Burnout among surgeons and surgical trainees: A systematic review and meta-analysis of the prevalence and associated factors

A review of selection criteria for ophthalmology training in the Western world

BACKGROUND

To (a) analyse, compare and learn from the global variations in ophthalmology training applicant selection criteria, specifically CV assessment, and (b) provide a discussion of evidence supporting such selection criteria.

METHODS

An observational analysis on the selection criteria used to assess candidates applying to ophthalmology training programs within the US, Canada, European Union / European Economic Union (EU/EEA), United Kingdom (UK) and Australia and New Zealand (ANZ). Presence of a publicly available selection criteria policy for the 2025 intake was searched for on national and local college, society, federation and training program websites. The selection criteria employed for assessing applicant CV, and its associated scoring (if existent), were recorded for the included programs. Descriptive statistics was applied to these data.

RESULTS

174 accredited ophthalmology training programs were identified, and 51/174 publish a publicly available selection criteria policy. Overall, the most important criteria from ophthalmic training bodies in the Western world include research experience, academic achievements, particularly in the form of awards and prizes, references supporting evidence of favourable personal and professional characteristics, and evidence of involvement in extracurricular activities that produce evidence of a well-founded interest in ophthalmology.

CONCLUSIONS

Each region adopts varying selection processes and frameworks, which, rather than reflect a standardised international approach to selecting an "ideal" ophthalmology trainee, perhaps select for the specific needs of the country and or training program. The study is limited by its observational nature.

Evaluation of a team-based approach for emergency department patients with time critical intracranial conditions

INTRODUCTION

Many time-critical neurosurgical brain conditions do not meet traditional ED major trauma or stroke team activation criteria and thus do not benefit from the associated expedited imaging and specialist review. To address this, a "Critical Head" protocol was developed. The aim was to determine the effect of this on time to CT scan, neurosurgical intervention (if indicated) and specialist team review.

METHOD

Quasi-experimental study, involving retrospective analyses of data of all potential Critical Head patients presenting to Wollongong ED from 1 January 2018 to 26 May 2023, with the protocol go-live on 7 March 2023. Descriptive statistics and study outcomes were compared before and after protocol implementation. R Studio 2024 was used for analyses and alpha was set to 0.05.

RESULTS

Two hundred and two patients were included (123 control/pre-intervention, 119 intervention). There was no significant difference in age, sex or presence of intracranial conditions between groups. Median time from triage to CT decreased in the intervention group by 15% (7 min, 47[33,95] to 40[25,66], P = 0.020). There was a 33% (67 min) reduction to surgery start time in the intervention (204[621752] to 137[108247] min, P = 0.042) (urgent neurosurgery). Reductions in time to specialist team reviews were observed in ICU (n = 86, 132[58192] to 42[6103] min, P < 0.001) and neurosurgery (n = 158, 104[69 202] to 44[16111] min, P < 0.001). ICU and hospital length of stay did not differ significantly, nor did Glasgow Coma Outcome Scale score at discharge.

CONCLUSION

The Critical Head protocol for patients with time-critical intracranial conditions reduced time to CT scan, operative intervention and specialist team review.

The Co-Surgeon Model for Microsurgical Free Flaps: A Survey of Perspectives and Utility

