PROFESSIONAL STRESS DURING MEDICAL INTERNSHIP

Al Sultan A.I., Parashar S.K., Wahass S.H. and Al Soweilem L.S.
King Faisal University, Saudi Arabia

Abstract:

One hundred and one interns who completed internship during the year 2000 were surveyed by questionnaire to study the factors, manifestations and management strategies of stresses affecting them. Factors considered included personal and family, work and working conditions, training and interpersonal matters.

Approximately one out of three interns reported significant stress from not having enough time for family, insecurity about future and career, long working hours, frequent duties, lack of encouragement and supervision, lack of feedback, no one caring, and discriminations in gender and evaluations. Marriage did not seem to add significant stress during training.

It is concluded that medical internship is a stressful training period and it is suggested that support groups or advisory committees are needed to help and counsel interns about professional stress and provide psychological assistance when necessary.

Introduction:

It is now an established fact that learning ability and performance is directly related to the working environment and job satisfaction yet very little is done towards implementation. Training, internship and residency combine to form the most stressful period in the life and career of medical professionals. This period is also the period of change in family and personal life, involving marriages, new home establishments, children etc. The physical and mental stress can leave an indelible mark on their future(1, 2) but timely help and counseling can reduce this stress and make the training more enjoyable and productive.

Stress amongst medical professionals has been the subject of research from many angles; which include the causative factors, grades and levels of stress, its manifestations and their recognition, self-styled management strategies and recommendations for minimizing the professional’s stress. Stress is a subjective phenomenon. There is no standard way to assess professional stress with objective accuracy. In most studies its quantitative and qualitative evaluation is based on response to well-structured questionnaires.

Although training-related factors are more or less common to most of the training centers, personal and social factors vary according to culture, customs and convictions. Within our culture and social context our trainees have special family and environmental situations that require special considerations over and above those that are present in the Western World. It is therefore important that we make efforts to know the stressful problems and situations faced by our trainees. This survey is the first step towards modifying programs and training environment in such a way that they can be most productive, and to establish special facilities for those who identify themselves as extremely stressed.

Materials and Methods:

The study was conducted at the College of Medicine in King Faisal University in Saudi Arabia. One hundred and one medical interns who had completed their one-year mandatory rotating internship during the calendar year 2000 were asked to fill a questionnaire. It was a modified version of that prepared by Buckley and Harasym(3) and modified with their permission to be consistent with the culture of the interns. The responses were anonymous.

The questionnaire divided the possible stress-related factors into four groups:

1. Personal and family.
2. Work and working conditions.
3. Training.
4. Interpersonal.

The responses were graded on a five-point scale; not stressed, mildly stressed, tolerably stressed, very stressed, and extremely stressed. The questionnaire was validated by experienced faculties and was adequately reliable by test and retest. The results were reviewed for factors causing significant stress. Responses under mild and tolerable stress were grouped together since they indicated stress that was tolerable or manageable. The very and extremely stressed were grouped together as to indicate significant stress and the observations and results discussed are based on this group which was cross-tabulated for sex and marital status and compared with the others. Chi-Square and Fisher Exact tests were carried out as appropriate and Odds ratios were calculated. In addition to stress related factors, the second part of the questionnaire included sections on stress manifestations and stress management strategies. The responses were required as simple ‘Yes’ or ‘No’. Descriptive analysis was performed.

Results:

Interns were requested to fill the questionnaire before processing their completion certificate, so compliance was hundred percent. The interns included 69 males and 32 females, giving a ratio of 2.1:1. There were 58 single and 43 married interns with a ratio of 1.35:1. Amongst the married ones were 31 males and 12 females. Eleven interns, seven males and four females, had children. Ninety-seven interns were Saudis and four were non-Saudis. Their age range was 21-29 years, median 25 years.

