May 7, 1999

The increased demands of residency training can cause interpersonal and academic difficulties for some residents. To assess and manage a range of resident problems in a systematic way, training directors should have guidelines in place, said James Lomax, M.D., at the March meeting of the American Association of Directors of Psychiatric Residency Training in Santa Monica, Calif.

"The vast majority of residents complete their training without a serious problem, but there is that 5 percent who require significant attention," said Lomax, associate chair and director of educational programs in the department of psychiatry at Baylor College of Medicine in Houston.

He continued, "I receive about one serious resident-related complaint and several minor complaints a year from attendings, house staff, or patients that need to be evaluated."

Lomax developed guidelines for dealing with resident problems for the psychiatry department about 15 years ago, and they are now being considered for use in every residency program at Baylor.

To detect problems early, Lomax suggested that directors inform chief residents that their job includes systematically reviewing the performance of each resident class and its supervisors and didactic teachers. The chief residents should meet regularly with training directors and inform them of any problems.

"At Baylor, we also have a departmental subcommittee made up of residency faculty coordinators at affiliated institutions that reviews each residency class twice a year beginning with new residents. We invite key clinical supervisors and didactic teachers to participate as we review the progress of each resident and the way the residency class is learning as a group," said Lomax.

He explained that residents might have adjustment problems because of greater professional expectations, disillusionment about the limits of the profession, dealing with chronic patient illnesses, and living and working in a competitive environment with other house staff.

Residents may also react unprofes-sionally or intensely to patients with certain illnesses, such as alcoholism, when they have family histories of that particular illness.

"Awkward exchanges with patients or hurt feelings can also result from a resident's ignorance, lack of empathy, or unfortunate assumptions made about unfamiliar backgrounds, dispositions, or orientations," observed Lomax.

Residents' inappropriate behavior may also reflect personal problems with a spouse or family member, although it is rare for a spouse to complain about the resident's behavior to program staff, Lomax noted.

Problems related to the learning process itself sometimes occur as well. "In some cases, very bright residents with specific learning disabilities have been able to compensate for their problems intuitively. But with the increasing expectations of professional education and certification exams, programs need to inform residents about specific performance measures so the residents can develop strategies to accommodate their disabilities successfully," said Lomax.

Some residents may experience mood and anxiety disorders because of stressful conditions, including sleep deprivation and increased performance expectations.

"Previously undetected or ignored personality disorders may surface during residency training because more collaboration is required with health care teams," said Lomax.

Reactions of residents with these disorders include an avoidant or hostile manner, difficulty appreciating the needs of others, and overcontrolling behavior, which other health care team members find exasperating or demeaning, noted Lomax.

Warning signs of substance abuse disorders in residents include a wide performance variation in relatively short periods, unexplained and/or frequent absences from duty, and sudden lapses in performance, said Lomax.

Training directors should be familiar with informational and support resources available at their institutions, such as counseling services and a drug-free workplace policy.

In some cases, a psychiatric consultation may be needed to clarify a resident's perceived difficulties. "This can be useful when a resident's behavior has changed; is inappropriate, violent, or rude; and does not respond to simple and direct counseling. This [consultation] is not useful when the resident's lack of competence clearly requires dismissal," said Lomax.

Residents should be told that a psychiatric consultation is voluntary and that confidentiality will be waived.

Training directors should also consider whether to meet with the resident alone or with other residents and faculty present. A group meeting can be helpful in situations involving different interpretations of the same event or when discussing emotionally charged allegations such as unethical behavior, said Lomax.

Prior to the meeting, a training director should have obtained as much information as possible about the problem from academic, medical, and personal sources; developed a description of the problem; and considered a tentative action plan with contingency steps, advised Lomax.

"My experience has been that most residents agree that a problem exists and want to correct it. However, if the resident disagrees, be firm and specific about what steps must be taken to meet departmental expectations," he advised.

Once the resident understands that there is a problem, it is useful to have a written outline of goals with specific actions and timeframes to achieve them, as well as the consequences for failing to meet the goals, said Lomax.

He recommended that the training director and resident sign the document for future reference and place a copy in the resident's file.

Lomax also suggested that training directors contact their institution's legal department early in the assessment process whenever a formal negative action is anticipated and will become part of the resident's permanent record.

Depending on the problem and severity, disciplinary action may be needed. Options include suspension to assess a potentially serious but unclear situation, probation, and dismissal. Lomax noted that probation should be accompanied by a written description of the problems and what must be done to remedy them.

Generally, placing a resident on probation follows documented discussions with the resident and often a letter giving the resident time to respond.

"The probationary letter serves to put the resident on notice that if the problem is not corrected, there may be more serious consequences. We also offer to discuss the problem in more detail," said Lomax.

One situation in which this is appropriate is a resident who seems to be trying hard but is repeatedly surprised that his or her performance is deficient or unprofessional, added Lomax.-C.L.