How the Personal Characteristics of Grit and Resilience Relate to Surgeon Well-Being

The rates of burnout and attrition in the field of general surgery are high, particularly among trainees.^1,2 Burnout has been estimated to affect up to 69 percent of surgical residents,³ and roughly 20 percent of surgical residents leave their training program.³ Contributing factors include long hours spent toiling in the hospital, the high-stakes nature of the work, and ever-conflicting demands between administrative tasks, patient care, and fulfilling the Accreditation Council for Graduate Medical Education (ACGME) training requirements. As the physician well-being crisis has been described and studied in recent years, efforts have been made to better understand contributing factors. The National Academy of Medicine has launched a collaborative focused specifically on physician well-being,⁴ and the American Medical Association has developed resources specifically to support physician well-being.⁵ Many efforts have explored how personal characteristics such as grit and resilience may be associated with well-being, burnout, and attrition.^2,6–9 Here, we review data on these characteristics and make practical suggestions to foster trainees' well-being.

Grit is defined by Angela Duckworth as "perseverance and passion for a long-term goal."¹⁰ Grit may predict achievement in challenging domains even more than talent or innate ability. For example, among military cadets and spelling bee contestants, grit was able to predict achievement above and beyond what was predicted based on prior achievement.¹⁰ Grit can be measured using either the full length grit scale that was originally validated (12 items)¹⁰ or the shorter grit scale that was later developed (8 items).¹¹ Within surgery, grit has been found to be positively correlated with psychological well-being and negatively correlated with burnout and attrition from training programs.^6–9

Resilience is defined as "an individual's ability to bounce back after adversity or failure."¹² Given this definition, there is understandable interest in fostering resilience among surgical trainees, who arguably face adversity daily. The measurement of resilience is unfortunately challenging. The concept of resilience is complex and multi-faceted. Although often thought of as an individual characteristic, resilience also depends on external factors including the environment and personal relationships.^13,14 There is no clear consensus on which tool is best for measuring resilience. In fact, one systematic review identified seventeen different resilience measurement scales in various studies.¹³ The 10-item Block Ego-Resiliency scale, which is thought to better assess resilience within changing environmental demands, has been used with surgical trainees. Using this scale, resilience has been negatively correlated with burnout, depression, anxiety, and distress.¹⁴

The data on grit and resilience in surgical training are all correlational, making it impossible and inappropriate to make causal inferences. Interestingly, the relationship between grit and resilience with well-being and burnout is often viewed as uni-directional, hypothesizing that higher levels of grit and resilience lead to improved well-being and decreased burnout.^9,14 However, it is also possible that improving well-being and decreasing burnout will increase grit and resilience among individual trainees. Given that surgical trainees likely already have, on average, higher levels of grit (and possibly resilience) than the general population,⁸ focusing on well-being to promote grit and resilience may be more fruitful than the opposite (promoting grit and resilience to improve well-being). In addition, instructing trainees to be grittier or have more resilience may actually be harmful since trainees are already vulnerable and may be struggling to keep up with their clinical work. Placing an additional burden on them could actually increase burnout and risk of attrition. Emphasizing grit and resilience implies that if trainees don't thrive in the adverse environment of surgical training, it is their fault. In other words, resilience and grit are often seen as an individual's ability to control her thoughts and behavior—rather than the product of her environment.¹⁵

Beyond individual characteristics, external factors, such as supportive relationships and having a culture of belonging, likely contribute to trainees' grit and resilience. Thus, the culture and environment of residency programs likely play a large role in trainees' outcomes. There may be certain conditions under which the inherent grit and resilience of trainees may be promoted and further developed. Thus, perhaps the key question is: how do we create a culture of surgical training that supports and nurtures the already high levels of grit and resilience within our surgical trainees?

Improve the environment and culture by optimizing the low-hanging fruit that promotes well-being: It is challenging to maintain physical health during surgical training. However, some relatively minor interventions might help trainees better maintain their health:

• Provide consistently healthy options for food and sustenance regardless of time of day. One method would be to stock healthy sustenance items in protected house officer lounges or call rooms. Another would be to work with Graduate Medical Education offices and the hospital cafeterias to provide healthier options, which would benefit trainees, staff, patients, and patients' loved ones.
• Provide protected time and opportunities for physical and mental well-being such as protected time for doctor appointments, increased access to mental health professionals, and opportunities for physical fitness.
• Facilitate mental health care by providing group care sessions (such as those mentioned in other RISE articles^15–18) and reducing the time/distance required to see a mental health professional. These sessions could be scheduled as a part of didactic time for trainees.

