Association between social skills and mental health outcomes in Health Science Residents in Brazil

Carina Rodrigues da Silva; Andreia Gonçalves Arruda; João Wellinton Pletti; Ana Amélia Domingues Gomes; Thaís Rabelo dos Santos-Doni; Rafael Felipe da Costa Vieira; Alexandre Coutinho Antonelli; Dagma Venturini Marques Abramides; Alexandre Redson Soares da Silva

doi:10.1371/journal.pone.0341773

Abstract

Residency programs play a crucial role in the development and technical training of young health professionals. However, mental health issues such as psychological distress, anxiety, and depression are prevalent, often influenced by work satisfaction and the learning environment. Despite their relevance, studies investigating the prevalence and associated factors of these conditions across medical, multidisciplinary, and veterinary residency programs remain scarce. This study aimed to determine the prevalence of psychological distress, anxiety, and depression, and to examine their association with social skills among residents in Brazilian health science programs. We conducted a voluntary online survey with residents from three major residency programs (medical, multidisciplinary, and veterinary) across different Brazilian institutions. The cross-sectional study sample consisted of a total of 51 participants. Mental health outcomes were assessed using validated instruments: the Resident Questionnaire (RQ) for emotional distress, General Anxiety Disorder (GAD-7) for anxiety, and Patient Health Questionnaire (PHQ-9) for depression. The Multidimensional Scale of Social Expression (MSSE-M) measured social skills. Multivariable mixed-effects linear regression models addressed each mental health outcome separately, with social skill scores as primary explanatory variables. The results revealed a high prevalence of emotional distress (86.3%), anxiety (58.8%), and depression (56.9%) among residents. Greater satisfaction with the learning environment was significantly associated with lower mental health symptom levels. Residents demonstrated a generally satisfactory overall repertoire of social skills (60.78%), with the “Start and keeping conversations” and “Express positive affect” subscales scoring highest across all programs. For emotional distress, the “ability to defend rights” subscale was significantly associated with its reduction (−0.58), while a broader overall social skill repertoire was significantly associated with reductions in anxiety (−3.14) and depression (−3.92). These findings highlight the significant burden of mental health challenges among residents and emphasize the role of a supportive environment. Social skills training may help mitigate psychological distress and support resident well-being.

Citation: Rodrigues da Silva C, Arruda AG, Pletti JW, Domingues Gomes AA, dos Santos-Doni TR, da Costa Vieira RF, et al. (2026) Association between social skills and mental health outcomes in Health Science Residents in Brazil. PLoS One 21(2): e0341773. https://doi.org/10.1371/journal.pone.0341773

Editor: Lakshminarayana Chekuri, University of Missouri School of Medicine, UNITED STATES OF AMERICA

Received: August 2, 2025; Accepted: January 12, 2026; Published: February 18, 2026

Copyright: © 2026 Silva et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data can be found at the following DOI: https://doi.org/10.5281/zenodo.18351431.

Funding: This study was supported by the Coordination for the Improvement of Higher Education Personnel – Brazil (CAPES) through two grants: Process No. 88887.612918/2021-00 under the Graduate Program Demanda Social (DS), and Process No. 88881.690286/2022-01 under the Institutional Program for Internationalization – PDSE (Sandwich PhD Program). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The professional residency period in the health sciences field is essential for professional growth, as it integrates recent graduates into the work environment, allowing specialization and improvement in their chosen area of work through theoretical and practical experiences [1]. This phase of professional and personal training is crucial for preparing professionals to face adversities, motivating young professionals to immerse themselves in postgraduate training work in search of solidifying theoretical and practical knowledge that complements their undergraduate education [2].

Residency is considered a challenging period due to intense demands for excellence from patients and supervisors, high levels of stress in the work environment and interpersonal relationships, work overload, and accumulation of academic activities [3–5]. Because of that, during this period, many residents experience a significant increase in mental health issues such as psychological distress, anxiety, and depression [5–8]. This trend is internationally supported, with studies consistently showing a substantial mental health burden among medical residents globally [9]. In veterinary medicine, recent evidence highlights concerning levels of mental health problems among interns and residents, with elevated rates of depression and suicidal ideation compared to the general population [10,11]. Additionally, factors such as being female [8,12], experiencing stressful events [6,8], and having low subjective well-being [13] have been associated with depression during residency training. These mental health issues can lead to severe consequences, including increased risk of suicidal thoughts, occurrence of medical errors, and reduced adherence to safety and practice standards [8,14–16]. Such consequences not only affect the well-being of residents but may also directly impact the patients and clients under their care [14–16].

Beyond individual-level factors, the residency program’s environment itself can significantly affect the mental health of residents [5]. Previous studies have linked the clinical learning environment within residency programs to the quality of education, performance, and overall well-being of residents [2,17,18]. Furthermore, studies showed that this professional environment is associated with resident depression, particularly when factors such as high effort, low reward, and lack of job autonomy are present [19–21]. Similar concerns extend beyond medicine, as researchers described veterinary and other health science residency programs as highly demanding, with limited institutional support to mitigate the psychological burden on trainees [10,11,22].

For these professionals, technical inexperience and lack of social skills can contribute to emotional exhaustion, psychological distress, sleep deprivation, psychoactive substance abuse, and work/life imbalance [5,23]. Given that residents commonly begin their practice in an unfamiliar context, it is essential for them to have an adequate repertoire of technical and social skills, as these are equally important in both professional and personal settings. Such abilities include communication, expressing positive and negative feelings, as well as civility, assertiveness, and empathy [24]. Social skills also play a key role in supporting resilience and well-being in clinical practice, fostering better teamwork and reducing burnout risk, as suggested by recent studies in interprofessional health education and veterinary training [10,22,25]. Given their relevance to health practices, several studies have focused on the psychosocial characteristics of professionals [3,7,26–28].

Despite the documented importance of social skills in improving professionals’ resilience, there is a lack of studies directly investigating their association with mental health among physicians, multidisciplinary, and veterinary professionals. The aim of our study was to determine the prevalence of mental health issues, including emotional distress, anxiety, and depression, amongst medical, multidisciplinary, and veterinary residents; to investigate the association between the repertoire of social skills and these mental health issues, while accounting for other important factors, such as satisfaction with the work and learning environment. We hypothesized that higher levels of social skills would be inversely associated with symptoms of anxiety, depression, and emotional distress.

Materials and methods

Ethics Committee approval was obtained before data collection from the Ethics Committee for Research with Human Beings of the Faculty of Dentistry of Bauru of the University of São Paulo (protocol code 02778218.3.0000.5417 and date of approval 15 February 2019); and the Federal University of São Francisco Valley (protocol code 02645518.6.0000.5196 and date of approval 11 July 2019) and registered with the Brazilian National Research Ethics Commission (CONEP), under the Ministry of Health. We obtained informed consent from all subjects involved in the study.

Study design, population and data collection procedures

This cross-sectional study employed an online survey instrument for data collection. The study population comprised medical, multidisciplinary, and veterinary residents enrolled in their respective residency programs across five institutions in Brazil. For the purposes of this study, residents were defined as professionals enrolled in Brazilian residency programs accredited by the Ministries of Health and Education. These programs are classified into three distinct modalities: medical, multidisciplinary, and veterinary.

The Multidisciplinary Residency Program in Brazil is a lato sensu postgraduate course structured as in-service training conducted within hospital units and affiliated health networks. Its primary objective is to integrate qualified professionals into priority areas of Sistema Único de Saúde – Brazilian Unified Health System (SUS), encompassing various health professions. These include, but are not limited to, veterinary medicine, biomedicine, biological sciences, physical education, nursing, pharmacy, physiotherapy, speech therapy, nutrition, dentistry, psychology, social work, and occupational therapy (Resolution CNS nº 287/1998; [27,28]). This program typically has a duration of approximately two years, with a minimum workload of 6,000 hours, and operates on a full-time, exclusive dedication basis, usually financed by a scholarship [29,30].

The Medical Residency Program also shares characteristics of a lato sensu postgraduate course in the form of in-service training, but it is exclusively directed towards physicians. It aims to specialize doctors in specific medical areas. Medical residency programs can be direct access, allowing physicians to enter without a prior specialty, or require a prerequisite, where completion of another residency is necessary. The weekly workload is 60 hours, including theoretical and practical activities, with a duration varying from 1 to 5 years depending on the specialty.

While legislatively often categorized under the multidisciplinary modality, in this study, the veterinary residency was considered as a separate category due to its specific and exclusive focus on animal medicine and the inherent particularities of veterinary training. This modality seeks technical-scientific specialization in specific areas of veterinary medicine, with a workload and duration comparable to other residency programs.

