Seeking to Enhance Surgical Resident Wellness Using Complications Small Groups and Shadowing

Rates of physician burnout have been increasing dramatically over the past decade. A recent study demonstrated that among surgical residents, the rate of burnout was 69 percent.¹ Hence, we must develop interventions which improve surgical resident well-being. Past research in other populations has taught us that a multidimensional model of health assists individuals in achieving their maximum potential for overall wellness.² In our recent paper,³ we presented an overview of the importance of viewing surgical resident wellness from a multidimensional perspective. This paper is focused solely on two of the interventions we briefly discussed in our original publication which are aimed at enhancing the emotional, social, and professional dimensions of surgeon wellness in our program.

West et al demonstrated that a small group intervention improved physician well-being and reduced depersonalization.⁴ Pinto et al found that complications can severely impact a surgeon’s emotional well-being and suggested that the creation of blame-free forums to discuss bad outcomes, as well as more mentoring, are necessary.⁵ Based on these findings, we recently developed and integrated a novel small group discussion component into the behavioral medicine curriculum in our surgical residency program to create a safe, supportive, and confidential environment which would be conducive in improving well-being by allowing residents to discuss the psychologic distress which results from complications. While the authors are not aware of other surgical programs which are offering this specific type of intervention to their trainees, we determined it was of critical importance to help our residents process their feelings of anxiety, guilt, and regret about complications, while also informing them that bad outcomes can occur even with the most senior and seasoned surgeons. In addition, we propose that assisting residents in the development of adaptive and effective coping strategies in the aftermath of complications is essential for their emotional well-being.

The residents preferred to meet in small PGY-level specific groups, so we offered five separate groups over a six-week period. Our behavioral medicine faculty facilitated all groups. We started each group with two PowerPoint slides, which presented findings from the Pinto et al study⁵ and some quotes from the 2003 book Complications: A Surgeon’s Notes on an Imperfect Science, by Atul Gawande, MD, FACS. A third and final slide posed the questions, “how do you feel when there’s a bad outcome (and) how do you cope with those feelings?” The facilitators also addressed group rules, including confidentiality and respect for each other’s opinions, at the onset of each group. For the PGY1 and PGY2 groups, a chief resident served as a mentor by co-facilitating during the first 10 minutes of both groups. The chief resident disclosed her feelings and coping strategies related to complications. During the remainder of the hour-long group, residents shared their experiences. A surgeon faculty member served as a mentor for the first 10 minutes of the remainder of the groups (PGY3-PGY5) and created a safe and open atmosphere by disclosing his own struggles with bad outcomes and how he had learned to cope with these extremely distressing events over the years. After each group, residents completed an anonymous evaluation based on a five-point Likert scale (5=strongly agree and 1=strongly disagree). A summary of these evaluations (Table 1) showed that residents in all PGY-level groups in our program highly valued this activity. However, based on some of the comments from the PGY1-PGY2 classes, it appears as though they might not be exposed to situations where bad outcomes occur as frequently as they do for senior residents, nor are they given the level of responsibility in these first two years of residency which would make them feel accountable for complications. Therefore, we propose that junior residents may be better served by having small group discussions about general issues, for example, how to cope with the rigors of residency and challenging rotations, rather than through a discussion about complications at this earlier stage of training.

