INTRODUCTION: Australian general practitioners suffer from high levels of stress, but the incidence among GP registrars during vocational training is less well described.\ud
\ud
METHODS: All 400 new Australian GP registrars in 1999 were invited to participate in the study. Consenting registrars completed an annual questionnaire and initial psychometric scales. Medical educators also provided information annually about known registrar problems.\ud
\ud
RESULTS: Participating numbers were 213 (year 1), 226 (year 2), 203 (year 3), and 98 (year 4). More than half reported at least one problem in years 2, 3 and 4. Those reporting problems scored significantly higher on initial psychometric scales, and reported lower enthusiasm for training (p<0.01). Problems reported included unsatisfactory work conditions, administrative concerns and issues with rural terms. These problems were often not detected by their training providers. Recommendations are presented to minimise the frequency and impact of training problems.\ud
\ud
CONCLUSION: Registrars in vocational training for Australian general practice commonly experience problems. Structural changes in the provision of general practice training provide an opportune time to consider ways to ameliorate some of these problems

Hays, Richard B.

Larkins, Sarah L.

Spillman, Margaret

Vanlint, JohnW.

ResearchOnline@JCU

Stress, personal and educational problems in vocational training: a prospective cohort study

INTRODUCTION: Australian general practitioners suffer from high levels of stress, but the incidence among GP registrars during vocational training is less well described.



METHODS: All 400 new Australian GP registrars in 1999 were invited to participate in the study. Consenting registrars completed an annual questionnaire and initial psychometric scales. Medical educators also provided information annually about known registrar problems.



RESULTS: Participating numbers were 213 (year 1), 226 (year 2), 203 (year 3), and 98 (year 4). More than half reported at least one problem in years 2, 3 and 4. Those reporting problems scored significantly higher on initial psychometric scales, and reported lower enthusiasm for training (p<0.01). Problems reported included unsatisfactory work conditions, administrative concerns and issues with rural terms. These problems were often not detected by their training providers. Recommendations are presented to minimise the frequency and impact of training problems.



CONCLUSION: Registrars in vocational training for Australian general practice commonly experience problems. Structural changes in the provision of general practice training provide an opportune time to consider ways to ameliorate some of these problems

