Beyond “the men of steel”

Commentary and Perspective From time to time, the Journal receives manuscripts which can be thought of as opinion pieces, essays, or editorial comment on matters of topical interest. Such submissions will be refereed in the usual fashion and if suitable, published in this section. The Editorial Board invites Letters to the Editor or rebutting commentary with the understanding that all submissions are subject to editing.

Beyond “The Men of Steel” The Origins and Significance of House Staff Training Stress Robert Levin, M.D. Mount Auburn Hospital,

Cambridge,

Massachusetts,

and

Abstract: Stress is a common and significant component of house stafftraining. It has a dual capacity to support and hinder the trainee’s education and we&being. However, fhere has been infrequent attention to the purpose and significance of training stress in the medical literature. The myths and traditions of medicine that foster sayings such as “in the days of the giants” OY “the men of steel” do not sufficiently explain the dynamics of house staff stress. This article examines the origins, effects, and meaning of house officer stress. Stress seems to originate from as well as influence: the psychology of physicians, patient care, hospital economics, and the relationship between trainees and educators. Adaptations to stress acquired in training influence the house officer’s future professional and personal wellbeing. Evaluation of training stress can help clarify related issues such as physician impairment and mentoring in medical education. I,

. . . he worked for seventy-six hours with half hours of sleep. . . ” Martin Arrowsmith’s internship in Arrowsmithby Sinclair Lewis Stress in house staff training is common if not universal [l-3]. Internship and residency probably represent the most stressful years in the physician’s entire educational career. House officer stress can affect the trainee’s clinical work as well as his or her emotions and behaviors [l-15], leading not uncommonly to unhappiness [16] or impairment [17]. As an integral part of the house staff’s experience, stress is easily observable in their patient care, peer group relationships, and even their jokes and joking. In an example where the distinction between the stressed trainee and the patient blur momentarily, one intern joked ironically: “I’m so tired from being up all night with admissions that I’ve made myself ‘DNR’ “. 114 ISSN 0163-8343/8X%3.50

Harvard Medical School, Boston, Massachusetts

Training stress influences the development of clinical skills and professional maturity-perhaps the most important goals of training-in a dual if not paradoxical way: whereas the stress of demanding workloads and schedules can maximize clinical experience and personal confidence, it can also undermine the ability to work, learn, and maintain psychological well-being. Amongst medical educators and trainees alike, many take opposing views about the necessity and effect of training stress [4]. Some see it as necessary and beneficial, others view it as unessential and harmful. Most of the literature on house staff stress is relatively limited and narrow in its scope. It describes, for example, some types of trainee responses to stress, as with the identification of depression in internship [5], sleep loss [6,7] and fatigue [S]; or, it addresses issues specific to certain specialties such as surgery [9], family practice [lo], radiology [ll], pediatrics [12], and psychiatry [13]. Interestingly, there has been little evaluation of central themes common to all specialties. Perhaps most importantly, there seems to be little discussion of the purpose and significance of the stress for house officer training, the clinical care of patients, and the field of medicine. Most physicians and house officers are not without some understanding of the purpose and justification behind training stress. This is seemingly derived largely from familiar medical traditions and mythology. Personal as well as collective ideals and attitudes are effectively conveyed through well known customs, stories, and assumptions. An examination of training stress should begin with the traditions of medicine and house officer training. Genernf HospitaalPsychiatry 10. 114-121, 1988 0 1988 Elsevier Science Publishing Co., Inc. 52 Vanderbilt Ave., New York, NY 10017

Beyond “The Men of Steel”

