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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.54 no.3 Campinas May/June 2004
Mentoring during residency in anesthesiology. The Irmandade da Santa Casa de Misericórdia, São Paulo program*
Tutoría con médicos practicantes en anestesiologia. El programa de la Hermandad Santa Casa de Misericordia de São Paulo
José Álvaro Marques Marcolino, M.D.I; Joaquim Edson Vieira, TSA, M.D.II; Luiz Piccinini Filho, M.D.III; Lígia Andrade da Silva Telles Mathias, TSA, M.D.IV
IProfessor Adjunto, Departamento de
Psiquiatria, Central Hospital, Irmandade da Santa Casa de São Paulo
IICoordenador do Centro para Desenvolvimento da Educação Médica, CEDEM da Faculdade de Medicina da Universidade de São Paulo
IIIDiretor do Serviço e Disciplina de Anestesiologia do Hospital Santa Isabel, São Paulo
IVDiretora do Serviço e Disciplina de Anestesiologia, Irmandade da Santa Casa de São Paulo e Faculdade de Ciências Médicas da Santa Casa de São Paulo; Responsável CET/SBA, ISCMSP; Coordenadora do Núcleo de Apoio a Projetos Pedagógicos da Faculdade de Ciências Médicas da Santa Casa de São Paulo
BACKGROUND AND OBJECTIVES: Medical training
programs may bring emotional distress. The main objective of this study was
describes a mentoring program during the residence training period of physicians
METHODS: The program was instituted at the Central Hospital of the Irmandade da Santa Casa de Misericórdia, São Paulo. In this program were included 27 residents in Anesthesiology and 4 health professionals that made up the mentoring team. The study was made through a evaluation of a questionnaire applied on first and second-year residents' opinion about education in Anesthesiology. It was developed, with twelve questions and three answers for each question, which has been applied before and after the program. Residents were divided in four groups: first year residents; second year residents; first and second-year residents (2 groups). Mentoring meetings were monthly held on Thursdays, 7 a.m. and lasted for one hour.
RESULTS: Residents routine was considered adequate. There has been decreased frustration and an improved self-confidence. A high number has reported higher enthusiasm for Anesthesiology and higher expectations as to post-Residency opportunities. Mentors have reported the importance of mandatory meetings, the increase of discussion about humanization and the possibility of mentors' un-preparedness as a limiting factor.
CONCLUSIONS: Mentoring programs may be tools for adapting residents to the training program in Anesthesiology.
Key Words: ANESTHESIOLOGY: medical education, mentoring
JUSTIFICATIVA Y OBJETIVOS: La práctica
médica puede traer desgaste emocional. Este artículo describe
un programa de tutoría durante el período de entrenamiento de los
médicos en Anestesiología.
MÉTODO: El programa fue instituido en la Hermandad de la Santa Casa de Misericordia de São Paulo. Veintisiete practicantes de Anestesiología participaron del programa y cuatro profesionales de salud constituyeron el equipo de tutoría. Un cuestionario sobre las impresiones de los médicos practicantes de primero y segundo año a respecto de la formación médica en Anestesiología fue desarrollado con doce preguntas y tres respuestas para cada uno, siendo aplicado antes y en el fin del programa. Fueron constituidos cuatro grupos de practicantes: practicantes del 1º ano; practicantes del 2º ano; practicantes del 1º ano y 2º ano (2). Las reuniones de tutoría ocurrieron mensualmente los jueves, 7h00, con duración de una hora.
RESULTADOS: El cotidiano del practicante fue considerado adecuado. Hubo reducción en la frustración y mejoría en la auto-confianza. Un número elevado describió mayor entusiasmo por la Anestesiología y expectativas más elevadas en relación al futuro después del aprendizaje. Los tutores relataron la importancia de reuniones obligatorias, la posibilidad de discutir la humanización y la posibilidad de despreparo de los tutores como un factor de la limitación.
CONCLUSIONES: El programa de tutoría puede ser considerado como un instrumento para la adaptación de los residentes en el programa de Anestesiología.
Physicians education during medical residency gives priority to technical contact with patients and chosen speciality instructors. If during graduation future physicians may enjoy a certain protection aura for mobilizing subjects or situations, during residency program this protection may totally disappear. Some times this situation is a cause of intensive emotional mobilization, which may result in stress or depression or even in non-adaptation to the speciality.
In a recent survey, one third of resident physicians in Medical Clinic have answered to STAI (Spielberger) and BDI (Beck) questionnaires suggesting mild to severe depression 1. Based on these results, the Medical Residency program of Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, has started with mentoring activities aiming at observing, reflecting and defining individual and collective experiences during medical residency. Regardless of individual or collective benefits, mentoring does not answer to several dilemmas or questions of professionals decided to dedicate themselves to Medical Clinic. However, and this seems to be paramount, mentoring may indicate that the search for such answers does not have to be clandestine or even solitary 2.