All interns reported one or more factors causing stress during training. There was not a single intern in the survey for whom none of the factors was the cause of stress. It is obvious that every intern, male or female, is stressed by one factor or another, or more than one factor in many instances. While analyzing our data, we considered a positive response of ‘very’ or ‘extremely stressed’ by thirty percent or more interns as significant (column ‘c’ of each table). This indicated that approximately one out of three interns suffers from stress, which is extreme, unbearable and unmanageable by their own resources. The frequency of such significant stress-causing factors is shown in tables 1-4 in descending order (column ‘c’ of each table). Sex and marital status frequency distributions are shown also.. Each table shows the responses of interns grouped as follows: A = not stressed, B = mildly and tolerably stressed, and C = very and extremely stressed. Each table’s column contains three frequency numbers listed in the following order; total, males, and single interns. Since the total number of interns is close to one hundred, only the frequencies are quoted.

The stress factors were as follows:

Personal and family factors (Table 1):

Most stressful factors were ‘being unable to spend time with the family’ (40.6 %) and ‘insecurity about the future’ (39.6%). This was followed by `lack of direction towards career planning` (34.7%), which was present significantly more in single (43.1%) than married (23.3%) interns. Financial difficulties and feeling mentally exhausted were the least stressful factors. Females (46.7%) found transport a stressful problem, significantly more than males (10.3%) with odds ratio of 7.6. Single (28.6%) more than married (11.9%) interns also faced transport difficulties.

Work and working conditions (Table 2):

Most stressful factors were ‘too long working hours’ and ‘too frequent duties’ (32.7% each). Males were more stressed than females by too frequent duties (43.3% versus 12.5%), as well as by uninviting accommodation (35.8% versus 10.7%). On the other hand, females (28.1%) seemed to be more stressed by emotional involvement with patients and their families than were males (11.6%). Married interns (19.5%) felt that work was monotonous and boring more than singles (5.2%). “Coping with computer technology” was not a problem.

Training factors (Table 3):

Most stressful factors were “lack of encouragement”(39.6%), “no one seems to care”(36.6%), “lack of feedback” (35.6%) and “lack of supervision” (30.7%). Interestingly, “demands for academic preparations and presentations”, and “too many responsibilities”, seemed to be causing more stress in males (34.8% and 29%) than in females (12.9% and 6.3%). More single interns (38.2%) than married (19.5%) suffered from inferiority complexes.

Interpersonal factors (Table 4):

Most stressful factors in this group were “discrimination between genders” (38.6%) and “discrimination in evaluations” (34.7%). There was no statistically significant difference between responses in the “very” and “extremely stressed” group with regard to sex or marital status.

Married interns with children (7 males and 4 females):

All denied that “inability to pay sufficient attention to children and dependents” or “too frequent duties” caused any stress. Factors that caused extreme stress in this group were “too long working hours”, “ difficulty in dealing with death and suffering”, “ insecurity about future”, “ lack of feedback” and “ no one seems to care”. Financial requirements, too many responsibilities, discrimination between genders; lack of compliance by juniors do not seem to bother nearly half of these interns.

Stress manifestations and Management strategies:

Most frequent symptoms of stress were “physical tiredness” (65%), “ headache” (60%), “ anxiety” (50%), and “ poor concentration” (40%). Regarding management of stress, 60 % accepted stress as part of training, 92% said stress was not serious, 67% said they have strategies to control stress, and 73% of these said their selected strategies were effective in controlling their stress. 57% developed relaxing habits. Ninety per cent said they did not resort to smoking or bad habits as a result of stress. Only one said stress was impossible to cope with.

Discussion:

Stress among family physicians(4) and residents(5-7) under training has been a subject of investigations and discussions in other countries. In Canada, committees at residency training program levels have been formed to try to prevent stress amongst resident housestaff(8). Buckley and Harasym from the University of Calgary, Canada, conducted a study to identify causes of stress amongst trainees, and recommended that strategies for fostering a healthy, productive work place should receive the highest priority(3). Internship year is equally stressful, if not more, than the residency years. However, not many studies have been done about stress amongst interns. It seems that published studies presume that conclusions drawn about residents apply also to interns. Amongst medical professionals the most stressful period is that of training, undergraduate as well as postgraduate, which covers ten to fifteen years of young productive life. While some authors(9) consider stress amongst trainees as minimal, manageable and of little consequence, others(10) have referred to suicidal tendencies as a result of professional stress.

