As residents and surgeons in training, the topic of wellness and resiliency resonates in our minds. The startling statistics of physician burnout are ever-present as we press on to finish surgical training and pursue our professional careers.1 Resident engagement in physician groups, national societies, and local organizations may serve as a way for trainees to remain connected to the practice of medicine, both practically and emotionally. Working alongside fellow trainees and colleagues on projects that we feel passionate about may lead to timeless bonds and help alleviate the burdens associated with busy clinical practice. Furthermore, having mentors and peers with whom to commiserate and to whom we can offer a helping hand or listening ear may keep our motivation strong and spirits high. Maintaining a focus on wellness and resiliency during training through membership in professional societies and community involvement can serve as a good foundation and preventative measure against burnout, and it may prove key to developing enduring resiliency.
Physician burnout: Causes and effects
Burnout is characterized by a state of emotional, mental, or physical exhaustion in response to stress. Changes in our health care system have led to increased demands on clinical productivity, decreased funding opportunities, limited resources, more extensive workloads, and longer hours spent completing administrative tasks, all of which make surgeons and surgical trainees prone to burnout. In fact, the rate of burnout among physicians is rising at an alarming rate and has been reported to be as high as 69 percent among surgical residents and up to 60 percent among practicing physicians.1,2-4 Burnout negatively affects people both personally and professionally. Professionally, burnout can lead to decreased quality of patient care, as it is associated with poor career satisfaction, decreased effectiveness, substandard prescribing patterns, increased medical errors, and medical liability lawsuits.5-8 Personally, burnout is associated with depression, substance abuse, attrition, and suicide.9-11
Several studies have examined risk factors for burnout among surgeons. A survey completed in June 2009 of the American College of Surgeons (ACS) membership included responses from 7,905 surgeons who identified the following independent predictors of burnout: younger age, female gender, parenthood, area of specialization, number of nights on call per week, hours worked per week, and compensation based entirely on billing.3,12-14
As public awareness of surgeon burnout has increased, new methods of prevention and intervention have emerged. Identifying those colleagues at risk and facilitating solutions are essential to averting the ramifications of burnout. Many residency programs are developing wellness programs to provide trainees with the necessary skills to effectively respond to stress and prevent burnout. These programs are designed to foster resilience and improve emotional intelligence.15,16 Some studies also suggest that mentoring relationships can aid in recognizing burnout and developing strategies to alleviate stressors.2 In addition, a good support system can be invaluable to maintaining emotional and physical wellness. The development of educational/wellness programs that promote skills and behaviors that strengthen compassionate interactions may be key to managing stress and avoiding burnout.17
Community and group support
Haslam and colleagues have noted, “Groups that provide us with a sense of place, purpose, and belonging tend to be good for us psychologically. They give us a sense of grounding and imbue our lives with meaning. They make us feel distinctive and special, efficacious and successful. They enhance our self-esteem and sense of worth.”18
Many surgeons have been fed a steady diet of rugged individual determinism—of pulling oneself up by one’s bootstraps, forging one’s own destiny, and being the captain of one’s own ship. Perhaps more than any other specialty, the surgical profession naturally self-selects individuals who embody these ideals.19 We tend to believe that we are self-sufficient and essentially invincible.20 When we are honest with ourselves, however, we must admit that every step of the journey to becoming competent, independent surgeons has been facilitated by other people. The instruction we receive in medical school and the mentoring provided in the operating room would not be possible without someone else’s involvement. One way or another, surgeons have a fundamental need for community and comradery, as these factors have been part of their development over the years.21 Family, civic or religious organizations, interaction with colleagues in the workplace, involvement in professional societies, or some combination thereof offer the human connection we all need to thrive—to build resilience and grow.
In their study of resilience among U.S. Navy SEALs (sea, air, and land teams) and World War II veterans, Everly and colleagues include “interpersonal connectedness” among the seven qualities that characterize resilient people.22 Peer support can be an effective antidote to potentially crippling adversities that surgeons routinely face, including the stress of long work hours, the risk of litigation, and coping with bad outcomes.23 Organizations that build such support into their programming structure can have a significant effect on the wellness of their physicians. This support can include changes in schedules and reductions in intensity of workload, increased supervision to decrease work demand, and enhanced job control, all of which have been demonstrated to significantly affect the wellness of physicians. In their meta-analysis of 19 randomized control trials examining the impact of interventions to reduce burnout among physicians, Panagioti and colleagues found that interventions initiated at the organizational level had a greater effect than interventions that physicians initiate themselves, suggesting that a systems-level approach to physician wellness is both feasible and effective.24
In another meta-analysis of randomized trial and cohort studies to prevent physician burnout, West and colleagues reviewed 2,617 articles studying 3,630 physicians, and likewise found that organizational strategies were effective in achieving a clinically meaningful reduction in burnout among physicians.15 A combined approach that targets both the individual and the system is likely to achieve the most promising results.25
Wellness and resilience are valuable not only to the individual physician but also to patients and colleagues. Individuals and organizations that take self-care and organizational care seriously initiate a domino effect that has far-reaching benefits beyond the immediately perceptible effects. Surgical societies like the ACS—which exist to preserve the highest standards of the profession through research, education, and advocacy—are important not only for the services they provide, but for the impact they have on the broader community. By engaging with these societies, surgeons expand their opportunities to advance personally and professionally and inspire the next generation of surgeons. There is evidence to suggest that membership in surgical societies contributes to greater academic productivity.26-28 Of equal importance, academic societies provide a platform for the exchange of ideas, innovations, and expertise.
