Ovid: Collier: Ann Intern Med, Volume 136(5).March 5, 2002.384-390

Collier, Virginia U. MD; McCue, Jack D. MD; Markus, Allan MD; Smith, Lawrence MD

From Christiana Care Health System, Newark, Delaware; University of California, San Francisco; St. Joseph’s Medical Center, Phoenix, Arizona; and Mt. Sinai Medical Center, New York, New York.

For author affiliations and current addresses, see end of text.

See related article on pp 358-367 and editorial comment on pp 394-396.

Acknowledgments: The Resident Services Committee of the Association of Program Directors in Internal Medicine (APDIM) designed the survey instrument used in this paper. Other than the authors, members were Drs. Preston Cannady Jr., Jonathan Weschler, and Kevin Yingling. Members of the APDIM Council reviewed this manuscript. In addition to making valuable suggestions, the APDIM Council approved the conclusions and recommendations. APDIM provided administrative support. The authors thank Musa Nsreko, MPH, for performing data analysis, Drs. Neil Farber and Kathy Upchurch for reviewing and critiquing the manuscript, and Cindy Chuidian and Michele Rodriguez for providing secretarial assistance.

Requests for Single Reprints: Virginia U. Collier, MD, Department of Medicine, Christiana Care Health System, PO Box 6001, Newark, DE 19718; e-mail, vcollier:christianacare.org .

Current Author Addresses: Dr. Collier: Department of Medicine, Christiana Care Health System, PO Box 6001, Newark, DE 19718.

Dr. McCue: Department of Medicine, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143.

Dr. Markus: St. Joseph’s Medical Center, 350 West Thomas Road, Box 2071, Phoenix, AZ 85013.

Dr. Smith: Mt. Sinai Hospital and Medical Center, One Gustave L. Levy Place, New York, NY 10029-6574.

Background: Although curricular reforms have attempted to address sources of stress in medical residency, no recent studies have examined the financial or emotional situations of current medicine residents.

Objective: To question medicine residents about financial status, educational debt, moonlighting, and psychological issues.

Results: According to the questionnaire responses submitted by the 4128 (18%) participating residents, a substantial number of residents had financial and emotional distress that could have interfered with training. The reported educational debt was at least $50 000 for 1657 (42%) of the respondents and at least $100 000 for 737 (19%). The monthly disposable income was $100 or less for 1620 (43%) of the residents, and 637 residents (16%) could not afford safe housing. Among respondents in their 2nd through 5th year of postgraduate training, 2187 (52%) had insufficient funds to purchase books and equipment, and 678 (29%) could not afford the required fees for the American Board of Internal Medicine certifying examination; 2659 (33%) worked as moonlighters, and this percentage increased progressively with increasing educational debt.

Four or five depressive symptoms during residency were reported by 1461 (35%) residents. Eight hundred ninety-nine residents (23%) thought they had become less humanistic over the course of their residency training; 2347 (61%) reported becoming more cynical. Female residents were more likely than male residents to report increased cynicism and multiple depressive symptoms. Increased cynicism and depressive symptoms were associated with increasing educational debt.

Conclusions: Despite recent curricular reforms, an alarming number of current medicine residents report depressive symptoms, increasing cynicism, and decreasing humanism, which were associated with increasing educational debt and a need to moonlight for financial survival. Ongoing curricular reform, legislative relief from early loan repayment, and salary increases may be necessary to address these problems.

During the 1970s and 1980s, medical educators attempted to examine the quality of the personal and professional lives of residents. Several small nonrandomized studies found a higher incidence of depression (1-4) and anger and hostility (5, 6) in residents than in the general population. These findings were partly attributed to chronic sleep deprivation and fatigue (7-11). In response, residency program directors suggested (12) and implemented procedures to identify, manage, and reduce resident stress and impairment. Although residents may still be overworked (13), duty hours are now carefully regulated, and program directors are required to regularly monitor resident stress (14). Currently, the American Board of Internal Medicine and others (15) emphasize the importance of fostering outstanding professional and humanistic characteristics in residents. Some researchers have suggested a link between long work hours and loss of professionalism among residents (13, 16).

