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GP registrar well-being: a cross-sectional survey

GP registrar well-being: a cross-sectional survey Objectives: To investigate the major stressors affecting GP registrars, how those at risk can be best identified and the most useful methods of managing or reducing their stress. Design, setting and participants: Cross-sectional postal questionnaire of all GP registrars in one large regional training provider’s catchment area. Main outcome measures: The Depression, Anxiety and Stress Scale (DASS), a specifically developed Registrar Stressor Scale consisting of five subscales of potential stressors, plus closed questions on how to identify and manage stress in GP registrars. Results: Survey response rate of 51% (102/199). Rural difficulties followed by achieving a work/life balance were the principal stressors. Ten percent of registrars were mildly or moderately depressed or anxious (DASS) and 7% mild to moderately anxious (DASS). Registrars preferred informal means of identifying those under stress (a buddy system and talks with their supervisors); similarly, they preferred to manage stress by discussions with family and friends, debriefing with peers and colleagues, or undertaking sport and leisure activities. Conclusions: This study supports research which confirms that poor psychological well-being is an important issue for a significant minority of GP trainees. Regional training providers should ensure that they facilitate formal and informal strategies to identify those at risk and assist them to cope with their stress. Introduction interest were: 1) What are the major stressors that affect A significant number of Australian general practitioners GP registrars in relation to their work and training? 2) (GPs) experience high levels of stress and have poor What are the most effective ways of identifying which psychological health, and this is likely to be due to a GP registrars are most at risk of stress? 3) What are the combination of individual characteristics and environ- most useful methods of managing and reducing GP mental factors such as frequent exposure to work- registrar stress? related stressors [1-3]. In recent times there have been changes to the Australian medical workforce and GP Methods training, with a decline in the number of registrars and GP registrar questionnaire development an apparent gradual attitudinal shift away from the rigid Thequestionnairewas developedfollowing aliterature medical ‘martyrdom’ of previous generations toward bet- review and interviews with 6 registrars. It was piloted ter ‘work/life balance’[4,5]. These changes may make with two recent medical graduates to establish face and stress as important an issue as it is among GP registrars’ content validity. These graduates indicated that the more senior colleagues. Stress might be related to speci- questionnaire could be completed within fifteen min- fic training issues as well as simply working in general utes. The questionnaire comprised four sections: demo- practice. graphics, the Depression, Anxiety Stress Scale (DASS), a This questionnaire survey aimed to identify causes and Registrar Stressor Scale (RSS) and questions on identify- potential responses to stress within one major regional ing and managing stress. training provider (RTP). The principal areas of research The RSS was developed by the research team and cov- ered five subscales representing the main stressors * Correspondence: peter.schattner@med.monash.edu.au which had been identified through the literature review Department of General Practice, Faculty of Medicine, Nursing and Health and the interviews. These were: rural difficulties (e.g. Sciences, Monash University, Building 1, 270 Ferntree Gully Rd, Notting Hill finding accommodation, separation from family), Vic 3168, Australia © 2010 Schattner 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. Schattner et al. Asia Pacific Family Medicine 2010, 9:2 Page 2 of 7 http://www.apfmj.com/content/9/1/2 isolation/low social support (e.g. not having time for the RSS in predicting stress, as measured by the total developing new social networks), work conditions (e.g. score on the DASS. SPSS version 17 was used for data excessive workload, difficulties in making complaints analysis. about training), insufficient teaching/vocational support, and work/life balance. The RSS items had four response Ethics Clearance choices using a Likert scale. Registrars were also asked The Standing Committee on Ethics in Research invol- to separately indicate one or more items in rank order ving Humans (SCERH) at Monash University granted to identify the factors contributing the most to registrar ethics approval for the study. stress, thestrategiestheynormallyuse to cope with stress and what they thought were the most effective Results ways of identifying registrars who experience significant Response rate and demographics stress. They were also asked about options for identify- A total of 102 GP registrars (females = 67, males = 35) ing and managing stress. completed the questionnaire, yielding a response rate of The final component of the questionnaire was the 21- 102/199 or 51 percent. The mean age of the sample was item version of the Depression Anxiety Stress Scale 33.10 (SD = 6.36), with a range of 25 to 51 years. (DASS) [6]. The DASS consists of three subscales The GP registrars were in the following stages of their designed to assess depression, anxiety, and stress training: subsequent term (42.2%); advanced term (32.4%); basic term (10.8%); hospital term (9.8%); and Procedure rural term (2.0%). On average, the GP registrars had The survey was conducted within a large metropolitan spent 1.93 years (SD = 1.11) in the training program. RTP and sent out to registrars in all levels of the pro- Participants reported the following living arrange- gram (excluding the six who participated in the inter- ments: with a partner/spouse (66.7%); with a friend(s) views). Registrars were in their hospital, basic, (10.8%); living alone (10.8%); and living at home with a subsequent and advanced terms of training, including parent(s) (6.9%). Thirty-nine percent of registrars report metropolitan and rural rotations. having a child in their care (49% have one child, 44% The RTP mailed the questionnaires, explanatory infor- have two children, and 7% have three or more children). mation and reply-paid envelopes to 199 registrars. The Seventeen percent were international medical graduates envelopes, which were addressed to the research team, (IMGs), and 60% had completed or were currently com- were coded so that non-responders could be followed pleting the rural term. up, with the RTP sending a reminder email to non- Twenty-eight percent of registrars reported a history responders after two weeks. of psychiatric/emotional problems (depression = 65%, stress = 12%, emotional problems = 12%, anxiety = 8%, Statistical analysis and psychosis = 3%). Ten registrars reported having a The results of the survey are presented with descriptive secondary mental health problem, that is, in addition statistics and with differences between sub-groups of to their primary one. Secondary problems included respondents tested by analysis of variance (ANOVA). anxiety (8), depression (1) and psychosis (1). Seventy- An hierarchical regression analysis was conducted to nine percent of GP registrars stated that they had their examine the relative strength of particular subscales of own GP. Figure 1 Percentages of raw scores in categories on the RSS subscales. Schattner et al. Asia Pacific Family Medicine 2010, 9:2 Page 3 of 7 http://www.apfmj.com/content/9/1/2 Table 1 Levels and causes of stress: means (and standard male GP registrars: Work conditions (females: mean = deviations) for the DASS and the RSS subscales 16.20, SD = 2.75; males mean = 14.50, SD = 