Nurturing wellness and fostering resilience during a surgical career: An introduction

It’s no secret that a surgical career is challenging, grueling, demanding, and emotionally and physically exhausting. We know that surgeons experience burnout at a significantly higher rate (37 percent to 53 percent) than both the general population and physicians of all specialties.¹ Burnout occurs for a variety of reasons, including challenges maintaining a work-life balance, the ever-changing health care landscape and associated bureaucracy, and prolonged training and delayed gratification. Furthermore, surgical trainees and young, new-to-practice surgeons are at particularly high risk for burnout.²

Nonetheless, every year, surgical residency positions are overloaded with medical school graduates drawn to the discipline. It sometimes can be hard to describe to a nonsurgeon the allure of the operating room environment, the technical beauty of a procedure, or the gratification of providing quality patient care—all of which make this vocation so rewarding at such a high, personal cost. In this issue of the Bulletin, the Resident and Associate Society of the American College of Surgeons (RAS-ACS) expands the focus beyond surgeon burnout to topics related to cultivating and nurturing surgeon wellness and resilience.

What is wellness?

It is tempting to define wellness as the antithesis of burnout; however, we should challenge ourselves to think more critically about what being well really means. What are we seeking, both personally and professionally, that would provide us optimal levels of emotional and intellectual fulfillment? Does it mean perfect work-life integration with equal time spent at work and time with family or friends? Does wellness mean daily workouts and a healthy diet? Does it mean always feeling like your work is meaningful and purpose-driven? A state of wellness undoubtedly has a different meaning to each surgeon, and so to provide a definition is a challenging endeavor. Physicians at the family medicine residency program at Oakland University William Beaumont School of Medicine, Rochester, MI, developed this shared definition of wellness when embarking on a culture change at their institution: “Wellness is defined as a dynamic and ongoing process involving self-awareness and healthy choices resulting in a successful, balanced lifestyle.”³

Promoting wellness among surgeons must be a conscious effort in the workplace, as well as a personally driven effort. Bohman and colleagues define three major reciprocal domains of well-being: efficiency of practice, culture of wellness, and personal resilience, noting that the first two are primarily organizational responsibilities, and the latter the responsibility of the individual surgeon.⁴ Each domain inevitably has an effect on the other, and expecting physicians to improve their self-care or build resilience without accompanying cultural improvements in the workplace environment, or vice versa, is illogical.

In recognition of the increasing evidence for a multipronged approach to wellness, the Accreditation Council for Graduate Medical Education issued revised standards in 2017 that, for the first time, include wellness as a training priority.⁵ These standards essentially identify self-care, meaning/purpose, mentorship, and education as pillars of well-being that should be cultivated as part of a physician’s professional development.

As of May 2019, Shapiro and colleagues have further clarified meaningful practical interventions for physician wellness. The result is the Health Professional Wellness Hierarchy. Modeled after Maslow’s hierarchy of needs, it defines key levels and factors at those levels that can be addressed in the workplace using a systematic approach to support wellness.⁶ Importantly, the structure of this hierarchy places physician autonomy, patient connection, contributions to the field, and the delivery of optimal care at the highest level, and suggests that the best patient care occurs when physician wellness, in terms of basic human needs, safety, respect, and appreciation, is promoted and nurtured.

The role of the ACS

As a result of the efforts of the ACS Board of Governors Physician Competency and Health Workgroup, the College has played an active role in promoting wellness among its members by providing an interactive, anonymous Physician Well-Being Index. This index allows you to benchmark yourself against other physicians nationally, as well as yourself over time. In addition, it provides local and national resources to help address your specific needs. Furthermore, the ACS maintains a repository of resources, which can be found on the Surgeon Well-Being Resources page.

The RAS-ACS, in many respects, represents the group of surgeons who are both most likely to suffer from burnout and also most likely to incorporate and perpetuate a wellness cultural change within surgery for generations to come. As such, we chose to dedicate this year’s August issue of the Bulletin to wellness and resilience in surgery. We approach this topic from diverse perspectives to provide readers with a well-rounded understanding of the subject matter, and we anticipate that readers will find these articles thought-provoking and insightful.

The articles emanate from each RAS-ACS standing committee and address themes such as perceptions of wellness across the history of surgery, the role of positive self-talk in nurturing wellness, membership and community as mediators of wellness, and the influence other industries have on promoting wellness and resilience in surgery. These articles are written primarily with trainees in mind, but we anticipate that the information presented will be useful to clinicians at all stages of their career.

References

1. Dimou FM, Eckelbarger D, Riall TS. Surgeon burnout: A systematic review. J Am Coll Surg. 2016;222(6):1230-1239.
2. Pulcrano M, Evans SR, Sosin M. Quality of life and burnout rates across surgical specialties: A systematic review. JAMA Surg. 2016;151(10):970-978.
3. Eckleberry-Hunt J, Van Dyke A, Lick D, Tucciarone J. Changing the conversation from burnout to wellness: Physician well-being in residency training programs. J Grad Med Educ. 2009;1(2):25-230.
4. Bohman B, Dyrbye L, Sinsky CA, et al. Physician well-being: The reciprocity of practice efficiency, culture of wellness, and personal resilience. NEJM Catalyst. August 2, 2017. Available at: https://catalyst.nejm.org/physician-well-being-efficiency-wellness-resilience/. Accessed May 30, 2019.
5. Accreditation Council for Graduate Medical Education. Summary of changes to ACGME common program requirements section VI:VI.C: Well-being. 2017. Available at: www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements/Summary-of-Proposed-Changes-to-ACGME-Common-Program-Requirements-Section-VI. Accessed May 28, 2019.
6. Shapiro DE, Duquette C, Abbott LM, Babineau T, Pearl A, Haidet P. Beyond burnout: A physician wellness hierarchy designed to prioritize interventions at the systems level. Am J Med. 2019;132(5):556-563.