New sources of stress to residents continue to emerge. These include increasing personal debt from medical school (17-20), unstable financial conditions in many academic medical centers, threats of residency closings (21), and decreased confidence in the availability of jobs upon completion of residency (22-24). Furthermore, an increasing effort is required to master a rapidly expanding scientific and clinical knowledge base. Patients are sicker and are discharged faster on inpatient services, and many residents continue to be overworked, despite regulations (25). Worse yet, the residents’ role models and teachers often openly express discontent with the practice of medicine (26).

To re-examine current residents’ psychological and financial situations, the Resident Services Committee of the Association of Program Directors in Internal Medicine (APDIM) mailed a survey in May 1998 to all 415 internal medicine program directors, who were asked to distribute copies to each of their medicine residents (residents in categorical, preliminary, and combined tracks). Strict confidentiality was assured, and no specific names of residents or programs were included in the questionnaire. Residents were questioned about demographic data, moonlighting activities, and finances, including monthly disposable income, student loan debt, and credit card debt. They were also asked whether they had experienced any or all of five depressive symptoms and whether they felt that they had become more or less cynical and more or less humanistic during residency training. Data on all respondents were included in the analysis, with missing data noted.

We received responses from 4128 (18%) of the medicine residents in the United States in 1998 (Table 1). The decision to maintain confidentiality made follow-up of nonrespondents impossible, and it is unknown how many residents received but did not complete the survey. In addition, the survey design precludes interpretation of these results as representative of all residents. Just as it is unlikely that we achieved a statistically accurate sampling of the resident population, it is also doubtful that all residents with serious personal difficulties responded. These factors prevent us from determining the true proportion of residents with financial or emotional distress.

Table 2 shows the financial data of responding residents. Among the 3961 residents who indicated their estimated educational debt, the average amount was $44 412 and the median was $25 000; 1657 residents (42% of responders) reported owing at least $50 000 in educational debt. The average estimated credit card debt was $3769; 1224 residents (31%) reported having at least $3000 in credit card debt, and 320 (8%) reported at least $15 000. From postgraduate year (PGY) 1 to PGY 4, the mean credit card debt increased from $3275 to $6194. One thousand six hundred twenty responding residents (43%) had a monthly disposable income--defined as income remaining after payment of required bills of food, rent, utilities, and debt--of $100 or less, including many with a negative monthly disposable income.

Two thousand one hundred eighty-seven residents (52%) reported having insufficient funds to purchase work items, such as books and equipment. Six hundred seventy-eight (30%) PGY-2 through PGY-5 residents could not afford the fee for the American Board of Internal Medicine certifying examination, and, most disturbingly, 637 responding residents (16%) could not afford safe and sufficient housing. Only 10%, however, said that salary was a consideration in choosing a specialty.

Of 2629 responding PGY-2 through PGY-5 residents, 857 (33%) had moonlighting jobs. Among the moonlighters, 167 (20%) worked 21 to 30 moonlighting hours per week, 101 (12%) worked 31 to 40 moonlighting hours per week, and 81 (9%) worked more than 40 moonlighting hours per week. Among those who completed the survey, moonlighting progressively increased with increasing educational and credit card debt (Figure 1). Fifty-four percent of moonlighting respondents had at least $50 000 in educational debt compared with 34% of nonmoonlighters. Similarly, 35% of moonlighters had at least $5000 of credit card debt compared with 22% of nonmoonlighters. Moonlighters were more likely to have sufficient money for books and equipment but were no more likely to be able to afford the board examination. Moonlighters and nonmoonlighters did not differ significantly in the amount of end-of-month disposable income ($292.60 vs. $294.36).

A substantial number of residents reported depressive symptoms since starting residency. Forty-nine percent had experienced appetite changes; 61%, mood swings; 52%, decreased recreational activities; 45%, depressed mood; and 74%, sleep disturbance. Four or five depressive symptoms were reported by 1461 residents (35% of respondents), and 991 (22%) reported all five symptoms. Seventeen percent reported a loss of a loved one or close friend during residency. Eight hundred ninety-nine responding residents (23%) reported becoming less humanistic during residency training, and 2347 (61%) reported becoming more cynical. Importantly, among survey respondents, increasing debt correlated with self-reports of increasing cynicism and multiple depressive symptoms (Figure 2).