3.55; F(1, Subscales (DASS and RSS) Mean (SD) 100) = 7.10, p = 0.009, partial eta squared = 0.07); Work/life balance (females: mean = 18.16, SD = 4.54; Depression (DASS) 6.33 (7.00) males mean = 15.00, SD = 4.90; F(1, 100) = 10.57, p= Anxiety (DASS) 3.40 (4.31) 0.002, partial eta squared = 0.10); and Rural difficulties Stress (DASS) 10.80 (7.64) (females: mean = 19.12, SD = 4.28; males mean = 16.42, Total (DASS) 20.43 (15.73) SD = 4.21; t(58) = -2.29, p < .05). There were no signifi- Rural difficulties (RSS) 18.30 (4.41) cant differences on the RSS between IMGs and non- Isolation/low social support (RSS) 16.20 (4.30) IMGs, or between registrars who had completed the Work conditions (RSS) 15.60 (3.14) rural term and those who had not. There were no sig- Insufficient teaching/social support (RSS) 15.00 (3.82) nificant group differences (males/females, IMGs/non- Work/life balance (RSS) 17.10 (4.88) IMGs, and completed rural term/not completed rural term) on the DASS scales. Causes of stress Specific factors that contribute most to registrar stress Each subscale on the RSS raw score ranges up to a max- The Registrar Questionnaire asked registrars to indicate imum of 30. The higher the mean score, the greater the which individual factors in their training and work con- impact level. These RSS raw scores are presented in tributed most to their stress, and to rank order the fac- Figure 1in fiveevenlydistributed categories.Although tors they had chosen, from the most stressful to the for most subscales the greatest number of participants least stressful (Table 3). Of the fifteen factors presented, rated the stressors in the 16 to 20 raw score category, about a quarter (27% and 23% respectively) of the regis- the three that were most often ranked as number one trars rated the rural difficulties and work/life balance were: managing tasks in limited time frames (24%); diffi- stressors in the higher 21 to 25 raw score category. cult patients (19%), and difficulties associated with the These two issues were seen to be the main stressors rural term (15%). The order of results from columns faced by registrars (Table 1). one and two are similar, i.e. the stressors faced by the greatest proportion of respondents were also those most Anxiety, depression and stress based on the DASS commonly ranked as being the most stressful. Lovibond and Lovibond have created cut-off scores for the subscales of the DASS, allowing the scores to be Methods of identifying GP registrar stress rated for severity across five categories: normal, mild, Table 4 shows that the preferred methods of identifying registrar stress were: a buddy system (26%); interviews moderate, severe, and extremely severe [6]. For each of with your GP supervisor (21%), and informal means the three subscales (i.e. depression, anxiety and stress), (e.g., staff noticing changes in demeanour) (13%). the majority of GP registrar scores were in the normal category. Approximately 10% of registrars reported mild Predicting GP registrar stress or levels of depression and stress, another 10% were A hierarchical regression analysis was conducted to exam- moderate, and 7% reported mild or moderate levels of ine the relative strength of subscales of the Registrar Stres- anxiety respectively. Very few of the GP registrars were sor Scale in predicting stress, as measured by the total in the ‘severe’ and ‘extremely severe’ categories on any score on the DASS. The Insufficient teaching/vocational subscale (Table 2). support subscale, and Age, were entered on the first step and Work conditions and Work/life balance subscales Group Differences across the RSS and the DASS were entered on the second to ascertain whether they Female GP registrars reported the following subscales of the RSS to be significantly greater stressors than for were able to predict a significant amount of variance on Table 2 Percentage of GP registrars in each DASS category Subscale Normal Mild Moderate Severe Extremely Severe Total Sample (N = 102) Depression 73.50 (0-9) 9.80 (10-13) 10.80 (14-20) 4.00 (21-27) 2.00 (28+) Anxiety 83.30 (0-7) 6.90 (8-9) 6.90 (10-14) 2.00 (15-19) 1.00 (20+) Stress 73.50 (0-14) 9.80 (15-18) 10.80 (19-25) 5.00 (26-33) 1.00 (34+) Note. Figures in parentheses denote the Lovibond and Lovibond (1995) DASS severity rating cut-offs for each category. Schattner et al. Asia Pacific Family Medicine 2010, 9:2 Page 4 of 7 http://www.apfmj.com/content/9/1/2 Table 5 Summary of hierarchical regression analysis for Table 3 Factors that have contributed most to stress variables predicting stress Percentages nominated for stress factors 1 2 Beta Weights Difficult patients 75 19 Step1 Managing tasks in limited time frames 67 24 Insufficient teaching .35* GP fellowship exams 52 10 Age -.05 Starting as a basic registrar 47 5 Step 2 Difficulties associated with the rural term 43 15 Insufficient teaching .06 Transition from hospital to independent GP work 39 6 Age -.06 Negotiating work or training conditions 35 3 Work conditions .29*** Session times when you are the only doctor working 32 1 in the practice Work/life balance .26*** Isolation from others 32 2 Note. Insufficient teaching = Insufficient teaching/vocational support subscale; beta weights = standardized beta coefficients; R Squared = .12 for Step 1; R Financial restraints 31 3 Squared Change = .15 for Step 2 (p < .001). *p < .001. **p < .01. ***p < .05. Long working hours 30 3 Different computer programs when beginning at a new 28 1 practice Assisting registrars to manage or reduce their stress Inadequate training support structures 20 1 Seventy five per cent of the GP registrars reported that Inadequate support from the practice 12 1 the RTP should be actively involved in identifying which Bullying from other staff members 10 2 registrars are stressed. The three strategies that were Note. 1 = the percentage of registrars endorsing this stress factor; 2 = the most often ranked as the number one most effective percentage of registrars overall who ranked the stress factor as the number one stress factor. means of managing stress by registrars include: debrief- ing with peers/colleagues (34%); education sessions on identifying/coping with stress (18%); and regular orga- nised sport or fitness activity (9%). Debriefing with Table 4 Most effective methods of identifying registrar peers/colleagues was reported as an effective strategy stress significantly more often by females than males c (1) = Percentages nominated for each method 1 2 6.30, p < .05, and was reported significantly more often Interviews with your GP supervisor 58 21 by local graduates compared to IMG’s c (1) = 19.48, A buddy system 57 26 p < .001. No other group differences were found (Table 6). Seeing your own GP 53 9 About half the registrars in this study had contem- plated leaving medicine as a result of stress, and more Informal means (eg., staff noticing changes in demeanour) 46 13 than a third reported that occupational stress had made Interviews with a VMA representative (eg., psychologist) 35 10 them want to leave their current workplace. Approxi- Stress screening on the annual GP registrar satisfaction survey 34 7 mately one quarter are thinking about leaving the train- Psychological paper and pencil test 26 6 ing program or general practice. Chat room forum facilitating discussion about registrar stress 23 3 Note. 1 = the percentage of registrars endorsing this method; 2 = the Discussion percentage of registrars overall who ranked the method as the number one method. The extent of psychological disturbance among GP registrars the DASS scores. The results are presented in Table 5. This survey showed that for the majority of GP regis- Insufficient teaching/vocational support was shown to be a trars, depression, stress, and anxiety levels were in the significant predictor at step one but Age was not shown to normal range. However, 