Reconstructive microsurgery remains a demanding field, requiring technical expertise and long operating hours. This places microsurgeons at increased risk of dissatisfaction and burnout. The co-surgeon model has been developed to mitigate these challenges. This study was designed to evaluate microsurgeon perspectives on the characteristics and impact of the co-surgeon model for microsurgical free flaps.An electronic anonymous survey was distributed via email to attending microsurgeon members of the American Society of Reconstructive Microsurgeons. The survey collected various demographic and practice-related information including Likert scale questions to assess microsurgeon perspectives on the utility of the co-surgeon model.A total of 862 microsurgeons received the survey, with 102 responses available for analysis. The average age of respondents was 46.6 (± 9.7) years. Most of the microsurgeons were male (71%) practicing in the United States (93%), with 74.5% of respondents utilizing a co-surgeon model in their practice. Bilateral breast flaps were the most common microsurgical procedure performed using a co-surgeon (85%), followed by head and neck free flaps (60%), with immediate lymphatic reconstruction being the least common (3.1%). On the day of the co-surgery case, the co-surgeon was more likely than the primary surgeon to have additional cases (68.4 and 36.4%, respectively), with the additional cases being rarely free flaps. More than 80% of microsurgeons stated that the co-surgeon model improves "very much" or "quite a bit" operative efficiency and duration, as well as surgeon well-being and career longevity.This study provides new insight into the utility of using a co-surgeon for free flap reconstruction by demonstrating that approximately 80% of microsurgeons have a positive perception of the model's impact on procedure efficiency, operative time, surgeon well-being, and career longevity. Therefore, adopting a co-surgeon model for microsurgical free flap reconstruction may be useful in reducing burnout and promoting well-being among microsurgeons.

GI Surgery Summit white paper: recruiting and training the next generation of surgeons

BACKGROUND

There is an ongoing debate on surgical training and its evolution to meet the demands of a complex and changing healthcare environment.

METHODS

A GI Surgery Summit was held in January 2024 that included prominent leaders and rising talents from the Society for Surgery of the Alimentary Tract, Society of Surgical Oncology, Association for Academic Surgery, and Society of University Surgeons. This meeting was held to address the multifaceted current and future challenges of surgery.

RESULTS

This paper addresses the topic of recruitment and training of the next generation of surgeons in the United States and abroad and reflects a collective focus on surgical education to ensure the delivery of high-quality care in an increasingly sophisticated medical and surgical landscape.

CONCLUSION

The discussions and recommendations from the 2024 GI Surgery Summit underscore the crucial need to support diversity, embrace innovative educational frameworks, build a robust global surgical workforce, and foster a culture of wellness and support. Focusing on these key areas ensures that the future leaders of surgery are not only skilled and knowledgeable but also resilient and compassionate, ready to meet the evolving challenges of the healthcare landscape.

Pointing to success: a discussion of the role of professional achievements in the selection of specialist surgical trainees

BACKGROUND

In Australia and New Zealand, competitive selection processes for surgical specialty training programs often use a standardized curriculum vitae (CV) to assess criteria such as professional achievements. This review aims to assess the predictive validity, standardization, and implicit biases of these selection methods, as well as their implications for trainees and the diversity of surgical cohorts.

METHODS

The 2023 CV scoring criteria were collected for all available specialty surgical programs in Australia and New Zealand. In 2023, each of the 11 surgical craft programs published publicly available standardized CV scoring criteria. In this study, scored items that constitute 'professional achievements' were recorded and tabulated. Observational analysis of the collected data was then conducted.

RESULTS

In 2023, each of the 11 specialty surgical craft programs published publicly available structured CVs, of which 10/11 allocated points for professional achievements. Designated points for professional achievements were classified as awards, scholarships, committee positions, and prior training courses: 4/11 programs offered points for scholarships/grants, 6/11 programs offered points for academic and/or non-academic prizes, and 8/11 programs offered points for professional development courses. Observational analysis of these findings suggests that professional achievements are desired in training program applicants.

CONCLUSION

Variability in medical school opportunities and inherent heterogeneity reduce the CV's efficacy, unfairly disadvantaging some applicants. Observational analysis of hence highlights the need for future research to assess potential updates in CV parameters to enhance predictive validity, reduce bias, and promote diversity.

Surgeon stress, anxiety, and workload: a descriptive study of participant reported responses to fundamentals of laparoscopic surgery exercises

BACKGROUND

Stress while operating is an important contributor to surgeon health and burnout. Measuring stress is key to improving surgeon and patient outcomes, however biological responses to stress during surgery are variable and difficult to interpret. Participant reported measures of stress have been suggested as an alternative, but the most appropriate measure has not been defined. This study's primary aim was to assess measures of anxiety, stress, and workload before and after surgical simulation and characterize the relationship between these measures.

