Prevalence and risk factors for burnout in U.S. vascular surgery trainees

Perception of shared learning environment differs between vascular surgery and general surgery residents

BACKGROUND

An enriching learning environment is integral to resident wellness and education. Integrated vascular (VS) and general surgery (GS) residents share 18 months of core GS rotations during the postgraduate years 1-3 (PGY1-3); differences in their experiences may help identify practical levers for change.

METHODS

We used a convergent mixed-methods design. Cross-sectional surveys were administered after the 2020 American Board of Surgery In-Training Examination and Vascular Surgery In-Training Examination, assessing eight domains of the learning environment and resident wellness. Multivariable logistic regression models identified factors associated with thoughts of attrition between categorical PGY1-3 residents at 57 institutions with both GS and VS programs. Resident focus groups were conducted during the 2022 Vascular Annual Meeting to elicit more granular details about the experience of the learning environment. Transcripts were analyzed using inductive and deductive logics until thematic saturation was achieved.

RESULTS

Surveys were completed by 205 VS and 1198 GS PGY1-3 residents (response rates 76.8% for VS and 82.5% for GS). After adjusting for resident demographics, PGY level, and program type, GS residents were more likely than their VS peers to consider leaving their programs (odds ratio [OR]: 2.61, 95% confidence interval [CI]: 1.37-4.99). This finding did not persist after adjusting for differences in perceptions of the learning environment, specifically: GS residents had higher odds of mistreatment (OR: 1.99, 95% CI: 1.36-2.90), poorer work-life integration (OR: 2.88, 95% CI: 1.41-5.87), less resident camaraderie (OR: 3.51, 95% CI: 2.26-5.45), and decreased meaning in work (OR: 2.94, 95% CI: 1.80-4.83). Qualitative data provided insight into how the shared learning environment was perceived differently: (1) vascular trainees expressed that early specialization and a smaller, more invested faculty allow for an apprenticeship model with early operative exposure, hands-on guidance, frequent feedback, and thus early skill acquisition (meaning in work); (2) a smaller program is conducive to closer relationships with co-residents and faculty, increasing familiarity (camaraderie and work-life integration); and (3) due to increased familiarity with program leadership, vascular trainees feel more comfortable reporting mistreatment, allowing for prompt responses (mistreatment).

CONCLUSIONS

Despite sharing a learning environment, VS and GS residents experience training differently, contributing to differential thoughts of attrition. These differences may be attributable to intrinsic features of the integrated training paradigm that are not easily replicated by GS programs, such as smaller program size and higher faculty investment due to early specialization. Alternative strategies to compensate for these inherent differences should be considered (eg, structured operative entrustment programs and faculty incentivization).

Reported pain at work is a risk factor for vascular surgery trainee burnout

BACKGROUND

Work-related pain is a known risk factor for vascular surgeon burnout. It risks early attrition from our workforce and is a recognized threat to the specialty. Our study aimed to understand whether work-related pain similarly contributed to vascular surgery trainee well-being.

METHODS

A confidential, voluntary survey was administered after the 2022 Vascular Surgery In-Service Examination to trainees in all Accreditation Council for Graduate Medical Education-accredited vascular surgery programs. Burnout was measured by a modified, abbreviated Maslach Burnout Inventory; pain after a full day of work was measured using a 10-point Likert scale and then dichotomized as "no to mild pain" (0-2) vs "moderate to severe pain" (3-9). Univariable analyses and multivariable regression assessed associations of pain with well-being indicators (eg, burnout, thoughts of attrition, and thoughts of career change). Pain management strategies were included as additional covariables in our study.

RESULTS

We included 527 trainees who completed the survey (82.2% response rate); 38% reported moderate to severe pain after a full day of work, of whom 73.6% reported using ergonomic adjustments and 67.0% used over-the-counter medications. Significantly more women reported moderate to severe pain than men (44.3% vs 34.5%; P < .01). After adjusting for gender, training level, race/ethnicity, mistreatment, and dissatisfaction with operative autonomy, moderate-to-severe pain (odds ratio, 2.52; 95% confidence interval, 1.48-4.26) and using physiotherapy as pain management (odds ratio, 3.06; 95% confidence interval, 1.02-9.14) were risk factors for burnout. Moderate to severe pain was not a risk factor for thoughts of attrition or career change after adjustment.