The health residency programs, established by Law No. 11,129 of 2005, are guided by the principles and guidelines of the SUS, based on local and regional needs and realities. Within these programs, the requirement for ‘shifts’ varies according to the specialty’s nature. In this context, shifts are defined as periods of continuous, supervised clinical activity in urgent, emergency, or 24-hour units, limited to a maximum of 24 uninterrupted hours, including overnight and/or weekend rotations. While some curricula demand intensive practical scales, others may not require any shifts, such as modalities focused on laboratory, diagnostic, or public health areas that may fulfill their requirements through outpatient or administrative schedules. This classification allows for a better understanding and analysis of the profiles and needs of residents in different professional contexts, contributing to the planning of educational and health policies aimed at these groups.

The five institutions that gave rise to the study subjects (source population) were conveniently selected based on co-author’s professional networks with the residency program coordinators. Four of them were located in the states of São Paulo and one in the state of Pernambuco. The institutions selected for the study had their specific names hidden to protect confidentiality of participants, but they all needed to be accredited by the Brazilian Ministries of Health and Education to be included in the study.

To recruit individual participants, the residency coordinators for each institution collaborated with each university’s Human Resources department, which compiled a comprehensive list of residents enrolled in the participating institutions. Based on this list provided, recruitment was conducted through email and social media platforms (e.g., WhatsApp^©), with invitations sent either by the research team, institutional administrative staff, or resident representatives, depending on the institution’s internal protocols. Participation was voluntary, with no incentives offered for participation in the study. All active residents were eligible to participate in the study, regardless of the length of time enrolled in their respective programs.

Weekly recruitment efforts were conducted, and the questionnaire was available for responses from August 6, 2019, to November 11, 2019. Participation was confirmed by study subjects through online agreement after a description of the study objectives and agreement to the Free and Informed Consent Form, which was approved by Ethics Committee for Research with Human Beings of the Faculty of Dentistry of Bauru at the University of São Paulo (protocol code 02778218.3.0000.5417); and the Federal University of São Francisco Valley (protocol code 02645518.6.0000.5196). None of the institutions mentioned were included in the study. Participant’s answers were collected anonymously. The source population comprised 434 residents enrolled in medical (n = 266), multidisciplinary (n = 124), and veterinary (n = 44) residency programs. Of the 434 eligible residents, 51 completed the survey, yielding a response rate of 11.75%. The final study sample included 10 residents from medical programs, 18 from multidisciplinary programs, and 23 from veterinary programs. A flowchart detailing the study design and participant selection process is provided in Fig 1, which includes the distribution of participants across the institutions (Medical and Multidisciplinary residents from four institutions in São Paulo, and veterinary residents from one institution in Pernambuco).

Download:

Fig 1. Flowchart of study design and sample collection.

https://doi.org/10.1371/journal.pone.0341773.g001

Questionnaire development

The questionnaire, developed using Google Forms^©, comprised six sections (instruments) and had an estimated average completion time of 40 minutes. Before data collection, it was internally tested by approximately five members of the study team, and feedback led to minor adjustments. Participants responded asynchronously, beginning with questions related to sociodemographic data and professional activities. The survey was completed anonymously, and no personally identifying data was collected or disclosed, ensuring full compliance with the Brazilian General Data Protection Law (LGPD) – Law 13,709/2018. They then proceeded to the validated instruments: Resident Questionnaire (RQ); General Anxiety Disorder-7 (GAD-7); Patient Health Questionnaire-9 (PHQ-9); and Multidimensional Scale of Social Expression – Motor Subscale (MSSE-M). The interpretation of all validated instruments and their score calculations are detailed in Table 1.

Download:

Table 1. Detailing of questionnaire’s validated instruments subscales, internal reliability, items numbers, and scoring interpretation.

https://doi.org/10.1371/journal.pone.0341773.t001

The first part of the survey, “Socio-demographic and professional activities”, included 20 questions on demographic and work-related information including sex, age, marital status, number of children, type and current year of the residency program, number of shifts by month, and weekly duty hours. The full questionnaire is included in Supporting Information File (S1 File).

To obtain information regarding residents’ perspectives on their programs and mental health, three components were measured using a 28-item Resident Questionnaire (RQ): workload satisfaction scale, learning environment satisfaction scale and emotional distress scale [31,32]. The workload satisfaction scale included 8 items such as call schedule, caseload, excess workload, allocated time for reading, clerical and administrative support, hospital support services, time demands, and workups. The learning environment satisfaction scale comprised 9 items concerning faculty feedback, counseling and support, learning experiences during in-patient rotations and scheduled conferences, instructions received, and cooperation among residents. The emotional distress scale included 11 items addressing feelings of overwhelm anxiety, isolation, self-doubt, and challenges with work-life balance. For all these scales participants provided their level of agreement with each statement on a five-point Likert scale, ranging from “strongly disagree” to “strongly agree”. The interpretation of the questionnaire was, for the work-related components, the higher the scores, the higher satisfaction with the work environment, and for emotional distress, the lower the scores the lower the stress level.

Anxiety was measured using the General Anxiety Disorder 7 (GAD-7), an instrument developed for diagnosing and monitoring the occurrence of anxiety symptoms in respondent’s last two weeks [33]. It is composed of seven items, arranged on a four-point Likert scale, from 0 (never) to 3 (almost every day). Punctuation greater than 10 is interpreted as indicators of anxiety. The instrument also evaluates the severity of anxiety symptoms considering scores below 5 to be the absence of anxiety, mild from five to nine, moderate from 10 to 14, and severe from 15 to 21.

We used the Patient Health Questionnaire (PHQ-9) to measure depression. It is an instrument consisting of nine questions that seek to detect symptoms that indicate a major depressive episode in the general population [34,35]. The nine symptoms consist of depressed mood, anhedonia (loss of interest or pleasure in doing things), problems with sleeping, tiredness, or lack of energy, change in appetite or weight, feelings of guilt or worthlessness, trouble concentrating, feeling sluggish or restless and suicidal thoughts. We evaluated the frequency of each symptom in the last two weeks on a Likert scale from 0 (never) to 3 (almost every day). The PHQ-9 scores were calculated adding the values of each participant response on the Likert scale. The absence or minimal depressive symptoms had scores ranging from 0 to 4; mild from 5 to 9; moderate from 10 to 14; moderately severe from 15 to 19 and severe from 20 to 27.

We assessed social skills using the Multidimensional Scale of Social Expression – Motor Subscale (MSSE-M), an instrument comprising 64 items, each rated on a five-point Likert scale ranging from 0 (never or very rarely) to 4 (always or very often) [36,37]. The MSSE-M is designed to evaluate eight theoretical dimensions of social competence: (1) initiating and maintaining conversations; (2) refusing requests; (3) receiving compliments; (4) speaking in public; (5) expressing positive emotions; (6) expressing negative emotions; (7) expressing disagreement; and (8) asserting one’s rights. For accurate scoring and to correct for response bias, 38 items were reverse-coded (a score of 4 was recorded as 0, 3 as 1, 1 as 3, and 0 as 4, with 2 remaining unchanged). A factor analysis explored the underlying structure of social skills measured by the MSSE-M, performed to derive meaningful subscale scores. This multivariate statistical technique identified latent dimensions (factors) by examining patterns of correlation among the 64 observed items, thereby grouping them into coherent subscales that reflect specific domains of social competence. The analysis resulted in eight factors, consistent with the instrument’s theoretical structure and corresponding to the eight dimensions listed above. Each factor score, also known as a factorial score, represents an individual’s relative proficiency within that specific domain. We computed factorial scores by summing the scores of items loading onto each respective factor, following the reverse coding where applicable. These scores enable a nuanced interpretation of a participant’s social skills repertoire, both overall (through a global score derived from these factors) and within specific social contexts. Higher factorial scores indicate a broader and more effective repertoire of social skills in the respective domain. For the purpose of this study, scores above the mean of the current study’s sample were considered indicative of a satisfactory level of social competence.

Statistical analysis

The minimum sample size for this study was calculated using Epitools [38] for detecting a 40 percentage-point difference in the proportions of general social skills repertoire among residents (e.g., assuming a difference between 10% and 50% prevalence). The calculation assumed a 95% confidence level and 80% statistical power. Under these assumptions, a minimum of 25 participants were required for each of the two major residency program categories (medical/multidisciplinary, and veterinary programs), resulting in a total minimum sample size of 50 residents.

To assure internal reliability of the six questionnaires used in the study, the Cronbach’s α coefficient was calculated for all instruments separately, with a cut-off of 0.80 being determined as acceptable internal reliability ([39]; Table 1).

Multivariable mixed-effects linear regression models were separately built for the three outcomes of interest: emotional distress, anxiety and depression. The social skills total score and the eight factorial scores were included as main explanatory variables of interest. To assess their association and avoid multicollinearity, they were tested in two distinct sets of multivariable models for each outcome, with adjustment for work-related variables (workload and learning environment satisfaction). Additionally, confounders (sex, age, marital status, children, residency program year, type of residency program, shifts per month, and weekly duty) were forced in the models. The conceptual relationship used for visualization of potential confounders are detailed in the causal diagram (Fig 2).

Download:

Fig 2. Conceptual causal diagram of hypothesized relationships.

