The Potential Role for Psychiatry Residents'
Councils
]. Thomas Pichot, M.D .
There are num erous books a nd articles within th e scie ntific literatu re that
d eal with issues of training psychiatry residents and th e cha racterist ics of that
milieu. Those authors that deal primarily with stress usu all y di scu ss the sources
of the stress and the resultant behavioral changes that are manifested by t he
trainees. Typically, a re latively small portion of th e dis cus sion is d evoted to how
these p roblems are, or m ig ht be , addressed. This paper, while not itsel f in tended
to be an overview of stress in resid ency; will co nce n trate on a literature review of
some specific aspects of the residency training process, primaril y role definition
and identity formation . There is also a review of so m e common , and some more
unique , ways to attempt to help residents avoid maladaptive responses to
training milieu stressors. The last section of th e articl e will look at ho w a
residents' organizationa l group (r esidents' co u nc il) might fu nc t ion to he lp
facilitate the id e ntity formation in a more adaptive manner and po ssibl y hel p to
alleviate some negative responses that are commonl y obser ved in t rai nees.
ST RESS IN RESID ENCY T RA IN ING
The stress in herent to the mi lieu of psychiatric training has been di scussed
in numerous contexts (1-42). Revie wing th e aggregate bibliographies of these
papers shows that few articles addressed this issue prior to 1965 , but th at
between 19 6 5 and the m id-1970 's there was a tremendous in crease in the
number of pa pers that dealt with stress in the psychiatric training p rocess. T hese
issues were discussed in two significant separate papers written b y J o el Yager ( I)
an d J o h n Graves (2) that were published in the mid-1970's. Both a u thors
considered separation/individuation, identity formation, and role d efinitio n as
key aspects in t he d e velopm e nt of a psyc hiatrist. Dr. Yager addressed th e
co ncept of "overchoice", r efer ri ng to the sit ua tion that faces th e beginn ing
resid en t when he is g iven the task of patient care prior to having a framewo rk to
uti lize. In attempting to de vel o p such a framework the resident is faced wit h a
mu lt itude of theories, techn iques, and concepts from which to choose ( I) . A long
these lines, Graves no te d th e transition from the medical model to the less
structured psych iatr ic model of patient care as a source of a nx iety for man y
beginning residents (2) . Graves further clarified the problems with pro fessio nal
identity formation by discussing the multitude of roles in whi ch th e resident
22
TH E POTENTIAL ROLE FOR PSYCHIATRY RESID ENTS' COUN C ILS
23
must function . Within a matter of hours the resident is swit ch ing " back and
forth between the roles of therapist, patient, student, seminar lead er, parent and
peer". Furthermore, Dr. Graves notes that such rapid tran sitions can be as
"awkward, co n fusi ng and as anxiety provoking as th e ch ild pendulum swings in
adolescence". However, he also acknowledges that some d egree of ide nt ity cri sis
is unavoidable, necessary and indeed, desirable in th e proc ess of fo r ming o ne's
professional identity (2).
A paper written in 1981 by Garfinkel and Waring (3), noted som e factors
common to all postgraduate medical training, such as prolonged d epend e ncy,
hostility e nge nd ered by competition, and relative socio-economic d ifficu lties in
comparison with non-training peers. Additionally, th e authors po int o u t some
factors specific to psychiatric training, including: 1) identification with th e
psychopathology of one's patients, 2) the impact of psychoth erapy supervisio n
and the associated development of psychological mindedness , and 3) th e sh ift
from the authoritarian role of the physician to the interdisciplinary team
approach of clinical psychiatry (3). Military training programs may ha ve so me
unique additional stresses, recently reviewed in an article by Hal es (4).
