SPECIAL TOPIC Social Problems in Plastic Surgery Residents: A Management Perspective Charles N. Verheyden, M.D., Ph.D. Mary H. McGrath, M.D., M.P.H. Peggy Simpson, Ed.D. Lisa Havens, J.D. Temple, Texas; San Francisco, Calif.; and Chicago, Ill.
Background: It is presumed that plastic surgery residents experience various social problems, just as do their peers in other specialty training programs and in the general public. These issues can occasionally disrupt the resident’s personal training experience and sometimes the program as a whole. A survey was performed to assess the magnitude of the problem, and the issues revealed were assessed to assist the program director and the resident in reaching successful completion of the residency. Methods: A survey was designed by the executive committee and staff of the American Council of Academic Plastic Surgeons and sent to all plastic surgery training programs in the United States. A response rate of 66 percent was achieved. The programs reported on the social issues occurring in their residents over the preceding 5 years. The results were presented at a business meeting of the Council. Results: Thirty-seven percent of programs reported that at least one resident had left their program during the study period. Twenty percent reported that a resident had been asked to leave the program. The frequency of social problems resulting in disruption of the training program was tabulated in the following areas: divorce; pregnancy/parturition; financial, legal, or family issues; drug or alcohol abuse; illness/injury; and interpersonal conflicts. Conclusions: Plastic surgery residents experience social problems that can affect the timely completion of their training. Attention to these issues requires patience, creativity, sensitivity, and a commitment to the residents’ ultimate success, and adherence to institutional, legal, and accreditation body mandates. (Plast. Reconstr. Surg. 135: 772e, 2015.)
P
lastic surgery residents are contemporary adults and, as such, experience the same problems as do their peers in other walks of life, although sometimes with different frequencies. Some of these problems impact the ability of the resident to carry out his or her duties, both educational and service related. This can result in other difficulties, not only for the individual resident, but also for the program director and the other residents in the program. When these issues become significant enough that training program disruptions occur, program directors may find themselves having to deal with circumstances that From the Division of Plastic Surgery, Department of Surgery, Scott & White Healthcare; the Office of Graduate Medical Education and Division of Plastic Surgery, University of California San Francisco; and the Accreditation Council for Graduate Medical Education. Received for publication February 14, 2014; accepted September 19, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001098
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may be unusual in their experience and that may also be unpleasant. Because some of these issues are fortunately infrequent, the program director may be unsure how to handle the situation from institutional and legal points of view and to also maintain confidentiality and due process in a way that meets both their institutional and Accreditation Council for Graduate Medical Education standards.1 At the same time, the program director wants to handle matters in such a way that the individual resident can be helped through the difficult time and successfully complete the program if possible.
METHODS To assess the magnitude of this problem, a questionnaire was prepared and reviewed by the Executive Committee and staff of the American
Disclosure: The authors have no financial information to disclose.
www.PRSJournal.com
Volume 135, Number 4 • Social Problems among Residents Council of Academic Plastic Surgeons. Questions were assessed for bias and structured to identify the presence of certain problems that residents may experience and to determine whether or not these problems had impacted the training of individual residents or the program. Questions were reviewed and ultimately revised by the committee until it was determined that the survey achieved face validity. The survey was sent to 89 programs; responses were received from the program directors of 59, for a response rate of 66 percent. A second reminder was sent to increase the response rate. The assessment of whether the resident’s performance was affected by the problem was performed by the program director. This assessment could well have included in-service examination scores, faculty evaluations, attendance/attention at conferences, or lapses in patient care, and the program director’s personal interaction with the resident. Further detail on how this assessment was made was not investigated. We tabulated the survey responses and present the frequency of responses along with corresponding 95 percent confidence intervals. The specific problems about which questions were asked are listed in Table 1. After the response period was closed, the results were tabulated and presented at an organizational retreat presented at the Annual Meeting of the American Council of Academic Plastic Surgeons. Perspectives on managing these issues were presented by Mary H. McGrath, M.D., M.P.H. (institutional), Peggy Simpson, Ed.D. (accreditation), and Lisa Havens, J.D. (legal). Case studies were also presented by various program directors and a discussion was held by the members of the association. After this review, it seemed appropriate to summarize the information for dissemination, so that program directors faced with these issues could develop a framework for dealing with them.
RESULTS In the survey, each question referred to all residents in the program in the previous 5 years. Table 1. Categories of Social Problems Addressed Divorce Pregnancy and childbearing Family, legal, or financial Drug/alcohol abuse Illness/injury Interpersonal conflicts
The median total number of residents in each program during this time was 10 (range, zero to 24). The total number of residents graduating in the preceding 5 years from the responding programs was 587. Thirty-seven percent of programs reported that at least one resident had not completed the program, and 20 percent reported that at least one resident did not complete the program because they had been asked to leave. Table 2 shows the tabulation of survey responses. In 25 percent of programs, at least one resident had divorced during the program, totaling 17 residents. For 10 of these residents, the divorce did affect their performance. In 73 percent of programs, at least one resident or their spouse became pregnant and delivered the baby during the residency, totaling over 131 residents. In situations where the resident delivered the baby, programs reported that 22 residents took more than three weeks of leave. Eleven made up the time; for seven, the missed time affected their performance. In situations where the spouse delivered the baby, programs reported that only 10 residents took more than 1 week of leave. Four made up the time, but the missed time did not affect performance of any of them. In 37 percent of programs, at least one resident experienced significant family, financial, or legal issues, totaling more than 39 residents (7 percent). Eighteen had family issues, 16 had financial issues, and three had legal issues. For nine, the program reported that these issues had Table 2. Tabulation of Survey Responses* Social Issue Divorce No. (%) 95% CI Pregnancy, spousal pregnancy No. (%) 95% CI Family, financial, legal issues No. 95% CI Drug/alcohol abuse No. (%) 95% CI Illness or injury No. (%) 95% CI Interpersonal conflict No. (%) 95% CI
Programs
Residents
15 (25) 15–39%
17 (3) 2–5%
43 (73) 60–83%
131†
22 (37) 25–51%
39†
5 (8) 3–19%
5 (0.9) 0.3–2%
18 (31) 20–44%
19 (3) 2–5%
33 (56) 42–69%
53 (9) 7–12%
*No response to a given question is counted as though the program had no residents dealing with the social issue. †The question was worded to allow responses of “more than 4” residents dealt with the issue. In these cases, precise counts were not possible.
