January 10, 2024
While residency programs continue to build an elaborate scaffolding of well-being programs to curb burnout, residents are struggling to maintain good mental and physical health, sometimes ignoring their own body’s signals to eat, rest, and relieve themselves in the name of patient care and sustaining a rigorous training schedule.1
According to a report published in 2023 by the American Medical Association that examined well-being and burnout in residents and fellows, second-year residents demonstrated the “highest job-related stress of any residency training year.”2 When queried about barriers to pursuing mental health services, respondents expressed preferences for pursuing counseling privately, citing concerns related to confidentiality and limited access to services.2
Beyond residency, burnout is experienced by many healthcare providers, including general surgeons (58.6%), which can result in diminished patient care and engagement, and poor outcomes.3
The authors of a study in the September 2023 issue of the Journal of the American College of Surgeons (JACS) noted that although the effects of burnout are well documented, strategies to mitigate this condition often have limited effects.4
“Focus on resident-level interventions, although valuable, neglects critical system- and cultural-level issues that contribute to burnout’s persistence,” wrote the authors.4 They suggest employing the concept of value congruence to “address the intersection between individual-, system-, and cultural-level components of burnout.”
Value congruence is a “measure of the salient workplace environment and is defined as the degree of alignment between worker and workplace values, [which may be] a strong measure of person–organization fit.” The concept of value congruence is routinely used by business organizations as an indicator of employee job satisfaction and is associated with enhanced levels of wellness and reduced attrition and burnout.
“Relatedness, in part, refers to the type of culture your institution creates and how it influences your relationship with your peers.”
Notably, value congruence also is a strong source of “intrinsic motivation,” a driver of employee satisfaction and performance that Carter C. Lebares, MD, FACS, coauthor of the JACS study, calls “the brass ring, the golden chalice” for optimizing well-being in residents and surgeons. Dr. Lebares is an associate professor of surgery at the University of California San Francisco (UCSF), and director of the UCSF Center for Mindfulness in Surgery.
“The concept of intrinsic motivation comes from Marylène Gagné’s Theory of Self-Determination and it refers to a motivation that is self-generated,” explained Dr. Lebares. “It doesn’t come from payment for performance or punishment for non-compliance. It comes from within an individual and is typically considered to be derived from the quality of work that one does. This doesn’t necessarily mean the qualitative difference between rocket science versus making widgets on an assembly line; it has more to do with the environment in which one works and whether or not that gives you joy, even if you’re doing something that’s intellectually kind of boring.”
The Marylène Gagné Theory of Self-Determination suggests that autonomy, competence, and relatedness are fundamental components of intrinsic motivation, and relatedness in the domain most associated with value congruence.5
“Relatedness, in part, refers to the type of culture your institution creates and how it influences your relationship with your peers,” Dr. Lebares said. “But it can also refer to the relationship between workers and leaders, which may be even more important. We know that if you trust your leadership, if you feel that what they say is reflected in what they do, and you believe that their motivations and their values align with yours, you get the best work possible from people—they put in the most effort, they’re the most creative, and they have the best performance.”
In an effort to examine general surgery residents’ perception of value congruence specifically tied to well-being initiatives and resources, Dr. Lebares and coauthors conducted a two-part, mixed-methods study of trainees from 16 Accreditation Council for Graduate Medical Education-accredited academic programs.
In Part 1 of the study (January 2021), surgical residents from general surgery residency programs answered questions related to well-being in survey 1. In April 2021, interviews with program directors or their proxies also were conducted.
“The first part of our study focused on analyzing the survey 1 responses to the open-ended question exploring residents’ training experiences,” said study coauthor Paul Adam Gonzales, MD, a research fellow at the UCSF Center for Mindfulness in Surgery. “We asked them questions like what well-being resources were beneficial or not beneficial? Or what elements of their day-to-day experiences were most antagonistic to their well-being? We thought it was important to understand these perceptions in a subjective manner since they are powerful influences of behavior.”
These data revealed a theme of residents’ mistrust in leadership and the perception of incongruent words and actions from leadership. In part, this was related to COVID-19 pandemic events but also to well-being overall.
For Part 2 (May to June 2022), a similar cohort of surgical residents participated in survey 2 in order to assess the association between perceived trust in leadership (value congruence) and individuals’ global well-being (flourishing).
“Flourishing represents the positive end of the Mental Health Continuum-Short Form (a 14-item measure of psychosocial well-being) where individuals with higher scores frequently experienced positive functioning and emotions, ‘every day’ or ‘almost every day’,” explained Dr. Gonzales. “In the context of our results, residents who perceived having this shared alignment or perceived authenticity within their residency programs had higher scores of individual well-being, representing a high sense of purpose, motivation, and resilience.”
