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prevalence of underperformance, but it is a significant risk factor. Burnout in resi-
dents has been associated with lower in-service scores, professionalism issues, lower
quality patient care, and greater self-reported medical errors [ 35 , 36 , 38 – 40 ].
Depression has also been associated with more self-reported medical errors [ 32 ].
Mental health issues such as depression, anxiety, and personality disorders have been
described as a causative factor in up to 22–38% of problem residents [ 1 , 3 , 4 ] and
substance misuse in 5–14% [ 1 , 3 ]. A resident with suspected or identified psychiatric
illness or substance abuse presents unique challenges for the program director, who
is in the difficult role of being a physician and a supervisor. Program directors should
first and foremost focus on managing performance, describing performance con-
cerns, providing examples, and holding residents to performance standards. Even in
the face of concern that there may be underlying medical issues impacting the resi-
dent’s performance, program directors must be cognizant that they are not the resi-
dent’s physician and refrain from attempting to diagnose. While the program director
must be aware and respectful of laws such as the Americans with Disabilities Act
(ADA), which allow employees (residents included) to keep their medical informa-
tion private, in some instances, it’s necessary to make a judgment about the resident’s
level of safety or risk for suicide and to enlist support from the GME office, human
resources, occupational health, or physician wellness services. Most of the time, a
Table 17.3 Contributors and potential resources
Underlying contributor Resources/interventions
Family or relationship stress Employee Assistance Program
Stress management
Resident support group
Schedule decompression
Promotion of self-awareness and self-care
Chronic interpersonal or
personality problemsFaculty mentoring
Assignment of coach
More frequent feedback
Liberal use of 360 degree evaluations
Discussion with risk manager about relationship between
interpersonal skills and malpractice rates
Insufficient fund of knowledge Assignment of reading/study materials with frequent
mini-assessments
Psychiatric illness (disclosed by
trainee)Mental health evaluation and treatment
Schedule decompression
Leave of absence
Substance misuse Referral to physician health program
Cultural issues Mentor/advisor
Cultural competence experiences
Poor study habits Assignment of reading/study materials with frequent
mini-assessments
Mentor/advisor
Poor organizational skills Performance and learning strategy evaluation
Poor test-taking skills Mentor/advisorAdapted from Reamy and Harman [ 3 ], Yao and Wright [ 10 ], Tabby et al. [ 4 ], Sullivan et al. [ 29 ]
K. Broquet and J.S. Padmore