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Plastic and Reconstructive Surgery • April 2015 affected their performance. Six missed more than 3 weeks from the program, and all six made up their missed time. In only 8 percent of programs (five residents, 0.9 percent of total) did a resident become involved in drug/alcohol abuse, and all of these programs reported that performance was affected and that the resident was referred to an impaired-physician program. In 31 percent of programs, at least one resident had experienced significant illness or injury, totaling 19 residents. Among these residents, the illness or injury affected the performance of seven of them, eight missed more than 3 consecutive weeks, and five made up the missed time; for three, the missed time affected their performance. In 56 percent of programs, at least one resident experienced significant interpersonal conflicts with other residents, office or hospital staff, faculty, or patients, totaling 53 residents. Twenty had conflicts with other residents, 17 had conflicts with faculty, seven had conflicts with staff, one had a conflict with a patient, and seven had conflicts with multiple groups. For 15 residents (2.5 percent), the program reported that their performance was affected. Accreditation Council for Graduate Medical Education/Residency Review Committee for Plastic Surgery Perspective The Accreditation Council for Graduate Medical Education’s purview of authority derives from both the institutional requirements and the program requirements. Institutional requirements pertaining to resident well-being, which the Accreditation Council for Graduate Medical Education expects sponsoring institutions and programs to provide, include the following: 1. Benefits and conditions of appointment (institutional requirement II.C). 2. Counseling services (institutional requirement II.D.4.k). 3. Physician impairment (institutional requirement II.D.4.1). 4. Harassment (institutional requirement II.D.4.m). 5. Accommodation for disabilities (institutional requirement II.D.4.n). The language provided in the institutional requirements allows for each local sponsoring institution to develop its own policies and procedures. When the Institutional Review Committee and the Residency Review Committee for Plastic Surgery review programs that have
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recently addressed issues for residents with social problems, it assesses the answers to the following questions: (1) Did the sponsoring institution/program have the required policies and procedures in place to address the issue? (2) Did the sponsoring institution/program follow its policies and procedures? (3) Is there a trend of residents with social problems in the sponsoring institution/program? The program requirements positively address these issues with requirements for education on being fit for duty, promoting resident well-being and patient safety, and promoting a culture of professionalism. Residents and faculty must recognize personal responsibility in time management, recognizing and reporting impairment, and transitioning patient care if necessary (VI.A.1,2,5.c-3; VI.A.6). Once the program director has determined that resident remediation and/or time off is required to address the issue, the program director is obligated to: 1. Notify the Residency Review Committee for Plastic Surgery of the remediation timeline and general activities included in the remediation plan. 2. Assess and notify the Residency Review Committee for Plastic Surgery if the remediation will cause the resident to graduate “off-cycle” (i.e., beyond June 30 of the original year of graduation). If the graduation date will be postponed and the program’s next cohort of resident complement is full, the program director must make a request for a temporary increase in resident complement through Accreditation Council for Graduate Medical Education’s Accreditation Data System. In this instance, the Residency Review Committee for Plastic Surgery advises program directors to contact the American Board of Plastic Surgery to ensure that any issues arising from an offcycle graduation are addressed so as to allow the affected resident to remain eligible for the certification process. Institutional Perspective In addition to an institution providing educational, fiscal, and administrative support for the institution’s graduate medical education programs, its scope of responsibility also includes support for the well-being and development of its residents. “Core Competencies for Institutional GME Leaders/Designated Institutional Officials”2 defines well-being and covers multiple
Volume 135, Number 4 • Social Problems among Residents environmental factors to be addressed when overseeing the institution’s residents and recommends various areas for focused attention. Understanding the factors that may contribute to distress during residency training and making proactive changes requires action at the institutional graduate medical education level, because many of them require resources that exceed those of any single residency program. These efforts should increase awareness, alleviate distress, and develop outreach to doctors in distress.3 The institutional graduate medical education office and the medical center leadership are required by accrediting bodies such as The Joint Commission to have processes in place to promote physician wellness.4 Residents are challenged continually by inefficiencies and mistreatment in the work environment. Graduate medical education can respond by giving credibility to resident complaints; in some institutions, providing an ombudsman has been helpful. The graduate medical education office can also provide institutional sources of support for residents and program directors such as providing free, “off-campus” mental health services at no charge and equipping program directors with appropriate information and education about these services. The institutional graduate medical education group can lead efforts to help residents by providing programming for residents about strategies for resiliency and wellness. Funding becomes an issue if a resident’s training period is extended, and arriving at the best arrangement to cover these costs requires careful planning between the institution, the department, and the program. Legal Perspective Residency is a challenging time in the life of a young physician and can have an adverse impact on the resident professionally, particularly if disruptive behavior or medical errors result. The legal and risk management team should be consulted early to provide a thorough investigation and appropriate documentation. They are most helpful in determining compliance with hospital policies and external laws dealing with employment, malpractice, and privacy. The objective is assessing risk, mitigating harm, and preparing for a possible legal case in a way that is safe and protected from discovery. A program director also may have a duty to report disciplinary action to state licensing boards and be involved in providing references and evaluations for a resident who is applying for
hospital privileges. In the case of a problematic resident, legal advice is advisable for answering and responding to these requests. The perspectives of the patient, the resident, the employer, the program and the public must be balanced with legal guidance.
