The transformation of surgical education and its influence on resident wellness

Resident wellness and its opposing state—burnout—are common themes in today’s graduate medical education discourse. There is growing recognition that burnout contributes not only to poor patient care,^1,2 but also to personal and professional dissatisfaction, as well as attrition, depression, suicidal ideation, and suicide.^2-4 Though burnout occurs in many occupations, it is much higher among medical professionals, with rates in U.S. physicians increasing from 45 percent in 2011 to 54 percent in 2014.³

Psychologist Herbert Freudenberger, PhD, originally defined burnout in 1974 as “the consequences of severe or prolonged stress and anxiety experienced by people working in the healing professions.”⁵ In 1981, Maslach and Jackson coined burnout’s three defining features: emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment.⁵ Surgical trainees particularly are at risk for burnout and difficulty maintaining well-being as the result of sustained levels of excessive stress, high acuity of patient diseases, extensive work hours, inadequate time for personal life, prolonged training with little autonomy, and a culture of professional shaming.^2,6-9 Interestingly, all of these factors are inherent to the environment of surgical training rather than characteristics of individual trainees. Some personal factors (such as personality traits, emotional intelligence, and grit/resolve)^6,10,11 may influence the risk of burnout, but by its very definition, burnout reflects a disorder tied to the workplace rather than a personal disorder or dysfunction.

Some surgeons may argue that the training environment has improved over the last 50 years, especially with the advent of duty-hour restrictions. Given these enhancements, the increasing pervasiveness of burnout may seem unusual. In an effort to evaluate this paradox, this article examines the defining features of historical and modern surgical training and then explores changes in the surgical training model over time and the potential impact of each adjustment on resident wellness.

The good old days: A historical perspective

Residents often hear disheartening statements, such as, “In my days of training, things were so much harder,” from more seasoned surgeons regarding burnout management. Perhaps a more appropriate response would be, “Things were so different.”

The term “resident” originates from the era of William S. Halsted, MD, FACS, when physicians-in-training inhabited the hospital, toiling and sleeping in the workplace.¹² Training under this pyramidal model, which was designed to fashion an elite group of surgical leaders, had no set time frame for completion.¹³ Surgical trainees worked all day, every day, and received minimal financial compensation.¹⁴ The Halstedian model lauded dedication to work and patient care over resident well-being. Weakness, complaints, or personal problems were not discussed openly.¹⁵ Marriage was discouraged,¹⁴ and we now know that single status during surgical residency is associated with psychological risk and depression.¹⁶ This archaic, intimidating, and hierarchical design of surgical training fostered certain behaviors that should have made surgeons in training susceptible to burnout.¹⁷ For example, repeated exposure to individually targeted shame and blame as a method of resident training is shown to result in high levels of depersonalization.⁹

This Halstedian model has evolved for myriad reasons, although it did have its advantages. For the resident, the continuous interaction between hospital staff and trainees increased camaraderie and rapport, thereby boosting communication.¹⁸ Importantly, this training model also fostered an all-in venture in mentorship. Mentorship influences the mentee’s work ethic, academic pursuits, social network, and reactions to adversity.¹⁹ Mentors who are dedicated to and invested in their mentees engender confidence and productivity, generating a legacy of formidable surgeons.

Another advantage of Halsted’s system was its positive effect on patient care. In-house residents benefitted patients because they were able to lead every step in perioperative management. The accessibility of the resident boosted patient confidence in a trainee’s ability to operate,¹³ and if the patient had concerns or an acute decompensation, the resident (usually the same individual who performed the operation) was immediately available. Furthermore, miscommunication was less common because residents practically never left the hospital, which eliminated potential errors during handoffs.²⁰

This model also maximized learning. There were no missed opportunities for clinical pearls or developing mature decision-making abilities because residents worked around the clock and rarely took vacations. Furthermore, maximizing all operative opportunities accelerated surgical dexterity. Alfred Blalock, MD, FACS, former American College of Surgeons (ACS) President, understood the balance between paternalism and autonomy and granted his residents independence on the wards and in the operating room (OR).¹⁹ Consequently, there was little perceived need for surgeons to pursue a fellowship or other additional training.^21,22 Although these working conditions were severe, the extent and volume of training during this time ultimately afforded a well-rounded surgeon capable of independently handling a multitude of operations.

