A Guide for Improving Wellness in Surgical Education

Surgeons were among the first physician groups to recognize the negative effects of burnout,¹ and the threats to wellness posed by the COVID-19 pandemic have further illuminated the need to attend to the wellness of the surgical education community. Surgical educational leaders have a unique opportunity to both address the immediate needs of the learners and, in doing so, positively shape the culture of surgery. The current state of scholarship specific to surgeon wellness is that suggestions for improving surgeon wellness are emerging^2,3 with some preliminary evidence of effectiveness.^4,5 Waiting for an accumulation of robust evidence specific to surgeon wellness creates the risk of burnout for current members of the community. However, rushing to implement programming without evidence creates the risks of implementing ineffectual programs. It is possible to act now by using applicable conceptual frameworks that include models, theories, and evidence-based programs as is recommended for other educational programming.⁶

This contemporary selective review is designed primarily for surgical education leaders who are seeking ways to improve wellness for their learners, colleagues, and themselves. A select group of conceptual frameworks briefly described are largely drawn from an extensive body of scholarship on workplace wellness from outside of medicine. This is followed by some categories of programs that a surgical education leader could implement with the reasonable expectation of a positive impact.

Workplace wellness is defined as a state where the demands of the job are balanced by the available resources, whereas stress results from an imbalance of these demands and resources.⁷ Wellness is important for its own benefits to the individual and should be of interest to surgical education leaders, as it is fundamental to learner engagement marked by a high self-efficacy, energy, and engagement.⁸ There are many sources of demands that are impacting surgery, with some arising from outside of an individual program.⁹ These outside demands can be addressed by advocacy through national surgical organizations. This allows a leader to focus on reducing demands arising from within the program and on increasing support, a combined approach that has been shown to improve workplace wellness.¹⁰

A surgical education leader should engage with the community of teachers and learners to consider specific possibilities, given that a group intervention that works in one setting may not work in another.¹¹ Additionally, it should be expected that not all interventions will work for all individuals. Program evaluation measures should be put into place before an intervention implementation to allow monitoring and the accumulation of program effectiveness evidence. This could be as simple as recording usage information or user opinions about the usefulness of a program. With this system in place, there are three different categories of wellness programs that should prove useful in a surgical education program.  

Address the Basic Human Needs of Surgical Learners (and Teachers)

Patient care may require a short-term sacrifice of what most reasonable people would consider basic needs. Unfortunately, the surgical culture has often celebrated this type of deprivation¹² and will need to be shifted to one that balances necessary sacrifices with the science of stress and wellness. It is important to remember that the most basic needs are physiological and that there are also social and psychological basic needs to including belonginess³. It may be that the social needs have been most degraded during the pandemic and can be rebuilt through gatherings and programs developed by both the program leadership and the residents themselves.

Surgical Teachers Should Be Developed to Use Their Influence to Promote Wellness

The evidence is overwhelming that surgeons have a tremendous impact on the learning culture.¹³ Therefore, they can use this influence to support wellness improving approaches that improve psychological safety.¹⁴ On the other hand, influence can also be impairing if surgical teachers engage in bullying or other anti-social activities.¹⁵ Creating a wellness-promoting teaching culture also includes preparing the learners to make difficult decisions or and navigate through the adverse circumstances that will certainly encounter during a surgical career.¹⁶ Addressing a teacher who is bullying learners should be done recognizing that the surgical teacher may be distressed or burnout which may be the first point of remediation. However, surgical faculty who continue to demean surgical learners may need to counseled or removed from the educational process.

Surgical Educational Leaders Should Role Model the Importance of Individual Wellness Practices

A surgical education can put into place a program for learners and teachers. The likelihood that this will have a positive impact is likely improved if all of the leaders in that department role model that they are mindful of their own wellness. Individual programs to improve wellness do not have to be burdensome and some contain aspects like forgiveness and compassion¹⁷ that can be practiced by even the busiest of surgical education leaders.¹⁷ Elsewhere we have recommended how one stress reduction program could be applied by surgeons.¹⁸ Gratitude, in the form of "three good things" is one of the practices that has been shown to promote wellness in healthcare workers.¹⁹ It can be practiced the surgical education leader by reflecting with gratitude on the great privilege that it is to be able to perform surgery with a great team and simultaneously impact the future of the field through teaching.

1. There is considerable evidence for the importance of wellness in the surgical education community.
2. The emerging literature on surgical wellness practices and the existing relevant theories provide some direction about specific programs that could be introduce with the goal of improving wellness in the surgical education community.
3. Program implementation should only occur after engaging with the local community and after putting measures in place that will allow the assessment of the effectiveness of the program.

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