of residency training for both men and women residents. Although the univariate analysis did not reveal statistically significant 1159141
STRESS Whitley et al
differences (despite the significant multivariate result), the increase in the average level of stress during the course of training is interesting in light of reports that the first year of training is particularly stressfulA -3 The results of this survey are in line with those of other studies demonstrating that residents experience stress at all levels of training. 4-7 One possible explanation is that the conflict between gaining independence in the provision of patient care while still playing a student role in the postgraduate medical education process may be perceived as stressful. In addition, o r g a n i z a t i o n a l requirem e n t s such as administrative dutiest3, 24 and routine clerical tasks 17 m a y be salient sources of stress throughout training. Finally, entering the job market and preparing to leave an educational setting to establish a career have been identified as potential sources of stress for residents nearing the c o m p l e t i o n of training.¢1o,17 The possibility of sampling error is a potentially important limitation of this survey. The small number of first-year residents in the sample is probably due to the fact that the survey was conducted early in the academic year before many first-year" residents had joined EMRA. However, a decision was made to obtain data early in the academic year from all potential respondents instead of waiting until a greater number of first-year residents had joined EMRA. A second possible source of bias is that residents who join EMRA may differ in important ways from residents who do not. Finally, the possibility does exist that only residents experiencing relatively high levels of stress and depression responded to the survey, which would certainly bias the results. A second potential limitation of this study is the inability to define the year of residency training for each respondent with great certainty. The difficulty arises from the fact that some emergency medicine resid e n c y programs e n c o m p a s s postgraduate training years two, three, and four. Although respondents were asked to provide their year in residency training and the years of training provided by their programs, residents may have interpreted their status differently. For example, some portion of the 20.7% of the respon42/1160
TABLE 3. A d j u s t e d m e a n HPSI and CES-D scores for each independent variable (actual m e a n +_ standard deviation) HPSI Training Year 1 2 3
CES-D
31.9 33.4 34.3
(31.3 ± 7.2)* (33.0 + 8.7) (33.8 + 9.0)
14.6 15.3 13.7
(13.5 _+ 9.1) (14.3 + 10.1) (12.6 ± 9.7)
32,2t 34,3
(32.6 + 8.3) (34.6 ± 9.4)
12.61. 16.4
(12.2 + 9.1) (16.4 ± 10.9)
(32.9 ± 8.3) (33.4 ± 9.1)
13.4115.6
(12.1 _+ 9.2) (14.8 ± 10.3)
Gender Men Women
Marital Status Married 33,1 Unmarried 33,3 *N = 488 for actual means. tp < .05. CP < .001.
dents from programs encompassing years two through four may have indicated that they were in the second year of residency training or in the first year of residency training in emergency medicine. Such inconsistencies may account for the fact that while the multivariate analysis of stress and d e p r e s s i o n by year in training revealed a significant difference, the univariate analyses did not make a more precise differentiation. The nature and timing of the survey also suggest potential limitations. By their very nature, crosssectional surveys provide data from a narrow time segment. The decision to conduct the survey in September was made to yield data characteristic of each year of training while minimizing bias due to unique stresses inherent in starting a new academic year and avoiding the lowered response rates expected when surveys are administered during holiday seasons. The impact of conducting the survey at other times during the academic year cannot be estimated accurately, but evidence does exist that resident emotional status changes during the course of the first year of trainingt, ~ s y and following certain rotations.6,uA4A7 Despite these p o t e n t i a l limitations, the importance of the issue and the need for further study are underscored by the revision of the Special R e q u i r e m e n t s for R e s i d e n c y Training in Emergency Medicine by the Residency Review C o m m i t t e e for Emergency Medicine. By defining Annals of Emergency Medicine
