Home Print this page Email this page Small font sizeDefault font sizeIncrease font size
Users Online: 105

 

Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
     


 
 Table of Contents    
ORIGINAL ARTICLE  
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 61-66
Stress and the pediatric dental resident: Contributing factors and coping mechanisms


1 Department of Pediatric Dentistry, Indiana University School of Dentistry, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana, USA
2 Private Practice, Dover, Delaware, USA
3 Department of Pediatrics, Indiana University School of Medicine, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana, USA
4 Department of Cariology, Operative Dentistry, and Public Health, Indiana University School of Dentistry, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana, USA

Click here for correspondence address and email

Date of Web Publication11-Jan-2018
 

   Abstract 


Aims: The purpose of this study was to determine self-reported stress levels and coping mechanisms utilized by current pediatric dental residents to generate recommendations to program directors.
Subjects and Methods: A 26-question online survey was completed by 250 current United States and Canadian pediatric dental residents and summarized using frequencies and percentages.
Statistical Analysis Used: Relationships between various factors and stress levels were evaluated separately using Mantel-Haenszel Chi-square tests for ordered categorical responses. Relationships between various factors and depressive symptoms were evaluated separately using Pearson Chi-square tests. All test were performed with a significance level of P = 0.05.
Results: Forty percent of respondents report their stress level as high or medium-high. Stress levels were individually related to gender, academic demands, clinical demands, sleep factors, and hours per week devoted to the residency program. The most common coping mechanisms employed include exercise or sports (68%), television (66%), and socializing (62%).
Conclusions: Prospective applicants should recognize the potential for additional stressors that present when one enters into a postgraduate training program; current residents should monitor their stress levels and employ healthy coping mechanisms. Program directors should be cognizant of lifestyle burdens encountered as a resident, evaluate stress levels at timely intervals, and refer to appropriate health and wellness assistance programs as necessary.

Keywords: Internship, pediatric dentistry, residency, stress, wellness

How to cite this article:
Vinson LA, Nies JQ, Jones JE, Tomlin AM, Jackson RD, Sanders BJ. Stress and the pediatric dental resident: Contributing factors and coping mechanisms. J Educ Ethics Dent 2016;6:61-6

How to cite this URL:
Vinson LA, Nies JQ, Jones JE, Tomlin AM, Jackson RD, Sanders BJ. Stress and the pediatric dental resident: Contributing factors and coping mechanisms. J Educ Ethics Dent [serial online] 2016 [cited 2018 Apr 22];6:61-6. Available from: http://www.jeed.in/text.asp?2016/6/2/61/223004





   Introduction Top


During the 1970s and 1980s, significant attention was focused on the quality of life of medical residents. Several studies found a higher incidence of depression as well as anger and hostility in medical residents when compared to the general public.[1],[2],[3],[4],[5] Contributing factors were identified as chronic sleep deprivation, fatigue, and greater frequency of being on call.[1],[4],[6],[7],[8],[9],[10] Although these stressors were addressed with various program regulations, they have persisted. New sources of stress have emerged including increasing personal debt due to the cost of medical education, unstable financial conditions, and associated heavy workload. A recent reevaluation of medical residents found that these financial and emotional stressors could potentially interfere with training.[1],[11],[12] Although updated studies have confirmed the persistence of these factors and symptoms in medical residents, no studies have evaluated the stress levels and possible contributing factors of pediatric dental residents.

Stress is defined as physical and psychological responses to threatening or challenging conditions. According to Kail and Cavanaugh, stress results after a situation or event is deemed taxing or exceeding personal, social, or other resources.[13] Daily tasks can be deemed stressful for the general public, but the additional, significant stressors associated with pediatric dentistry training programs may contribute to residents' hypothesized elevated stress levels.

Financial stressors have heightened for most health-care professionals as the cost of education steadily increases. A study in 1991 estimated the average debt following medical school to be more than $35,000.[14] In July 2001, Glaspy et al. found that half of the respondents in a survey of emergency medicine residents had over $100,000 of debt.[15] Educational debt upon graduating dental school is reported to be as high. The average debt of 2014 dental graduates as reported by the American Dental Education Association was $247,227, and over half the respondents in Keck et al.'s survey of pediatric dental program directors reported debt burden of pediatric dental residents to be over $100,000.[16],[17] As demonstrated these figures will likely continue to increase for many residents, placing graduates in a difficult position in today's economy.