Adapting Levinson's (5) theoretical framework of male adult d evelo pm en t,
the majority of residents fall in the Era ofEarly Adulthood and mo re spec ifica lly,
the Middle Period ofthe Age 30 Transition . This transition period falls between th e
ages of26 to 34, and according to Levinson , typically lasts four to five yea rs . T he
basic life structure is always different at the end of the Age 30 Transition th e n it is
at the beginning; for some individuals this transition is smooth , " a t ime of
reform, not revolution", but for most of us a moderate to severe cris is is very
common during this period (5). Furthermore, the Age 30 crisis is described as a
time of revising the first, provisional life structure formed in the precedin g
stage, a time of reappraising the past and considering the future . An Age 30
transition is not merely a delayed adolescent crisis, (although unresol ved
conflicts of adolescence will be reactivated and perhaps more fully resolved in it),
nor is it a precocious mid-life crisis, (although it has much in common with
transitional problems of persons who, at about 40, feel caught in a life str uctu re
that has become intolerable). Actually, it is a crisis which is ve ry ch aracterist ic
for the developmental issues of that particular period of life (5). G raves
addresses these issues in residency training while describing this e xper ience as a
period of intense peer identification and notes that it is not unusual to have th e
feeling that one is reliving late high-school and early college days (2). H e furth er
notes that often this leads to feelings that one is playing out and search ing fo r
roles suitable for "the real world" or for "when I grow up" . However , here
again it is noted that this experience is more than a simple relivi ng and
recapitulation of the past; instead, it is " a reworking of personal issues o n a
professional level from the perspective of some eight to ten years of maturation "
(2). A few authors, including Speigel (6) and Scanlan (7), have noted that training
programs should avoid viewing the predictable manifestations of role transition
24
JEFFE RSON JO URNAL OF PSYCHI ATRY
as for ms of psych opa th ol ogy. Speigel emphasizes that when these problems "are
seen as part of the no rmal p rocess of lea rn ing , ra ther than as a perso nal
aberratio n " , the y ca n be d ea lt with in a more effective manner (6) .
REVI EW OF SOM E OF TH E CO STS O F ST RESS I N PSYCHIATRIC
T RA IN ING PROGR AM S
I ntrapsych ic conflic t a nd regression occurs to some degree in all resid en ts.
Merki n a nd Little d escribed a co m mon , but usu all y temporary synd rome of
neurotic sym ptoms an d psych o so m a tic d istu r ban ces they ca lled the "begi nn in g
psychiatry trai ning syndrome" (8). Perha ps more specific to the current di scu ssion, Tisch ler ad d ressed the ways in which regressio n re lates to professio nal
id en tity fo r ma tion (9) . H e sta tes th at o ne co m mon occurrence is a regressio n to
former modes o f professional fun ction in g wh ere so me success has bee n achie ved
in the past. This primarily presents as "a fra mework of me ntal illness sol ely as a
refl ecti on o f o rga nic pathol ogy an d di stu r bed beha vio r as resulting primarily
from a ltered brai n fu nc t io ni ng" . It a lso ca n resu lt in a facade of scientific a nd
p r o fessio nal inte rest "as a barrier between self a nd patient" (9). Dr. Tisch ler also
d iscu sses h o w t he psychiatric resident sea rches for ex ternal validation of hi s
fu nctioning in t hese new a nd va r ied roles and that commonly this is accompan ied b y so me feelings of insecurity. T h is combination of insecure feelin gs and
th e need fo r external va lidat ion , places the train ee in " a dependent position in
r el ati on to role models and va lidators" (9). Addi t iona lly, Tisch ler notes th at
" dependen t r elationships o f this typ e in variably exert a regressive pull , but thi s
regression is usually transitory" . H e su ggests t hat d an ge r exists only if the
"regressio n is so p rotract ed o r th e d ependen cy so p rofou nd that problem s in
and about learning become insoluble , r ol e d efi ni tio n is incomplete, professio nal
se lf-defin it io n is ne ver a ttem p te d or p rofessional identity is fused prematurely"
(9).
Multiple papers ad d ress th e issues of psychopathology, training failures,
and su icide in psychiat r y resid e nts (1,2,6,8- 18).
HOW CA N RESID ENTS AN D RESID ENCY PROGR AMS FACILITATE ROL E
DEV ELOPM EN T ?
If we assume that one o f the primary goa ls of resid e ncy programs is to
foste r the appropriate professional id enti ty fo r mat ion of its resi dents, what
techn iques a re used to d eal with these st ressors which ma y interfere with this
process? Some co m mon m ethods include exper ie ntial process groups, staff
ad visor s fo r resid ents, a nd th e liaiso n rol e of th e d irector of residency training .
Fo r residen ts who a re di spl aying overt evi dence of impaired performance,
inc reased supervisory t ime, d ec reased service workload and ind ivid ual therapy
are often utilized to help the resid ent im prove hi s fu nc tion ing.
