Health and quality of life of medical residents

Lourenção, Luciano Garcia; Moscardini, Airton Camacho; Soler, Zaida Aurora Sperli Geraldes

doi:10.1590/S0104-42302010000100021

Abstracts

OBJECTIVE: This article highlights the relationship between health and quality of life among the resident medical staff. METHODS: A review was carried out to analyze the content of the relationship under study. Sources for this search were the Virtual Health Library (VHL), by BIREME (Centro Latino-American and Caribbean Center on Health Sciences Information), the Electronic databases Medline (Medical Literature Analysis and Retrieval System On-Line) Lilacs (Literatura Latino-American and Caribbean Health Sciences), SciELO (Scientific Electronic Library Online) and the email address scholar.google.com.br. Descriptors used were: Quality of life, Burnout, Internship and Residency. Planning and analysis of scientific literature, was performed to evaluate and discuss issues presented in the studies related to the subject, considering the distribution of publications according to country of origin, date of publication, source and title, focus of study and main conclusions. RESULTS: Studies published point to high rates of burnout, stress, depression, fatigue and insomnia among medical residents; moreover a lack of coping strategies, the relationship between workload and quality of life, require a change of medical legislation regarding work-based learning. CONCLUSION: Studies have shown that an adequate training program is needed not only to increase professional qualification and personal quality of life, but also to provide safety during patient treatment. It is known that residency training is stressful; it is nevertheless a process required to prepare for a solid career and personal growth of the young medical staff.

Quality of Life; Stress; Internship and Residency

OBJETIVO: Discutir sobre saúde e qualidade de vida de médicos residentes. MÉTODOS: Estudo de revisão bibliográfica no qual se realizou a análise de conteúdo do assunto enfocado. A fonte de busca foi a Biblioteca Virtual em Saúde (BVS), por meio da BIREME (Centro Latino-Americano e do Caribe de Informação em Ciências da Saúde), nas Bases Eletrônicas Medline (Medical Literature Analysis and Retrietal System On-Line), Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde), SciELO (Scientific Eletronic Library On Line) e pelo endereço eletrônico scholar.google.com.br. Os descritores utilizados foram: qualidade de vida, estresse, internato e residência. Realizou-se o ordenamento e a análise da bibliografia científica, de modo a avaliar e discutir aspectos apresentados nos estudos com relação à temática, considerando a distribuição das publicações segundo país de origem, o período de publicação, a fonte e o título, o foco de estudo e as principais conclusões. RESULTADOS: As publicações analisadas abordam aspectos importantes como incidências elevadas de Burnout, estresse, depressão, fadiga e sono entre os residentes; dificuldade de enfrentamento; relação entre carga horária de trabalho e qualidade de vida; necessidade de melhorias na legislação da residência médica para melhorar as condições de trabalho e aprendizado. CONCLUSÃO: A implementação de programas de assistência aos residentes produz melhorias na qualidade da capacitação profissional e na qualidade de vida pessoal, melhorando o relacionamento com os pacientes. Apesar de estressante, a residência médica é uma experiência enriquecedora, que propicia o desenvolvimento profissional e pessoal dos jovens médicos.

Qualidade de Vida; Estresse; Internato e residência

ORIGINAL ARTICLE

^ICoordenador do Curso de Enfermagem da União das Faculdades dos Grandes Lagos -UNILAGO; Docente da União das Faculdades dos Grandes Lagos - UNILAGO e da Fundação Municipal de Educação e Cultura de Santa Fé do Sul -FUNEC e Coordenador da Vigilância Epidemiológica do município de São José do Rio Preto, são José do Rio Preto, SP?

^IIDocente e orientador da graduação e pós-graduação da Faculdade de Medicina de São José do Rio Preto -FAMERP, São José do Rio Preto, SP

^IIILivre-Docente do Departamento de Enfermagem em Saúde Coletiva e Orientação Profissional; Docente e Orientadora da graduação e pós-graduação; Diretora Adjunta de Extensão de Serviços à Comunidade da Faculdade de Medicina de São José do Rio Preto -FAMERP, São José do Rio Preto, SP

ABSTRACT

OBJECTIVE: To discuss the health and quality of life of medical residents.

METHODS: Literature review analyzing the content of studies about the subject at hand. Sources for this search consisted of: Biblioteca Virtual em Saúde (BVS [Virtual Science Library]), via BIREME (Latin American and Caribbean System on Health Sciences Information); electronic databases Medline (Medical Literature Analysis and Retrietal System On-Line), Lilacs (Latin American and Caribbean Health Science Literature Database), and SciELO (Scientific Electronic Library On Line); and the search engine scholar.google.com.br. The following descriptors were used: quality of life, stress, internship, and residency, in English and in Portuguese. The bibliography collected in the process was then sorted and analyzed to assess and discuss the primary aspects of the subject, considering which countries the studies came from, when they were published, source, title, focus of study, and primary conclusions.