This diagram illustrates the assumed causal pathways from demographic and organizational exposure confounders to main exposures (social skills, learning environment satisfaction, and workload satisfaction) and mental health outcomes (emotional distress, anxiety, and depression). Arrows represent hypothesized direct causal effects. Specific variables within each conceptual grouping are detailed.

https://doi.org/10.1371/journal.pone.0341773.g002

For model building, the first step was assessing linearity between all continuous variables and the outcomes of interest (separately) with linear smooth plots. When the linearity assumption was not met, the variable was dichotomized at the median (if no data was available to inform the categories) or considering the scores categorization as described in Table 1. Second, univariable mixed-effect models (Table 2) were built for each predictor variable. Variables with a P value ≤ 0.20 in the univariable analysis were eligible to be tested for inclusion in the final multivariable model. Third, the Spearman correlation method was used to check for collinearity between all independent explanatory variables, with a cutoff of 0.80 to determine highly correlated variables.

Download:

Table 2. Results from univariable mixed-effect linear regression models for emotional distress, anxiety, and depression in veterinary and multidisciplinary residents. Statistically significant results and trends are bolded.

https://doi.org/10.1371/journal.pone.0341773.t002

Lastly, we constructed final multivariable mixed-effect linear models. In these models, participants’ institutions were included as a random effect to account for clustering of residents within the same university. We used a manual backwards stepwise approach, starting with all explanatory variables (those with a univariable P ≤ 0.20) and all pre-specified confounding variables (which were forced in the models). Variables were maintained in the final models only if they reached statistical significance (P ≤ 0.05). Additionally, we used the Akaike Information Criterion (AIC) and the Bayesian Information Criterion (BIC) for model selection and comparison, considering the lowest values as a better fit. The normality of residuals was checked using the Best Linear Unbiased Predictors (BLUPs). All analyses were performed using Stata/BE (version 17; StataCorp LLC^®).

Results

Fifty-one residents were enrolled in the study, resunting in a response rate of 11.75%. The lowest response rate was for medical residents (3.75%), followed by multidisciplinary (13.51%) and veterinary residents (52.27%). The mean (±SD) age of residents was 28 years ± 4.92 (range 23–48 years, n = 45). Most participants were female (N = 40, 78.43%), single or not cohabiting with others (N = 40, 78.43%), and with no children (N = 48, 94.12%). Table 3 presents the detailed descriptive analysis of the study participants, including sex, age (n = 45), marital status, children, residency program year, type of residency program, shifts per month, and weekly duty (n = 48). The general prevalence of emotional distress, anxiety, and depression in this study, for the three residency types, was 86.27% (n = 44), 58.82% (n = 30), and 56.86% (n = 29), respectively.

Download:

Table 3. Descriptive analysis of veterinary, medical, and multidisciplinary residents.

https://doi.org/10.1371/journal.pone.0341773.t003

Medical residents presented higher medians of emotional distress, anxiety, and depression when compared with the multidisciplinary and veterinary residents (Fig 3A). However, the multivariate analysis found no significant difference between the mental health conditions examined and type of residency program. Briefly, for the scales presented in Figure 3: higher scores on GAD-7 and PHQ-9 indicate greater anxiety and depression symptoms, respectively (with scores above 10 on both suggesting clinically relevant levels). Conversely, lower scores on the emotional distress scale denote less stress. For social skills (MSSE-M), higher scores reflect a broader repertoire, and scores above the study sample’s mean indicate satisfactory competence (Fig 3B). Higher scores on the workload and learning environment satisfaction scales indicate greater satisfaction.

Download:

Fig 3. A) Scores of mental health issues by type of residency program and B) Total scores of social skills by type of residency program.

https://doi.org/10.1371/journal.pone.0341773.g003

Veterinary residents showed higher scores on “learning environment satisfaction” (65.21%, n = 15), but in contrast, only 21.73% (n = 5) for workload satisfaction. For comparison, medical residents reported 40% (n = 4) for learning environment satisfaction and 40% (n = 4) for workload satisfaction. Multidisciplinary residents reported 44.44% (n = 8) for learning environment satisfaction and 61.11% (n = 11) for workload satisfaction.

Overall, 60.78% (n = 31) of residents presented a “satisfactory” (above average of scores) repertoire of social skills in the total scores. Within the type of residency program, the multidisciplinary residents had the higher total scores of social skills (Fig 3B) and also presented the higher means of workload satisfaction (n = 18, mean 3.17, SD = .40). Among the factorial social skills subscales, “Start and keeping conversations” and “Express positive affect” showed the highest scores across residents of all three programs (Fig 4).

Download:

Fig 4. Total scores of social skills subscales by the type of residency program.

https://doi.org/10.1371/journal.pone.0341773.g004

The final multivariable model (Table 4) for emotional distress retained two significant associated factors: the “ability to defend rights” social skills subscale (score ≥ 13, which showed a protective effect, reducing distress; Coeff. −0.58, 95% CI [−1.08, −0.08], P = .02); and “learning environment satisfaction” (score ≥ 3, where higher satisfaction associated with reduced distress; Coeff. −0.48, 95% CI [−0.77, −0.19], P = < .01). For anxiety and depression, both final models retained the total score for the “social skills” variable (score ≥ 94, where higher social skills scores associated with reduced anxiety and depression; Coeff. −3.14, 95% CI [−6.31, 0.03], P = .05 and Coeff. −3.92, 95% CI [−6.28, −1.57], P = ≤.01, respectively), along with “learning environment satisfaction” (score ≥ 3, where higher satisfaction was associated with reduced anxiety and depression; Coeff. −5.96, 95% CI [−9.20, −2.72], P ≤ .01 for anxiety and Coeff. −5.40, 95% CI [−6.99, −3.82], P ≤ .01 for depression). Additionally, being married (vs. single/does not cohabit) increased anxiety scores by approximately 5 units (Coeff. 4.97, 95% CI [0.47, 9.46], P = .03). Lastly, several demographic variables were significant associated factors for depression in the final multivariable model: identifying as a female (vs. male, associated with increased depression scores; Coeff. 5.49, 95% CI [2.64, 8.34], P = ≤.01), having more than 26 years of age (vs. ≤ 26 years, associated with increased depression scores; Coeff. 2.78, 95% CI [0.29, 5.28], P = .03), having more than one child (vs. none, associated with decreased depression scores; Coeff. −5.72, 95% CI [−10.41, −1.04], P = .02), and doing between one and five shifts per month (vs. none, associated with increased depression scores; Coeff. 3.21, 95% CI [0.39, 6.03], P = .03).

Download:

Table 4. Results from final multivariable mixed-effect linear regression model for emotional distress, anxiety and depression in veterinary and multidisciplinary residents.

https://doi.org/10.1371/journal.pone.0341773.t004

Discussion

We observed a high prevalence of emotional distress (86.27%), anxiety (58.82%), and depression (56.86%) in our results, in line with other studies that analyzed residents [28,40–42]. It is important to contextualize these findings, as the data were collected between August and November 2019, prior to the COVID-19 pandemic. Consequently, these results reflect the pre-pandemic mental health situation of residents and may not be directly comparable to the current, post-COVID context, where professional demands and mental health dynamics have been profoundly transformed [43].

Surprisingly, the type of residency program didn’t show significant differences regarding the mental health issues in the models, but medical residents descriptively presented higher median scores for emotional distress, anxiety, and depression when compared to multidisciplinary and veterinary residents (Fig 3A). The high prevalence of emotional distress and anxiety observed in our sample is in line with international studies, underscoring the systemic and global nature of these stressors [9].

Physicians and veterinarians are professionals that are vulnerably exposed to high levels of stress, anxiety and depression, faced by work stressors such as high levels of responsibility, exposure to death and grieving, and high workload [24,41]. Research has recently explored the mental health of veterinarians since they have higher rates and risk of suicide deaths when compared to the general population and physicians [44–47]. Moral dilemmas, such as legal or financial constraints, veterinarians can specifically face more commonly, forcing them to make difficult clinical decisions such as performing euthanasia, even if other treatment options are available.

The recurring feeling of regret, and avoidance to acknowledge feelings and distress can lead these health professionals to seek relief in drug substances and alcohol [48,49]. In contrast with many studies that have shown the high prevalence of anxiety and depression in veterinary residents, our study’s descriptive findings indicated that medical residents had higher median scores for anxiety and depression when compared to residents from the veterinary residency program. This could be explained by the differences between the three programs regarding the institutional policies, number of shifts per month, workload, and responsibilities.

Descriptive analysis showed that multidisciplinary residents had numerically higher scores for social skills and workload satisfaction compared to medical and veterinary residents. While these differences were not statistically significant in our models, a plausible explanation for the observed trend could be related to the mandatory regulations of this type of residency program, restricting the residents to strictly follow a specific number of shifts per month, and have a workload of 60 hours maximum per week [50]. Other programs, such as some medical residencies in our study, reported varying regulations and higher workloads, with some residents working more than 100 hours per week and doing more than 8 shifts per month.