From talking with educators and trainees, and in reviewing the literature, I’ve identified two traditional theories that attempt to answer the question, “Why does the stress exist?” One popular theory might be called “The Rites of Passage.” It holds that training physicians historically have experienced hardships and that stress is a necessary part of “making it.” Medicine is like a professional club or guild, the apprentices to which are the house staff. The “bootcamp” [9], “trial by ordeal” [14], and “hazing” [15] are unquestioned if not desirable customs that give house staff training its unique identity. The historical development of house staff training supports this theory. Actual apprenticeships were common ways of obtaining graduate medical education before World War I. The medical hierarchy was exclusionary, and internship was a gateway for those wanting access to it [18]. But whereas this theory helps clarify the history of training, it is less an explanation than an idealization that protects against unpleasant memories of training by fostering the common but factually unsupported belief that medical training was more difficult in bygone days. Rather, such nostalgic idealization helps more to preserve ideals such as “in the days of the giants” and “the men of steel” than to clarify present-day training stress. They lack relevancy and focus. Perhaps one significance of the “men of steel” sayings is how they reflect this hazing and hierarchical nature of yesterday’s training. Myths about training stress possibly served a dual role to challenge and reward house officers: as a barrier to the domain of the practicing physician, they limited the number of trainees gaining full-fledged physician status, and for those surviving training, they offered the rewards and symbols of success-near super-human qualities of giant, steel-like men. These allusions to heroism may address the profession’s selectivity and standards as much as the personal characteristics required for it. They seem to say, “You need to be a hero to be a physician; if you make it, you join other heroes.“ The profession’s desirability was in part determined and heightened by the difficult and selective access to it. A second theory views stress as purposefully enhancing the trainee’s development-it is the “Skill Improvement” theory. This contends that the dual stresses of long hours and heavy patient loads contribute to and are an inviolate part of medical training and character development. Many in medicine agree, seeing training as intentionally stressful for the trainee’s growth; for example, “lack of sleep has its bene-

fits” [4], and internship and residency should be “tough” [4] to provide “conditioning” [4]. Hence, there is no need to monitor stress since it is unavoidable and necessary. This theory fails to recognize any diminishing returns of excessive stress or the possibility of house staff morbidity; the trainee’s limitations as a person are not considered. As well, it originates from an era before biotechnical advances, when sick patients required constant and direct monitoring by trainees. These traditional theories contain longstanding though unexamined assumptions. The myths, sayings, and historical assumptions of medical training add a nolstalgic valor to training similar to collegiate, athletic, or military rites of passage. To a large degree, they reflect a relevance and purpose from previous eras, which, due to social, economic, and educational developments, do not necessarily apply now. Today, gaining acceptance to and completing medical school may serve more as the profession’s “selection process” than obtaining and surviving house-officer training. There is a need for critical and updated understanding about training stress. This article’s purpose is to identify sources of stress in house officer training and the subsequent effects not only on trainees, but also on patient care and the field of medicine. It will also discuss additional theories that explain the origins and significance of house staff stress. The emphasis will be on the complex interrelationships between house staff, senior physicians, and contemporary medical institutions. An attempt will be made to identify training stresses and themes basic to all specialties. Though my training and perspective are that of a psychiatrist, this work is based on my experience working and teaching in a general hospital with trainees of all specialties.

Causes of Stress The following observations on the causes of training stress emphasize common and important factors specific to house officers.

The Amount of Time Spent in the Hospital Few jobs demand a greater time commitment than a house officer’s. Seventy-hour weeks are not unusual. The 6-day work week is a result of Saturday morning rounds in some programs; in others, Sunday rounds are mandatory. Traditional breaks from 115

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the workday are frequently unavailable. Conferences serve as lunch hours and the responsibility of coverage prohibits even short sojourns away from the hospital. And beepers keep house officers “electronically” on the job all the time, uninterruptedly available to nurses, colleagues, and patients’ families.

Nigh tcall Duty The expanded clinical responsibility of on-call duty has traditionally been viewed as an opportunity for valuable clinical experience and a time of unequaled stress. Night-call stress is due to sleep loss and the responsibility of covering more patients with less assistance. Friedman et al. examine sleep loss in medical interns in two papers [6,7]. They evaluate the effects of sleep loss and find changes in both cognitive performance and emotional functioning. Symptoms most commonly mentioned by their subjects are: difficulty thinking, depression, irritability, extreme sensitivity to criticism, depersonalization-derealization, inappropriate affect, and recent memory deficit [7]. Night call may subject house staff to a level of repetitive sleep loss unsurpassed by any other work group. Even the cherished “quiet night” is made fitful by underlying anticipation and tension. One intern commented, “I didn’t get called most of the night, but I could hardly sleep. It’s impossible to sleep soundly in a bed which isn’t yours when you’re apt to be called at any moment.” Night is also when work can be most arduous, as night admissions are by definition nonelective and therefore are rather ill patients. The frequent absence of supporting records and following physician complicate the work-up of these patients. Inhouse complications are also more difficult because of the reduced level of nursing and ancillary staffing. A senior resident told a new intern, “The most valuable teaching point I can make this year is the secret to the x-ray filing system. Otherwise, you’ll never find a film at night.”