Other examples o f wa ys to ad d ress st ress in res idency training h ave
THE POTENTIAL ROLE FOR PSYCHI ATRY R ESIDEN T S' COUNCILS
25
included jensen 's (19 ) " T ra nsitio n to resid ency se m inar" a nd Ge rbe r 's (20 )
time-limited group process experience. These approach es sha red common
features in that both were group e xpe r ie n ces with the co re of the group
members being residents in their first year of psychiatric trainin g an d both
groups used didactic material to address these issues. Jensen presented a journal
club format which included discussions of articles related to residency trainin g
issues. H e concluded that some of the benefits of his approach we re : I ) a
non-threatening forum (attributed in part to the absence o f senior staff) in which
residents could di scuss their feelings about the residency, a nd 2) th e prese nce o f
chief residents and junior staff members benefiting the group b y sharing that
they had experienced similar problems during their train in g (19) . Ge r be r
reports addressing th ese issues by " e xp lor in g th e d yn amics of adolescen t
rebellion " in a shared group experience that included , but theoreticall y is not
lead by, a senior staff member trained in group process. Gerber also di scussed
group cohesion , identification with the group advisor and universaliza tion of t he
common experience, as the factors that lead to an enhanced forma tio n o f
id entity as a psychiatrist (20).
Other than jensen's work very little has been written ab out ho w resid e nts
themselves could work to foster th eir own development of p rofessional identity.
While active and thoughtful utilization of group process may be one way for
residents to approach these issues, a review of the literature re veals a pau city o f
information on the actual prevalence of resident organi zations, temporary or
otherwise, within residency training programs or the function suc h groups may
se r ve. An article written in the early 1970's by residents at the Mennin ge r
School of Psychiatry (21) described the existence of a house staff organi zati o n
and suggested that it "may play some part in the residents person al a nd
professional development", but did not elaborate on how this ma y be brough t
about. The article also did not describe what function this organi zation actuall y
served, except to note that the majority of residents felt that it shou ld " pri marily
represent their personal interests (salary, benefits, and education) by se rvi ng as a
liaison with the Menninger School of Psychiatry a nd only secondar ily t hat it
concern itself with social issues and community se rv ice" (2 1).
STRUCTURE OF A PSYCHIATRY RESIDENTS' COUNCIL (PRC)
The structure of the PRC at Eisenhower Arm y Medical Center, wh ere t he
author did his residency training, is provided in the b y-Laws th a t were
established by previous resident groups and have been revised b y each succeeding yea r' s group. The general structure of these by-laws is included as Tab le I .
There are several important reasons wh y there should be written gu idelines for
these councils. First, they provide an objective structure as a sta r t ing poi nt , and
as a continuing reference point when there are conflicts and questions abou t the
councils purpose and function. By-laws also function as a constant to co n nect
each successive academic yea r , allowing for some modification as needed, but in
TABLE 1.
Example of By-laws of a P sychiatry Residents' Co unci l
I. The name of th e organization shall be the Psychiatry Resid en ts' Council (P RC).
II. T he voting me mbe rsh ip will consist of all psychiatry residents.
Il l. Goals an d Pu rpose:
a. T he PR C will provide a mutual support syslem for the members.
b . T he PR C will p romote the professiona l education and personal growth of
th e member s.
c . T he PR C will serve as a foru m for resident opinion , for peer sharing and
fee d back.
d. T he PR C will coordi na te resident re presentation to faculty committees.
e . T he PR C will influence th e selection of ne w residents, welcome them , and facilitate th eir or ie n ta tio n .
f. T he PRC will provide resid ent fee dba ck a nd evaluation of faculty performance a nd curricu lu m design.
g. T he PRC will plan soci al fu nc tio ns and promote fe llows hi p among the mem bers.
1V. Role s ofOfficers
a . President
1. Will co nd uc t PRC meetin gs as cha ir-person.
2. Will keep h im sel f informed o f th e issu es of co ncern to each intergroup o f
th e PRC; and have th e au thor ity to ac t as a representative of the PRC du ring th e in te r im between meetings.
3 . Will serve as r epresentati ve of th e PR C as a whole, to include attendance
at pysch iatry departmental meet in gs.
4. Will hold office for twel ve months.
5. Will hav e au thor ity to a ppo in t co m mittee cha ir -persons.
6 . Sh all cast th e d eciding vote in case of a tie.
b. Vice President I Secreta ry:
1. W ill se rve as chair-pe rso n of th e PR C meetings in the absence of the President.
2. Will work with th e Presid ent to keep informed of current issues of each
intergroup of th e PRC.
3. Will hold office for twel ve months.
4. Ma y be called upon to act as Ch air-pe rson fo r special pu rpose groups, e .g .,
welcoming com m ittees .