Forty percent of responding female residents (n = 667) and 32% of responding male residents (n = 777) noted four or five depressive symptoms. Sixty-seven percent of responding female residents (n = 1033) reported increasing cynicism versus 56% of responding male residents (n = 1294). Eighty-five percent (n = 1342) of female respondents believed that residency increased the complications of pregnancy. Twenty-eight percent of responding female residents (n = 328) felt faculty pressure to delay pregnancy, and 52% (n = 533) said that peers were resentful about pregnancy and maternity leave.

Residents with children less often reported feelings of depression than residents without children (41% vs. 47%). Similarly, residents with children less often reported increased cynicism (50% vs. 65%) and more often reported increased humanistic feelings (27% vs. 23%).

Our survey indicates that despite extensive efforts to reduce stress during residency, many medical residents had financial and emotional distress that could have interfered with training. Although our study is, to our knowledge, the largest to have examined these issues in this population, it is unlikely that the responses represent a statistically accurate sampling. However, even if we assume that only discontented, maladjusted, or financially distressed residents returned the survey, the absolute number of internal medicine residents reporting significant problems must serve as a serious alert to all concerned with our medical educational system and demands remediation.

In 1996, Reynolds (27) reported an average debt of $39 707 in internal medicine residents, which is similar to our figure of $44 412. The average debt in our study is lower than the 1997 mean medical student debt of $80 462 reported by the Association of American Medical Colleges (19, 28). A possible explanation for the reduced amount may be that residents with lower debt, such as those who graduated from publicly supported institutions, are overrepresented among our survey respondents (28). Furthermore, a disproportionately greater percentage of the residents working in internal medicine training programs are international medical graduates, most of whom have no educational debt (29). Although studies have shown that increasing debt only weakly affects specialty choice (30-32), very high debt (33, 34) may reduce the likelihood that a medical student will choose a career in primary care.

In our survey, residents with debt more often turned to moonlighting as an extra source of income. Moonlighting did not generate increased disposable income, and thus, the extra income from moonlighting was probably being used to pay for debt services and fixed monthly expenses. The rate of moonlighting among respondents is similar to rates in several previous nonrandomized studies (23% to 40%) (35-42). Moreover, similar to earlier studies, educational debt in our study correlated with increased moonlighting. Of great concern is that 349 (40.7%) moonlighting respondents worked more than 20 hours per week at their moonlighting jobs. The substantial time spent moonlighting, combined with an average 80-hour work week of most residents, could result in undue fatigue and potentially jeopardize resident education and patient care.

Other studies (27, 30) have noted that debt repayment markedly decreases satisfaction with personal lifestyle during residency by limiting time for leisure activities. Although we did not specifically ask about lifestyle, 43% of respondents had less than $100 of monthly disposable income, which is clearly insufficient to support substantial leisure activities. Undoubtedly, many residents must borrow money, perhaps from family members, to cover their most basic needs and to pay for unexpected expenses, additional professional costs, or personal entertainment.

Emotional distress in residents--especially depression--has been well documented (1-4, 6). After conducting structured psychiatric interviews, Valko and Clayton (1) concluded that 30% of the residents they interviewed had significant depression during internship. Using the Center for Epidemiologic Studies scale, Reuben (2) demonstrated that 28.7% of the medical interns tested were depressed, and Ford (6) found that 33% of interns rated themselves as depressed. Our finding that approximately 35% of respondents noted four of five depressive symptoms is similar, and is higher than the estimates for the adult U.S. population, which has a lifetime risk of 7% to 25% and a point prevalence of approximately 5% (43, 44).

Despite the efforts of most training programs to improve professionalism in their graduates, more than half of the responding residents reported increasing cynicism, and 25% reported decreasing humanism during residency. Increasing cynicism has also been seen in medical students (45) and may be related to increasing anger during residency (5).

Our study also suggests that the unique mental health needs of many female medicine residents are not being met. More female respondents reported depressive symptoms and increased cynicism than their male counterparts. In addition, large numbers of female residents expressed concerns about the possibility of future pregnancy, an added stress from faculty and peers. The increased stress of pregnancy during residency, concerns about the pregnancy experience, and increased hostility from male peers have been well documented (49-57). Female residents’ concern about increased medical complications of pregnancy during residency has been noted previously, despite evidence that, except for increased preterm labor, the outcomes of pregnancy are not greatly affected by residency training (58-64). However, one recent study from Israel (65) showed an increased incidence of stillbirths, and a 1988 study (66) showed a trend toward increased pregnancy-induced hypertension. Thus, although the preponderance of evidence is reassuring, some evidence supports the concern of female residents in our survey about the increased medical complications of pregnancy during residency training.