Recently, professional societies have played a more active role in improving physician well-being. The College, for example, provides numerous resources focused on physician wellness, such as the Physician Well-Being Index, which is a tool to help physicians track their well-being over time and compare their results with colleagues.29 Similarly, the American Medical Association offers a collection of modules called STEPS Forward, to help understand and improve physician wellness.30 Medical students and residents can access similar resources through the Association of American Medical Colleges, which offers articles, conferences, programs, and courses pertaining to well-being.31
Perhaps one of the largest efforts to address physician well-being is the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience, which comprises more than 150 organizations that are working to improve physician well-being.32 The three goals of this collaborative are improving understanding of challenges to clinician well-being, raising the visibility of stress and burnout, and elevating evidence-based solutions. Most of the programs described in this article are in their infancy; thus, identification, design, and improvement of targeted support that mitigates burnout need to be a high priority.
There is good evidence to suggest that membership and engagement in professional societies such as the ACS is an important step toward overcoming physician burnout. Beyond the benefits of educational resources, mentoring, and networking, group membership has been shown to boost psychological well-being and self-esteem.18,33,34 Why is group membership so important and beneficial? Psychologically speaking, groups provide us with a sense of belonging and meaning and are a source of grounding and support. In other words, they help us understand ourselves and our role in the world, and they help us feel better about both. Group membership provides us with a common perspective, a lens that shapes our view of the world and moves us from isolation toward connection—from “me” to “we.” Active membership in groups, such as the Resident and Associate Society (RAS) committees, provides members with intellectual stimulation, opportunities for collaborative learning, social companionship, and emotional bonding.18
Group membership repeatedly has been shown to provide significant health benefits.35-37 The evidence suggests that belonging to social groups can protect against depression, alleviate symptoms of depression, and reduce the risk of depression relapse. An evaluation of more than 9,000 participants demonstrated this effect even when individuals joined one group alone.35
Life transitions make one particularly susceptible to burnout. For instance, the transition from medical school to residency and from residency or fellowship into practice can pose particular challenges to personal well-being.38 Fortunately, research has shown that group membership can help buffer individuals from the negative consequences of change by providing a strong source of personal identity.38 The even better news is that the effect is additive; membership in more groups appears to enhance the benefits of belonging.33,38
Social media and venues to build resilience
Social media connects surgeons around the world and provides a large community with which to network, mentor, and collaborate. The use of social media among physicians, and particularly among surgeons, has increased rapidly over the years. More than 90 percent of physicians are involved in social media for personal or professional use.39 At its inception, Twitter and blogs were the preferred platforms,40 but as the use of social media became widely accepted, additional platforms blossomed, including video- and photo-sharing sites and professional online networking sites targeted to physicians.40 Today, widely used platforms include Twitter, YouTube channels, Facebook, SnapChat, and Instagram, among others. The use of social media in health care can enhance professional networking, improve marketing for individual physicians and organizations, disseminate patient education, and serve as a tool for professional and patient advocacy. However, social media engagement also poses certain risks because of the potential sharing of misinformation, violation of patient privacy, or breach of institutional social media guidelines.41
For surgery residents, one potential benefit of social media engagement is the opportunity to strengthen a sense of community through interaction with trainees who share similar professional and personal experiences. It is well established in the literature that social and organizational influences contribute to a decrease in burnout. The ability to engage with others via social media allows for the sharing of expertise and the capacity to devise solutions to ease stress and enhance wellness. The widespread distribution of literature shared on social media platforms like Twitter allows users to learn from the challenges and successes of physician wellness programs that have already been implemented. Social media provides a possible antidote to burnout insofar as it provides a virtual community where communication, support, and collaboration can develop.
While joining an ACS chapter or the RAS may not be the ultimate solution to burnout, membership in societies has been well documented as a deterrent to burnout and a contributor to physician resiliency. Membership in these groups provides an opportunity to access resources on physician wellness and burnout and to collaborate with peers and mentors who have similar experiences and interests. Ongoing engagement in societies and groups not only provides support for the individual, but also drives the individual’s engagement in the organization, resulting in ongoing contributions because of the fostered sense of community.
Engaging physicians in group participation during times of transition—from resident or fellowship to practice or from student to residency, for example—is critical because of their vulnerability and susceptibility to burnout. This sense of community is well fostered in the age of social media, which provides a forum in which members may be engaged from a distance, contemporaneously, or in a delayed fashion.
- Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general U.S. working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613.
- Elmore LC, Jeffe DB, Jin L, Awad MM, Turnbull IR. National survey of burnout among U.S. general surgery residents. J Am Coll Surg. 2016;223(3):440-451.
- Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-471.
- Lebares CC, Guvva EV, Ascher NL, O’Sullivan PS, Harris HW, Epel ES. Burnout and stress among U.S. surgery residents: Psychological distress and resilience. J Am Coll Surg. 2018;226(1):80-90.
- Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
- Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136(5):358-367.
- Melville A. Job satisfaction in general practice: Implications for prescribing. Soc Sci Med Med Psychol Med Sociol. 1980;14A(6):495-499.
- Jones J, Barge B, Steffy B, Fay L, Kunz L, Wuebker L. Stress and medical malpractice: Organizational risk assessment and intervention. J Appl Psychol. 1988;73(4):727-735.
- Dyrbye LN, Shanafelt TD, Balch CM, Satele D, Sloan J, Freischlag J. Relationship between work-home conflicts and burnout among American surgeons: A comparison by sex. Arch Surg. 2011;146(2):211-217.
- Oreskovich MR, Kaups KL, Balch CM, et al. Prevalence of alcohol use disorders among American surgeons. Arch Surg. 2012;147(2):168-174.
- Shanafelt T, Balch, Charles M., Dyrbye L, et al. Special report: Suicidal ideation among American surgeons. JAMA Surg. 2011;146(1):54-62.
- Campbell DA, Sonnad SS, Eckhauser FE, Campbell KK, Greenfield LJ. Burnout among American surgeons. Surgery. 2001;130(4):696-705.
- Kuerer HM, Eberlein TJ, Pollock RE, et al. Career satisfaction, practice patterns and burnout among surgical oncologists: Report on the quality of life of members of the Society of Surgical Oncology. Ann Surg Oncol. 2007;14(11):3043-3053.
- Ramirez A, Richards M, Cull A, et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer. 1995;71(6):1263-1269.
- West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.
- McCue JD, Sachs CL. A stress management workshop improves residents’ coping skills. Arch Intern Med. 1991;151(11):2273-2277.
- Lown BA. A social neuroscience-informed model for teaching and practising compassion in health care. Med Educ. 2016;50(3):332-342.
- Haslam SA, Jetten J, Postmes T, Haslam C. Social identity, health and well‐being: An emerging agenda for applied psychology. Appl Psychol. 2009;58(1):1-23.
- Drosdeck JM, Osayi SN, Peterson LA, Yu L, Ellison EC, Muscarella P. Surgeon and nonsurgeon personalities at different career points. J Surg Res. 2015;196(1):60-66.
- Cope A, Bezemer J, Mavroveli S, Kneebone R. What attitudes and values are incorporated into self as part of professional identity construction when becoming a surgeon? Acad Med. 2017;92(4):544-549.
- Money SR. Surgical personalities, surgical burnout, and surgical happiness. J Vasc Surg. 2017;66(3):683-686.
- Everly GSJ, McCormack DK, Strouse DA. Seven characteristics of highly resilient people: Insights from Navy SEALs to the “greatest generation.” Int J Emerg Ment Health. 2012;14(2):87-93.
- Shapiro J, Galowitz P. Peer support for clinicians: A programmatic approach. Acad Med. 2016;91(9):1200-1204.
- Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.
- Ruzycki SM, Lemaire JB. Physician burnout. CMAJ. 2018;190(2):E53.
- Milgrom DP, Koniaris LG, Valsangkar NP, et al. An assessment of the academic impact of Shock Society members. Shock Augusta Ga. 2018;49(5):508-513.
- Valsangkar NP, Milgrom DP, Martin PJ, et al. The positive association of Association for Academic Surgery membership with academic productivity. J Surg Res. 2016;205(1):163-168.
- Valsangkar NP, Kays JK, Feliciano DV, et al. The impact of members of the Society of University Surgeons on the scholarship of American surgery. Surgery. 2016;160(1):47-53.
- American College of Surgeons. Surgeon well-being resources. Available at: facs.org/member-services/surgeon-wellbeing/resources. Accessed June 1, 2019.
- American Medical Association. Professional well-being. Available at: https://edhub.ama-assn.org/steps-forward/pages/professional-well-being. Accessed June 1, 2019.
- Association of American Medical Colleges. Well-being in academic medicine. www.aamc.org/initiatives/462280/well-being-academic-medicine.htm. Accessed June 1, 2019.
- National Academy of Medicine. Action Collaborative on Clinician Well-Being and Resilience. Available at: https://nam.edu/initiatives/clinician-resilience-and-well-being/. Accessed June 1, 2019.
- Jetten J, Branscombe NR, Haslam SA, et al. Having a lot of a good thing: Multiple important group memberships as a source of self-esteem. PLoS One. 2015;10(5):e0124609.
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