Psychological well-being of interns in Hong Kong: What causes them stress and what helps them

Abstract

Background: Many doctors experience psychological ill health. Interns are known to be particularly vulnerable.

Aim: To examine the level of depression, anxiety and stress in interns in Hong Kong, as well as the causes and how they cope.

Methods: A questionnaire was designed based on the themes identified in three focus groups of medical graduates of Year 2004 of the University of Hong Kong. The 21-item Depression, Anxiety and Stress Scale (DASS 21) was also administered. All 155 graduates of the same year were invited to participate with a response rate of 63%.

Results: Percentages of respondents with abnormal levels of depression, anxiety and stress were 35.8%, 35.4% and 29.2%, respectively. Frequent calls during night shift, long working hours and heavy workload constituted the most significant stressors. Factor analysis of the stressors showed that seven factors could explain 68% of the total variance: multidisciplinary team working issues, clinical difficulties, job seeking and employment, workload issues, ethical and interpersonal issues, adjustment to job rotation and performance appraisal. Holidays, peers and sleep offered the most significant relief.

Conclusion: Interns experience considerable depression, anxiety and stress. The source of stress is multi-faceted, but workload is the most significant stressor. Peer support groups may relief stress.

Introduction

Many doctors experience emotional and physical health problems as a result of the stress of medical practice. Doctors are also known to have higher rates, when compared to the general public, of marital discord, drug abuse and suicide (Pullen et al. 1995).

Despite the above, there is evidence that many doctors do not provide adequately for their own medical care. Many do not have their own general practitioner (Pullen et al. 1995). Doctors appear to be reluctant patients (Rawnsley 1991). They look after their health in a haphazard way (Allibone et al. 1981), through corridor consultations, self-medication and sometimes inappropriate direct referrals for themselves and their family members to specialist services (Chambers & Belcher 1992). As it has been suggested that there is a relationship between the general well-being of doctors and the standard of medical practice (Firth-Cozens 2001), the concern is that unhealthy doctors would provide a poor quality of medical service to their patients. In this article, we focus on interns who are fresh graduates undergoing the final stage of their training before they are granted the full licence to practise medicine. Their well-being requires our special attention so that they can develop into well-adjusted physicians to better care for the communities they serve.

High prevalence of anxiety and depression has been reported among junior doctors (Schneider & Phillips 1993; Shapiro et al. 2000; Peterlini et al. 2002) in Western countries. Female doctors tend to be more vulnerable than their male counterparts (Kirsling et al. 1989; Hendrie et al. 1990). However, such information is generally lacking in Asia.

In Hong Kong, approximately 300 medical students graduate each year from the two medical schools. Medical interns are often required to perform frequent overnight on-call duties of once in every 2–3 days. They are also expected to work on all Saturdays while their annual leave entitlement is only 14 days. Because of the difference in cultural background and other situational factors, the causes of stress and the way they cope with such stresses may also differ from the interns in Western countries. In this study, we aim to examine if mental health problems are common among medical interns, as well as the sources of their distress and the kind of support they need.

Table

Practice points

Interns are subjected to high level of stress. Workload and long working hours cause significant stress among interns. Holidays and peers in medical field are the best means to help interns relieve their stress. Negative emotional states are less severe among interns than final year medical students.

Methods

Both qualitative and quantitative methods, administered in the form of focus group interviews and questionnaire survey, respectively, were adopted in this study. The focus group interviews aimed to collect in-depth information for drafting the questionnaire used in the survey, which was designed to explore the nature, extent and sources of stress experienced by medical interns and the kind of support they needed.

Focus group interviews

Participants

From a list of 155 medical graduates of The University of Hong Kong in 2004, provided by the Faculty of Medicine, 23 interns were invited to participate in three focus group interviews in December 2004 and January 2005. Information in the list included the details of specialty rotations for each intern serving from July 2004 to June 2005. The selection of potential participants was based on three criteria, namely, the hospitals and specialties for the internship they had completed and their gender. Efforts were made to achieve a balance in the number of participants of both sexes with experience in different hospitals (regional hospitals vs. teaching hospitals) and specialties (medicine, obstetrics and gynaecology, orthopaedics and traumatology, paediatrics, surgery). Eighteen (6 females and 12 males) turned up as scheduled. There were five to seven participants per group.

Interns’ busy schedule and the fact that two career-related workshops for medical interns which were organized by the faculty coincided with the two focus group interviews held in January accounted for the unavailability of some interested interns, and in turn the imbalance in participants’ gender. Nevertheless, a sample comprising interns with experiences in serving a diversity of hospitals and specialties had been obtained.

