November 20, 1998

By Diana L. Dell, M.D.
APA Member-in-Training Trustee

I have "waxed philosophical" many times over the last few weeks-ending a residency, starting a fellowship, thinking about things that change and things that refuse to change.

My hazy internal dialogue about "endings" and "beginnings" was superimposed on my ever-present concerns about the evolution of medical training in the U.S. The men and women who undertake medical training in this decade are challenged in ways that our forefathers and foremothers could not even have envisioned. Increasing information, increasing technology, increasing administrative duties, and sicker patients are all crowded into days-and nights-that never have enough hours.

In many ways, I guess I knew from the start of this, my second, residency, that I had a distinct advantage over my colleagues who were undertaking postgraduate medical training for the first time. I knew that it was abusive-and I knew that it would end. Knowing that the abuse will end is not so important now, in the fall, as it will be in late winter or early spring. Or during the first week in May, when you are close but not close enough. Or during rotations that drain your spirit and leave you lost inside yourself in a way that only physicians can know. . . .

The physical and intellectual abuse of medical trainees has been "woven into the fabric" of medical training for so long that it is no longer visible. It is so institutionalized that faculty and trainees alike actually honor the abuse as a "rite of passage" and essential for making the transition from student to physician. I continue to encounter otherwise distinguished faculty members who either deny that the system is abusive or actually believed that continuing to "do things the way we have always done them" is ultimately a virtue and in the best interest of both the trainee and the system.

But ours is a system that needs revision-and needs it urgently.

I recently read the new edition of Dr. Allan Peterkin's book called Staying Human During Residency Training (University of Toronto Press, 1998). Dr. Peterkin is a Canadian psychiatrist who is trying to help physicians in training cope with this difficult period of their lives. Here are a few of the alarming statistics he sites:

In one study, 40 percent of residents (all specialties) reported impaired performance as a result of anxiety or depression lasting four weeks or longer. Another sample, with similar numbers, documented that residents are at highest risk for depression during the first two months of training and when their workweeks are longer than 100 hours. In another study, 29 percent of first-year residents, 22 percent of second-year residents, and 10 percent of third-year residents were significantly depressed.

With high rates of depression, suicide is a significant risk. One survey showed that among residents who had taken a leave of absence from training, 5 percent did so after an attempted suicide. From another sample of depressed residents, 25 percent had suicidal ideation and 18 percent had a plan. Suicide is the second-highest cause of death among medical students.

Dr. Peterkin listed the top 10 stressors among residents:

1. Insufficient sleep (fewer than three hours)


2. Frequent night calls (every third night or more often)


3. Uncompromising attending physicians


4. Large patient loads


5. Too much "scut" work


6. Too much medical-records work


7. High rates of death among patients


8. Little or no contact with fellow residents


9. Inadequate sexual activity


10. High peer competition to impress staff

Adverse effects are not limited just to residency. The effects on personal and professional development persist into subsequent careers. Among doctors under age 40, who were recently surveyed by the AMA, 31 percent would not have gone to medical school if they "had known then what they know now." Moreover, the suicide rate among physicians under age 40 is three times greater than the general population.

One of my favorite arguments for residency reform comes from Dr. Michael Green in the article "What, if anything, is wrong with residency overwork?," which was published in the October 1, 1995, issue of the Annals of Internal Medicine. He says that the strongest argument for reduced work hours is an ethical one. He believes that overwork interferes with the moral curriculum of residency. It interrupts formation of the basic values that underlie clinical encounters: compassion, empathy, honesty, integrity, and a commitment to serve the best interests of the patient. Dr. Green says that fatigue cultivates anger, resentment, and bitterness. Embittered physicians develop undesirable and unprofessional attitudes when their most basic physical and emotional needs are in competition with patient needs.

His notion of fatigue interfering with the "moral curriculum" was given new voice by Daugherty, Baldwin, and Rowley in "Learning, satisfaction, and mistreatment during medical internship: A national survey of working conditions" in the April 15 issue of the Journal of the American Medical Association. The authors presented data from a large survey (n=1,277) indicating that 70 percent of residents had seen a colleague working in an impaired condition, most often caused by a lack of sleep, and that 45 percent of residents had observed another individual falsifying medical records.

At times I have had a sense that some improvements were emerging. But the abusive hours, abusive styles of teaching or supervising, and abusive expectations do not appear to be limited to a stalwart bastion of practitioners who are nearing retirement. Newly certified and mid-career faculty appear to have internalized this abusive model and given it new life. And new recruits are lining up. I shudder when I hear a second-year resident giving voice to the "I had to do it, so should they" argument.

Psychiatry, of all specialties, should recognize that it does not make sense to demand that residents provide compassionate care to patients when they are not receiving compassionate care from the colleagues entrusted with their training. We must take the lead in ending resident abuse and beginning training reform. Whether that reform means initiating night-float systems, supporting house-staff unionization, or simply beginning to treat our interns and residents as true professional colleagues-we are urgently in need of change.

Members-in-training are invited to submit articles for the Residents' Forum. Articles may be sent to Cathy Brown, Psychiatric News, APA, 1000 Wilson Boulevard, Arlington, Va. 22209-3901; fax: (202) 682-6031; or to Dr. Dell directly via e-mail at ddell@torhosp.toronto.on. Dr. Dell also invites members-in-training to contact her about concerns or issues regarding APA or affecting members-in-training.