In developing mentoring programs, institutions have more opportunities to identify education problems and possible solutions 3. It may be very important to emphasize that members may bring proposals coming from those living such problems and that they may suggest different directions, complementing or even going beyond Institutions' interpretation.
Mentoring activities may be defined as close follow up and systematic guidance of resident physicians groups, by people experienced in medical education. Its general objectives are to enhance professional education perspectives, integrating biological, psychological and social dimensions. This activity assures an institutional space to translate learning experience into services, fundamental characteristic of Medical Residency. Mentoring creates a moment of individual resident recognition by the Institution. Mentoring may favor workgroup abilities, promoting continuous cooperation and encouragement among group members. Exchange of experiences in facing difficulties, respect to common objectives and, especially, a less solitary and more creative analysis of problems related to future professional practice development are part of mentoring activities.
This article describes the implementation of a mentoring pilot project to follow up resident physicians education. The program was instituted for Anesthesiology at the Central Hospital of the Irmandade da Santa Casa de Misericórdia, São Paulo.
Participated in this study first and second year resident and trainee physicians of the Anesthesiology Department of Santa Casa de Misericórdia, São Paulo, in a total of 27 physicians.
Mentoring group was made up of four health professionals, three physicians and one nurse. These professionals were invited by the Anesthesiology Department Directors and had no previous experience with mentoring. All had shown interest in medical education and main in Mentoring Programs for medical students.
Two preliminary meetings were held in the presence of a four guest experienced in Mentoring Programs with resident physicians and graduation students.
The preparatory phase consisted of mentors' experience reports, group discussions about this experience, group's expectations with the new program and willingness to encourage dialog and experience sharing during medical education.
A questionnaire on first and second year resident and trainee physicians' opinion about medical education in Anesthesiology was applied. Questionnaire had 12 questions with three answer alternatives each, considering situations adequate or maintained, good or improved, poor or decreased. The same questionnaire was applied at the end of the Pilot Program (Attachment 1).
Resident and trainee physicians were divided in four groups with 6 to 7 participants each and organized as follows:
· first year residents and trainees with seven participants;
· second year residents and trainees with six participants;
· two groups of first and second year residents and trainees with seven participants each.
This way, groups represented what was considered a uniform, or common, group, exclusive with representatives of first or second residence year; and two groups considered heterogeneous, or complementary, with representatives of first and second residence year. Guest mentors were allocated to these four groups. Mentoring meetings were organized as follows:
· four meetings were scheduled with groups and their respective mentors;
· the meetings were monthly, starting at last week of October 2002 and lasted to January 2003;
· the meetings were scheduled for Thursday at 7 a.m. because this is the traditional and established time for Anesthesiology department meetings, with mandatory attendance of the whole Anesthesiology Department team, which allowed resident and trainee physicians to be freed from the meeting and to participate in the mentoring meeting;
· only resident and trainee physicians in immediate post-shift period or on vacations were freed from mentoring meetings;
· the meetings lasted one hour.
In the week following the meeting of mentors with resident and trainee physicians, a mentors meeting was held with department directors and was considered a supervision meeting. A mentor, specialized in psychiatry, has accumulated the functions of group mentor and supervisor and collected reports about mentoring meetings.
The results were submitted to descriptive analysis. The Chi-square test was used for exploratory evaluations and results were considered in three categories.
Median groups attendance was higher for first year residents (Table I). Routine work could be described as adequate for most residents throughout mentoring. Mild frustration decrease could be detected (Chi-square = 2.18, p = 0.336) (Figure 1). There has been, however, improved self-confidence during the period, although without statistical significance. A total of 6 residents has not considered preserved or decreased self-confidence for considering it high (Chi-square = 4.25, p = 0.119) (Figure 2). Even more positive has been the fact that a higher number of residents have described increased enthusiasm for Anesthesiology (Chi-square = 8.63, p = 0.013) (Figure 3). Higher self-confidence and enthusiasm may have influenced the expectation of higher potential as professionals after residency (chi-square = 3.86, p = 0.145) (Figure 4).
In terms of abilities to deal with professional stress, residents have not considered changes. Increased cognition observed, although mild, might have been a consequence of the progression process from the first to the second year. The same could be detected for personal and professional initiative or related to professional practice. Anesthesiology residents, however, have reported changes in patients' care during the period. Finally, there have been no reports on intensive learning method changes, and on relationships with colleagues anesthesiologists, but a mild decrease on relationships with colleagues of different specialties (Table II). Chi-square test results of table II data were not significant. In all tests however, it is necessary to stress the low representative power since there are cells with values below five. So, our results should be carefully interpreted.
