In this article, we discuss the stress of residency training, indicate some of the strategies that various institutions have developed to help their residents combat stress, and then describe in detail the assistance program at our medical school and what it has accomplished over its first eight years of operation.
The Problem and Ways to Combat It
Residency training has undergone tremendous change in recent years, and with those changes have come increasing stressors. Residents are at a higher risk than the general population for the development of stress-related problems as well as depression and suicide.1 The stress of residency has been extensively discussed in the literature and includes high patient loads with increasing levels of acuity, sleep deprivation despite recent work hour restrictions, and an ever-expanding amount of medical information to learn, which leads to information overload. Recent curricular changes such as competency-based curricula can also lead to stress. Personal issues such as feelings of isolation, other social problems, lack of a support system, financial concerns, cultural and minority issues, and future career planning play additional roles in adding stress to the lives of residents. In addition, residents performing in a marginal fashion often have significant psychosocial problems—many from this group question their goal of becoming a physician throughout their residencies. Gender-related issues still exist in many areas of medicine, and family responsibilities, both psychosocial and financial, can add to residency stress. Last, a preexisting psychiatric history is not uncommon in trainees.2
Further, residents are increasingly concerned about the medical–legal issues they will encounter in practice and may meet during residency. The increase in external forces governing physician behavior (e.g., lawsuits, patients, and Internet resources, leading to less physician control) certainly adds to stress.3,4 The above-described stressors can lead to or exacerbate significant mental health problems such as anxiety, depression, obsessive-compulsive illness, and substance abuse.
Residents’ stress is not a new problem—a survey of internal medicine programs from 1979–1984 found that 56% of the programs granted leaves of absence because of “emotional impairments” and that 1% of the residents required a leave, with the rate twice as common in female residents. Most impaired residents did well, but the survey found that 10% dropped out completely, 3% attempted suicide, and 2% succeeded.5 Several studies have demonstrated that residents have an equal or greater rate of depression compared to the general population, but a higher percentage is seen in first-year residents and in those working on more arduous rotations such as the intensive care units.6,7
Additional stress may be related to the changing demographics of residents. The number of women in medicine has increased significantly over the past 20 years; approximately 50% of all residents are women and a large number of both male and female residents are married—many with children.8 Balancing family and career has become a common challenge for residents. Finally, financial matters can play a significant role in resident stress. The average medical student debt was $135,000 for private school graduates and $100,000 for public school graduates; 4.5 times higher than the student indebtedness in 1984.9 This increase does not, however, take into consideration the impact of inflation or salary adjustments. These factors all add to increase in resident stress.
Residency programs have developed numerous ways to combat stress—one approach is the use of retreats. Retreats, usually designed for interns, are compact in time, usually last one to three days, and may deal with some of the stressful issues affecting residents along with programmatic curricular issues.10 Another system to combat stress is the use of wellness, or assistance, programs, which first appeared in the mid 1980s, primarily at psychiatric and family medicine residencies.11 These developed as a response to the lack of mental health services available at that time.12
Numerous institutions now have assistance programs for their residents, but there is little in the literature that describes these programs. The Universidade Federal de São Paul-Escola Paulista de Medicina in Brazil began their program in 1996 and collected data until 2002. The program was designed for medical and nursing residents as well as those getting masters or doctorate degrees. Their trainees were primarily young (average age was 27), single (82%), women (79%), and in their first year of training (63%). The majority self-initiated their referrals (71%). Depression and anxiety were the most frequent diagnoses, and 22% mentioned a tendency toward suicidal thoughts.13
A description of the wellness program at (what is now called) the David Geffen School of Medicine at UCLA was published in 1985. Depression followed by anxiety were the most frequent diagnoses reported. Their review supported the provision of confidential psychiatric assistance and documented their trainees’ acceptance of the program.14 Currently, the Accreditation Council for Graduate Medical Education (ACGME) requires that programs should “facilitate residents’ access to appropriate and confidential counseling, medical and psychological support services.”15 Levey2 describes the significant benefit these programs can provide.
The Program at the University of South Florida College of Medicine
The University of South Florida College of Medicine (USF) currently (2005–06) has 46 residencies and 16 fellowship programs with a total of 580 residents. The residents work at five primary hospitals and a total of 16 hospitals and clinics spread out over a large geographic area. Prior to l996, assistance to residents was provided by the psychiatry department. The university’s graduate medical education (GME) program recognized the increasing stress the residents were encountering and, in 1997, addressed the problem by creating an assistance program designed specifically for them. The program’s requirements were that it be broad-based (more than psychiatric services), readily available, easily accessible, totally confidential, and not reportable to the state board of medicine. It was modeled after an employee assistance program but was tailored specifically to enhance the well-being of residents. In the rest of this article, we describe that program and its effect so far.
Development of the program
The USF Residency Assistance Program (RAP) was designed to deal with a wide range of problems encountered during residency such as general stress, behavioral issues, marriage or family problems, financial troubles, substance abuse, disruptive physicians, or any other issues that could affect trainees’ mental health.
