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 Table of Contents  
SOCIAL SCIENCES AND MEDICINE
Year : 2017  |  Volume : 3  |  Issue : 3  |  Page : 150-153

Short timer's syndrome among medical trainees: Beyond burnout


OPUS 12 Foundation, Bethlehem, PA, USA

Date of Web Publication21-Apr-2017

Correspondence Address:
Stanislaw P Stawicki
Department of Research and Innovation, St. Luke's University Health Network, EW2 Research Administration, 801 Ostrum Street, Bethlehem, PA, 18015
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_4_17

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  Abstract 


The short timer's syndrome (STS) was first described and studied in the military. Although not a new phenomenon, it was more formally recognized in the 20th century during the two World Wars. The STS has been well documented during all major military conflicts and deployments since then. In a way, STS can be viewed as an extreme form of burnout. As such, STS can be observed among medical trainees who are on busy clinical services for prolonged periods of time. In addition to its negative effects on the health-care team, burnout and STS have the potential to adversely affect patient care. It is important to be aware of signs and symptoms associated with medical trainee burnout and STS because early recognition of these signs may allow prompt intervention and prevent further progression of burnout.
The following core competencies are addressed in this article: Interpersonal and communication skills, Professionalism, Systems-based practice.
Republished with permission from: Stawicki SP. Short timer's syndrome among medical trainees: Beyond burnout. OPUS 12 Scientist 2008;2(1):30-32.

Keywords: Burnout, identification strategies, medical training, prevention strategies, short timer's syndrome


How to cite this article:
Stawicki SP. Short timer's syndrome among medical trainees: Beyond burnout. Int J Acad Med 2017;3, Suppl S1:150-3

How to cite this URL:
Stawicki SP. Short timer's syndrome among medical trainees: Beyond burnout. Int J Acad Med [serial online] 2017 [cited 2020 Jan 25];3, Suppl S1:150-3. Available from: http://www.ijam-web.org/text.asp?2017/3/3/150/204957




  Introduction Top


The short timer's syndrome (STS) was first described and studied in the military.[1],[2] Although known since the antiquity, it was more formally recognized in the 20th century during the two World Wars. The STS has been well documented during all major military conflicts and deployments since then.

Associated with longer tours of duty, the STS is defined as a drop in morale, rise in anxiety, and a withdrawal from commitment to combat. In many cases, soldiers lost so much combat effectiveness that they had to be moved to noncombatant positions as the end of their tour approached.[3] The behavioral patterns noted among short timers in the military could be dramatic. In 1967, Dowling provided the “classic” description of how STS evolves:[2]

”There is the period of anxious apprehension, a potentially severe syndrome of emotional distress beginning mildly 2-3 months before rotation, but usually occurring obviously in the last 3 weeks of the tour and most marked the last 3 days prior to rotation. Irritability seems to alternate with euphoria. Pacing is a common sign. Quiet hard working individuals who for 11 and 3 quarters months have put up with deprivations, long working hours, and continually increased demands will suddenly behave in a rather inappropriate manner.”

After all, few men wished to be the last to be killed or wounded as the war or the deployment approached its final days.[4] The STS was at times noted as much as 2-3 months before the soldier's expected date of return back home as he or she counted down the remaining days of deployment [Figure 1].[4] In a way, STScan be thought of as an extreme form of burnout.
Figure 1: Cartoon showing a soldier's 100-day countdown before coming back home. It is not uncommon among medical trainees to count days till the end of the rotation and/or the training program

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At times, one can observe STS-like behavior occurring among house officers rotating on busy clinical services. Behavioral patterns observed in house staff with STSappear to represent a spectrum, with the traditional burnoutat one end and the “disabled-like” state of STSon the other end. Most of us are well familiar with the phenomenon of burnoutamong medical professionals, which has been defined as a subtle process, in which a medical practitioner is gradually caught in a state of depersonalization, mental fatigue, feeling completely empty, and drained of energy. Five multiple reasons for burnouthave been proposed, including long working hours, chronic sleep deprivation, negative relationship(s) with peers, inability to forgive oneself and others, lack of professional growth, and difficulty adapting to adversities.[5],[6],[7]

Here is a theoretical scenario of how STS may evolve among house staff. Anxious and insecure at the beginning of the residency, the house officer tries to impress his or her superiors and slowly gains confidence and required skills as the training rather quickly advances past the midpoint. After completing approximately three-fourths of the required training, although this is not universal and varies from individual to individual, house staff may gradually show signs of burnout. These signs may take a form of obvious lack of interest, ambivalence, lack of proactive behavior, avoidance of responsibility, lack of attention to detail, and tendency toward reduced availability to perform even simple tasks (i.e., “disappearing”). At times, this pattern may manifest first as a decline in academic performance (i.e., a “stellar” resident who unexpectedly fails the in-service examination).

Some house officers may manifest a mild form of STS, characterized by selectively choosing to perform “easy” tasks or only tasks of personal interest to them. For example, a mid-level surgical resident completes only two interesting consultations out of the total seven assigned and performs none of the postoperative checks even though he or she was not in the operating room and received only eight easy triage calls during the entire night. The most severe forms of house officer STS, or “disappearing” and “insubordination,” consist of the house officer simply not responding to calls or pages, behaving abusively toward their peers, and refusing to perform even simple tasks or fulfill minimal requirements during their clinical rotations. In these severe cases, a disabled-like state virtually “removes” the house officer from their respective team, much like the STSeffectively “removes” the soldier from the battlefield. While quite disabling to the individual experiencing this extreme form of burnout, the effect of STS-associated behavior can be very disruptive to the entire health-care team and can potentially jeopardize patient care. In addition, burnout can significantly affect other parts of a medical practitioners' life - including their home and family.[5]

