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The happy docs study: a Canadian Association of Internes and Residents well-being survey examining resident… Cohen, Jordan S; Leung, Yvette; Fahey, Meriah; Hoyt, Linda; Sinha, Roona; Cailler, Lisa; Ramchandar, Kevin; Martin, John; Patten, Scott Oct 29, 2008

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ralssBioMed CentBMC Research NotesOpen AcceShort ReportThe happy docs study: a Canadian Association of Internes and Residents well-being survey examining resident physician health and satisfaction within and outside of residency training in CanadaJordan S Cohen*1, Yvette Leung2, Meriah Fahey3, Linda Hoyt4, Roona Sinha5, Lisa Cailler6, Kevin Ramchandar7, John Martin8 and Scott Patten9Address: 1University of Calgary Faculty of Medicine, Foothills Medical Center, Assistant Clinical Professor in the Department of Psychiatry, Calgary, Alberta, Canada, 2University of Calgary, Fellow in the Department of Gastroenterology, Calgary Alberta, Canada, 3University of Manitoba, Resident in the Department of Obstetrics, Gynecology and Reproductive Sciences, Winnipeg, Manitoba, Canada, 4Dalhousie University, Resident in the Department of Psychiatry, Halifax, Nova Scotia Canada, 5University of Alberta, Resident in the Department of Pediatrics, Edmonton, Alberta, Canada, 6University of British Columbia, Resident in the Department of Radiation Oncology. Vancouver, British Columbia, Canada, 7McMaster University, Resident in the Department of Radiation Oncology. Hamilton, Ontario, Canada, 8Memorial University, Resident in the Department of Pediatrics. St. John's, Newfoundland, Canada and 9University of Calgary Faculty of Medicine, Department of Community Health, Calgary, Alberta, CanadaEmail: Jordan S Cohen* - jordan.cohen@calgaryhealthregion.ca; Yvette Leung - ypyleung@telus.net; Meriah Fahey - meriah_fahey@hotmail.com; Linda Hoyt - Linda.Hoyt@dal.ca; Roona Sinha - sinha@ualberta.ca; Lisa Cailler - caillier@interchange.ubc.ca; Kevin Ramchandar - kevin_ramchandar@pairo.org; John Martin - johnh_martin@hotmail.com; Scott Patten - patten@ucalgary.ca* Corresponding author    AbstractBackground: Few Canadian studies have examined stress in residency and none have included a large sample of residentphysicians. Previous studies have also not examined well-being resources nor found significant concerns with perceivedstress levels in residency. The goal of "The Happy Docs Study" was to increase knowledge of current stressors affectingthe health of residents and to gather information regarding the well-being resources available to them.Findings: A questionnaire was distributed to all residents attending all medical schools in Canada outside of Quebecthrough the Canadian Association of Internes and Residents (CAIR) during the 2004–2005 academic years.In total 1999 resident physicians responded to the survey (35%, N = 5784 residents). One third of residents reportedtheir life as "quite a bit" to "extremely" stressful (33%, N = 656). Time pressure was the most significant factor associatedwith stress (49%, N = 978). Intimidation and harassment was experienced by more than half of all residents (52%, N =1050) with training status (30%, N = 599) and gender (18%, N = 364) being the main perceived sources. Eighteen percentof residents (N = 356) reported their mental health as either "fair" or "poor". The top two resources that residentswished to have available were career counseling (39%, N = 777) and financial counseling (37%, N = 741).Conclusion: Although many Canadian resident physicians have a positive outlook on their well-being, residentsexperience significant stressors during their training and a significant portion are at risk for emotional and mental healthproblems. This study can serve as a basis for future research, advocacy and resource application for overall improvementsto well-being during residency.Published: 29 October 2008BMC Research Notes 2008, 1:105 doi:10.1186/1756-0500-1-105Received: 4 June 2008Accepted: 29 October 2008This article is available from: http://www.biomedcentral.com/1756-0500/1/105© 2008 Cohen et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 8(page number not for citation purposes)BMC Research Notes 2008, 1:105 http://www.biomedcentral.com/1756-0500/1/105FindingsThe goal of the survey was to increase knowledge of cur-rent stressors affecting the well being of residents and togather information regarding the well-being resourcesavailable to them.MethodsThe CAIR Happy Docs Study was conducted during the2004–2005 academic year. The CAIR membership listserved as the sampling frame for the study. CAIR via itsmembership represents all resident physicians employedin Canada, with the exception of resident physicians inthe province of Quebec. The entire resident populationindexed in the sampling frame was considered eligible forinclusion. This included residents