A Request for Proposals was disseminated to all identified employee assistance programs (EAP) in the local area. A clear definition of requirements was given. Four organizations were identified that could provide the needed services, and representatives of three met with the associate dean of GME. One EAP was chosen after agreeing to all the necessary requirements: that the services be confidential with no reporting of any details of individual cases to anyone at the institution, that the location be away from the university and its hospital, and that there be dedicated phone access availability at all times. Members of the organization would participate in residency education, and this program would function as a full-service EAP that was integrated into the residency programs.
After selecting the specific organization, three initial meetings were held with the EAP staff and university representatives, including psychiatrists and psychologists, to develop common strategies and gain understanding of essential aspects of the residency experience. The meetings included discussions of work schedules, locations and finances, lifestyle, common problems residents encounter, and potential barriers to acceptance of the assistance program. The need for the mental health professionals to have a firm grasp of the common issues and problems of residency was considered crucial to the success of the program. The EAP and university staff then created the program around the principles of confidentiality, reliability, convenience, and professional competence.
The costs of the program were bundled into the existing resident funding schema so the economic impact was negligible. The overall cost of the program is estimated to be seven cents per resident per day based on a flat yearly rate ($15,000) that is paid to the EAP.
Implementation of the program began in 1997. It provides confidential evaluation, brief counseling, and referral services to assist all residents and their dependent family members in obtaining help for a wide range of problems. The program is not focused solely around crisis intervention; it assists with both large and small problems.
The RAP is available 24 hours a day, seven days a week on a voluntary basis and has a dedicated phone line. A member of the RAP staff is always available to respond to urgent situations after hours. Three psychologists provide the majority of the care for the residents. Intake is performed over the phone or through a face-to-face office visit by a licensed counselor, who makes a recommendation for appropriate follow-up care. Each resident is entitled to three visits per year at no cost to the resident, and visits can be expanded to eight per year on a case-by-case basis. Arrangements are made for more frequent or more intense counseling whenever necessary. The RAP maintains extended office hours to accommodate the residents’ work schedules and has three office locations, removed from the university, which facilitates access and convenience and eliminates the possibility that a resident seeking help will be observed by patients, other residents, or faculty. The clinical offices are designed with separate entrance and exit routes so that passing back through the waiting room is unnecessary after an office visit. Appointments are not scheduled back-to-back, to avoid having residents accidentally meet in the waiting room. When referrals are made, they are done to specific identified providers who have experience working with residents and are outside the university but within the health plan provider network.
The initial visits are not reportable to the state board of medicine. However, if a resident is diagnosed with a psychiatric illness and requires ongoing care or if a substance abuse problem is identified, that must be reported. The GME office is closely linked with the RAP program and assists in providing for seamless entry to continuing care. Representatives of the RAP program meet with the residents at orientation when they are given descriptive brochures, which include the program’s phone number. In addition, all program directors, program coordinators, and the GME office have information about the program and how to make referrals (however, they are discouraged from making mandatory referrals). A description of the RAP and access information is included in the residency program’s handbook. RAP personnel participate in orientations, resident retreats, and program director workshops.
The primary philosophy of the RAP centers around confidentiality. Residents can contact the program without notifying anyone within the college of medicine, and all information and records remain in confidence. No information is disclosed without the resident’s written permission except in extreme circumstances such as potential criminal behavior. If a resident’s condition might require medical leave or some other accommodation, an informed consent for consultation between the RAP and the program director may be obtained. The associate dean for GME meets with the RAP quarterly to discuss general administrative issues and facilitate planning and further program development efforts. General trends are discussed along with total numbers of residents seen and the types of presenting problems. No information about specific cases is ever disclosed.
A quarterly newsletter, distributed to all residents, is intended to serve as a vehicle for providing information and education through articles related to stress management, wellness, family matters, and other health-related topics. It also helps highlight the availability and visibility of the RAP. A column devoted to financial matters appears in each issue; there is also a “tool box” section for practical lessons. The newsletter is mailed and sent electronically to all residents and is available at various training locations and on the college of medicine Web site. The newsletter clearly states that the goals of the RAP are to provide “counseling, personalized coaching and extra support to help one become a more successful physician” and to be a resource for “problem-solving, goal-setting and fine-tuning interpersonal skills.” The information in this newsletter addresses issues that directly relate to all of the six core ACGME competencies.
To assess the residents’ opinions about the program, an annual confidential resident survey is sent to senior residents in May and all other residents in January to determine their levels of awareness and views of the program.
Over the program’s first eight years, an average of 24 residents per year have used the program, with a range of 13–36 cases per year. Based on an average of 514 residents per year enrolled in residency from 1997–2005, the mean annual utilization rate of the RAP program was 4.7%. There was a trend toward greater program use over time. During the initial program year, a total of 13 cases were handled. By year 3 there were 36 cases; a 177% increase from year 1, which illustrates the rapid acceptance of the program. Initially, there was a predominance of male residents, but this leveled out over time for an overall equal distribution of men and women.