ResearchOnline at James Cook University

Reprinted from Australian Family Physician Vol. 32, No. 6, June 2003 • 473Doctors, including Australian generalpractitioners, have poor psychologi-cal health.1,2 Stress affecting GPs hasphysical and psychological sequelae andimpacts on the entire family unit.3 Generalpractitioners are also often reluctant toseek appropriate professional assistance.4Sources of stress for GP registrars in theUnited Kingdom include conflictsbetween home and work, studying for thequalifying examination, unrealistic expec-tations from patients, and disruption tosocial life.5 Psychological problems amongregistrars enrolled in the RoyalAustralian College of GeneralPractitioners Training Program, undoubt-edly present, have not been studiedpreviously. We aimed to assess problemsas perceived by registrars, and determineany predictors of developing problems. MethodsAll 400 registrars commencing training in1999 were invited to participate.Registrars could opt out of the study atany stage. A stringent confidentiality pro-tocol was developed in consultation withthe national registrar representative body.All participants were initially asked tocomplete the Depression Anxiety StressScales,6 and the General HealthQuestionnaire 30 item form7 to assesssymptoms of stress, anxiety or depression.They are relatively quick, easy to com-plete, and well validated.8,9Consenting registrars provided demo-graphic details, enthusiasm for generalpractice training, satisfaction with traininglocation, family circumstances, and per-Stress, personal and educational problems in vocational trainingA prospective cohort studySarah L Larkins, Margaret Spillman, John W Vanlint, Richard B HaysSarah L Larkins, MBBS, MPH&TM, is a Research Fellow, Department of General Practice and Rural Medicine, James Cook University, Townsville, Queensland. Margaret Spillman, BSc (Hons), is a Research Assistant, Department of General Practice and Rural Medicine, James Cook University, Townsville, Queensland. John W Vanlint, DRCOG, FRACGP, was Senior Lecturer, Department of General Practice and Rural Medicine, James Cook University, Townsville, Queensland. Richard B Hays, PhD, FRACGP, is Professor of General Practice and Rural Medicine,James Cook University, Townsville, Queensland. INTRODUCTION Australian general practitioners suffer from high levels of stress, but the incidence among GP registrarsduring vocational training is less well described.METHODS All 400 new Australian GP registrars in 1999 were invited to participate in the study. Consenting registrarscompleted an annual questionnaire and initial psychometric scales. Medical educators also provided informationannually about known registrar problems. RESULTS Participating numbers were 213 (year 1), 226 (year 2), 203 (year 3), and 98 (year 4). More than half reportedat least one problem in years 2, 3 and 4. Those reporting problems scored significantly higher on initial psychometricscales, and reported lower enthusiasm for training (p<0.01). Problems reported included unsatisfactory work conditions,administrative concerns and issues with rural terms. These problems were often not detected by their training providers.Recommendations are presented to minimise the frequency and impact of training problems.CONCLUSION Registrars in vocational training for Australian general practice commonly experience problems. Structuralchanges in the provision of general practice training provide an opportune time to consider ways to ameliorate some ofthese problems.474 • Reprinted from Australian Family Physician Vol. 32, No. 6, June 2003ceived level of support from family,friends and professional colleagues (usingfive-point Likert-type scales). Every year registrars were askedabout any problems during the previous12 months of training, actions taken, andfeelings about what might help. Theywere also given advice on how to accessconfidential assistance for personal ortraining problems.Medical educators in each state wereasked to provide information about regis-trars in the 1999 cohort, including theirtraining terms, perceptions of their enthusi-asm, participation and academic progress,and any personal or training problems.We coded qualitative information bythemes. Two researchers independentlycoded all the year 1 responses andachieved 77% agreement. Data wereentered into SPSS version 1010 and wereanalysed using chi-square tests, confi-dence intervals, and unpaired Wilcoxonrank sum tests as appropriate.11We established a process to manageregistrars who reported potentially seriousproblems, or scored highly on psychomet-ric scales. An acknowledgment letter wassent with advice to consider seeking helpwhere appropriate. Had we identified apotentially serious risk, we were preparedto directly refer a registrar for confidentialexpert advice. This was not necessary.Ethics approval was obtained.ResultsRegistrar participation in year 1 (1999)was 213/395 (54%), year 2, 226/353(64%), year 3, 203/234 (87%), and in year 4, 98/115 (85%). Falling denomina-tors resulted from the exclusion ofregistrars who opted out of the study ordid not respond to six mailings, and tomany registrars completing training (year4). The equivalent responses frommedical educators were 371/400 (93%)for year 1, 300/335 (90%) year 2, 293/323(91%) year 3, and 103/117 (88%) for year4 (2002). Participating registrars wereslightly younger and more likely to bewomen than nonparticipants. There wasno significant difference in problemsreported by training programs in year 1between participating and nonparticipat-ing registrars, suggesting that there maynot be a response bias on the grounds ofproblems experienced. The proportion of registrars whoreported a problem rose after year 1.Registrars reported more problems thantheir medical educators (Table 1).Registrars were more likely to report aproblem if they had abnormal scores onany psychometric subscale, lower enthusi-asm for training, or were having troublebalancing training requirements with theneeds of a partner or children (Table 2).Table 1. Proportions of registrars and medical educators reportingproblems n [%] (95% confidence interval)Year 1 Year 2 Year 3 Year 4Registrars 74/212 125/217 100/197 54/98reporting [35] (29, 41) [58] (51, 64) [51] (44, 58) [55] (45, 65)problemsTraining 15/191 39/185 54/178 10/85program [8] (4, 12) [21] (15, 27) [30] (24, 37) [12] (5, 19)reporting problemsTable 2. Year 1 participants reporting problems compared with year 1participants not reporting problemsVariable Registrars Registrars  p-valuereporting not reporting (Wilcoxon problems a problem test)n=74 n=134Age 29.6 29.1 NS Depression Anxiety 6.4 3.7 0.002 Stress Scales (DASS) –Depression subscale DASS – Anxiety subscale 