from all training pro-grams for all post-graduate years of residency. This volun-tary study was distributed to residents in the samplingframe and collected by CAIR board members in eachregion. Academic days, local mailboxes, e-mail communi-cation, and websites were all tools used to help promoteand distribute the surveys [see Additional file 1].The goals of the study were broad-based and descriptive.The questionnaire was divided into five sections: demo-graphics, stress, intimidation and harassment, well-beingand resources. Survey questions included qualitative rat-ing scales, multiple choice responses and yes/no ques-tions. To minimize response acquiescence bias in ratingscales responses, the survey included a mixture of posi-tively and negatively stated items [1]. To ensure adequatecontent validity, the survey stress questions were devel-oped by a study team that consisted of residents and thuscontained items that referred to the actual concept ofstress that were most germane to residency. The well-being items from the CCHS come from a fully validatedinstrument developed by Massé and associates [2]. Itemsderived from Statistics Canada have undergone extensivefield-testing and focus group evaluation.The stress section of the survey contained questionsregarding sources of stress as well as methods for dealingwith stress. The terms "stress" and "intimidation and har-assment" were not formally defined in the survey to allowmeasurement of "perceived stress" and "perceived intimi-dation and harassment" which may vary both quantita-tively and qualitatively among individuals. Well-beingquestions were derived from the Canadian CommunityHealth Survey (CCHS) so that results could be comparedwith members of the general Canadian population [3].Mental illness screening questions from the CCHS werealso included to identify possible psychiatric symptoms inresidents. Questions on resources focused on knowledgeof current resources, perceived need for future resources,StatisticsStatistical analysis was conducted with help from theCanadian Post MD Educational Registry (CAPER).Descriptive statistics were used to give an overview of thedata as well as for comparison with the CCHS. In caseswhere not all residents responded to individual questions,percentages fall short of 100%. Percentages reported fordifferent forms of intimidation and harassment reflect theoverall percent of residents completing the entire surveyand not those that reported intimidation and harassment,except where directly quoted in text. Confidence intervals,Chi-squares, and Fisher exact tests were used to comparedifferences between groups. P-values less then 0.05 wereinterpreted as indicating a statistical difference. Wherenumbers were large enough for valid statistical inference,groups were stratified.Results(A) DemographicsOverall, 1999 resident physicians responded to the sur-vey, which accounted for 35% of the 5784 residents in thesampling frame. Regional response rates are noted inTable 1 and vary from 28% to 51%. The gender distribu-tion was 47% (N = 942) male and 52% (N = 1043)female. Respondents came from all years of post-graduatetraining with 31% (N = 612) in their first year, 28% (N =556) in second year and 42% (N = 831) in their third yearof post-graduate medical training or higher.Average hours worked per week were 1% (N = 13) lessthan or equal to thirty five hours per week, 11% (N = 213)worked on average thirty five to fifty hours per week, 26%(N = 514) worked fifty one to sixty five hours per week,39% (N = 787) worked sixty six to eighty hours per week,and 22% (N = 435) worked more than eighty hours perweek.(B) StressOne third of residents reported that most days of there lifewere "a bit" to "extremely stressful" (33%, N = 656). Inthe last 12 months, 41% (N = 820) of residents reportedmost days to be "quite a bit" to "extremely" stressful. Timepressure was the most reported source of stress by resi-dents (Table 2). Overall, males reported less "extreme"stress due to time pressure (33%, N = 310/942) as com-pared to their female counterparts (41%, N = 432/1043).Demographic associations with factors contributing to stressThere was a statistically significant relationship betweensources of stress and many of the demographic groups ofresidents (Table 3).Ways of dealing with StressPage 2 of 8(page number not for citation purposes)and barriers and limitations to resident physicians seekingaid.Individuals reported both positive and negative copingmechanisms in dealing with stress during their residencyBMC Research Notes 2008, 1:105 http://www.biomedcentral.com/1756-0500/1/105training (Table 4). 92% of respondents (N = 1839) spokewith others while 17% (N = 342) used alcohol to copewith stress. Approximately 16% (N = 316) of residentssurveyed reported considering changing their residencyprogram. When residents were asked if they could relivetheir lives, would they pursue another career, 23% (N =466) said yes.