Physicians deal with a patient's life, death and the process of death. In addition, they may work with the calling consciousness. Nevertheless, they may often be exposed to stressful situations. A so-called 'stress' denotes a biological, psychological, or behavioral reaction that occurs in the body in response to mental and physical stimuli impinging on a living body. A proper amount of work stress improves job motivation and productivity. On the contrary, excessive work stress can cause reduction in work-related desire and productivity, as well as more accidents, and may act as a primary factor for various health disorders including cardiovascular, mental, and musculoskeletal diseases.¹⁾ They are subject to great responsibility and clinicians possess significant social prestige and high economic status for their expert knowledge and training. However oppressive stress due to the urgent nature of clinical practice and difficulty of decision making as opposed to those in other occupations.²⁾ Particularly, excessive workload, discord with patients and their guardians, and lawsuits following malpractice are well known as primary stress factors for doctors, particularly residents.^3,4)

A certain level of stress is unavoidable for residents during the residency program and may even be helpful in the performance of a clinician role. On the other hand, undue stress may cause burnout. 'Burnout' is a pathologic symptom, first defined by Maslach et al.,⁵⁾ which implicates emotional exhaustion and loss of integrity and sensibility caused by tremendous exhaustion or stress. Such burnout negatively affects not only the immediate and long-term physical and mental health of residents, but also threatens patients themselves.⁶⁾ In fact, one foreign study reported that the greater the stress of resident doctors and the lower the sympathy toward stress, the more numerous the malpractice had occurred.⁷⁾ For this reason, arguments on the issue of a doctor's stress and burnout, as well as the measures for resolving these problems are notably examined in advanced nations. However, unlike efforts seen in such advanced nations, not even assessments on the extent of stress or related factors associated with a doctor's work are performed in Korea. Accordingly, it is imperative to develop tools to grasp the extent of work-related stress and associated factors in Korean doctors. Also, it is urgent to attain the measures of improvement on the basis of this understanding.

Family medicine (FM) residents perform outpatient clinical duties in their training program, as well as carry out clinical rotations in other medical specialties to attain expertise in each discipline and execute their responsibilities as the physician in charge in each corresponding department of clinical rotations. Accordingly, FM residents encounter groups of various patients and come across stress diversely in each rotation. Thus, this investigation incorporates a work stress measurement tool for Koreans that has been verified for its validity in various occupations, and examines work-related stress and the level of physical symptoms targeting FM residents engaged in various disciplines. It attempts to carry out discussions by making comparisons between these measured data and standards of the nationwide reference values, and find general characteristics of numerous physical symptoms of FM residents and work stresses associated with these symptoms.

The extent of occupational stress perceived by nationwide FM residents showed a mean score of 49.4 points, which belongs to that of the lower 25% to 50% group in comparison with the reference values of workers in Korea, corresponding to group with a relatively low occupational stress. Nevertheless, among the subscales, high job demand, insufficient job control, organizational injustice, and discomfort in occupational climate belonged to the top 50% of nation-wide reference values. The level of occupational stress in these subcategories exceeded the nation-wide mean reference value, entailing a concern on this issue.

The valuation of occupational stress secondary to 'high job demand' means that of the extent of a job burden. Considering the excessive job load and numerous responsibilities demanded upon FM residents, owing to time pressure, work load increase and undue responsibility in the resident training process, enormous occupational stress is a matter of course. Particularly, significant differences shown in occupational stress among training yearly levels of FM residents may be associated with the condition in which work load and night duty days are largely concentrated among early year residents. Occupational stress must be enormous in the subscales of 'inadequate social support' and 'organizational injustice', considering the fact that residents are fresh physicians in their early social life and at the lowest level of the vertical social strata among medical doctors. In addition, lack of assistance and support by predecessor doctors, nurses, and other ancillary personnel, organizational discord, and irrational communication in a hospital may work as occupational stress factors. Stress due to 'discomfort in occupational climate' scored 49.1 points, belonging to the group just below the top 75%, which is rather high. Unlike the highly formal, rational job culture of the West, primary stress factors at work in Korea might be related to the group-oriented culture in Korea, system of irrational communication, and unofficial job culture. Summing such factors up, these are stresses which come from collective culture, including factors such as group dining, non-standard or illogical work directions, and authoritarian leadership and hospital hierarchy. It is necessary to bring about change in organization of doctors in hospitals.

Among the subscales of occupational stress in this study, job stress due to 'insufficient job control' belonged to the bottom 25% to 50% range, while that of 'job insecurity' and 'lack of reward' belonged to the bottom 25%. This study was the first of its kind to target medical doctors and may not be compared with any previous study. However, the results of this study may reflect the social phenomenon of preference for medical profession in the aspect of expertise and economic compensation.