CONCLUSIONS

Physical pain is prevalent among vascular surgery trainees and represents a risk factor for trainee burnout. Programs should consider mitigating this occupational hazard by offering ergonomic education and adjuncts, such as posture awareness and microbreaks during surgery, early and throughout training.

Educational challenges and opportunities for the future generation of surgeons: a scoping review

PURPOSE

Surgery offers exciting opportunities but comes with demanding challenges that require attention from both surgical program administrators and aspiring surgeons. The hashtag #NoTrainingTodayNoSurgeonsTomorrow on 𝕏 (previously Twitter) underscores the importance of ongoing training. Our scoping review identifies educational challenges and opportunities for the next generation of surgeons, analyzing existing studies and filling gaps in the literature.

METHODS

Following the PRISMA guidelines, MEDLINE/PubMed was searched in February 2022, using the MeSH terms "surgeons/education," for articles in English or German on general, abdominal, thoracic, vascular, and hand surgery and traumatology targeting medical students, surgical residents, future surgeons, and fellows.

RESULTS

The initial search yielded 1448 results. After a step-by-step evaluation process, 32 publications remained for complete review. Three main topics emerged: surgical innovations and training (n = 7), surgical culture and environment (n = 19), and mentoring (n = 6). The articles focusing on surgical innovations and training mainly described the incorporation of structured surgical training methods and program initiatives. Articles on surgical culture examined residents' burnout, well-being, and gender issues. Challenges faced by women, including implicit bias and sexual harassment, were highlighted. Regarding mentoring, mentees' needs, training challenges, and the qualities expected of both mentors and mentees were addressed.

CONCLUSION

At a time of COVID-19-driven surgical innovations, the educational and working environment of the new generation of surgeons is changing. Robotic technology and other innovations require future surgeons to acquire additional technological and digital expertise. With regard to the cultural aspects of training, surgery needs to adapt curricula to meet the demands of the new generation of surgeons, but even more it has to transform its culture.

Burnout and Its Consequences among Vascular Surgeons and Trainees: A Danish National Survey

BACKGROUND

Burnout among physicians has widespread negative consequences. Little is known about burnout among European vascular surgeons (VS). A previously published study found that 82% of VS and vascular surgical trainees (VST) in Denmark experience burnout symptoms. The present study aimed to investigate work- and health-related consequences of burnout.

STUDY DESIGN

An electronic survey was distributed to all VS/VST in Denmark in January 2020. Validated assessment tools were used to measure burnout, mental health, and psychosocial work environment aspects.

RESULTS

Of 104 invited VS/VST, 82% (n = 85) completed the survey. VS accounted for 72% (n = 61) of the respondents, and 40% (n = 33) were female. Statistically significant associations were found between higher levels of burnout and a range of work- and health-related outcomes, including a sense of meaning at work, workplace commitment, conflicts between work and private life, work stress, sick leave, and depressive symptoms. VS/VST using pain medication daily or weekly had significantly higher burnout scores than respondents who rarely or never use pain medication. A significant association between burnout and job satisfaction and retention was found, with respondents indicating an intention to stay within the specialty having significantly lower burnout scores than those who considered leaving within 5 years. Among those who indicated leaving the specialty, 35% (n = 13) attributed this to their current working conditions.

CONCLUSIONS

Burnout among VS/VST in Denmark is negatively associated with various work- and health-related outcomes. The work environment seems to play an essential role in these associations, and alterations in workplace organization may remedy this situation.

Vascular Surgery Training Positions and Applicant 10-Year Trends with Consideration for Further Expansion

BACKGROUND

There is a significant shortage of vascular surgeons in the United States and projections for these practicing surgical specialists continue to worsen. Annual appraisal of our workforce recruitment and growth is imperative.

