Gaining traction on resident wellness
One life lost to suicide is one too many, but it remains a leading cause of death – second only to malignancy – among all residents, according to a 2017 study published in Academic Medicine. Despite article after published article that highlights the signs of burnout and suggests "wellness modules" to preemptively snuff-out the darkness, the rates of depression, burnout and suicidal ideation remain disproportionately high among residents as compared to the general population. Is this phenomenon a novelty – or one that's always lurked in the background, only to recently position itself front and center?
The three pillars of burnout involve emotional exhaustion, depersonalization/cynicism and feelings of inefficacy/inadequate personal achievement. The nature of medicine is grueling and unforgiving, with long hours and maddening isolation. Social media, the lingering effects of the COVID-19 pandemic and another looming recession only seem to magnify the significant difference in the path of residents when compared with the general population – and how vulnerable residents can feel. Full-grown adults have no say in work hours, vacation time or even pay. We're at the mercy of those above us.
Focusing on residents
That doesn't mean they're alone. ASPS past President Jeffrey Janis, MD, who's now chairman of the recently instituted ASPS Wellness Subcommittee, says residents have always been part of the Society's conversation around improving wellness and increasing awareness of burnout – and resident input will always need to be part of the discussion at both the programming and national levels.
"Wellness is a topic that spans every stage of a plastic surgeon's career life cycle," he says. "Residents are, and have always been, critical to the development and ultimate success of the ASPS Wellness initiatives. They've been involved from the very beginning – especially as there has been published data that burnout can affect medical students and residents, not just in the United States, but everywhere in the world. If we are to have progress in this discussion, then it's one that needs to be inclusive of residents every step of the way."
In fact, Dr. Janis is co-author of a soon-to-be-published study that examined the current state of plastic surgery residency wellness programs in the United States, which finds that wellness program leadership can influence plastic surgery residents have a vested interest in leading, or at least remaining active, within their respective wellness program(s) as that's the key difference-maker between effective and ineffective programs. Moreover, the study notes that "greater collaboration within and between plastic surgery residency programs, potentially facilitated by the specialties' national organizations, can benefit the lives of residents as they navigate challenges in their professional and personal lives."
The task force headed by Dr. Janis was behind the launch of a program to directly address the physical, mental and emotional stressors that literally no plastic surgeon has avoided. ASPS Project Well modules have been designed to serve as a comprehensive wellness resource that, cumulatively, address the physical, emotional, social, financial and occupational dimensions of wellness. Fortunately, members of the ASPS Residents and Fellows Forum have free access to the modules, which are easily accessible on the Society's website. Go to PlasticSurgery.org/Wellness, click on "Project Well Modules," log-in with your EdNet credentials, then click on the "Launch" button to get started.
Quality, not quantity
Balance – whether walking a tightrope or finding that work/life equilibrium in one's personal journey – is never easily achieved. It's perfectly valid to argue that without the grueling hours logged by our predecessors, we will never achieve the technical precision required of a plastic surgeon. The response, then, becomes deliberate practice.
With advancements in technology and learning resources, we've eliminated much of the "scut" that once occupied a resident's day. It has been proven time and again that it isn't the amount of time, but the quality of the time that you spend honing your skills that matters. With the institution of the 80-hour work week, residents gained the opportunity to focus on aspects that made a surgeon excellent rather than assume the role of scribe or secretary.
In an effort to gain a unique perspective, Plastic Surgery Resident interviewed UNLV Residency Program Director Ashley Pistorio, MD, MS, and John Brosious, MD, of Vegas Plastic Surgery Institute and former UNLV residency program director, regarding their individual training experiences and what they have seen work – and not work – for residents.
PSR: Did you ever experience burnout during residency/fellowship? If so, how did you deal with it?
Dr. Pistorio: Yes, 100 percent. There was no way to take a "break" to reset, so I relied on value-added activities or relaxation during the times I wasn't working to help reset and recenter.
Dr. Brosious: Yes. I mainly relied on exercise and maximizing my weekends off to clear my head.
PSR: Why is burnout becoming more openly discussed in today's society versus in past years?
Dr. Pistorio: We've transitioned from the baby-boomer generation, which identified as hard workers who didn't job jump for greener pastures and didn't really question working conditions. With the arrival of subsequent generations, different priorities surfaced in working conditions, satisfaction and growth, and also in prioritizing workers as people with lives outside of work. Social media and the internet in general played a large role in raising awareness of these subjects. The IT business boom and its model of working conditions (e.g., having massages and spa time, healthy food that's accessible during the workday) while still maintaining productivity and revenue generation changed the mindset of corporate America as to how businesses can be run while maintaining efficiency and employee retention. Medicine – particularly surgery – has been slow to catch up with this shift in priorities, but it's inevitable given that society has been moving steadily in this direction.
