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The Toxic Intern Syndrome Revisited: Genetics vs. Environment
by Kirsti A. Dyer M.D., M.S.

I wrote the "Toxic intern syndrome,"1 at the end of my internship in a "toxic" residency program. The toxic intern is recognized by characteristic coping techniques which develop to survive. These include pervasive cynicism, irritability, scapegoating, "buffing" patients to "dump" them on another person or service, etc. Most succumb at one time or another.

Now coming to the end of my residency training at a more congenial program, I wonder, if I had been `raised' in a less malignant, more amiable environment, would I have developed the "Toxic intern syndrome?" I believe that genetics and environment both influence the formation of a toxic intern. It might have made a difference.

The "genetics" are those factors inherent to a residency programs. These include long hours, little pay, less respect, "county" patients, with the multitude of social problems. It also includes those traits inherent in those chosen to be physicians, the intangible components of a personality which determine how a person may react when pushed to the limits.

The issue of long hours is being addressed as many programs have voluntarily adopted an 80-hour work week averaging one day off in seven. Until recently, residents, who make daily critical decisions about patient care, were under no restrictions for work hours. Airline pilots and truck drivers are under stricter limitations for the total number of working hours than resident physicians. Fortunately this is changing.

Many of the problems common to serving a "county" patient population, the immigrant, Medical, Medicare, homeless, and psychiatric patients, are not easily solved. Residents are faced with locating places to discharge homeless or psychiatric patients, relying on drug representatives samples for medication, or convincing surgeons to donate their services for emergent operations for immigrant patients. The daily frustrations are usually balanced by those patients genuinely grateful for the care residents provide. Their "thanks" takes on special meaning--the veteran baking his favorite berry pie, the psychiatric patient crocheting a hat for warmth, the chemotherapy patient bringing chocolates, the heart patient bringing special treats from Mexico.

The "environment" in which residents are raised, the manner in which program directors, attendings, nurses, and ancillary staff interact with the residents--plays a big part in influencing overall morale. The question is, What role do residents play? Are we merely a cheap labor force providing care to a patient population that would otherwise go under-served, dealing with the routing "scut" in order to obtain on-the-job education, or Are we junior colleagues striving to further our medical training, and as such should be treated as a colleague, not a "scut monkey"?  Our primary responsibility as residents is obtaining a higher medical education, not just provide service to patients.

There appears to be something inherent, "genetic," in the process of residency training, and in the resident, contributing to the creation of toxic interns. Certain dispositions may be more susceptible. Few appear to be immune to the effects of the "Toxic intern syndrome." Fortunately, the cases at my current program are not as severe as in my former program.

Residency is innately a stressful time, a time of transition from medical student to physician, a time of mastering the intricacies of medicine and a time of challenge--physical, intellectual, and emotional. Frequently residents just try to survive day-to-day. The cumulative effect of dealing with "tough issues" e.g. patients with new cancer diagnosis, patient admitted for "comfort care only," another alcoholic G.I. bleeder, or IVDA'er, the unexpected death, usually someone young--these daily stressors can take a toll on residents. Too often time is not allowed for the physician to "heal thyself." We are supposed to be invincible, omniscient, and always under every circumstance be right. There is no place for fallibility. The overwhelming, self-protective drive to deal with nothing else demanding once out of the hospital takes hold. Interpersonal relationships--friends, family, spouses--fall into disarray because of the time commitment exacted by a residency program. Often those closest to you prior to residency, just cannot understand the demands--physical and emotional.

We diagnose and treat the effects of stress in our patients, but fail to see it in ourselves, or those around us. Recognition of stress and the early signs of impending "toxicity" e.g. irritability, anger, irrational behavior, passive-aggressiveness, fatigue, cynicism--in ourselves and colleagues can help. Debriefing, talking to other residents or attendings, or use of other stress reduction methods can help prevent maladaptive coping patterns from developing or the slide into becoming a toxic intern.
Is there hope? I believe there is. Things are changing. Program directors are recognizing how essential time away from the hospital, free from duties, is to the overall health and morale of the residents. Going is the stoicism of "I survived it, so can you." Additionally, recognition of residents as colleagues, not just "scut monkeys," by attendings, helps promote esprit de corps. Finally fostering an open work environment that allows residents to express their concerns, identify their needs, change their surroundings, and improve the program. Learning to recognize the warning signs and symptoms of toxicity can help enormously in the prevention of "Toxic Intern Syndrome." We cannot change much about the "genetics" of residency, but we can impact our "environment," and create a more positive experience.

1. Dyer KA: Toxic intern syndrome. West J Med 1994;160:378-379.

Sacramento Medicine
The Toxic Intern Syndrome Revisited appeared in the Sacramento Medicine Magazine in 1996. The indexing for this article is as follows:
Dyer KA. The Toxic Intern Syndrome Revisited: Genetics vs. Environment. Sac Med. 1996;47:16.

Last updated August 15, 1998
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