Procedure

The three focus group interviews were conducted on three Saturday afternoons. Participants were encouraged to talk freely after the introduction of the theme of the study by the facilitator who was experienced in conducting focus groups (Lam et al. 2001). Four specific areas were included in the interview schedule: (1) stress/emotional problems at work or in life; (2) the sources of these stress/problems; (3) how would they cope with these stress/problems and (4) the ways that they found helpful in dealing with stress at the workplace.

Each discussion session lasted for 1½ h, which overran the scheduled time of 1 h due to the participants’ eagerness in expressing their views. Generally, the discussion atmosphere was good, and the participants reckoned it an opportunity to voice their opinions and were willing to share their experiences.

With confidentiality emphasized, the interviews were audiotaped for record and analysis purposes. Field notes were prepared by another observer to record any non-verbal responses of the focus group members during the interviews.

Analysis

The interviews were transcribed verbatim. Transcripts were then reviewed and verified by TPL who is an experienced qualitative researcher. The data were coded independently and analysed by TPL and a research assistant who is also experienced in qualitative research using a grounded theory approach. The consistency between both was analysed. The key factors that caused distress among interns and the support they needed were identified and incorporated into the questionnaire that was distributed to all the interns in the year.

Questionnaire survey

We invited all 155 medical graduates of Year 2004 of our faculty to fill in a mailed questionnaire which was anonymous. The questionnaire had three main parts. The first involved collection of demographic information. In the second part, symptoms of depression, anxiety and stress experienced by interns were evaluated using the 21-item Depression Anxiety Stress Scale 21 (DASS 21; Lovibond & Lovibond 1995). DASS 21 is a well-validated tool to measure negative emotional states, with specified score ranges indicating different severity levels from normal to extremely severe (Crawford & Henry 2003). The third part of the questionnaire concerned stress-causing factors and stress-relieving means/resources. The contents of this part of the questionnaire were drafted based on themes identified in the three focus groups interviews. Questionnaire respondents were asked to indicate if these items were very significant, significant, insignificant and very insignificant. There was space for respondents to write down other items they considered important. The data were analysed using JMP (Release 7.0; SAS Institute Inc.). Descriptive statistics were used to summarize the results to make simple interpretations. Exploratory factor analysis was performed to identify the key factors causing stress among the interns.

This study has the approval of the local institutional review board.

Results

A response rate of 62.6% (97 out of 155) was obtained after three rounds of mailing from April to June 2005. Just over half of the respondents (50.5%) were females. The mean age was 24.4 years (range 23–28).

Depression, anxiety and stress

The mean depression score was 10.6 (SD = 8.5), within the mild range according to the severity score ranges as defined in the DASS Manual (Lovibond & Lovibond 1995). The mean anxiety score was 7.8 (SD = 7.2) and mean stress score was 14.7 (SD = 9.2). These were all within the normal range. These mean scores compare favourably with the scores of the same cohort in an earlier study in which the DASS 21 was also used. It was conducted when the same cohort was in the final year of their medical studies and the mean depression score (13.6, SD = 9.6), mean anxiety score (11.8, SD = 10.0) and mean stress score (19.4, SD = 9.6) were all within moderate severity range (Wong et al. 2005). However, these mean scores were higher compared to previously published normative data (Lovibond & Lovibond 1995; Crawford & Henry 2003), and to the scores of 729 local Chinese from the general population in Hong Kong (Taouk et al. 2001). The proportion of interns with abnormal levels of depression, anxiety and stress were 35.8%, 35.4% and 29.2%, respectively (Table 1).

Table 1.  Severity distribution of DASS scores (percentage, number)

Subscale	Normal	Mild	Moderate	Severe	Extremely Severe
Depression	50.5 (48)	13.7 (13)	24.2 (23)	7.4 (7)	4.2 (4)
Anxiety	57.3 (55)	7.3 (7)	21.9 (21)	7.3 (7)	6.3 (6)
Stress	54.2 (52)	16.7 (16)	17.7 (17)	6.3 (6)	5.2 (5)

What causes stress in interns

Table 2 summarized the frequencies in which items were reported as significant or very significant in causing stress among interns. Workload and working hours were the top items in causing distress in interns (over 90% of respondents thought these were significant or very significant). Quotes from the focus group interviews illustrate how interns viewed these major causes of their distress.