The mean score of physical symptoms of FM residents was 2.1 points. This score was shown to be higher than that of average healthy adults (0.86 points) in the region of Seoul and Gyeonggi Province, diabetes patients (1.22 points), or patients admitted to neuropsychiatric clinic with a chief complaint of physical symptoms (1.87 points), which were measured with the K-PSI used in this study.⁸⁾ K-PSI was devised to measure the scale and strength of physical symptoms inflicted. Considering the fact that K-PSI has high reliability and validity in the diagnosis of various physical symptoms, it acknowledged distinctive differences in the group of FM residents as opposed to that of a general group. The score of physical symptoms higher than that of diabetes patients might be due to the possibility of having physical manifestations as defensive mechanisms against stress and the actual physical and mental disease that needed to be addressed with an appropriate treatment.

In this study, FM residents most frequently had fatigue, and had complaints of various physical symptoms such as lower back pain, indigestion, myalgia, and headache in a decreasing order. Such results may be explained by the results of a study asserting that continuous stress neuro-physiologically affected the brain, changing pain sensibility leading to physical manifestation and chronic headache, and the outcome of a study reporting that incessant stress was associated with digestive disorders, such as irritable bowel syndrome in the group with immense stress and high score of physical symptoms.^10,11) Furthermore, chronic fatigue syndrome is associated with irritable bowel syndrome and fibromyalgia. Pain, digestive disturbance, myalgia, and headache frequently reported by FM residents are included in the diagnostic criteria of chronic fatigue syndrome. Thus, it is necessary in the future to conduct proper evaluations on a correlation between such various physical symptoms reported by FM residents and fatigue of residents.¹²⁾

The statistical correlation between early-year residents and more on-duty time, work days, night duty days, and patient loads having significantly greater occupational stresses concurred with that of the study conducted on interns, residents, and professors at a US hospital.¹³⁾ This may be associated with the increased time required for patient care due to less experience seen in doctors of early year residency, and possible discord with senior doctors and senior residents having less on-duty time, work days, night duties, and smaller patient loads. This study showed that the shorter the sleep duration and the worse the quality of sleep had an effect of higher occupational stress. The result of this investigation concurred with that of other studies that a lack of sleep largely affected occupational stress, and inadequate sleep and resultant extreme fatigue might increase malpractice.¹⁴⁾

Even after adjustments of on-duty time, work days, night duty days, daily patient loads, number of ICU patients assigned, sleep duration, and sleep quality, there was statistically a significant positive correlation in all 6 subscales, except for work insecurity, between occupational stress and physical symptoms. Among them, 'high job demand' showed the highest correlation between work stress and physical symptoms. An intervention in lofty physical symptomatic manifestations associated with occupational stresses may necessitate adjustments in excessive job-related behaviors including the scope of undue on-duty time, night duties, patient loads, and ICU patient loads allotted for residents.

In an attempt to ameliorate various physical symptoms developing among residents, an intervention with respect to management of occupational stress and removal or reduction of causative factors, as well as comprehensive mediation of policy management and personal approach should be undertaken. It was demonstrated in numerous reports, as an issue associated with occupational stress, that there was a correlation between excessive work hours and lack of sleep and job stress and exhaustion with resultant increase in malpractice in the US. A law, enacted in 2003, stipulated that working hours should be 80 hours or less per week and continuous work duration should not exceed 30 hours.¹⁵⁾ Furthermore, it was also demonstrated through study that occupational stress and malpractice actually decreased significantly after the enactment of the law.¹⁶⁾ Medical discipline related behaviors, which could affect residents and patients, inclusive of continuous work duration and night duties by doctors in their residency program should be managed in our medical community as well. It is urgent to gain a better understanding of occupational stress and the extent of physical symptoms of doctors in their residency program. Measures of mediation such as the Employee Assistance Program for the management of occupational stress, which is widely used in other vocations recently, should be arranged in order to manage job stress and various physical symptoms.

This study had several limitations. The response rate was low as the survey questionnaire was administered via e-mail. The method of verifying precise e-mail delivery of surveying contents to targeted doctors in their FM residency program was inadequate. Despite repeated sending of e-mails pressing for an answer, the response rate was low at 13.1%, which is insufficient to represent all doctors in FM residency programs. Also, medical institutions may have dissimilar FM residency programs and assessment on this aspect has not been included. Nevertheless, the survey was conducted relatively without bias with respect to sex or the year of residency training. The questionnaire was faithfully answered, except for one subject, and inquiries on inclination of the investigated theme were quite meaningful. The reference values of occupational stress among nationwide workers we utilized have implications for a multitude of jobs and include a large number of workers in other age groups. Therefore, comparisons of the precise extent of stress are easier said than done. However, it is quite consequential when examining work stresses of doctors in their residency program, which may interfere with the training process itself. It is also pertinent to suggest modalities for additional management and enhancement in the FM disciplinary process.

A further study is needed for the improvement of occupational stress and physical symptoms of doctors in FM residency program, including those who did not respond to this investigation, and realistic measures should be suggested. Moreover, this study was conducted only among FM residents, but follow-up studies could include doctors of residency programs of other specialties as well as on-field physicians.