Research has shown that dissatisfaction and burnout are increased among physicians who report a higher frequency of difficult doctor-patient interactions.⁶ In addition, a recent review article demonstrated that interventions which include those that are aimed at building competence are associated with resident well-being.⁷ In response to these findings, in March 2017, in addition to ongoing lectures aimed at enhancing professional wellness,³ we developed and implemented a shadowing activity focused on improving residents’ confidence and skills during patient encounters—and, in particular, during encounters which residents perceived as “difficult.” Another program which used a somewhat similar model to shadow, or “coach,” residents found that observation is feasible and beneficial for improving professionalism and wellness among surgical residents.⁸ In our program, in addition to receiving feedback, our residents are encouraged to engage in self-reflection about what went well and what could have been done better during the observed physician-patient interaction. Residents also receive targeted suggestions based on models^9,10 which were developed to help physicians decrease their feelings of distress and dissatisfaction by learning how to better manage difficult doctor-patient scenarios. Specifically, our behavioral medicine faculty member follows each resident in trauma and burn clinics and notes their performance in two ACGME-core competency areas: verbal and nonverbal interpersonal and communication skills and professionalism, using the SEGUE framework¹¹ (Figure 1). The SEGUE tool is a research-based checklist of medical communication tasks and is the most widely-used structure for communication skills teaching and assessment in North America.¹¹ Immediately following this observed interaction, the behavioral medicine faculty member provides the resident with positive reinforcement of their strengths, as well as constructive feedback on how they might improve their performance. The resident and faculty member also have a brief but comprehensive discussion of each patient’s psychosocial and family dynamics. Following this targeted feedback session, residents are then directed to rate themselves on each of the SEGUE dimensions and then complete two short self-reflection sections (which we added as an adaptation to the back of the standard SEGUE form) by exploring what they did that was effective during the physician-patient interaction as well as where they could improve in these core competency areas (note: we use this measure to specifically focus on ACGME/ABS Milestones PROF1, PROF2 and ICS1). Residents then return the form to our behavioral medicine faculty member, who adds her ratings and comments alongside the resident’s, noting any differences in ratings. Each trainee is sent several post-shadowing questions following this activity in order to gain further insight into their experience. All 12 residents (PGY1-PGY5) who have been shadowed thus far found this activity to be a “helpful educational experience” and all answered affirmatively to the statement, “receiving immediate verbal feedback about your communication and professionalism skills is more valuable than not being observed at all.” In addition, 100 percent of the residents indicated they were satisfied (n=4) or very satisfied (n=7) with this shadowing experience and verbal feedback about their communication and professionalism skills, which was also reflected in their comments (Table 2).

In summary, it appears that both complications small groups and shadowing are perceived by our general surgery residents to be acceptable and valuable educational endeavors. These interventions may contribute to the overall well-being of residents by targeting specific dimensions of surgeon wellness, including emotional, social, and professional, which may in turn reduce burnout. We will seek to confirm this possible relationship by administering items from the Maslach Burnout Inventory (MBI) to our residents in the future, as well as investigate whether these interventions impact their performance.

We should note that while interventions enhancing wellness on an individual level may be quite beneficial, it is also critically important to consider organizational¹² and environmental factors which contribute to stress among surgeons. Organizational factors include the burden from documentation, ineffective work flow, not having adequate support staff, scheduling problems, and administrative requirements which do not result in meaningful improvements in care. Environmental variables relate to the ever-increasing complexity of our world: crowding, traffic, noise, and pollution, which have all been shown in social and environmental psychology literature to be positively correlated with significant increases in perceived stress. To truly stem the tide of burnout, we must go beyond the individual physician and actively lobby to affect change on organizational, institutional, and systemic levels.

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Heidi Allespach, PhD, is an associate professor of clinical surgery and director of behavioral medicine of the surgical residency program at the University of Miami Miller School of Medicine/Jackson Memorial Hospital. She is a clinical psychologist who has worked with graduate medical learners for more than 20 years and she devotes her time in the program exclusively to resident (and surgeon faculty as needed) well-being.

Danny Sleeman, MD, is a professor of clinical surgery, program director of the surgical residency program, chief of the division of surgical critical care, co-director of Ryder Trauma Center, and vice chair of residency education at the University of Miami Miller School of Medicine/Jackson Memorial Hospital.

Maymoona Attiyat, MBBS is chief resident of general surgery at Jackson Health System, University of Miami Miller School of Medicine, and was previously a trauma/critical care fellow at Ryder trauma center.

Gerd D. Pust, MD, FACS, is an assistant professor of clinical surgery, associate director of the surgical residency program, and director of the surgical intensive care unit at the University of Miami Miller School of Medicine/Jackson Memorial Hospital.

Carl I. Schulman, MD, MSPH, PhD, is a professor of clinical surgery, associate director of the surgical residency program, and director of the William Lehman Research Center at the University of Miami Miller School of Medicine/Jackson Memorial Hospital.