The Nature of the Work The fundamental and universal stress of medical work is compounded for house officers. All physicians experience some elements of stress in their work, but house officers generally experience more stress than other physicians. For them, there is significant stress from uncertainty about their ca116

pabilities due to a brusque transition from student to physician [16]. Uncertainty in house staff training is similar to Fox’s observations with medical students, where uncertainty is from both the incomplete personal mastery of knowledge and the inherent limitations of medical knowledge itself t191. Further stress is derived from independent functioning of interns and residents [20], as patient care cannot always be shared with a team or attending physician. This is especially true with complicated psychosocial and ethical patient-care issues where trainees may need to manage single-handedly “DNR” decisions, patients’ sexual concerns, fears about dying, etc. The pressure of treating very ill patients, many of whom are the most sick and complex of the trainee’s career, is an additional stress. Also, few practicing physicians work as consistently as house staff in areas like the ICU, CCU, or emergency room where the level of stress can be inescapably high. It is possible for an intern or resident to rotate sequentially through the emergency room, intensive care unit, oncology service, or some other emotionally demanding unit.

The Job Role The house officers’ job role causes stress in subtle but significant ways. It includes but is not limited to the responsibilities of patient care and individual training. Whether communicated either in a written or verbal contract with the hospital, or in implicit and standard house officer expectations, this job role often becomes complex and unclear in practice. Such stress-producing characteristics of the job role overlap each other, but for the purpose of examination they will be discussed separately. These are: the ambiguity of the job role creating an unfixed and expandable workload, and, the job’s numerous implicit responsibilities. Job Role Ambiguity. This is produced by the trainee’s status as both practicing physician and student; in actuality, he is neither. Practically, the house officer has work obligations particular to trainees occupying a relatively low point in the hospital hierarchy and, simultaneously, obligations characteristic of physicians having positions of authority and leadership. A house officer can serve as the primary physician for very ill patients with all the dignity and responsibility accompanying such a role, and at the same time perform so-called

Beyond “The Men of Steel”

“scut work” such as patient transportation.+ An inconsistent and ambiguous job role complicates the trainee’s identity and sense of purpose, commonly leading to frustration, helplessness, and a sense of having no control. One second-year medical resident commented, “I look forward to my elective rotations on the consult services. Then, I do the consults and present to the attendingthere’s no confusion as to what I’m to do and what is expected of me. It’s such a relief.” An unclear job role also permits expansion of house staff responsibilities. The trainee’s role and work load frequently expand to meet the work’s demands especially with nonclinical work such as patient transporter, ward secretary, or disposition planner. Implicit Responsibilities. Implicit job responsibilities not directly related to patient care or training produce stress. One responsibility is to teach junior house staff, medical and nursing students, and floor personnel. The meaning behind the saying, “See one, do one, teach one” emphasizes not only how teaching strengthens the learning process, but also how in medicine one assumes the role of teacher with relatively limited experience. Another implicit responsibility is that of hospital employee [21]. The house officer as hospital physician is in a key position to influence hospital economics, image, and efficiency, and trainees are frequently asked to keep a finger on the economic pulsebeat of their employer, the hospital. As one senior resident commented, “In addition to my concerns about my ward patients and interns, I’ve been told to admit more patients to help keep the beds filled.” These numerous obligations add to the stress of patient care by requiring the acquisition of new skills and consuming valuable time.

