Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training

#1

https://www.nejm.org/doi/full/10.1056/NEJMsa1903759

BACKGROUND

Physicians, particularly trainees and those in surgical subspecialties, are at risk for burnout. Mistreatment (i.e., discrimination, verbal or physical abuse, and sexual harassment) may contribute to burnout and suicidal thoughts.

METHODS

A cross-sectional national survey of general surgery residents administered with the 2018 American Board of Surgery In-Training Examination assessed mistreatment, burnout (evaluated with the use of the modified Maslach Burnout Inventory), and suicidal thoughts during the past year. We used multivariable logistic-regression models to assess the association of mistreatment with burnout and suicidal thoughts. The survey asked residents to report their gender.

RESULTS

Among 7409 residents (99.3% of the eligible residents) from all 262 surgical residency programs, 31.9% reported discrimination based on their self-identified gender, 16.6% reported racial discrimination, 30.3% reported verbal or physical abuse (or both), and 10.3% reported sexual harassment. Rates of all mistreatment measures were higher among women; 65.1% of the women reported gender discrimination and 19.9% reported sexual harassment. Patients and patients’ families were the most frequent sources of gender discrimination (as reported by 43.6% of residents) and racial discrimination (47.4%), whereas attending surgeons were the most frequent sources of sexual harassment (27.2%) and abuse (51.9%). Proportion of residents reporting mistreatment varied considerably among residency programs (e.g., ranging from 0 to 66.7% for verbal abuse). Weekly burnout symptoms were reported by 38.5% of residents, and 4.5% reported having had suicidal thoughts during the past year. Residents who reported exposure to discrimination, abuse, or harassment at least a few times per month were more likely than residents with no reported mistreatment exposures to have symptoms of burnout (odds ratio, 2.94; 95% confidence interval [CI], 2.58 to 3.36) and suicidal thoughts (odds ratio, 3.07; 95% CI, 2.25 to 4.19). Although models that were not adjusted for mistreatment showed that women were more likely than men to report burnout symptoms (42.4% vs. 35.9%; odds ratio, 1.33; 95% CI, 1.20 to 1.48), the difference was no longer evident after the models were adjusted for mistreatment (odds ratio, 0.90; 95% CI, 0.80 to 1.00).

CONCLUSIONS

Mistreatment occurs frequently among general surgery residents, especially women, and is associated with burnout and suicidal thoughts.

Turns out surgery residents are treated very poorly, especially if they are women.

#2

I wonder how this compares to treatment of residents in other subspecialties.

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#3

Surgery is known to be among the worst.

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#4

That is my impression, but I wonder if there is any hard data. I also wonder if there are differences among surgical subspecialties. Are cardiothoracic surgeons worse than orthopedic surgeons?

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#5

What is wrong with people?

#6

Given the fatigue, stress, power imbalances and tunnel-vision-inducing environment often created by medical residencies, it isn’t really that surprising that they often bring out the darker sides of human nature. You’ll see a similar dynamic in military boot-camps (or even darker with Russian conscription).

I don’t see the problem seriously improving until the underlying dynamics are altered.

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#7

Since @swamidass has had a foot in both worlds, I am wondering how the medical field compares to graduate school with respect to burnout and harassment. Both have the same power structure and opportunities for abuse, but I don’t have a handle on how prevalent harassment is in academia and research.

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#8

I’d be curious to see that comparison, as well. I made it through my graduate school experience, but just barely. I ended up in a lab with a LOT of verbal abuse and didn’t have a good avenue to get out. My PI liked to bring in international students because he felt they had fewer options for leaving. Two of my good friends (one a Chinese post-doc and the other a Chinese PhD student) decided to leave the lab and pursued advanced degrees in computer science.

#9

There is a difference, and it is a institutional difference.

I think the difference is that abusive residencies are abusive at the level of a whole program, or even a whole field. In contrast, abusive PhD programs are abusive at the level of specific PhD advisors (usually). This gives residence far less recourse than PhD students when facing abuse. In a PhD program, several other faculty are available to help, and one can always switch labs. The same is not true for residencies. Because abuse in residencies is not focused on individual people, moreover, even switching to a new program or boss does not solve the problem, because the same issues might be found there.

This institutional component of the abuse is a real challenge, and very difficult to overcome without institutional change.

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#10

Thanks, that fills in a few blanks. The vast majority of the PhD faculty I have come into contact with seem to be good folks and their students/staff usually have good things to say about them, even if they are demanding and tough at times. I can’t imagine what it would be like if the entire academic department was full of bad actors, that would stink.

#11

In my experience there are a lot of “Type A” personalities among surgeons.

I’m not sure if this is universally true of medical schools, but at my institution once a professor is appointed head of a department they tend to stay in that role for an indefinite period, often ending in retirement, promotion to administration, or moving somewhere else. Compare this to academic institutions where being a department head of usually a rotating job, with senior faculty taking the role for several years before passing it on. The “Forever Chief” tends to have (IMO) greater power and authority with fewer consequences, while a temporary chief needs to be more diplomatic.

Agreed. Institutionalized hazing is still hazing.

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