It is interesting to note that some quantitative aspects investigated during the mentoring period could be grouped in positive and negative characteristics (Chart I). Other qualitative data were revealed during meetings: mentoring as a nice space to be and to share opinions, assurance of continuity, implementation of mentoring in the beginning of Medical Residency, specialist physician dignity and valuation, discussion of confrontations with other specialties, financial needs, low importance or attention to the academic career. On the other hand, mentors have reported the importance of mandatory attendance to meetings replacing one department meeting, the possibility of real, rather than theoretical humanistic experience, mentoring process questions and the possibility of mentors un-preparedness be a limiting or disaggregating factor.
This may be the first study describing the implementation of a mentoring program for Anesthesiology residents. Quantitative evaluations suggest that the program is adequate for personal and professional support during medical residency. Qualitative aspects may vary among Institutions but suggest that mentoring is an adequate moment for trust and dialog between the institution and its professionals.
The group's discussions for personal and professional support and the increase in the understanding of the stress situations during the education process during the on-hands training have been considered effective for the mental's health of this professional 4. Such programs could even be considered essential, if not mandatory 5. In this sense, the institution represented by the Anesthesiology Department, Irmandade da Santa Casa, São Paulo, has tried to carry out the program described in this article. This was due to the acknowledgment that non-adaptations may occur even among medical professionals, like the Anesthesiology residents, who have their decision assured.
The so-called "burnout" syndrome, characterized by depersonalization, emotional exhaustion and a sensation of ineffectiveness or non-productiveness may affect medical residents. Burnout is different from depression, which affects all activities of the involved person. Burnout affects people's primary activity, such as their performance during medical residency. This syndrome may affect up to 76% of resident physicians and even pose risks to patients' care 6. On the other hand, the image of resident physicians not adjusted to the service or specialty may be investigated as reason for intervention and is often considered a negative factor in a residency program. Among reasons considered indications of non-adaptation, there are: medical knowledge, clinical judgment and ineffective use of time, associated to stress or depression. It is interesting to note that such "problems" are identified by other involved people, but seldom by residents themselves 7.
The above-described aspects may point to a unidirectional approach for the problem. The training institution may offer technical conditions, even if excellent, but may not have means to measure the degree of adaptation and conformity of participants involved in it. The concept of people should be emphasized because it encompasses the professional and the individual, who are not dissociable in any relationship.
Mentoring could be seen as an institutional tool, however totally different from what could be called a control tool. Conversely, a mentoring meeting is a moment of recognition of the resident as a person and encourages his/her perception of a more solidary medicine. Solidary because both are involved in the care process: the institution exists for those looking for it, for those working with it and for the wellbeing of both, since it is made of both.
Mentoring may go beyond, because it extends truly significant relationship opportunities to other people involved with health care. It may promote a more qualified view of recognizing patients as unique human beings. It may favor workgroup abilities promoting continuous cooperation and encouragement of its members. Experience exchanges about facing difficulties, respect to common objectives, and less solitary and more creative analysis of problems related to future professional practice are part of mentoring activities.
It is important to remember that mentoring is not a group psychotherapy, is not scientific guidance or a research group. It is not pedagogic orientation or a study group, although considering all these dimensions during its periodic meetings.
Questions rose during the mentoring process and the possibility of mentors' un-preparedness be a limiting or disaggregating factor should be considered. If the health mentors should be health professionals is still to be questioned. They do not need specialized training in psychology areas. Mentors should, to the best of their efforts, know how to listen and share opinions. In a way, mentors acting this way have a chance to fully practice humanism and instigate and encourage this same behavior among training physicians. Humanism is understood as the process of humanization, of humanizing. This is a very simple process: being men probably the only living beings able to tell their story through reports and readings, the humanization process is based on the simple attitude of being open to listen and tell, to exchange experiences and compare ones history process with the others. The identification with others, the reciprocity of lives and actions is what allows human identity and awareness of potential imperfections, but also the unlimited possibility of doing it again.
Mentoring programs may be adequate tools for residents' adaptation. Higher attendance of first year residents may help their adjustment to the career. On the other hand, adjustment of second year residents to the market could be the dominant subject. Low attention to the academic career has been observed. Obligatoriness, assured by the institution, was considered a positive factor.
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Profa. Dra. Lígia Andrade da Silva Telles Mathias
Alameda. Campinas 139/41
01404-000 São Paulo, SP
Submitted for publication July 11, 2003
Accepted for publication September 17, 2003
* Received from CET/SBA da Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP), SP