11% experienced moderate be significant. The step one model explained 12 percent of levels of depression and stress and 6% experienced the variance. Following step 2, Work conditions (beta = severe depression and stress, which is of concern and .29) and Work/life balance (beta = .26) were both found to should warrant action. Moderate levels of depression as be significant predictors of stress, with the former the indicated by the DASS screening tool are often signifi- stronger one. The ANOVA table indicates that the model, cant enough to warrant a clinical diagnosis [6]. By com- which explained 27 per cent of the variance, was signifi- parison, a major survey of mental health among the cant [F(4, 97) = 8.90, p < .001]. This result suggests that Australian population has found that the prevalence of negative work conditions and difficulties with balancing all affective disorders among younger people (aged 18 - work and life commitments are greater predictors of stress 35) is between 6 and 7% [7]. for GP registrars than the teaching program, vocational Thefindingsofthe studysuggest that occupational support or age. stress had a significant impact, with 50% of current GP Schattner et al. Asia Pacific Family Medicine 2010, 9:2 Page 5 of 7 http://www.apfmj.com/content/9/1/2 registrars having thought, at least at some point in time, Table 6 The most effective strategies for managing GP registrar stress about leaving the medical profession due to stress related reasons. Rural term difficulties and problems Coping Strategies 1 2 with achieving a work/life balance were the general Debrief with peers/colleagues 78 34 stressors with the greatest impact, with females signifi- Seeing a clinician 55 7 cantly more affected than males. A study by Larkins et Regular organised leisure activities 53 5 al also found both of these stressors to be of significant Education sessions on identifying/coping with stress 50 18 concern for Australian GP registrars, and others have Regular organised sport or fitness activity 49 9 also highlighted the many problems in the rural term Relaxation training (eg., meditation) 40 4 which can lead to increased stress levels [8-12]. Facilitate greater support from family or peers 43 8 Significantly more females than males in the sample Time management course 42 2 reported rural term difficulties, consistent with previous A targeted approach, addressing the specific problems 39 8 research into the negative effects of the rural placement A buddy system focussing on immediate strategies 38 6 on female GP registrars [13]. Importantly, previous Online or face-to-face support groups 31 4 research has indicated that improving the psychological Easy to use self-help book with handy tips 25 1 well-being of rural GPs increases the likelihood of Note. 1 = the percentage of registrars endorsing this strategy; 2 = the retaining them in rural practice [14]. percentage of registrars overall that ranked the strategy as the most effective. Poor work/life balance has also been found to be an important stressor in studies of GPs, UK GP registrars, Australian GP registrars and Australian medical stu- remains of some concern. Further, although the survey dents [15-18]. Although some research indicates that asked specifically about training issues, much of the work/life balance issues are equally disruptive for both stress is likely to be bound up with the work of being female and male medical graduates, this study found a GP rather than a registrar; it is not really possible to that balancing these commitments was more of an issue separate these two states. Although any training pro- for female GP registrars than males [19,20]. This is con- gram will inevitably have some degree of stress, this sistent with other research which has emphasised the survey suggests levels that are higher than many would ‘balancing-act’ between medicine and the additional accept as reasonable. work that women do in managing family commitments [11,21]. Identifying which GP registrars are most at risk of stress Investigation of the individual stress factors for GP Recent research has shown that as psychological pro- registrars revealed that managing tasks in limited time blems increase among Australian GPs, their help-seek- frames and difficult patients were the highest and sec- ing decreases [25]. This suggests that identifying GP ond highest ranking individual stress factors. Difficulties registrar stress may be difficult. The GP registrars ’ with such work conditions have reportedly contributed reported preference for informal assessment of their to a drop in GP registrar numbers in the UK and should stress suggests a lack of confidence in more formal sys- therefore be carefully addressed by Australian training tems such as consultation with a GP, or psychological programs [22-24]. screening. In addition, the findings from the work conditions The identification of GP registrar stress may also be subscale of the RSS revealed that this stressor was sig- aided by the better understanding of which situations or nificantly greater among females than males. This high- factors are predictive of registrar stress. Difficult work lights the suggestions by researchers such as McDonald conditions and problems with balancing work/life com- et al on the need for mentorship, supervision, and train- mitments were shown to be greater predictors of stress ing to be gender-specific because of the underlying mas- for GP registrars than the teaching program/vocational culine character of medical culture [12]. The third support or the age of registrars. This is in line with the highest ranking individual stress factor was difficulties Larkins studies which found that workload, the negotia- associated with the rural term, which reinforces its sig- tion of work terms and conditions, and feeling powerless nificant impact. to influence change at work were particularly associated This study has examined the relationship between with registrar stress [26,27]. training and psychological distress, but has not explored the extent to which uniquely individual and Assisting GP registrars to manage and reduce their stress pre-existing personality factors contribute to coping The stress reduction strategies most frequently used by difficulties. Caution must be applied in assuming the respondents include talking to family or friends, cause-and-effect relationships in individual cases, debriefing with peers or colleagues, and sport or exer- although the overall results for this group of registrars cise. These strategies involve dialogue with other people Schattner et al. Asia Pacific Family Medicine 2010, 9:2 Page 6 of 7 http://www.apfmj.com/content/9/1/2 and appear to be problem-focused coping strategies. Appendix 1: Key recommendations to regional These are typically more adaptive in the long-term than training programs emotion-focused strategies such as avoidance or distrac- List of recommendations arising from this study to tion [27]. This study could not ascertain whether these regional training programs registrars deliberately under-reported less acceptable 1. GP registrar well-being remains an important and strategies such as alcohol or substance use. The fourth relevant issue for RTPs most reported strategy was just putting up and getting 2. The rural rotation continues to be problematic and on with it, which would suggest some level of emotion- further investigation on how this term can be made focused coping. more satisfying should be undertaken. The majority of the participants reported that the RTP 3. RTPs should pay further attention to improvements should be involved in helping them manage their stress in working conditions, including providing more flexibil- levels. The most effective stress reduction strategies ity in rosters and in time off. were identified as debriefing with peers/colleagues, edu- 