In the final multivariable models, the significant associated factors with depression were being female, having more than 26 years of age, having more than one child, and doing between one and five shifts per month. Being married increased the anxiety scores significantly when compared to being single, although it has been suggested that being married could have a protective psychological effect [51]. The role of workload is also crucial in resident well-being; for instance, De Mélo Silva Júnior et al. (2022)[40] found that duty-hours were associated with lack of work-life balance and increased anxiety and headache in medical residents. While our multivariable models did not find a significant association between shifts per month and anxiety, our findings for depression highlight the impact of workload as a stressor.

The multivariable models identified the variable “learning environment satisfaction” as an important associated factor for emotional distress, anxiety, and depression. Numerous studies have suggested that a positive and supportive learning environment contributes to residents’ well-being, job satisfaction, performance, quality of resident education, and overall resident’s mental health [2,17,52,53]. Although our models did not find a significant association for workload satisfaction, some studies have highlighted the importance of manageable workload; for example, one study examining physician residents found that increased work hours were associated with depressive symptoms [5]. This indicates that while workload is generally recognized as a factor [40,54], in our study, the perceived satisfaction with the learning environment emerged as a more critical associated factor for mental health outcomes.

Finally, our study found that a good repertoire of social skills played a protective role for emotional distress, anxiety, and depression. Specifically, for emotional distress, the “ability to defend rights” social skills subscale emerged as a significant associated protective factor (Table 4). This finding is particularly noteworthy as it suggests that the capacity for self-advocacy and setting boundaries plays a crucial role in mitigating emotional distress among residents. The ‘ability to defend rights’ encompasses assertiveness, the capacity to express one’s needs, and to stand up for oneself in challenging environments common in residency training, such as high workload or demanding interpersonal interactions [55]. This skill may empower residents to manage stress, avoid burnout, and maintain psychological well-being by allowing them to navigate professional demands more effectively and prevent situations that could otherwise lead to distress [56]. For depression, higher overall social skills scores were significantly protective (P ≤ .01). For anxiety, this protective association was also observed, reaching the threshold of statistical significance (P = .05), aligning with other studies [24] that suggest a broader repertoire of social competencies reduces emotional exhaustion and promotes mental health. These abilities are closely linked to effective communication, assertiveness, and positive emotions, thereby contributing to the creation of a supportive and psychologically healthy environment for residents [57].

Studies have shown the expression of positive affect to be closely related to experiencing pleasurable emotions, such as feelings of satisfaction, achievement, motivation, and desire for social connection [58]. In line with our findings, Dominguez-Espinosa et al. (2022)[58] emphasized the importance of cultivating a culture of gratitude and appreciation among colleagues to address the reported lack of positive affect. Therefore, incorporating social skills training into educational programs can be beneficial for resident doctors, as suggested by Yutani et al., (2016)[59], and could possibly be extrapolated to the other disciplines. By enhancing their social skills to navigate challenging situations, residents can improve their ability to provide high-quality medical care, reduce stress levels, and safeguard their mental health [59,60].

Strengths and limitations

This study offers several notable strengths. To the best of our knowledge, it is the first to assess the association between social skills, emotional distress, anxiety, and depression specifically within Brazilian medical, multidisciplinary, and veterinary residents. Our findings provide valuable insights into the mental health of residents, examining their relationship with social skills and various work-related factors. A unique contribution of this study is the comparative analysis across these three distinct categories of health professionals, which allows for a nuanced understanding of their differing mental health profiles. By investigating these diverse residency programs, we identified potential risk factors for stress, anxiety, and depression, thereby offering a comprehensive perspective on these prevalent issues. Furthermore, our research highlights the crucial role of social skills and satisfaction with the learning environment in promoting the mental well-being of medical, multidisciplinary, and veterinary residents, enriching broader discussions on resident wellness. Finally, the application of multivariable analysis, carefully accounting for demographic variables as potential confounders, enhanced the reliability and accuracy of our findings. This robust modeling approach strengthened the validity of the study by mitigating bias and providing a clearer understanding of the relationships between the exposure and outcome variables of interest.

Despite these strengths, it is essential to acknowledge the study’s limitations. Firstly, the relatively modest sample size and the inclusion of only a small proportion of Brazilian medical, multidisciplinary, and veterinary residents necessitates careful consideration when generalizing the findings to broader resident populations. Crucially, the reliance on a convenience sampling strategy coupled with a notably low response rate (11.75%) poses significant limitations to the external validity and generalizability of the findings. This methodological approach introduces an inherent risk of selection bias, as participants were not randomly selected and those who chose to respond may differ systematically from non-respondents. Consequently, the representativeness of the sample relative to the broader population of health residency professionals in Brazil is limited, particularly due to the lack of national geographical representation, as participants were drawn from only five institutions. Likewise, the majority of our respondents were females, which may have impacted study findings. These factors should be carefully weighed during the interpretation of the results. It is also important to acknowledge that only five institutions were used as random effects, which may produce unstable model estimates.

Secondly, recruiting participants exclusively online may have further discouraged response rates. Residents might have been hesitant to participate due to the questionnaire’s length and the sensitive nature of the topic, as previous studies indicate that online surveys are generally associated with lower participation rates compared to mail or in-person questionnaires [61–63]. While efforts were made to address potential response bias, alternative data collection methods were not feasible given the geographical distribution of the five participating institutions.

Thirdly, a limitation of this study is the absence of data on participants’ socioeconomic conditions or their access to formal psychosocial support mechanisms. Such variables could serve as important confounders or mediators of mental health outcomes and their omission may limit a comprehensive understanding of the observed associations. Lastly, the use of a cross-sectional design limits our ability to establish causal relationships among the variables, only allowing for the identification of associations. It is also important to note that using a causal diagram and univariable analysis as a screening approach represents only one possible strategy for analyzing the data. Future work could explore and compare alternative exploratory techniques to assess variables to investigate whether they yield additional insights.

Conclusions

This study highlights the association between social skills and mental health concerns among Brazilian medical, multidisciplinary, and veterinary residents, while considering demographic and work-related satisfaction variables. Our findings reveal a high prevalence of mental health issues among residents in these programs, with learning environment satisfaction emerging as a significant associated factor in the final multivariable analysis for all three programs. Notably, a strong repertoire of social skills, particularly in overall scores, exhibited a protective association against mental health issues, confirming our initial hypothesis. These results emphasize the importance of incorporating social skills training within residency programs, specifically focusing on assertiveness, as exemplified by the ability to defend rights and express positive affect, to safeguard residents’ mental health. Furthermore, we recommend fostering a supportive learning environment and promoting the training of social skills, especially the abilities of communication and assertiveness, during residency programs as a routine tool for mental health promotion and safe work environment for residents in training. Based on these insights, it is also important to consider the development of institutional policies aimed at promoting social skills and overall well-being in residency settings. For future research, longitudinal studies would be valuable to further explore these relationships and establish causal effects.

Supporting information

S1 File. Complete study questionnaire and validated instrument scales.

https://doi.org/10.1371/journal.pone.0341773.s001

(DOCX)

Acknowledgments

We thank the medical, multidisciplinary, and veterinary residency programs that authorized data collection and all the residents who voluntarily participated in this study. We are also grateful to the research support teams and institutional review boards that assisted with the administrative and ethical aspects of the project.