Modern training: Transitioning to today’s model

In 1937, the American Board of Surgery (ABS) was formed to standardize the training and education of aspiring surgeons. After its creation, the ABS asserted that “technical training under supervision in an institution must replace unsupervised experience obtained in private practice at the expense of an unsuspecting public.”²³ However, multiple factors, including the litigious and profit-driven nature of health care, the advent of the electronic health record (EHR), and pressures from hospital administration, can hinder the modern-day resident’s quest to become a board-certified general surgeon. Furthermore, in comparison with less than a century ago, a significantly larger proportion of the U.S. population lives with multiple chronic conditions, including obesity, hypertension, and diabetes, making surgical care more complex and time-consuming.^24,25

In part, the increasing prevalence of these conditions, as well as the drive to remain competitive and satisfactorily reimbursed, has driven surgeons to specialization. Consequently, more surgical specialists than generalists now train general surgery residents.²⁶ Some surgeon educators may argue that subspecialists are less invested in trainees because of the mentality that any relevant training deficiencies can be corrected during fellowship.²⁶ Why teach a surgical resident how to do a peroral endoscopic myotomy for achalasia, or robotic portal lymph node dissection for gallbladder carcinoma when the individual will rarely, if ever, perform the procedure as a breast surgeon? Nevertheless, the decreasing preparedness and dwindling confidence of graduating chiefs has been cited as one reason more residents are pursuing fellowships and new apprenticeship models.²⁷ However, with longer training and growing debt, trainees may become financially hampered and jaded.²⁸

In addition to these modifications in surgical education and training, new technology has changed how operations and procedures are performed (that is, open, laparoscopic, robotic, and endoscopic). To standardize the product of general surgery residency with these innovations, the Accreditation Council for Graduate Medical Education and the ABS have instituted requirements to apply for the qualifying and certifying exam in general surgery. Chief residents must complete and maintain certification in Advanced Cardiovascular Life Support and Advanced Trauma Life Support^®, pass the Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery courses, take the ABS In-Training Examination, meet the appropriate threshold for the subjectively graded surgical milestones, participate in at least six operative performance assessments and six clinical assessment and management exams (outpatient), all while meeting the quota for operative cases in each defined category.²⁹

Although today’s residents perform in total an equal number of operations as their counterparts in the Halsted era, chief residents perform fewer operations with less autonomy in part because of the supervision requirements from governing bodies.³⁰ The only increases in volume that residents experience are in the clerical responsibilities that remove them from clinical training. As use of the EHR becomes more widespread, more resident hours are spent outside of the hospital, performing nonscholarly activities. A recent study shows that 30 percent of resident hours in the hospital are used for documentation, and one-third of total EHR usage time is done outside of inhospital work hours.³¹

Many surgical training programs and organizations have pushed for more simulations to avert surgical training deficiencies, but the technology and infrastructure surrounding this movement are still in their infancy. These changes are designed to prepare residents for practice, but they also serve as significant burdens that did not always exist.