This multicenter study exploring value congruence within the general surgery training setting produced three core findings, according to study authors:
“I think the most important thing to know is that what we’re proposing is not the end of the story or the whole story,” said Dr. Lebares. “We created a study with a mixed methods approach that allows us to begin to understand what’s at work here and provides the opportunity for us to start drilling deeper by looking at much bigger cohorts to understand where the truth lies.”
Four common “subthemes” related to deficient value congruence and the availability of wellness resources surfaced in the results from Part 1, survey 1: inaccessibility, insufficiency, inconsiderateness, and inauthenticity.
Inaccessibility: The subtheme that was most frequently mentioned was inaccessibility, according to Dr. Gonzales, which refers to interventions that are well-intentioned, but typically cumbersome or difficult to use, such as half-days that directly conflict with residents’ other responsibilities.
“We’ve selected and trained these people to be responsible for patients, and now we’re telling them to ignore that responsibility—albeit briefly—for their own well-being. Sort of like, you can have this marvelous reward if you can swim across the ocean to get it. It’s just not realistic,” Dr. Lebares said.
Insufficiency: Residents identified wellness resources that they perceived to be “unrealistically sparse in quantity or quality,” according to the study. Lack of mental health interventions, the desire for more frequent or longer wellness days, and the need for these opportunities to become standard practice rather than negotiated one-offs were routinely noted by survey respondents.
“A real killer of intrinsic motivation or joy in work or people feeling an affinity for the place where they work has to do with their sense of the authenticity of their leadership."
Inconsiderateness: Perceptions of an insensitive approach to implementation of wellness programs by residency program directors were expressed by some survey respondents, particularly interventions that were deemed mandatory.
“Program directors told us that making an initiative mandatory was to protect that time,” explained Dr. Gonzales. “But I think residents feel like they are being forced to do something, which actually works against the goal of finding peace or engaging in a restorative activity.”
He cited an example of an institution requiring residents to take yoga even when they’ve been on call for 24 hours. (Dr. Lebares pointed out that yoga is often considered to be an evidence-based wellness intervention, although residents may prefer other solutions despite the data, due to their own biases or lack of understanding.)
Inauthenticity: This subtheme refers to resident perception of departmental leadership exhibiting “insincere prioritization” of well-being, or asserting that well-being is critically important but not taking actions that reflect this stated priority, according to the study.
“A real killer of intrinsic motivation or joy in work or people feeling an affinity for the place where they work has to do with their sense of the authenticity of their leadership,” said Dr. Lebares. “And it was interesting because what the residents described reflects things that we’ve been hearing in work with faculty or with practicing surgeons, and it includes the idea that physicians and surgeons feel like they are being exploited by a healthcare system that is increasingly focused on profit.”
She was quick to point out that people who select medicine or healthcare as a career overwhelmingly do so because they wish to serve others, although being paid fairly is still important. “However, there isn’t enough money in the world to compensate for the heartache, the devotion, the duration of training, the fact that maybe you have to urinate or sleep, but you’ll actually subjugate those physical needs to care for someone who you might not even know.”
As a result of this reality, a critical “compensation” for surgeons and residents comes in the form of intrinsic motivation, which includes a sense of purpose, enjoyment of the work itself, and overall fulfillment. “When value congruence with one’s institution and leadership is perceived as authentic and trustworthy it reinforces these qualitative, intrinsic experiences. When those things are not present, it can feel as if one’s intrinsic motivation is being exploited,” explained Dr. Lebares.
Comments from survey respondents, some of which are excerpted in the JACS study, include the following quote underscoring some residents’ deep-rooted desire for authentic leadership and action: “The healthcare hero shirts and mugs…they are not helping. They are propaganda to normalize the oppression and suffering of healthcare workers. Give us better food, adequate PPE, time off, staff coverage and hazard pay…We are physically and emotionally dying here.” This sentiment underscores the fact that material rewards do not replace the fulfilment of essential needs, such as workplace safety and manageable workload, to which residents and all surgeons are entitled.
“In fact, trying to use cheery rewards to offset fundamental problems just exacerbates things by adding a sense of leadership insincerity and utter disconnect,” Dr. Lebares said. “This particular quote highlights why trust in leadership and sincere communication is so important.”
Program directors from the 16 institutions that participated in the study’s Part 1, survey 1, were invited to be part of an interview process to assess leadership perspectives on well-being initiatives. Between April and May 2021, nine program directors or their representatives participated in a 60-minute interview using a semi-structured script.4
“We asked them questions like ‘What is the overall goal for your resident well-being program?’ ‘What are the biggest hurdles to implementation?’ and ‘What was the rationale behind the decision to implement current wellness interventions?,’” said Dr. Gonzales.