METHODS

Surgeons completed three laparoscopic exercises from the fundamentals of laparoscopy program (peg transfer, pattern cutting, intracorporeal suturing) in a neutral environment and "stressed" environment (ergonomic, noise, or time pressure). State trait anxiety and self-reported stress on a visual analogue scale were collected prior to simulation and again immediately afterwards. The NASA task load index (TLX) was also administered post-simulation.

RESULTS

Of the 26 participants from gynecological and general surgery specialties, state anxiety increased in 98/148 simulations (62%) with a significant mean increase during simulation (32.9 ± 7.9 vs 39.4 ± 10.2, p < .001). Self-reported stress increased in 107/148 simulations (72%), with a significant increase in mean scores during simulation (38.7 ± 22.5 vs 48.9 ± 23.7, p < .001). NASA-TLX scores immediately after simulation ranged from 40 to 118 (mean 60.5 ± 28.7). Greater anxiety and stress scores were reported in "stressed" simulations (43.6 ± 23.1 vs 54.2 ± 23.3; 68.7 ± 27.0 vs 52.4 ± 28.2 respectively) with a significant interaction effect of the "stressed" environment and type of exercise. Anxiety and stress were moderately positively correlated prior to simulation (r = .40) and strongly positively correlated post-simulation (r = .70), however only stress was strongly correlated to workload (r = .79).

CONCLUSION

Stress and anxiety varied by type of laparoscopic exercise and simulation environment. Correlations between anxiety and stress are stronger post-simulation than prior to simulation. Stress, but not anxiety, is highly correlated with workload.

Impostor Phenomenon Among Recently Graduated General Surgeons

BACKGROUND

Imposter phenomenon can occur in highly competitive fields causing internal feelings of fraud and self-doubt. Significant imposterism has been recently reported amongst general surgery residents.

STUDY DESIGN

We hypothesized that attending surgeons, navigating the transition into independent practice, would report a similar experience. We surveyed and collected Clance Imposter Phenomenon Scale (CIPS) scores from 24 Army general surgeons within 4 years of graduation.

RESULTS

Nearly all exhibited at least moderate imposterism, and over half reported significant or intense imposterism. Women reported statistically higher scores than men. Surgeons who engaged in off-duty employment or participated in mentorship were less likely to have significant or intense imposterism.

CONCLUSION

Transition to practice is a challenging and highly variable time for new surgeons. Identifying factors that attenuate these feelings could help with early career advancement.

"I don't know if I can keep doing this": a qualitative investigation of surgeon burnout and opportunities for organization-level improvement

Introduction

Burnout is a pressing issue within surgical environments, bearing considerable consequences for both patients and surgeons alike. Given its prevalence and the unique contextual factors within academic surgical departments, it is critical that efforts are dedicated to understanding this issue. Moreover, active involvement of surgeons in these investigations is critical to ensure viability and uptake of potential strategies in their local setting. Thus, the purpose of this study was to explore surgeons' experiences with burnout and identify strategies to mitigate its drivers at the level of the organization.

Methods

A qualitative case study was conducted by recruiting surgeons for participation in a cross-sectional survey and semi-structured interviews. Data collected were analyzed using reflexive thematic analysis, which was informed by the Areas of Worklife Model.

Results

Overall, 28 unique surgeons participated in this study; 11 surgeons participated in interviews and 22 provided responses through the survey. Significant contributors to burnout identified included difficulties providing adequate care to patients due to limited resources and time available in academic medical centers and the moral injury associated with these challenges. The inequitable remuneration associated with education, administration, and leadership roles as a result of the Fee-For-Service model, as well as issues of gender inequity and the individualistic culture prevalent in surgical specialties were also described as contributing factors. Participants suggested increasing engagement between hospital leadership and staff to ensure surgeons are able to access resources to care for their patients, reforming payment plans and workplace polities to address issues of inequity, and improving workplace social dynamics as strategies for addressing burnout.