DISCUSSION This study raises additional questions. Although these issues and their frequencies are documented in this study, the solutions for dealing with them remain elusive, at least partially because individual circumstances come to bear on each case. The problem-solving abilities of the resident and the program director are influential variables, and the nuances of the perspectives covered in this article will vary from institution to institution. It does seem appropriate, however, to make some recommendations. Divorce The divorce rate in the United States is 4.1 per 1000 people.5 It has been reported that the rate in physicians is 10 to 20 percent higher.6 Gander and colleagues7 have shown that difficulties in home life, social life, and personal relationships are statistically significantly related to fatigue. Multiple other factors may impact this issue, however, such as psychological predisposition of those entering medical school8; perfectionism9; suppressing feelings of inadequacy or distress; invincibility or a lack of trust in others10; having a “VIP” mentality11; and difficulty setting appropriate limits.12 Specialty also impacts divorce, and surgeons are second only to psychiatrists in divorce rates over the long term.13 Our survey showed that at least 2.9 percent of residents (17 of 587) became divorced during their residency, a relatively small window of their lives, indicating that the ultimate rate is probably significantly higher. It would seem to be appropriate that marriage support be provided during the residency years in the form of counseling resources or even an occasional conference on relationship issues. A generic inquiry (e.g., “How are things outside the hospital?”) could lead to a conversation that would be helpful in facilitating the social and professional success of the resident. However, the resident should never be pressured to share personal information with the program director.
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Plastic and Reconstructive Surgery • April 2015 Pregnancy and Childbearing In the United States, 42 percent of all residents and 24 percent of all plastic surgery residents are female.14 Pregnancy and parturition was an issue in almost three-fourths of plastic surgery programs during the 5-year survey period. It has been shown in obstetrics and gynecology residencies that missed time did not significantly affect surgical experience.15 Whether they miss significant time or not, this is a very stressful time for these women and it does not end after the baby is born.16 It has also been shown that pregnancy complications are higher than in the rest of the population,17–19 although most have a good pregnancy outcome.20 Three-fourths of residents who were pregnant during residency reported it to be an unpleasant experience.18 In a survey of pediatric residents, 26 percent believed they were penalized for their maternity leave and 24 percent believed their pregnancies were actively discouraged.21 It is certainly to be expected that young women will get pregnant during this phase of their lives, and pregnancy should not be considered a “problem,” explicitly or implicitly. Therefore, the institution’s parental leave policies should be distributed and understood by everyone. Family, Legal, and Financial Problems There is not a lot of information in the literature regarding family and legal matters, but there are two studies that show that residents have an average educational debt exceeding $100,000.22,23 Ten percent of residents have credit card debt over $10,000. Compared with controls, residents hold greater median ratios of debt to household income, less net wealth to income, and fewer assets to income. Surgery residents were the least “financially conservative.”24 These problems can carry over into practice. As incomes rise, a pattern of poor financial choices can lead to serious difficulties. It would seem prudent to include personal financial management in program conferences, such as the annual Chief Residents’ Conference held by American Society of Plastic Surgeons and The Plastic Surgery Foundation, and making financial counseling available in the institution. Drug and Alcohol Abuse This issue is less of a problem in residents than in their age-matched peers.25,26 In practicing physicians, the rate of narcotic addition has been reported in the past to be 30 to 100 times greater than in the general population.27 There
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is no gender differential.28 A significant minority begin using drugs or alcohol during residency.25 The number reported was only 0.9 percent in our study of plastic surgery residents, but in every instance, the resident’s performance was affected, and all were referred to an impairedphysician program. This referral is important, because the death rate related to abuse in physicians has been reported to be over 16 percent,29 not to mention the potential impact on patient safety. Fortunately, when treated properly, physicians have a good record of responding favorably to treatment.26,29 These facts emphasize the importance of identifying and addressing substance abuse problems as early as possible, particularly because the resident is often reluctant to seek help.30,31 Illness and Injury Most of the literature dealing with resident illness focuses on those of a psychiatric/psychological nature (e.g., stress, anxiety, burnout, sexual health, suicidal thinking), situations that are unfortunately common.28,32–35 Our survey results indicated that even nonpsychiatric illnesses are not rare and occasionally do have negative outcomes for the individuals involved. The absence of a trainee for several weeks or months can be very problematic. Counseling or ombudsman arrangements should be not only available but also actively promoted to residents and detailed in institutional and program literature. Interpersonal Conflicts Although reported by the majority of programs [53 total residents (56 percent)], intrinsic personality disorders are difficult to differentiate from those resulting from the other issues mentioned. Baldwin and Daugherty36 reported a significant increase in significant medical errors and adverse medical outcomes when residents were having interpersonal conflicts with other residents, supervising faculty, or nurses.36 Consequently, prompt conflict resolution must be initiated, optimally consistent with existing institutional policies. These policies must allow for considerable individual variation,32 and they make handling the specific situation much easier for the program director.
CONCLUSIONS Reamy and Harman37 have summarized a 25-year experience of a single family medicine residency, finding a 9.1 percent incidence of
Volume 135, Number 4 • Social Problems among Residents “residents in trouble.” A faculty advisor program and facilitation of psychiatric counseling were recommended, and remediation was frequently successful. Although there are considerable differences between family medicine and plastic surgery training programs, many of the social characteristics of the individuals involved are the same. Attention to these issues requires patience, creativity, sensitivity, and a commitment to the residents’ ultimate success, and adherence to institutional, legal, and accreditation body mandates. Physician well-being is the foundation of professionalism, and residency is the time when physicians need to learn the skills to have a balanced life. Residents traditionally handle the training experience by putting their personal lives on hold. They adopt a “survival attitude” and believe that “things will get better” when they finish training.38 Unfortunately, this approach means they do not get experience prioritizing, balancing, and developing a personal philosophy about work, self-care, family, and broader interests. Physicians have a higher prevalence of affective disorders, substance abuse, social isolation, and self-neglect than does the general population. The propensity for these problems may well be engendered during residency. It is the responsibility of educators in graduate medical education to reverse this trend. Charles N. Verheyden, M.D., Ph.D. Scott and White Healthcare Division of Plastic Surgery 2401 South 31st Street Temple, Texas 76508 [email protected]
references 1. Accreditation Council for Graduate Medical Education. Accreditation Council for Graduate Medical Education Web site. Available at: http://www.acgme.org. Accessed January 15, 2014. 2. Association of Medical Colleges Group on Resident Affairs. Core competencies for institutional GME leaders/designated institutional officials. Available at: https://www.aamc.org/ download/84440/data/core_competencies_08.pdf. Accessed September 18, 2014. 3. The Joint Commission. Comprehensive Accreditation Manual for Hospitals, Standard MS.11.01.0. Available at: http://www. jointcommission.org/standards_information/edition.aspx. Accessed September 18, 2014. 4. The Joint Commission. Sentinel event alert. Available at: http://www.jointcommission.org/assets/1/18/SEA_48.pdf. Accessed September 18, 2014. 5. United States Census Bureau. 2011 Statistical Abstract, The National Data Book, U. S. Census Bureau, Table 129. Available at: http://www.census.gov/prod/www/statistical_abstract. html. Accessed September 18, 2014. 6. Sotile WM, Sotile MO. The Medical Marriage: A Couple’s Survival Guide. New York: Carol Publishing; 1996.
