Burnout Phenotypes Among U.S. General Surgery Residents

The obstetric experience among vascular surgery trainees

BACKGROUND

Vascular surgery training poses unique risks to pregnancy, including long hours, physically demanding work, and radiation exposure. Our objectives were to (1) understand pregnancy and parenthood experiences among vascular surgery trainees, (2) assess the rate of obstetric complications among vascular trainees, and (3) evaluate factors associated with trainee-parent wellness.

METHODS

A survey was administered after the 2021 Vascular Surgery In-Training Examination. Residents and fellows who (or whose partners) experienced pregnancies during their clinical years of training were asked about their perceptions of the learning environment (work hours and mistreatment, including discrimination, bullying, and harassment), obstetric complications (miscarriage, pre-eclampsia, placental abruption, intrauterine growth restriction, cesarean section, and postpartum depression), and burnout. Multivariable logistic regression models identified factors associated with burnout.

RESULTS

Among 510 trainees from 123 vascular surgery training programs (response rate 85.9%), 128 (25.1%) reported pregnancy during clinical training (12.7% female and 35.4% male; P < .001). Compared with male trainees, female trainees more frequently reported delaying having children owing to training (53.1% vs 30.0%; P < .001) and being advised against having children during residency (7.9% vs 0.4%; P < .001). Both female trainees and the partners of male trainees had high rates of obstetric complications (female 47.1% vs partners of male trainees 34.0%; P = .3). Compared with male trainees who had female partners, female trainees more frequently reported pregnancy/parenthood-related mistreatment (female 60.0% vs male 15.6%; P = .002) and duty-hour violations (female 47.4% vs male 12.0%; P < .001). Female gender was associated with increased risk for burnout (odds ratio, 4.8; 95% confidence interval,1.14-20.15); however, this difference was no longer significant after adjusting for mistreatment and duty-hour violations.

CONCLUSIONS

Vascular trainees experience high rates of obstetric complications. Senior-level trainees were more likely to experience obstetric complications, potentially owing to older age, longer and more complex surgical cases, and increased frequency of overnight calls. Women experienced more stigma related to pregnancy and childbearing, which may be associated with higher rates of burnout. Increased support for childbearing during training may help to maintain the wellness of a diverse workforce and better maternal-fetal health.

Characterizing the Relationships Amongst Psychological Safety, the Learning Environment, and Well-Being in Surgical Faculty and Trainees

OBJECTIVE

Learning environments affect the well-being of surgical faculty and trainees. Psychological safety (PS) has been linked with learning behaviors and aspects of well-being within medicine; however, given the unique challenges inherent to the surgical learning environment, there is a need to more closely examine these concepts for surgical faculty and trainees. The objective of this study is to examine the relationships between learning environment and PS, as well as PS and well-being with surgery.

DESIGN

Multi-institutional, cross-sectional survey study. The electronic survey included assessments of PS, professional fulfillment, and the learning environment. Exploratory and confirmatory factor analyses were performed to identify learning environment constructs. Index construct scores were generated. Multivariable multivariate regression analyses were used to examine the relationships between constructs in the learning environment and PS as well as PS and well-being.

SETTING & PARTICIPANTS

The electronic survey was distributed to surgical faculty, fellows, and residents at 8 institutions across the United States.

RESULTS

For faculty, higher levels of professional interactions and rapport/climate within the learning environment were significantly associated with higher levels of PS (β = 0.39, p < 0.01; β = 0.34, p < 0.01, respectively). Higher levels of PS were significantly associated with lower levels of interpersonal disengagement (β = -0.16, p = 0.04). For trainees, higher levels of disrespect/retaliation and personal performance worry within the learning environment were significantly associated with lower levels of PS (β = -0.45, p < 0.001; β = -0.11, p = 0.048, respectively). Higher levels of PS were significantly associated with higher levels of professional fulfillment (β = 0.24, p = 0.01) and lower levels of work exhaustion (β = -0.27, p < 0.01) and interpersonal disengagement (β = -0.36, p < 0.001).

CONCLUSIONS

This study identified factors within the learning environment that were positively and negatively associated with psychological safety for surgical faculty and trainees. In addition, it identified a direct relationship between psychological safety and elements of well-being and burnout.

