EDITORIALS shock to this writer who likes to believe that published infor- mation on topics such as these becomes known to practicing physicians and influences their patient care decisions. The findings in this paper therefore raise some important ques- tions, particularly in the present environment of medical prac- tice, where physicians are expected to present state-of-the-art information to patients for shared decision making and in- formed consent for whatever procedure is to be undertaken. Assuming the physicians in this study were considered to be competent (and there is no reason to suspect they were not), how does one account for such a wide lack of knowledge of existing published information? Perhaps our elaborate mecha- nisms for disseminating accurate medical information to phy- sicians are not working as well as they should, or perhaps the information itself may not always have been thought to be accurate. After all, different case studies often give different rates for complications or deaths. Perhaps the data may not be considered to be current or specific to the situation where it is to be used, and therefore not relevant. It is certainly true that most physicians have been trained to be critical of experi- mental studies, particularly when the results do not seem to fit with their own professional experience. And all are aware that any individual patient may be anywhere along a curve of statistical probability. But none of these possible explanations seems fully to account for the wide lack of knowledge of existing information exposed in Kronlund and Phillips's study. There is much food for thought in all this, particularly as patient care evolves toward an ever more exact science, with practicing physicians expected to be authoritative for that science before their patients and the public. MSMW Stress and Coping in Internal Medicine Residency ALTHOUGH THE HANDSOME and tireless intern in his scrub suit has been the subject of many romantic portrayals, there has recently been more serious attention in both the lay and medical press to the rigors of residency training and its effect on house officers. The article by Wolfe and Jones in this issue focuses on problems they have noted in the areas of profes- sional socialization, conflicts between personal and profes- sional life, "role strain," pregnancy and the role of the spouse. As the program they describe has a predominance of women, the authors feel they may be observing "gender dif- ferences in how residents are affected by and respond to cer- tain problems in residency training." However, I question the validity and the productiveness of labeling difficulties experi- enced by women trainees as "women's problems." The ex- haustion, uncertainty, fear and personal deprivation as- sociated with residency affect both men and women. The culture of medicine remains predominantly male but that does not legitimize the labeling of the coping responses of women trainees as abnormal simply because they are different from the responses of men. The fundamental problem from which the maladaptive coping responses of men and women flow is the stress associated with residency training; thoughtful con- sideration of the origins of this stress is more likely to be fruitful for trainees of both sexes . Training stress is a complex and incompletely described phenomenon. Some hardships of residency -training are dra- matic and readily identified; these include the extraordinary time demand and consequent physical and emotional exhaus- tion, the intense and sudden responsibility for life-or-death decisions and the tremendous amount of information to be mastered. Other aspects of residency training are perhaps equally stressful but less often appreciated. The daily work of a house officer, particularly an intern, is in large part unex- pectedly monotonous. Teaching is unstructured and learning unpredictable. Ethical dilemmas in patient care are ubiquitous and typically are not explicitly addressed or resolved. The climate of a residency program is often inhospitable or overtly hostile to expressions of personal or professional distress. The list could be extended almost indefinitely by anyone who has recently completed an internship. Some of these hardships are inherent in the nature of medical work while others reflect oversight or traditions of training. In considering possible remedies, it is useful to view stress as originating in either the content, the process or the atmosphere of medical training. Once the source of stress has been firmly located, possible solutions tend to suggest themselves. Challenges arising from the fundamental content of medi- cine relate to the overwhelming amount of medical knowl- edge, to the high level of uncertainty surrounding many major decisions, to the burden of responsibility for the well-being of other persons and to the ethical tensions frequently associated with this responsibility. Efforts to reduce training stress by direct manipulation of these fundamental attributes is unlikely to be effective or beneficial. However, explicit discussion of these issues in residents' reports, morbidity and mortality and attending rounds could promote a maturing understanding of the nature of medical practice in parallel with the develop- ment of technical expertise that already occurs during resi- dency. Rather than suggesting that the best residents always know the right course of action, discussions should support the accurate identification of one's limitations and appropriate consultation. The pain, sadness, uncertainty and occasional error inherent in medicine should not be denied. Ethical ten- sions in the care of patients should be sought out and thought- fully discussed. All of this would best be accomplished as an integral part of training by teachers who are also respected for technical competence. As these issues are part of medical practice, it is logical and natural that their discussions should be undertaken by practitioners in the course of caring for patients. The challenges of the process of medical training include the extraordinary time demand and consequent exhaustion, the personal deprivation and family stress resulting from a workweek that is three times longer than that enjoyed by "normal people," the interpersonal demands of frequent rota- tion and team changes and the unpredictable nature of clinical teaching. These stresses reflect the traditions and habits of residency more than the fundamental nature of medical prac- tice. Whether they should all be preserved is open to question. Recognizing the central importance of residents to the experi- ence of everyone on a team suggests that more formal atten- tion to the development of teaching and leadership skills could decrease interpersonal strain and increase team learning and the satisfaction that goes with it. Call schedules of every fourth night or better, alternating ward and consultation or clinic months and cross-coverage by a night float all offer the potential of humanizing the experience for residents without impairing learning or patient care. APRIL 1985 * 142 * 4 547