7. Gander P, Briar C, Garden A, Purnell H, Woodward A. A gender-based analysis of work patterns, fatigue, and work/ life balance among physicians in postgraduate training. Acad Med. 2010;85:1526–1536. 8. Vaillant GE, Sobowale NC, McArthur C. Some psychologic vulnerabilities of physicians. N Engl J Med. 1972;287:372–375. 9. Christensen JF, Levinson W, Dunn PM. The heart of darkness: The impact of perceived mistakes on physicians. J Gen Intern Med. 1992;7:424–431. 10. Forsythe M, Calnan M, Wall B. Doctors as patients: Postal survey examining consultants and general practitioners adherence to guidelines. BMJ 1999;319:605–608. 11. Stoudemire A, Rhoads JM. When the doctor needs a doctor: Special considerations for the physician-patient. Ann Intern Med. 1983;98:654–659. 12. Miller MN, McGowen KR. The painful truth: Physicians are not invincible. South Med J. 2000;93:966–973. 13. Rollman BL, Mead LA, Wang NY, Klag MJ. Medical specialty and the incidence of divorce. N Engl J Med. 1997;336:800–803. 14. Accreditation Council for Graduate Medical Education. Graduate Medical Education Data Resource Book, Academic Year 2009–2010. Available at: https://www.acgme.org/ acgmeweb/Portals/0/PFAssets/PublicationsBooks/2009. Accessed: September 18, 2014. 15. Lashbrook DL, Frazier LM, Horbelt DV, Stembridge TW, Rall MJ. Pregnancy during obstetrics and gynecology residency: Effect on surgical experience. Am J Obstet Gynecol. 2003;189:662–665. 16. Walsh A, Gold M, Jensen P, Jedrzkiewicz M. Motherhood during residency training: Challenges and strategies. Can Fam Physician 2005;51:990–991. 17. Finch SJ. Pregnancy during residency: A literature review. Acad Med. 2003;78:418–428. 18. Klevan JL, Weiss JC, Dabrow SM. Pregnancy during pediatric residency: Attitudes and complications. Am J Dis Child. 1990;144:767–769. 19. Phelan ST. Pregnancy during residency: II. Obstetric complications. Obstet Gynecol. 1988;72:431–436. 20. Gabbe SG, Morgan MA, Power ML, Schulkin J, Williams SB. Duty hours and pregnancy outcome among residents in obstetrics and gynecology. Obstet Gynecol. 2003;102:948–951. 21. Sells JM, Sells CJ. Pediatrician and parent: A challenge for female physicians. Pediatrics 1989;84:355–361. 22. Price MA, Cohn SM, Love J, Dent DL, Esterl R. Educational debt of physicians-in-training: Determining the level of interest in a loan repayment program for service in a medically underserved area. J Surg Educ. 2009;66:8–13. 23. McDonald FS, West CP, Popkave C, Kolars JC. Educational debt and reported career plans among internal medicine residents. Ann Intern Med. 2008;149:416–420. 24. Teichman JM, Cecconi PP, Bernheim BD, et al. How do residents manage personal finances? Am J Surg. 2005;189: 134–139. 25. Milling TJ. Drug and alcohol use in emergency medicine residency: An impaired resident’s perspective. Ann Emerg Med. 2005;46:148–151. 26. Flaherty JA, Richman JA. Substance use and addiction among medical students, residents, and physicians. Psychiatr Clin North Am. 1993;16:189–197. 27. Murray RM. Psychiatric illness in doctors. Lancet 1974;1:1211–1213. 28. Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Stress and coping among orthopaedic surgery residents and faculty. J Bone Joint Surg Am. 2004;86:1579–1586.
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Plastic and Reconstructive Surgery • April 2015 29. Yarborough WH. Substance use disorders in physician training programs. J Okla State Med Assoc. 1999;92:504–507. 30. Dunn LB, Green Hammond KA, Roberts LW. Delaying care, avoiding stigma: Residents’ attitudes toward obtaining personal health care. Acad Med. 2009;84:242–250. 31. Moutier C, Cornette M, Lehrmann J, et al. When residents need healthcare: Stigma of the patient role. Acad Psychiatry 2009;33:431–441. 32. Levey RE. Sources of stress for residents and recommendations for programs to assist them. Acad Med. 2001;76: 142–150. 33. Goebert D, Thompson D, Takeshita J, et al. Depressive symptoms in medical students and residents: A multischool study. Acad Med. 2009;84:236–241.
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34. Sangi-Haghpeykar H, Ambani DS, Carson SA. Stress, workload, sexual well-being and quality of life among physician residents in training. Int J Clin Pract. 2009;63:462–467. 35. van der Heijden F, Dillingh G, Bakker A, Prins J. Suicidal thoughts among medical residents with burnout. Arch Suicide Res. 2008;12:344–346. 36. Baldwin DC Jr, Daugherty SR. Interprofessional conflict and medical errors: Results of a national multi-specialty survey of hospital residents in the US. J Interprof Care 2008;22:573–586. 37. Reamy BV, Harman JH. Residents in trouble: An in-depth assessment of the 25-year experience of a single family medicine residency. Fam Med. 2006;38:252–257. 38. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114:513–519.