Mood changes have been associated with enrollment in residency programs including anticipation and excitement, self-doubt, anxiety, elation, and depression, the most experienced change.[3],[10] In 1975, Valko and Clayton reported that 30% of medical house officers suffered from depression during their internship, and in 1985, Reuben found that the prevalence of depression varied with postgraduate year and current rotation of training.[3],[5] Depression has not been evaluated in dental residency programs, but it, along with panic disorders and general anxiety disorders, has been known to affect practicing dentists who suffer from numerous sources of professional stress.[18]

Several recommendations have been made to support residency programs attempt to address stress levels of current residents. Levey recommended that program directors should evaluate the presence of depression in residents through periodic assessment.[11] If indicated, short-term counseling should be available to the affected resident as well as members of his or her family. Follow-up services should be available for as long as needed and referrals should not be delayed if the need for further intervention or counseling is present. Levey emphasized that confidentiality should always be maintained when possible.[11] McCue recommended more informal supports, stressing a collegial and friendly environment where emphasis was placed upon cooperation and enjoyment of patient care rather than competition and toughness.[10] McCue also stressed communication to residents through encouraging outside involvement in relationships and activities.[10] Formal support systems are also recommended including thorough orientation for residents, support groups for residents and spouses, regular social events, and access to financial, legal, and medical advisors.[9],[10]


   Subjects and Methods Top


Following approval from the Institutional Review Board (Study #EX0912-23), a 26-question survey examining pediatric dental residents' current psychological status was sent through electronic mail to all pediatric dental residents currently enrolled in the United States or Canadian pediatric dental residency programs using contact information provided by the American Academy of Pediatric Dentistry. The survey was published through an online survey tool (SurveyMonkey.com, Palo Alto, CA, USA) which allowed for anonymous responses. Survey responses were summarized using frequencies and percentages. Relationships between demographic and other factors and stress level were evaluated separately for each factor using Mantel-Haenszel Chi-square tests for ordered categorical responses. Percentages and frequencies by stress levels and P values were obtained for variables with a significant relationship. Multivariable models using the survey responses to predict stress level were analyzed using cumulative logistic regression with a stepwise variable selection technique. Interactions between the significant factors were examined. Odds ratios for significant relationships were calculated.

Relationships between demographic and other factors and depression symptoms were evaluated separately for each factor using Pearson Chi-square tests. Percentages and frequencies of depressive symptoms presence status and P values were presented for variables with a significant relationship. Multivariable models were analyzed using logistic regression with a stepwise variable selection technique. Odds ratios for significant relationships were calculated. A 5% significance level was used for all analyses.


   Results Top


Eight hundred and eighty-six surveys were sent through electronic mail. Of those contacted, 17 were residents who had recently graduate, 13 were considered undeliverable, and 5 were residents in overseas programs leaving 861 potential respondents. There were 250 responses to the survey, a response rate of 29%. The breakdown of survey respondents is summarized in [Table 1]. Money borrowed for education, estimated credit card debt, and monthly discretionary income are presented in [Table 2].
Table 1: Breakdown of survey respondents

Click here to view
Table 2: Financial information of Survey respondents

Click here to view


Sixty-three percent of the respondents were female and 55% were aged 24–29 years. The majority of the respondents were in their 2nd year of residency (54%), and 40% attended a combined hospital- and university-based program. Sixty-seven percent devoted at least 51 h/week to their residency program with 5% devoting >80 h/week [Figure 1].
Figure 1: Hours per week devoted to the residency program

Click here to view


Forty percent reported their stress level as high or medium-high [Figure 2]. Eleven depressive symptoms were evaluated. Depressive symptoms of survey respondents are summarized in [Figure 3].
Figure 2: Stress levels of pediatric dental residents

Click here to view
Figure 3: Depressive symptoms of pediatric dental residents

Click here to view


Twenty-two percent of respondents reported no depressive symptoms, 44% reported 1–3 symptoms, 23% reported 4–6 symptoms, and 10% reported over 7 depressive symptoms. [Figure 4] shows the coping utilized by pediatric dental residents that responded to the survey. Thirty-nine percent did not know if a health and wellness program was available to residents, 24% did not have a program available, 33% had one available but did not use it (mostly because of not having time or not feeling it necessary), and 4% used a program.
Figure 4: Coping mechanisms among pediatric dental residents

