SAN FRANCISCO: Half of U.S. general surgery residents, especially women, experience workplace mistreatment at least a few times a year, which greatly raises their risk of burnout and suicidal thoughts, results from a national survey reveal. These survey findings were presented today at the American College of Surgeons Clinical Congress 2019 and published on the New England Journal of Medicine website ahead of print.
Surgical residents who reported any on-the-job mistreatment happening to them regularly—several times each month—were 300 percent more likely to suffer burnout and suicidal thoughts than residents without personal exposure to mistreatment, survey responses showed. The forms of mistreatment reported by survey respondents included discrimination, harassment, and verbal abuse/bullying, particularly for women trainees.
"Exposure to workplace mistreatment was the largest driver of surgical residents' burnout," said the principal investigator Karl Y. Bilimoria, MD, MS, FACS, director of the Surgical Outcomes and Quality Improvement Center at Northwestern University Feinberg School of Medicine, Chicago. "Preventing these types of mistreatment could reduce the huge problem of burnout in the specialty of surgery."
Survey responses came from 7,409 residents in 262 residency training programs in the U.S.— more than 99 percent of the nearly 7,500 physicians in training to become general surgeons in this country, according to the article.
"Because of this near-complete response rate, we were able to provide some of the best data on burnout, probably anywhere in health care," Dr. Bilimoria said.
Burnout in physicians is linked to poor well-being, including depression, and increases the chance of making medical errors or leaving the field of medicine, past research findings show.1 Multiple studies2 report that physician burnout is higher in trainees, women, and surgeons, although the reasons are unclear. Furthermore, burnout is increasing among surgical residents, as identified in the 2016 Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial.3
After interviews with some participants of the FIRST Trial revealed that workplace mistreatment was common, the investigators undertook this new study to quantify the rates of specific mistreatment types and their impact on burnout and suicidal thoughts.
In January 2018 the survey on burnout and mistreatment was administered immediately after the American Board of Surgery In-Training Examination, which is taken by all residents training in general surgery programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). The American Board of Surgery collected the survey responses, and residents' identifying information was removed before data analysis.
Key findings of the survey follow.
Workplace mistreatment
- The most common types of workplace mistreatment that surgical residents reported were sex discrimination (31.9 percent), verbal abuse/bullying (30.2 percent), racial discrimination (16.6 percent), and sexual harassment (10.3 percent).
- Nearly 31 percent of residents reported the frequency of mistreatment as a few times per year. Another 19 percent reportedly experienced mistreatment a few times or more each month.
- Women, who made up less than 40 percent of the survey respondents, reported any exposure to mistreatment at about twice the rate of their male counterparts: 70.6 percent versus 36.1 percent.
- Patients and their family members were the most frequently cited sources for exhibiting racial discrimination toward trainees (reported among 47.4 percent of residents) and sex discrimination (43.6 percent). Attending surgeons were the most frequent sources for displaying verbal or physical abuse toward residents (51.9 percent) and sexual harassment (27.2 percent).
Burnout and suicidal thoughts
- Symptoms of burnout—emotional exhaustion and depersonalization—occurred weekly among 38.5 percent of residents.
- Residents reported a 4.5 percent rate of suicidal thoughts during the past year.
- Women were 33 percent more likely than men to report burnout symptoms. However, when the researchers adjusted their statistical analyses for exposure to mistreatment, there was no sex-based difference in burnout frequency, indicating that more frequent mistreatment largely explains women's higher prevalence of burnout, Dr. Bilimoria commented.
"These findings add to the growing body of knowledge about the challenges for resident well-being, and have applicability across all of graduate medical education, as well as the profession," said Thomas J. Nasca, MD, MACP, president and CEO, Accreditation Council for Graduate Medical Education (ACGME), and a study coauthor.
Improving residents' well-being
Although Dr. Bilimoria called the prevalence of surgical residents' mistreatment concerning, he said some residency programs had very low or no rates of mistreatment, suggesting that improvements in the training environment are feasible.
The finding that patients and their families were the most common sources of racial and sex discrimination for residents surprised the researchers, according to Dr. Bilimoria. "It completely changes how we should intervene," he said. "We need to arm residents with the skills and ability to address discrimination from patients and patients' families affecting them and their colleagues."
Findings from this survey will contribute to data for the SECOND Trial, or Surgical Education Culture Optimization through targeted interventions based on National Data. The SECOND Trial, of which Dr. Bilimoria is co-principal investigator, will examine ways that participating surgery residency programs can improve their residents' well-being and learning environment.
"The surgical community welcomes these survey findings, because they steer us in the direction of improvement, particularly as the SECOND Trial gets underway. This Trial will represent an important milestone toward understanding surgical residents' well-being," said ACS Executive Director David B. Hoyt, MD, FACS, and a study coauthor. "Trial results will help inform our understanding about trainees' wellness in surgical residency programs around the country and move a path forward for ensuring it becomes a priority for surgical training programs in the future."
"The culture of surgical training and within operating rooms in general has changed for the better over the course of my career. Looking at the issue in this scientific, quantitative way will be a valuable tool towards improving things even more," said Jo Buyske, MD, president and chief executive director of the American Board of Surgery, and a study coauthor.
Other study authors are: Yue-Yung Hu, MD, MPH (first coauthor), Ryan J. Ellis, MD (first coauthor), Anthony D. Yang, MD, Elaine Ooi Yan Cheung, PhD, Judith T. Moskowitz, PhD, MPH, all from Northwestern University Feinberg School of Medicine, Chicago; John R. Potts III, MD, from the ACGME; and D. Brock Hewitt, MD, MPH, from Thomas Jefferson University Hospital, Philadelphia.
"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.
This study received funding from the American College of Surgeons; the Accreditation Council for Graduate Medical Education; and the American Board of Surgery, which administered the resident survey.
Citation: "Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training," New England Journal of Medicine, Online ahead of the print edition of October 31, 2019.
- West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA. 2011;306:952-960. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146:54-62. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92:129-146. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177:1826-1832.
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- Bilimoria KY, Chung JW, Hedges LV, et al. National cluster-randomized trial of duty-hour flexibility in surgical training. N Engl J Med. 2016 Feb 25;374(8):713-77.