Background: It is presumed that plastic surgery residents experience various social problems, just as do their peers in other specialty training programs and in the general public. These issues can occasionally disrupt the resident’s personal training experience and sometimes the program as a whole. A survey was performed to assess the magnitude of the problem, and the issues revealed were assessed to assist the program director and the resident in reaching successful completion of the residency. Methods: A survey was designed by the executive committee and staff of the American Council of Academic Plastic Surgeons and sent to all plastic surgery training programs in the United States. A response rate of 66 percent was achieved. The programs reported on the social issues occurring in their residents over the preceding 5 years. The results were presented at a business meeting of the Council. Results: Thirty-seven percent of programs reported that at least one resident had left their program during the study period. Twenty percent reported that a resident had been asked to leave the program. The frequency of social problems resulting in disruption of the training program was tabulated in the following areas: divorce; pregnancy/parturition; financial, legal, or family issues; drug or alcohol abuse; illness/injury; and interpersonal conflicts. Conclusions: Plastic surgery residents experience social problems that can affect the timely completion of their training. Attention to these issues requires patience, creativity, sensitivity, and a commitment to the residents’ ultimate success, and adherence to institutional, legal, and accreditation body mandates. (Plast. Reconstr. Surg. 135: 772e, 2015.)
P
lastic surgery residents are contemporary adults and, as such, experience the same problems as do their peers in other walks of life, although sometimes with different frequencies. Some of these problems impact the ability of the resident to carry out his or her duties, both educational and service related. This can result in other difficulties, not only for the individual resident, but also for the program director and the other residents in the program. When these issues become significant enough that training program disruptions occur, program directors may find themselves having to deal with circumstances that From the Division of Plastic Surgery, Department of Surgery, Scott & White Healthcare; the Office of Graduate Medical Education and Division of Plastic Surgery, University of California San Francisco; and the Accreditation Council for Graduate Medical Education. Received for publication February 14, 2014; accepted September 19, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001098
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may be unusual in their experience and that may also be unpleasant. Because some of these issues are fortunately infrequent, the program director may be unsure how to handle the situation from institutional and legal points of view and to also maintain confidentiality and due process in a way that meets both their institutional and Accreditation Council for Graduate Medical Education standards.1 At the same time, the program director wants to handle matters in such a way that the individual resident can be helped through the difficult time and successfully complete the program if possible.
METHODS To assess the magnitude of this problem, a questionnaire was prepared and reviewed by the Executive Committee and staff of the American
Disclosure: The authors have no financial information to disclose.
www.PRSJournal.com
Volume 135, Number 4 • Social Problems among Residents Council of Academic Plastic Surgeons. Questions were assessed for bias and structured to identify the presence of certain problems that residents may experience and to determine whether or not these problems had impacted the training of individual residents or the program. Questions were reviewed and ultimately revised by the committee until it was determined that the survey achieved face validity. The survey was sent to 89 programs; responses were received from the program directors of 59, for a response rate of 66 percent. A second reminder was sent to increase the response rate. The assessment of whether the resident’s performance was affected by the problem was performed by the program director. This assessment could well have included in-service examination scores, faculty evaluations, attendance/attention at conferences, or lapses in patient care, and the program director’s personal interaction with the resident. Further detail on how this assessment was made was not investigated. We tabulated the survey responses and present the frequency of responses along with corresponding 95 percent confidence intervals. The specific problems about which questions were asked are listed in Table 1. After the response period was closed, the results were tabulated and presented at an organizational retreat presented at the Annual Meeting of the American Council of Academic Plastic Surgeons. Perspectives on managing these issues were presented by Mary H. McGrath, M.D., M.P.H. (institutional), Peggy Simpson, Ed.D. (accreditation), and Lisa Havens, J.D. (legal). Case studies were also presented by various program directors and a discussion was held by the members of the association. After this review, it seemed appropriate to summarize the information for dissemination, so that program directors faced with these issues could develop a framework for dealing with them.
RESULTS In the survey, each question referred to all residents in the program in the previous 5 years. Table 1. Categories of Social Problems Addressed Divorce Pregnancy and childbearing Family, legal, or financial Drug/alcohol abuse Illness/injury Interpersonal conflicts
The median total number of residents in each program during this time was 10 (range, zero to 24). The total number of residents graduating in the preceding 5 years from the responding programs was 587. Thirty-seven percent of programs reported that at least one resident had not completed the program, and 20 percent reported that at least one resident did not complete the program because they had been asked to leave. Table 2 shows the tabulation of survey responses. In 25 percent of programs, at least one resident had divorced during the program, totaling 17 residents. For 10 of these residents, the divorce did affect their performance. In 73 percent of programs, at least one resident or their spouse became pregnant and delivered the baby during the residency, totaling over 131 residents. In situations where the resident delivered the baby, programs reported that 22 residents took more than three weeks of leave. Eleven made up the time; for seven, the missed time affected their performance. In situations where the spouse delivered the baby, programs reported that only 10 residents took more than 1 week of leave. Four made up the time, but the missed time did not affect performance of any of them. In 37 percent of programs, at least one resident experienced significant family, financial, or legal issues, totaling more than 39 residents (7 percent). Eighteen had family issues, 16 had financial issues, and three had legal issues. For nine, the program reported that these issues had Table 2. Tabulation of Survey Responses* Social Issue Divorce No. (%) 95% CI Pregnancy, spousal pregnancy No. (%) 95% CI Family, financial, legal issues No. 95% CI Drug/alcohol abuse No. (%) 95% CI Illness or injury No. (%) 95% CI Interpersonal conflict No. (%) 95% CI
Programs
Residents
15 (25) 15–39%
17 (3) 2–5%
43 (73) 60–83%
131†
22 (37) 25–51%
39†
5 (8) 3–19%
5 (0.9) 0.3–2%
18 (31) 20–44%
19 (3) 2–5%
33 (56) 42–69%
53 (9) 7–12%
*No response to a given question is counted as though the program had no residents dealing with the social issue. †The question was worded to allow responses of “more than 4” residents dealt with the issue. In these cases, precise counts were not possible.