Our attempt in this study was to explore the etiology, degree of manifestations and management of professional stress amongst interns, the intermediate group between undergraduates and postgraduates. One year of mandatory rotating internship puts them through rigorous training and a process of deciding their future career and training. Our results are important in drawing attention to local problems and ways of solving them. It is significant that none of our interns rejected all the factors and claimed to be unstressed. Every one was stressed to a varying degree by one or more factors.

Amongst personal and family related factors, the most stressful one was “unable to spend time with the family”, as interns work many hours in hospital(11). In addition Saudi interns belong to a very close family structure of an extended type with many being married and having children, with whom they want to spend their time. They are divided between family and training responsibilities. In this group females, naturally, are most stressed. This is consistent with their family ties and responsibilities. Similarly, insecurity about future and lack of direction towards career planning have also been identified as extremely stressful factors, the latter being more evident in unmarried interns who are not yet socially settled. This calls for more administrative response towards their counseling and provision of advisory services. In work and working conditions related factors, most stressful were “too long working hours” and “too frequent duties”. This is a universal phenomenon, as has been recognized in most of the studies(3,11). Our internship program permits female interns to stay on duty up to 6 pm only, while males, like residents, will be on duty for the whole day. This explains why males are more stressed about the frequency of duties and the status of accommodation. Female interns are more stressed than males from the emotional involvement with patients and their families. Though infrequent, married interns rather than singles find work to be monotonous and boring. However, more significant stress causing factors are related to training conditions. Lack of encouragement and lack of feedback can be detrimental to their overall professional development and should not be ignored. Interns are rotating in five obligatory departments including internal medicine, surgery, obstetric and gynecology, pediatrics, and primary healthcare with one month elective. Support groups or committees are needed to overcome the cumulative general feeling generated by different rotations that “no one seems to care”. Internship is designed as a transition year from a medical student to a physician. The extent of supervision was perceived as inadequate. Some unsupervised training is part of preparing them to be independent. This might be excessive as noted by Corby and Herbison of being only 12% of work in four clinical teaching schools in New Zealand(11). It must be monitored and regulated.

It seems that male interns, because of their gender, are expected to do more and are significantly more stressed from heavy demands for academic preparations and having many patient responsibilities. Single interns experience more stress from inferiority complexes than married ones. Discrimination between genders and evaluations were perceived as most stressful in interpersonal related factors. Interestingly, both males and females equally view that they were discriminated against based on their gender. Communication with superiors and colleagues were reported least stressful and very likely this helped better management of the stress. The fact that females, especially single interns, were more stressed than males by transport problems is self-explanatory since local regulations prohibit females driving. It is interesting to note that financial remunerations have not been identified as a cause of significant stress. Apparently they consider themselves well paid.

It is apparent that professional stress does not cause severe symptoms in our trainees. Most symptoms are manageable by their own strategies. They seem to take this in their stride and do not resort to unpleasant means or habits. Responses from married interns with children have shown that they are not particularly overstressed by their family status except for the fact that they like to spend more time with their family, which is natural. On the whole, marriage does not seem to add significant stress during training.

Our study has confirmed that our interns would like to have a program where they can have more time for their families and that they have better attention paid towards the security of their future and the planning of their career. Improved transport facilities for females and less discrimination between genders are also indicated. Although training is stressful for most interns, its manifestations are not serious and can be managed by self-styled habits or through seeking psychological assistance.

Conclusion:

The objectives of this study have been met by identifying a number of factors that cause significant stress to interns. These should be looked for in similar programs and dealt with appropriately. It is obvious that, apart from improvement in working conditions, our interns would like to have more appreciation of their work and guidance in planning their future. Special attention should be paid to their social and family obligations. It is also satisfying that females are on a par with their male counterparts in their responses, except for transport related problems. It is a prerogative of program directors to address these issues in order to organize regular counseling services to minimize stress and its negative effects; and to enhance their capabilities to cope efficiently.

Acknowledgement :

We thank Dr. Ahmad A. Bahnnassy, biostatistician from the Department of Family and Community Medicine for his advice on the statistics, and Josefina E. Asilo and Jessie F. Asilo for their secretarial help.

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