Effects of Stress Patient Care House officer stress influences the quality of patient care, though this has received little formal attention [22]. Stress appears either in unintentional errors in judgment or technique, or more ‘The term “scut work” is probably derived from the slang usage of the word “scut,” which means dregs or undesirable parts. As used in medical work, scut connotes work with no redeeming value; practically, it means work that no one else will do. That which is scut work in one hospital may not exist as such in another because someone other than the physician is responsible to do it.

in the quality of the doctor-patient subtly, relationship. House staff may need to relax standards of patient care when resources of time, patience, and stamina are limited. They frequently acknowledge the adverse effects of stress on patient care, especially as a result of night call. One dedicated medical resident commented in the emergency room, “I hope the patient who just came in did in fact have an MI; then he’d go to the CCU. I was up all last night and I’m too tired to admit him as a ‘rule-out’ to my ward service.” Stress also harms the doctor-patient relationship via a spilling-over phenemonon where frustration is unwillingly expressed on patients who might be seen as “annoying,” “manipulative,” or a “faker,” if time and patience are limited. Patients become unwanted impositions during times of stress. The term “hits,” a slang term for admissions, as in “How many ‘hits’ did you receive last night?” metaphorically conveys the perception of being militarily besieged, as well as the patient as a member of an enemy army. The pejorative labels for patients-terms conveying anger and frustration-are used most frequently in stressful settings like the emergency room or crowded ward service where resources of time and tolerance are scarce [23] and the trainee feels frustrated and helpless [24]. Mumford notes, “The terms ‘crocks’, ‘turkeys’ and ‘gomers’ are sometimes summary criticisms which express frustrations and stress that interns and residents experience . . . ” [23]. Observation suggests that house officers may scapegoat patients when they feel scapegoated themselves-i.e., exploited, blamed, or dominated by a callous system and unalterable workload.

Training Whereas exemplary training includes both education and service, excessive work and service demands detract from time reserved for education. One casualty of service demands is time for study or teaching conferences. Another is the “good teaching patient,” which, along with the unusual physical finding, loses relevance when the trainee is hurried or tired. Work obligations or sleep often take understandable albeit costly precedence over the interesting teaching case. House staff may act more like post-training physicians than trainees when trapped in a demanding schedule. The regulatory mechanisms maintaining 117

R. Levin an appropriate equilibrium between service and education deteriorate, with the house staff unable by themselves to recreate the balance necessary for good training.

amine the functioning of house officers as physicians, trainees, and colleagues of senior physicians within the complex socioeconomic context of contemporary medical institutions.

The House Officer’s Personal Life

The Hospital Social System

Perhaps nowhere is the stress of training more pronounced than in the trainee’s personal life. Four years of medical school are followed by 3 or more years demanding even greater time and emotional commitment. Family life takes a backseat to demanding schedules, as time away from the hospital focuses on the necessities of sleep and relaxation. Friedman et al. note that “. . . intimate relationships. . . suffered due to lack of participation. Marriages were subject to stress and friendships were not reinforced’ [6]. A full-time intern or resident is forced to become a part-time spouse, parent, or friend. In a study of family practice residents, Nelson and Henry found that the most frequent complaint was a lack of leisure time [Xl]. Bates et al. report similar findings in a study of married interns [ 161. Similarly, single house staff may have limited time for developing and maintaining satisfying social lives. Training stress is most keenly experienced in such erosion of the boundaries of personal life. Hobbies, physical exercise, and other forms of necessary relaxation are curtailed. The house staff feel distant from their former selves and society as a whole. Ironically, the need for diversion from nonmedical sources increases while the opportunity to utilize them diminishes, forcing the house staff to rely wholly on their jobs for personal satisfaction. By excluding contributions from extra-hospital sources for life’s activities, trainees turn to the hospital for the gratification of social, intellectual, and emotional needs. This is the limiting and “monastic” quality of house-staff training.

Trainees are part of the socioeconomic fabric of the modern hospital that often requires dramatic expansion of their job responsibilities and work load. One model for this contextual role of house staff might be that of hospital workforce, or “proletariat.” A need for house staff primarily as workers in the hospital is not new [12,25]. The role of education in the house staff’s experience from the onset was ambiguous and tentative, but the need for house staff labor was not. By 1900 the medical establishment was uncertain whether those seeking positions after medical school should receive an educational experience. House officers were frequently unsupervised [18]. At the turn of the century, interns provided an invaluable service for many hospitals, but medical schools had virtually no influence over postgraduate medical education; hospitals used house staff as they pleased. As their names reveal, interns and residents remained in the hospital more to help run it than to further their own training.* Service needs today continue as a significant part of the house staff’s time; one study suggests that 84% of it can be spent in service work [9]. The growth of the modern academic medical center, with its emphasis on treating very ill patients with technically complex modalities, may actually expand rather than relieve the service requirements for house officers [25]. I have observed one house-officer attitude that is derived primarily from the hospital and training program system: trainees not infrequently see themselves in an adversarial “we-versus-they” position. The “they” may be patients or senior physicians or hospital administrators who seem distant and uncaring. This adversarial experience probably stems from house-staff disillusionment and alienation within a hospital-training system where they feel powerless and like “outsiders.” Unlike staff physicians and patients, house officers have a timelimited connection with the hospital.

