Careers in medicine, particularly the intense years of residency, have been known to be stressful for quite some time.11,12
Although reasonable levels of stress may not have a negative impact on the successful training of medical or surgical specialists, excessive levels of stress might be harmful. In the present study, we assessed the stress of surgical residents across Canada by conducting a survey. This study is unique as, to our knowledge, there are no previous studies solely focused on the stress of surgical residents. As a nationwide sampling was undertaken, our study may have applicability across a wide range of surgical residencies. We also considered the effect of sex and other factors on stress reporting.
How do you define stress? Most would agree that stress is ever present in the lives of surgeons. The ability to react, respond and cope with a set of particular stressors determines success in one’s career. Some individuals may react or deal with stress in a positive manner, hence leading to good outcomes. Over time, the ability to deal with what one considers to be a stressful situation successfully then changes what one finds stressful. However, others who respond in a maladaptive pattern that causes a less than optimal outcome will find that particular circumstances remain stressful in the future. This makes it difficult to nail down an exact definition of stress for surgical residents. Certainly, this line of reasoning also allows us to consider that whereas junior residents may find a particular situation stressful, that same situation may no longer cause stress once they have gained experience and become senior residents. Our study examines how residents cope with stress and which mechanisms they choose to relieve the stress. Hence, one must be cognizant that not only is the definition of stress fluid, but also that responses to stress shift as different techniques and adaptations are subject to the process of trial and error. Dictionary definitions broadly consider stress to be a physical, mental or emotional strain or tension, or a situation, occurrence or factor causing strain. Our study allows for the identification of more residency-specific examples of both of these definitions.
For both sexes, we found that time pressure and the number of working hours were the most highly rated contributors to stress during residency. Also, when asked to rate specific components of the residency program in relation to their stress, the factors rated as highly stressful by most respondents were insufficient sleep and frequent call (). We found no differences between men and women in the number of hours slept. On average, women reported 2.32 hours of sleep on nights when they were on call and men reported 2.59 hours of sleep when on call. Hours slept when off call were similar between men and women, with men reporting 6.55 hours of sleep and women reporting 6.57 hours.
Previous research has concluded that sleep deprivation can affect optimum quality of care for patients.13
Sleep deprivation leads to increased levels of stress and illness. It has been reported that sleep deprivation of residents can be harmful to the patients they care for as well as the residents themselves, and it has also been suggested that overworking of residents may interfere with the moral growth and advancement that is required for the job.13
These considerations are well known, and work hour restrictions and home after call policies are now a focus in all residency programs.
Our survey revealed that financial issues were a cause of stress to 15% of residents. It has previously been reported that financial factors can disrupt the training of medical residents.1
It is important for directors of surgical programs to note this finding as a potential factor in program disruption that could possibly be averted with early intervention. An interesting finding was that men reported more stress related to their financial situations than women, and the difference between men and women requires more study.
Our survey also asked about the methods of coping mechanisms used by surgical residents for reducing stress. We found that the most common coping mechanism was staying optimistic, followed by engaging in enjoyable activities. The least frequent coping mechanism reported was turning to drugs and medication for reducing stress levels. In previous research, it has been reported that the most popular coping mechanisms are consulting others (such as family members) about problems, staying optimistic and adapting to the stressor.14
Certainly, staying optimistic can be accomplished in different ways; our study did not have the capacity to delve into the exact mental and emotional strategies used by residents to stay optimistic. Details of such internal conversations would be a fascinating topic for future study. Exercise was also one of the highly rated coping strategies for fighting stress. Exercise is known to decrease stress levels by causing the body to increase the release of hormones that combat the symptoms of stress and enhance positive mood.15
The least frequent coping strategy reported by Rudner14
was use of drugs and alcohol, which is consistent with our findings.
