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Biaggi and co-authors [1] are to be congratulated on their study of the stressors and strains of medical training and practice. A troublesome finding is that emotional exhaustion and patient aversion was common among physicians they studied. One must consider some of the possible additional causes (stressors) for this finding not addressed in this study and possible steps for amelioration. Despite reducing the number of work hours for young physicians to approximately 55 hours per week, a level that is humane and should be well tolerated by enthusiastic young people in the early stages of a career, stress remains at a high level. We argue that a prime factor that contributes to emotional exhaustion and patient aversion is the basic emotional and psychological difficulty of medical work and insufficient training and support that most physicians receive in this aspect of the medical role. Because tremendous technical strides in medicine have resulted in successful treatments for some diseases there is an unrealistic expectation on the part of both patient and physician that problems should be solvable. The reality is that physicians have no ready “fix” to alleviate most of the human suffering they witness daily. A major aspect of the physician’s role therefore, becomes leading the patient through the complexities of adapting to their situation. That this difficult expectation and the physician’s daily fare of grief, anxiety, heavy responsibility and unsolvable dilemmas provoke stress should be obvious. However, given the paucity of overt teaching and general consideration to the psychosocial aspects of medicine during training, it appears that these challenges and their importance are underestimated. Additional stressors relate to the physician’s leadership role within the medical care team, the difficulty of negotiating one’s role in a medical institution as trainee or faculty member, and the consummate issue of balancing one’s private and professional life. It is essential that training programs acknowledge that managing the broad range of psychosocial issues constitutes a major component of the physician’s role and that efforts be made to prepare them for acceptance of these stressful professional challenges. If one polls young physicians about the reasons they chose the field of medicine, one finds that the answers reflect their genuine interest in the intense human drama in which they participate. It is our experience that making this aspect of the role an overt part of the training increases expertise and comfort and decreases the incidence of emotional distress and patient aversion. The importance of this aspect of medicine has been recognised by the ACGME, the organisation that accredits post-graduate training programs in the U.S., which now requires teaching of “interpersonal and communication skills” and “professionalism” [2]. In order to address the humanistic aspect of the medical role in the paediatric haematology-oncology fellowship program at our institution, we have instituted a twicemonthly seminar for the first year fellows to teach what we call “reflective practice”. The fellows present a broad range of psychosocial issues from their daily experience to the group. These issues are as diverse as the difficulty of dealing with a dying patient (perhaps, the same age as their own child), the complexities of obtaining informed consent for experimental studies, and the strain of balancing the demands of a young family with the time and emotional constraints of an intense academic training program. Their colleagues in the fellowship share their own experiences with the issues raised. Selected, experienced faculty members participate by framing provocative questions and, at times, relating their own experiences. This process raises the fellow’s consideration of these complex issues and their own internal processes that relate to them to a conscious (reflective) level. They broaden their base of experience through input from their colleagues and mentors and learn to frame the issues in a way that promotes further consideration and action. Like the complex disease processes and treatments that occupy the attention of physicians of today the subjects of these conferences have no easy answers. What is learned is a process of thinking that parallels the medical model. The causes and dynamics of psychosocial problems are framed into tentative hypotheses that are tested by observations and interventions. The hypotheses are further refined and tested in an iterative process. This reflective practice model allows the trainee to delve into the complex psychological and social situations that they find inherently fascinating. It encourages them to build a “database” of experience that will inform their further practice. The seminar promotes critical self-reflection that leads to what others have termed “mindful practice”. We have outcome data to support the effectiveness of this approach. In summary, a major source of the stress that is translated into emotional exhaustion and patient aversion emanates from the “difficult work” required of every physician. While the practice of medicine neither will nor should be stress-free this major source of stress can become an even greater source of satisfaction in medical practice.

Stressors and strains of medical training and practice