4. Registrars need further education and support in cation sessions on identifying/coping with stress, and learning how to manage tasks in a limited time, how to regular organised sport or fitness activity. Again, the deal with difficult patients and how to cope with rural first two methods are problem-focused and adaptive in terms. nature [27]. The strategies address stress reduction from 5. The use of a buddy system should be encouraged. a combination of approaches: involving colleagues, 6. Registrars should be encouraged to talk to family learning more about stress and how to approach it, and and friends about their difficulties, and to debrief with the physical and social benefits associated with orga- colleagues rather than ‘bottle things up’. nised sport or fitness. This finding provides clear guide- 7. RTPs should facilitate regular discussions between lines for RTPs to address stress among their trainees. registrars and their GP supervisors about the registrar’s welfare and educate supervisors about the typical stres- Limitations of the Study sors encountered and how they can help registrars cope The study had a 51% response rate which raises the with these. question of response bias. Unfortunately, surveys among 8. RTPs should inform practices, perhaps largely but doctors tend not to have high response rates; this study not exclusively through the supervisors, about the need is therefore not exceptional. Although the attitudes of to be sensitive to the emotional health of registrars. non-responders cannot be known, it is reassuring that 9. Where possible, RTPs should encourage registrars participants did arise from a reasonable cross-section of to engage in extra-curricular activities such as sport or registrars according to gender and year of training. A other relaxing pastimes. second limitation is that the study relied on self-report 10. RTPs should include educational sessions in the by registrars who originate from one RTP, albeit a large training program curriculum on how to cope better one. Nevertheless, this survey is consistent with other with stress. research which indicates that improving GP registrar well-being remains an important issue for the future of Acknowledgements general practice [28]. The authors of this report would like to sincerely thank Dr Mark Rowe and his administrative staff at the Victorian Metropolitan Alliance (VMA) for their cooperation with this project, particularly during the data collection stage. Conclusion We also sincerely thank the VMA for funding this project. Finally, our thanks Mental health difficulties are common in this group, to the GP registrars who responded to the survey and participated in the with almost 30 percent of the respondents having interviews. reported a history of psychiatric or emotional problems. Author details Ten out of the 28 reported a secondary mental health Department of General Practice, Faculty of Medicine, Nursing and Health problem in addition to their primary one. Half the regis- Sciences, Monash University, Building 1, 270 Ferntree Gully Rd, Notting Hill Vic 3168, Australia. School of Psychology, Deakin University, 221 Burwood trars in this study had contemplated leaving medicine as Highway, Burwood Vic 3125, Australia. Monash Institute of Health Services a result of stress, and more than a third reported that Research, School of Public Health and Preventive Medicine, Faculty of occupational stress had made them want to leave their Medicine, Nursing and Health Sciences, Locked Bag 29, Clayton 3168, Australia. current workplace, with approximately one quarter thinking about leaving the training program or general Authors’ contributions practice. Appendix 1 lists several recommendations PS was the chief investigator and wrote the final version of the article; DM was the research officer, did most of the data analysis and wrote the first which arise logically from the findings of this study draft of the article; all authors were equally involved in the design of the which RTPs may wish to consider in order to improve study and in reviewing drafts of the paper. All authors read and approved the psychological health of their trainees. the final manuscript. Schattner et al. Asia Pacific Family Medicine 2010, 9:2 Page 7 of 7 http://www.apfmj.com/content/9/1/2 gender composition, structures and occupational cultures in medicine. Competing interests Medical Education 2007, 41:39-49. The Victorian Metropolitan Alliance (a regional training program) funded the 22. Rowsell R, Morgan M, Sarangi J: General practice registrars’ view about a study which was conducted at Monash University (department of general career in general practice. Br J of Gen Pract 1995, 45:601-604. practice). The RTP sent out the survey questionnaires but these were 23. Appleton K, House A, Dowell A: A survey of job satisfaction, sources of collected by the university department. The RTP did not have any role in stress and psychological symptoms among general practitioners in designing the research methods or the questionnaire, or in data analysis Leeds. Br J of Gen Pract 1998, 48:1059-1063. and interpretation. There were no other competing interests. 24. Longhurst S, Shipman C, Dale J: Working out of hours: the experiences and training needs of general practice registrars. Br J of Gen Pract 1998, Received: 21 July 2009 48:1247-1248. Accepted: 9 February 2010 Published: 9 February 2010 25. Davies F, Deane F, Dalley A: General practitioners’ help-seeking intentions for mental health problems. Aust J of Primary Health 2006, 12:66-71. References 26. Larkins S, Spillman M, Vanlint J, Hays R: Stress, personal and educational 1. Caplan R: Stress, anxiety, and depression in hospital consultants, general problems in vocational training. A prospective cohort study. Aust Fam practitioners, and senior health service managers. BMJ 1994, Phys 2003, 32:473-480. 309:1261-1263. 27. Suls J, Fletcher B: The relative efficacy of avoidant and non-avoidant 2. Clode D: The Conspiracy of Silence: Emotional health among medical coping strategies: A meta-analysis. Health Psychology 1985, 4:249-288. practitioners. Royal Australian College of General Practitioners: South 28. Wilcock S, Daly M, Tennant C, Allard B: Burnout and psychiatric morbidity Melbourne 2004. in new medical graduates. MJA 2004, 181:357-60. 3. Schattner P, Coman G: The stress of metropolitan general practice. MJA 1998, 169:133-137. doi:10.1186/1447-056X-9-2 4. Pearce C, Hogarty K: The decision to enter general practice. Aust Fam Cite this article as: Schattner et al.: GP registrar well-being: a cross- Phys 2002, 31:1013-1015. sectional survey. Asia Pacific Family Medicine 2010 9:2. 5. Cong M: More on the ‘Future of General Practice’ debate: Letter to the editor. Aust Fam Phys 2002, 31:506-507. 6. Lovibond P, Lovibond S: The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy 1995, 33:335-343. 7. Australian Bureau of Statistics: Mental Health and Wellbeing: Profile of adults, Australia. ABS, Commonwealth of Australia, Canberra 1997. 8. Larkins S, Spillman M, Parison J, Hays R, Vanlint J, Veitch C: Isolation, flexibility and change in vocational training for general practice: personal and educational problems experienced by general practice registrars in Australia. Family Practice 2004, 21:559-556. 9. Han G, Wearne B, O’Meara P, McGrail M, Chesters J: Medical students’ and GP registrars’ accommodation needs in the rural community: insight from a Victorian study. Australian Health Review 2003, 26:92-105. 10. Wearne S: Pilot study on the factors that influence learning by general practice registrars in central Australia. Rural and Remote Health 3 (online) 2003, 223http://www.rrh.org.au/publishedarticles/article_print_223.pdf. 11. Margolis S, Davies L, Ypinazar V: Isolated rural general practice as the focus for teaching core clinical rotations to pre-registration medical students. BMC Medical Education 2005, 5:1-7. 