Table 2.  Frequency of items being reported as significant or very significant in causing stress

	N	%
Frequent call during night shift	93	95.9
Long working hour	90	92.8
Heavy workload	88	90.7
Keen competition for job	87	89.7
Uncertainty in securing a satisfactory job	86	88.7
Making clinical errors	77	79.4
Lack of openness and transparency in recruitment system	74	76.3
Heavy responsibility	71	74.0
Performance assessment by supervisor/mentor	71	73.2
Incompetence in managing clinical problem	70	72.2
Poor attitude of some colleagues, e.g. nurse, senior doctor	71	73.2
Demanding supervisor	63	64.9
Lack of mechanism to express opinion without fearing for adverse consequence	63	64.9
Unfamiliar task/procedure	59	60.8
Lack of training	58	59.8
Lack of recognition of your effort from others	58	59.8
Having to adapt to different policies at different workplaces	56	57.7
Inadequacy of back-up by other staff	54	55.7
Unequal sharing of duty among interns	51	52.6
Patient and/or relative's unreasonable request/compliant	51	52.6
Lack of sense of belonging to a team	43	44.3
Tension with other staff	41	42.3
Frequent specialties rotation	35	36.1
Having to handle life/death situation	35	36.1
Asking for senior's advice	34	35.1
Self-initiated clinical attachment during vacation	31	32.0

Frequent calls during night shift

C4: (C5's mobile phone is just ringing) This is also a great source of pressure, always hearing [the beeping of] the pager. (laughed) You get paged every three to four minutes; this is causing the biggest stress for me. (laughed)

Interviewer: Does it happen when you’re on call or when you’re at work in the hospital?

C4: When I’m on call, on duty and at work in the hospital. There may be three or four calls when I’m [spending a short time] taking blood.

Interviewer: To handle many requests simultaneously.

C4: Yes, if your pager rings in a beeping sound, then later when you hear the microwave oven beeping (C2 & C3 laughed), you feel the stress! (interviewer laughed). For example, when I’m dining in the canteen, and someone uses the microwave oven (C3 laughed), then all the MOs [medical officers] will look over to that side [when it beeps]. It's real, the stress is huge … it trains you to be like this …

Interviewer: To respond quickly. (laughed)

C2: Usually when one pager beeps, more than a dozen interns will check their pagers. (C3 laughed)

Long working hour

C3: Before I didn’t understand why people said interns had to work 36 consecutive hours, but now I understand how (laughed) this could happen.

C4: The work schedule is too tight, and there's little time to recover after you have been on call, I think both situations will affect our work performance. For example, to be on call at 3 a.m. is tough enough for me … and [I have] to continue to work for another twelve hours after being on call [overnight].

C3: It's a full day's work. The nurses have had several shifts already, but you’re still working there! The nurses say they’re busy and overloaded. What would you say about interns? (laughed) What's more, they get their sleeping day after each night shift! (laughed)

C2: Usually you start working with a certain nurse, then she finishes work and goes home, and she comes to work again, and you’re still there (laughed), seeing her again! (C3 laughed)

C5: This is often the case.

C2: This happens when you’re on night duty. (nodding)

C4: For example, my first placement was at XXX Hospital, I had to be on call once every three days, and worked for ten consecutive days or longer after being on call. I fell asleep as soon as I lay in bed, but the bad thing was I was taking up ward duties even in my dreams! (laughed) How awful! I think it's horrible! (interviewer laughed) … It's a real experience. I had dreamt that I was working in the ward, seeing patients, the same group of nurses, the same ward manager and sister that you’re working with during daytime. It seems that you’re seeing them all 24 hours, and you feel a lot of pressure! (C5 laughed)

Heavy workload

B5: I think the pressure comes mainly not from my supervisor, but from the heavy workload, and may be the pressure from the patients. For example, the patient said, ‘I’ll be discharged soon, can you make the arrangements?’ They did not say this to me but to the nurse, and within a few minutes, the nurse would continually ask me to do it [till it is done]. At times, I have to shoulder the extra work of others who are on leave, and then I’m doing two or three persons’ work. This is where the pressure comes from, because you will be called upon by different wards at the same time. (Others nodded) The worst case was when I was working at XXX Hospital's Surgery Department, when all the graduates from the other university went to their graduation ceremony ….

B2: Poor guy. (laughed)

B5: We had seven interns at XXX Hospital then (B3 felt surprised), all my team members came from the other university, I was the only one from the University of Hong Kong (others laughed), and I alone had to take up the work of six persons, I was in sole charge of XXX Hospital's Surgery Department. (laughed)

Interviewer: But this only happened once, didn’t it?