Historical training and wellness

Considering the lack of work/life balance in the Halsted era, burnout should have been a bigger issue for physicians then; however, no evidence is available to support that perspective. Perhaps surgical trainees at that point in time were more resistant to stress, more dispassionate, and better able to tolerate the severe training environment.^16,32 More plausible, however, is that stress related to medical bureaucracy seen in the modern age of surgical training simply was not a factor during the Halsted era.³³ For example, paper charts containing the patient’s bare essentials were acceptable during this period.³⁴ Surgeons were not expected to document a visit diagnosis or update the problem list. Furthermore, no accrediting body had been established in the early 1900s to evaluate the knowledge and abilities of a chief surgical resident. National standards for competency and safety were nonexistent and requirements for Fellowship in the ACS were rudimentary:²³

• A year’s internship, usually rotating
• Two years as an assistant under a preceptor
• Visits to surgical clinics
• Submission of a list of 50 consecutive operations

Graduation from an approved medical school became a requirement for Fellowship in the ACS as late as 1920.²³

Reis and colleagues offer a different explanation regarding why trainees during the Halstedian era avoided burnout. The authors state that well-being is sustained by three elements: autonomy, competence, and relatedness.³⁵ Successful achievement of a particular surgical skill (competence) on one’s own terms or direction (autonomy) promotes well-being, and modern research has shown burnout decreases when people can point to personal accomplishments and competencies.⁶ Halsted’s model was stringent, but it centered on autonomy and independent action, perhaps mitigating burnout.⁶

Furthermore, previous-era trainees had renowned mentors. Mentoring relationships promoted job satisfaction, self-confidence, motivation, companionship, and elevated personal aspirations.³⁶ Edward Delos Churchill, MD, FACS, believed that these time-honored academic pairings were dangerous because residents would idolize only one surgeon who might be anti-intellectual and anti-scientific.²³ There was little room for deviation from the mentoring surgeon’s dogma in these “quasi-parental, self-aggrandizing, and authoritarian tutelages,” which potentially wasted the creativity and passion of vibrant, young trainees.²³ More recently, however, Zhang and colleagues have shown that effective formal mentorship programs in surgical residency may alleviate stress and burnout, and facilitate personal satisfaction and a better quality of life.³⁷

Training and burnout

The attrition rate for general surgery residency is approximately 20 percent, placing it higher than other specialties.¹⁰ Several studies have suggested that an increased workload, including longer hours, more days on call, and more patients, is the reason.^32,28 Combining this excessive workload with other educational and societal pressures, resident work hours were restricted to 80 hours per week. However, according to Lindeman and colleagues, the new duty-hour regulations have had a limited impact on the quality of life for residents.¹¹ So, if not long hours or fatigue, why do 69 percent of U.S. general surgery trainees meet the criteria for burnout, while 44 percent have contemplated dropping out?^11,38

Family physician, chief executive officer of TheHappyMD.com, and Burnout Proof mobile phone application developer Dike Drummond, MD, offers the following five common causes of burnout:³⁹

• The practice of clinical medicine (great responsibility with little control)
• The specific job (call schedules, salaries, politics)
• Having a life (family and social pressures)
• The conditioning of medical education (to never show weakness)
• The leadership abilities of supervisors

The first three reasons are intuitive, but the latter two merit exploration. The personal characteristics that once led to success in medical education also may predispose residents to burnout. Whether one is the workaholic, the superhero, the perfectionist, or the lone ranger, the stress of caring so aggressively for patients eventually will end in fatigue, chronic defensiveness, or guilt.³⁹

The quality of a supervisor and mentor also has a direct effect on burnout. Van Vendeloo and colleagues support this claim and cite supervisory support, accessibility of supervisors, and mutually supportive relationships with supervisors as key factors to prevent burnout.⁴⁰ Schönrock-Adema and colleagues have shown that the ability to identify positive role models and the ability to receive direct feedback correlate with resident burnout.⁴¹ Unfortunately, because of the increased clinical and academic demands affecting the surgical trainee experience,⁴² mentorship has, in many respects, devolved, and these formative relationships are in short supply.³⁶