faculty supervision requirements and the number of hours that residents may work in specified time periods, the specialty is dealing with sources of resident stress identified by other investigators such as lack of role models, 28 the associated need for supervising physicians to become acquainted with residents on a personal basis, 1 and sleep deprivation.3, ~3 Other investigators have suggested s u p p o r t groups, lO,t2,22,24 d i d a c t i c i n s t r u c t i o n a b o u t stress management, 1s,29 and promotion of health maintenance practices 29 to help residents cope with stress. Any of these methods should be beneficial, both to effectively functioning residents and to residents at risk for stress and depression. CONCLUSION The results of this study reveal both similarities and differences in the nature of the occupational stress and depression experienced by emergency medicine residents in comparison with residents studied by other investigators. Individuals responsible for emergency medicine residency programs certainly should be alert to the potentially differential effects of stress on men and women residents and to evidence of depression among unmarried residents of either sex and women residents. Although the evidence provided by this study is not conclusive, emergency medicine residents appear to perceive about the same levels of stress and depression throughout their training. However, 18:11 November 1989
the r e s u l t s do s u g g e s t t h a t e m e r g e n c y medicine residents may experience varying l e v e l s of t h e s e c o n s t r u c t s at different points in their training. T h i s s t u d y s h o u l d be v i e w e d as a n initial a t t e m p t to i d e n t i f y s o m e b a s i c factors a s s o c i a t e d w i t h o c c u p a t i o n a l stress among emergency medicine residents. T h e still i n c o m p l e t e picture of s t r e s s d u r i n g r e s i d e n c y t r a i n ing i n all s p e c i a l t i e s s u p p o r t s t h e n e e d for l o n g i t u d i n a l s t u d i e s t h a t ext e n d b e y o n d r e s i d e n c y t r a i n i n g 2z t o i n v e s t i g a t e t h e s o u r c e s a n d e f f e c t s of stress at d i f f e r e n t p o i n t s i n t h e t r a i n ing a n d c a r e e r s of p h y s i c i a n s a n d to clarify c o n f l i c t i n g r e s u l t s i n p r e v i o u s studies. I n v e s t i g a t i o n s of s p e c i f i c i n t e r v e n t i o n s s u c h as s u p p o r t g r o u p s or didactic instruction about stressrelated topics that have b e e n favorably r e c e i v e d b y o t h e r g r o u p s s h o u l d be u s e f u l also. S u c h s t u d i e s a p p e a r especially important in emergency m e d i c i n e b e c a u s e of t h e p o t e n t i a l i m p a c t of o c c u p a t i o n a l s t r e s s a n d dep r e s s i o n o n p a t i e n t care p r o v i d e d i n emergency situations. The authors thank Ms Joni Farmer for her assistance with data storage and her help in manuscript preparation.
REFERENCES 1. Girard DE, Sack RL, Reuler JB, et ah Survival of the medical internship. Forum Med 1980; 3:460-463. 2. Cousins N: Internship: Preparation or hazing? JAMA 198I;245:377.
3. McCue JD: The distress of internship: Causes and prevention. N Engl J Med 1985;312: 449-452. 4. Rotbart HA, Nelson WL, Krantz J, et ah The developmental process of residency education: Issues of stress and happiness. A m J Dis Child 1985;139:762-765. 5. Purdy RR, Lemkau JP, Rafferty JP, et ah Resident physicians in family practice: Who's burned out and who knows. Faro Med 1987; 19:203-208. 6. Schwartz AJ, Black ER, Goldstein MG, et ah Levels and causes of stress among residents. J Med Educ 1987;62:744-753. 7. Taylor AD, Sinclair A, Wall EM: Sources of stress in postgraduate medical training. J Med Educ 1987;62:425-428. 8. Janus CL, Janus SS, Price S, et ah Residents: The pressure's on the women. JAMWA 1983;38: 18-21. 9. Kelner M, Rosenthal C: Postgraduate medical training, stress, and marriage. Can J Psychiatry 1986;31:22-24. 10. Brashear DB: Support groups and other supportive efforts in residency programs. J Med Educ 1987;62:418-424. 11. Rudner HL: Stress and coping mechanisms in a group of family practice residents. J Med Educ 1985;60:564-566. 12. Mazie B: Job stress, psychological health I and social support of family practice residents. J Med Educ 1985;60:935-941. 13. Martin AR: Stress in residency: A challenge to personal growth. J Gen Intern Med 1986; 1:252-257. 14. Smith JW, Denny WF, Witzke DB: Emotional impairment in internal medicine house staff: Results of a national survey. JAMA 1986; 255:1155-1158. 15. Adler R, Werner ER, Korsch B: Systematic study of four years of internship. Pediatrics 1980;66:1000-1008. 16. Russell AT, Pasnau RO, Taintor ZC: Emo-
tiona] problems of residents in psychiatry. Am J Psychiatry 1975;132:263-267.