RESULTS: The studies analyzed showed key results and conclusions, such as high rates of burnout syndrome, stress, depression, fatigue, and sleep disorders among residents; problems coping; correlation between duty hours and quality of life; and the need to better regulate medical residency to improve work and educational conditions.

CONCLUSION: Implementing resident assistance programs leads to improvements in professional education and personal quality of life, improving relationships with patients. Though stressful, medical residency is an enriching experience, providing professional and personal development for physicians.

Key words: Quality of life. Stress. Internship and residency.

INTRODUCTION

Medical residency is a training process during which residents should find a balance between the will to care and heal, handling the feeling of helplessness before the complex health care system they are inserted, and establishing the limits of their own personal and professional identity.⁽¹⁾

The practice of medicine has intrinsic characteristics which, by themselves or in combination, define a professional environment consisting of the emotional stimuli accompanying the process of becoming sick. Stimuli include frequent contact with pain and suffering, handling physical and emotional intimacy, caring for terminal patients, and handling difficult, whiny, rebellious, uncooperative, demanding, self-destructive, and/or chronically depressed patients, as well as handling the uncertainties and limitations of medical knowledge and the health care system, which clash with demands and expectations from patients and family members, who want nothing but certainty and assurances^(2,3,4).

Various determining factors impact the health and quality of life of medical residents. In that context, assessing their quality of life (QOL) helps support actions aimed at improving the personal and professional quality of life of residents. Consequently, the process helps ensure improvements in service quality for patients.

Quality of life depends on intrinsic and extrinsic factors. Therefore, because of their places in society, quality of life means something unique for each individual. This means we cannot standardize quality of life, as it has different meanings for different individuals, depending on their objectives, goals and intentions⁽⁵⁾. QOL cannot be measured solely in terms of how long someone lives, because various factors can influence it, such as health, housing, work, leisure, and satisfaction, among others⁽⁶⁾.

This article discusses the issue of the health and quality of life of medical residents, making considerations about the literature on the subject.

METHODS

This study reviews the literature about health and quality of life of medical residents, as well as studies connected to the subject, and analyzes study content in terms of the issue.

Sources for this search consisted of: Biblioteca Virtual em Saúde (BVS [Virtual Health Library]), via BIREME (Latin American and Caribbean System on Health Sciences Information); electronic databases Medline (Medical Literature Analysis and Retrietal System On-Line), Lilacs (Latin American and Caribbean Health Science Literature Database), and SciELO (Scientific Electronic Library On Line); and the search engine scholar.google.com.br. The following descriptors were used: quality of life, stress, internship, and residency.

The bibliography collected in the process was then sorted and analyzed to assess and discuss the primary aspects of health and quality of life of medical residents in the studies, considering which countries the studies came from, when they were published; for each study, the review considered source, title, focus of study, and primary conclusions.

RESULTS

Forty two studies about health and quality of life of medical residents or connected to the subject were selected and analyzed, comprehending 38 (90.48%) articles, two (4.76%) doctoral dissertations, one (2.38%) master's thesis, and one (2,38%) editorial.

Table 1 shows the distribution of studies by country of origin of authors, showing that 37 (88.10%) studies come from the Americas, 16 of which (38.10%) from Brazil.

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In terms of year of publication, we see an increase in the number of studies starting in the 1990s. The increase grows even stronger in 2004, as shown by Table 2.

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Table 3 shows the distribution of studies by source/title, focus of study, and conclusions. We find that studies in this review discussed subjects such as burnout syndrome, sleep, stress and fatigue, coping strategies, and quality of life and duty hours of residents, as well as how residents see their education. The studies analyzed showed key results and conclusions, such as high rates of burnout syndrome, stress, depression, fatigue, and sleep disorders among residents; problems coping; correlation between duty hours and quality of life; and the need to better regulate medical residency to improve work and educational conditions.

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DISCUSSION

In reviewing the literature about health and quality of life of medical residents, we find that studies about the subject increase significantly from 2004 onwards, with many studies written by Brazilian (38.10%) and American (33.34%) authors. The primary issues discussed are burnout syndrome, sleep disorders, stress, fatigue, and life and work coping strategies.

Considering medical residencies are teaching programs defined by full-time training under supervision, they are the best method available for enhancement and specialization in the health sciences.

It is well known that residents experience various types of stress during training, and that such stress factors can cause harmful effects on residents, impacting quality of patient care.