Click here to view


Gender, various sleep factors, weekly hours devoted to residency program, working for experience, academic demands, clinical demands, family life, financial status, on-call responsibilities, sleep deprivation, using video games to cope with stress, and using prayer or meditation to cope with stress were all individually related to stress levels. More males than females reported low/low-medium stress (43% and 16%, respectively) and more females (46%) than males (30%) reported medium-high/high stress. Sixty-five percent of respondents with no sleep deprivation contributing to their stress level reported low/low-medium stress and 73% with very much sleep deprivation reported medium/medium-high stress. Fifty-eight percent of respondents who used video games to cope with stress reported low/low-medium stress and 42% who were not using video games to cope with stress reported medium/medium-high stress.

Hours of sleep, academic demands, clinical demands, sleep deprivation, and using video games to cope with stress were significant in the multivariate cumulative logistic regression model. Getting 6 h or less of sleep compared to 7 h of sleep or more increased the odds of having a higher stress level by 1.09. Not using video games to reduce stress compared to using video games to reduce stress increased the odds of having a higher stress level by 4.36.

Hours per week devoted to one's residency program was individually related to stress levels and several depressive symptoms. Eight percent of respondents who devoted 51–60 h, 11% of respondents who devoted 50 h or less, and 22% of respondents who devoted over 60 h to their residency program reported feelings of helplessness and hopelessness, whereas fifteen percent who devoted 50 h or less per week to their program, 17% who devoted 51–60 h, and 31% who devoted over 60 h reported feelings of sadness. Of those who devoted over 60 h per week to their program, 57% reported feelings of irritability or anger, 35% reported frequent mood changes, 47% reported appetite or weight changes, and 53% reported sleep changes. Concentration problems were also exhibited by 43% of this group as well as feelings of restlessness (35%).

Various sleep factors were related to 9 of the 11 depressive symptoms studied. Twenty-seven percent of respondents getting 6 h or less of sleep per night and 15% who reported getting 7 h or more had feelings of sadness. Thirty percent of respondents who had inadequate sleep and 11% who had adequate sleep reported feelings of sadness. Not getting adequate sleep increased the odds of feeling sad by 2.30. Fifty-eight percent of respondents getting inadequate sleep and 28% of respondents getting adequate sleep reported feelings of irritability or anger. Nonetheless, not getting adequate sleep increased the odds of feelings of irritability and anger by 2.68.

Thirty-one percent of respondents getting 6 h or less of sleep per night and 16% getting 7 h or more of nightly sleep reported frequent mood changes, whereas 45% of respondents getting 6 h or less of sleep per night and 20% getting 7 h or more reported appetite or weight changes. Getting 6 h or less of sleep per night increased the odds of experiencing appetite or weight change by 224%.

Thirty-nine percent of respondents getting 6 h or less of sleep per night and 23% getting 7 h or more reported feeling of restlessness. Thirty-six percent of respondents getting inadequate sleep and 24% of respondents getting adequate sleep reported feeling of restlessness. Getting 6 h or less of sleep per night increased the odds of experiencing feelings of restlessness by 1.10.

Sixty percent of respondents getting inadequate sleep and 38% of respondents getting adequate sleep reported a loss of energy. Seventy-one percent of respondents getting inadequate sleep because of only professional reasons, 61% getting inadequate sleep because of only personal reasons, 52% for both reasons equally, and 38% getting adequate sleep reported a loss of energy. Not getting adequate sleep increased the odds of experiencing loss of energy by 77%.

Forty-one percent of respondents getting inadequate sleep and 19% of respondents getting adequate sleep reported concentration problems. Fifty-three percent of respondents getting inadequate sleep because of only professional reasons, 35% getting inadequate sleep because of only personal reasons, 36% for both reasons equally, and 19% getting adequate sleep reported concentration problems. Getting 6 h or less of sleep per night increased the odds of experiencing concentration problems by 230%.


   Discussion Top


This study is the first documented investigation of self-reported stress levels in pediatric dental residents. It should be remembered that the respondents constituted approximately 30% of those contacted, and the results may not be generalizable to all pediatric dental residents. Nevertheless, the data reveal several factors that contribute to elevated stress levels and highlight some of the coping mechanisms used by this population. Like our medical colleagues, these sources of stress have the potential to interfere with academic training.