Discussion

The high prevalence and negative sequalae of burnout in surgery necessitates the formation of targeted interventions to address this issue. A collaborative approach to developing interventions to improve burnout among surgeons may lead to feasible and sustainable solutions.

Hard shell, soft core? Multi-disciplinary and multi-national insights into mental toughness among surgeons

Background

With the prevalence of burnout among surgeons posing a significant threat to healthcare outcomes, the mental toughness of medical professionals has come to the fore. Mental toughness is pivotal for surgical performance and patient safety, yet research into its dynamics within a global and multi-specialty context remains scarce. This study aims to elucidate the factors contributing to mental toughness among surgeons and to understand how it correlates with surgical outcomes and personal well-being.

Methods

Utilizing a cross-sectional design, this study surveyed 104 surgeons from English and German-speaking countries using the Mental Toughness Questionnaire (MTQ-18) along with additional queries about their surgical practice and general life satisfaction. Descriptive and inferential statistical analyses were applied to investigate the variations in mental toughness across different surgical domains and its correlation with professional and personal factors.

Results

The study found a statistically significant higher level of mental toughness in micro-surgeons compared to macro-surgeons and a positive correlation between mental toughness and surgeons' intent to continue their careers. A strong association was also observed between general life satisfaction and mental toughness. No significant correlations were found between the application of psychological skills and mental toughness.

Conclusion

Mental toughness varies significantly among surgeons from different specialties and is influenced by professional dedication and personal life satisfaction. These findings suggest the need for targeted interventions to foster mental toughness in the surgical community, potentially enhancing surgical performance and reducing burnout. Future research should continue to explore these correlations, with an emphasis on longitudinal data and the development of resilience-building programs.

Eyes on incivility in surgical teams: Teamwork, well-being, and an intervention

Incivility in surgery is prevalent and negatively impacts effectiveness and staff well-being. The purpose of this study was to a) examine relationships between incivility, team dynamics, and well-being outcomes, and b) explore a low-cost intervention of 'eye' signage in operating theater areas to reduce incivility in surgical teams. A mixed methods design was used in an orthopedic hospital. Surveys of incivility, teamwork, and well-being were administered three months apart in a small private hospital. An intervention of signage with eyes was placed in the theater area after administration of the first survey, using a pretest-posttest design. Participants also responded to an open-ended question about suggestions for improvements at the end of the survey which was then thematically analyzed. At the individual level (n = 74), incivility was statistically significantly related to team dynamics which in turn was significantly related to burnout, stress, and job attitudes. At the aggregate level, reported incivility was statistically significantly lower after the 'eye' sign intervention. Thematic analysis identified core issues of management behaviors, employee appreciation, communication, and work practices. Incivility in surgical teams has significant detrimental associations with burnout, stress, and job attitudes, which occurs through its impact on decreased team dynamics and communication. A simple intervention that evokes perceptions of being observed, such as signage of eyes in theater areas, has the potential to decrease incivility at least in the short term, demonstrating that incivility is amenable to being modified. Additional research on targeted interventions to address incivility are needed to improve teamwork and staff well-being.

Surgical trainee burnout during the COVID-19 pandemic: a systematic review

INTRODUCTION

The impact of the COVID-19 pandemic has been particularly significant for surgical trainees. The aim of this study was to systematically review the prevalence of burnout in surgical trainees during the pandemic, to compare rates of burnout between different specialties and to identify factors that may modify the risk of burnout.

METHODS

A systematic review was undertaken following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist to identify articles related to the keywords "surgeons burnout COVID-19" and "surgical trainees burnout COVID-19". A search was carried out on the PubMed/MEDLINE® and ScienceDirect® databases for articles published from January 2020 to August 2022.