References

1. Rosa SD, Lopes RE. Residência multiprofissional em saúde e pós-graduação lato sensu no Brasil: apontamentos históricos. Trab educ saúde. 2009;7(3):479–98.
- View Article
- Google Scholar
2. Weiss KB, Bagian JP, Nasca TJ. The clinical learning environment: the foundation of graduate medical education. JAMA. 2013;309(16):1687–8. pmid:23613072
- View Article
- PubMed/NCBI
- Google Scholar
3. Furr MO, Raczkoski BM. A decision-tree model of career choice for veterinarians in clinical residency programs. J Am Vet Med Assoc. 2022;260(5):549–58. pmid:34986122
- View Article
- PubMed/NCBI
- Google Scholar
4. Gupta S, Higgins S, Torre D. Wellbeing and burnout in residency. J Gen Intern Med. 2022;37(9):2137–8. pmid:35606642
- View Article
- PubMed/NCBI
- Google Scholar
5. Pereira-Lima K, Gupta RR, Guille C, Sen S. Residency program factors associated with depressive symptoms in internal medicine interns: A prospective cohort study. Acad Med. 2019;94(6):869–75. pmid:30570500
- View Article
- PubMed/NCBI
- Google Scholar
6. Fried EI, Nesse RM, Guille C, Sen S. The differential influence of life stress on individual symptoms of depression. Acta Psychiatr Scand. 2015;131(6):465–71. pmid:25650176
- View Article
- PubMed/NCBI
- Google Scholar
7. Jaworski JL, Thompson LA, Weng H-Y. Quality of life of veterinary residents in AVMA-Recognized Veterinary Specialty Organizations using the WHOQOL-BREF instrument. PLoS One. 2022;17(5):e0268343. pmid:35551334
- View Article
- PubMed/NCBI
- Google Scholar
8. Sen S, Kranzler HR, Krystal JH, Speller H, Chan G, Gelernter J, et al. A prospective cohort study investigating factors associated with depression during medical internship. Arch Gen Psychiatry. 2010;67(6):557–65. pmid:20368500
- View Article
- PubMed/NCBI
- Google Scholar
9. Obeng Nkrumah S, Adu MK, Agyapong B, da Luz Dias R, Agyapong VIO. Prevalence and correlates of depression, anxiety, and burnout among physicians and postgraduate medical trainees: a scoping review of recent literature. Front Public Health. 2025;13:1537108. pmid:40697832
- View Article
- PubMed/NCBI
- Google Scholar
10. McPhetridge JB, Scharf VF, Dickson R, Thieman KM, Oblak ML, Regier PJ, et al. Veterinary house officer perceptions of dimensions of well-being during postgraduate training. J Am Vet Med Assoc. 2022;260(11):1369–76. pmid:35429376
- View Article
- PubMed/NCBI
- Google Scholar
11. Monticelli P, Seymour C, Adami C. Risk of burnout and depression: A survey of veterinary anaesthesia specialists in-training during COVID-19. Vet Anaesth Analg. 2023;50(4):325–32. pmid:37179142
- View Article
- PubMed/NCBI
- Google Scholar
12. Guille C, Clark S, Amstadter AB, Sen S. Trajectories of depressive symptoms in response to prolonged stress in medical interns. Acta Psychiatr Scand. 2014;129(2):109–15. pmid:23581856
- View Article
- PubMed/NCBI
- Google Scholar
13. Grant F, Guille C, Sen S. Well-being and the risk of depression under stress. PLoS One. 2013;8(7):e67395. pmid:23840872
- View Article
- PubMed/NCBI
- Google Scholar
14. de Oliveira GS, Chang R, Fitzgerald PC, Almeida MD, Castro-Alves LS, Ahmad S, et al. The prevalence of burnout and depression and their association with adherence to safety and practice standards: A survey of United States anesthesiology trainees. Anesth Analg. 2013;117(1):182–93. pmid:23687232
- View Article
- PubMed/NCBI
- Google Scholar
15. Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW, et al. Rates of medication errors among depressed and burnt out residents: Prospective cohort study. BMJ. 2008;336(7642):488–91. pmid:18258931
- View Article
- PubMed/NCBI
- Google Scholar
16. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294–300. pmid:19773564
- View Article
- PubMed/NCBI
- Google Scholar
17. Jennings ML, Slavin SJ. Resident wellness matters: Optimizing resident education and wellness through the learning environment. Acad Med. 2015;90(9):1246–50. pmid:26177527
- View Article
- PubMed/NCBI
- Google Scholar
18. Nasca TJ, Weiss KB, Bagian JP. Improving clinical learning environments for tomorrow’s physicians. N Engl J Med. 2014;370(11):991–3. pmid:24467307
- View Article
- PubMed/NCBI
- Google Scholar
19. Li J, Weigl M, Glaser J, Petru R, Siegrist J, Angerer P. Changes in psychosocial work environment and depressive symptoms: A prospective study in junior physicians. Am J Ind Med. 2013;56(12):1414–22. pmid:24038041
- View Article
- PubMed/NCBI
- Google Scholar
20. Sakata Y, Wada K, Tsutsumi A, Ishikawa H, Aratake Y, Watanabe M, et al. Effort-reward imbalance and depression in Japanese medical residents. J Occup Health. 2008;50(6):498–504. pmid:18946190
- View Article
- PubMed/NCBI
- Google Scholar
21. Weigl M, Hornung S, Petru R, Glaser J, Angerer P. Depressive symptoms in junior doctors: A follow-up study on work-related determinants. Int Arch Occup Environ Health. 2012;85(5):559–70. pmid:21956449
- View Article
- PubMed/NCBI
- Google Scholar
22. Wilson AN, Dow E, Hanami D, Vasa M, Billimek J. Encouraging mental health care in family medicine residents. PRiMER. 2022;6:24. pmid:36119905
- View Article
- PubMed/NCBI
- Google Scholar
23. Duijn C, Bok H, ten Cate O, Kremer W. Qualified but not yet fully competent: Perceptions of recent veterinary graduates on their day‐one skills. Veterinary Record. 2020;186(7):216–216.
- View Article
- Google Scholar
24. Pereira-Lima K, Loureiro SR. Burnout, anxiety, depression, and social skills in medical residents. Psychol Health Med. 2015;20(3):353–62. pmid:25030412
- View Article
- PubMed/NCBI
- Google Scholar
25. Treister-Goltzman Y, Samson T, Rosenberg R, Granek-Catarivas M, Gaver A, Alperin M, et al. Burnout among family medicine residents: A cross-sectional nationwide study. Isr J Health Policy Res. 2024;13(1):5. pmid:38279151
- View Article
- PubMed/NCBI
- Google Scholar
26. Barfield AD, Adamantos S. Looking after interns and residents. Veterinary Record. 2019;184:99–100.
- View Article
- Google Scholar
27. Rodrigues H, Cobucci R, Oliveira A, Cabral JV, Medeiros L, Gurgel K, et al. Burnout syndrome among medical residents: A systematic review and meta-analysis. PLoS One. 2018;13(11):e0206840. pmid:30418984
- View Article
- PubMed/NCBI
- Google Scholar
28. Rotta DS, Pinto MH, Lourenção LG, Teixeira PR, Gonsalez EG, Gazetta CE. Anxiety and depression levels among multidisciplinary health residents. Rev Rene. 2016;17(3):372.
- View Article
- Google Scholar
29. Cheade M de FM, Frota OP, Loureiro MDR, Quintanilha ACF. Residência multiprofissional em saúde: A busca pela integralidade. Cogitare Enferm. 2013;18(3).
- View Article
- Google Scholar
30. Guido L de A, Goulart CT, da Silva RM, Lopes LFD, Ferreira EM. Stress and burnout among multidisciplinary residents. Rev Lat Am Enfermagem. 2012;20(6):1064–71. pmid:23258719
- View Article
- PubMed/NCBI
- Google Scholar
31. Pereira-Lima K, Silva-Rodrigues APC, Marucci FAF, Osório F de L, Crippa JA, Loureiro SR. Cross-cultural adaptation and psychometric assessment of a Brazilian-Portuguese version of the Resident Questionnaire. PLoS One. 2018;13(9):e0203531. pmid:30180216
- View Article
- PubMed/NCBI
- Google Scholar
32. Seelig CB, DuPre CT, Adelman HM. Development and validation of a scaled questionnaire for evaluation of residency programs. South Med J. 1995;88(7):745–50. pmid:7597480
- View Article
- PubMed/NCBI
- Google Scholar
33. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7. pmid:16717171
- View Article
- PubMed/NCBI
- Google Scholar
34. Santos IS, Tavares BF, Munhoz TN, Almeida LSP, Silva NTB, Tams BD, et al. Sensibilidade e especificidade do Patient Health Questionnaire-9 (PHQ-9) entre adultos da população geral. Cad Saúde Pública. 2013;29(8):1533–43.
- View Article
- Google Scholar
35. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13. pmid:11556941
- View Article
- PubMed/NCBI
- Google Scholar
36. Caballo VE. La multidimensionalidad conductual de habilidades sociales: Propiedades psicométricas de una medida de autoinforme, la EMES-M. Psicologia Conductual. 1993;1:221–31.
- View Article
- Google Scholar
37. Pereira AS, Dutra-Thomé L, Koller SH. Propriedades psicométricas da escala multidimensional de expressão social -parte motora (EMES-M) em uma amostra brasileira. Aval Psicol. 2017;17(01).
- View Article
- Google Scholar
38. Sergeant ESG. Epitools Epidemiological Calculators. Australia: Ausvet; 2018.
39. Gliem JA, Gliem RR. Calculating, interpreting, and reporting Cronbach’s alpha reliability coefficient for Likert type scales. Columbus, Ohio: The Ohio State University. 2003. https://hdl.handle.net/1805/344
40. de Mélo Silva Júnior ML, Valença MM, Rocha-Filho PAS. Individual and residency program factors related to depression, anxiety and burnout in physician residents - a Brazilian survey. BMC Psychiatry. 2022;22(1):272. pmid:35436910
- View Article
- PubMed/NCBI
- Google Scholar
41. Golob A, Beste LA, Stern M, Johnson K. Emotional distress among physician residents and fellows: An observational study of trainees seeking counseling visits. Acad Psychiatry. 2018;42(1):25–30. pmid:28608232
- View Article
- PubMed/NCBI
- Google Scholar
42. Raimo J, LaVine S, Spielmann K, Akerman M, Friedman KA, Katona K, et al. The correlation of stress in residency with future stress and burnout: A 10-year prospective cohort study. J Grad Med Educ. 2018;10(5):524–31. pmid:30386477
- View Article
- PubMed/NCBI
- Google Scholar
43. Caminiti M, Mercogliano M, Cussotto F, Briganti GL, Genovese D, Priano W, et al. Study protocol for the residents’ mental health investigation, a dynamic longitudinal study in Italy (ReMInDIt). Healthcare (Basel). 2024;12(10):1020. pmid:38786430
- View Article
- PubMed/NCBI
- Google Scholar
44. Glaesmer H, Bahramsoltani M, Schwerdtfeger K, Spangenberg L. Euthanasia distress and fearlessness about death in german veterinarians. Crisis. 2021;42(1):71–7. pmid:32431195
- View Article
- PubMed/NCBI
- Google Scholar
45. Milner AJ, Niven H, Page K, LaMontagne AD. Suicide in veterinarians and veterinary nurses in Australia: 2001-2012. Aust Vet J. 2015;93(9):308–10. pmid:26313208
- View Article
- PubMed/NCBI
- Google Scholar
46. Kelly JE. Notes From the Field. The Historian. 2019;81(2):209–12.
- View Article
- Google Scholar
47. Tomasi SE, Fechter-Leggett ED, Edwards NT, Reddish AD, Crosby AE, Nett RJ. Suicide among veterinarians in the United States from 1979 through 2015. J Am Vet Med Assoc. 2019;254(1):104–12. pmid:30668293
- View Article
- PubMed/NCBI
- Google Scholar
48. Blum NR. Professional development groups help physicians; why not veterinarians?. J Am Vet Med Assoc. 2018;253(6):704–8. pmid:30179098
- View Article
- PubMed/NCBI
- Google Scholar
49. Dalum HS, Tyssen R, Hem E. Prevalence and individual and work-related factors associated with suicidal thoughts and behaviours among veterinarians in Norway: A cross-sectional, nationwide survey-based study (the NORVET study). BMJ Open. 2022;12(1):e055827. pmid:34980627
- View Article
- PubMed/NCBI
- Google Scholar
50. Secretaria de Educação Superior. Resolução Comissão Nacional de Residência Multiprofissional em Saúde. 2012. http://portal.mec.gov.br/index.php?option=com_docman&view=download&alias=15448-resol-cnrms-n2-13abril-2012&Itemid=30192
- View Article
- Google Scholar
51. Perret JL, Best CO, Coe JB, Greer AL, Khosa DK, Jones-Bitton A. Association of demographic, career, and lifestyle factors with resilience and association of resilience with mental health outcomes in veterinarians in Canada. J Am Vet Med Assoc. 2020;257(10):1057–68. pmid:33135980
- View Article
- PubMed/NCBI
- Google Scholar
52. Pelzer JM, Hodgson JL, Werre SR. Veterinary students’ perceptions of their learning environment as measured by the Dundee Ready Education Environment Measure. BMC Res Notes. 2014;7:170. pmid:24661621
- View Article
- PubMed/NCBI
- Google Scholar
53. Quansah F, Hagan JE, Sambah F, Frimpong JB, Ankomah F, Srem-Sai M, et al. Perceived safety of learning environment and associated anxiety factors during COVID-19 in Ghana: Evidence from physical education practical-oriented program. Eur J Investig Health Psychol Educ. 2022;12(1):28–41. pmid:35049532
- View Article
- PubMed/NCBI
- Google Scholar
54. Pohl R, Botscharow J, Böckelmann I, Thielmann B. Stress and strain among veterinarians: A scoping review. Ir Vet J. 2022;75(1):15. pmid:35729648
- View Article
- PubMed/NCBI
- Google Scholar
55. Gutgeld-Dror M, Laor N, Karnieli-Miller O. Assertiveness in physicians’ interpersonal professional encounters: A scoping review. Med Educ. 2024;58(4):392–404. pmid:37725417
- View Article
- PubMed/NCBI
- Google Scholar
56. Ghannam J, Afana A, Ho EY, Al-Khal A, Bylund CL. The impact of a stress management intervention on medical residents’ stress and burnout. International Journal of Stress Management. 2020;27(1):65–73.
- View Article
- Google Scholar
57. R K, Sujathamalini J, Gunasekaran K, Pandimeenal A. Correlation study on assertiveness and empathy among young adults. Int J Psychol Res. 2025;7(1):45–8.
- View Article
- Google Scholar
58. Dominguez-Espinosa ADC, Montes de Oca-Mayagoitia SI, Sáez-Jiménez AP, de la Fuente-Zepeda J, Monroy Ramírez de Arellano L. The moderating role of sociodemographic and work-related variables in burnout and mental health levels of Mexican medical residents. PLoS One. 2022;17(9):e0274322. pmid:36112642
- View Article
- PubMed/NCBI
- Google Scholar
59. Yutani M, Takahashi M, Takizawa T, Miyaoka H. Social skills training improves clinical residents’ communication skills. Kitasato Medical Journal. 2016;1:53–9.
- View Article
- Google Scholar
60. Mueser KT, Bellack AS. Social skills training: Alive and well?. Journal of Mental Health. 2007;16(5):549–52.
- View Article
- Google Scholar
61. Suppan M, Suppan L, Beckmann TS, Samer CF, Savoldelli GL. Enhancing response rates in web-based surveys: The impact of direct participant contact. Healthcare (Basel). 2024;12(14):1439. pmid:39057582
- View Article
- PubMed/NCBI
- Google Scholar
62. Daikeler J, Bošnjak M, Lozar Manfreda K. Web versus other survey modes: An Updated and extended meta-analysis comparing response rates. Journal of Survey Statistics and Methodology. 2019;8(3):513–39.
- View Article
- Google Scholar
63. Zhang X, Kuchinke L, Woud ML, Velten J, Margraf J. Survey method matters: Online/offline questionnaires and face-to-face or telephone interviews differ. Computers in Human Behavior. 2017;71:172–80.
- View Article
- Google Scholar