17. Reuben DB: Depressive symptoms in medical house officers: Effects of level of training and work rotation. Arch Intern Med 1985; 145:286-288. 18. Anwar RAH: A longitudinal study of residency-trained emergency physicians. Ann Emerg Med 1982;12:20-24. 19. Reuben DB: Psychologic effects of residency. South Med J 1983;76:380-383. 20. May HJ, Revicki DA, Jones JG: Professional stress and the practicing family physician. South Med ] 1983;76:1273-1276. 21. Radloff LS: The CES-D Scale: A self-report depression scale for research in the general population. Appl Psych Meas 1977;1:385-401. 22. Young EH: Relationship of residents' emotional problems, coping behavior, and gender. J Med Educ 1987;62:642-650. 23. Small GW: House officer stress syndrome. Psychosomatics 1981;22:860-869.
24. Reuben DB, Novack DH, Wachtel TJ, et ah A comprehensive support system for reducing house staff distress. Psychosomatics 1984; 25:815-820. 25. Rinke CM: The professional identities of women physicians. JAMA 1981;245:2419-2421. 26. Valko RJ, Clayton PJ: Depression in the internship. Dis Nerv Syst 1975;36:26-29. 27. Girard DE, Elliot DL, Hickam DH, et ah The internship: A prospective investigation of emotions and attitudes. West J Med 1986; 144:93-98. 28. Ford CV: Emotional distress in internship and residency: A questionnaire study. Psychiatr Med 1983;1:143-150. 29. Alexander D, Monk JS, Jonas AP: Occupational stress, personal strain, and coping among residents and faculty members. J Med Educ 1985;60:830-839.
See related editorial, p 1248
18:11 November 1989
Annals of Emergency Medicine
1161/43
Factors Associated With Stress Among Emergency Medicine Residents A survey of members of the Emergency Medicine Residents Association was conducted to investigate the occupational stress and depression experienced by this group. The 488 respondents provided demographic reformation and completed measures of stress and depression. Multivariate analysis of variance revealed statistically significant differences in stress and depression by year of training (P < .00I), gender (P < .01), and marital status (P < .01). Univariate analyses of variance revealed overall differences in both stress and depression. Mean levels of stress and depression were higher for women residents, and unmarried residents reported more depressive symptomatology. The results indicate that women emergency medicine residents experience more stress and depression than men and that spouses can buffer some of the stress of residency training for men and women residents. No significant differences in stress or depression by year in training were revealed by univariate analysis of variance, which suggests that residents experience stress throughout the course of training. The similarities and differences in the occupational stress and depression experienced by emergency medicine residents in comparison with residents from other specialties suggest that additional study in emergency medicine is warranted. [Whitley TW, Gallery ME, Allison EJ Jr, Revicki DA: Factors associated with stress among emergency medicine residents. Ann Emerg Med November 1989;18:1157-1161.]
INTRODUCTION Occupational stress and resultant emotional disturbances such as depression among residents have been the subject of numerous investigations and commentaries in recent years. Investigators have been particularly interested in the impact of stress during the first year of residency training, 1~3 but other studies have demonstrated that residents experience substantial amounts of stress during ensuing years of training. 4-7 In addition, the special nature of the occupational stress experienced by women residents has received particular attention, 8 as has the effect of marriage on the stress of women residents 9 and residents in general, lo Studies of resident stress have been conducted in family medicineS,11,1~ internal medicine,13,14 pediatrics,4,15 and psychiatry, 16 but no studies of stress among emergency medicine residents have been reported in the emergency medicine literature. Residents surveyed by other investigators have indicated that rotations in emergency departments were highly stressful, 6 and depression has been observed following rotations on emergency medicineJ 7 These responses are not surprising in light of responses to Anwar's ~s survey predicting that the physical and mental stress encountered in the practice of emergency medicine would contribute to attrition from the specialty. Anwar's findings, in conjunction with concerns that maladaptive responses to stress during residency training may be reflected in future physician practices, S,12,19 suggested that an investigation of occupational stress and its emotional consequences might provide useful information. The purpose of this study was to assess the levels of occupational stress and depression experienced by emergency medicine residents as a function of year of residency training, gender, and marital status.
