key: cord-1016951-3ep0ty41
authors: Chow, Oliver S.; Sudarshan, Monisha; Maxfield, Mark W.; Seese, Laura M.; Watkins, Ammara A.; Fleishman, Aaron; Gangadharan, Sidhu P.
title: National Survey of Burnout and Distress among Cardiothoracic Surgery Trainees
date: 2020-08-28
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2020.06.062
sha: 915abe03846c7ab7f164d1e11abcd6ca1b0af34a
doc_id: 1016951
cord_uid: 3ep0ty41

Background Burnout has been linked to poor job satisfaction, increased medical errors, and is prevalent among healthcare professionals. We sought to characterize burnout and distress among US cardiothoracic surgical (CTS) trainees. Methods A 19-question survey was sent to CTS trainees in collaboration with the Thoracic Surgery Residents Association. We queried sociodemographic variables, balance/quality of life (QOL), and indicators of depression and regret. We included questions along the emotional exhaustion, depersonalization, and personal accomplishment subscales of the Maslach Burnout Inventory. Results The survey was sent to 531 CTS trainees across 76 institutions and there were 108 responses (20.3%). Over 50% of respondents expressed dissatisfaction with balance in their professional life and over 40% screened positively for signs of depression. Over 25% (n=28) of respondents would not complete CTS training again, given a choice. More than half met criteria for burnout on emotional exhaustion and depersonalization subscales. CTS residents with children were more likely to express regret towards pursuing CTS training. A greater proportion of women than men reported poor levels of balance/QOL during training as measured by missed health appointments, negative impact on relationships, and self-perception. Similarly, those in the final three years of training were more likely to report poor levels of balance/QOL. Conclusions High rates of burnout, regret, and depression are present among US CTS trainees. Efforts to promote trainee well-being and implement interventions that support those at high risk for burnout are warranted, to benefit trainees as well as the patients they serve.

the initial request. The survey consisted of four sociodemographic questions, four questions focused on work-life balance and QOL, two questions as a screen for depression, two questions evaluating regrets towards pursuing CTS training, six questions along emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA) subscales of the Maslach Burnout Inventory (MBI), and one question on awareness of wellness-related resources.

The balance/QOL questions were based on the linear analog self-assessment scale, which has been validated across multiple populations and used widely in QOL research 12, 13 . They also included questions used in prior research on work-life balance 4, 5, 10, 12 . The four balance/QOL questions were given a combined score (0 -worst, 16 -best balance/QOL) and a good degree of work-life balance/QOL was attributed to those with a score of twelve or higher. Two questions were included that have been used as a screen for depression, which has also been used in other survey studies 14, 15 .

Both of these were binary and respondents were counted as screening positive for depression if they answered positively to both questions. The two questions screening for regret were based on other published surveys that also included questions to assess potential resident attrition 3, 11 . Regret was attributed to respondents who indicated they have considered leaving their training program once a month or more often, and responding 'no' to whether they would choose to complete training again. Questions assessing the various domains of burnout were included, and were derived from the MBI 2, 6, 16, 17 . The responses were separated into the three subscales of emotional exhaustion (4 questions), depersonalization (1 question), and personal accomplishment (1 question), and were also analyzed together with burnout being attributed to respondents with a high score in at least one subscale. There were no missing items or responses as survey respondents were prompted by the survey platform if questions were left blank. Pearson's Chi-squared tests were used to evaluate associations between sociodemographic variables and the outcomes of interest. We wanted the sample to be representative of all cardiothoracic surgery trainees. According to the Thoracic Surgery Residents Association, there were 531 CTS residents at the time of survey. With a confidence interval of 95% and a 20.3% response rate (n = 108), our margin of error (MOE) is ± 8.4%. The MOE calculation is as follows:

J o u r n a l P r e -p r o o f This study was approved under IRB (#2018P000347) of the principal investigator's institution.

The survey was sent to 531 CTS trainees across 76 institutions and there were 108 responses (20.3%).

Seventy-seven responses were received following the first e-mail over the first 11 days, and an additional 31 responses were received following the second e-mail over eight days. The baseline demographic data of the trainees who responded are shown in (Figure 1) , and nearly 50% screened positive on the two questions for depression. Over 25% would not complete CTS training again, given a choice.

Along the MBI subscales, emotional exhaustion and depersonalization was prevalent with over 50% of respondents reporting high levels of both, and meeting criteria for burnout in those subscales. Scoring along the personal accomplishment subscale was more positive, with most trainees reporting at least some sense of personal achievements at least once a week. Statistical associations between demographic data and the outcomes of interest are outlined in Table 2 .