MATERIALS AND METHODS

Retrospective data were analyzed using the National Resident Matching Program from 2012-2022 applicant appointment years (specialty code for vascular surgery 450). Simple linear trend analysis was performed for the number of positions available and the number of applicants, stratified by fellowship or residency.

RESULTS

Over the 10-year study period, the total vascular surgery trainee positions expanded from 161 to 202. Integrated residency positions increased (41 positions in 2012 vs. 84 in 2022) while available fellowship positions remained stagnant (120 in 2012 vs. 118 in 2022). Total applicants rose as well, from 213 to 311. In 2022, unmatched applicants have increased for both paradigms (25 fellowship and 84 residency applicants) and 100% of programs filled. On average, the number of residency positions offered increased by 4 each year (P < 0.0001) and the number of fellowship positions increased by 0.5 each year (P = 0.1617). The number of integrated residency applicants increased by approximately 9 per year (P = 0.001), while the number of fellowships applicants increased by approximately 1.5 per year (P = 0.121).

CONCLUSIONS

Applicants for both vascular tracks have increased since 2012 indicating successful recruitment; however, all 2022 programs filled, leaving many applicants unmatched. Residency positions have continued to expand while fellowship positions have not. With the demonstrated surge among applicants, the disproportionate lack of increasing training positions, and the existing shortage of vascular surgeons, there is an urgency to meet the increasing demand. A concerted effort should be made toward adding additional residency and fellowship positions where feasible.

Defining sources and ramifications of mistreatment among female vascular surgery trainees

OBJECTIVE

Mistreatment among vascular surgery trainees is a known risk factor for physician burnout. This study aims to characterize forms of and identify sources of mistreatment.

METHODS

This is a cross-sectional study of United States vascular surgery trainees who voluntarily participated in an anonymous survey administered after the 2021 Vascular Surgery In-Training Examination. The primary outcome measures were self-reported mistreatment and sources of mistreatment between genders. Logistic regression was used for multivariable analysis.

RESULTS

Representing all 125 vascular surgery training programs, 510 trainees (66.9% male) participated in the survey (83.6% response rate). Mistreatment was reported by 54.8% of trainees, with twice as many women reporting as men (82.3% vs 41.0%; P < .001). Women reported higher rates of being shouted at (44.1% vs 21.1%; P < .001); repeatedly reminded of errors (24.3% vs 16.1%; P = .04); ignored/treated hostilely (28.9% vs 10.5%; P < .001); subjected to crude/sexually demeaning remarks, stories, jokes (19.2% vs 2.1%; P < .001); evaluated by different standards (29.3% vs 2.1%; P < .001); and mistaken for a non-physician (75.2% vs 3.5%; P < .001). Among trainees reporting bullying, attendings were the most common source (68.5%). Patients and their families were the most common source of sexual harassment (66.7%), gender discrimination (90.4%), and racial discrimination (74.4%). Compared with men, women identified more patients and families as the source of bullying (50.0% vs 29.7%; P = .005), gender discrimination (97.2% vs 50.0%; P < .001), and sexual harassment (78.4% vs 27.3%; P = .003). Compared with men, women more frequently felt unprepared to respond to the behavior in the moment (10.4% vs 4.6%; P = .002), did not know how to report mistreatment at their institution (7.6% vs 3.2%; P = .04), and did not believe that their institution would take their mistreatment report seriously (9.0% vs 3.9%; P = .002). On multivariable analysis, female gender was an independent risk factor for both gender discrimination (odds ratio, 56.62; 95% confidence interval, 27.89-115) and sexual harassment (odds ratio, 26.2; 95% confidence interval, 3.34-14.8) when adjusting for children, training year, relationship status, and training program location.

CONCLUSIONS

A majority of vascular surgery trainees experience mistreatment during training. Sources and forms of abuse are varied. Understanding the sources of mistreatment is critical to guide intervention strategies such as faculty remediation and/or sanctions; allyship training for staff, residents, and faculty; and institutional procedures for patient-initiated abuse.