18:11 November 1989
Annals of Emergency Medicine
Theodore W Whitley, PhD* Greenville, North Carolina Michael E Gallery, PhDt Dallas, Texas E Jackson Allison Jr, MD/MPH, FACEP* Greenville, North Carolina Dennis A Revicki, PhD¢ Washington, DC From the Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina;* American College of Emergency Physicians, Dallas, Texas;t and Battelle Human Affairs Research Centers, Washington, DC.:~ Supported in part by the American College of Emergency Physicians. Presented at the Second International Conference on Emergency Medicine, Brisbane, Queensland, Australia, October 1988. Address for reprints: Theodore W Whitley, PhD, Department of Emergency Medicine, East Carolina School of Medicine, Brody 4W54, Greenville, NC 27858-4354.
1157/39
STRESS Whitley et al
MATERIALS A N D M E T H O D S A cross-sectional mail survey of members of the Emergency Medicine Residents Association (EMRA) was conducted during the fall of 1987. The survey questionnaire requested basic demographic information including gender, marital status, and year of residency training. Questionnaires returned by residents currently in the first, second, or third year of training were selected for analysis. Responses from fourth-year residents and fellows were not included in this study so that the results would be c o m p a r a b l e to those reported by other investigators. Occupational stress was measured by the Health Professional Stress Inventory (HPSI). A revision of the Physician Stress Inventory originally developed to assess the stress experienced by family physicians, ~o this latest version of the HPSI consists of 18 statements (Figure) dealing with perceived productivity at work, relationships with coworkers, and ability to disengage from work during off hours. Residents used a four-point Likert scale anchored by "Does not apply to me" at the low stress end and "Does apply to me" at the high stress end. With values 1 and 4 indicating low and high stress, respectively, HPSI scores can range from 18 to 72. The internal consistency reliability coefficient (Cronbach's alpha) for this study was 0.86. The C e n t e r for E p i d e m i o l o g i c Studies - Depression Scale (CES-D) was used to measure depression. 21 Designed for use in the general population, the CES-D consists of 20 statements describing emotions such as happiness and fear and behaviors such as eating or sleeping disturbances. Residents again used a fourpoint Likert scale to indicate the extent to which they had' experienced these emotions or behaviors during the past week. With 0 indicating rare or no occurrence of the emotion or behavior and 3 indicating that the emotions or behaviors had been experienced often, scores on the CES-D Scale can range from 0 to 60. The alpha coefficient was 0.91. Because a significant relationship between stress and depression was anticipated, a multivariate analysis of variance (MANOVA) was planned to determine whether there were any differences between mean HPSI and CES-D s c o r e s a n a l y z e d s i m u ] 40/1158
FIGURE. A b r i d g e d s t a t e m e n t s on the Health Professional Stress Inventory. taneously by year in training, gender, and m a r i t a l s t a t u s . A P e a r s o n product-moment correlation coefficient was calculated to confirm the relationship between stress and depression. Univariate analyses of variance were planned to permit identification of group differences following a statistically significant MANOVA. Because two residents did not complete the CES-D, the responses of 486 residents are reflected in these analyses. An alpha level of 0.05 was set as the criterion for statistical significance.
