Training resilient surgeons: Where do we go from here?

The goal of medical training is to equip future physicians and surgeons with the skills and knowledge they need to support the health and well-being of their patients. Paradoxically, the demands associated with the U.S. medical education system can have well-documented negative effects on the health and well-being of trainees.^1-3 Despite the fact that college graduates who are matriculating into medical school have significantly lower levels of depression and burnout than their age- and education-matched peers who are entering other fields, by the time they graduate from training, levels of depression and burnout in medical students are nearly twice that of nonphysician professionals.^1,3

Levels of burnout continue to rise as trainees enter residency.^4-6 This trend is especially apparent in general surgery residents, with approximately 70 percent of these individuals meeting the criteria for burnout.^5,6 Additionally, nearly one in five general surgery residents leave residency before completing their training.⁷ Reasons cited for attrition include a lack of work-life balance and the high personal cost of residency training.^8,9 In addition to the tremendous personal cost of residency attrition, these losses in the surgical workforce further tax an already under-resourced health care system and erode its ability to provide appropriate care to patients.¹⁰

Perhaps most concerning is the fact that as trainees advance from residency into professional practice, they generally continue to display signs of burnout. It is reasonable to say that burnout among U.S. physicians has reached epidemic levels.^11,12 The effect on patient care is substantial. In a study of 7,905 practicing surgeons in the U.S., approximately 10 percent reported that they had made a major medical error within the preceding three months.¹³ These errors were significantly associated with the presence of burnout. Furthermore, symptoms of both burnout and depression were revealed to be independent predictors of reporting major medical errors.^13,14

The gravity of this issue is further compounded by the effect of burnout on the mental and emotional health of physicians. One survey of 25,073 U.S. surgeons found that approximately 14 percent of men and 26 percent of women met criteria for alcohol abuse or dependence and that the presence of symptoms of burnout or depression were significant risk factors.¹⁵ A similar study of 7,905 U.S. surgeons showed that surgeons who met the criteria for burnout were nearly twice as likely to exhibit suicidal ideation in the last 12 months as surgeons who did not meet the criteria for burnout after controlling for personal and professional characteristics.¹⁶ These stark findings demonstrate that addressing surgeon burnout is imperative for our professional and societal well-being. A call to action has been issued, and surgical organizations are searching for solutions to this troubling trend across all levels of training and experience.

Addressing burnout in surgical training

Initial efforts to address physician burnout largely focused on improving resilience by providing support for individual wellness and stress management through activities such as meditation and yoga.¹⁷ Yoga and meditation are shown to reduce stress hormones, as well as improve relaxation response and parasympathetic functions, which can help instill a feeling of greater control over situations.¹⁸ These strategies provide benefits for practitioners, with multiple studies offering moderate-quality evidence to support the role of yoga in mitigating depression, anxiety, and fatigue.¹⁹

Mindfulness-based therapies also have been shown to alleviate a variety of mental and physical conditions associated with chronic stress.²⁰ One study involving primary care physicians used mindfulness-based techniques such as meditation and self-awareness exercises to train health care professionals to deal more effectively with unpleasant thoughts and feelings, to better manage conflict, to more effectively set boundaries, and to prioritize self-care. This intervention resulted in both short-term and sustained improvements in well-being.²⁰ Although these results have been promising, a meta-analysis of interventions to reduce burnout showed that though individual-level interventions successfully reduce burnout, the benefits are modest.¹⁷ This finding illustrates that additional institutional-level interventions are needed to sufficiently address burnout.

Duty-hour restrictions

Some of the first attempts to tackle burnout in health care at a systemic level were instituted in 2003 with the implementation of the 80-hour resident workweek. Although this intervention did result in a measurable reduction in burnout, it did not eliminate the issue and had almost no effect on attrition rates.^21,22 In 2011, the Accreditation Council for Graduate Medical Education (ACGME) attempted to improve on these advances with the initiation of duty-hour limits aimed at reducing burnout and its complications. In a two-year evaluation of these new policies involving 213 surgical interns, 82 percent of residents reported a neutral or good overall quality of life, but approximately one-third of the respondents continued to report symptoms of burnout.²³

Duty-hour restrictions are not linked to notable improvements in patient outcomes, patient safety, or resident satisfaction in terms of well-being.²⁴ In fact, it is possible that the increased frequency of handoffs associated with duty-hour restrictions leads to additional opportunities for mistakes, decreases educational opportunities, and interferes with continuity in patient care, thereby creating an additional burden for residents who are forced to choose between professional values of patient care continuity and regulatory compliance.²⁵ Duty-hour restrictions, while well-intentioned, ultimately demonstrate that burnout, wellness, and patient care are predicated on more than the number of hours worked.