Resident physician duty hours, resting times and European Working Time Directive compliance in Spain: a cross-sectional study

BACKGROUND

There is a growing interest in understanding the impact of duty hours and resting times on training outcomes and the well-being of resident physicians. However, to this date no state-wide analysis exists in any European country.

OBJECTIVES

Our aim is to describe the shift work scheduling and to detail the degree of compliance with the Spanish legislation and the European Working Time Directive (EWTD) of Spanish resident physicians, focusing on territorial and specialty distribution.

MATERIAL AND METHODS

A descriptive cross-sectional analytical study was designed through an online survey adapted from the existing literature.

RESULTS

Out of the 2035 surveyed resident physicians undergoing PGT in Spain, 80.49% exceeded the 48 h per week limit set by the EWTD and 13% of them did not rest after a 24-h on-call shift. The mean number of on-call shifts in the last 3 months was 15.03, with the highest mean reported in Asturias, La Rioja, and Extremadura. 51.6% of respondents had a day-off after a Saturday on-call shift. Significant differences are observed by region and type of specialty.

CONCLUSION

Resident physicians in Spain greatly exceed the established 48 h/week EWTD limit. Likewise, non-compliance with labor regulations regarding mandatory rest after on-call duty and minimum weekly rest periods are observed.

The USMLE® STEP 1 Pass or Fail Era of the Vascular Surgery Residency Application Process: Implications for Structural Bias and Recommendations

MOTIVES BEHIND THE SHIFT

USMLE® STEP 1 score reporting has been changed to a binary pass/fail format since January 26, 2022. The motives behind this change were (1) the questionable validity of using USMLE® STEP 1 as a screening tool during the candidate selection process and (2) the negative impact of using standardized examination scores as an initial gatekeeping threshold for the underrepresented in medicine (URiM) candidates applying to GME programs, given their generally lower mean standardized exams scores compared to non-URiM students. The USMLE® administrators justified this change as a tactic to enhance the overall educational experience for all students and to increase the representation of URiM groups. Moreover, they advised the program directors (PDs) to give more attention to other important qualities and components such as the applicant's personality traits, leadership roles and other extracurricular accomplishments, as part of a holistic evaluation strategy. IMPACT OF USMLE® STEP 1 PASS/FAIL: At this early stage, it is unclear how this change will impact Vascular Surgery Integrated residency (VSIR) programs. Several questions are outstanding, most importantly, how VSIR PDs will evaluate applicants absent the variable which heretofore was the primary screening tool. Our previously published survey showed that VSIR PDs will move their attention to other measures such as USMLE® STEP 2CK and letters of recommendation during the VSIR selection process. Furthermore, more emphasis on subjective measures such as the applicant's medical school rank and extracurricular student activities is expected. Given the expected higher weight of USMLE® STEP 2CK in the selection process than ever, many anticipate that medical students will dedicate more of their limited time to its preparation at the expense of both clinical and non-clinical activities. Potentially leaving less time to explore specialty pathways and to determine whether VS is the appropriate career for them.

A FRAMEWORK FOR CANDIDATE EVALUATION

The critical juncture in the VSIR candidate evaluation paradigm presents an opportunity to thoughtfully transform the process via current (Standardized Letter of Recommendation, USMLE® STEP 2CK, and clinical research) and future (Emotional Intelligence, Structure Interview and Personality Assessment) measures which constitute a framework to follow in the USMLE® STEP 1 pass/fail era.

Cross-sectional survey of sleep, fatigue and mental health in veterinary anaesthesia personnel

OBJECTIVE

To evaluate the sleep quality, prevalence of fatigue and depressive symptoms in veterinary anaesthesia personnel.

STUDY DESIGN

Anonymous online voluntary survey.

METHODS

Sleep quality, fatigue, depressive symptoms and self-perceived burnout were scored using the Pittsburgh Sleep Quality Index (PSQI), Fatigue Severity Scale (FSS), Patient Health Questionnaire-9 (PHQ-9) and single-item burnout measure, respectively. Demographic data and questions about work-related fatigue, out-of-hours duty, transport and rest periods were included. PSQI, FSS and PHQ-9 scores were compared using Spearman rank correlation tests.