Contemporary Evaluation of Work-Life Integration and Well-Being in US Surgical Residents: A National Mixed-Methods Study

BACKGROUND

The demands of surgical training present challenges for work-life integration (WLI). We sought to identify factors associated with work-life conflicts and to understand how programs support WLI.

STUDY DESIGN

A cross-sectional national survey conducted after the 2020 American Board of Surgery In-Training Examination queried 4 WLI items. Multivariable regression models evaluated factors associated with (1) work-life conflicts and (2) well-being (career dissatisfaction, burnout, thoughts of attrition, and suicidality). Semistructured interviews conducted with faculty and residents from 15 general surgery programs were analyzed to identify strategies for supporting WLI.

RESULTS

Of 7,233 residents (85.5% response rate), 5,133 had data available on work-life conflicts. A total of 44.3% reported completing noneducational task work at home, 37.6% were dissatisfied with time for personal life (eg hobbies), 51.6% with maintaining healthy habits (eg exercise), and 48.0% with performing routine health maintenance (eg dentist). In multivariable analysis, parents and female residents were more likely to report work-life conflicts (all p < 0.05). After adjusting for other risk factors (eg duty-hour violations and mistreatment), residents with work-life conflicts remained at increased risk for career dissatisfaction, burnout, thoughts of attrition, and suicidality (all p < 0.05). Qualitative analysis revealed interventions for supporting WLI including (1) protecting time for health maintenance (eg therapy), (2) explicitly supporting life outside of work (eg prioritizing time with family), and (3) allowing meaningful autonomy in scheduling (eg planning for major life events).

CONCLUSIONS

Work-life conflicts are common among surgical residents and are associated with poor resident well-being. Well-designed program-level interventions have the potential to support WLI in surgical residency.

Associations Between Program Doximity Reputation Rank and Well-Being in General Surgery Residents

INTRODUCTION

Burnout and mistreatment are prevalent among surgical residents with considerable program-level variation. Applicants consider "program reputation," among other factors, when ranking programs. Although highly subjective, the only available measure of program reputation is from a physician survey by Doximity. It is unknown how program reputation is associated with resident well-being and mistreatment.

METHODS

Resident burnout and personal accomplishment were assessed via the 2019 post-American Board of Surgery In-Training Examination survey. Additional outcomes included mistreatment, thoughts of attrition, and suicidality. Residents were stratified into quartiles based on their program's Doximity reputation rank. Multivariable logistic regression models examined the relationship between each outcome with Doximity rank quartile.

RESULTS

6956 residents (85.6% response rate) completed the survey. Higher-ranked programs had significantly higher burnout rates (top-quartile 41.3% versus bottom-quartile 33.2%; odds ratio [OR] 1.35, 95% confidence interval [CI] 1.04-1.76). There was no significant difference in personal accomplishment by program rank (OR 1.26, 95% CI 0.86-1.85). There also was no significant association between program rank and sexual harassment (OR 0.90, 95% CI 0.70-1.17), gender discrimination (OR 1.14, 95% CI 0.86-1.52), racial discrimination (OR 1.18, 95% CI 0.91-1.54), or bullying (OR 1.03, 95% CI 0.76-1.40). Suicidality (P = 0.97) and thoughts of attrition (P = 0.80) were also not associated with program rank.

CONCLUSIONS

Surgical residents at higher-ranked programs report higher rates of burnout but have similar rates of mistreatment and personal accomplishment. Higher-ranked programs should be particularly vigilant to trainee burnout, and all programs should employ targeted interventions to improve resident well-being. This study highlights the need for greater transparency in reporting objective program-level quality measures pertaining to resident well-being.

Perceived Pager Burden Among Trainees Across Medical Specialties

BACKGROUND

The experiences of pager use among trainees across medical specialties is underexplored. The aim of this study was to assess experiences of pager burden and communication preferences among trainees in different specialties.

METHODS

An online survey was developed to assess perceived pager burden (eg, pager volume, mistake pages, sleep, and off-time interruptions) and communication preferences at a tertiary center in the United States. All residents and fellows were eligible to participate. Responses were grouped by specialty: General surgery [GS], Surgical subspecialty [SS], Medicine, Anesthesiology, and Psychiatry. Multivariable linear regression was used to assess factors associated with pager burden. Free text responses were analyzed using open coding methods.