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Plastic and Reconstructive Surgery • April 2015 affected their performance. Six missed more than 3 weeks from the program, and all six made up their missed time. In only 8 percent of programs (five residents, 0.9 percent of total) did a resident become involved in drug/alcohol abuse, and all of these programs reported that performance was affected and that the resident was referred to an impaired-physician program. In 31 percent of programs, at least one resident had experienced significant illness or injury, totaling 19 residents. Among these residents, the illness or injury affected the performance of seven of them, eight missed more than 3 consecutive weeks, and five made up the missed time; for three, the missed time affected their performance. In 56 percent of programs, at least one resident experienced significant interpersonal conflicts with other residents, office or hospital staff, faculty, or patients, totaling 53 residents. Twenty had conflicts with other residents, 17 had conflicts with faculty, seven had conflicts with staff, one had a conflict with a patient, and seven had conflicts with multiple groups. For 15 residents (2.5 percent), the program reported that their performance was affected. Accreditation Council for Graduate Medical Education/Residency Review Committee for Plastic Surgery Perspective The Accreditation Council for Graduate Medical Education’s purview of authority derives from both the institutional requirements and the program requirements. Institutional requirements pertaining to resident well-being, which the Accreditation Council for Graduate Medical Education expects sponsoring institutions and programs to provide, include the following: 1. Benefits and conditions of appointment (institutional requirement II.C). 2. Counseling services (institutional requirement II.D.4.k). 3. Physician impairment (institutional requirement II.D.4.1). 4. Harassment (institutional requirement II.D.4.m). 5. Accommodation for disabilities (institutional requirement II.D.4.n). The language provided in the institutional requirements allows for each local sponsoring institution to develop its own policies and procedures. When the Institutional Review Committee and the Residency Review Committee for Plastic Surgery review programs that have
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recently addressed issues for residents with social problems, it assesses the answers to the following questions: (1) Did the sponsoring institution/program have the required policies and procedures in place to address the issue? (2) Did the sponsoring institution/program follow its policies and procedures? (3) Is there a trend of residents with social problems in the sponsoring institution/program? The program requirements positively address these issues with requirements for education on being fit for duty, promoting resident well-being and patient safety, and promoting a culture of professionalism. Residents and faculty must recognize personal responsibility in time management, recognizing and reporting impairment, and transitioning patient care if necessary (VI.A.1,2,5.c-3; VI.A.6). Once the program director has determined that resident remediation and/or time off is required to address the issue, the program director is obligated to: 1. Notify the Residency Review Committee for Plastic Surgery of the remediation timeline and general activities included in the remediation plan. 2. Assess and notify the Residency Review Committee for Plastic Surgery if the remediation will cause the resident to graduate “off-cycle” (i.e., beyond June 30 of the original year of graduation). If the graduation date will be postponed and the program’s next cohort of resident complement is full, the program director must make a request for a temporary increase in resident complement through Accreditation Council for Graduate Medical Education’s Accreditation Data System. In this instance, the Residency Review Committee for Plastic Surgery advises program directors to contact the American Board of Plastic Surgery to ensure that any issues arising from an offcycle graduation are addressed so as to allow the affected resident to remain eligible for the certification process. Institutional Perspective In addition to an institution providing educational, fiscal, and administrative support for the institution’s graduate medical education programs, its scope of responsibility also includes support for the well-being and development of its residents. “Core Competencies for Institutional GME Leaders/Designated Institutional Officials”2 defines well-being and covers multiple
Volume 135, Number 4 • Social Problems among Residents environmental factors to be addressed when overseeing the institution’s residents and recommends various areas for focused attention. Understanding the factors that may contribute to distress during residency training and making proactive changes requires action at the institutional graduate medical education level, because many of them require resources that exceed those of any single residency program. These efforts should increase awareness, alleviate distress, and develop outreach to doctors in distress.3 The institutional graduate medical education office and the medical center leadership are required by accrediting bodies such as The Joint Commission to have processes in place to promote physician wellness.4 Residents are challenged continually by inefficiencies and mistreatment in the work environment. Graduate medical education can respond by giving credibility to resident complaints; in some institutions, providing an ombudsman has been helpful. The graduate medical education office can also provide institutional sources of support for residents and program directors such as providing free, “off-campus” mental health services at no charge and equipping program directors with appropriate information and education about these services. The institutional graduate medical education group can lead efforts to help residents by providing programming for residents about strategies for resiliency and wellness. Funding becomes an issue if a resident’s training period is extended, and arriving at the best arrangement to cover these costs requires careful planning between the institution, the department, and the program. Legal Perspective Residency is a challenging time in the life of a young physician and can have an adverse impact on the resident professionally, particularly if disruptive behavior or medical errors result. The legal and risk management team should be consulted early to provide a thorough investigation and appropriate documentation. They are most helpful in determining compliance with hospital policies and external laws dealing with employment, malpractice, and privacy. The objective is assessing risk, mitigating harm, and preparing for a possible legal case in a way that is safe and protected from discovery. A program director also may have a duty to report disciplinary action to state licensing boards and be involved in providing references and evaluations for a resident who is applying for
hospital privileges. In the case of a problematic resident, legal advice is advisable for answering and responding to these requests. The perspectives of the patient, the resident, the employer, the program and the public must be balanced with legal guidance.