How can we address or try to prevent the STS-like behavior among house staff? Can active education regarding this phenomenon help prevent it or would it simply legitimize this behavioral pattern? As previously mentioned, numerous causes of burnoutamong health-care professionals have been identified.[5],[7] Perhaps trying to identify and address these potential causes as well as providing environment that fosters honest and quality feedback between the house staff and their superiors could be a good start. This may take a form of a “bonding day” or a “town hall meeting,” where issues are identified and appropriate solutions proposed. Moreover, let us not forget that positive reinforcement works a lot better than oppressive “beating down.” In addition, there are resident wellness programs, which have been shown to help residents cope with stress and traumatic events and could be helpful in STS-like situations.[8]

It has been proposed that to “escape” from the burnoutstate, the affected individual needs to change his or her perceptions of the work environment.[5] One way to start is to foster mentorship within the training program - a healthy relationship with senior members of the team and recognition of their accomplishments appears to be effective in preventing burnout.[5],[9] This may then be followed by trying to eliminate overly harsh, “unhealthy” self-criticism, which is known to decrease self-esteem; planning for continued professional growth and development; and enriching the resident's personal life away from hospital or medical office.[5],[10] It is also important to learn to look at adversities as tests that must be “passed” on the path to accomplishment, which includes accepting and adapting to these adversities.[11] It has been suggested that the difference between high achievers and underachievers is that high achievers use adversity and struggles to fuel personal and professional growth, and underachievers allow difficulty and adversity to overwhelm and discourage them.[12] It may also be helpful to educate the house staff about having reasonable expectations, especially when it comes to seniority within the residency. Specifically, it is important for house staff to realize that as they advance in rank, although their roles change, the amount of work tends to remain the same - a potential factor leading to disappointment.[13] Furthermore, it is crucial to remember that medical trainees are very likely to suffer from depression and that both burnout and depression can contribute to suboptimal patient care and increase in medical errors, respectively [Figure 2].[14],[15] It is not clearly known what is the overlap between burnout, STS, and depression among medical trainees, but there seems to be at least some association.[14],[15]
Figure 2: Prevalence of burnout and depression (top part of figure) among medical trainees in two major studies.[14],[15] Number of medical errors per resident month among medical trainees with depression (1.55) and those without (0.25) (left lower figure). Incidence of episodes of suboptimal patient care among medical trainees with burnout (53%) and without burnout (21%) (right lower figure)[14],[15]

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  Summary Top


Many questions regarding burnout and STS-like behavior among medical and surgical residents remain to be answered, but the ability to identify and address burnout and STS among house staff may result in improved resident satisfaction, better patient care, as well as better communication, and overall lower levels of conflict among health-care team members. Perhaps educating health-care professionals and trainees about the phenomena of burnout and STS as well as encouraging open discussion of these problems could be the best first step to the solution. Given the fact that STS-like phenomena among medical trainees are poorly understood, further research is warranted into the etiology, identification, and remediation of this serious problem.

Acknowledgement

Justifications for re-publishing this scholarly content include: (a) The phasing out of the original publication after a formal merger of OPUS 12 Scientist with the International Journal of Academic Medicine and (b) Wider dissemination of the research outcome(s) and the associated scientific knowledge.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dedic G, Krstic J. The personality of soldiers with inappropriate behavior patterns at the end of military service. Vojnosanit Pregl 1997;54:11-7.  Back to cited text no. 1
    
2.
Dowling JJ. Psychological aspects of the year in Vietnam. USARV Med Bull 1967;2:45-8.  Back to cited text no. 2
    
3.
Moskos CC Jr. The American combat soldier in Vietnam. J Soc Issues 1975;31:31.  Back to cited text no. 3
    
4.
Towell P. Forging the Sword: Unit-Manning in the US Army. Center for Strategic and Budgetary Assessments Report. Washington, DC; 2004.  Back to cited text no. 4
    
5.
Espeland KE. Overcoming burnout: How to revitalize your career. J Contin Educ Nurs 2006;37:178-84.  Back to cited text no. 5
    
6.
Martini S, Arfken CL, Balon R. Comparison of burnout among medical residents before and after the implementation of work hours limits. Acad Psychiatry 2006;30:352-5.  Back to cited text no. 6
    
7.
Papp KK, Stoller EP, Sage P, Aikens JE, Owens J, Avidan A, et al. The effects of sleep loss and fatigue on resident-physicians: A multi-institutional, mixed-method study. Acad Med 2004;79:394-406.  Back to cited text no. 7
    
8.
Dabrow S, Russell S, Ackley K, Anderson E, Fabri PJ. Combating the stress of residency: One school's approach. Acad Med 2006;81:436-9.  Back to cited text no. 8
    
9.
Weger N. My mentors. Curr Surg 2006;63:66-7.  Back to cited text no. 9
    
10.
Ruiz MA. The Four Agreements: A Practical Guide to Personal Freedom. San Rafael, CA: Amber-Allen Publishing, Inc.; 1997.  Back to cited text no. 10
    
11.
Tracy B. Goals: How to Get Everything You Want Faster Than You Ever Thought Possible. San Francisco, CA: Berrett-Koehler Publishers; 2003.  Back to cited text no. 11
    
12.
Tracy B. Change Your Thinking, Change Your Life: How to Unlock Your Full Potential for Success and Achievement. Hoboken, NJ: John Wiley & Sons; 2003.  Back to cited text no. 12
    
13.
Stawicki SP. Changes I experienced as a resident. Curr Surg 2004;61:98-9.  Back to cited text no. 13
    
14.
Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW, et al. Rates of medication errors among depressed and burnt out residents: Prospective cohort study. BMJ 2008;336:488-91.  Back to cited text no. 14
    
15.
Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136:358-67.  Back to cited text no. 15
    


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