I m anxious, exhausted, and overwhelmed. And, I don t know what to do.

Transcription

1 I m anxious, exhausted, and overwhelmed. And, I don t know what to do. Comparing the transition experience of trainees making use of counselling supports during third year clerkship or first year residency. Christopher Hurst M.Ed Dr. Susan Edwards Dr. Dawn Martin Dr. Leslie Nickell

2 Context A number of studies attest to the significant challenges experienced by trainees transitioning from preclinical studies to clerkship and from clerkship to first year residency. However, there is a lack of literature exploring the two experiences from the perspective of trainees seeking counselling help. 88% of third year medical students met the criteria of moderate or high emotional exhaustion. Santen (2010) Among 114 first year residents who began free of burnout, 75% developed burnout. Ripp, (2011) Office of Resident Wellness PGY Year of Clients PGY1 PGY2 PGY3 PGY4 PGY5 PGY6+

3 Research Questions What are the challenges described by third year clerks and first year residents who sought counselling supports? How did trainees manage these challenges? What are the similarities and differences among challenges and changes described by each group?

4 Qualitative Methodology A thematic analysis of the case notes of 25 third-year clerks and 27 first-year residents who attended counseling sessions between between August 2008 and July 2011 at the Faculty of Medicine, University of Toronto. Case notes were coded for presenting states, challenges, and changes. The themes emerged from the data.

5 Findings: Presenting State Both groups: Overwhelmed, exhausted, don t know what to do, intense anxiety, self-described depression, low motivation, insomnia, altered eating, social isolation, illness, not able to concentrate I m overwhelmed. Exhausted. I feel out of control don t know what to do. I can t relax my body.

6 Findings: Personal Challenges Both groups: Relationship conflicts, break-ups, family conflicts, family crisis, serious health issues Feel like I lost my best friend. Don t understand why I m alone. I wake up at night with intense feelings of grief.

7 Findings: Training Challenges Residents: Workload exhausting On-calls draining Adapting to new rotations/environments Encounters with unsupportive staff Conflicts between career and personal life/family goals Questions about program fit Shock of responsibility Feelings of inadequacy/incompetence Fears about harming patients Evaluation anxiety No time to look after self Clerks: Adapting to new rotations/environments Frequent exams Encounters with unsupportive staff Different study routine Uncertainty about career choice/carms Concerns about personal life/family and career choices Fears about inadequate knowledge Anxiety affecting ability to study and to perform during exams and in clinic Information overload

8 Do I have the strength to do this? Is this for me? Feel Incompetent I m not motivated Feel exhausted Feel hopeless I m afraid of not knowing Less Confidence Low Mood Not interested in medicine anymore Can t relax; can t eat Feel behind everyone else Everyone is evaluating me Increased Anxiety Cycle of Diminished Adaptation (Both groups) Overwhelmed Feel overwhelmed Feel out of control Can t settle my mind I m afraid I will harm someone Froze during exam Want one thing to make sense This is too hard; I m going to fail Uncertainty Don t know what to do Don t know where I am Difficult to trust feedback No one to guide me

9 Both groups: Findings: Changes Taking Action Stage One Implementing a plan for better sleep and diet Reintroducing former self-care activities: gym, running, yoga, meditation, music, writing Reaching out to friends, family, mentors, program supports Starting to see a mental health practitioner on a regular basis Beginning medication Differences: Seeking assessment and support for learning disabilities (clerks) Took leaves of absence or days off (residents)

10 Findings: Changes: Taking Action Stage Two Reappraisal of goals and expectations as a single person, as a learner, as a partner, as a couple Increasing supportive self-talk Risking sharing with others Setting boundaries with family, patients, partners Experimenting with new study techniques (clerks) Practicing managing performance anxiety Grounding and self-talk tasks for panic attacks Choosing to be more actively engaged/assertive on rotation

11 Findings: Changes Firmer ground Better sleep, food, exercise, more positive self-talk Feel able to focus more, perform and study better More satisfaction in training activities Cycle of positive experiences on rotation building confidence More motivation, less anxiety and low mood Feel in control

12 I should be talking about this more Talked things out with partner/friend/family What are my needs? What do I want right now? Need strategies for connecting/coping Don t know why I am doing what I am doing Thinking Things Through Started exercising/yoga /meditation Taking Action Took a leave of absence Started medication/regular visits for follow-up No time to reflect about my life Need to meet with someone for a while Can t keep going Academy Director/PD/friend said I should come here Reaching Out Cycle of Enhanced Adaption (Both groups) Drawing new boundaries Consolidating and Expanding Changes Following study plan Created ground rules for clinic Trying to be more assertive More active with self-talk Able to concentrate/ study Work feels better - reassuring Firmer Ground Positive image of self as a good doctor I am happy where I am Able to ground during breaks

13 Findings: Summary Trainees who sought help were typically overwhelmed by a combination of training challenges and significant personal losses and conflicts. They experienced a combination of uncertainty, low self-confidence, high anxiety and depressive feelings that impeded focus, academic performance, motivation and perspective-taking. When moving from a diminished adaptive cycle to a more effective adaptive process, trainees tended to reach out for help, establish basic self-care activities, connect more with others in meaningful ways, think things through, reframe thoughts and expectations, and risk new behaviors.

14 Discussion Trainees may benefit from the development of a psychological model of transition in medical education. Such a model would outline inner challenges and processes of adaptation that frequently occur during transition phases. Medical educators may assist trainees in better negotiating transition phases by offering skills-based training in cognitive, emotional and physical approaches to managing the stress of training environments. A skills-based approach to managing psychological transitions that was begun early in medical school might prove beneficial to third year clerks and first year residents struggling with the transition experience.

15 Questions?

16 References Bernabeo, E., Holtman, M., Ginsburg,S., et al. Lost in translation: The experience of frequent changes in the inpatient learning environment. Academic Medicine, Vol. 86, No.5/ May 2011 Luthya, A., Perrierb, A., Perrinc, E., et al. Exploring the major difficulties perceived by residents in training: a pilot study Swiss Med. Wkly 2004;134: O Brian, B., Cooke, M., & Irby, D.. Perceptions of third year student struggles in clerkships: Do students and clerkship directors agree? Academic Medicine, Vol.82, No.10/ October 2007 Ripp, J., Babyatsky, M., Fallar, R., et al. The incidence and predictors of job burnout in first year internal medicine residents: A five-institution study. Academic Medicine, Vol.86, No.10/ October 2011 Santen, S., Hold, D., Kemp, J., & Hemphill R. Burnout in Medical Students: Examining the prevalence and associated factors. Southern Medical Journal Vol. 103, #8, August 2010 Westerman, M., Teunissen, P., van der Vleuten, C., et al. Understanding the transition from resident to attending physician: A transdisciplinary, qualitative study. Academic Medicine, Vol.85, No. 12/ December 2010