4.1 2.4 0.004 DASS – Stress subscale 11.4 8.1 0.005 General Health 6.8 2.8 <0.0005Questionnaire (GHQ)Chronicity scoring for GHQ 13.0 8.7 <0.0005Ordinal categories Percentage of Percentage of p-valueregistrars registrars chi-square reporting not reporting test for problems a problem trend High enthusiasm 41% 46% 0.007First location preference 81% 88% NSHigh spouse problems 21% 6% 0.00001High children problems 11% 4% 0.043Female gender 69% 63% NSReprinted from Australian Family Physician Vol. 32, No. 6, June 2003 • 475There was no significant associationbetween age, gender or perceived supportand reporting a problem. There was a sig-nificant inverse association between theregistrar’s self reported enthusiasm forgeneral practice training and the likeli-hood of reporting a problem (except inyear 4).Most reported problems related to theorganisation of training such as workplaceconditions, administrative problems andrural terms (Table 3). More than 100actions taken were described in each yearof the study, most often involving arequest for help from the trainingprogram, liaison with training supervisors,or changing terms. Suggestions for min-imising problems included organisationalchange with increased flexibility, changesto their own circumstances, and practisingself help strategies. We analysed training program ques-tionnaires when we could match themwith registrar data. Age, poor academicprogress, low enthusiasm for training, andgraduating in 1990 or earlier were signifi-cantly associated with training programreports of problems. Gender and obtain-ing a degree overseas were not. DiscussionThe proportion of registrars reporting aproblem was high, peaking in year 2 whenregistrars had most contact with the train-ing program, and the additional pressureof meeting their rural commitment with itsheavy workload and family disruption. A comparison group was impractical forthis descriptive study, however, it is possi-ble that trainees in other disciplines,especially those requiring relocations, mayexperience similar levels of problems. The association of psychological dis-tress with reporting problems is difficultto interpret in terms of causal direction.Nevertheless, psychometric screeningmay be a useful means of detecting regis-trars at risk in time for intervention, andwarrants further work. Medical educators reported fewerproblems than registrars, although thismight relate to confidentiality concerns,or suboptimal training supervision. Thenature of problems reported by registrarswas conventional.5 However, personalstress symptoms and family problemswere frequently attributed by registrars totraining stressors. We found equal preva-lence of problems in men and women,contrary to previous research.12Literature studying doctors, theirsupport structures and work problemsoften highlights lack of control.13,14Registrars clearly have a reduction inautonomy during training, and this lack ofchoice emerges as an important issue,particularly in terms of the impact onother family members.The current state of flux of generalpractice training in Australia is an oppor-tunity to minimise the frequency andimpact of training related stressors.AcknowledgmentsThanks to the RACGP for funding thestudy, to the General Practice Registrars’Association which supported it, to CraigVeitch and Lisa Crossland for comment-ing on the manuscript, to Catherine Joycefor developing the coding system, and toFrank McDonald for psychologicaladvice.Conflict of interest: Sarah Larkins was a GPregistrar for the duration of this project.References1. Caplan R P. Stress, anxiety and depressionin hospital consultants, general practition-ers, and senior health service managers. BrMed J 1994; 309:1261–1263.2. Schattner P L, Coman G J. The stress ofmetropolitan general practice. Med J Aust1998; 169:133–137.3. Nelson E G, Henry W F. Psychosocialfactors seen as problems by family practiceresidents and their spouses. J Fam Pract1978; 6(3):581–589.4. Lawrence J M. Stress and the doctor’shealth. Aust Fam Physician 1996;Implications of this studyfor general practice• Over half of registrars experiencepersonal or educational problems duringtheir period of vocational training.• Problems are significantlyassociated with initial psychologicalvulnerability, low enthusiasm fortraining, and training causingproblems for a partner or children.• Training providers may be unawareof these problems.• Improved communication, clearguidelines and maximising trainingprogram flexibility may helpminimise problems.Table 3. Problems reported by year compared with by groupingcategoryGrouping category % (95% confidence interval)Problems related to: Year 1 Year 2 Year 3 Year 4n=162 n=273 n=254 n=144Training program * 52 (44, 60) 70 (65, 76)** 63 (57, 69) 59 (51, 67)Other professional 6 (3, 10) 2 (0.2, 3) 1 (-0.1, 3) 4 (0.5, 7)Personal and family 22 (16, 29) 15 (11, 19) 16 (12, 21) 15 (9, 21)Health issues 15 (10, 21) 11 (8, 15) 18 (13, 22) 18 (12, 24)Others 4 (1, 7) 2 (0.1, 3) 2 (0.5, 4) 4 (1, 8)* includes work conditions, administrative issues, rural terms** = significant difference at p=0.05 level between years 1 and 2476 • Reprinted from Australian Family Physician Vol. 32, No. 6, June 200325:1249–1256.5. Chambers R, Wall D, Campbell I. Stresses,coping mechanisms and job satisfaction ingeneral practitioner registrars. Br J GenPract 1996; 46:343–348.6. Lovibond S H, Lovibond P F. Manual forthe Depression Anxiety Stress Scales. 2ndedn. Sydney: The Psychology Foundationof Australia, 1996.7. Goldberg D, Williams P. A user’s guide tothe general health questionnaire. London:NFER-Nelson, 1991.8. Lovibond P F, Lovibond S H. The structureof negative emotional states: Comparisonof the Depression, Anxiety Stress Scales(DASS) with the Beck depression andanxiety inventories. Behav Res Ther 1995;33(3):335–336.9. Goodchild M E, Duncan-Jones P.Chronicity and the general health ques-tionnaire. Br J Psych 1985; 146:55–61.10. SPSS for Windows. Chicago: SPSS Inc., 2000.11. Bland M. An introduction to medical statis-tics. Oxford: Oxford University Press, 1987.12. Stewart D, Ahmad F, Cheung A, BergmanB, Dell D. Women physicians and stress.Journal of Women’s Health and GenderBased Medicine 2000; 9(2):185–190.13. Rout U. Stress among general practitionersand their spouses: A qualitative study. Br JGen Pract 1996; 46:157–160.14. McGlone S J,  Chenoweth I G. Jobdemands and control as predictors ofoccupational satisfaction in general prac-tice. Med J Aust 2001; 175:88–91.CorrespondenceEmail: sarah.larkins@jcu.edu.auAFP

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Stress, personal and educational problems in vocational training: a prospective cohort study

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