Our finding that parenthood reduced the stress of residency in some of the respondents is intriguing. How parenthood may blunt the negative effect of financial stress and may confer greater humanism and less cynicism needs further exploration. Perhaps being a young parent engenders hope in the future and a more altruistic view of life, or the family unit may act as a stabilizing force in the resident’s life.

Although the limitations of our study are clear, we have identified a significant number of residents with alarming financial and psychological distress. The large number of residents in whom increasing debt burden correlated with self-reports of depressive symptoms, increasing cynicism, and increasing need for moonlighting for financial survival is of great concern. Leaders in academic medicine must develop solutions to the significant negative impact of debt. Relief--in the form of tuition subsidies for medical education, increases in residents’ salaries, full loan deferral of principal and interest without interest accrual during residency training, and improved financial advice for residents--are all pieces of a solution to this major problem. Of note, efforts to limit moonlighting through regulation should be undertaken with caution in the absence of concomitant measures to alleviate the financial distress of residents. Finally, program directors, medicine department chairs, and senior medical education leaders must become aware of the additional stress in the lives of at least some of their female residents and develop systems in their programs for detection and prompt intervention.

Successful training of well-educated, humanistic physicians is a priority, and current stresses may thwart the accomplishment of that goal in some residents. We hope that this perspective paper will stimulate medical educators to further study the extent and causes of resident stress in both male and female residents in a randomized fashion. More important, our own results should mobilize the medical education community to respond immediately and effectively to the unmet needs expressed by many of the trainees under our care.

1.Valko RJ, Clayton PJ. Depression in the internship. Dis Nerv Syst. 1975;36:26-9. [PMID: 1109883] [Medline Link] [Context Link]

2.Reuben DB. Depressive symptoms in medical house officers. Effects of level of training and work rotation. Arch Intern Med. 1985;145:286-8. [PMID: 3977488] [Medline Link] [BIOSIS Previews Link] [Context Link]

3.Girard DE, Elliot DL, Hickam DH, Sparr L, Clarke NG, Warren L, et al. The internship--a prospective investigation of emotions and attitudes. West J Med. 1986;144:93-8. [PMID: 3953083] [Medline Link] [Context Link]

4.Gordon GH, Hubbell FA, Wyle FA, Charter RA. Stress during internship: a prospective study of mood states. J Gen Intern Med. 1986;1:228-31. [PMID: 3772596] [Medline Link] [BIOSIS Previews Link] [Context Link]

5.Uliana RL, Hubbell FA, Wyle FA, Gordon GH. Mood changes during the internship. J Med Educ. 1984;59:118-23. [PMID: 6141296] [Medline Link] [Context Link]

6.Ford CV, Wentz DK. The internship year: a study of sleep, mood states, and psychophysiologic parameters. South Med J. 1984;77:1435-42. [PMID: 6494967] [Medline Link] [Context Link]

7.Friedman RC, Kornfeld DS, Bigger TJ. Psychological problems associated with sleep deprivation in interns. J Med Educ. 1973;48:436-41. [PMID: 4699420] [Medline Link] [Context Link]

8.McCue JD. The distress of internship. Causes and prevention. N Engl J Med. 1985;312:449-52. [PMID: 3969107] [Medline Link] [Context Link]

9.Taylor AD, Sinclair A, Wall EM. Sources of stress in postgraduate medical training. J Med Educ. 1987;62:425-8. [PMID: 3573022] [Medline Link] [Context Link]

12.Stress and impairment during residency training: strategies for reduction, identification, and management. Resident Services Committee, Association of Program Directors in Internal Medicine. Ann Intern Med. 1988;109:154-61. [PMID: 3382106] [BIOSIS Previews Link] [Context Link]

14.American Medical Association. Accreditation Council for Graduate Medical Education (U.S.). Graduate Medical Education Directory. Chicago: American Medical Association; 1993. [Context Link]

15.Medical Professionalism in the New Millennium: A Physician Charter. Project of the ABIM Foundation, ACP-ASIM Foundation, and European Federation of Internal Medicine. Ann Intern Med. 2002;136:243-6. [Fulltext Link] [Medline Link] [BIOSIS Previews Link] [Context Link]