Departmental wellness programs

To further promote an institutional culture of wellness, many residency programs have begun to implement curricular interventions into their program infrastructure. Researchers at Stanford University, CA, designed a multifaceted Balance in Life program that addresses six components of resident well-being, including a resident mentoring program, counseling sessions, healthy food options, and resource guides.²⁶ Although this intervention yielded little statistical improvement in psychological well-being or burnout, implementation did correlate with increased “grit” scores, increased resident-reported sleep, and increased rates of resident-reported exercise and physical activity.²⁶

Other programs have responded to low resident morale by organizing monthly social events, such as family-friendly activities, and support groups to encourage sharing of common experiences to foster a sense of relatedness and belonging.²⁷ Other residency programs have taken these interventions a step further by attempting to apply additional objective measures to their wellness programs. The department of neurosurgery at the Medical University of South Carolina, Mount Pleasant, employed activity monitors and psychological and physical testing to track health measures, including resident weight, blood pressure, and sleep habits.²⁸ This information was shared with residents, and trainees were provided with wellness lectures, group exercise sessions, and an increased availability of healthy food options. To date, this intervention has shown modest improvements in weight loss and an increase in self-reported team comradery.²⁸

Multipronged approaches to addressing wellness often use a combination of training in mindfulness, teambuilding, stress-reduction techniques, and emotional intelligence. Other novel strategies that have been implemented to enhance resident well-being include dry cleaning service for surgical residents, mandatory quarterly or monthly half-days to attend to personal needs, and even meal delivery for residents returning to clinical duties after parental leave. Many residency programs host annual resident retreats during which residents are free of clinical duties for the entire day to participate in team-building activities.

Despite these innovative approaches and the progress that has been made, we are far from achieving optimal wellness in the field of surgery and surgical education. What will the next chapter of wellness interventions look like, and how can we as learners and educators influence this work?

Learning from other high-stress fields

Research examining the major domains that contribute to physician well-being have identified efficiency of practice, an institutional culture of wellness, and personal resilience as key factors for avoiding burnout and professional fulfillment (see Figure 1).²⁹ This work demonstrates that both individuals and health care institutions must be equal partners in addressing surgeon burnout in order to create a culture of wellness. To highlight novel strategies for moving to the next phase of burnout prevention, we examined comparable professions—specifically high-stress fields that require near-perfect levels of performance—to see what interventions and techniques have been used to maintain a culture of wellness and resilience.

Figure 1. Institutional and individual factors both contribute to surgeon wellness

Lessons from the field of aviation

Many parallels have been made between aviation and the health care fields, which have led to advances in promoting passenger and patient safety, including checklists, simulation training, team-based work, performance analysis, and incident reporting.³⁰ Similar associations can be made when considering the management of pilot and health care professional well-being and fatigue. In both aviation and health care, fatigue and burnout can lead to errors, reduced reaction time, poor communication, and an overall increased risk to individuals who count on professionals to deliver safe outcomes.^30,31 For instance, long days with multiple short flights and quick ground turnaround times are comparable to performing multiple short operations with fast turnover times, leaving little time for nutrition and hydration. Night flights and night duties contribute to disrupted circadian rhythms and rest periods during normal awake hours. Analogous to what has been seen in surgical residency, duty hours in the aviation industry have limitations that often paradoxically aggravate or compound fatigue.³² Ideal minimum break periods between shifts—defined as nine hours in aviation and eight hours in surgery—do not account for factors such as travel time to home, meal preparation, and family responsibilities, which cut into the amount of time remaining for sleep and recuperation.

To combat pilot fatigue and the associated negative consequences, the airline industry has introduced the fatigue risk management system (FRMS) as an alternative to prescriptive duty limitations. An FRMS is a data-driven, flexible process of monitoring and managing fatigue risk to maximize operational efficiency.^31,32 The minimum components of an FRMS include a managing policy published by the governing or regulating body, education and awareness training, nonpunitive identification and reporting systems for fatigue-related incidents, and enforcement at all levels within the organization.³² The four main objectives of an FRMS are used to establish policies for plan enforcement, manage pilot workload through predictive scheduling models, require safety data collection through air safety and flight reports, and provide sleep and fatigue assessments using in-flight observations and self-generated feedback. The FRMS also ensures that pilots receive regular training on the physiologic consequences of fatigue and learn strategies for recovery, planning, and optimized break time.³¹ As more research has been conducted to assess reduced break times before shifts in the aviation industry, researchers have found that the longest duty times do not always correlate with the highest number of adverse events, suggesting that team cooperation and automation are more heavily relied upon during the longer shifts to compensate for individual fatigue.

The aviation industry’s FRMS initiative has significant implications for surgical residencies and duty hours. Shifting from a prescriptive, time-based approach to a more strategic fatigue management system might better mitigate the effects of acute and cumulative fatigue. Moreover, the promotion of restorative break times that incorporate a good balance of family time, meals, and rest would allow for greater alertness and better mood during duty time. When longer duty hours are required, as in the instance of overnight call coverage, incorporating automation, such as cell phone reminders and electronic health record notifications, as well as increased emphasis on teamwork, may reduce the number of safety incidents secondary to fatigue and diminished well-being. Most importantly, an FRMS intervention emphasizes the importance of creating a culture of wellness at the institutional level and enhances ease of practice—two essential components in a holistic model of surgeon wellness.