RESULTS

A total of 19 articles met the inclusion criteria, with 3,866 surgical trainees included across all the studies. The overall prevalence of burnout in surgical trainees across the globe during the pandemic was between 9.1% and 95.2%. Burnout rates were higher in general surgery (33.1-95.2%) than in urology (17.6-54.6%), neurosurgery (16.2-44.1%) and orthopaedic surgery (9.1-44.1%). Otolaryngology trainees had the lowest burnout rate (10.9%). Factors associated with an increased risk of burnout included being a female trainee, being a more junior trainee and increased working hours.

CONCLUSIONS

There has been a high level of burnout among surgical trainees across the globe during the pandemic. In light of the devastating effect of COVID-19 on surgical training and the serious consequences of surgeon burnout (both for the individual and for the patients), targetted interventions for the prevention and treatment of burnout in surgical trainees are urgently needed, and must be prioritised by healthcare institutions and training programmes.

Cardiac autonomic and cortisol stress responses to real operations in surgeons: relationship with individual psychobiological characteristics and experience

BACKGROUND

Surgeons are exposed to high levels of intraoperative stress, which could compromise their psychological well-being in the long term. This study aimed at exploring the effects of real operations on the activity of stress response systems (i.e., cardiac autonomic function and hypothalamic-pituitary-adrenal axis) during and in the aftermath of surgery, and the moderating role of individual psychobiological characteristics and different levels of experience (senior vs expert surgeons).

METHODS

Heart rate, heart rate variability, and salivary cortisol measures (as indexes of cardiac autonomic and hypothalamic-pituitary-adrenal axis activity, respectively) were assessed during real operations and in the perioperative period in a sample of surgeons (n = 16). Surgeons' psychometric characteristics were collected using questionnaires.

RESULTS

Real operations triggered both cardiac autonomic and cortisol stress responses which were independent from surgeons' level of experience. Intraoperative stress responses did not affect cardiac autonomic activity during the following night but were associated with a blunted cortisol awakening response. Moreover, senior surgeons reported higher levels of negative affectivity and depressive symptoms than expert surgeons prior to the surgery. Lastly, the magnitude of heart rate responses to surgery positively correlated with scores on negative affectivity, depression, perceived stress, and trait anxiety scales.

CONCLUSION

This exploratory study allows to put forward the hypotheses that in surgeons cardiac autonomic and cortisol stress responses to real operations (i) may be associated with specific individual psychological characteristics regardless of the level of experience, (ii) and may have a longer lasting impact on hypothalamic-pituitary-adrenal axis function with potential implications for surgeons' physical and psychological well-being.

Environmental Factors Impacting Wellness in the Trauma Provider

Purpose of Review

The purpose of this review is to evaluate the recent literature on environmental factors impacting wellness for the acute care surgeon. This includes factors influencing physical, mental, and emotional well-being.

Recent Findings

Recent studies have identified challenges to surgeon wellness including increased incidence of sleep deprivation, musculoskeletal pain and injuries, pregnancy complications, moral injury, posttraumatic stress disorder (PTSD), and burnout. Qualitative studies have characterized the surgeon's emotional response to occupational stress, adverse events, and surgical complications. Further descriptive studies offer interventions to prevent moral injury after adverse events and to improve surgeon work environment.

Summary

Acute care surgeons are at increased risk of sleep deprivation, musculoskeletal pain and injury, pregnancy complications, moral injury, PTSD, and burnout. Surgeons experience feelings of isolation and personal devaluation after adverse events or complications, and this may lead to practice limitation and progression to PTSD and/or burnout. Interventions to provide mentorship, peer support, and education may help surgeons recover after adverse events. Further study is necessary to evaluate institution-driven interventional opportunities to improve surgeon well-being and to foster an inclusive and supportive environment.