Comparing comments between residents and program directors, it became apparent to researchers that the need for heightened levels of communication and developing a common vision around well-being intervention selection were shared perceptions.
Both groups also concede to the fact that there are inherent barriers to using well-being resources, and that there is a “zero-sum game represented by current workloads and educational requirements,” noted the study authors.
Successfully overcoming these barriers starts with “explicitly naming this situation [which] would clarify program directors’ intentions and constraints and may improve resident understanding and appreciation for program directors’ efforts,” wrote the study authors.
“For the most part, program directors agreed with some of the issues raised by residents. However, program directors are up against the wall. They often have these system-level factors that they can’t address,” said Dr. Gonzales.
Confronting system-level challenges when implementing well-being programs is only part of the solution. The other piece—as described in episode 15 of the JACS podcast The Operative Word—is related to what Dr. Lebares asserts is the contrast between “immediate survival” and “preparedness.”6
“This was a pretty interesting finding to us,” said Dr. Lebares. “We really saw from the residents a focus on interventions, perks, and proposed next steps that seemed to pertain to immediate survival: What will make my day more livable, my week less horrible, my year more conducive to having friendships or physical health?”
“Although the concept of immediate survival versus preparedness stems from two different perspectives, they both share a common goal of ensuring resident well-being.”
Program directors generally acknowledge the value of “immediate survival,” particularly for overburdened trainees, but they are equally invested in preparing these individuals for the long haul.
In fact, while residents are adult learners in their 20s and 30s (and even older), with varying degrees of life experiences and skills, they tend to know very little about what it means to be an independent practicing surgeon.
“The program directors—I think pretty much unanimously in each their own way—talked about this idea of preparedness that is really critical for things that residents could not know are coming, but that program directors know will be in their future in one way or another,” she said.
In other words, a resident might feel the need to spend what precious free time they have going for a long run, for example, but such activities will not prepare them to manage their first case with a complication or how to effectively manage the stress of malpractice litigation.
“Although the concept of immediate survival versus preparedness stems from two different perspectives, they both share a common goal of ensuring resident well-being,” explained Dr. Gonzales. “Program directors should set clear expectations regarding wellness interventions and encourage open communication to understand the challenges and needs of residents while ensuring that professional development resources are accessible, including mentorship opportunities and expert workshops on financial literacy, leadership skills training, and so on. It’s important for both to understand each of their priorities, knowing they have a common goal in mind, and employ a collaborative approach to create a supportive and holistic training environment.”
While residents and program directors may have different views on prioritizing immediate survival and preparedness, both groups continue to work toward building work settings that are drivers of well-being. Attention to promoting value congruence could come in the form of both groups clearly identifying and stating their shared values, which can serve as a North Star.
Program directors can better explain the rationale behind decisions pertaining to well-being interventions (i.e., why mandatory, why a certain intervention), and residents can work to identify where, when, and how mistrust or perceived incongruence occurs. This can help clarify targets for intervention and clarify if some issue are on the institutional not residency program level.
“No one is the villain in this,” said Dr. Lebares. “It’s like two super, well-intentioned planes crossing in the night.”
Ultimately, successful well-being interventions should support residents and surgeons—individuals who have committed their lives to caring for others—in a way that feels authentic and is considerate of personal preferences, acknowledging that a one-size-fits-all approach does not alleviate burnout for everyone.
Program directors and other administrators are encouraged to ask residents questions such as “What part of your job compels you to show up every day?” or "What is the one thing that seems to actively work against you as a resident?” Leaders should be transparent about plans to decrease these burdens, including any limitations that may untimely stymie these interventions.
“It’s important to acknowledge that wellness is going to look different for everyone. Understanding what works and what doesn’t with the current interventions, actively listening to proposed solutions, and having open dialogue about the limitations of what can and can’t be implemented is essential,” said Dr. Gonzales. “This approach ensures both sides are well-informed and have a shared understanding of their goals and priorities.”
Mary Brandt, MD, MDiv, FACS, discusses with Susan Mackinnon, MD, FACS the benefits of a professional time out.
The ACS provides curated resources on mental health awareness and resources specific to physicians.
This mindfulness body scan audio from Dr. Carter Lebares helps alleviate physical tension.
The ACS provides resources to help individuals engage with their own well-being.
These resources address physician suicide prevention and awareness, including crisis resources, peer support, confidential and professional support, and video resources.
ACS members share their hobbies, interests, and passions outside of the OR and discuss how their outside interests support their well-being.
For ACS members, Zeamo provides access to gym membership discounts for month-to-month memberships consultations with registered dietitians, and more.
Tony Peregrin is the Managing Editor of Special Projects in the ACS Division of Integrated Communications in Chicago, IL.