The Purpose of House-Staff

Stress

I would like now to return to the question, “Why does the stress exist?” As suggested before, prevailing theories and assumptions from medical traditions seem incomplete and outmoded. A more comprehensive and relevant understanding of training stress requires examination of themes beyond common traditions. Three potentially explanatory accounts are presented below, which ex118

*“Intern” is probably derived from the French “inteme,” which means “confined within certain specific boundaries”; interestingly, a 1981 edition of a popular medical dictionary states that interns are “serving and residing in a hospital” [26]. The origin of the word “resident” needs no clarification.

Beyond “The Men of Steel”

Whether house officers feel alienated or not from the hospital-training “community” will, in my experience, significantly influence their satisfaction with the training program.

House Officers us Contributors Stress

to Their Own

New interns and residents assume important roles as physicians, after 4 years of medical school characterized by passivity and deference. The unprecedented clinical and professional responsibilities of training require psychological changes and adaptation. Instead, house officers frequently overutilize the character traits of self-reliance and determination that were valuable for acceptance to and completion of medical school. Such traits are necessary but not sufficient for the greater psychological and physical stresses of house-staff training. Rather than developing new ways of adapting to stress, house officers often see themselves as immune to stress because ignoring it is a common though risky attempt at coping. An inability to acknowledge fallibility leads to phenomena described as “omnipotent-omniscience” [14] and “I can’t say ‘no’ “ [27]. Stress is aggravated rather than abated by such attitudes when, without conscious knowledge or intent, house officers deny its existence or minimize its influence. Their physical and psychological wellbeing are at risk when the deleterious effects of stress are ignored [17]. Vaillant has suggested that doctors are hesitant to acknowledge difficulty, express anger, or request help. He notes that physicians often cope with personal problems independently so as to avoid inconveniencing others-they are almost phobic about asking for help [28]. His work suggests that doctors’ personalities are largely influenced by early life events, but it is likely that house staff training unintentionally aggravates underlying vulnerability in many young physicians.

Senior Physicians us Unintentional

Contributors

Senior physicians contribute to training stress in two ways, neither of which appears intentional. These result from the different roles and responsibilities of senior physicians. First, as administrators who organize training programs, they directly influence stress via key decisions about workload,

medical educators set the rhythm and tone of training programs by mediating the hospital’s service needs with the house staff’s requirements for learning. Secondly, senior physicians influence stress indirectly through their presence as role models: physicians, teachers, and colleagues. They are highly visible figures who affect and indirectly “teach’ trainees as much in the personal and professional realm as in the clinical. House officers, like all students, imitate their teachers; faculty attitudes about stress will mold the developing values of their observant younger colleagues. For example, “a need to toughen out each and every stress” from the “men of steel” philosophy will convey a dramatically different professional ideology than an acknowledgement of the human limitations of physicians as people. One should not be quick to blame medical educators, as changes in hospital training programs and faculty teaching practices over the past 30 years have undermined consistent and optimal teachertrainee relationships. The growth of specialties, the evolution of the teaching hospital in large academic medical centers, and the emphasis on multiple training sites for diversity of experience and income for the department, may all militate against the development of relationships conducive to optimal training [29,30]. Moreover, the medical school faculty’s roles have expanded to include research and administration in addition to clinical teaching [25]. As a result, today’s faculty includes numerous parttime physicians who have diminished opportunities to develop collegial relationships with house officers whom they see and teach inconsistently.