(C) Intimidation and HarassmentAs seen in Figure 1, residents reported intimidation andharassment most often from nursing staff (54%, N =1070) and staff physicians (39%, N = 781). The majorityof the intimidation and harassment was experienced inthe form of inappropriate verbal comments (66%, N =1330). The perceived basis for the intimidation and har-assment was mainly training status (30%, N = 599), orgender (18%, N = 364).(D) Well-beingThe results for life satisfaction and self-rated mentalhealth used in this survey are compared to the CCHS esti-mates (ages 26 to 64 years) for the Canadian populationin Figure 2 and 3, respectively.Perceived life satisfaction/well-beingWhen asked about satisfaction with life in general, 78%(N = 1551) of residents reporting being "satisfied" (Figure2). The majority of residents reported "excellent" to "verygood" (N = 993, 50%), or "good" physical health (N =662, 33%), with 17% perceiving their physical health as"fair" to "poor" (N = 334). Mental health ratings as com-pared to the Canadian Community Health Survey are alsopresented in Figure 3.History of emotional or mental health problemsAlmost one-third of residents (30%, N = 607) reportedhaving experienced a mental health problem. Fourteenpercent (N = 290) consulted a psychiatrist or psychologistfor help in their life. Almost one quarter of residentsreported experiencing an emotional or mental health con-cern during training (23%, N = 453).Table 1: Response rate distribution by regionRegion Number and Percent Response Number of Eligible Residents Response Rate Newfoundland N 196 54% 100% 28%Maritimes N 400 118% 100% 30%Ontario N 3136 1011% 100% 32%Manitoba N 374 127% 100% 34%Saskatchewan N 210 47% 100% 22%Alberta N 813 414% 100% 51%British Columbia N 655 228% 100% 35%Total N 5784 1999% 100% 35%Table 2: Distribution of factors associated with high stress in residency (scores of 4 or 5 on 5 point scale)Source of Stress N Percent (%)Time pressure 1403 70Own work situation 847 43Financial situation 758 38Residency program 631 32Personal relationship 492 24Own personal or family responsibilities 439 22Own emotional mental health problem 280 14Employment status 267 14Own physical health problem 268 13Caring for own children 230 12Caring for others 203 10Discrimination 128 7Page 3 of 8(page number not for citation purposes)Personal/family safety 91 4BMC Research Notes 2008, 1:105 http://www.biomedcentral.com/1756-0500/1/105Psychiatric illness screeningCCHS screening questions were used to identify possiblepsychiatric symptoms in residents.Positive predictive values (PPV) of the screening questionsfor each disorder (generalized anxiety disorder was notcompleted in CCHS) were used to predict lifetime risk ofeach psychiatric disorder (Table 5).Significant associations with Mental HealthResidents reporting "poor" to "fair" mental health indi-cated they deal with stress by drinking alcohol often (6%,N = 21/356), compared to those reporting "good" mentalhealth (2%, N = 11/663), or "excellent" mental health(1%, N = 9/969) [P < 0.001]. Residents reporting "poor"to "fair" mental health indicated they would change resi-dency programs if they could live their life over again,more often (28%, N = 101/356), compared to residentsreporting "good" (19%, N = 129/663), or "excellent"mental health (9%, N = 85/969) [P < 0.001]. Residentsreporting "poor" to "fair" mental health indicated theywould choose a new career (outside of medicine) if theycould live life over again (45%, N = 159/356), more oftencompared to residents reporting good (26%, N = 174/663), and excellent mental health (14%, N = 133/969) [P< 0.001].Residents reporting "fair" to "poor" mental health weremore likely to report financial stress (51%, N = 181/356),compared to residents reporting "good" (43%, N = 284/663), or "excellent" mental health (30%, N = 288/969) [P< 0.001]. Better mental health was associated with beinginvolved in a relationship ("excellent" or "very good"mental health, 58%, N = 562/969; "good", 58%, N = 387/663; compared with "fair" to "poor" mental health, 48%,N = 172/356) [P < 0.001].(E) ResourcesResidents most frequently reported wanting career coun-seling (39%, N = 777) and financial counseling (37%, N= 741) as a priority. Program ombudsman and residentsupport group were also identified as desired resources(27%, N = 545 and 23%, N = 466 respectively). Residentcolleague (65%, N = 1305), program director (53%, N =1066), psychiatrist/psychologists (49%; N = 982), chiefTable 3: *Highlighted differences among demographic subgroups contributing to significant resident differences when reporting sources of stressDemographic Group Subgroups Possible Stress Factors Contributing to differences in subgroupsAge < 27 years and 27–30 years Increased stress reported for all factors except "caring for own children" (e.g. time pressure 69%, N = 662/960)Gender Men Increased stress reported for finances (64%, N = 154/241), employment status (61%, N = 14/23), and discrimination (65%, N = 13/20).Women Increased stress for mental health (55%, N = 23/42)Relationship status Single Increased stress with personal relationship (55%, N = 57/103)Location of MD training MD outside of Canada Overall less stress reported, except for discrimination (65%, N = 13/20)Residency year of training PGY-3 or above Increased stress due to time pressure (42%, N = 413/974), financial (42%, N = 100/241), employment status (87%, N = 20/23)PGY-1 More stress for own work situation (48%, N = 102/214)Range of hours worked/week 51–65 & 66–80 average hours per week worked Increased reporting of time pressure as a stress (69%, N = 665/961)* Note: not all potential differences within a demographic groupMD = Medical degreePGY = postgraduate yearTable 4: Frequency of different responses of dealing with stress (reported by residents as occurring often or sometimes)Response to stress N Percent (%)Talk to others 1839 92Relax by doing something enjoyable 1808 90Look on the bright side of things 1793 89Jog or do other exercise 1512 76Wish the situation would go away 1383 70Avoid being with people 1027 52Blame yourself 1009 50Eating more or less than usual 953 47Sleep more than usual 896 45Pray or seek spiritual help 758 38Drinking alcohol 342 17Using drugs or medication 105 5Page 4 of 8(page number not for citation purposes)resident (45%; N = 904) and support telephone lines (33–44%, N = 667–815) were highest ranked as currentlySmoking more cigarettes than usual 81 4BMC Research Notes 2008, 1:105 http://www.biomedcentral.com/1756-0500/1/105available resources residents would use in a time of per-sonal crisis. When asked what would they do if they sus-pected that one of their colleagues was experiencing anemotional or mental health problem, most residentsreported either suggesting that to their colleague to gethelp (88%, N = 1754), or offer to escort their colleague to"get help" (75%, N = 1503).ConclusionLimitations of the StudyAlthough the survey response rate of 35% was comparablequestion a vulnerability to bias. The results are to someextent more representative of residents who are earlier intheir training since junior residents made up half of thesampling frame while 59% of the respondents. Many fac-tors are associated with postgraduate year level that mayreflect a response bias leading to an increased reporting ofstress (i.e. experience and hours of work). Previous studieshave also indicated that the first year of residency is anindependent factor contributing to burnout [6]. However,seniority in training has other stresses that may be equallyconcerning to residents (e.g. final examinations, higherFrequency of groups perceived by residents as being intimidating and harassing to residentsigur  1Frequency of groups perceived by residents as being intimidating and harassing to residents. Program director  (8% )Residents in own program (9% ) Other  Residents (25% ) Residents in other  programs (29% )Staff physicians (39% )  Patients (45% )  Nursing Staff (54% )  Page 5 of 8(page number not for citation purposes)to other Canadian studies like the National Physician Sur-vey and other resident surveys [4,5], it does lead one toexpectations). One must also wonder whether the resultsare due to a reporting bias among genders, in that femalesBMC Research Notes 2008, 1:105 http://www.biomedcentral.com/1756-0500/1/105Page 6 of 8(page number not for citation purposes)Comparison of relative frequencies of self rated life satisfaction results between residents from the study and the Canadian populationFig re 2Comparison of relative frequencies of self rated life satisfaction results between residents from the study and the Canadian population.0102030405060708090VerySatisfied orSatisfied Neithersatisfied nordissatisfiedDissatisfiedor verydissatisfiedHappy Doc LifeSatisfactionCCHS LifeSatisfactionHappy Doc MentalHealthCCHS Mental Health %Comparison of relative frequencies of self rated mental health results between residents from the study and the Canadian pop-ulationFigure 3Comparison of relative frequencies of self rated mental health results between residents from the study and the Canadian population. 