Lessons from the field of education

Another decidedly influential and demanding field in the U.S. is teaching. High daily stress frequently leads to educator burnout, with 40–50 percent of teachers leaving the profession within the first five years.³³ Educators regularly face increasing job demands, including increased number and frequency of standardized exams, student behavioral issues, and parental concerns. This trend directly parallels the all-too-familiar struggle of surgical residents and new-to-practice surgeons, who are expected to develop an exponentially increasing medical knowledge base, engage more patients with compassion, and tackle ever-increasing documentation requirements. Physicians, who regularly assume the role of teacher to colleagues, residents, and patients, face similar stressors and may benefit from interventions that are being used in education.

Interventions to improve the wellness of our nation’s teachers and educational system as a whole have been divided into three levels: individual, organizational-individual interface, and organizational.³⁴ Individual-level interventions, such as cognitive behavioral techniques, have been shown to enhance awareness development, provide a coping mechanism for managing difficulties, and increase emotional well-being by reducing anxiety and depression.³⁴ In randomized controlled trials of educators, contemplative practices like yoga and meditation were found to decrease burnout, lessen the impact of negative emotions, decrease the physical symptoms of stress, increase mindfulness, improve emotional well-being, increase positive emotions, and improve teaching efficacy.^34,37 Interestingly, these interventions also resulted in improved overall quality of teaching.³⁴

Organization-individual interface interventions, which focus on building workplace relationships and support, have been found to result in significant improvements in teacher well-being.³⁴ Longitudinal mentoring programs for novice teachers have proven particularly effective in increasing educator satisfaction and retention and bolstering student achievement. Workplace wellness programs, focused on nutrition or exercise, have been found to reduce health risk, health care costs, and absenteeism. Although many organizational initiatives are directed at the culture of wellness in education, little data is available to indicate the impact these interventions have had on educator wellness and performance.

Four key factors have been identified as major contributors to teacher stress: school organization, job demands, work resources, and social and emotional competence.³⁴ These findings echo the conceptual framework outlined in job demands-resource theory,^35,36 a model for understanding burnout that is used in occupational psychology and has direct implications for understanding burnout in surgery (see Figure 2). From a systems perspective, a collegial, supportive environment is paramount to high performance, as well-being requires both a sense of belonging as well as the ability to contribute as an individual. The creation of a supportive environment involves strong leadership with a clear sense of direction, trustworthy colleagues, and suitable working conditions. Institutional support in the form of ease of practice and a culture of wellness plays a key role in maintaining and enhancing teacher well-being.

Figure 2. Simplified job demands-resources model applied to surgeon burnout and wellness

Analogous to findings from the medical field, educator wellness is heavily influenced by the work environment, which encompasses factors such as institutional culture, resources, and support. Though much of the early research in educator well-being focused on interventions at the individual level that are aimed at enhancing personal resilience, current studies are now moving toward an increased focus on the importance of policy and program changes in improving educator wellness.

Recommendations for moving forward

Frequently the focus is on individual-level interventions to promote surgeon well-being; however, both the aviation and education professions demonstrate that concurrent systemic changes are necessary to foster a surgical culture that encourages and actively enhances physician wellness. Fortunately, leaders in surgery and education are making great strides in this regard. The American College of Surgeons now offers access to a Physician Well-Being Index³⁸ that allows members to complete an online self-assessment and track various measures of well-being over time, with free resources tailored to respond to the risks identified in the self-assessment. The ACGME also has taken steps to address wellness through more explicit wording in the common program requirements³⁹ and through the use of resident feedback in the Clinical Learning Environment Review program. The American Medical Association offers an innovative STEPS Forward program, designed to educate physicians about evidence-based individual- and organizational-level interventions to improve physician wellness.⁴⁰ These and other initiatives empower surgeons at all levels to alleviate burnout through increased engagement in shaping the culture of medicine and creating interventions to enhance ease of practice at both the local and the national level.

Recent research has suggested adapting Maslow’s hierarchy of needs as a framework for addressing physician wellness.^41,42 This hierarchy provides a guideline for thinking about a progressive approach to addressing wellness. It suggests that as needs are met at each level, individuals are motivated to progress upward toward higher-order needs and achievement. This model is exceedingly practical; it assumes that ultimately surgeons will be most fulfilled when their higher-order needs—such as finding joy in practice—are met. It acknowledges, however, that to reach this state, surgeons must first have their basic physiologic needs met, such as hydration, sustenance, and sleep.

Moving forward, strategies to promote wellness and mitigate burnout should focus on approaches that address both institutional issues, such as a culture of wellness and efficiency of practice, as well as personal resiliency.²⁹ As demonstrated in other high-stress fields such as aviation and education, these strategies need to be responsive and creative—not prescriptive. Surgeons can expand our understanding of the factors that drive burnout by studying applications of occupational psychology. This approach explores how ideas such as job-crafting—the process of actively engaging workers in defining their scope of work and providing them with structural job resources while minimizing negative job demands—may move us even further toward achieving a true reduction in resident and surgeon burnout.⁴³

Involvement of all stakeholders, including policymakers, individual institutions, faculty, and residents, is imperative to making real, sustainable change. The national and international dialogue about how to address the epidemic of burnout in the field of surgery should continue, and trainees and health care professionals at all levels should be empowered to be change agents in shaping the process of moving from burnout to wellness.

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