RESULTS The demographic characteristics of the residents used as independent variables in the MANOVA are shown (Table 1). The percentages of men and w o m e n in each of the three years were similar, as were the percentages of married and unmarried residents in their first two years of residency training. However, a lower percentage of third-year residents were married. Table 1 also shows that completed questionnaires were returned by 78 first-year residents, 163 second-year residents, and 247 third-year residents for a total of 488 respondents. EMRA m e m b e r s h i p was approximately 1,100 at the time this survey was conducted. Because the mailing list included some attending physicians, fourth-year residents, and fellows who were not included in this analysis, the response rate for this survey is conservatively estimated to be 50% to 55%, which is comparable to the 45.8% and 60% response rates reported by Taylor and colleagues 7 and Young, 22 respectively, for similar surveys. Data on year in residency t r a i n i n g were not available from EMRA records. The Pearson product-moment correlation between HPSI and CES-D scores of 0.67 (P < .0001) was of sufficient magnitude to warrant multivariate analysis. The MANOVA (Table 2) revealed statistically significant differences on each of the three independent variables: year of training, gender, and marital status. No statistically significant interactions a m o n g the independent variables were detected. Annals of Emergency Medicine
Decreased personal contribution Unrealized professional expectations Decreased productivity Colleagues failing to contribute Work interference with family life Stagnating professional growth and skills Difficulty disengaging at home Increased edginess Inadequate recognition Guilt about failing to understand patients More effort, but less accomplishment Being taken advantage of Frequent tardiness Avoiding others at work Increased arguments at home Increased daydreaming Different responsibilities than anticipated Support for contribution lacking Because the M A N O V A revealed statistically significant differences between mean scores on the HPSI and CES-D analyzed simultaneously, the results of univariate analyses of variance (Table 2) were examined. The u n i v a r i a t e analysis of HPSI scores revealed significantly different mean scores for men and women residents, while the analysis of CES-D scores demonstrated significantly different mean scores for both men and women residents and for married and unmarried residents. Comparison of the adjusted mean scores used in the M A N O V A (Table 3) s h o w e d that w o m e n residents reported higher levels of stress, and unmarried resid e n t s reported experiencing more symptoms of depression. The univariate analysis of variance on mean HPSI and CES-D scores by year in training did not reveal any statistically significant differences.
DISCUSSION Many factors contribute to the occupational stress experienced by residents. In a frequently cited review article, Small 23 i d e n t i f i e d sleep deprivation, excessive work loads, assumption of responsibility for patient care, continually changing work en18:11 November 1989
TABLE
1. Gender
and marital
1
status by year in residency training
Year in Residency 2
Training 3
Total
N
%
N
%
N
%
N
%
Gender Men Women
58 20
74.4 25.6
117 46
71.8 28.2
188 59
76.1 23.9
363 125
74.4 25.6
Marital Status Married Not married
43 35
55.1 44.9
97 66
59.5 40.5
138 109
44.1 55.9
278 210
57.0 43.0
TABLE Variable Year in Training HPSI CE$-D Gender HPSI CES-D
2. MANOVA
x 0.96
0.97
Marital Status 0.98 HPSI CES-D *Multivariate F, all others univariate. vironments, and competition with peers as sources of stress for residents. He noted further that while coping with stress has some benefit, resident stress may lead to episodic cognitive impairment, chronic anger, pervasive cynicism, family discord, depression, suicidal ideation, or substance abuse. Other specific outcomes of stress that have been identified include decreased sensitivity to patients,15 patient care of poor quality,Q24 poor professional attitudes,24 and reduced quality of personal life.12J5 Many of these sources of stress persist throughout residency training, and new sources of stress such as those accompanying the search for a joblo may surface during later years of training. Moreover, residents have expressed concern that undesirable behaviors and emotional responses acquired under the stress of residency training will persist into their careers.5J2J19 The results of this study demonstrate that residents in emergency 18:ll November1989
results P
df 4,960 2,481 2,481 2,480 1,481 1,481
F 4.87* 2.45 1.37 6.93* 5.28 13.79
c.001 NS NS <.Ol c.05 c.001
2,480 1,481 1,481
4.68* 0.09 5.96
c.01 NS c.05
medicine do experience occupational stress and depression. In particular, differences in stress and depression related to gender and marital status were detected. Before discussing these specific differences, it should be noted that in relation to the maxlmum possible score, mean HPSI scores do not indicate that residents experience extreme levels of occupational stress, regardless of their status on any independent variables. On the other hand, using a criterion score of 16,21 the actual mean CES-D score for women residents suggests clinically significant depressive symptomatology, and the mean for unmarried residents is close to the criterion. The relationship between the means and standard deviations indicating skewed distributions, coupled with the similarity between the means and the criterion, does not warrant the conclusion that women or unmarried residents suffer serious depression. However, the percentage of women (44.8%) and unmarried Annals