RESULTS

Of the total 306 responses, the majority were female (58.8%), 30-39 years (59.2%), and White (70.6%). Specialty breakdown was: Medicine (40.2%), Psychiatry (10.8%), SS (18.0%), GS (5.6%), and Anesthesiology (3.6%). GS respondents reported receiving more mistake pages (P < .001), spending more time redirecting mistake pages (P = .003), and having the highest sleep time disruptions (P < .001). For urgent communications, surgical trainees preferred physical pagers, while nonsurgical trainees preferred smartphone pagers (P = .001). "Receive fewer nonurgent pages" was the most common change respondents desired.

DISCUSSION

In this single center study, subjective experiences of pager burden were disproportionately high among GS trainees. Reducing nonurgent and mistake pages are potential targets for improving trainee communication experiences. Hospitals should consider incorporating trainee preferences into paging systems. Additional studies are warranted to increase the sample size, assess generalizability of the findings, and contextualize trainee experiences with objective hospital-level paging data.

Burnout syndrome and anxiety among healthcare workers during global pandemics: An umbrella review

BACKGROUND

Burnout syndrome and anxiety are two mental health symptoms experienced by healthcare workers (HCWs) that can be exacerbated during pandemics due to increased job demands and the global health workforce crisis.

AIM

To provide a comprehensive review and summary of evidence on burnout and anxiety in HCWs during previous global pandemics.

METHODS

A systematic search on electronic databases such as PubMed Central and MEDLINE was conducted to identify high-quality systematic review studies that reported on the prevalence of burnout and/or anxiety in HCWs during any previous global pandemic.

RESULTS

Twenty-four high quality systematic review articles were found to be suitable for inclusion. Twenty articles focused merely on Coronavirus disease 2019, while four articles examined multiple pandemics. Burnout was examined in nine articles, while anxiety was examined in the remaining 21 articles. Female HCWs and nurses were identified to be at a higher risk of developing burnout and anxiety during pandemic. We also observed a variation in the prevalence of burnouts and anxiety across different studies due to different mental health instruments were used in different studies.

CONCLUSION

Nurses and females HCWs had a high prevalence of burnout syndrome and anxiety during pandemic. More emphasis and attention should be paid to safeguarding the psychological well-being of these at-risk populations in the future pandemics.

Early career acute care surgeons' priorities and perspectives: A mixed-methods analysis to better understand full-time employment

BACKGROUND

Understanding the expectations of early career acute care surgeons will help clarify the practice and employment models that will attract and retain high-quality surgeons, thereby sustaining our workforce. This study aimed to outline the clinical and academic preferences and priorities of early career acute care surgeons and to better define full-time employment.

METHODS

A survey on clinical responsibilities, employment preferences, work priorities, and compensation was distributed to early career acute care surgeons in the first 5 years of practice. A subset of agreeable respondents underwent virtual semistructured interviews. Both quantitative and thematic analysis were used to describe current responsibilities, expectations, and perspectives.

RESULTS

Of 471 surgeons, 167 responded (35%), the majority of whom were assistant professors within the first 3 years of practice (80%). The median desired clinical volume was 24 clinical weeks and 48 call shifts per year, 4 weeks less than their median current clinical volume. Most respondents (61%) preferred a service-based model. The top priorities cited in choosing a job were geography, work schedule, and compensation. Qualitative interviews identified themes related to defining full-time employment, first job expectations and realities, and the often-misaligned system and surgeon.

CONCLUSION

Understanding the perspectives of early career surgeons entering the workforce is important particularly in the field of acute care surgery where no standard workload or practice model exists. The wide variety of expectations, practice models, and schedule preferences may lead to a mismatch between surgeon desires and employment expectation. Consistent employment standards across our specialty would provide a framework for sustainability.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Flourishing and the Prioritization of Workplace Elements in General Surgery Residents

INTRODUCTION

To explore and begin to operationalize workplace elements that influence general surgery (GS) resident wellbeing. Tailoring workplace wellbeing interventions is critical to their success. Occupational science has revealed that a person-centered approach to identifying positive and negative workplace influences can inform tailoring while accounting for individual differences. To our knowledge, this approach has not been applied to the surgical training environment.

