'Alarming' Burnout Rate in General Surgery Residents

Diana Phillips

June 20, 2016

More than two thirds of general surgery residents in a national survey meet the criteria for burnout, and many of them have considered leaving their residency program because of it, a study shows.

Leisha C. Elmore, MD, MPHS, from the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, and colleagues report their findings in an article published online May 27 in the Journal of the American College of Surgeons, as well at the American College of Surgeons 101st Annual Clinical Congress in October 2015. The study adds to a growing body of research suggesting that burnout among physicians in training has reached epidemic proportions, they write.

In a 2015 study reported by Medscape Medical News looking at burnout rates among medical residents by specialty, general surgery residents had the highest burnout rates, followed by residents in radiology, surgical subspecialties, anesthesiology, and internal medicine. Pediatrics, family medicine, and pathology had the lowest burnout rates. The current study is the first national survey to investigate the burden of burnout in general surgery trainees.

Because burnout can negatively influence clinician health and job performance, the high prevalence of burnout in this population threatens the well-being of these trainees, and potentially that of the patients they care for, according to senior author Isaiah R. Turnbull MD, PhD, from the Department of Surgery, Washington University School of Medicine, St Louis, Missouri. "We need to better understand the drivers and implications of burnout in surgical residents so we can identify who is at risk and develop strategies to reduce that risk," Dr Turnbull told Medscape Medical News.

This is especially true, Dr Turnbull said, given the higher attrition rates observed among general surgery residents compared with medical residents, despite comparable burnout rates. "The question we need to ask is, 'What is it about general surgery training and expectations specifically that is putting these trainees at risk, and what can we do about it?' "

The researchers used the Maslach Burnout Inventory to characterize the burden of burnout in surgical training. They defined burnout as scoring in the highest tertile of the Emotional Exhaustion (EE) or Depersonalization (DP) subscales, or in the lowest tertile of Personal Accomplishment (PA) subscales.

The researchers surveyed surgical residents from all 246 Accreditation Council for Graduate Medical Education–accredited US general surgery residency programs from April to December 2014, and 665 residents (mean age, 30 years) provided complete data for analysis. Of those with complete data available, an "alarming" 69% met the criterion for burnout on at least one subscale of the Maslach Burnout Inventory, the authors report.

Of those who met burnout criteria, 57% scored in the highest tertile of EE, 50% scored in the highest tertile of DP, and 16% scored in the lowest tertile of PA. Further, nearly half (44%) reported that they had considered dropping out of their residency, and the same percentage would not choose general surgery again if they had the option. Forty percent would choose a career outside of medicine entirely, the researchers report.

Burnout appears to be more of burden for female general surgery residents, "which is in contrast to much of the existing literature on burnout in residents training in other specialties," the authors note. Compared with men, women were significantly more likely to report burnout (73.4% vs 64.8%; P = .02), with a greater proportion of women than men reporting burnout on the EE or PA subscales.

It is possible that surgical training differentially affects women when compared with other medical training programs, the authors hypothesize. "[F]or example previous investigators have found that female surgical residents are more likely than nonsurgical residents to perceive stereotyped bias against women," they write. Women may also face additional pressure managing work–life balance when compared with men, "and may find it challenging to find mentorship in a historically male-dominated field."

An analysis of burnout rates by the number of hours worked weekly showed high burnout rates, "despite the majority of respondents adhering to work hour limitations," a finding that suggests "attempts to address burnout should extend beyond work-hour restrictions," the authors note. On average, residents reported 80-hour work weeks, and burnout was significantly more common in those who worked 81 vs 79 hours weekly (P = .001).

When considered in the context of future professional plans, residents who intended to enter private practice or an alternative career, such as military surgery, nonsurgical clinical practice, or a nonclinical career, were more likely to meet the criteria for burnout than those who planned a career in academic medicine.

Although no significant differences in burnout rates were observed by geographic location or type of training program, residents in programs with training in both academic and community settings (mixed) had a greater proportion of lowest-tertile PA scores compared with those in training programs in one setting only.

Structured mentoring appears to provide some protection against burnout, the authors write, noting that a lower proportion of residents with personal or professional support through such a program experienced burnout than residents without such a program (63% vs 76%; P < .001).

In a multivariate regression analysis, "[o]lder residents, women, residents who lacked availability of a structured mentoring program and who worked longer hours were more likely to meet the criterion for burnout; but chief residents and residents who planned academic careers were less likely to meet the criterion for burnout," the authors write.

Although common in surgical residents, "the experience of burnout and contributing factors are likely to be highly individualized," and thus not addressable through a "catch-all" approach, but mentoring programs may offer a first line of defense. "Mentoring relationships can aid in early identification of burnout and help trainees develop strategies to mitigate their individual experience of burnout," the authors note.

Additional research to identify risk and protective factors for burnout in surgical residents is warranted to develop strategies "to identify early signs of burnout and to support residents' personal and professional development," the authors conclude.

Some of the investigators received funding support in part from a grant from the National Institutes of Health National Cancer Institute and the National Cancer Institute Cancer Center Support Grant to the Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine. The authors have disclosed no other relevant financial relationships.

J Am Coll Surg. Published online May 26, 2016. Abstract

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