of Emergency
Medicine
(36.7%) residents with CES-D scores at or above the criterion does suggest a source of concern for both residents and faculty, particularly when compared with the percentages of first[28.7%), second- (21.5%), and thirdyear (10.3%) residents surveyed by Reuben19 whose CES-D scores were equal to or exceeded the same criterion. The significant differences in the levels of stress and depression reported by men and women residents were not surprising. Evidence has been provided8 that women residents experience more pressure in their social lives and have more difficulty achieving successful marriages, perhaps because of the conflict between career advancement requirements and more traditional family roles. In addition, Brashearlo notes that although both men and women firstyear residents who move to new geographic areas are subject to emotional distress attributable to leaving networks of established friendships and associations, women residents may realistically fear that their level of achievement may make establishment of affectional or marital relationships more difficult. New social networks may be difficult to establish because the adoption of personality traits expected in medicine such as assertiveness, dominance, independence, and ambitiousness may result in negative reactions from colleagues.z5 The effects of marriage during residency training appear to be varied. Although Schwartz and his colleague+ observed no relationship between resident stress and either gender or marital status, marriage has been associated with both stres+,ls and depression 26 in residents. Nevertheless, spouses have been identified as important sources of support for residents,g,lO and the results of this survey support this view. Specifically, while married and unmarried residents reported virtually identical levels of occupational stress, unmarried residents reported significantly greater levels of depressive symptomatology. The absence of a significant interaction between marital status and gender indicates that spouses serve to buffer some of the stresses of residency training for both men and women residents. Although the univariate analysis did not reveal statistically significant 1159141
STRESS Whitley et al
differences (despite the significant multivariate result), the increase in the average level of stress during the course of training is interesting in light of reports that the first year of training is particularly stressfulA -3 The results of this survey are in line with those of other studies demonstrating that residents experience stress at all levels of training. 4-7 One possible explanation is that the conflict between gaining independence in the provision of patient care while still playing a student role in the postgraduate medical education process may be perceived as stressful. In addition, o r g a n i z a t i o n a l requirem e n t s such as administrative dutiest3, 24 and routine clerical tasks 17 m a y be salient sources of stress throughout training. Finally, entering the job market and preparing to leave an educational setting to establish a career have been identified as potential sources of stress for residents nearing the c o m p l e t i o n of training.¢1o,17 The possibility of sampling error is a potentially important limitation of this survey. The small number of first-year residents in the sample is probably due to the fact that the survey was conducted early in the academic year before many first-year" residents had joined EMRA. However, a decision was made to obtain data early in the academic year from all potential respondents instead of waiting until a greater number of first-year residents had joined EMRA. A second possible source of bias is that residents who join EMRA may differ in important ways from residents who do not. Finally, the possibility does exist that only residents experiencing relatively high levels of stress and depression responded to the survey, which would certainly bias the results. A second potential limitation of this study is the inability to define the year of residency training for each respondent with great certainty. The difficulty arises from the fact that some emergency medicine resid e n c y programs e n c o m p a s s postgraduate training years two, three, and four. Although respondents were asked to provide their year in residency training and the years of training provided by their programs, residents may have interpreted their status differently. For example, some portion of the 20.7% of the respon42/1160
TABLE 3. A d j u s t e d m e a n HPSI and CES-D scores for each independent variable (actual m e a n +_ standard deviation) HPSI Training Year 1 2 3
CES-D
31.9 33.4 34.3
(31.3 ± 7.2)* (33.0 + 8.7) (33.8 + 9.0)
14.6 15.3 13.7
(13.5 _+ 9.1) (14.3 + 10.1) (12.6 ± 9.7)
32,2t 34,3
(32.6 + 8.3) (34.6 ± 9.4)
12.61. 16.4
(12.2 + 9.1) (16.4 ± 10.9)
(32.9 ± 8.3) (33.4 ± 9.1)
13.4115.6
(12.1 _+ 9.2) (14.8 ± 10.3)
Gender Men Women
Marital Status Married 33,1 Unmarried 33,3 *N = 488 for actual means. tp < .05. CP < .001.