For Tokarz et al.⁷, factors such as student-doctor transition, professional responsibility, social isolation, fatigue, sleep deprivation, overwork, fear of committing mistakes and other factors connected to the residency educational process are associated with psychological, psychopathological and behavioral responses, including depressive states accompanied by suicidal thoughts, excess alcohol consumption, drug addiction, chronic anger and the development of bitter skepticism and gallows humor, turning medical residents into a high risk group for emotional conditions.

According to Lima et al.⁸, medical residents can be more susceptible to burnout syndrome (defined by Maslach⁽⁹⁾ as a cumulative reaction to continuous occupational stress factors, characterized by severity, disruption of adaptation, development of negative attitudes and behaviors leading to lower personal achievement at work) because they have to answer to demands from supervisors, society at large and themselves. They also experience dual roles: supervisors expect they will learn like students, with exhaustive work shifts and mandatory assignments, but also act like professionals, which requires increasing levels of responsibility, competence, and efficiency.

Studying burnout syndrome among the medical residents of the Universidade Federal de Uberlândia, Lima et al.⁸ found high rates of burnout among residents, a worrisome fact indicating the need for preventive and healing measures. According to the authors, variables such as duration of course, work overload, duty hours, major personal investment, and giving up time for leisure, family, friends and all other activities, as well as the need to complement education with medical residency can all cause residents to burn out.

In reviewing the scientific literature on training as part of medical residency, primarily in particular specialties, we find that professionals suffer high rates of health issues that interfere with quality of life and, consequently, with the quality of care provided to patients.

In the United States, Fahrenkopf et al.¹⁰ studied rates of depression and burnout syndrome among pediatrics residents to assess the relationship between the two conditions and medication errors. Though they found no relation between burnout syndrome and increased rates of medical errors, they did find that these two are the primary conditions afflicting pediatrics residents.

In an epidemiological survey of depressive symptoms among medical students and residents, Gabriel et al.¹¹ found that medical students have major rates of depression, which can compromise the quality of patient care. The authors also found that female students and residents suffer more than male ones, and that most residents habitually drink alcoholic beverages.

Ríos et al.¹² assessed stress levels among residents and relation between stress and compromises in family life, finding that stress interferes with family relationships and can be harmful to family life.

In the United States, Archer et al.¹³ assessed stress factors among residents and their psychosocial adaptations; they found that duty hours and low pay were the primary sources of stress.

Another important problem afflicting residents is excessive sleepiness secondary to long shifts. An American study found that most residents feel sleepy and have trouble sleeping, regularly turning to alcohol or sleeping aids to try and fall asleep¹⁴.

A study on prolonged duty hours and fatigue among gynecology and obstetrics residents in Venezuela showed that professionals, especially males, ingest stimulants, and that residents in this condition have unacceptably high rates of fatigue. The author stresses the need for work schedules that include periods of rest during 12-hour shifts¹⁵.

Residents have informal knowledge about quality of life, but it is not actually applied.¹⁶ Macedo¹⁷ found that residents' quality of life in terms of vitality, social life, emotional life, and mental health are comparable to those of patients with chronic conditions. González et al.¹⁶ suggest knowledge about quality of life, as well as its practical usefulness in professional life, should be incorporated into medical education.

Buddeberg-Fischer et al.¹⁸ found the primary complaint among Swiss residents is the structural deterioration of working conditions, including an imbalance between personal and professional lives. In their study about arguments for and against a career in medicine, residents claim that making medicine an appealing career once more would require making sustainable changes to health and to the social and political scenario.

Studying duty hour restrictions for residents, Whang et al.¹⁹ found that most residents mentioned improved quality of life following duty hour restrictions.

Gopal et al.²⁰, however, in surveying residents about acceptance of duty hour restrictions and longer curricula in the United States, found that most disagree with the notion of extending the educational period. Only residents with burnout syndrome or who knew the criteria for the syndrome were flexible in accepting a 60-hour work week in lieu of an 80-hour one.

Shanafelt et al.²¹ found that the greater the mental well-being of residents, the more enhanced their empathy. Ratanawongsa et al.²² found that well-being interferes with patient relations, interactions with peers, performance, and motivation. The Irish residents surveyed by the authors claimed greater well-being favored the decision-making process. The results reaffirm the need for investing in improvements to this professional training system.

According to Ratanawongsa et al.²², resident training and patient care would improve with actions focused on the well-being of residents. Cohen and Patten²³, in a study on the well-being of residents in Alberta, Canada, found that 34 percent of residents consider their lives stressful, with more women afflicted than men. Prolonged pressure was singled out as the primary stress factors by residents, who claim they would not choose a career in medicine if they could start their professional lives over. There was also a strong correlation between intimidation and sexual harassment of female residents.