12. McDonald M, Wainer J, Spike N: Towards best practice delivery: Meeting the needs of female registrars within Victorian Metropolitan Alliance general practice training. Centre for Gender and Medicine, Monash Institute of Health Services Research, Monash University, Melbourne 2006. 13. Charles D, Ward A, Lopez D: Experiences of female general practice registrars: Are rural attachments encouraging them to stay?. Aust J of Rural Health 2005, 13:331-336. 14. Gardiner M, Sexton R, Kearns H, Marshall K: Impact of support initiatives on retaining rural general practitioners. Aust J of Rural Health 2006, 14:196-201. 15. White C, Ferguson S: Female medical practitioners in rural and remote Queensland: an analysis of findings, issues, and trends. Queensland Rural Medical Support Agency, Brisbane 2001. 16. Tolhurst H, Lippert N: The national female rural general practitioners research project. University of Newcastle, Newcastle 2003. Submit your next manuscript to BioMed Central 17. Chambers R, Wall D, Campbell I: Stresses, coping mechanisms and job and take full advantage of: satisfaction in general practitioner registrars. Br J of Gen Pract 1996, 46:343-346. 18. Tolhurst H, Stewart S: Balancing work, family, and other lifestyle aspects: • Convenient online submission A qualitative study of Australian medical students’ attitudes. MJA 2004, • Thorough peer review 181:361-364. 19. Australian Medical Association: Training and workplace flexibility. Final • No space constraints or color figure charges report. Canberra: AMA 2001. • Immediate publication on acceptance 20. Shanley B, Schulte K, Chant D: Factors influencing career development of • Inclusion in PubMed, CAS, Scopus and Google Scholar Australian general practitioners. Aust Fam Phys 2002, 31:49-54. 21. Kilminster S, Downes J, Gough B, Murdoch-Eaton D, Roberts T: Women in • Research which is freely available for redistribution medicine - is there a problem? A literature review of the changing Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

GP registrar well-being: a cross-sectional survey

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Springer Journals
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Copyright © 2010 by Schattner et al; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
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10.1186/1447-056X-9-2
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20181138
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Abstract

Objectives: To investigate the major stressors affecting GP registrars, how those at risk can be best identified and the most useful methods of managing or reducing their stress. Design, setting and participants: Cross-sectional postal questionnaire of all GP registrars in one large regional training provider’s catchment area. Main outcome measures: The Depression, Anxiety and Stress Scale (DASS), a specifically developed Registrar Stressor Scale consisting of five subscales of potential stressors, plus closed questions on how to identify and manage stress in GP registrars. Results: Survey response rate of 51% (102/199). Rural difficulties followed by achieving a work/life balance were the principal stressors. Ten percent of registrars were mildly or moderately depressed or anxious (DASS) and 7% mild to moderately anxious (DASS). Registrars preferred informal means of identifying those under stress (a buddy system and talks with their supervisors); similarly, they preferred to manage stress by discussions with family and friends, debriefing with peers and colleagues, or undertaking sport and leisure activities. Conclusions: This study supports research which confirms that poor psychological well-being is an important issue for a significant minority of GP trainees. Regional training providers should ensure that they facilitate formal and informal strategies to identify those at risk and assist them to cope with their stress. Introduction interest were: 1) What are the major stressors that affect A significant number of Australian general practitioners GP registrars in relation to their work and training? 2) (GPs) experience high levels of stress and have poor What are the most effective ways of identifying which psychological health, and this is likely to be due to a GP registrars are most at risk of stress? 3) What are the combination of individual characteristics and environ- most useful methods of managing and reducing GP mental factors such as frequent exposure to work- registrar stress? related stressors [1-3]. In recent times there have been changes to the Australian medical workforce and GP Methods training, with a decline in the number of registrars and GP registrar questionnaire development an apparent gradual attitudinal shift away from the rigid Thequestionnairewas developedfollowing aliterature medical ‘martyrdom’ of previous generations toward bet- review and interviews with 6 registrars. It was piloted ter ‘work/life balance’[4,5]. These changes may make with two recent medical graduates to establish face and stress as important an issue as it is among GP registrars’ content validity. These graduates indicated that the more senior colleagues. Stress might be related to speci- questionnaire could be completed within fifteen min- fic training issues as well as simply working in general utes. The questionnaire comprised four sections: demo- practice. graphics, the Depression, Anxiety Stress Scale (DASS), a This questionnaire survey aimed to identify causes and Registrar Stressor Scale (RSS) and questions on identify- potential responses to stress within one major regional ing and managing stress. training provider (RTP). The principal areas of research The RSS was developed by the research team and cov- ered five subscales representing the main stressors * Correspondence: peter.schattner@med.monash.edu.au which had been identified through the literature review Department of General Practice, Faculty of Medicine, Nursing and Health and the interviews. These were: rural difficulties (e.g. Sciences, Monash University, Building 1, 270 Ferntree Gully Rd, Notting Hill finding accommodation, separation from family), Vic 3168, Australia © 2010 Schattner 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. Schattner et al. Asia Pacific Family Medicine 2010, 9:2 Page 2 of 7 http://www.apfmj.com/content/9/1/2 isolation/low social support (e.g. not having time for the RSS in predicting stress, as measured by the total developing new social networks), work conditions (e.g. score on the DASS. SPSS version 17 was used for data excessive workload, difficulties in making complaints analysis. about training), insufficient teaching/vocational support, and work/life balance. The RSS items had four response Ethics Clearance choices using a Likert scale. Registrars were also asked The Standing Committee on Ethics in Research invol- to separately indicate one or more items in rank order ving Humans (SCERH) at Monash University granted to identify the factors contributing the most to registrar ethics approval for the study. stress, thestrategiestheynormallyuse to cope with stress and what they thought were the most effective Results ways of identifying registrars who experience significant Response rate and demographics stress. They were also asked about options for identify- A total of 102 GP registrars (females = 67, males = 35) ing and managing stress. completed the questionnaire, yielding a response rate of The final component of the questionnaire was the 21- 102/199 or 51 percent. The mean age of the sample was item version of the Depression Anxiety Stress Scale 33.10 (SD = 6.36), with a range of 25 to 51 years. (DASS) [6]. The DASS consists of three subscales The GP registrars were in the following stages of their designed to assess depression, anxiety, and stress