dents from programs encompassing years two through four may have indicated that they were in the second year of residency training or in the first year of residency training in emergency medicine. Such inconsistencies may account for the fact that while the multivariate analysis of stress and d e p r e s s i o n by year in training revealed a significant difference, the univariate analyses did not make a more precise differentiation. The nature and timing of the survey also suggest potential limitations. By their very nature, crosssectional surveys provide data from a narrow time segment. The decision to conduct the survey in September was made to yield data characteristic of each year of training while minimizing bias due to unique stresses inherent in starting a new academic year and avoiding the lowered response rates expected when surveys are administered during holiday seasons. The impact of conducting the survey at other times during the academic year cannot be estimated accurately, but evidence does exist that resident emotional status changes during the course of the first year of trainingt, ~ s y and following certain rotations.6,uA4A7 Despite these p o t e n t i a l limitations, the importance of the issue and the need for further study are underscored by the revision of the Special R e q u i r e m e n t s for R e s i d e n c y Training in Emergency Medicine by the Residency Review C o m m i t t e e for Emergency Medicine. By defining Annals of Emergency Medicine
faculty supervision requirements and the number of hours that residents may work in specified time periods, the specialty is dealing with sources of resident stress identified by other investigators such as lack of role models, 28 the associated need for supervising physicians to become acquainted with residents on a personal basis, 1 and sleep deprivation.3, ~3 Other investigators have suggested s u p p o r t groups, lO,t2,22,24 d i d a c t i c i n s t r u c t i o n a b o u t stress management, 1s,29 and promotion of health maintenance practices 29 to help residents cope with stress. Any of these methods should be beneficial, both to effectively functioning residents and to residents at risk for stress and depression. CONCLUSION The results of this study reveal both similarities and differences in the nature of the occupational stress and depression experienced by emergency medicine residents in comparison with residents studied by other investigators. Individuals responsible for emergency medicine residency programs certainly should be alert to the potentially differential effects of stress on men and women residents and to evidence of depression among unmarried residents of either sex and women residents. Although the evidence provided by this study is not conclusive, emergency medicine residents appear to perceive about the same levels of stress and depression throughout their training. However, 18:11 November 1989
the r e s u l t s do s u g g e s t t h a t e m e r g e n c y medicine residents may experience varying l e v e l s of t h e s e c o n s t r u c t s at different points in their training. T h i s s t u d y s h o u l d be v i e w e d as a n initial a t t e m p t to i d e n t i f y s o m e b a s i c factors a s s o c i a t e d w i t h o c c u p a t i o n a l stress among emergency medicine residents. T h e still i n c o m p l e t e picture of s t r e s s d u r i n g r e s i d e n c y t r a i n ing i n all s p e c i a l t i e s s u p p o r t s t h e n e e d for l o n g i t u d i n a l s t u d i e s t h a t ext e n d b e y o n d r e s i d e n c y t r a i n i n g 2z t o i n v e s t i g a t e t h e s o u r c e s a n d e f f e c t s of stress at d i f f e r e n t p o i n t s i n t h e t r a i n ing a n d c a r e e r s of p h y s i c i a n s a n d to clarify c o n f l i c t i n g r e s u l t s i n p r e v i o u s studies. I n v e s t i g a t i o n s of s p e c i f i c i n t e r v e n t i o n s s u c h as s u p p o r t g r o u p s or didactic instruction about stressrelated topics that have b e e n favorably r e c e i v e d b y o t h e r g r o u p s s h o u l d be u s e f u l also. S u c h s t u d i e s a p p e a r especially important in emergency m e d i c i n e b e c a u s e of t h e p o t e n t i a l i m p a c t of o c c u p a t i o n a l s t r e s s a n d dep r e s s i o n o n p a t i e n t care p r o v i d e d i n emergency situations. The authors thank Ms Joni Farmer for her assistance with data storage and her help in manuscript preparation.
