General surgery residents reported high levels of stress linked to burnout, but those who exhibited characteristics of mindfulness were less likely to experience this dynamic, a survey-based study has found.
Carter C. Lebares, MD, of the department of surgery at the University of California, San Francisco, and her colleagues wrote, “Stress is a double-edged sword, with a dose-response relationship between stress and performance described as an ‘inverted U-shaped curve.’ Although stress is initially stimulating, there is a tipping point when demands outstrip resources and stress becomes overwhelming,” the researchers wrote. Surgical trainees purposefully join a high-stress profession and presumably thrive on a demanding environment, but “that does not make individuals immune to the effects of overwhelming stress.”
The investigative team aimed to assess the prevalence and root causes of burnout among surgical trainees. They sent a survey questionnaire to 246 general surgery training program directors and asked them to distribute the survey to their residents (J Am Coll Surg. 2018 Jan;226:80-90. doi: 10.1016/j.jamcollsurg.2017.10.010). The investigators focused on the components of burnout identified in the literature (emotional exhaustion, depersonalization, perceived stress, depression, anxiety, and alcohol misuse/abuse).
The survey, a voluntary and confidential exercise, was based on scales and tools to assess symptoms of burnout (Maslach Burnout Inventory), stress (Cohen’s Perceived Stress Scale), anxiety (Spielberger’s State Trait Anxiety Index), and depression/suicidal ideation (Patient Health Questionnaire).
The researchers also looked at personality traits that could make the difference between the usual stress of residency and burnout in individual trainees. Mindfulness was studied using the Cognitive Affective Mindfulness Scale–Revised. A personality characteristic “trait resilience” was captured in a 10-item Block Ego-Resiliency Scale, which measured ability to adapt to a demanding and changing environment. “Dispositional mindfulness, that is, the innate ability to pay attention to one’s thoughts, emotions, and experiences in a nonreactive way, has been shown to have a buffering effect against perceived stress and burnout among healthcare workers and trainees,” they wrote.
A total of 566 surgery residents responded to the survey; 51% were female and 76% were based in an academic training program. Overall, the survey found that burnout prevalence among general surgery residents was 69%, which confirms the findings of earlier studies of this population, and was significantly higher than rates seen in age-matched peers in the general population and among practicing surgeons. Burnout was equally prevalent among men and women, but men appeared more likely to experience depersonalization (62% vs. 51%). Emotional exhaustion was lower among lab trainees. Alcohol misuse and abuse was somewhat higher in women (58% vs. 41% and 40% vs. 26%, respectively). Although symptoms of burnout were not strongly associated with training level, PGY3 residents experienced the most (58% reported higher stress, 16% suicidal ideation, 50% high anxiety, and 61% alcohol abuse). A high level of stress was reported significantly less often by lab trainees, but alcohol misuse was significantly greater. A high level of stress and emotional exhaustion and depersonalization were strongly linked. And all of these elements were strongly associated with moderate to severe depressive symptoms, suicidal ideation, and high anxiety.
The study is limited by potential biases in the responses, inevitable in a voluntary, self-selected sample. The survey was sent to ACGME-accredited program directors who may or may not have distributed it to their trainees. The investigators suggested that whereas the findings of this study in general confirm earlier research on trainee burnout, the perception of lack personal accomplishment in this sample was less dominant in this sample. “Although this might be because we included residents in lab/research years (widely thought to be a time of very high productivity), it is more likely due to our use of an abbreviated (9-item) form of the Maslach Burnout Inventory-Human Services Survey” and therefore underreported the personal accomplishment factor.
The impact that personality traits (mindfulness and trait resilience) on burnout risk was notable in this sample. “Greater dispositional mindfulness was associated with an 85% decrease in the risk of high stress, and a greater trait resilience was associated with a 65% decrease in the risk of high stress.” Some individuals have traits to help them cope better with stress but the investigators stated that mindfulness and resilience can be taught and fostered in trainees.
The current research on burnout has identified both institutional factors and personal factors. This study suggests that strategies to address both, simultaneously, are needed to truly change the current burnout risk prevalence among surgical trainees. They concluded: “Our findings demonstrate that inherent mindfulness is already in use to combat stress and burnout in surgical trainees and, more importantly, it appears to work. Based on this evidence, mindfulness training can be a critical component of any intervention aimed at enhancing stress resilience and preventing or treating burnout in surgical trainees.”
The researchers reported no relevant financial conflicts.