METHODS

A national sample of GS residents from 16 Accreditation Council for Graduate Medical Education training programs ranked the importance of workplace elements via an anonymous survey. Latent profile analysis was performed to identify shared patterns of workplace element prioritization and their relation to levels of flourishing, a measure of global wellbeing.

RESULTS

GS trainee respondents (n = 300, 34% response rate - average for studies with this sample population) expressed a hierarchy of workplace element importance which differed by gender and race. "Skills to manage stress" and "a team you feel a part of" were prioritized higher by non-males than males. Residents of color and residents underrepresented in medicine, respectively, prioritized "recognition of work/effort" and "skills to manage stress" more than White and overrepresented in medicine residents. Flourishing prevalence varied by 40% with small differences in the specific profile of workplace element prioritization.

CONCLUSIONS

Differences in prioritization of workplace elements reveal subtle but important differences that may guide the design of wellbeing interventions for different populations within surgery.

Doctors' alertness, contentedness and calmness before and after night shifts: a latent profile analysis

BACKGROUND

While night shifts are crucial for patient care, they threaten doctors' well-being and performance. Knowledge of how the impact of night shifts differs for doctors is needed to attenuate the adverse effects of night shifts. This study aimed to obtain more precise insight into doctors' feelings surrounding night shift by: identifying profiles based on doctors' alertness, contentedness and calmness scores before and after night shifts (research question (RQ) 1); assessing how doctors' pre- and post-shift profiles change (RQ2); and determining associations of doctors' demographics and shift circumstances with alertness, contentedness and calmness change (RQ3).

METHODS

Latent Profile Analysis using doctors' pre- and post-shift self-rated alertness, contentedness and calmness scores was employed to identify pre- and post-shift profiles (RQ1). A cross-tabulation revealed pre- and post-shift profile changes (RQ2). Multiple regressions determined associations of demographics (i.e. age, sex, specialty) and night shift circumstances (i.e. hours worked pre-call, hours awake pre-call, shift duration, number of consecutive shifts, total hours of sleep) with alertness, contentedness and calmness change (RQ3).

RESULTS

In total, 211 doctors participated with a mean age of 39.8 ± 10 years; 47.4% was male. The participants included consultants (46.4%) and trainees (53.6%) of the specialties surgery (64.5%) and obstetrics/gynaecology (35.5%). Three pre-shift (Indifferent, Ready, Engaged) and four post-shift profiles (Lethargic, Tired but satisfied, Excited, Mindful) were found. Most doctors changed from Ready to Tired but satisfied, with alertness reducing most. Age, specialty, sleep, shift duration and the number of consecutive shifts associated with alertness, contentedness and calmness changes.

CONCLUSIONS

The results provided nuanced insight into doctors' feelings before and after night shifts. Future research may assess whether specific subgroups benefit from tailored interventions.

What We Talk About When We Talk About Coping: A Qualitative Study of Surgery Resident's Coping After Complications and Deaths

OBJECTIVE

To explore how surgery residents cope with unwanted patient outcomes including postoperative complications and death.

BACKGROUND

Surgery residents face a variety of work-related stressors that require them to engage in coping strategies. Postoperative complications and deaths are common sources of such stressors. Although few studies examine the response to these events and their impacts on subsequent decision-making, there has been little scholarly work exploring coping strategies among surgery residents specifically.

METHODS

This study investigated the ways, in which general surgery residents cope with unwanted patient outcomes, including complications and deaths. Mid-level and senior residents (n = 28) from 14 academic, community, and hybrid training programs across the United States participated in exploratory semistructured interviews conducted by an experienced anthropologist. Interview transcripts were analyzed iteratively, informed by thematic analysis.

RESULTS

When discussing how they cope with complications and deaths, residents described both internal and external strategies. Internal strategies included a sense of inevitability, compartmentalization of emotions or experiences, thoughts of forgiveness, and beliefs surrounding resilience. External strategies included support from colleagues and mentors, commitment to change, and personal practices or rituals, such as exercise or psychotherapy.