[ref1] 1. Rosa SD, Lopes RE. Residência multiprofissional em saúde e pós-graduação lato sensu no Brasil: apontamentos históricos. Trab educ saúde. 2009;7(3):479–98.
View Article
Google Scholar

[2] View Article

[3] Google Scholar

[ref2] 2. Weiss KB, Bagian JP, Nasca TJ. The clinical learning environment: the foundation of graduate medical education. JAMA. 2013;309(16):1687–8. pmid:23613072
View Article
PubMed/NCBI
Google Scholar

[5] View Article

[6] PubMed/NCBI

[7] Google Scholar

[ref3] 3. Furr MO, Raczkoski BM. A decision-tree model of career choice for veterinarians in clinical residency programs. J Am Vet Med Assoc. 2022;260(5):549–58. pmid:34986122
View Article
PubMed/NCBI
Google Scholar

[9] View Article

[10] PubMed/NCBI

[11] Google Scholar

[ref4] 4. Gupta S, Higgins S, Torre D. Wellbeing and burnout in residency. J Gen Intern Med. 2022;37(9):2137–8. pmid:35606642
View Article
PubMed/NCBI
Google Scholar

[13] View Article

[14] PubMed/NCBI

[15] Google Scholar

[ref5] 5. Pereira-Lima K, Gupta RR, Guille C, Sen S. Residency program factors associated with depressive symptoms in internal medicine interns: A prospective cohort study. Acad Med. 2019;94(6):869–75. pmid:30570500
View Article
PubMed/NCBI
Google Scholar

[17] View Article

[18] PubMed/NCBI

[19] Google Scholar

[ref6] 6. Fried EI, Nesse RM, Guille C, Sen S. The differential influence of life stress on individual symptoms of depression. Acta Psychiatr Scand. 2015;131(6):465–71. pmid:25650176
View Article
PubMed/NCBI
Google Scholar

[21] View Article

[22] PubMed/NCBI

[23] Google Scholar

[ref7] 7. Jaworski JL, Thompson LA, Weng H-Y. Quality of life of veterinary residents in AVMA-Recognized Veterinary Specialty Organizations using the WHOQOL-BREF instrument. PLoS One. 2022;17(5):e0268343. pmid:35551334
View Article
PubMed/NCBI
Google Scholar

[25] View Article

[26] PubMed/NCBI

[27] Google Scholar

[ref8] 8. Sen S, Kranzler HR, Krystal JH, Speller H, Chan G, Gelernter J, et al. A prospective cohort study investigating factors associated with depression during medical internship. Arch Gen Psychiatry. 2010;67(6):557–65. pmid:20368500
View Article
PubMed/NCBI
Google Scholar

[29] View Article

[30] PubMed/NCBI

[31] Google Scholar

[ref9] 9. Obeng Nkrumah S, Adu MK, Agyapong B, da Luz Dias R, Agyapong VIO. Prevalence and correlates of depression, anxiety, and burnout among physicians and postgraduate medical trainees: a scoping review of recent literature. Front Public Health. 2025;13:1537108. pmid:40697832
View Article
PubMed/NCBI
Google Scholar

[33] View Article

[34] PubMed/NCBI

[35] Google Scholar

[ref10] 10. McPhetridge JB, Scharf VF, Dickson R, Thieman KM, Oblak ML, Regier PJ, et al. Veterinary house officer perceptions of dimensions of well-being during postgraduate training. J Am Vet Med Assoc. 2022;260(11):1369–76. pmid:35429376
View Article
PubMed/NCBI
Google Scholar