Increase meaning in work: Many trainees pursue surgical training, despite knowing about the long days (and nights), because they find the work meaningful. This meaning can sometimes be lost in writing medical notes, charting in electronic medical charts, and managing relationships with either patients or other health care workers in a high-stakes environment. Indeed, increasing meaning in work may have more durable benefits including overall health.¹⁹ Facilitating mental and physical health care as mentioned above and allowing trainees time to reflect may increase meaning. Reflection could be done individually or as a group. Other activities, such as Schwartz Rounds,²⁰ in which caregivers can discuss social and emotional aspects of their work, also offer opportunities for reflection. Finally, training programs can try to optimize the time trainees spend in the operating room or advocating for patients.

Acknowledge individual limits: Even the grittiest and most resilient individual may encounter obstacles that can only be overcome with assistance and support. Acknowledging and normalizing these challenges and the need for assistance may improve the well-being of trainees. In addition, this requires acknowledging that each trainee is unique and will start at different levels of grit and resilience. Training programs should then work to meet trainees where they are and provide individualized support both through the methods discussed above and by keeping in mind trainees' varying backgrounds, in particular in evaluative settings.

Examine and address local barriers to grit, resilience, and well-being: Surgical trainees work long hours. Although call is unavoidable, the call structure, schedule, and quality can be adjusted and optimized. For example, the quality of call rooms can be improved, or more dedicated trainee work-space can be created on the wards. The call rooms and work-space could have healthy food and drink options and dedicated computers for trainees to utilize for call-related items. Making these types of structural changes signals to trainees that they are valued. Taken together, these changes can fuel trainees during the unavoidably long days and nights and ultimately promote well-being. Certainly, these are all potentially costly changes. However, occupational stress is associated with other costly problems including substance abuse, accident proneness, and depression.²¹ Improving well-being reduces absenteeism and turnover and improves job satisfaction and productivity.²² It may also be beneficial to approach hospital administrators or the Graduate Medical Education officers from the perspective of physicians as athletes. Just as athletes need nutrition and sleep to perform optimally, so do physicians. Unlike athletes, though, our performance impacts patients' lives.

A growing body of work supports the association of grit and resilience with well-being, burnout, career satisfaction, emotional distress, and attrition.^2,6,23,24 Consequently, surgical educators may think fostering grit and resilience among trainees will improve their well-being and decrease attrition. However, little is known about how to foster the development of these traits within individuals. Grit and resilience likely develop over the course of one's lifetime, rather than in classrooms and formal education settings. Focusing on individual characteristics such as these also unduly places responsibility on individual trainees who are already stressed, emotionally exhausted, and demoralized.^1,14 Given the high rate of burnout even among practicing physicians,^8,23 it is likely the system, rather than the individuals, that is flawed. Making changes such as those suggested above may enable trainees to reserve their grit and resilience for the inevitable and unavoidable challenges such as patient death, complications, inevitable personal errors, the gravity of being responsible for the lives of others, and unexpected personal life events. To be sure, interventions at the level of individuals may also be effective,²⁵ but what is becoming clearer is that those interventions will be unsuccessful without addressing the bigger failings of the system in which the individuals work.

In recent years, as researchers have tried to understand risk factors for burnout, they have explored aspects of personality such as grit and resilience. Grit is passion and perseverance for long-term goals. Resilience is one's ability to bounce back from adversity. Both grit and resilience are positively associated with well-being and negatively associated with burnout. However, there are many external factors, such as the learning environment, that contribute to burnout. Suggestions for improving the learning environment include providing easier access to healthy food and beverages, finding a better balance between charting and meaningful work, acknowledging and accommodating individual variation, and modifying local factors that may contribute to poor well-being.

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2. Yeo HL, Abelson JS, Symer MM, et al. Association of time to attrition in surgical residency with individual resident and programmatic factors. JAMA Surg. 2018;153(6):511-517. doi:10.1001/jamasurg.2017.6202
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17. Anton NE, Stefanidis D. Making Average Performance Excellent: Mental Skills for Performance Enhancement. RISE: Resources in Surgical Education. https://www.facs.org/education/division-of-education/publications/rise/articles/performance. Published 2018.
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Britta Han, MD, MSEd, is a general surgery resident at the Washington University School of Medicine in St. Louis, MO.

Arghavan Salles, MD, PhD, is a minimally invasive and bariatric surgeon; scholar in residence; and Dean for Medical Student Education at Stanford University School of Medicine, Palo Alto, CA.