A study on abuse, discrimination and sexual harassment among Canadian residents shows that 50 percent of residents suffered psychological violence from patients, family members and supervisors, women more often than men; 5.38 percent of residents, all female, claimed to have been victims of sexual discrimination; 40 percent claimed to have suffered sexual harassment of some kind, their most common reactions to it being embarrassment (24%), anger (23.8%), and frustration (20.8%). The data show that psychological violence, discrimination and sexual harassment are common problems among residents, requiring work from multiple professional specialties²⁴.

Buddeberg-Fischer et al.²⁵ surveyed the work experiences of first-year medical residents and their impact on their physical integrity and psychological well-being. They found that women receive less guidance than men during residency, but have more positive social relations and work harder on activities than their male peers. The absence of supervisors, undefined hierarchies, stress and excess responsibilities were mentioned as risk factors for symptoms of anxiety and depression.

Barack et al.²⁶ surveyed orthopedic surgery residents and university faculty to measure quality of life, burnout syndrome, and overall health. Students had high rates of burnout and emotional exhaustion. The authors found that shorter duty hours lead to higher quality of life, decreasing burnout rates among residents.

Belgium restricted the work week to 48 hours for residents in 1999, a measure still being debated in Europe. The United States recently restricted the work week to 80 hours for residents⁽²⁷⁾. Several studies have been performed in the United States to assess the impact of duty hour restrictions on professional training and patient care^27-31.

In the United States, Dola et al.³² surveyed resident and faculty opinions about duty hour restrictions for residents. They found that 45.3 percent of residents believe restricting duty hours improves the quality of patient care, while only 8.8 percent of professors share that notion. However, both agree that the reform improved the quality of life of residents.

In Brazil, though the law (Decreto 80.281/1977) already restricts the work week to 60 hours, with 80 to percent assigned to service and the rest to classroom and complementary work, several studies find major health issues secondary to prolonged duty hours, including burnout syndrome, depression, fatigue, stress, and anxiety^8,15,33-37. The results tell us the service and resident training should be reformed to improve the quality of life of residents, thus improving the quality of patient care in Brazilian health care facilities.

In 1981, the National Medical Residency Committee created Programa de Requisitos Comuns (Common Requirements Program) to regulate the work hours of medical residents.

Oliveira Filho et al.³⁸ found that violations of the common requirements program are associated with poorer perception of key aspects of overall quality of life, residency quality of life, and worsened educational environments.

Residents have a lot of trouble coping with stress and poor working conditions. Studies about coping strategies have shown that almost half of all residents have problems coping with emotional stress, which has a negative impact on the doctor-patient relationship and on performance, thus proving the need for strategies to help residents cope with stress.^33,34 Blandin et al.³³ stress that medical residents with dysfunctional coping strategies are more susceptible to burnout syndrome.

Studies have shown that implementing resident assistance programs leads to improvements in professional education, in terms of managing the stress caused by the educational process, and personal quality of life, improving relationships with patients^{34,35,37,39,40}.

Oliveira Filho⁴⁰ assessed the acquisition of knowledge, learning strategies, satisfaction with learning environment, and quality of life of anesthesiology residents. He finds that residents with positive affective and motivational profiles show significant gains in knowledge during the first two years of residency.

In assessing the quality of life of residents at the São Paulo School of Medicine, part of Universidade Federal de São Paulo (UNIFESP-EPM), Macedo¹⁷ found second-year residents had better quality of life than first-year residents, especially in terms of social aspects, vitality and mental health, but poorer quality of life in terms of emotional aspects. The author also found that 32 percent of residents were unhappy with the residency and 83.6 percent thought they did not have enough leisure time; female residents performed better than males in terms of vitality, emotional aspects and mental health, while residents happy who were with residency and who though they had enough leisure time had better quality of life in all aspects.

According to Massuda et al.⁴¹, fighting for better work and learning conditions for medical residents requires improvements to the legislation regulating medical residency, as well as, above all, its enforcement. Also, regulatory bodies urgently need empowerment and the involvement of all stakeholders.

Though stressful, medical residency is an enriching experience, providing professional and personal development for young physicians.⁴² However, Residency is associated with feelings of depression, anger, cynicism and emotional retraining, but there is no great concern with the possible effects of those feelings on future actions and professional attitude of physicians. Therefore, residents need more support and personal guidance to become good physicians and residency programs should offer support to help professionals develop the communication skills they need to become competent professionals.⁴³

CONCLUSION

In reviewing the literature on the quality of life of medical residents, we found high rates of health issues that interfere with the quality of life of medical residents and, consequently, with the quality of care provided to patients.

Though stressful, often with improper arrangements for professional training, which compromises the quality of life of medical residents, medical residency is an enriching experience, providing professional and personal development for recent graduates from medical schools.

The review found that Brazil needs to change the legal regulatory standards for medical residency, as well as that resident assistance programs should be implemented to improve work and learning conditions, which in turn would aid the development of professional skills and improve personal quality of life for medical residents.

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