Stress levels and various depressive symptoms were individually related to gender, clinical demands, academic demands, sleep factors, and hours per week devoted to the residency program. The differences among males and females were not surprising. Females were more likely to report medium-high or high stress levels, and females are historically more likely to visit the doctor and report symptoms.[19] As expected, those that report academic and clinical demands contributed “somewhat” or “very much” to current stress levels reported higher stress levels.

Sleep factors were most often related to stress levels and depressive symptoms, much like our colleagues in the medical field.[1],[4],[6],[7],[8],[9],[10] Less sleep per night is related to increasing stress levels [Figure 5] and the presence of various depressive symptoms. Although hours of sleep per night is controlled by the individual resident and not determined by the program, there does not seem to be excessive work hours or on call hours reported. It is an important topic to be reviewed by program directors at the start of the program before poor habits are formed.
Figure 5: Stress levels of pediatric dental residents by hours of sleep

Click here to view


Like sleep, time devoted to the residency program is a difficult contributing factor for program directors to control. It is, however, an interesting descriptive statistic useful for prospective applicants. The more time devoted to residency, the greater likelihood of increased stress levels, and various depressive symptoms. Program directors should be cognizant of workloads and encourage the maintenance of a regular schedule.

The financial status of residents is as anticipated given the current cost of education. Over 80% of survey respondents report over $100,000 borrowed for education with 11.6% of respondents noting an educational debt of over $300,000. This figure is greater than recent reports, and one might expect that greater debt would increase the likelihood of higher stress levels.[17],[20] The amount of financial debt, however, was not individually related to higher stress levels. The only correlation between financial debt and stress levels was those respondents that reported financial status contributed “somewhat” or “very much” to their stress levels had a greater tendency to report higher stress levels.

The presence of depressive symptoms is notable based on the results of this survey. Nearly 80% of respondents reported at least one depressive symptom. Although this does not indicate a major depressive episode, it is an important descriptive statistic that is valuable information for program directors and prospective applicants. Program directors should evaluate for the presence of these symptoms at regular intervals and know when and where to refer individual residents for further evaluation and interventions. Pediatric dental residents and other postgraduate residents should realize the higher likelihood of professional stress encountered by practicing dentists.[18]

The respondents of this survey utilized several healthy coping mechanisms such as regular participation in sports or exercise activities and socialization in person. These activities should be encouraged by program directors at the start of the residency program. If possible, team building activities involving physical exercise should be utilized. Ten percent of respondents used video games to cope with stress and this coping mechanism was individually related to stress levels. Fifty-eight percent of respondents using this method have low or low-medium stress, whereas 42% of those not using video games to cope with stress report medium or medium-high stress. This finding may be associated with the difference in stress levels between males and females mentioned above as typically more males than females play video games.[21]

Thirty-seven percent of survey respondents stated that there was a health and wellness assistance program available for use as part of his or her residency program. Twenty-four percent of respondents stated that there was no assistance program available and 39% stated that they were not sure if one existed. A high number of respondents do not know where to get help if needed. Program directors should address this issue by providing new residents with this information and following the recommendations by both Levey and McCue.[10],[11] One drawback of the study was the lack of clarification of a health and wellness assistance program. Many respondents commented that they did not know what a program was or that they belonged to a gym instead.


   Conclusions Top


Based on the survey results, significant stress levels exist among pediatric dental residents, and over three-fourths of respondents report the presence of at least one depressive symptom. Contributing factors identified through this survey include academic demands, clinical demands, sleep deprivation, and hours per week devoted to residency program. Prospective residents, current residents, and program directors may all benefit from the following recommendations generated from the results of the present study:

  • Prospective applicants should recognize the potential for additional stressors that are present when one enters into a postgraduate training program
  • Current residents should monitor their stress levels and recognize symptoms of depression
  • Healthy coping mechanisms should be employed
  • Program directors should be cognizant of the lifestyle burdens encountered as a pediatric dental resident, evaluate stress levels at timely intervals, and refer to appropriate health and wellness assistance programs as necessary.


