August 1, 2022
Surgical residency is considered a grueling and arduous journey. Long hours, little sleep, and extensive mental, physical, and emotional demands take a toll on all trainees. The expectations and requirements of surgical training programs affect residents on a personal basis.
Over the last decade, wellness programs have been introduced into surgical training curricula. Still, no standardized metrics have been established to define a successful wellness program or even comparable metrics to quantify resident well-being. In fact, the term “wellness” has been the subject of debate. Lall and colleagues define wellness as multifactorial, encompassing variables such as work-life balance, quality of life, mindfulness, and resilience.1
Resident-reported questionnaires have periodically assessed well-being and quality of life. The results have been disappointing. The results of a 2016 study showed that almost two-thirds of general surgery residents in the US met criteria for burnout.2 A study published a year later found that one-third of surgery residents experienced mild depression, and one-quarter experienced clinical psychological distress.3
The COVID-19 pandemic had a largely negative affect on resident wellness.4 Coleman and colleagues evaluated residents’ perceptions of the impact of COVID on surgical training (n = 1,160) and found that most experienced a deleterious impact on their surgical education, and nearly half reported a negative or extremely negative effect on their sense of physical safety.4 Perhaps most disconcerting, 70% of residents reported a negative or extremely negative effect on their mental health.4
As a follow-up to these results, another survey was distributed to general surgery residents to assess the 2-year impact of COVID-19 on resident well-being. Participants were asked to report their perceptions of how COVID directly affected their physical, mental, and emotional well-being during surgical training (n = 1,879). The results were sobering. Many residents expressed concerns related to changes in educational opportunities (63%), inequitable risk exposure (49%), fear of contracting COVID-19 (13%), and low resource availability for promoting wellness (53%) (see Figure 1). All of these factors have contributed to feelings of emotional exhaustion, depersonalization, anxiety, and depression among residents. It is clear from these findings that resident wellness should be prioritized further nationwide to encourage long-term growth and career satisfaction.
Residents and fellows have been on the front lines of the physician response to COVID-19. One of the most significant concerns the survey results illustrated was that surgical education was forced to yield to the pandemic-related care of patients. COVID-19 significantly altered instructional designs and content delivery, as well as assessment of clinical competencies. At the expense of surgical skills training and curricula implementation, programs were required to swiftly implement social distancing and virtual learning.
Simulation-based strategies served as an additional safeguard to ensure adequate training and preparation, and several other educational strategies were integrated in the initial stages of the pandemic. These abrupt changes required quick adaptation to a new learning environment and significantly affected opportunities to interact with peers and faculty. As a result, 10.3% of residents were concerned about their educational experience, and 11.9% were concerned about meeting clinical competency benchmarks—ultimately contributing to heightened stress and anxiety.
Furthermore, when rating several of their biggest concerns during the COVID-19 pandemic, residents rated their surgical caseload experience high on their list of priorities. Previous studies have investigated the trends in surgical residents’ case logs and operative experience and found increased case volume but decreased breadth of case types.5,6 Given the previously reported trends in surgical caseload numbers and the abrupt halt in elective cases, it is understandable that approximately 30% of surveyed residents were fearful about the impact of the pandemic on their operative experience.
In the face of institutional emergencies and to mitigate exposure risks to older attending physicians, the Accreditation Council for Graduate Medical Education established that fellows may spend up to 20% of their academic year serving as fully independent physicians.7
Our survey indicated that nearly half of the surveyed residents (49%) felt that they carried a greater exposure risk than attending physicians. At times, residents (12%) reported inadequate access to personal protective equipment (PPE) and were even asked to supply their own PPE (9%). More than 40% of the respondents indicated that one of their most prominent concerns was the possibility of contracting COVID-19 themselves and spreading infection to their families.
Furthermore, more than 50% of respondents reported that testing for COVID-19 was optional at their institution and only done if the resident was symptomatic. Most alarming, 15% of respondents reported that they were required to continue working if they tested positive.
Most respondents (74%) stated that their hospital system did not provide residents with bonuses or hazard pay. More than 50% of patients considered high risk for COVID-19 whose tests were pending were initially evaluated by chief residents rather than attendings (5%). This finding not only illustrates the disproportionate risk at which residents were exposed to COVID-19, but also explains why residents experienced increased anxiety, depression, and burnout. Noteworthy is the apparent disparity in treatment between trainees and faculty, which raises valid concerns about how much value institutions assign to trainees’ well-being.
Considering the many educational and safety concerns residents have faced during the pandemic, the renewed need for wellness resources became even more evident. Queries regarding the establishment of formal mechanisms to support wellness and promote resiliency illustrated this need, as 52.7% of respondents reported that their institutions had not provided any new resources. Furthermore, 85.9% of residents did not use the American College of Surgeons (ACS) wellness toolkit or other society-offered resources. The reasons behind this drastic underuse may be multifactorial; however, the Resident and Associate Society (RAS) Communications Committee surmises that lack of awareness played a significant role.
Overall, more than half of trainees reported experiencing new or increased symptoms of depression and anxiety in the year before this survey. In addition, approximately 72% of respondents reported emotional exhaustion, and 61% reported depersonalization toward patients during the same time. Only 62% of trainees reported feeling personally accomplished in the year before this survey, specifically described as “feelings of competence and successful achievement in one’s work.” Furthermore, 32% of respondents reported they had considered making a significant change in job status, including leaving the profession, changing employers, moving into significantly different roles, and leaving medicine altogether.
Numerous studies have identified these symptoms, collectively referred to as burnout, as risk factors for physician self-harm, alcohol and substance abuse, broken personal relationships, and even suicide.8-11
An extensive ACS study published in 2010 also found that surgeon burnout was an independent predictor of reporting a recent major medical error.12 In our survey, 38% of trainees tested positive for burnout or exhaustion, similar to results from the cross-sectional survey administered in conjunction with the 2018 American Board of Surgery In-Training Examination.13 However, 49% of trainees reported they had not been issued an employer-directed survey or screening to identify symptoms of burnout during the last academic year, suggesting institutions may be unaware of the severity of these problems within their own systems. In the wake of the added stress associated with COVID-19, some may find this lack of insight alarming given the far-reaching implications of physician burnout. With an aging American population and a well-documented physician shortage, resident and fellow retention is critical.14
The findings from this survey reveal a sobering reality heightened by the COVID-19 pandemic: resident wellness is in a state of emergency. The deleterious impact of social isolation, compounded by anxiety, stress, and uncertainty, brings forth several urgent action items for surgical societies and institutions alike. In addition to interventions aimed at improving awareness of and access to wellness resources, a redesign of training paradigms, even during a pandemic, to incorporate resident wellness as a core value is sorely needed. The accelerated digitalization of interpersonal interactions using online meeting platforms as seen during the pandemic can provide avenues for sharing of resources.
RAS is committed to continuing to understand the issues facing surgical trainees and advocating for resident wellness. The RAS Membership Committee and social media campaigns led by the RAS Communications Committee, such as the #SurgMatch2022 campaign, are examples of effective outreach tools. In its December 2021 Statement on Surgeon Well-Being, the ACS recognized how critical surgeon wellness is to ensuring optimal patient care and addressed the predicted physician shortage.15
Ultimately, these data highlight an undeniable truth: much needs to be done. RAS is committed to developing strategies to enhance surgery trainees’ experiences and will continue to be at the forefront of the change that is needed.
Dr. Nadege Fackche is a complex general surgical oncology postdoctoral fellow at Moffitt Cancer Center, Tampa, FL.