Steven A. Wartman

Stress in social and family relationships during the medical residency

A study of stress during residency training involved data analysis of questionnaires completed by 108 residents and fellows in internal medicine. Over 40 percent of the respondents experienced important problems with their spouse or partner. Of these, 72 percent believed that these problems were due to the residency, and 61 percent reported that their spouse or partner agreed with this assessment. Only 21 percent of the residents with relationship problems felt that their hospital work was being affected negatively. A multiple regression analysis showed that 10 variables accounted for 50 percent of the variance in predicting relationship stress. The results suggest that scheduling and structural changes in residencies are necessary in order to reduce stress among residents. Perhaps equally important is the finding that stress can be buffered by family relationships and social contact. The authors conclude that social support systems need to be fostered during the residency.

A comprehensive support system for reducing house staff distress

The stresses of postgraduate medical training may lead to depression, impaired patient care, and a poor professional attitude. The goal of the Rhode Island Hospital House Staff Support System is to reduce stress among residents by providing them with a forum for their views and by offering counseling to those who need it. The authors report that the program has been well received during its first three years, and they offer guidelines for implementing similar support programs at other institutions.

Debt, Moonlighting, and Career Decisions Among Internal Medicine Residents.

In the study reported here, medical residents were surveyed to determine their patterns of educational indebtedness, the effects of debt on their decisions about training and career, the frequency with which they begin making loan payments during training, the extent to which they moonlight and the reasons for doing so, and their opinions about the effects of moonlighting on house staff training. A total of 223 residents from four residency programs were surveyed; 181 responded. Most (86 percent) had educational debt (mean =

The service/education conflict in residency programs: a model for resolution.

20,500), and more than half of those with debt were making loan payments. Forty percent of the residents moonlighted, and moonlighting was related to the presence of educational debt, monthly loan payments, and number of dependents.

Toward a virtuous cycle: the changing face of academic health centers.

Residency programs consist of a range of activities involving service to patients and education of residents. The observation that a conflict exists between the service and education components of residency is widespread and has been used to explain many of the problems afflicting such programs today. The authors believe that the service/education conflict is a significant barrier to change in residency programs. A model is presented for residency education that reorganizes the service and education components. First, they present a broad overview of the conflict. Then they provide a brief historical perspective and comment on some of the current recommendations for residency programs. Next, they discuss how principles of adult learning relate to residency and propose a new model of residency that adheres more closely to these principles. Finally, the proposed model is presented in some detail and its implications are discussed. Only if the service and education components of residency are carefully delineated can residency programs adapt to the changing and growing needs of postgraduate medical education.

Primary Care Internal Medicine: A Challenging Career Choice for the 1990s

Editor’s Note: This month, the journal features a group of articles that tell important stories of change at 10 academic health centers in the United States. Dr. Steven A. Wartman served as guest editor for those articles and wrote this month’s column discussing them. I thank him for that and also for his extensive efforts and those of his assistant, Alcenia McIntoshPeters, in working with the authors and Al Bradford and his colleagues at the journal to develop and organize the articles so that they share valuable lessons and document pivotal events in an important part of the history of academic medicine.

Alumni perspectives comparing a general internal medicine program and a traditional medicine program

A career in primary care internal medicine can be challenging and rewarding, yet during the last decade fewer medical students have selected training in internal medicine. We wish to inform medical students, their advisors, and other physicians about the field of primary care internal medicine. We define the discipline, compare it with traditional internal medicine and with family practice, and describe features of strong primary care internal medicine training programs. We discuss common misconceptions and concerns about training programs and the career and give examples of career paths chosen by graduates of primary care programs. We encourage students to consider the option of primary care internal medicine when making career decisions and provide faculty advisors unfamiliar with primary care internal medicine training programs with a reference resource.

The Development of a Medical Ethics Curriculum in a General Internal Medicine Residency Program.

Objective:To evaluate a primary care internal medicine curriculum, the authors surveyed four years (1983–1986) of graduates of the primary care and traditional internal medicine residency programs at their institution concerning the graduates’ preparation.Design:Mailed survey of alumni of a residency training program.Setting:Teaching hospital alumni.Subjects/methods:Of 91 alumni of an internal medicine training program for whom addresses had been found, 82 (90%) of the residents (20 primary care and 62 traditional) rated on a five-point Likert scale 82 items for both adequacy of preparation for practice and importance of training. These items were divided into five groups: traditional medical disciplines (e.g., cardiology), allied disciplines (e.g., orthopedics), areas related to medical practice (e.g., patient education), basic skills and knowledge (e.g., history and physical), and technical procedures.Main results:Primary care residents were more likely to see themselves as primary care physicians versus subspecialists (84% versus 45%). The primary care graduates felt significantly better prepared in the allied disciplines and in areas related to medical practice (p<0.01). There was no significant difference overall in perceptions of preparation in the traditional medical disciplines, basic skills and knowledge, and procedures. The same results were obtained when the authors looked only at graduates from the two programs who spent more than 50% of their time as primary care physicians versus subspecialists. There was no significant difference between the two groups in the perceived importances of these areas to current practice.Conclusions:These results suggest that the primary care curriculum has prepared residents in areas particularly relevant to primary care practice. Additionally, these individuals feel as well prepared as do their colleagues in the traditional medical disciplines, basic skills and knowledge, and procedural skills.

Emergency room leavers - A demographic and interview profile

&NA; Since 1984, a three‐year curriculum in medical ethics has operated at Rhode Island Hospital as part of the General Internal Medicine Residency Program at the Rhode Island Hospital and Brown University. The residency program was founded in 1980 to develop a model training program for internal medicine residents with a primary care focus. The three objective of the curriculum are (1) to enable residents to recognize the ethical implications of both inpatient and outpatient clinical cases, (2) to teach residents to recognize ethics issues and alternatives in order to arrive at a well‐rounded clinical strategy, and (3) to help them learn to communicate sensitively with patients and others about these ethics issues and proposed management plans. The six major topics covered by the curriculum (for example, informed consent) are co‐taught in a seminar format by one or more of the three members of the multidisciplinary ethics faculty (a philosopher, an internist, and a communications specialist) and experienced physicians. The authors describe the program, the roles of the various faculty members, the programs focus on case discussions, the receptivity of the residents and faculty to the program, the use and training of a multidisciplinary faculty, efforts aimed at evaluation, and future directions of the program.

Implementing a simpler approach to mission-based planning in a medical school.

Emergency rooms are used frequently by patients who do not require urgent treatment. Furthermore, a small but sizable number of these patients in busy emergency rooms leave (walk out) before they are actually examined by medical personnel.Data were analyzed for all patients presenting to a university-affiliated hospital emergency room during a one-year period. Six hundred forty-four persons left the emergency room before being seen (leavers). Based on a code routinely assigned to their presenting complaint, patients were divided into urgent and nonurgent categories. A random sample of 100 leavers was matched with nonurgent stayers by age, sex, race, and shift of presentation. Information was collected from medical records and telephone interviews.A multiple discriminant analysis revealed the following profile of the leaver: a person who lives within 2 1/2 miles of the hospital has either Medicare/caid or no medical insurance, has no private physician, and has a nonserious presenting complaint. Stayers, on the other hand, have more serious complaints, tend to have medical insurance, more often have a private physician, and may live at any distance from the hospital. In addition, leavers presented with drug, alcohol, or psychiatric problems more frequently than stayers. Leavers, on the average, spend 90 minutes waiting for treatment they never receive. This study characterizes a small but problematic subgroup for emergency department planners and suggests the need for community-based health education and referral of such patients to primary care centers.