Increased administrative duties are another major source of stress for surgical trainees. Electronic charting consumes much of the time of a surgical resident, which often thwarts physicians from directly caring for patients.⁴³ In a previous era, the physician-patient relationship provided satisfaction for both physicians and patients, but research shows that contemporary physicians spend more time working on EHRs than with their patients.⁴⁴ Furthermore, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 imposed financial penalties for providers who do not use the EHR. Since the Centers for Medicare & Medicaid Services began implementation of this legislation, clinical documentation has nearly doubled among U.S. physicians, and U.S. clinical notes are now four times longer than the rest of the developed world using EHRs.³⁴ This increased computer time equates to patient encounters in which less than 25 percent of the visit is spent communicating with a patient.³⁴ Chung and Ahmed, in a study on resident efficiency, found that junior residents spend excessive time on rounds and the remainder of their day completing aimless, less educational tasks that provide no sense of accomplishment.⁴⁵ The anxiety and disparaging chores become toxic, resources are depleted, and burnout becomes inevitable.

In his 2009 book, Drive: The Surprising Truth About What Motivates Us, Daniel H. Pink argues that staying motivated and avoiding burnout centers on autonomy, mastery, and purpose.⁴⁶ Surgical trainees are self-directed and want to be able to control a task, time, technique, and team in order to be productive. However, because of increasing managerial constraints, government cost regulations, and patient safety demands, residents have less autonomy than ever.¹ Mastery involves a healthy work environment with clearly defined goals and the infrastructure necessary to achieve a task.⁴⁶

However, administrative obligations erode clinical mastery. In fact, residents diagnosed with work-related post-traumatic stress disorder (PTSD) cite these tasks as one of the top sources of their condition.⁴⁷ A 2015 study by Thompson and colleagues revealed that 17 percent of 144 surgical trainees had pathological symptoms consistent with PTSD, attributed not only to the burden of overregulation but also to the negative media portrayal of surgeons and the shame physicians experience when medical errors occur.⁴⁸

Mr. Pink describes purpose as the fuel for autonomy and mastery. From a trainee standpoint, purpose is the sense that the work one does is meaningful, important, and consequential. Direct patient care, rather than administrative work or research, is often cited as the most meaningful aspect of a physician’s occupation. Shanafelt and colleagues demonstrated that physicians who spend less than 20 percent of their time on the activity that is most meaningful to them had significantly higher rates of burnout.⁴⁹ Exploitation of residents as scribes, secretaries, and laparoscope navigators is making the concept of purpose increasingly elusive for these trainees. While burnout transpires when at least one of the elements of Mr. Pink’s trinity (autonomy, mastery, and purpose) is disrupted, in the contemporary training system, all three often are jeopardized.

Rekindling the fire without burning out

Several factors have been implicated in trainee burnout, including the length of training, extensive working hours, imbalance between career and family, and poor mentorship. Despite these factors, general surgery resident education has continued to evolve in many notable ways. Residents are able to live outside the hospital, and the system is now geared toward having all residents, rather than just an elite few, successfully finish a training program. Furthermore, the culture has shifted toward more reasonable treatment of trainees and the health care team as a whole. Surgeons are expected to treat individuals with respect, and the culture of safety encourages all team members, regardless of their perceived position in the hierarchy, to be patient advocates.⁵⁰ Nonetheless, it is important to continue to examine the state of surgical education.

Because residents must meet more regulatory requirements but experience less time in the hospital, we must find solutions to maximize clinical and educational opportunities to achieve adequate training. As with any complex problem, many separate routes can be taken to improve the system. For example, resident autonomy previously stemmed from residents operating without the attending’s presence in the OR. Perhaps resident autonomy could be improved with implementation of a formal system of graded independence in the OR.⁸ More flexibility in the work-hour restrictions may facilitate more comprehensive perioperative management, while still maintaining reasonable expectations as to the time commitment of residents. Modifying the EHR to improve workflow and decreasing the administrative burden on physicians is an opportunity to develop wellness and reduce the risk of burnout in both resident and attending physicians.

Because resident wellness is negatively affected by an increased administrative burden and decreased autonomy, burnout could be mitigated by prioritizing the educational tactics that support self-actualization among surgical trainees. Above all, altering surgical education can only occur in a manner that maintains the patient at the center of care.

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