CONCLUSIONS

In this novel qualitative study, general surgery residents described the coping strategies that they organically used after postoperative complications and deaths. To improve resident well-being, it is critical to first understand the natural coping processes. Such efforts will facilitate structuring future support systems to aid residents during these difficult periods.

Patients' rights in physicians' practice during Covid-19 pandemic: a cross-sectional study in Romania

BACKGROUND

Although the Covid-19 epidemic challenged existing medical care norms and practices, it was no excuse for unlawful conduct. On the contrary, legal compliance proved essential in fighting the pandemic. Within the European legal framework for the pandemic, patients were still entitled to be treated equally, by a specialized physician, with the possibility of seeking a second medical opinion, in a confidential setting, following prior and informed consent. This study examines physicians' practices regarding patients' rights during the Covid-19 pandemic and the effects of age, experience, and specialty on physicians' behavior and preferences. Additionally, it explores the nexus of malpractice complaints, malpractice fear, and legal compliance.

METHODS

A cross-sectional study was conducted on a convenience sample of attending physicians and general practitioners to assess compliance with patients' rights regulations. Respondents were physicians practicing in private and public settings in Southwestern Romania from July 2021 to May 2022.

RESULTS

396 attending physicians and 109 general practitioners participated in the research. Attending physicians acknowledged patients' rights in 55.7% of statements, while general practitioners showed a slightly higher level of compliance at 59.9%. Emergency and Anesthesia and Intensive Care physicians showed the lowest compliance. There were no significant behavioral differences based on physicians' age, years in practice, work sector, or location. However, when faced with the question of prioritizing treatment for patients with similar medical conditions, 46.2% of attending physicians reported favoring the younger patients. This preference was common among physicians under 39. Additionally, over half of the attending physicians reported working outside their area of expertise due to staff shortages. Malpractice fear was high among physicians, although unrelated to patients' claims, legal compliance, or working outside the scope of practice. It resulted in pressure and behavioral changes.

CONCLUSION

Adherence to patients' rights was low during the Covid-19 pandemic. Physicians could benefit from educational and administrative support to ensure better legal compliance. Further research is needed to determine if this behavior persists beyond the pandemic context.

Black clouds in surgery: A study of surgical resident workload and burnout

BACKGROUND

The concept of a 'black cloud' is a common unfounded perception in the healthcare workforce that attributes a heavier workload to specific individuals or teams. Prior studies in non-surgical disciplines have demonstrated that 'black cloud' perceptions are not associated with workload, albeit such perceptions may influence behavior. The influence of 'black cloud' perceptions on surgical resident workload and burnout remains to be investigated. This study assesses the associations between 'black cloud' self-perception with actual workload and burnout among surgical residents in different specialties.

METHODS

A cross-sectional survey study of postgraduate year (PGY) 2 and 3 residents enrolled in different surgical residencies at the Icahn School of Medicine at Mount Sinai was conducted between September-November 2021.

RESULTS

The survey response rate was 62.1% (41/66). 46.3% of respondents were female. The majority of subjects were single (61%) and PGY2 trainees (56.1%). In a multivariate regression analysis demographic factors and workload variables, such as the number of pages responded, notes, and amount of sleep, were not significant predictors of a 'black cloud'-self-perception. A significantly lower Burnout Index Score (BIS) was observed among females (p< .001). A significantly higher BIS was observed among residents who are single (p = .003), training in general surgery (p = .02), and orthopedic surgery (p = .03). There was no significant association between 'black cloud' self-perception and BIS.

DISCUSSION

The findings demonstrate that a 'black cloud' self-perception is not associated with a high workload and burnout among surgical residents. Gender, marriage/domestic partnership, and certain surgical specialties influenced burnout among the study cohort.

Burnout in oral medicine and orofacial pain residents

BACKGROUND

The authors sought to identify the prevalence of burnout in oral medicine (OM) and orofacial pain (OFP) residents and investigate potential contributing factors.

METHODS

A cross-sectional questionnaire-based study was conducted. An anonymous 22-item online survey was emailed to the residents of all Commission on Dental Accreditation-accredited OM and OFP residency programs in the United States. Abbreviated Maslach Burnout Inventory was included to gauge the following details of burnout: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment. Questions also addressed the impact of residency program characteristics, work-life balance, and possible discrimination or abuse on burnout.