16.Reynolds PP. Professionalism and residency reform. Bull N Y Acad Med. 1991;67:369-77. [PMID: 1868294] [Medline Link] [Context Link]

17.Garrard PS. National policy perspectives AHCPR: the shared responsibility of medical students’ debt. Acad Med. 1998;73:416-7. [Context Link]

18.Korcok M. Financial troubles abound for new US medical grads. CMAJ. 1998;159:702-4. [PMID: 9780973] [Medline Link] [Context Link]

21.Greene J. Residents scramble after programs close. American Medical News. 28 June 1999:1, 30. [Context Link]

22.Miller RS, Dunn MR, Richter TH, Whitcomb ME. Employment-seeking experiences of resident physicians completing training during 1996. JAMA. 1998;280:777-83. [PMID: 9729988] [Fulltext Link] [Medline Link] [Context Link]

24.Greene J. First year physicians disappointed with pay, options. American Medical News. 16 August 1999:11-5. [Context Link]

25.Daugherty SR, Baldwin DC Jr, Rowley BD. Learning, satisfaction, and mistreatment during medical internship: a national survey of working conditions. JAMA. 1998;279:1194-9. [PMID: 9555759] [Fulltext Link] [Medline Link] [Context Link]

27.Reynolds PP. The impact of indebtedness on residents’ professionalism, lifestyle, and career [Abstract]. J Gen Intern Med. 1996;11(Suppl)1:83. [Fulltext Link] [Context Link]

28.Heinig SJ, Quon AS, Meyer RE, Korn D. The changing landscape for clinical research. Acad Med. 1999;74:726-45. [PMID: 10386106] [Medline Link] [Context Link]

29.American Medical Association. Graduate Medical Education. JAMA. 1998;280(Appendix II):836-45. [Fulltext Link] [Context Link]

30.McLaughlin MA, Daugherty SR, Rose WH, Goodman LJ. The impact of medical school debt on postgraduate career and lifestyle. Acad Med. 1991;66:43-5. [Context Link]

31.Kassenbaum DG, Szenas PL. Relationship between indebtedness and the specialty choices of graduating medical students. Acad Med. 1992;67:700-7. [Medline Link] [Context Link]

32.Kassenbaum DG, Szenas PL. Factors influencing the specialty choices of 1993 medical school graduates. Acad Med. 1994;69:164-70. [Context Link]

33.Marci CD, Roberts TG. The increasing debt of medical students: how much is too much? JAMA. 1998;280:1879-80. [PMID: 9846787] [Fulltext Link] [Medline Link] [Context Link]

34.Schnipper J, Dorwart RA. Medical students’ opinions of health system reform. JAMA. 1995;273:80-1. [PMID: 7996659] [Medline Link] [Context Link]

35.Moss AJ. Moonlighting house officers: the silent majority. N Engl J Med. 1984;311:1375-7. [PMID: 6493291] [Medline Link] [Context Link]

36.Bazzoli GJ, Culler SD. Factors affecting residents’ decisions to moonlight. J Med Educ. 1986;61:797-802. [PMID: 3761341] [Medline Link] [Context Link]

37.Silliman RA, Dittus RS, Velez R, Wartman SA, Young MJ, Fletcher RH. Debt, moonlighting, and career decisions among internal medicine residents. J Med Educ. 1987;62:463-9. [PMID: 3599034] [Medline Link] [Context Link]

38.McCue JD, Janiszewski M, Stickley WT. Residents’ views of the value of moonlighting. Arch Intern Med. 1990;150:1511-3. [PMID: 2369249] [Medline Link] [Context Link]

39.Hough DE, Bazzoli GJ. The economic environment of resident physicians. JAMA. 1985;253:1758-62. [PMID: 3974055] [Medline Link] [Context Link]

40.Culler SD, Bazzoli GJ. The moonlighting decisions of resident physicians. J Health Econ. 1985;4:283-92. [PMID: 10275172] [Medline Link] [Context Link]

41.Silberger AB, Thran SL, Marder WD. The changing environment of resident physicians. Health Aff (Millwood). 1988;7:121-33. [PMID: 3378727] [Medline Link] [Context Link]

43.Blazer DG, Kessler RC, McGonagle KA, Swartz MS. The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey. Am J Psychiatry. 1994;151:979-86. [PMID: 8010383] [Medline Link] [BIOSIS Previews Link] [Context Link]