RESULTS

Responses from 393 participants were obtained from an estimated population of 1374 including diplomates of the American and European Colleges of Veterinary An(a)esthesia and Analgesia (43.9%), residency-trained veterinarians (15.6%), residents-in-training (13.8%) and veterinary technicians and nurses (12.0%), from 32 countries. Most were employed in clinical university teaching hospitals (54.2%) or clinical private practice (41.5%). PSQI scores > 5 were reported by 71.2% of respondents, with 52.4% reporting insufficient sleep to meet their job demands. Many showed high or borderline fatigue (56.4%), and 74.7% reported mistakes due to work-related fatigue. Major depressive symptoms (PHQ-9 score ≥ 10) were found in 42.7%, with 19.2% reporting they had thought about suicide or self-harm in the previous 2 weeks. Over half (54.8%) met the criteria for burnout and more veterinary nurses and technicians suffered from burnout than other roles, with 79.6% of this group affected (p < 0.001). Scores for PSQI and FSS [r (388) = 0.40, p < 0.001]; PSQI and PHQ-9 [r (389) = 0.23, p < 0.001]; and FSS and PHQ-9 [r (387) = 0.24, p < 0.001] were all positively correlated.

CONCLUSIONS AND CLINICAL RELEVANCE

This survey demonstrates a high prevalence of poor sleep, fatigue, depressive symptoms and burnout in veterinary anaesthesia personnel, and more should be done to improve the health of those in the profession.

An analysis of vascular surgery education publications reveals an educational shortage

BACKGROUND

As vascular surgery training continues to evolve with the growth of integrated vascular surgery residency (0+5) programs and the consolidation of fellowship programs, optimizing all aspects of the education for vascular surgery trainees, both fellows and 0+5 residents, has become increasingly important. In the present study, we aimed to determine the prevalence, quality, and content of vascular surgery education publications across journals.

METHODS

Journal websites (n = 26) and PubMed were queried to identify vascular surgery education publications from 2012 to 2021. The publications were organized into 11 content categories: (1) curriculum, (2) simulation, (3) trainee assessment, (4) program evaluation, (5) wellness/burnout, (6) diversity/inclusion, (7) mentorship/career, (8) case outcomes, (9) perceptions of training, (10) social media, and (11) other. Publication interactivity and quality were measured via PlumX data and Medical Education Research Study Quality Instrument scores. The data were analyzed via univariate analysis and linear regression.

RESULTS

A total of 115 vascular surgery education publications (0.2% [interquartile range (IQR), 0.04%-0.5%] of total publications) were identified from the selected journals. The Journal of Vascular Surgery had the highest proportion (0.8%) of vascular surgery education publications, followed by the Journal of Surgical Education (0.7%) and Annals of Vascular Surgery (0.6%). Vascular surgery journals constituted most (79%) of the publications. Of the authors, 15% (IQR, 0%-25%) had a master's or doctorate degree in education. Senior authors were more often identified as male gender (77%), and more first authors (41%) were identified as female gender. An interactivity analysis showed that there were 10.3 citations (IQR, 12), 33.1 captures (IQR, 34), and 8.4 social media interactions (IQR 14) per publication. The educational quality had a median Medical Education Research Study Quality Instrument score of 11 (IQR, 9-12.5), with 49% of publications having a score greater than the median. Publications on training (44% curriculum and 20% simulation) were significantly more frequent than other topics (P < .001), with no change in the publication content over 10 years (P = .29). The volume of vascular surgery education publications did not change during the study period (P = .13) despite the ongoing changes in the educational environment.

CONCLUSIONS

Despite the increasing importance placed on vascular surgery education by national vascular societies, publications on vascular surgery education have remained sparse among all journals. Also, the vascular surgery educational content has not changed during the past 10 years, with a primary focus on curriculum and simulation training. Further promotion of vascular surgery educational research is required to increase the quality, volume, and diversity of education publications.