RESULTS

Six OM and 12 OFP programs (72 residents) were contacted, and 46 residents responded (response rate, 64%). Overall prevalence of burnout was 35% (29% in OM residents, 40% in OFP residents). High EE burnout was noted in 57% of residents, high DP burnout in 11% of residents, and high personal accomplishment burnout in 59% of residents. Working for fewer than 40 hours per week was significantly associated with low DP burnout (P < .05). Moderate to high DP burnout was more prevalent in men and unmarried residents (whether in a relationship or not) were more likely to experience moderate to high EE burnout (P < .05).

CONCLUSIONS

Burnout among OM and OFP residents is an emerging concern due to its detrimental effect on the physical and mental well-being of the residents. To the authors' knowledge, this study is the first to report burnout prevalence in the 2 most recent dental specialties recognized by the American Dental Association in 2020.

PRACTICAL IMPLICATIONS

Early detection of signs of burnout among residents would allow program faculty and administrators to provide required support and resources.

Trends in Surgeon Burnout in the US and Canada: Systematic Review and Meta-Regression Analysis

BACKGROUND

Burnout among surgeons is increasingly recognized as a crisis. However, little is known about changes in burnout prevalence over time. We evaluated temporal trends in burnout among surgeons and surgical trainees of all specialties in the US and Canada.

STUDY DESIGN

We systematically reviewed MEDLINE, Embase, and PsycINFO for studies assessing surgeon burnout from January 1981 through September 2021. Changes in dichotomized Maslach Burnout Inventory scores and mean subscale scores over time were assessed using multivariable random-effects meta-regression.

RESULTS

Of 3,575 studies screened, 103 studies representing 63,587 individuals met inclusion criteria. Publication dates ranged from 1996 through 2021. Overall, 41% of surgeons met criteria for burnout. Trainees were more affected than attending surgeons (46% vs 36%, p = 0.012). Prevalence remained stable over the study period (-4.8% per decade, 95% CI -13.2% to 3.5%). Mean scores for emotional exhaustion declined and depersonalization declined over time (-4.1 per decade, 95% CI -7.4 to -0.8 and -1.4 per decade, 95% CI -3.0 to -0.2). Personal accomplishment scores remained unchanged. A high degree of heterogeneity was noted in all analyses despite adjustment for training status, specialty, practice setting, and study quality.

CONCLUSIONS

Contrary to popular perceptions, we found no evidence of rising surgeon burnout in published literature. Rather, emotional exhaustion and depersonalization may be decreasing. Nonetheless, burnout levels remain unacceptably high, indicating a need for meaningful interventions across training levels and specialties. Future research should be deliberately designed to support longitudinal integration through prospective meta-regression to facilitate monitoring of trends in surgeon burnout.

Comprehensive Assessment of Burnout Among Surgical Trainees and Practicing Surgeons: A Systematic Review

OBJECTIVE

Surgeon burnout has received increasing attention due to evidence of high prevalence across specialties. We aimed to (1) systematically characterize existing definitions of burnout, (2) evaluate tools to measure burnout, and (3) determine risk factors of surgical burnout.

DESIGN

PubMed, Google Scholar, and Embase databases were searched to identify burnout rates and tools used to measure the quality of life (QoL) published from January 2000-December 2021.

PARTICIPANTS

Surgical Trainees and Practicing Surgeons.

RESULTS

We identified 39 studies that defined surgical burnout, with 9 separate tools used to measure QoL. Surgeon burnout rates were found to be highest among general surgery trainees (20%-95%). Burnout among general surgery attendings ranged from 25% to 44%. Those most likely to experience burnout were younger and female. High rates of surgeon burnout were reported among all surgical specialties; however, these rates were lower than those of general surgeons.

CONCLUSION

Definitions of burnout vary throughout the surgical literature, but are consistently characterized by emotional exhaustion, depersonalization, and lack of personal accomplishment. The most utilized tool to measure surgical burnout has been the Maslach Burnout Inventory. Across specialties, there are high rates of burnout in both surgical trainees and attendings, indicating that this is a systemic issue within the field of surgery. Given the wide-scale nature of the problem, it is recommended that institutions provide support to surgical trainees and attending surgeons and that individual surgeons take steps toward mitigating burnout.