44.Murphy JM, Laird NM, Monson RR, Sobol AM, Leighton AH. A 40-year perspective on the prevalence of depression: the Stirling County Study. Arch Gen Psychiatry. 2000;57:209-15. [PMID: 10711905] [Medline Link] [BIOSIS Previews Link] [Context Link]

45.Eron LD. Effect of medical education on medical students’ attitudes. J Med Educ. 1955;30:559-66. [Context Link]

46.Hsu K, Marshall V. Prevalence of depression and distress in a large sample of Canadian residents, interns, and fellows. Am J Psychiatry. 1987;144:1561-6. [PMID: 3688279] [Medline Link] [BIOSIS Previews Link]

47.Smith JW, Denny WF, Witzke DB. Emotional impairment in internal medicine house staff. Results of a national survey. JAMA. 1986;255:1155-8. [PMID: 3945035] [Medline Link] [BIOSIS Previews Link]

48.Crowley AE. Graduate medical education in the United States, 1984-1985. JAMA. 1985;254:1585-93. [PMID: 3839856] [Medline Link] [BIOSIS Previews Link]

49.Gabram SG, Allen LW, Deckers PJ. Surgical residents in the 1990s. Issues and concerns for men and women. Arch Surg. 1995;130:24-8. [PMID: 7802572] [Fulltext Link] [Medline Link] [Context Link]

50.Young-Shumate L, Kramer T, Beresin E. Pregnancy during graduate medical training. Acad Med. 1993;68:792-9. [PMID: 8397614] [Medline Link] [Context Link]

51.Sinal S, Weavil P, Camp MG. Survey of women physicians on issues relating to pregnancy during a medical career. J Med Educ. 1988;63:531-8. [PMID: 3385751] [Medline Link] [Context Link]

52.Tamburrino MB, Evans CL, Campbell NB, Franco KN, Jurs SG, Pentz JE. Physician pregnancy: male and female colleagues’ attitudes. J Am Med Womens Assoc. 1992;47:82-4. [PMID: 1624671] [Medline Link] [Context Link]

53.Klevan JL, Weiss JC, Dabrow SM. Pregnancy during pediatric residency. Attitudes and complications. Am J Dis Child. 1990;144:767-9. [PMID: 2356795] [Medline Link] [BIOSIS Previews Link] [Context Link]

54.Phelan ST. Sources of stress and support for the pregnant resident. Acad Med. 1992;67:408-10. [PMID: 1596341] [Medline Link] [Context Link]

55.Sayres M, Wyshak G, Denterlein G, Apfel R, Shore E, Federman D. Pregnancy during residency. N Engl J Med. 1986;314:418-23. [PMID: 3945268] [Medline Link] [Context Link]

56.Yogev S, Harris S. Women physicians during residency years: workload, work satisfaction and self concept. Soc Sci Med. 1983;17:837-41. [PMID: 6879241] [Medline Link] [Context Link]

57.Harris DL, Osborn LM, Schuman KL, Reading JC, Prather MB, Politzer RM. Implications of pregnancy for residents and their training programs. J Am Med Womens Assoc. 1990;45:127-8, 131. [PMID: 2398223] [Medline Link] [Context Link]

58.Klebanoff MA, Shiono PH, Rhoads GG. Outcomes of pregnancy in a national sample of resident physicians. N Engl J Med. 1990;323:1040-5. [PMID: 2215563] [Medline Link] [BIOSIS Previews Link] [Context Link]

61.Osborn LM, Harris DL, Reading JC, Prather MB. Female residents not at increased risk for adverse pregnancy outcome. Proc Annu Conf Res Med Educ. 1988;27:120-6. [PMID: 3218845] [Medline Link] [Context Link]

64.Katz VL, Miller NH, Bowes WA Jr. Pregnancy complications of physicians. West J Med. 1988;149:704-7. [PMID: 3074567] [Medline Link] [Context Link]

65.Pinhas-Hamiel O, Rotstein Z, Achiron A, Gabbay U, Achiron R, Barak Y, et al. Pregnancy during residency--an Israeli survey of women physicians. Health Care Women Int. 1999;20:63-70. [PMID: 10335156] [Medline Link] [CINAHL Link] [Context Link]