Half of Surgical Residents Report Mistreatment, Tied to Burnout, Suicidal Thoughts

Diana Phillips

October 28, 2019

Discrimination, abuse, and harassment are common experiences among surgical residents in general, and among female surgical residents in particular, new survey data show. The mistreatment likely contributes to high rates of burnout and suicidal thoughts in these trainees, according to the authors.

The kinds of mistreatment observed in this study are not likely unique to general surgery programs, said senior author Karl Bilimoria, MD, the John B. Murphy Professor of Surgery at Northwestern University Feinberg School of Medicine in Chicago, Illinois. Although the settings may vary, the underlying factors do not.

The success of program changes and other interventions designed to reduce burnout and suicidal thoughts will be limited if mistreatment continues to be pervasive in the training environment, he said. "Our findings suggest that targeting mistreatment and its sources may be a key to reducing burnout symptoms and suicidal thoughts in trainees," Bilimoria told Medscape Medical News.

Yue-Yung Hu, MD, MPH, an assistant professor of pediatric surgery at Northwestern University Feinberg School of Medicine, and colleagues reported the findings today at the American College of Surgeons Clinical Congress in San Francisco. The study was published online in the New England Journal of Medicine.

To assess the prevalence of mistreatment among surgical residents and the association of mistreatment with burnout and suicidal thoughts, researchers administered the survey with the 2018 American Board of Surgery In-Training Examination.

Half (49.9%) of the 7409 residents from 262 surgical residency programs who completed the survey reported experiencing some form of mistreatment. Female surgical residents (70.6%) reported experiencing all forms of mistreatment more frequently than their male peers (36.1%), the authors write. The increased prevalence of mistreatment among female trainees may explain the higher rates of burnout that have been observed among women residents.

Verbal or emotional abuse was the most common form of mistreatment reported by male residents (28.3%; female residents, 33.0%), while gender discrimination was the most common form of mistreatment reported by female residents (65.1%; male residents, 10.0%).

For men and women, respectively, the rates of reported racial discrimination were 15.1% and 18.6%; the rates of discrimination based on pregnancy or childcare status were 3.2% and 13.0%; and the rates of physical abuse were 2.4% and 1.9%, the authors report.

The sources of mistreatment varied depending on the form and residents' gender. For example, the most common source of gender discrimination for female residents was patients or patients' families (49.2%). For male residents, the source cited most frequently was attending surgeons (28.5%), the authors report. Further, the most common sources of sexual harassment among women residents were patients or their families (31.2%) and attending surgeons (30.9%), while the most common source among men was nurses or staff (22.7%).

For both male and female residents, the most common source of racial discrimination was patients and families (47.4%), followed by attending surgeons, nurses and staff, and other residents. Other surgeons were the most common source of both pregnancy/childcare-associated discrimination (attending surgeons, 36.8%; other residents, 22.6%) and verbal or emotional abuse (attending surgeons, 52.4%; other residents, 20.2%).

Duty-hour violations were more commonly reported by men (66.5% vs 52.7% for female residents).

Burnout, defined as symptoms of emotional exhaustion or depersonalization occurring at least weekly, was more commonly reported by women (42.4% vs 35.9% for male residents), as were suicidal thoughts during the past year (5.3% vs 3.9%).

In adjusted models, a dose-response relationship was observed between mistreatment and burnout. Specifically, increasing frequency of any mistreatment exposures was linked to an increase in burnout, from a few times per year (odds ratio [OR] compared with no exposure, 2.02; 95% confidence inteval [CI], 1.81 – 2.25) to a few times per month or more (OR, 2.94; 95% CI, 2.58 – 3.36).

Similarly, increasing frequency of exposure to mistreatment was associated with an increase in suicidal thoughts, from a few mistreatment exposures per year (OR, 2.08; 95% CI, 1.57 – 2.76) to a few or more exposures per month (OR, 3.07; 95% CI, 2.25 – 4.19).

Similar patterns were observed between duty-hour violations and both burnout and suicidal thoughts, the authors report.

The authors point out that the rate of suicidal thinking in this study (4.5%) may be a more accurate estimate than has previously been observed because of the high response rate to the survey (99%). "This finding is of particular importance because suicide is the second leading cause of death among trainees," they write.

After adjusting for mistreatment exposure, there was no significant difference in burnout risk between men and women (OR, 0.90; 95% CI, 0.80 – 1.00), nor was there a difference between risk for suicidal thoughts (OR, 0.90; 95% CI, 0.69 – 1.18).

"It's been shown previously that women have higher burnout rates than men, but one unfortunate conclusion that people have drawn is that women are weaker and just can't cut it," said Hu.

"I hope this data is reassuring to women because it shows that the burnout rate is higher but not when we control for mistreatment, which unfortunately is very common. It's not us; it's our environment," she told Medscape Medical News.

Program Variations

The study, which was supported by the American College of Surgeons, the Accreditation Council for Graduate Medical Education, and the American Board of Surgery, showed wide variation at the program level. "The percentage of residents within each program who reported each type of mistreatment varied widely," the authors report. They note that there was minimal agreement between pairwise comparisons. "[P]rograms that had a higher prevalence of one type of mistreatment did not necessarily have a higher prevalence of another."

A substantial number of programs did have low rates of mistreatment, suggesting the feasibility of improvements in the training environment, the authors write. They note that researchers with the SECOND Trial are currently investigating this. Program-level solutions targeting specific types of mistreatment will likely be the most effective approach for improving the well-being of residents, the authors state.

As one of the first large-scale studies to "peel back" some of the factors that contribute to burnout differences between male and female general surgery residents, "we were able to identify sources of mistreatment as an important variable, which can help as we look to develop solutions," said Bilimoria, who is also director of the Northwestern Surgical Outcomes and Quality Improvement Center (SOQIC).

N Engl J Med. Published online October 28, 2019. Abstract

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