32 SAJCC July 2023, Vol. 39, No. 2

SOAP BOX

The residency programme transforms medical students from novices to

competent physicians/academic teachers. Being a professional course, it

requires not only reading to deepen the theoretical understanding but

also intellectual inquiry and practical training.[1] However, keeping up

with the unrelenting responsibilities of being a responsible healthcare

provider is not easy in the ever-evolving world of medical knowledge

and practice. Therefore, experienced physicians-cum-teachers supervise

and train residents to enhance their learning, inculcate accountability,

and secure patient safety. It is a common practice to guide residents with

a caring but disciplined hand, which often includes inducing fear by

scolding, depending on the nature of the event. The aim is to push them

to continue putting in their best efforts at attaining the highest standards

of knowledge and skill while at the same time travelling along the path of

the continuous journey of acquiring wisdom and taking wiser decisions

during their medical life. 2,3] In this context, I (SS) wish to recount one

such experience during my residency training period in critical care

medicine, as follows:

A patient presented with almost 100% burns late in the night. After initial

resuscitation with crystalloid fluid, the patient was put on a mechanical

ventilator because of anticipated respiratory failure and ventilated as per

the lung protective ventilation strategy. As a resident, Ialways got confused

by low v. high tidal volume, positive end-expiratory pressure (PEEP), and

their association with barotrauma. I used to mix up the benefits of PEEP

with the drawbacks of high tidal volume. Despite multiple readings, I could

not sort it out. During the morning presentation, I was told to increase the

PEEP because of acute respiratory distress syndrome (ARDS). On my asking

why, my superior scolded me and said, ‘Just go and read.’ Immediately, I felt

my brain jolted and cleared out, the cobwebs swept away, and a newfound

illumination on tidal volume (high v. low), PEEP, and its effects on the lungs.

Years later, when I became one of the teaching faculty, and was in

charge of the academic section at one of the premier medical institutions

in our country, I was finally able to reminisce about the shenanigans of

our training days. I realised that the impact of scolding on the brain was

similar to the recruitment effect of PEEP on the lungs. As I was sharing

this enthusiastic thought with my colleagues during lunch hour, a

psychiatrist colleague (GB) pointed out that not every resident may have

a similar reaction to such scolding. While one may attain clarity, another

may go silent or even feel anxious or tearful. Prolonged exposure to such

stress may also have varying impacts on residents, based on individual

differences. A recent paper, in agreement with the psychiatrist’s opinion,

reported that the PEEP effect was observed to vary between different

phenotypes of ARDS, with beneficial effects of a higher PEEP with the

hyper-inflammatory phenotype.[4] Similarly, studies on medical students

indicated that resilience, generally understood as the ability to be flexible

and adaptive in response to challenges, demonstrated a protective

role in the negative relationship between residency demands and

residents’ psychological well-being.[5,6] Furthermore, studies indicated

that resilience increases directly with stress, up to a limit beyond which

it becomes almost constant.[7]

Thus, while a healthy dose of stress in the form of scolding with

continuous feedback may inspire a resident to attain a higher standard

of training, as per the Yerkes-Dodson law, being subject to chronic stress

beyond one’s coping skills may lead to long-term adverse psychological

consequences, including a reduction in empathy, interpersonal

reactivity, and development of psychiatric illnesses.[8] Much like lungs,

where excessive PEEP may be harmful. It is therefore recommended

that teaching faculty in any specialty must find and choose an optimum

balance between positive and negative feedback techniques that suit

each and every resident trainee in a specific individual manner instead

of using a generalised approach. This will produce not only competent

health providers but psychologically healthy ‘healers’ with good

interpersonal, managerial and social skills.

Acknowledgements. None.

Author contributions. SS and MV were involved in the conceptualisa-

tion, SS and GB draed the original manuscript, and MV and SS edited

the original manuscript. All authors have reviewed and approved the nal

manuscript.

Funding. None.

Conicts of interest. None.

1. Van der Leeuw RM, Lombarts KM, Arah OA, Heineman MJ. A systematic review of the effects

of residency training on patient outcomes. BMC Med 2012;10:65. https://doi.org/10.1186/1741-

7015-10-65

2. Grover AK. Residency training in India: Time for a course correction. Indian J Ophthalmol

2018;66:743-744. https://doi.org/10.4103/ijo.IJO_328_18

3. Wartman SA, O’Sullivan PS, Cyr MG. The service/education conflict in residency programs. J

Gen Intern Med 1990;5:S59–S69. https://doi.org/10.1007/BF02600439

4. Matthay MA, Arabi YM, Siegel ER, et al. Phenotypes and personalised medicine in the acute

respiratory distress syndrome. Intensive Care Med 2020;46:2136-2152. https://doi.org/10.1007/

s00134-020-06296-9

Is scolding analogous to positive end-expiratory

pressure(PEEP)?

S Singhal,1 MD, EDRM ; M Verma,2 MD, NFPM; G Bhatia,3 MD, DM (Addiction Psychiatry)

1Department of Pulmonary Medicine, All India Institute of Medical Sciences, Rajkot, India

2Department of Radiation Oncology, King George’s Medical University, Lucknow, India

3Department of Psychiatry, All India Institute of Medical Sciences, Rajkot, India

Corresponding author: S Singhal (drsanjaysinghal79@yahoo.co.in)

South Afr J Crit Care 2023:39(2):e563 https://doi.org/10.7196/SAJCC.2023.v39i2.563

Keywords: PEEP, ARDS, scolding, medical training