B5: Yes, once. But there’re times when people are on leave, or they take time off, vacation leave etc., then one has to take up three or four persons’ work, that's where the pressure comes from. I know the nurses didn’t want to push me but they just couldn’t help. There’re patient admissions and discharges to do, the patients pushed the nurses and the nurses pushed me, that's what things are like.

Concerns about their future career were also a significant cause of stress amongst interns.

Exploratory factor analysis was performed to identify the key factors causing stress among interns. The associated Kaiser–Meyer–Olkin measure of sampling adequacy (KMO) was 0.766 indicating that the degree of common variance among the 26 variables was meritorious and the factors extracted would account for a substantial amount of variance. The Bartlett's test for sphericity revealed a p-value < 0.0001 and hence we may conclude that the population correlation matrix is not an identity matrix. A varimax rotation was adopted and we chose the number of factors by accepting all factors with eigenvalues > 1.0. Seven factors were extracted that explained 68% of the total variance. The resulting significant factor loadings are shown in Table 3. Factor 1 relates to ‘multidisciplinary team working issues’ while Factor 2 relates to ‘clinical difficulties’. Factor 3 concerns ‘job-seeking and employment’. Factor 4 consists of ‘workload issues’. Factor 5 relates to ‘ethical and interpersonal issues’, while Factor 6 is concerned with ‘adjustment to job rotation’. Factor 7 is concerned with ‘performance appraisal’.

Table 3.  Factor loadings for a 7-factor exploratory analysis

	Component
	1	2	3	4	5	6	7
Unequal sharing of duty among interns	0.62
Inadequacy of back-up by other staff	0.69
Poor attitude of some colleagues, e.g. nurse, senior doctor	0.72
Tension with other staff	0.70
Lack of sense of belonging to a team	0.80
Lack of recognition of your effort from others	0.66
Heavy responsibility		0.63
Making clinical errors		0.62
Unfamiliar task/procedure		0.78
Lack of training		0.69
Incompetence in managing clinical problem		0.82
Self-initiated clinical attachment during vacation			0.50
Keen competition for job			0.85
Uncertainty in securing a satisfactory job			0.90
Lack of openness and transparency in recruitment system			0.73
Long working hour				0.88
Heavy workload				0.84
Frequent call during night shift				0.81
Patient and/or relative's unreasonable request/compliant					0.40
Having to handle life/death situation					0.58
Asking for senior's advice					0.78
Demanding supervisor					0.71
Having to adapt to different policies at different workplaces						0.76
Frequent specialties rotation						0.83
Performance assessment by supervisor/mentor							0.75
Lack of mechanism to express opinion without fearing for adverse consequence							0.50

Note: n = 96.

What helps interns relieve stress

Table 4 showed the stress-relieving methods used by the interns. Holidays, peers within the profession and sleep are the top three methods of stress relief with over 90% of respondents indicating that these are significant or very significant. These are further illustrated by the following quotes from the focus groups.

Table 4.  Stress-relieving methods reported as significant or very significant

	N	%
Holiday	96	99.0
Peer (in medical field)	94	96.9
Sleep	93	95.9
Hobby (e.g. shopping, music listening, TV/film watching, video games)	86	88.7
Family support	81	83.5
Friend (outside medical field)	72	74.2
Exercise	35	36.1
Religion	35	36.1
Senior medical colleague	27	27.8
Others	7	7.2
Alcohol	5	5.2
Psychologist/counsellor	2	2.1
Your own doctor	2	2.1
Smoking	1	1.0
Help-seeking hotline	0	0.0
Soft drug	0	0.0

Holiday

C5: Get days off and you will forget all those problems.

Peers (in medical field)

C2: Up till now the most practical help comes from other [medical] colleagues.

Interviewer: Do you mean mutual help among interns?

C3: Yes, meeting classmates cheers me up! (laughed)

C4: Yeah, chatting at the [hospital's] canteen. (laughed)

C3: To have meals together and chatting is the happiest. You feel good when you can sneak off from your busy work to find something to eat, and run into your classmates at the canteen.

C4: It feels warm.

C3: We share our grievances. (laughed)

C4: (laughed) That's right, we grumble together. (laughed)

Interviewer: Grumbling together, can this help relieve pressure to a certain extent?

C4: Yes, very important!

C3: You don’t want to leave even after the meal is over! (laughed)

Sleep

A6: Just go to sleep, and everything will be alright when you wake up the next day. There will be a new start for each day and new troubles as well.

A2: What's bothering me the most at present is lack of sleep.