[37] View Article

[38] PubMed/NCBI

[39] Google Scholar

[ref11] 11. Monticelli P, Seymour C, Adami C. Risk of burnout and depression: A survey of veterinary anaesthesia specialists in-training during COVID-19. Vet Anaesth Analg. 2023;50(4):325–32. pmid:37179142
View Article
PubMed/NCBI
Google Scholar

[41] View Article

[42] PubMed/NCBI

[43] Google Scholar

[ref12] 12. Guille C, Clark S, Amstadter AB, Sen S. Trajectories of depressive symptoms in response to prolonged stress in medical interns. Acta Psychiatr Scand. 2014;129(2):109–15. pmid:23581856
View Article
PubMed/NCBI
Google Scholar

[45] View Article

[46] PubMed/NCBI

[47] Google Scholar

[ref13] 13. Grant F, Guille C, Sen S. Well-being and the risk of depression under stress. PLoS One. 2013;8(7):e67395. pmid:23840872
View Article
PubMed/NCBI
Google Scholar

[49] View Article

[50] PubMed/NCBI

[51] Google Scholar

[ref14] 14. de Oliveira GS, Chang R, Fitzgerald PC, Almeida MD, Castro-Alves LS, Ahmad S, et al. The prevalence of burnout and depression and their association with adherence to safety and practice standards: A survey of United States anesthesiology trainees. Anesth Analg. 2013;117(1):182–93. pmid:23687232
View Article
PubMed/NCBI
Google Scholar

[53] View Article

[54] PubMed/NCBI

[55] Google Scholar

[ref15] 15. Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW, et al. Rates of medication errors among depressed and burnt out residents: Prospective cohort study. BMJ. 2008;336(7642):488–91. pmid:18258931
View Article
PubMed/NCBI
Google Scholar

[57] View Article

[58] PubMed/NCBI

[59] Google Scholar

[ref16] 16. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294–300. pmid:19773564
View Article
PubMed/NCBI
Google Scholar

[61] View Article

[62] PubMed/NCBI

[63] Google Scholar

[ref17] 17. Jennings ML, Slavin SJ. Resident wellness matters: Optimizing resident education and wellness through the learning environment. Acad Med. 2015;90(9):1246–50. pmid:26177527
View Article
PubMed/NCBI
Google Scholar

[65] View Article

[66] PubMed/NCBI

[67] Google Scholar

[ref18] 18. Nasca TJ, Weiss KB, Bagian JP. Improving clinical learning environments for tomorrow’s physicians. N Engl J Med. 2014;370(11):991–3. pmid:24467307
View Article
PubMed/NCBI
Google Scholar

[69] View Article

[70] PubMed/NCBI

[71] Google Scholar

[ref19] 19. Li J, Weigl M, Glaser J, Petru R, Siegrist J, Angerer P. Changes in psychosocial work environment and depressive symptoms: A prospective study in junior physicians. Am J Ind Med. 2013;56(12):1414–22. pmid:24038041
View Article
PubMed/NCBI
Google Scholar

[73] View Article

[74] PubMed/NCBI

[75] Google Scholar

[ref20] 20. Sakata Y, Wada K, Tsutsumi A, Ishikawa H, Aratake Y, Watanabe M, et al. Effort-reward imbalance and depression in Japanese medical residents. J Occup Health. 2008;50(6):498–504. pmid:18946190
View Article
PubMed/NCBI
Google Scholar

[77] View Article

[78] PubMed/NCBI

[79] Google Scholar

[ref21] 21. Weigl M, Hornung S, Petru R, Glaser J, Angerer P. Depressive symptoms in junior doctors: A follow-up study on work-related determinants. Int Arch Occup Environ Health. 2012;85(5):559–70. pmid:21956449
View Article
PubMed/NCBI
Google Scholar

[81] View Article

[82] PubMed/NCBI

[83] Google Scholar

[ref22] 22. Wilson AN, Dow E, Hanami D, Vasa M, Billimek J. Encouraging mental health care in family medicine residents. PRiMER. 2022;6:24. pmid:36119905
View Article
PubMed/NCBI
Google Scholar

[85] View Article

[86] PubMed/NCBI

[87] Google Scholar

[ref23] 23. Duijn C, Bok H, ten Cate O, Kremer W. Qualified but not yet fully competent: Perceptions of recent veterinary graduates on their day‐one skills. Veterinary Record. 2020;186(7):216–216.
View Article
Google Scholar

[89] View Article

[90] Google Scholar

[ref24] 24. Pereira-Lima K, Loureiro SR. Burnout, anxiety, depression, and social skills in medical residents. Psychol Health Med. 2015;20(3):353–62. pmid:25030412
View Article
PubMed/NCBI
Google Scholar

[92] View Article

[93] PubMed/NCBI

[94] Google Scholar

[ref25] 25. Treister-Goltzman Y, Samson T, Rosenberg R, Granek-Catarivas M, Gaver A, Alperin M, et al. Burnout among family medicine residents: A cross-sectional nationwide study. Isr J Health Policy Res. 2024;13(1):5. pmid:38279151
View Article
PubMed/NCBI
Google Scholar

[96] View Article

[97] PubMed/NCBI

[98] Google Scholar

[ref26] 26. Barfield AD, Adamantos S. Looking after interns and residents. Veterinary Record. 2019;184:99–100.
View Article
Google Scholar

[100] View Article

[101] Google Scholar

[ref27] 27. Rodrigues H, Cobucci R, Oliveira A, Cabral JV, Medeiros L, Gurgel K, et al. Burnout syndrome among medical residents: A systematic review and meta-analysis. PLoS One. 2018;13(11):e0206840. pmid:30418984
View Article
PubMed/NCBI
Google Scholar

[103] View Article

[104] PubMed/NCBI

[105] Google Scholar

[ref28] 28. Rotta DS, Pinto MH, Lourenção LG, Teixeira PR, Gonsalez EG, Gazetta CE. Anxiety and depression levels among multidisciplinary health residents. Rev Rene. 2016;17(3):372.
View Article
Google Scholar

[107] View Article

[108] Google Scholar

[ref29] 29. Cheade M de FM, Frota OP, Loureiro MDR, Quintanilha ACF. Residência multiprofissional em saúde: A busca pela integralidade. Cogitare Enferm. 2013;18(3).
View Article
Google Scholar

[110] View Article

[111] Google Scholar

[ref30] 30. Guido L de A, Goulart CT, da Silva RM, Lopes LFD, Ferreira EM. Stress and burnout among multidisciplinary residents. Rev Lat Am Enfermagem. 2012;20(6):1064–71. pmid:23258719
View Article
PubMed/NCBI
Google Scholar

[113] View Article

[114] PubMed/NCBI

[115] Google Scholar

[ref31] 31. Pereira-Lima K, Silva-Rodrigues APC, Marucci FAF, Osório F de L, Crippa JA, Loureiro SR. Cross-cultural adaptation and psychometric assessment of a Brazilian-Portuguese version of the Resident Questionnaire. PLoS One. 2018;13(9):e0203531. pmid:30180216
View Article
PubMed/NCBI
Google Scholar

[117] View Article

[118] PubMed/NCBI

[119] Google Scholar

[ref32] 32. Seelig CB, DuPre CT, Adelman HM. Development and validation of a scaled questionnaire for evaluation of residency programs. South Med J. 1995;88(7):745–50. pmid:7597480
View Article
PubMed/NCBI
Google Scholar

[121] View Article

[122] PubMed/NCBI

[123] Google Scholar

[ref33] 33. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7. pmid:16717171
View Article
PubMed/NCBI
Google Scholar

[125] View Article

[126] PubMed/NCBI

[127] Google Scholar

[ref34] 34. Santos IS, Tavares BF, Munhoz TN, Almeida LSP, Silva NTB, Tams BD, et al. Sensibilidade e especificidade do Patient Health Questionnaire-9 (PHQ-9) entre adultos da população geral. Cad Saúde Pública. 2013;29(8):1533–43.
View Article
Google Scholar

[129] View Article

[130] Google Scholar

[ref35] 35. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13. pmid:11556941
View Article
PubMed/NCBI
Google Scholar

[132] View Article

[133] PubMed/NCBI

[134] Google Scholar

[ref36] 36. Caballo VE. La multidimensionalidad conductual de habilidades sociales: Propiedades psicométricas de una medida de autoinforme, la EMES-M. Psicologia Conductual. 1993;1:221–31.
View Article
Google Scholar

[136] View Article

[137] Google Scholar

[ref37] 37. Pereira AS, Dutra-Thomé L, Koller SH. Propriedades psicométricas da escala multidimensional de expressão social -parte motora (EMES-M) em uma amostra brasileira. Aval Psicol. 2017;17(01).
View Article
Google Scholar

[139] View Article

[140] Google Scholar

[ref38] 38. Sergeant ESG. Epitools Epidemiological Calculators. Australia: Ausvet; 2018.