5. Will record, publish, and distribute, to r esid ents th e minu tes of P RC
meetings.
6 . Will co llect and handle monies as direct ed by th e Pr esident.
7. Will handle correspondence for th e PRC.
c . Removal of officers will be by two-thirds majority o f th e entire membersh ip.
V. Meetings:
a. The PRC will meet each month at
_
b. Emergency meetings ma y be called by the Presid ent or Vice-Presiden t.
c . A quorum is defined as at least 50 % of the psychiatry residents.
d. A motion will be carried by simp le majority.
e. A member must be present in order to have a vote in a meeting.
f. Conduct of the meeting will be under sim p lified Roberts's Rul es of O r der.
g. The PRC meetings will be closed meetings, however th e cha ir or a maj or ity
vote of the membership ma y at an ytime open th e meeting to a ppropriate outside parties.
VI. Amendments to these By-Laws will be by simple majority
T HE PO T ENT IA L RO LE FO R PSYCHI AT RY RESIDENT S' COUNCILS
27
ge nera l giving th e co u nc il so me tradition and continuit y from year to year as
co u nc il leadership and mem bership changes. Per ha ps most importantly th ey
help cla r ify th at resp onsibil ity for what the Psych iatr y Reside nts' Council is, a nd
what it does or doesn't do, lies with th e residen ts a nd no t wit h th e staff, th e chi e f,
o r a nyone else in th e resid ency p rogram .
T he cu r re n t PRC at Eise n hower has a PC Y-3 serving as the Presid e nt and a
PCY-2 se rv ing as the Vice -President/Secretary. Attendance at the monthl y
meetings varies fro m 30 % to 90 % of the residents. Examples of some recent
issues have incl uded: I ) curricu lum changes, with formation of resident committees to d r aft and present specific proposals to the faculty, 2) communicatio n
p roblems between residents th at are arranging outpatient fo llow-up fo r di scharged patients a nd t he resid e nts who will p r ovid e that follow-up care, 3)
disc uss io n of regional A PA activities, to pro vid e information on these activiti es
and to encou rage resident and staff in vol veme n t, 4) revising the system for
resid ent ca ll roster co vera ge , 5) a meet in g with th e di r ecto r of residency training
to d iscu ss th e JCAH acc re d itation p rocess, a nd 6) d iscussion of various training
Fello wship op portu nities .
DIS CUSSIO
Invol veme nt in a resident 's organization with the goal of co m m u nication
and d ecision making about residency issues, could be of sig nificant benefit to th e
d evel opment o f th e resident's p rofessio nal and personal identity. Possibl e
fac to rs ma y include: I ) grou p characteristics of universa lity, group cohesion and
role modeling whi ch co u ld occu r d esp ite this bei ng an overtly non-therapeutic
gro up (these benefits may be maximi zed if no t on ly begin ning residents, but
rather, all resid ents are co unci l mem bers), 2) by being titled council, rather than
group, an d by havin g a primar y task of so lving problems within the residency
program, t he au ra o f th erapy is avoided an d more of a "work group" (2 2) co uld
be mai ntain ed, 3) some of the resident's ex terna l val idation could come fr om
suc h a group, ra ther th an exclusive dependence on staff for professional
validation as note d in Dr. T ischl e r 's pa per (9), 4) the transitory and universal
nature of th e reacti ons to trai ning stressors can be shared by having more
exper ienced resid ents be a part of suc h a group, 5) peer cooperation in
identifyin g , di scus sin g and addressin g problems ca n d evelop ad min istrative skills
a nd could provid e valua b le exper ience in fun ction in g o n committees of peers
(t h is ma y a lso in crease the r esid en t 's willingness to beco me involved in other
organ izatio na l acti vities bo th wit h in th e resid ency and in the community), 6) as
ind ivid ua ls are se pa rated throughout the training system on various rotations,
th e co u nc il wo u ld p ro vid e a fo rum to enhance resident communication, with
each o ther and wit h th e staff, 7) th e diffic ul ty of maintaining a work group focu s,
in th e face of basic assum ptio n group forces (43) (present in this type of group as
it is in a ll groups), will be a ce ntra l feat ure of any P RC. Deal ing with these group
28
J EFFERSON JO UR NA L OF PSYCH IAT RY
forces will be an experiential process, above and beyond the intell ectual study o f
group relations theory, that is essential to psychiatric training.
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