J o u r n a l P r e -p r o o f

CTS trainees with children were significantly associated with having regrets toward training compared with those without children (31% vs. 14%, χ 2 =4.07, p=0.044), with regret being counted if they reported they would not select CTS training over again in addition to having thoughts of quitting at least once every month. Having children was the only variable measured within our survey that held an association with demonstrating regrets with respect to CTS training.

A higher proportion of female CTS trainees expressed regret towards pursuing CTS training than their male counterparts, but this association did not reach statistical significance (31% vs. 16%, χ 2 =3.32, p=0.069) 

Similarly, CTS residents in the last 3 years of their training (last 4 years for the 6 trainees enrolled in a 4+3 program) were far less likely to report positive ratings for balance/QOL, compared to those in the more junior years of their training (6% vs. 26%, χ 2 =7.79, p=0.0053).

Most trainees (46%) were at least somewhat aware of resources available to optimize performance, nutrition, and exercise, but there were still 13% (n=14) who reported they were "not at all aware" of and had not received these supportive resources.

This study identified high rates of burnout, regret, and depression among US CTS trainees. These findings corroborate a growing body of literature on the mental distress faced by surgical trainees, practicing surgeons and those in other surgical subspecialties 2,4,10,12,17-19 . It may come as no surprise that cardiothoracic surgery trainees report high degrees of burnout and regret, but its predictability should not lessen its impact. Burnout has not only been linked to medical errors, but also has profound impacts on the interpersonal relationships of the distressed individual and carries the potential risk of physician suicide. With over 400 physician suicides a year in the US, over double the rate of the general public, there is no room for dismissing these issues among CTS trainees.

In response to our survey, CTS trainees showed a high prevalence of burnout on the emotional exhaustion and depersonalization subscales, while a majority (nearly 80%) maintained positive levels of personal accomplishment. This discrepancy among burnout subscales was also noted among general surgery Several studies have identified differences in burnout rates according to gender 5, 20 , and a recent study by There are limitations of this study inherent in its design. The first limitation is the possibility of nonresponse bias. We decided it was important to keep the survey voluntary, accepting that this would lower the number of responses and limit the generalizability of the results, since systematic differences could exist between respondents and non-respondents. Importantly, the distribution of survey respondents between traditional, integrated, and 4/3 CTS programs was nearly equal to the distribution of all potential respondents (χ 2 =0.79, p=0.67), suggesting that an acceptable representation of CTS trainees was obtained.

Several studies have coupled similar questionnaires with in-training exams 21, 25 , which dramatically increases response rates, but also introduces other potential confounders. As with most surveys, the findings present a single snapshot in time for the respondent, and so recall bias can also be present. traditional roles, we should be prepared to adjust our traditional training systems to reflect a commitment to optimizing trainee well-being and growth.

In summary, this represents the first national survey across cardiothoracic surgery trainees that objectively

demonstrates and documents what many of us have known intuitively for years; a high prevalence of burnout, depression, and poor levels of balance and QOL. While we hope that displaying the rather negative view trainees have of their programs might diminish the stigma associated with burnout and distress, our broader aim is to improve the training paradigm. The authors humbly suggest that as a surgical society and as educators, the measures we take from here should target three main priorities: 1) improve cardiothoracic surgery culture by ending sexual harassment and other forms of discrimination, 2) nurture trainee resilience and accomplishment by providing consistent mentorship, and 3) identify ways to provide increased flexibility to CTS trainees to balance their responsibilities and interests outside of the hospital. If we can do this effectively, it will be to the benefit of our trainees, our societies as they join our ranks, and the patients we serve together. The following brief survey will take less than 5 mins to complete. It aims to examine your quality of life as a cardiothoracic surgery resident. Your participation is voluntary and completely anonymous. Your answers will be valuable to evaluate wellness and shape future interventions aimed at decreasing burnout and distress among CTS residents.

The responses to this survey are completely anonymous and cannot be traced back to any identifiable information. Please visit the ACGME site for resources to aid in physician well-being and provide support for depression, burnout or suicide ( https://www.acgme.org/What-We-Do/Initiatives/Physician-Well-Being/Resources ).

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For immediate support on mental health crises please call 1.800.273.TALK (8255), the National Suicide Prevention Lifeline or contact the Crisis Text Line by texting TALK to 741741

IRB #2018P000347) 19. Are you aware of, or have been provided with useful resources and training regarding performance optimization in terms of nutrition, sleep, exercise? * Mark only one oval