A6: Right, to have time to sleep is good!

A2: True, true, enough sleep will do me good.

Discussion

In this study, we found that interns are shown to have increased depression, anxiety and stress when compared to the general public. These findings are consistent with the studies done in Western countries (Schneider & Phillips 1993; Shapiro et al. 2000; Peterlini et al. 2002). The exploratory factor analysis of the items causing stress among interns indicates that all the 26 items listed in Tables 2 and 3 are important items causing stress among the interns. Looking at the specific items causing stress as listed in Table 2, it is probably not surprising to find the interns considered workload (including the duration and quantity of work) as the most significant source of stress. Despite effort to cut working hours in recent years, it is still a regular practice for interns to work 60–70 h per week. Night call duties are taken usually one in three or four nights. Even if not on call, interns often have to stay late to finish the day's work. Patient numbers and patient turnover rate are high, thus adding to the work pressure. Fatigue and sleep deprivation leads to deterioration in judgement, reaction time, as well as physical and psychological stress, thus adversely affecting work performance (Lewis et al. 2002; Baldwin & Daugherty 2004). It is therefore not surprising that interns found sleep an important means of relieving stress. The second most important factor is related to the confidence of the interns in their ability to adapt to the challenges of the clinical work. This can be improved by providing further clinical training to the interns.

Apart from taking a break from work (e.g. sleeping, taking a holiday, engaging in hobbies), support from peers within the medical profession provide significant help to interns. This emphasizes the importance of comradeship and empathy. Other interpersonal connections, for example family and friends outside the medical circle, are also important support resources. These findings suggest that peer support network similar to those established in the United Kingdom (http://www.dsn.org.uk/DSL.html) and Australia (http://www.racgp.org.au/peersupport) may be a valuable resource. It is interesting to note that merely 2% of interns considered their own doctors or counsellors to be able to offer help to relieve their stress. This raises alarm bell on how doctors look after their own health (Royal College of Psychiatrists et al. 2001; Edwards et al. 2002; Miller 2002). A report published in 2008 in the United Kingdom (Department of Health 2008) highlighted the high rates of mental morbidity in doctors, and doctors’ tendency to deny or conceal their problems and would delay in seeking help or continue working despite being ill. Since they have access to prescription drugs, they may avoid formal channels of help. In addition, their work environment and work conditions may add to their distress. Currently, the establishment of health promotion and mental health services is advocated to address the doctors’ reluctance in help seeking and their latent needs. The services have to be non-stigmatizing, confidential and accessible. Employers should work towards reducing stress in the workplace, enhancing stress management training and ensuring their occupational health services are sensitive to the needs of doctors in psychological distress.

Despite the general belief that interns are under severe stress and many may experience negative emotional states, our study showed that these negative emotions are in fact less severe than for final year medical students. This is similar to the findings of another recent study (Goebert et al. 2009) and may appear a little unexpected, given the fact that interns are dealing with real life sufferings and major life events. However, in view of the stress of final qualifying examinations at the end of undergraduate training and the consequences if one fails, it is understandable that the stress at intern year, which mainly comes from clinical practice, is less severe. Still, the need to help interns in handling stress should not be compromised so as to assure the quality of service they deliver to the patients. It will certainly be beneficial to heighten their awareness of their own mental health at an early stage as any delay may have a severe impact.

The adoption of both qualitative and quantitative methods allowed us to collect complementary data, which might not have been possible by using one method alone. However, there are certain limitations in interpreting the findings of this study. All the interns who took part in this study came from one single medical school. Their prior educational experience might have affected their perception of stress.

Our study provides valuable data on the source of stress and relieving factors for the Hong Kong medical interns. This information should also be useful for the management and senior doctors who are responsible for the training of their interns in other countries with similar system.

Acknowledgements

The financial support of the Committee on Research and Conference Grants of the University of Hong Kong is gratefully acknowledged.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Additional information

Notes on contributors

T. P. Lam

TP LAM is a professor of the Family Medicine Unit, Department of Medicine, and assistant dean in Clinical Affairs in the Faculty of Medicine.

J. G. W. S. Wong

JGWS WONG is the honorary clinical assistant professor of the Department of Psychiatry.

MARY S.M. IP

Mary SM IP is the chair professor of the Department of Medicine and associate dean in education in the Faculty of Medicine.

K. F. Lam

KF LAM is an associate professor of the Department of Statistics and Actuarial Science.

S. L. Pang

SL PANG is the honorary assistant professor of the Family Medicine Unit, the Department of Medicine.