REFERENCES 1. Girard DE, Sack RL, Reuler JB, et ah Survival of the medical internship. Forum Med 1980; 3:460-463. 2. Cousins N: Internship: Preparation or hazing? JAMA 198I;245:377.
3. McCue JD: The distress of internship: Causes and prevention. N Engl J Med 1985;312: 449-452. 4. Rotbart HA, Nelson WL, Krantz J, et ah The developmental process of residency education: Issues of stress and happiness. A m J Dis Child 1985;139:762-765. 5. Purdy RR, Lemkau JP, Rafferty JP, et ah Resident physicians in family practice: Who's burned out and who knows. Faro Med 1987; 19:203-208. 6. Schwartz AJ, Black ER, Goldstein MG, et ah Levels and causes of stress among residents. J Med Educ 1987;62:744-753. 7. Taylor AD, Sinclair A, Wall EM: Sources of stress in postgraduate medical training. J Med Educ 1987;62:425-428. 8. Janus CL, Janus SS, Price S, et ah Residents: The pressure's on the women. JAMWA 1983;38: 18-21. 9. Kelner M, Rosenthal C: Postgraduate medical training, stress, and marriage. Can J Psychiatry 1986;31:22-24. 10. Brashear DB: Support groups and other supportive efforts in residency programs. J Med Educ 1987;62:418-424. 11. Rudner HL: Stress and coping mechanisms in a group of family practice residents. J Med Educ 1985;60:564-566. 12. Mazie B: Job stress, psychological health I and social support of family practice residents. J Med Educ 1985;60:935-941. 13. Martin AR: Stress in residency: A challenge to personal growth. J Gen Intern Med 1986; 1:252-257. 14. Smith JW, Denny WF, Witzke DB: Emotional impairment in internal medicine house staff: Results of a national survey. JAMA 1986; 255:1155-1158. 15. Adler R, Werner ER, Korsch B: Systematic study of four years of internship. Pediatrics 1980;66:1000-1008. 16. Russell AT, Pasnau RO, Taintor ZC: Emo-
tiona] problems of residents in psychiatry. Am J Psychiatry 1975;132:263-267.
17. Reuben DB: Depressive symptoms in medical house officers: Effects of level of training and work rotation. Arch Intern Med 1985; 145:286-288. 18. Anwar RAH: A longitudinal study of residency-trained emergency physicians. Ann Emerg Med 1982;12:20-24. 19. Reuben DB: Psychologic effects of residency. South Med J 1983;76:380-383. 20. May HJ, Revicki DA, Jones JG: Professional stress and the practicing family physician. South Med ] 1983;76:1273-1276. 21. Radloff LS: The CES-D Scale: A self-report depression scale for research in the general population. Appl Psych Meas 1977;1:385-401. 22. Young EH: Relationship of residents' emotional problems, coping behavior, and gender. J Med Educ 1987;62:642-650. 23. Small GW: House officer stress syndrome. Psychosomatics 1981;22:860-869.
24. Reuben DB, Novack DH, Wachtel TJ, et ah A comprehensive support system for reducing house staff distress. Psychosomatics 1984; 25:815-820. 25. Rinke CM: The professional identities of women physicians. JAMA 1981;245:2419-2421. 26. Valko RJ, Clayton PJ: Depression in the internship. Dis Nerv Syst 1975;36:26-29. 27. Girard DE, Elliot DL, Hickam DH, et ah The internship: A prospective investigation of emotions and attitudes. West J Med 1986; 144:93-98. 28. Ford CV: Emotional distress in internship and residency: A questionnaire study. Psychiatr Med 1983;1:143-150. 29. Alexander D, Monk JS, Jonas AP: Occupational stress, personal strain, and coping among residents and faculty members. J Med Educ 1985;60:830-839.
See related editorial, p 1248
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