Discussion The fundamental nature of medical work and the house officer’s status as a trainee produce stress. However, the work conditions and not merely the work, and the system of medical training and not just training status, also contribute to stress. The “men of steel” legends and sayings can help clarify the roles and values of trainees, past and present. They seem to have three relevant meanings for medical training: 1) to represent and depict the idealized, model physician who prevails over the challenges of illness and the profession’s stress; 2) to help maintain the hierarchical and exclusionary nature of the medical profession; and 3) to help defend against the unpleasant realities of stressful

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training by generating and highlighting positive, nostalgic memories. However, these sayings alone cannot explain the meaning and significance of training stress. They do not reflect important changes in medical education or the medical profession, and probably apply more to Martin Arrowsmith and his peers than to today’s trainees. An important objective of house staff training should be the acquisition of skills to cope with stress. The habits and values house officers develop in training for coping with stress will, like clinical skills, extend into their post-training career as critical influences on physician adaptation, health, and impairment. Identifying, confronting, and understanding training stress, while fostering appropriate house staff adaptation, would help not only the house officer as a trainee but in his future career as well. How could stress be reduced without compromising the goals of good training? Structural aspects of training such as work schedules [31], patient caseloads, and on-call rotations need effective monitoring to minimize unneccesary and harmful emotional and physical fatigue. Changes in scheduling would offer house officers appropriate opportunities to provide good patient care without rushing or cutting corners. Recently, the lay public and press have acknowledged the effect of trainee stress on patient care and welfare.* As a result, the New York State Health Commission has proposed changes in house officer work schedules to minimize untoward effects on patients and house officers. For the stressed trainee, one program has devised a confidential psychiatric referral service for house officers [32]. Early detection and intervention for the overly stressed individual is crucial. In addition to the important analysis of program structure and assisting trainees in difficulty, senior physicians need to change their values and roleresponsibilities in order to acknowledge the significance of training stress. This would, by example, encourage house officers to do the same. It should be the professional and personal obligation of physician educators to recognize and address training stress openly. Discussion of stress should occur both in didactic [14,33] and informal sessions to forewarn and forearm trainees. Helpful, nonadversarial collegiality should be emphasized [34]. *Nm York Times, June 3, 1987, p. 1.

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Recent work on adult development by authors such as Levinson [35] clarifies the importance of mentoring relationships between senior and junior colleagues. The mentor’s role transcends that of mere teacher to influence the trainee’s intellectual, personal, and professional growth. The mentor is a guide or host for entry into the world of the shared profession. This relationship can be harmful as well as helpful. Valuable moral and personal support are provided, or, as Levinson warns, unhealthy competition can develop between the mentor and junior colleague. Varied reasons promote ineffective mentoring in today’s medical setting. Competition for positions and patients can develop between educators and trainees; male physicians may have inadequate experience in mentoring women; and senior physicians may become insecure and defensive when faced with ever-changing biotechnical advances. Medical educators may use intellectual one-upsmanship to maintain authority in a field where their trainees are often closer to advances in knowledge. The competitive and intimidating elements in medical teaching may serve as much to maintain the teacher’s self-esteem as to educate younger colleagues [36]. One resident described the sine qua non of his training program as “the abc’s: attack, blame, and criticize.” Professional and personal distancing between educators and trainees contribute to the unfortunate “pathology model” of training stress: normal reactions to stress are interpreted as signs and symptoms of a pathologic process. Terms such as “house officer syndrome” [37] and “training syndrome” [13], in which house-staff stress is an illness or weakness, and trainees are discussed in the familiar terms of patienthood, prevent acceptance of trainees as colleagues and people. Successful mentoring in medicine requires educators and trainees to acknowledge their mutual stresses, needs, and ambitions. Physicians should recognize a responsibility for other physicians. In particular, medical educators have responsibilities towards their house officers who are also their students and colleagues. Hippocrates encouraged physicians to aid their colleagues [38]. More recently, there is a conviction that our profession should act like an extended family in which physicians are sensitive to the needs of their colleagues [39]. We should promote good training and the appropriate growth of train-

Beyond “The Men of Steel”

ees as physicians and as individuals. The teaching of good doctoring-of patients, of colleagues, of oneself-should begin in the house staff years.

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Direct reprint requests to: Robert Levin, M.D. Department of Psychiatry Mt. Auburn Hospital 330 Mt. Auburn Street Cambridge, MA 02238

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