training: subsequent term (42.2%); advanced term (32.4%); basic term (10.8%); hospital term (9.8%); and Procedure rural term (2.0%). On average, the GP registrars had The survey was conducted within a large metropolitan spent 1.93 years (SD = 1.11) in the training program. RTP and sent out to registrars in all levels of the pro- Participants reported the following living arrange- gram (excluding the six who participated in the inter- ments: with a partner/spouse (66.7%); with a friend(s) views). Registrars were in their hospital, basic, (10.8%); living alone (10.8%); and living at home with a subsequent and advanced terms of training, including parent(s) (6.9%). Thirty-nine percent of registrars report metropolitan and rural rotations. having a child in their care (49% have one child, 44% The RTP mailed the questionnaires, explanatory infor- have two children, and 7% have three or more children). mation and reply-paid envelopes to 199 registrars. The Seventeen percent were international medical graduates envelopes, which were addressed to the research team, (IMGs), and 60% had completed or were currently com- were coded so that non-responders could be followed pleting the rural term. up, with the RTP sending a reminder email to non- Twenty-eight percent of registrars reported a history responders after two weeks. of psychiatric/emotional problems (depression = 65%, stress = 12%, emotional problems = 12%, anxiety = 8%, Statistical analysis and psychosis = 3%). Ten registrars reported having a The results of the survey are presented with descriptive secondary mental health problem, that is, in addition statistics and with differences between sub-groups of to their primary one. Secondary problems included respondents tested by analysis of variance (ANOVA). anxiety (8), depression (1) and psychosis (1). Seventy- An hierarchical regression analysis was conducted to nine percent of GP registrars stated that they had their examine the relative strength of particular subscales of own GP. Figure 1 Percentages of raw scores in categories on the RSS subscales. Schattner et al. Asia Pacific Family Medicine 2010, 9:2 Page 3 of 7 http://www.apfmj.com/content/9/1/2 Table 1 Levels and causes of stress: means (and standard male GP registrars: Work conditions (females: mean = deviations) for the DASS and the RSS subscales 16.20, SD = 2.75; males mean = 14.50, SD = 3.55; F(1, Subscales (DASS and RSS) Mean (SD) 100) = 7.10, p = 0.009, partial eta squared = 0.07); Work/life balance (females: mean = 18.16, SD = 4.54; Depression (DASS) 6.33 (7.00) males mean = 15.00, SD = 4.90; F(1, 100) = 10.57, p= Anxiety (DASS) 3.40 (4.31) 0.002, partial eta squared = 0.10); and Rural difficulties Stress (DASS) 10.80 (7.64) (females: mean = 19.12, SD = 4.28; males mean = 16.42, Total (DASS) 20.43 (15.73) SD = 4.21; t(58) = -2.29, p < .05). There were no signifi- Rural difficulties (RSS) 18.30 (4.41) cant differences on the RSS between IMGs and non- Isolation/low social support (RSS) 16.20 (4.30) IMGs, or between registrars who had completed the Work conditions (RSS) 15.60 (3.14) rural term and those who had not. There were no sig- Insufficient teaching/social support (RSS) 15.00 (3.82) nificant group differences (males/females, IMGs/non- Work/life balance (RSS) 17.10 (4.88) IMGs, and completed rural term/not completed rural term) on the DASS scales. Causes of stress Specific factors that contribute most to registrar stress Each subscale on the RSS raw score ranges up to a max- The Registrar Questionnaire asked registrars to indicate imum of 30. The higher the mean score, the greater the which individual factors in their training and work con- impact level. These RSS raw scores are presented in tributed most to their stress, and to rank order the fac- Figure 1in fiveevenlydistributed categories.Although tors they had chosen, from the most stressful to the for most subscales the greatest number of participants least stressful (Table 3). Of the fifteen factors presented, rated the stressors in the 16 to 20 raw score category, about a quarter (27% and 23% respectively) of the regis- the three that were most often ranked as number one trars rated the rural difficulties and work/life balance were: managing tasks in limited time frames (24%); diffi- stressors in the higher 21 to 25 raw score category. cult patients (19%), and difficulties associated with the These two issues were seen to be the main stressors rural term (15%). The order of results from columns faced by registrars (Table 1). one and two are similar, i.e. the stressors faced by the greatest proportion of respondents were also those most Anxiety, depression and stress based on the DASS commonly ranked as being the most stressful. Lovibond and Lovibond have created cut-off scores for the subscales of the DASS, allowing the scores to be Methods of identifying GP registrar stress rated for severity across five categories: normal, mild, Table 4 shows that the preferred methods of identifying registrar stress were: a buddy system (26%); interviews moderate, severe, and extremely severe [6]. For each of with your GP supervisor (21%), and informal means the three subscales (i.e. depression, anxiety and stress), (e.g., staff noticing changes in demeanour) (13%). the majority of GP registrar scores were in the normal category. Approximately 10% of registrars reported mild Predicting GP registrar stress or levels of depression and stress, another 10% were A hierarchical regression analysis was conducted to exam- moderate, and 7% reported mild or moderate levels of ine the relative strength of subscales of the Registrar Stres- anxiety respectively. Very few of the GP registrars were sor Scale in predicting stress, as measured by the total in the ‘severe’ and ‘extremely severe’ categories on any score on the DASS. The Insufficient teaching/vocational subscale (Table 2). support subscale, and Age, were entered on the first step and Work conditions and Work/life balance subscales Group Differences across the RSS and the DASS were entered on the second to ascertain whether they Female GP registrars reported the following subscales of the RSS to be significantly greater stressors than for were able to predict a significant amount of variance on Table 2 Percentage of GP registrars in each DASS category Subscale Normal Mild Moderate Severe Extremely Severe Total Sample (N = 102) Depression 73.50 (0-9) 9.80 (10-13) 10.80 (14-20) 4.00 (21-27) 2.00 (28+) Anxiety 83.30 (0-7) 6.90 (8-9) 6.90 (10-14) 2.00 (15-19) 1.00 (20+) Stress 73.50 (0-14) 9.80 (15-18) 10.80 (19-25) 5.00 (26-33) 1.00 (34+) Note. Figures in parentheses denote the Lovibond and Lovibond (1995) DASS severity rating cut-offs for each category. Schattner et al. Asia Pacific Family Medicine 2010, 9:2 Page 4 of 7 http://www.apfmj.com/content/9/1/2 Table 5 Summary of hierarchical regression analysis for Table 3 Factors that have contributed most to stress variables predicting stress Percentages nominated for stress factors 1 2 Beta Weights Difficult patients 75 19 Step1 Managing tasks in limited time frames 67 24 Insufficient teaching .35* GP fellowship exams 52 10 Age -.05 Starting as a basic registrar 47 5 Step 2 Difficulties associated with the rural term 43 15 Insufficient teaching .06 Transition from hospital to independent GP work 39 6 Age -.06 Negotiating work or training conditions 35 3 Work conditions .29*** Session times when you are the only doctor working 32 1 in the practice Work/life balance .26*** Isolation from others 32 2 Note. Insufficient teaching = Insufficient teaching/vocational support subscale; beta weights = standardized beta coefficients; R Squared = .12 for Step 1; R Financial restraints 31 3 Squared Change = .15 for Step 2 (p < .001). *p < .001. **p < .01. ***p < .05. Long working hours 30 3 Different computer programs when beginning at a new 28 1 practice Assisting