Financial support and sponsorship

This study was financially supported by Indiana University School of Dentistry.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Collier VU, McCue JD, Markus A, Smith L. Stress in medical residency: Status quo after a decade of reform? Ann Intern Med 2002;136:384-90.  Back to cited text no. 1
[PUBMED]    
2.
Ford CV, Wentz DK. The internship year: A study of sleep, mood states, and psychophysiologic parameters. South Med J 1984;77:1435-42.  Back to cited text no. 2
[PUBMED]    
3.
Reuben DB. Depressive symptoms in medical house officers. Effects of level of training and work rotation. Arch Intern Med 1985;145:286-8.  Back to cited text no. 3
[PUBMED]    
4.
Schwartz AJ, Black ER, Goldstein MG, Jozefowicz RF, Emmings FG. Levels and causes of stress among residents. J Med Educ 1987;62:744-53.  Back to cited text no. 4
[PUBMED]    
5.
Valko RJ, Clayton PJ. Depression in the internship. Dis Nerv Syst 1975;36:26-9.  Back to cited text no. 5
[PUBMED]    
6.
Friedman RC, Kornfeld DS, Bigger TJ. Psychological problems associated with sleep deprivation in interns. J Med Educ 1973;48:436-41.  Back to cited text no. 6
[PUBMED]    
7.
Taylor AD, Sinclair A, Wall EM. Sources of stress in postgraduate medical training. J Med Educ 1987;62:425-8.  Back to cited text no. 7
[PUBMED]    
8.
Butterfield PS. The stress of residency. A review of the literature. Arch Intern Med 1988;148:1428-35.  Back to cited text no. 8
[PUBMED]    
9.
Colford JM Jr. McPhee SJ. The ravelled sleeve of care. Managing the stresses of residency training. JAMA 1989;261:889-93.  Back to cited text no. 9
    
10.
McCue JD. The distress of internship. Causes and prevention. N Engl J Med 1985;312:449-52.  Back to cited text no. 10
[PUBMED]    
11.
Levey RE. Sources of stress for residents and recommendations for programs to assist them. Acad Med 2001;76:142-50.  Back to cited text no. 11
[PUBMED]    
12.
Defoe DM, Power ML, Holzman GB, Carpentieri A, Schulkin J. Long hours and little sleep: Work schedules of residents in obstetrics and gynecology. Obstet Gynecol 2001;97:1015-8.  Back to cited text no. 12
[PUBMED]    
13.
Kail RV, Cavanaugh JC. Human Development: A Life-Span View. 4th ed. Belmont, CA: Thomson Wadsworth; 2007.  Back to cited text no. 13
    
14.
Keill SL. Moonlighting: Why training programs should monitor residents' activities. Hosp Community Psychiatry 1991;42:735-8.  Back to cited text no. 14
[PUBMED]    
15.
Glaspy JN, Ma OJ, Steele MT, Hall J. Survey of emergency medicine resident debt status and financial planning preparedness. Acad Emerg Med 2005;12:52-6.  Back to cited text no. 15
[PUBMED]    
16.
American Dental Education Association; 2015. Available from: http://www.adea.org/GoDental/Money_Matters/Educational_Debt.aspx. [Last accessed on 2017 Mar 10].  Back to cited text no. 16
    
17.
Keck DB, Rutkauskas JS, Clothey RA. Evaluating the need for alternative didactic learning options in pediatric dental residency training. J Dent Educ 2009;73:706-17.  Back to cited text no. 17
[PUBMED]    
18.
Rada RE, Johnson-Leong C. Stress, burnout, anxiety and depression among dentists. J Am Dent Assoc 2004;135:788-94.  Back to cited text no. 18
[PUBMED]    
19.
Bertakis KD, Azari R, Helms LJ, Callahan EJ, Robbins JA. Gender differences in the utilization of health care services. J Fam Pract 2000;49:147-52.  Back to cited text no. 19
[PUBMED]    
20.
Chmar JE, Weaver RG, Valachovic RW. Survey of dental student financial assistance, 2003-04. J Dent Educ 2005;69:1278-92.  Back to cited text no. 20
[PUBMED]    
21.
Hoeft F, Watson CL, Kesler SR, Bettinger KE, Reiss AL. Gender differences in the mesocorticolimbic system during computer game-play. J Psychiatr Res 2008;42:253-8.  Back to cited text no. 21
[PUBMED]    

Top
Correspondence Address:
Dr. LaQuia A Vinson
705, Riley Hospital Drive, #4205, Indianapolis, IN 46202
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jeed.jeed_23_16

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Subjects and Methods
   Results
   Discussion
   Conclusions
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed136    
    Printed1    
    Emailed0    
    PDF Downloaded39    
    Comments [Add]    

Recommend this journal