DISCUSSION This study raises additional questions. Although these issues and their frequencies are documented in this study, the solutions for dealing with them remain elusive, at least partially because individual circumstances come to bear on each case. The problem-solving abilities of the resident and the program director are influential variables, and the nuances of the perspectives covered in this article will vary from institution to institution. It does seem appropriate, however, to make some recommendations. Divorce The divorce rate in the United States is 4.1 per 1000 people.5 It has been reported that the rate in physicians is 10 to 20 percent higher.6 Gander and colleagues7 have shown that difficulties in home life, social life, and personal relationships are statistically significantly related to fatigue. Multiple other factors may impact this issue, however, such as psychological predisposition of those entering medical school8; perfectionism9; suppressing feelings of inadequacy or distress; invincibility or a lack of trust in others10; having a “VIP” mentality11; and difficulty setting appropriate limits.12 Specialty also impacts divorce, and surgeons are second only to psychiatrists in divorce rates over the long term.13 Our survey showed that at least 2.9 percent of residents (17 of 587) became divorced during their residency, a relatively small window of their lives, indicating that the ultimate rate is probably significantly higher. It would seem to be appropriate that marriage support be provided during the residency years in the form of counseling resources or even an occasional conference on relationship issues. A generic inquiry (e.g., “How are things outside the hospital?”) could lead to a conversation that would be helpful in facilitating the social and professional success of the resident. However, the resident should never be pressured to share personal information with the program director.
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Plastic and Reconstructive Surgery • April 2015 Pregnancy and Childbearing In the United States, 42 percent of all residents and 24 percent of all plastic surgery residents are female.14 Pregnancy and parturition was an issue in almost three-fourths of plastic surgery programs during the 5-year survey period. It has been shown in obstetrics and gynecology residencies that missed time did not significantly affect surgical experience.15 Whether they miss significant time or not, this is a very stressful time for these women and it does not end after the baby is born.16 It has also been shown that pregnancy complications are higher than in the rest of the population,17–19 although most have a good pregnancy outcome.20 Three-fourths of residents who were pregnant during residency reported it to be an unpleasant experience.18 In a survey of pediatric residents, 26 percent believed they were penalized for their maternity leave and 24 percent believed their pregnancies were actively discouraged.21 It is certainly to be expected that young women will get pregnant during this phase of their lives, and pregnancy should not be considered a “problem,” explicitly or implicitly. Therefore, the institution’s parental leave policies should be distributed and understood by everyone. Family, Legal, and Financial Problems There is not a lot of information in the literature regarding family and legal matters, but there are two studies that show that residents have an average educational debt exceeding $100,000.22,23 Ten percent of residents have credit card debt over $10,000. Compared with controls, residents hold greater median ratios of debt to household income, less net wealth to income, and fewer assets to income. Surgery residents were the least “financially conservative.”24 These problems can carry over into practice. As incomes rise, a pattern of poor financial choices can lead to serious difficulties. It would seem prudent to include personal financial management in program conferences, such as the annual Chief Residents’ Conference held by American Society of Plastic Surgeons and The Plastic Surgery Foundation, and making financial counseling available in the institution. Drug and Alcohol Abuse This issue is less of a problem in residents than in their age-matched peers.25,26 In practicing physicians, the rate of narcotic addition has been reported in the past to be 30 to 100 times greater than in the general population.27 There
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is no gender differential.28 A significant minority begin using drugs or alcohol during residency.25 The number reported was only 0.9 percent in our study of plastic surgery residents, but in every instance, the resident’s performance was affected, and all were referred to an impairedphysician program. This referral is important, because the death rate related to abuse in physicians has been reported to be over 16 percent,29 not to mention the potential impact on patient safety. Fortunately, when treated properly, physicians have a good record of responding favorably to treatment.26,29 These facts emphasize the importance of identifying and addressing substance abuse problems as early as possible, particularly because the resident is often reluctant to seek help.30,31 Illness and Injury Most of the literature dealing with resident illness focuses on those of a psychiatric/psychological nature (e.g., stress, anxiety, burnout, sexual health, suicidal thinking), situations that are unfortunately common.28,32–35 Our survey results indicated that even nonpsychiatric illnesses are not rare and occasionally do have negative outcomes for the individuals involved. The absence of a trainee for several weeks or months can be very problematic. Counseling or ombudsman arrangements should be not only available but also actively promoted to residents and detailed in institutional and program literature. Interpersonal Conflicts Although reported by the majority of programs [53 total residents (56 percent)], intrinsic personality disorders are difficult to differentiate from those resulting from the other issues mentioned. Baldwin and Daugherty36 reported a significant increase in significant medical errors and adverse medical outcomes when residents were having interpersonal conflicts with other residents, supervising faculty, or nurses.36 Consequently, prompt conflict resolution must be initiated, optimally consistent with existing institutional policies. These policies must allow for considerable individual variation,32 and they make handling the specific situation much easier for the program director.
CONCLUSIONS Reamy and Harman37 have summarized a 25-year experience of a single family medicine residency, finding a 9.1 percent incidence of
Volume 135, Number 4 • Social Problems among Residents “residents in trouble.” A faculty advisor program and facilitation of psychiatric counseling were recommended, and remediation was frequently successful. Although there are considerable differences between family medicine and plastic surgery training programs, many of the social characteristics of the individuals involved are the same. Attention to these issues requires patience, creativity, sensitivity, and a commitment to the residents’ ultimate success, and adherence to institutional, legal, and accreditation body mandates. Physician well-being is the foundation of professionalism, and residency is the time when physicians need to learn the skills to have a balanced life. Residents traditionally handle the training experience by putting their personal lives on hold. They adopt a “survival attitude” and believe that “things will get better” when they finish training.38 Unfortunately, this approach means they do not get experience prioritizing, balancing, and developing a personal philosophy about work, self-care, family, and broader interests. Physicians have a higher prevalence of affective disorders, substance abuse, social isolation, and self-neglect than does the general population. The propensity for these problems may well be engendered during residency. It is the responsibility of educators in graduate medical education to reverse this trend. Charles N. Verheyden, M.D., Ph.D. Scott and White Healthcare Division of Plastic Surgery 2401 South 31st Street Temple, Texas 76508 [email protected]
references 1. Accreditation Council for Graduate Medical Education. Accreditation Council for Graduate Medical Education Web site. Available at: http://www.acgme.org. Accessed January 15, 2014. 2. Association of Medical Colleges Group on Resident Affairs. Core competencies for institutional GME leaders/designated institutional officials. Available at: https://www.aamc.org/ download/84440/data/core_competencies_08.pdf. Accessed September 18, 2014. 3. The Joint Commission. Comprehensive Accreditation Manual for Hospitals, Standard MS.11.01.0. Available at: http://www. jointcommission.org/standards_information/edition.aspx. Accessed September 18, 2014. 4. The Joint Commission. Sentinel event alert. Available at: http://www.jointcommission.org/assets/1/18/SEA_48.pdf. Accessed September 18, 2014. 5. United States Census Bureau. 2011 Statistical Abstract, The National Data Book, U. S. Census Bureau, Table 129. Available at: http://www.census.gov/prod/www/statistical_abstract. html. Accessed September 18, 2014. 6. Sotile WM, Sotile MO. The Medical Marriage: A Couple’s Survival Guide. New York: Carol Publishing; 1996.
