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A new national survey of residents published in the April 15 Journal of the American Medical Association (JAMA) indicates that psychiatry residents reported the least satisfaction overall with their first year of residency, while primary care residents reported the highest level of satisfaction. Overall, residents at U.S. medical schools are moderately satisfied with their first year of residency training but complain of mistreatment, unethical conduct, impairment, and insufficient time with attending physicians.
Commenting on the relatively low satisfaction of psychiatry residents, lead author Steven Daugherty, Ph.D., told Psychiatric News, "This is probably because psychiatry residents spend the least amount of time with attending physicians (1.9 hours per day) of any specialty. In contrast, residents in surgery, family practice, radiology, pathology, and physical rehabilitation spend an average of three hours per day with attendings and thus receive more instruction."
Daugherty, a senior investigator at the Rush Primary Care Institute in Chicago, observed that attending physicians may have less time for teaching residents because of managed care pressures.
"If residents do not receive the time and education they need, they will not be prepared in the future to practice medicine," he said.
Daugherty and his research colleagues survey a sample (10 percent) of all second-year residents listed in the AMA's medical research and information database. They received 1,274 completed surveys, representing a close approximation of specialty distribution for 1991.
David Goldberg, M.D., executive secretary of the American Association of Directors of Psychiatric Residency Training (AADPRT), told Psychiatric News that he was surprised at the findings but added that several factors could account for the low level of satisfaction among first-year psychiatry residents, including spending a total of six months on medicine and neurology units, where they often encounter a bias toward the field of psychiatry.
"First-year psychiatry residents also tend to be more isolated from each other than residents in other specialties, and their psychiatric rotation involves dealing with very sick, disturbed patients on inpatient units with quick turnover, which adds to their dissatisfaction," Goldberg continued.
Residents across specialties ranked time spent with attending physicians fourth in contributing to their learning experience after other residents, special patients, and patient rounds, according to the article.
Goldberg commented, "It is likely that attending psychiatrists are spending less time with residents on inpatient units because of a trend in health care driven by economics toward rapid diagnosis, focus on pharmacotherapy, and cost efficiency."
"At the same time, this finding underscores the need for faculty to spend committed, real time with residents, which is important didactically but also to becoming a psychiatrist and physician," added Goldberg.
Daugherty suggests that resident satisfaction may be negatively impacted by residents' perceptions of mistreatment. Ninety-three percent (1,185 residents) reported at least one experience of mistreatment, with public humiliation or belittlement being the most common. This was perceived as the most distressing type of mistreatment.
Residents also complained of others' taking credit for their work, tasks for punishment, and sexual harassment.
Attending faculty were the most frequently cited source of mistreatment, followed by senior residents, patients, and nurses.
Daugherty noted that medical students have reported similar high levels of mistreatment in previous surveys. However, he cautioned that generally such mistreatment does not occur on an ongoing basis."
Goldberg commented, "I found the high level of mistreatment reported appalling and certainly unacceptable. Training directors and chairs of departments need to discuss with teaching faculty the proper conduct and respectful way to relate to trainees. There also needs to be a place where attendings can discuss their frustrations about their jobs rather than venting them on residents and other housestaff."
Physical abuse, being slapped, kicked, pushed, or hit was less commonly reported and occurred mostly at the hands of patients, according to the article.
Daugherty commented, "Psychiatry and emergency room residents reported more physical abuse by patients than other specialties because they have a more difficult patient population."
First-year women residents experienced four times the amount of sexual harassment as men (60 percent compared with 15 percent). The most frequently cited types were sexual slurs or comments, favoritism, and sexual advances. The most common sources were attending faculty, patients, and senior residents.
"This high rate of behavior when women make up an increasing proportion of physicians is cause for concern," stated the authors.
More than 45 percent of the residents reported having observed staff falsifying medical records on at least one occasion, with nurses cited as the most common source followed by fellow residents.
More than 10 percent of the residents reported sleep deprivation as a daily occurrence. Surgery residents had the most on-call hours a week (73), and psychiatry residents had the second lowest (37 hours), according to the authors.
Seventy percent of residents said they saw a colleague working in an impaired condition, most often a resident at the same or higher level. Sleep deprivation was the most commonly reported cause of impairment (57 percent), followed by working hurriedly (40 percent), incompetence (37 percent), and emotional problems (37 percent).
Alcohol as a reason for impairment was reported by less than 15 percent of respondents, while prescription drug abuse and illegal drugs were cited by 5 percent of respondents.
Daughtery commented, "Incompetence may be a greater problem than sleep deprivation. Even with a good night's sleep, some residents may still not know what they're doing. It appears some residents are inadequately prepared for the responsibilities given them."
To improve first-year residents' level of satisfaction, Daugherty and his coauthors recommend that residency training directors take a two-pronged approach.
They should enhance the learning opportunities for residents by increasing the accessibility of attending faculty, facilitating contacts among residents, and providing time for independent reading. Residency directors must "also make clear the standards of conduct for all professional personnel and intervene when their conduct falls short."
Golberg recommended that first-year residents in psychiatry have a regular forum to discuss their difficulties with psychiatry and other rotations. "Residents also need a reporting structure to convey incidents of mistreatment or impairment anonymously. Training directors should establish a culture of positive feedback and reassure residents that they will work with the individual in question to make changes."