6 opportunities to encourage wavering doctor trainees to chin up and soldier on

Last month saw the release of research showing a nontrivial number of physicians quit the job soon after completing residency training. Now comes a separate study suggesting the reasons for the phenomenon are often deep, diffuse and knotty—and thus difficult to address in a strictly programmatic way. 

The authors arrived at their observations after analyzing 56 relevant studies. The Journal of General Internal Medicine published their work June 8.

Utpal Sandesara MD, PhD, and colleagues at the University of California, Los Angeles report their core finding was that residents’ work-related emotional experiences tend to “emerge from the interaction between their evolving identities and the demands of residency, with interpersonal and structural factors influencing that interaction.”

Rather than framing residents’ emotions as linear outcomes of stressful labor conditions—or of other individual, interpersonal and systemic causes—“it might be more helpful to conceptualize those emotions as products of the complex interaction between external conditions and a dynamic process of personal and professional development,” they write. 

The team’s findings arrive as U.S. healthcare’s physician shortage continues to worsen. Here are six of their actionable observations, lightly edited for clarity and conciseness. 

1. Residents frequently face emotional challenges related to workload, hours and inability to satisfy basic needs. However, these drivers are often linked to underlying issues of identity and development. 

For example, where long hours and heavy workload impose stress, the emotional impacts of such stress are mitigated if accompanied by opportunities to learn and provide meaningful care, Sandesara and co-researchers offer. 

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In short, the literature suggests that it is not exclusively work that generates work-related emotions but, rather, the interplay between work and issues of the developing self.

2. Commonplace residency scenarios evoke strong feelings partly because they affect trainees’ sense of self. 

The researchers found that articles centering resident errors indicated that these might generate distress partly by engendering crises of confidence and responsibility. 

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Multiple articles described how negative patient-directed emotions arise from encounters that challenge resident authority, competence or ethicality. One explicitly mapped negative emotions onto challenges to residents’ identities as physicians, learners, teachers and workers. 

3. Co-workers and supervisors are critical influences on the work-identity interplay that generates resident emotions. 

Numerous analyzed studies found that, when residents face scenarios that challenge their competency or values, connecting with other residents and care-team members can help with emotional processing and learning from the experience, the authors report. They add that such connections can, in turn, reduce distress and promote wellbeing.  

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In many studies, residents describe supportive supervisors and leaders—particularly those who display investment and fostered trust—as enhancing resident well-being and morale. 

4. Relatives and friends outside the workplace play an important identity-related role in residents’ feelings. 

Studies described how residents tied de-prioritization of outside relationships to burnout, diminished well-being and even “loss of self,” Sandesara and colleagues write. 

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Conversely, other studies identified maintenance of non-work identities as promoters of resilience or happiness.

5. Healthcare corporatization and litigiousness can impinge on residents’ emotional wellbeing by clashing with their developing professional identities. 

One article in the present analysis traced how prioritization of profits and skewed incentives generated pervasive distress, as residents experienced conflicts between increased revenue and optimal care, the authors report. 

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Another article described how fear of lawsuits contributed to residents’ distress by creating conflicts between personal values and administratively favored actions. 

6. Poverty, stigma and other health inequities can impact residents’ moral development and contribute to negative work-related emotions. 

One study explained how social policy and marginalization could worsen the care of vulnerable populations, Sandesara and team write. They add that this can lead to residents feeling powerless and eventually enduring negative psychological impacts while attempting to go “above and beyond.”

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Several studies illustrated how experiences of caring for stigmatized patients, when not adequately processed, could negatively affect moral development, promoting frustration, anger, avoidance, apathy and detachment.

“Pragmatically,” the authors conclude, “our findings argue for broadening beyond logistical interventions—such as duty-hour restrictions—and psychologically oriented interventions—such as mindfulness training—to directly address the existential challenges inherent to transitioning from student to physician while developing competence through action.”

They add that long-view interventions would recognize personal wellbeing and professional growth as “mutually reinforcing.”

The study is posted in full for free.