7. Gander P, Briar C, Garden A, Purnell H, Woodward A. A gender-based analysis of work patterns, fatigue, and work/ life balance among physicians in postgraduate training. Acad Med. 2010;85:1526–1536. 8. Vaillant GE, Sobowale NC, McArthur C. Some psychologic vulnerabilities of physicians. N Engl J Med. 1972;287:372–375. 9. Christensen JF, Levinson W, Dunn PM. The heart of darkness: The impact of perceived mistakes on physicians. J Gen Intern Med. 1992;7:424–431. 10. Forsythe M, Calnan M, Wall B. Doctors as patients: Postal survey examining consultants and general practitioners adherence to guidelines. BMJ 1999;319:605–608. 11. Stoudemire A, Rhoads JM. When the doctor needs a doctor: Special considerations for the physician-patient. Ann Intern Med. 1983;98:654–659. 12. Miller MN, McGowen KR. The painful truth: Physicians are not invincible. South Med J. 2000;93:966–973. 13. Rollman BL, Mead LA, Wang NY, Klag MJ. Medical specialty and the incidence of divorce. N Engl J Med. 1997;336:800–803. 14. Accreditation Council for Graduate Medical Education. Graduate Medical Education Data Resource Book, Academic Year 2009–2010. Available at: https://www.acgme.org/ acgmeweb/Portals/0/PFAssets/PublicationsBooks/2009. Accessed: September 18, 2014. 15. Lashbrook DL, Frazier LM, Horbelt DV, Stembridge TW, Rall MJ. Pregnancy during obstetrics and gynecology residency: Effect on surgical experience. Am J Obstet Gynecol. 2003;189:662–665. 16. Walsh A, Gold M, Jensen P, Jedrzkiewicz M. Motherhood during residency training: Challenges and strategies. Can Fam Physician 2005;51:990–991. 17. Finch SJ. Pregnancy during residency: A literature review. Acad Med. 2003;78:418–428. 18. Klevan JL, Weiss JC, Dabrow SM. Pregnancy during pediatric residency: Attitudes and complications. Am J Dis Child. 1990;144:767–769. 19. Phelan ST. Pregnancy during residency: II. Obstetric complications. Obstet Gynecol. 1988;72:431–436. 20. Gabbe SG, Morgan MA, Power ML, Schulkin J, Williams SB. Duty hours and pregnancy outcome among residents in obstetrics and gynecology. Obstet Gynecol. 2003;102:948–951. 21. Sells JM, Sells CJ. Pediatrician and parent: A challenge for female physicians. Pediatrics 1989;84:355–361. 22. Price MA, Cohn SM, Love J, Dent DL, Esterl R. Educational debt of physicians-in-training: Determining the level of interest in a loan repayment program for service in a medically underserved area. J Surg Educ. 2009;66:8–13. 23. McDonald FS, West CP, Popkave C, Kolars JC. Educational debt and reported career plans among internal medicine residents. Ann Intern Med. 2008;149:416–420. 24. Teichman JM, Cecconi PP, Bernheim BD, et al. How do residents manage personal finances? Am J Surg. 2005;189: 134–139. 25. Milling TJ. Drug and alcohol use in emergency medicine residency: An impaired resident’s perspective. Ann Emerg Med. 2005;46:148–151. 26. Flaherty JA, Richman JA. Substance use and addiction among medical students, residents, and physicians. Psychiatr Clin North Am. 1993;16:189–197. 27. Murray RM. Psychiatric illness in doctors. Lancet 1974;1:1211–1213. 28. Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Stress and coping among orthopaedic surgery residents and faculty. J Bone Joint Surg Am. 2004;86:1579–1586.
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Plastic and Reconstructive Surgery • April 2015 29. Yarborough WH. Substance use disorders in physician training programs. J Okla State Med Assoc. 1999;92:504–507. 30. Dunn LB, Green Hammond KA, Roberts LW. Delaying care, avoiding stigma: Residents’ attitudes toward obtaining personal health care. Acad Med. 2009;84:242–250. 31. Moutier C, Cornette M, Lehrmann J, et al. When residents need healthcare: Stigma of the patient role. Acad Psychiatry 2009;33:431–441. 32. Levey RE. Sources of stress for residents and recommendations for programs to assist them. Acad Med. 2001;76: 142–150. 33. Goebert D, Thompson D, Takeshita J, et al. Depressive symptoms in medical students and residents: A multischool study. Acad Med. 2009;84:236–241.
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34. Sangi-Haghpeykar H, Ambani DS, Carson SA. Stress, workload, sexual well-being and quality of life among physician residents in training. Int J Clin Pract. 2009;63:462–467. 35. van der Heijden F, Dillingh G, Bakker A, Prins J. Suicidal thoughts among medical residents with burnout. Arch Suicide Res. 2008;12:344–346. 36. Baldwin DC Jr, Daugherty SR. Interprofessional conflict and medical errors: Results of a national multi-specialty survey of hospital residents in the US. J Interprof Care 2008;22:573–586. 37. Reamy BV, Harman JH. Residents in trouble: An in-depth assessment of the 25-year experience of a single family medicine residency. Fam Med. 2006;38:252–257. 38. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114:513–519.
