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Short timers syndrome among medical trainees: Beyond burnout

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Stanislaw P. Stawicki at St. Luke's University Health Network
Stanislaw P. Stawicki
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The short timers 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 healthcare 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. Citation: Stawicki SP. Short timers syndrome among medical trainees: Beyond burnout. OPUS 12 Scientist 2008;2(1):30-32. Keywords: Medical training, Short timers syndrome, Burnout, Prevention strategies, Identification strategies. Copyright 2007-2008 OPUS 12 Foundation, Inc.
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OPUS 12 Scientist 2008 Vol. 2, No. 1 S. P. Stawicki
Submitted 09/2006 – Accepted 01/2008 – Published 02/2008
Copyright 2007-2008 OPUS 12 Foundation, Inc. 30
Short timers syndrome among medical trainees: Beyond burnout
S. P. Stawicki, MD 1
1 Principal Scientist, OPUS 12 Foundation, King of Prussia, PA, USA
ABSTRACT
The short timers 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 healthcare 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.
Cite as: Stawicki SP. OPUS 12 Scientist 2008;2(1):30-32.
Correspondence to: S. P. Stawicki, MD. OPUS 12 Foundation, 304 Monroe
Blvd, King or Prussia, PA, 19406 USA.
Keywords: Medical training, Short timers syndrome, Burnout, Prevention
strategies, Identification strategies.
The short timers syndrome (STS) was first described and studied
in the military. 1-2 Although known since the antiquity, it was
more formally recognized in the 20t h 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 two to three months before rotation,
but usually occurring obviously in the last three weeks
of the tour and most marked the last three days prior
to rotation. Irritability seems to alternate with
euphoria. Pacing is a common sign. Quiet hard
working individuals who for eleven and three 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 short
timers syndrome was at times noted as much as two to three
months before the soldier’s expected date of return back home, as
he or she counted down the remaining days of deployment. 4 In a
way, STS can be thought of as an extreme form of burnout.
At times, one can observe STS-like behavior occurring among
house officers rotating on busy clinical services. Behavioral
patterns observed in house staff with STS appear to represent a
spectrum, with the traditional burnout at one end and the
‘disabled-like’ state of STS on the other end. Most of us are well
familiar with the phenomenon of burnout among 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. 5 Multiple reasons for burnout have 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. 5-7
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.
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 mid-point. 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
OPUS 12 Scientist 2008 Vol. 2, No. 1 S. P. Stawicki
Submitted 09/2006 – Accepted 01/2008 – Published 02/2008
Copyright 2007-2008 OPUS 12 Foundation, Inc. 31
a form of obvious lack of interest, ambivalence, lack of proactive
behavior, avoidance of responsibility, lack of attention to detail,
and tendency towards 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’, consists 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 STS effectively ‘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
healthcare 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
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
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
burnout among healthcare 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. And let’s 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 in order to ‘escape’ from the burnout
state, 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 appear 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 Also, 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
SUMMARY
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 healthcare team members. Perhaps educating
healthcare 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.
74%
20%
26%
76%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Prevalence of burnout Prevalence of depression
OPUS 12 Scientist 2008 Vol. 2, No. 1 S. P. Stawicki
Submitted 09/2006 – Accepted 01/2008 – Published 02/2008
Copyright 2007-2008 OPUS 12 Foundation, Inc. 32
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