[ref39] 39. Gliem JA, Gliem RR. Calculating, interpreting, and reporting Cronbach’s alpha reliability coefficient for Likert type scales. Columbus, Ohio: The Ohio State University. 2003. https://hdl.handle.net/1805/344

[ref40] 40. de Mélo Silva Júnior ML, Valença MM, Rocha-Filho PAS. Individual and residency program factors related to depression, anxiety and burnout in physician residents - a Brazilian survey. BMC Psychiatry. 2022;22(1):272. pmid:35436910
View Article
PubMed/NCBI
Google Scholar

[144] View Article

[145] PubMed/NCBI

[146] Google Scholar

[ref41] 41. Golob A, Beste LA, Stern M, Johnson K. Emotional distress among physician residents and fellows: An observational study of trainees seeking counseling visits. Acad Psychiatry. 2018;42(1):25–30. pmid:28608232
View Article
PubMed/NCBI
Google Scholar

[148] View Article

[149] PubMed/NCBI

[150] Google Scholar

[ref42] 42. Raimo J, LaVine S, Spielmann K, Akerman M, Friedman KA, Katona K, et al. The correlation of stress in residency with future stress and burnout: A 10-year prospective cohort study. J Grad Med Educ. 2018;10(5):524–31. pmid:30386477
View Article
PubMed/NCBI
Google Scholar

[152] View Article

[153] PubMed/NCBI

[154] Google Scholar

[ref43] 43. Caminiti M, Mercogliano M, Cussotto F, Briganti GL, Genovese D, Priano W, et al. Study protocol for the residents’ mental health investigation, a dynamic longitudinal study in Italy (ReMInDIt). Healthcare (Basel). 2024;12(10):1020. pmid:38786430
View Article
PubMed/NCBI
Google Scholar

[156] View Article

[157] PubMed/NCBI

[158] Google Scholar

[ref44] 44. Glaesmer H, Bahramsoltani M, Schwerdtfeger K, Spangenberg L. Euthanasia distress and fearlessness about death in german veterinarians. Crisis. 2021;42(1):71–7. pmid:32431195
View Article
PubMed/NCBI
Google Scholar

[160] View Article

[161] PubMed/NCBI

[162] Google Scholar

[ref45] 45. Milner AJ, Niven H, Page K, LaMontagne AD. Suicide in veterinarians and veterinary nurses in Australia: 2001-2012. Aust Vet J. 2015;93(9):308–10. pmid:26313208
View Article
PubMed/NCBI
Google Scholar

[164] View Article

[165] PubMed/NCBI

[166] Google Scholar

[ref46] 46. Kelly JE. Notes From the Field. The Historian. 2019;81(2):209–12.
View Article
Google Scholar

[168] View Article

[169] Google Scholar

[ref47] 47. Tomasi SE, Fechter-Leggett ED, Edwards NT, Reddish AD, Crosby AE, Nett RJ. Suicide among veterinarians in the United States from 1979 through 2015. J Am Vet Med Assoc. 2019;254(1):104–12. pmid:30668293
View Article
PubMed/NCBI
Google Scholar

[171] View Article

[172] PubMed/NCBI

[173] Google Scholar

[ref48] 48. Blum NR. Professional development groups help physicians; why not veterinarians?. J Am Vet Med Assoc. 2018;253(6):704–8. pmid:30179098
View Article
PubMed/NCBI
Google Scholar

[175] View Article

[176] PubMed/NCBI

[177] Google Scholar

[ref49] 49. Dalum HS, Tyssen R, Hem E. Prevalence and individual and work-related factors associated with suicidal thoughts and behaviours among veterinarians in Norway: A cross-sectional, nationwide survey-based study (the NORVET study). BMJ Open. 2022;12(1):e055827. pmid:34980627
View Article
PubMed/NCBI
Google Scholar

[179] View Article

[180] PubMed/NCBI

[181] Google Scholar

[ref50] 50. Secretaria de Educação Superior. Resolução Comissão Nacional de Residência Multiprofissional em Saúde. 2012. http://portal.mec.gov.br/index.php?option=com_docman&view=download&alias=15448-resol-cnrms-n2-13abril-2012&Itemid=30192
View Article
Google Scholar

[183] View Article

[184] Google Scholar

[ref51] 51. Perret JL, Best CO, Coe JB, Greer AL, Khosa DK, Jones-Bitton A. Association of demographic, career, and lifestyle factors with resilience and association of resilience with mental health outcomes in veterinarians in Canada. J Am Vet Med Assoc. 2020;257(10):1057–68. pmid:33135980
View Article
PubMed/NCBI
Google Scholar

[186] View Article

[187] PubMed/NCBI

[188] Google Scholar

[ref52] 52. Pelzer JM, Hodgson JL, Werre SR. Veterinary students’ perceptions of their learning environment as measured by the Dundee Ready Education Environment Measure. BMC Res Notes. 2014;7:170. pmid:24661621
View Article
PubMed/NCBI
Google Scholar

[190] View Article

[191] PubMed/NCBI

[192] Google Scholar

[ref53] 53. Quansah F, Hagan JE, Sambah F, Frimpong JB, Ankomah F, Srem-Sai M, et al. Perceived safety of learning environment and associated anxiety factors during COVID-19 in Ghana: Evidence from physical education practical-oriented program. Eur J Investig Health Psychol Educ. 2022;12(1):28–41. pmid:35049532
View Article
PubMed/NCBI
Google Scholar

[194] View Article

[195] PubMed/NCBI

[196] Google Scholar

[ref54] 54. Pohl R, Botscharow J, Böckelmann I, Thielmann B. Stress and strain among veterinarians: A scoping review. Ir Vet J. 2022;75(1):15. pmid:35729648
View Article
PubMed/NCBI
Google Scholar

[198] View Article

[199] PubMed/NCBI

[200] Google Scholar

[ref55] 55. Gutgeld-Dror M, Laor N, Karnieli-Miller O. Assertiveness in physicians’ interpersonal professional encounters: A scoping review. Med Educ. 2024;58(4):392–404. pmid:37725417
View Article
PubMed/NCBI
Google Scholar

[202] View Article

[203] PubMed/NCBI

[204] Google Scholar

[ref56] 56. Ghannam J, Afana A, Ho EY, Al-Khal A, Bylund CL. The impact of a stress management intervention on medical residents’ stress and burnout. International Journal of Stress Management. 2020;27(1):65–73.
View Article
Google Scholar

[206] View Article

[207] Google Scholar

[ref57] 57. R K, Sujathamalini J, Gunasekaran K, Pandimeenal A. Correlation study on assertiveness and empathy among young adults. Int J Psychol Res. 2025;7(1):45–8.
View Article
Google Scholar

[209] View Article

[210] Google Scholar

[ref58] 58. Dominguez-Espinosa ADC, Montes de Oca-Mayagoitia SI, Sáez-Jiménez AP, de la Fuente-Zepeda J, Monroy Ramírez de Arellano L. The moderating role of sociodemographic and work-related variables in burnout and mental health levels of Mexican medical residents. PLoS One. 2022;17(9):e0274322. pmid:36112642
View Article
PubMed/NCBI
Google Scholar

[212] View Article

[213] PubMed/NCBI

[214] Google Scholar

[ref59] 59. Yutani M, Takahashi M, Takizawa T, Miyaoka H. Social skills training improves clinical residents’ communication skills. Kitasato Medical Journal. 2016;1:53–9.
View Article
Google Scholar

[216] View Article

[217] Google Scholar

[ref60] 60. Mueser KT, Bellack AS. Social skills training: Alive and well?. Journal of Mental Health. 2007;16(5):549–52.
View Article
Google Scholar

[219] View Article

[220] Google Scholar

[ref61] 61. Suppan M, Suppan L, Beckmann TS, Samer CF, Savoldelli GL. Enhancing response rates in web-based surveys: The impact of direct participant contact. Healthcare (Basel). 2024;12(14):1439. pmid:39057582
View Article
PubMed/NCBI
Google Scholar

[222] View Article

[223] PubMed/NCBI

[224] Google Scholar

[ref62] 62. Daikeler J, Bošnjak M, Lozar Manfreda K. Web versus other survey modes: An Updated and extended meta-analysis comparing response rates. Journal of Survey Statistics and Methodology. 2019;8(3):513–39.
View Article
Google Scholar

[226] View Article

[227] Google Scholar

[ref63] 63. Zhang X, Kuchinke L, Woud ML, Velten J, Margraf J. Survey method matters: Online/offline questionnaires and face-to-face or telephone interviews differ. Computers in Human Behavior. 2017;71:172–80.
View Article
Google Scholar

[229] View Article

[230] Google Scholar

Figures

Abstract

Introduction

Materials and methods

Study design, population and data collection procedures

Questionnaire development

Statistical analysis

Results

Discussion

Strengths and limitations

Conclusions

Supporting information

S1 File. Complete study questionnaire and validated instrument scales.

Acknowledgments

References