registrars to manage or reduce their stress Inadequate training support structures 20 1 Seventy five per cent of the GP registrars reported that Inadequate support from the practice 12 1 the RTP should be actively involved in identifying which Bullying from other staff members 10 2 registrars are stressed. The three strategies that were Note. 1 = the percentage of registrars endorsing this stress factor; 2 = the most often ranked as the number one most effective percentage of registrars overall who ranked the stress factor as the number one stress factor. means of managing stress by registrars include: debrief- ing with peers/colleagues (34%); education sessions on identifying/coping with stress (18%); and regular orga- nised sport or fitness activity (9%). Debriefing with Table 4 Most effective methods of identifying registrar peers/colleagues was reported as an effective strategy stress significantly more often by females than males c (1) = Percentages nominated for each method 1 2 6.30, p < .05, and was reported significantly more often Interviews with your GP supervisor 58 21 by local graduates compared to IMG’s c (1) = 19.48, A buddy system 57 26 p < .001. No other group differences were found (Table 6). Seeing your own GP 53 9 About half the registrars in this study had contem- plated leaving medicine as a result of stress, and more Informal means (eg., staff noticing changes in demeanour) 46 13 than a third reported that occupational stress had made Interviews with a VMA representative (eg., psychologist) 35 10 them want to leave their current workplace. Approxi- Stress screening on the annual GP registrar satisfaction survey 34 7 mately one quarter are thinking about leaving the train- Psychological paper and pencil test 26 6 ing program or general practice. Chat room forum facilitating discussion about registrar stress 23 3 Note. 1 = the percentage of registrars endorsing this method; 2 = the Discussion percentage of registrars overall who ranked the method as the number one method. The extent of psychological disturbance among GP registrars the DASS scores. The results are presented in Table 5. This survey showed that for the majority of GP regis- Insufficient teaching/vocational support was shown to be a trars, depression, stress, and anxiety levels were in the significant predictor at step one but Age was not shown to normal range. However, 11% experienced moderate be significant. The step one model explained 12 percent of levels of depression and stress and 6% experienced the variance. Following step 2, Work conditions (beta = severe depression and stress, which is of concern and .29) and Work/life balance (beta = .26) were both found to should warrant action. Moderate levels of depression as be significant predictors of stress, with the former the indicated by the DASS screening tool are often signifi- stronger one. The ANOVA table indicates that the model, cant enough to warrant a clinical diagnosis [6]. By com- which explained 27 per cent of the variance, was signifi- parison, a major survey of mental health among the cant [F(4, 97) = 8.90, p < .001]. This result suggests that Australian population has found that the prevalence of negative work conditions and difficulties with balancing all affective disorders among younger people (aged 18 - work and life commitments are greater predictors of stress 35) is between 6 and 7% [7]. for GP registrars than the teaching program, vocational Thefindingsofthe studysuggest that occupational support or age. stress had a significant impact, with 50% of current GP Schattner et al. Asia Pacific Family Medicine 2010, 9:2 Page 5 of 7 http://www.apfmj.com/content/9/1/2 registrars having thought, at least at some point in time, Table 6 The most effective strategies for managing GP registrar stress about leaving the medical profession due to stress related reasons. Rural term difficulties and problems Coping Strategies 1 2 with achieving a work/life balance were the general Debrief with peers/colleagues 78 34 stressors with the greatest impact, with females signifi- Seeing a clinician 55 7 cantly more affected than males. A study by Larkins et Regular organised leisure activities 53 5 al also found both of these stressors to be of significant Education sessions on identifying/coping with stress 50 18 concern for Australian GP registrars, and others have Regular organised sport or fitness activity 49 9 also highlighted the many problems in the rural term Relaxation training (eg., meditation) 40 4 which can lead to increased stress levels [8-12]. Facilitate greater support from family or peers 43 8 Significantly more females than males in the sample Time management course 42 2 reported rural term difficulties, consistent with previous A targeted approach, addressing the specific problems 39 8 research into the negative effects of the rural placement A buddy system focussing on immediate strategies 38 6 on female GP registrars [13]. Importantly, previous Online or face-to-face support groups 31 4 research has indicated that improving the psychological Easy to use self-help book with handy tips 25 1 well-being of rural GPs increases the likelihood of Note. 1 = the percentage of registrars endorsing this strategy; 2 = the retaining them in rural practice [14]. percentage of registrars overall that ranked the strategy as the most effective. Poor work/life balance has also been found to be an important stressor in studies of GPs, UK GP registrars, Australian GP registrars and Australian medical stu- remains of some concern. Further, although the survey dents [15-18]. Although some research indicates that asked specifically about training issues, much of the work/life balance issues are equally disruptive for both stress is likely to be bound up with the work of being female and male medical graduates, this study found a GP rather than a registrar; it is not really possible to that balancing these commitments was more of an issue separate these two states. Although any training pro- for female GP registrars than males [19,20]. This is con- gram will inevitably have some degree of stress, this sistent with other research which has emphasised the survey suggests levels that are higher than many would ‘balancing-act’ between medicine and the additional accept as reasonable. work that women do in managing family commitments [11,21]. Identifying which GP registrars are most at risk of stress Investigation of the individual stress factors for GP Recent research has shown that as psychological pro- registrars revealed that managing tasks in limited time blems increase among Australian GPs, their help-seek- frames and difficult patients were the highest and sec- ing decreases [25]. This suggests that identifying GP ond highest ranking individual stress factors. Difficulties registrar stress may be difficult. The GP registrars ’ with such work conditions have reportedly contributed reported preference for informal assessment of their to a drop in GP registrar numbers in the UK and should stress suggests a lack of confidence in more formal sys- therefore be carefully addressed by Australian training tems such as consultation with a GP, or psychological programs [22-24]. screening. In addition, the findings from the work conditions The identification of GP registrar stress may also be subscale of the RSS revealed that this stressor was sig- aided by the better understanding of which situations or nificantly greater among females than males. This high- factors are predictive of registrar stress. Difficult work lights the suggestions by researchers such as McDonald conditions and problems with balancing work/life com- et al on the need for mentorship, supervision, and train- mitments were shown to be greater predictors of stress ing to be gender-specific because of the underlying mas- for GP registrars than the teaching program/vocational