From Pages to Practice

By Krista Nottage, MBBS

Published December 18, 2019


How often have you found yourself working hard and exhausted but feeling like you are accomplishing little, with an outlook that’s more than a touch cynical? These feelings are symptoms of burnout and not uncommon. How do we get there? 

Residency is a high-stress, high-pressure environment, and the surgical service is among the most demanding. The high expectations, long hours, and performance demands challenge mental and physical endurance. During residency, you are expected to be everywhere and always ready to go, but after many hours, you are simply running on empty. Luckily, when the tank is empty, enthusiasm pushes you through … until the morning when the attending dresses you down on rounds.

Humiliated in front of your team and patients alike, you’re knocked down a peg. 

Then, after you spend time carefully explaining an admission and treatment plan to the family of an ill patient in the emergency department, a family member turns to your male medical student and asks, “Doctor, what do you think”?

Down another peg.

Finally, at the end of a long day you get a call informing you that your simple admission from the previous night just got complicated and you can forget about going home anytime soon. You hang up with a sigh.

This time it’s a knock down and a setback.

When the pressures build up and demands from all directions don’t stop, we often walk away with slumped shoulders and burning eyes and wonder how we got to his point. Results  of a recent cross-sectional national survey published in NEJM indicate that mistreatment occurs frequently among general surgery residents, especially among women, and is associated with burnout.

The following NEJM Journal Watch summary explains the study in more detail.


Surgical Residents Often Are Mistreated and Miserable

Abigail Zuger, MD reviewing Hu Y-Y et al. N Engl J Med 2019 Oct 31

Informal hospital culture has long considered surgical residents to be among the most overworked and generally unhappy employees. Still, for all the recent surge of studies on professional burnout, little quality research has targeted this at-risk group. In January 2018, a multiple-choice survey focused on mistreatment and burnout was appended to the American Board of Surgery in-service exam that is required for all U.S. general surgery residents.

Of 7409 respondents — virtually all clinically active residents in the country's 262 accredited training programs — about half reported having been mistreated at some time during residency. Thirty percent reported verbal or emotional abuse, 32% reported sex discrimination, and 10% reported sexual harassment. About 40% of those who reported mistreatment said it occurred a few times monthly or more often. Women (40% of the total respondents) reported higher rates of all forms of mistreatment than did men: 65% of women reported sex discrimination (far more often from patients and their families than from attendings or other medical staff), and 20% reported sexual harassment (equally often from patients/families and attendings). Symptoms of burnout were reported by almost 40% of respondents, and 5% had experienced suicidal thoughts. More frequent mistreatment was associated with more burnout symptoms. Rates of reported mistreatment varied widely among training programs.

Comment: Surgical residents are at risk for early professional burnout. Not much surprise there, but the data do contain some surprises. One is that patients and their families often are the problem (or are perceived as such), which suggests that lessons in finessing difficult encounters have a place in surgical training; stronger institutional protocols to support mistreated surgical residents also might help. Meanwhile, the wide interprogram variability in resident complaints confirms that, indeed, we can train residents without making them miserable for the duration.

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Krista is a 2019-2020 editorial fellow at the New England Journal of Medicine. She is from Nassau, Bahamas where she is training in general surgery at the University of the West Indies.