Across these eight years there were 193 total cases. In 154 (80%) cases, the resident was the primary client; 16 (8%) involved the resident and a family member seen together, and 13 (7%) a family member alone. The remaining three cases (5%) involved the resident and a significant other. In 158 cases (82%), program services were accessed on a self-referral basis. Referrals from supervisors accounted for five cases (4.5%) during the first five years but increased to 12 (14.6%) in years 6–8. The remaining cases were initiated by fellow residents, family members, or others.
In 149 (76%) cases, individuals reported an awareness of the RAP program and services through orientation, in-service training, or a brochure. For the first seven years of the program, approximately six clients (8%) indicated that a fellow resident was instrumental in making them aware of the program. However, in 2005, no residents indicated that a fellow resident had played that role. In the second through seventh years, an average of 15 clients (10%) indicated an awareness of the program through having participated in a previous year. This number dropped to only one client (3%) in 2005.
The kinds of problems or difficulties that were most highly represented among cases were emotional ones—102 cases (52.8%) include stress, anxiety, depression, and other adjustment problems—followed by marital problems in 29 cases (15%), financial problems in 13 cases (6.7%), and legal problems in 13 cases (6.7%) concerns. A smaller number of residents have obtained assistance for alcohol/drug issues (nine residents, 4.7%) and other interpersonal relationships (eight residents, 4.1%). Other presenting problems include grief (five residents, 2.6%), family (four residents, 1.9%), physical (three residents, 1.6%), child/adolescent (one resident, <1%), and other (six residents, 3.1%). The majority of these problems are similar to those seen in other business wellness programs except for the lower number of problems related to children.
In each of the 193 cases, recommendations were made for further follow-up with the RAP counselor and/or referrals to an outside resource for additional assistance. In 186 cases (96.5%), referrals were immediately accepted, while the remaining clients were initially undecided about whether to accept or follow through with a referral. There were no instances in which an individual declined recommended follow-up either with the RAP counselor or an outside resource.
There has been one suicide since the RAP’s inception. The response to that suicide was immediate. The RAP group mobilized without delay and met with all residents to provide debriefing and support, along with follow-up grief counseling as needed.
A confidential resident questionnaire is distributed annually to all residents about their overall residency experience. The electronic questionnaire currently includes a question about knowledge of the RAP program’s availability. In 2004, 273 of 535 (51%) responded to the questionnaire and in 2005, 225 of 522 (43%). Respectively, 216 of 224 (96.6%) and 251 of 273 (92%) of all residents responding stated they were aware of the RAP.
No postresidency follow-up data are available from residents who received services. However, there is anecdotal information that the program has been widely accepted by residents, spouses, and program directors. The RAP personnel are very responsive to the residents’ needs; they are available 24 hours a day and respond within five minutes when called. The associate dean for GME meets with the residency coordinators monthly, which increases their awareness and support of the program and provides much-needed feedback about the program. This program has forged an invaluable link with behavioral experts outside the university and has been able to effectively interface with the health insurance program of the residents.
The Value of Assistance Programs
Our experience with the RAP program at the University of South Florida College of Medicine convinces us that such programs should be made available to residents throughout our country. The USF program meets all ACGME requirements and provides an infrastructure for behavioral and emotional competencies. The program also demonstrates some key aspects of a successful assistance effort, including maintaining total confidentiality, easy access, education regarding availability of services, and overall integration with the GME program. Assistance programs such as these may require several years to take hold but the history of the USF program suggests that once that happens, such programs will be viewed as an important benefit of residency.16 It is important that program participation be voluntary and not linked with any specific discipline. Our experience indicates that it is very easy to obtain uniform support and acceptance from the residency program directors and the hospital, since the program is a true win-win endeavor.
Schools may face multiple barriers when trying to create a program such as the one we have described. Getting buy-in from all involved—faculty, residents, community agency, and support personal—is of critical importance to achieving acceptance. Without this, a program is less likely to succeed. Program visibility and the guarantee of confidentiality will also foster success. The issue of cost should not deter a school from establishing an assistance program, for even though a relatively low number of residents will be served, those that are served achieve significant benefit for very large problems. The cost is very manageable; low per individual enrolled in the residency program but high per individual use. The fact that initial services should not be reported to the state board of medicine makes assistance programs very palatable, encouraging residents to seek help for difficulties early on before they become extreme and pose a risk to health, well-being, and the performance of duties.
Future directions at our institution include developing a better system for evaluating the individual resident’s experience with the RAP program during the residency and after graduation. This presents significant challenges due to the difficulty in maintaining contact with residents once they graduate and because of the confidential nature of the program. Second, our institution plans to institute a faculty assistance program as a component of a “disruptive physician” module. Lastly, in response to the success of the RAP and new requirements of the Liaison Committee on Medical Education, our university has recently implemented an assistance program for medical students modeled after the one described above for residents.