Gender Differences in Utilization of Duty-Hour Regulations, Aspects of Burnout, and Psychological Well-Being Among General Surgery Residents in the United States

Allison R. Dahlke, MPH; Julie K. Johnson, MSPH, PhD; Caprice C. Greenberg, MD, MPH; Remi Love, MPPA; Lindsey Kreutzer, MPH; Daniel B. Hewitt, MD; Christopher M. Quinn, MS; Kathryn E. Engelhardt, MD; Karl Y. Bilimoria, MD, MS


Annals of Surgery. 2018;268(2):204-211. 

In This Article

Abstract and Introduction


Objective: The aim of the study was to (1) assess differences in how male and female general surgery residents utilize duty-hour regulations and experience aspects of burnout and psychological well-being, and (2) to explore reasons why these differing experiences exist.

Background: There may be differences in how women and men enter, experience, and leave residency programs.

Methods: A total of 7395 residents completed a survey (response rate = 99%). Logistic regression models were developed to examine the association between gender and resident outcomes. Semistructured interviews were conducted with 42 faculty and 56 residents. Transcripts were analyzed thematically using a constant comparative approach.

Results: Female residents reported more frequently staying in the hospital >28 hours or working >80 hours in a week (≥3 times in a month, P < 0.001) and more frequently feeling fatigued and burned out from their work (P < 0.001), but less frequently "treating patients as impersonal objects" or "not caring what happens" to them (P < 0.001). Women reported more often having experienced many aspects of poor psychological well-being such as feeling unhappy and depressed or thinking of themselves as worthless (P < 0.01). In adjusted analyses, associations remained significant. Themes identified in the qualitative analysis as possible contributory factors to gender differences include a lack of female mentorship/leadership, dual-role responsibilities, gender blindness, and differing pressures and approaches to patient care.

Conclusions: Female residents report working more, experiencing certain aspects of burnout more frequently, and having poorer psychological well-being. Qualitative themes provide insights into possible cultural and programmatic shifts to address the concerns for female residents.


As the number of women in surgical residency programs continues to increase, there is a growing recognition that women and men may enter, experience, and even leave residency programs differently.[1] Some studies have shown that women have less favorable experiences[2,3] and higher rates of attrition[4,5] whereas others report that measures of quality of life and burnout may not differ by gender.[3] In one study, up to 65% of female surgical residents met criteria for a high level of burnout, compared with only 52% of males.[6] Moreover, a survey of physician mothers found that over 60% experienced gender discrimination in the workplace,[7] whereas another study found that women may have a slower rate of surgical milestone attainment due to implicit gender bias, creating a gender gap in surgeon evaluation scores by the end of residency.[8] Finally, studies suggest that rates of psychological distress are generally higher among female medical students, and that overall rates are higher among medical trainees than age-matched peers in the general population[9,10] but may be lower than in some other fields such as law students.[11]

The Flexibility in Duty-Hours Requirements for Surgical Trainees (FIRST) Trial was a cluster-randomized trial that designated surgical residency programs to follow standard 2011 Accreditation Council for Graduate Medical Education (ACGME) duty-hour policies or to follow flexible duty-hour policies that maintained the 80-hour work week limit, but relaxed some rules like the 16-hour work week for interns.[12] Although there was no overall gender difference in dissatisfaction with education or well-being between trial arms,[13] subsequent analyses found gender differences in perceptions of the effect of duty-hours on aspects of resident training, patient safety, and well-being by postgraduate year (PGY).[14]

The objectives of this study are to build on these analyses using a mixed-methods approach (1) to assess differences by gender in how residents utilize duty-hours and experience aspects of burnout and psychological well-being, and (2) to examine reasons why women and men may have differing experiences with duty-hours, rates of burnout, and issues with psychological well-being.