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Stress in Medical Residency: Status Quo after a Decade of Reform?

Virginia U. Collier, MD; Jack D. McCue, MD; Allan Markus, MD; and Lawrence Smith, MD
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From Christiana Care Health System, Newark, Delaware; University of California, San Francisco; St. Joseph's Medical Center, Phoenix, Arizona; and Mt. Sinai Medical Center, New York, New York.

Acknowledgments: The Resident Services Committee of the Association of Program Directors in Internal Medicine (APDIM) designed the survey instrument used in this paper. Other than the authors, members were Drs. Preston Cannady Jr., Jonathan Weschler, and Kevin Yingling. Members of the APDIM Council reviewed this manuscript. In addition to making valuable suggestions, the APDIM Council approved the conclusions and recommendations. APDIM provided administrative support. The authors thank Musa Nsreko, MPH, for performing data analysis, Drs. Neil Farber and Kathy Upchurch for reviewing and critiquing the manuscript, and Cindy Chuidian and Michele Rodriguez for providing secretarial assistance.

Requests for Single Reprints: Virginia U. Collier, MD, Department of Medicine, Christiana Care Health System, PO Box 6001, Newark, DE 19718; e-mail, vcollier@christianacare.org.

Current Author Addresses: Dr. Collier: Department of Medicine, Christiana Care Health System, PO Box 6001, Newark, DE 19718.

Dr. McCue: Department of Medicine, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143.

Dr. Markus: St. Joseph's Medical Center, 350 West Thomas Road, Box 2071, Phoenix, AZ 85013.

Dr. Smith: Mt. Sinai Hospital and Medical Center, One Gustave L. Levy Place, New York, NY 10029-6574.

Ann Intern Med. 2002;136(5):384-390. doi:10.7326/0003-4819-136-5-200203050-00011
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Background: Although curricular reforms have attempted to address sources of stress in medical residency, no recent studies have examined the financial or emotional situations of current medicine residents.

Objective: To question medicine residents about financial status, educational debt, moonlighting, and psychological issues.

Design: Survey distributed in a nonrandomized fashion to medicine residents.

Setting: All 415 U.S. medicine residency programs.

Results: According to the questionnaire responses submitted by the 4128 (18%) participating residents, a substantial number of residents had financial and emotional distress that could have interfered with training. The reported educational debt was at least $50 000 for 1657 (42%) of the respondents and at least $100 000 for 737 (19%). The monthly disposable income was $100 or less for 1620 (43%) of the residents, and 637 residents (16%) could not afford safe housing. Among respondents in their 2nd through 5th year of postgraduate training, 2187 (52%) had insufficient funds to purchase books and equipment, and 678 (29%) could not afford the required fees for the American Board of Internal Medicine certifying examination; 2659 (33%) worked as moonlighters, and this percentage increased progressively with increasing educational debt.Four or five depressive symptoms during residency were reported by 1461 (35%) residents. Eight hundred ninety-nine residents (23%) thought they had become less humanistic over the course of their residency training; 2347 (61%) reported becoming more cynical. Female residents were more likely than male residents to report increased cynicism and multiple depressive symptoms. Increased cynicism and depressive symptoms were associated with increasing educational debt.

Conclusions: Despite recent curricular reforms, an alarming number of current medicine residents report depressive symptoms, increasing cynicism, and decreasing humanism, which were associated with increasing educational debt and a need to moonlight for financial survival. Ongoing curricular reform, legislative relief from early loan repayment, and salary increases may be necessary to address these problems.


Grahic Jump Location
Figure 1.
Relationship of credit card and educational debt to moonlighting.
Grahic Jump Location
Grahic Jump Location
Figure 2.
Relationship of educational debt to depressive symptoms and increased cynicism in physician residents.

White bars = residents with four or five depressive symptoms; gray bars = residents with increased cynicism.

Grahic Jump Location




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