Persistent racial discrimination among vascular surgery trainees threatens wellness

OBJECTIVE

Racial/ethnic discrimination is one form of mistreatment and a known risk factor for physician burnout. In the present study, we aimed to characterize the forms and identify the sources of racial/ethnic discrimination among vascular surgery trainees.

METHODS

We performed a cross-sectional study of U.S. vascular surgery trainees who had voluntarily participated in an anonymous survey administered after the 2021 Vascular Surgery In-Training Examination. The primary outcome measures were self-reported mistreatment and sources of mistreatment between race and ethnicity groups. We used χ² tests and logistic regression for bivariate and multivariable analyses, respectively.

RESULTS

Representing all 123 vascular surgery training programs, 510 trainees (66.9% men) participated in the survey (83.6% response rate). Most of the trainees had self-identified as White (53.1%), followed by Asian (24.4%), Hispanic/Latinx (7.6%), Black (4.2%), and other/prefer not to say (10.8%). No significant differences were found in the self-reported duty hour violations among the groups. Black (56.3%) and Asian (36.3%) trainees reported higher rates of racial/ethnic discrimination compared with the White, Hispanic/Latinx, and other/prefer not to say groups (P < .001). Patients and their families were reported as the most common source (74.7%). Other reported sources of discrimination included nurses or staff (60%), attendings (37.4%), co-residents (31.3%), and administration (16.9%). Regarding specific forms of racial discrimination, Black and Asian trainees reported the highest rates of different standards of evaluation (20% and 5.9%, respectively), being mistaken for a nonphysician (50.0% and 5.9%, respectively), slurs and/or hurtful comments (13.3% and 5.9%, respectively), social isolation (13.0% and 1.0%, respectively), and being mistaken for another trainee of the same race/ethnicity (60.0% and 33.7%, respectively). Only 62.5% of Black trainees reported their program/institution would take their mistreatment report seriously compared with the White (88.9%), Hispanic/Latinx (88.2%), Asian (83.2%), and other/prefer not to say (71.4%) trainees (P = .01). On multivariable analysis, female gender (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.44-4.33), Asian race (OR, 6.9; 95% CI, 3.53-13.3), Black race (OR, 13.6; 95% CI, 4.25-43.4), and training in the Southeastern United States (OR, 3.8; 95% CI, 1.17-12.80) were risk factors for racial/ethnic discrimination.

CONCLUSIONS

The results from the survey revealed that racial/ethnic discrimination persists in surgical training programs, with Asian and Black trainees reporting higher rates than other racial and ethnic groups. Overall, patients and family members were the most common source of racial/ethnic discrimination. However, faculty, staff, and co-trainees also contributed to racial/ethnic discrimination. Further interventions that optimize diversity, equity, and inclusion strategies and policies to address all forms of racial/ethnic discrimination with faculty, staff, and patients within the hospital are critically needed.

Prevalence and associated factors of bullying in medical residents: A systematic review and meta-analysis

OBJECTIVE

To assess the prevalence of bullying in medical residents and its associated factors.

METHODS

In this systematic review and meta-analysis, articles from MEDLINE, EMBASE, Scopus, PsycInfo, Cochrane databases, and Web of Science were searched. Published and unpublished cross-sectional studies were included. Cochrane's Q test and I2 statistics were used to assess the existence of heterogeneity. Subgroup analysis and sensitivity analysis were performed on evidence of heterogeneity. Egger's test and funnel plots were performed to investigate publication bias.

RESULTS

A total of 13 cross-sectional studies with a total of 44 566 study participants from different medical residencies were analyzed. The overall prevalence of bullying was 51% (95% CI 36-66). Furthermore, female residents and residents that belong to a minority group had higher odds of experiencing bullying compared to their peers.

CONCLUSION

A high prevalence of bullying in medical residents exists around the world. There is a need for education, dissemination, and more effective interventions among the residents and authorities about bullying to build and promote adequate behaviors and diminish bullying prevalence.

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.