0102030405060Excellentto verygoodGood Fair topoorHappy Doc MentalHealthCCHS Mental Health%BMC Research Notes 2008, 1:105 http://www.biomedcentral.com/1756-0500/1/105tend to be more open about their stress than their malecounterparts. This study did not separate residency spe-cialties and thus we were unable to comment on whetherwell-being results reflected individual medical residencyprograms. The stigma of mental illness may have pre-vented full disclosure and/or abstinence from the surveyaltogether. Prior studies in medical students have reportedpoor response rates due to fear of anonymity and confi-dentiality within the study [7].Although many Canadian resident physicians have a pos-itive outlook on their well-being, residents experience sig-nificant stressors during their training and are at risk foremotional and mental health problems. This study canserve as a basis for future research, advocacy and resourceapplication for overall improvements to well-being dur-ing residency.Competing interestsAll of the authors have in the past or are currently servingas volunteers for the Canadian Association of Internes andResidents.Authors' contributionsJC conceived the study, designed the questions and wasresponsible for coordination of the pilot project inAlberta, which was published in BMC Medical Educationin June 2005 [8]. JC, YL, and LH were involved in expand-ing the pilot project into a national scale survey and coor-dinated survey distribution through all of the CAIR boardmembers. SP was involved in expanding the pilot projectinto a national survey, data analysis and editing of themanuscript. All of the authors were involved in the devel-opment of the manuscript for publication. YL wasinvolved in the final formatting and editing for submis-sion.Additional materialAcknowledgementsWe would like to thank all members of the Canadian Association of Internes and Residents (CAIR) who participated in this survey and who were brave enough to discuss the stress they were incurring during resi-dency training. This Well-being survey would not have been possible with-out the dedication of all of the CAIR board members who diligently distributed and collected these surveys to Canadian Residents. We also thank the Provincial Housestaff Organizations who make up CAIR, as they were instrumental in the administration and success of the survey. These include the Professional Association of Residents of British Columbia (PAR-BC), Professional Association on Residents of Alberta (PARA), Professional Association of Internes and Residents of Saskatchewan (PAIRS), Profes-sional Association of Residents and Interns of Manitoba (PARIM), Profes-sional Association of Internes and Residents of Ontario (PAIRO), Professional Association of Residents in the Maritime Provinces (PARI-MP), and the Professional Association of Internes and Residents of Newfound-land (PAIRN). Appreciate the contributions of Dr. Michael Myers for his helpful suggestions in the preparation of the final manuscript. Finally, we thank the Canadian Post MD Educational Registry (CAPER) for their work on managing the data.References1. Tyssen R, Vaglum P, Grenvold NT, Ekeberg O: The impact of jobstress and working conditions of mental health problemsamong junior house officers. A nationwide Norwegian pro-spective cohort study.  Medical Education 2000, 34:374-384.2. Massé R, Poulin C, Dassa C, Lambert J, Belair S, Battaglini MA: Elab-oration et validation d'un outil de mesure du bien-etre psy-chologique: L'EMMBEP.  Can J Pub Hlth 2006, 89:352-357.3. Statistics Canada: Canadian Community Health Survey, Mental Healthand Well-being 2002.4. Hendrie HC, Clair DK, Brittain HM, Fadul PE: A study of anxiety/depressive symptoms of medical students, house staff, andtheir spouses/partners.  J Nerv Ment Dis 1990, 178(3):204-207.5. Canadian Institute of Health Information: 2004 National Physician Sur-vey Response Rates and Comparability of Physician Demographic Distribu-tions with Those of the Physician Population 2005.Additional file 1The Happy Docs Survey Questions. Word file with the original questions from the Happy Docs Survey.Click here for file[http://www.biomedcentral.com/content/supplementary/1756-0500-1-105-S1.doc]Table 5: Estimated lifetime risk of psychiatric disorders in residentsPsychiatric Disorder Number reported; and Percentage Positive Predictive Value* Lifetime Risk* (%)Depression 1345; 67 0.23 15Social Phobia 346; 17 0.39 7Agoraphobia 147; 7 0.85 6Panic Disorder 622; 31 0.08 2Mania 238; 12 0.12 1*Positive predictive values and lifetime risks are based upon positive screens and resultant lifetime risk associated from the Canadian Community Health Survey (CCHS)Page 7 of 8(page number not for citation purposes)Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central BMC Research Notes 2008, 1:105 http://www.biomedcentral.com/1756-0500/1/1056. Martini S, Arfken CL, Churchill A, Balon R: Burnout ComparisonAmong Residents in Different Medical Specialties.  AcademicPsychiatry 2004, 28:240-242.7. Myers MF: Commentary: on the importance of anonymity insurveying medical student depression.  Academic Psychiatry 2003,27(1):19-20.8. Cohen JS, Patten S: Well-being in residency training: a surveyexamining resident physician satisfaction both within andout of residency training and mental health in Alberta.  BMC(Medical Education) 2005, 5:21.yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 8 of 8(page number not for citation purposes)

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