culine character of medical culture [12]. The third support or the age of registrars. This is in line with the highest ranking individual stress factor was difficulties Larkins studies which found that workload, the negotia- associated with the rural term, which reinforces its sig- tion of work terms and conditions, and feeling powerless nificant impact. to influence change at work were particularly associated This study has examined the relationship between with registrar stress [26,27]. training and psychological distress, but has not explored the extent to which uniquely individual and Assisting GP registrars to manage and reduce their stress pre-existing personality factors contribute to coping The stress reduction strategies most frequently used by difficulties. Caution must be applied in assuming the respondents include talking to family or friends, cause-and-effect relationships in individual cases, debriefing with peers or colleagues, and sport or exer- although the overall results for this group of registrars cise. These strategies involve dialogue with other people Schattner et al. Asia Pacific Family Medicine 2010, 9:2 Page 6 of 7 http://www.apfmj.com/content/9/1/2 and appear to be problem-focused coping strategies. Appendix 1: Key recommendations to regional These are typically more adaptive in the long-term than training programs emotion-focused strategies such as avoidance or distrac- List of recommendations arising from this study to tion [27]. This study could not ascertain whether these regional training programs registrars deliberately under-reported less acceptable 1. GP registrar well-being remains an important and strategies such as alcohol or substance use. The fourth relevant issue for RTPs most reported strategy was just putting up and getting 2. The rural rotation continues to be problematic and on with it, which would suggest some level of emotion- further investigation on how this term can be made focused coping. more satisfying should be undertaken. The majority of the participants reported that the RTP 3. RTPs should pay further attention to improvements should be involved in helping them manage their stress in working conditions, including providing more flexibil- levels. The most effective stress reduction strategies ity in rosters and in time off. were identified as debriefing with peers/colleagues, edu- 4. Registrars need further education and support in cation sessions on identifying/coping with stress, and learning how to manage tasks in a limited time, how to regular organised sport or fitness activity. Again, the deal with difficult patients and how to cope with rural first two methods are problem-focused and adaptive in terms. nature [27]. The strategies address stress reduction from 5. The use of a buddy system should be encouraged. a combination of approaches: involving colleagues, 6. Registrars should be encouraged to talk to family learning more about stress and how to approach it, and and friends about their difficulties, and to debrief with the physical and social benefits associated with orga- colleagues rather than ‘bottle things up’. nised sport or fitness. This finding provides clear guide- 7. RTPs should facilitate regular discussions between lines for RTPs to address stress among their trainees. registrars and their GP supervisors about the registrar’s welfare and educate supervisors about the typical stres- Limitations of the Study sors encountered and how they can help registrars cope The study had a 51% response rate which raises the with these. question of response bias. Unfortunately, surveys among 8. RTPs should inform practices, perhaps largely but doctors tend not to have high response rates; this study not exclusively through the supervisors, about the need is therefore not exceptional. Although the attitudes of to be sensitive to the emotional health of registrars. non-responders cannot be known, it is reassuring that 9. Where possible, RTPs should encourage registrars participants did arise from a reasonable cross-section of to engage in extra-curricular activities such as sport or registrars according to gender and year of training. A other relaxing pastimes. second limitation is that the study relied on self-report 10. RTPs should include educational sessions in the by registrars who originate from one RTP, albeit a large training program curriculum on how to cope better one. Nevertheless, this survey is consistent with other with stress. research which indicates that improving GP registrar well-being remains an important issue for the future of Acknowledgements general practice [28]. The authors of this report would like to sincerely thank Dr Mark Rowe and his administrative staff at the Victorian Metropolitan Alliance (VMA) for their cooperation with this project, particularly during the data collection stage. Conclusion We also sincerely thank the VMA for funding this project. Finally, our thanks Mental health difficulties are common in this group, to the GP registrars who responded to the survey and participated in the with almost 30 percent of the respondents having interviews. reported a history of psychiatric or emotional problems. Author details Ten out of the 28 reported a secondary mental health Department of General Practice, Faculty of Medicine, Nursing and Health problem in addition to their primary one. Half the regis- Sciences, Monash University, Building 1, 270 Ferntree Gully Rd, Notting Hill Vic 3168, Australia. School of Psychology, Deakin University, 221 Burwood trars in this study had contemplated leaving medicine as Highway, Burwood Vic 3125, Australia. Monash Institute of Health Services a result of stress, and more than a third reported that Research, School of Public Health and Preventive Medicine, Faculty of occupational stress had made them want to leave their Medicine, Nursing and Health Sciences, Locked Bag 29, Clayton 3168, Australia. current workplace, with approximately one quarter thinking about leaving the training program or general Authors’ contributions practice. Appendix 1 lists several recommendations PS was the chief investigator and wrote the final version of the article; DM was the research officer, did most of the data analysis and wrote the first which arise logically from the findings of this study draft of the article; all authors were equally involved in the design of the which RTPs may wish to consider in order to improve study and in reviewing drafts of the paper. All authors read and approved the psychological health of their trainees. the final manuscript. Schattner et al. Asia Pacific Family Medicine 2010, 9:2 Page 7 of 7 http://www.apfmj.com/content/9/1/2 gender composition, structures and occupational cultures in medicine. Competing interests Medical Education 2007, 41:39-49. The Victorian Metropolitan Alliance (a regional training program) funded the 22. Rowsell R, Morgan M, Sarangi J: General practice registrars’ view about a study which was conducted at Monash University (department of general career in general practice. 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Australian Medical Association: Training and workplace flexibility. Final • No space constraints or color figure charges report. Canberra: AMA 2001. • Immediate publication on acceptance 20. Shanley B, Schulte K, Chant D: Factors influencing career development of • Inclusion in PubMed, CAS, Scopus and Google Scholar Australian general practitioners. Aust Fam Phys 2002, 31:49-54. 21. Kilminster S, Downes J, Gough B, Murdoch-Eaton D, Roberts T: Women in • Research which is freely available for redistribution medicine - is there a problem? A literature review of the changing Submit your manuscript at www.biomedcentral.com/submit

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Asia Pacific Family MedicineSpringer Journals

Published: Feb 9, 2010

References