Some of the questions in our survey served to demonstrate the residents’ health levels. About one-quarter of residents reported annual checkups from their physicians, and of these respondents, 71% were women and 29% were men. This suggests that female residents may be more concerned with their health or more likely to attend annual physical examinations than male residents. Most of the residents who reported mental or emotional problems during residency were women. This may have been the reason that women were more likely to get annual checkups, but it is also possible that men were less likely to divulge mental or emotional illnesses, even on a confidential survey. Differences between male and female residents have been noted before.1,16
Other studies have shown that female residents were more likely than male residents to experience symptoms related to mental problems, such as depression.1
Furthermore, a recent study on general surgery residents in the United States found that the residents’ attitudes, experiences and expectations regarding training varied by sex and year of program.16
Of the residents who reported weight changes during their residency, 67% were in PGY-3 or above. In previous research, it has been noted that increased levels of stress can be correlated with weight changes.17
Since residents in PGY-3 or above were more likely to experience weight changes, it may be that they experience greater levels of stress in their residency program. An increase in time pressures and number of working hours can be the cause of higher levels of stress and less time for physical activity among more senior residents. In addition, those in the senior years of training are closer to final examinations and may experience stress related to studying and skill acquisition.
The balance between stress and coping mechanisms is important. Although stress may be reported and identified, the ability to cope with stress will determine mental and physical health outcomes. Even though many residents reported mental and physical symptoms during their residency program, 39% reported their general health as very good and 41% rated their mental health as very good. When asked if they had any mental or physical health problems diagnosed during their residency, only 3% reported receiving a diagnosis of a mental health disorder and only 9% reported receiving a diagnosis of a physical problem that was found by their physician to be due to high levels of stress. Tyssen and colleagues18
reported that job stress was correlated with mental health problems among residents and young doctors. The high stress levels of young doctors was found to be due to meeting others’ high expectations as well as anxiety about lack of skills and training while caring for patients.18
Our study found time pressures and the number of working hours to be the main contributors to the residents’ high stress levels. This shows that contributors to residents’ high stress levels are multifactorial and include mental and physical health problems. Training programs may benefit from addressing sources of stress among trainees and reinforcing healthy coping mechanisms.
Almost half of the participants believed that their stress levels would decrease once their program was completed. However, Tyssen and colleagues18
reported that young doctors also experience high stress levels after graduation owing to perceived lack of skills. This was also found to lead to mental health problems. Interestingly, 92% of residents reported that they did not notice high levels of stress in their fellow residents. This may be because residents attempt to hide their stress or that they are simply too busy to notice stress among their colleagues.
Graduates of foreign medical schools reported significantly more stress related to working conditions, residency program, caring for family members, discrimination and personal and family safety than Canadian medical school graduates. Perhaps this is because of their lack of familiarity with the Canadian residency training system. The coping strategies od foreign graduates were also somewhat different from those of Canadian graduates.
It has been noted that anesthesiologists do not experience high levels of stress during their residency program19
and has otherwise been suggested that there are no significant differences in the levels of stress experienced by residents in different specialties.20
However, when evaluating the specific stressors of residents across various specialties, including anesthesiology,19
obstetrics and gynecology,21
and surgery (present study), factors causing resident stress are unique to each specialty. This observation illustrates the importance of studies such as these to identify stressors unique to a particular specialty and inform the development of stress management programs built around the needs of a specific group of residents.
For comparison, in future studies, we recommend a standardized and validated stress survey to be administered among 6 populations: surgical specialists, medical specialists, surgical residents, medical residents and skilled (i.e., people in professions that require a certain level of education and training) and nonskilled general population.
Finally, it is worthwhile discussing the limitations of this study. After the invitation of all surgical residents across Canada and subsequent reminders to participate in our survey, our response rate was 28%. Although this response rate might be an acceptable standard for survey response, our sample may still have been too small given the breadth of trainees; therefore, the generalizability of our findings to a Canadian population of surgical residents may be limited. Despite our efforts to encourage participation from all disciplines, nearly 80% of respondents were enrolled in general surgery programs; therefore, the findings might be more generalizable to general surgery residents than to those in other disciplines. However, we feel that the response rate to our survey does not limit our ability to draw conclusions from our data. The survey included questions and topics commonly associated with stress during residency. These questions were derived from analysis of another established survey,9
but we found it useful to add new questions, which we thought would be important in assessing the specific causes of stress levels in surgical residents. We felt that these were not adequately covered by previously established and generalized surveys, and thus these surveys were not used. Another limitation of our survey was the lack of a comparison group. It would have been useful to compare the stress levels of surgical residents to those of other highly motivated trainees to put our findings in perspective. However, the findings from our survey would still help to identify specific issues that could be addressed in the future planning of surgical education programs and in designing a more comprehensive survey with a comparison group. Finally, we used a self-assessment stress questionnaire, which may have been prone to recall bias and overestimation of stress levels.