Dr. Brosious: The old "macho" mentality of surgery/medicine lent itself to keeping things bottled-up inside. The younger generations have a much greater focus on mental health and work/life balance.
PSR: What are telltale signs of burnout you look for in your residents?
Dr. Pistorio: Exhaustion, distraction, acting out, loss of patience in a usually patient person, missing details, irritability, tardiness and decreased interaction during conference or cases.
Dr. Brosious: Emotional lability, going through the motions at work.
PSR: Is burnout is an inevitable part of residency and something that we all must overcome?
Dr. Pistorio: I do think it's inevitable in surgical training and as an attending. We must overcome it – and each individual will need to find their own best way to accomplish this. Supportive institutions, partners and attending faculty are key to helping residents overcome burnout.
Dr. Brosious: I believe burnout will always be part of medical education. However, hopefully it manifests itself in small, short doses, rather than prolonged chronic issues.
PSR: What's your opinion of the 80-hour work week and its impact upon the technical skills of residents?
Dr. Pistorio: Provided there's sufficient caseload for operative and nonoperative management, 80 hours per week is plenty to get the needed repetitions and see sufficient volume. Residents and Fellows get overwhelmed with low-yield service activities.
Dr. Brosious: The 80-hour work week is reasonable; however, it will lead to less experience in general, and this will probably affect training in all aspects, most notably judgment and technical ability, which are largely fortified by the amount of experience a resident has. However, that doesn't mean they won't be competent. As long as the education is balanced, they still should be safe, competent doctors – just with slightly less experience.
PSR: With the continual push for wellness and work/life balance, what do you see plastic surgery residency programs looking like in the future?
Dr. Pistorio: Hopefully they will have more awareness, a stronger team mentality and no compromise in training.
Dr. Brosious: It might get to the point where a comprehensive education in plastic surgery is not attainable in six years, and perhaps subspecialties will break out (e.g., microsurgery, hand surgery, craniofacial, etc.) that will only focus on that one, small area of plastic surgery.
PSR: Although burnout is normally talked about in relation to residency, there's also a very real prospect for burnout as an attending. Will things improve or simply change?
Dr. Pistorio: Things tend to get worse as an attending for various reasons. There are different pressures, and hours can be more difficult and demanding. There's often less of a support system available – and most attendings will not use employer-based help, due to implications in license and credentialing.
Dr. Brosious: I actually had more burnout as an attending, likely because there's no built-in time off after you graduate. However, I chose to have an intense career in reconstruction right after I graduated. Residents have no choice in how rigorous their lives are; that's dictated by the program.
PSR: Every plastic surgery residency program – and individual resident – will handle burnout in their own way. Are there overarching keys that must be part of the approach and/or response?
Dr. Pistorio: The keys are recognition, self-awareness, knowing your limitations and knowing the best ways to decompress that work for you. It's good to have "quick fixes" to decompress or reset, as well as long-acting ones. For example, are you having a bad day but can't escape it? Sometimes a quick, three-to-five-minute breathing exercise. or a change in location can help you reset to get through the rest of the day. Longer-acting relief is usually found in more time-consuming activities that can be done evenings or on weekends.
Dr. Brosious: The most important thing is to remind trainees that burnout is a common experience, and it doesn't imply weakness of the trainee. The residents need an environment that allows them to feel comfortable discussing burnout and not fear being dubbed "weak."
PSR: How did your own experience with burnout affect your residency or your work as an attending?
Dr. Pistorio: I can't say this is past tense. It's a never-ending cycle – and awareness of it and countermeasures have to be deployed on a rolling basis. During residency it created exhaustion and enhanced "imposter syndrome," and generated feelings of apathy and worthlessness – and it all certainly felt impossible to escape at times. Now that I'm an attending, I can say I still feel overwhelmed and burned-out at times, but my overall coping skills allow me to avoid the extremes felt as a trainee. I'm still guilty of saying "yes" too often, of overstretching and overextending, overcommitting my time and not taking enough breaks. I love what I do, and that makes it even more difficult to say "no."
Dr. Brosious: I often will counsel the trainees on techniques that I used to help combat burnout.
PSR: What are you most excited to see in the evolution of awareness of wellness and burnout as it pertains to resident education?
Dr. Pistorio: A more humane environment starts from the top down, and I think many of us are now able to speak openly about it at all levels. Sharing the management of burnout and promotion of wellness should be a continuing conversation in residency programs. We're tasked with training future plastic surgeons, and I firmly believe that part of this must include teaching them not just the theory and techniques of plastic surgery, but also practice management – which includes the management of wellness for themselves and their future colleagues/staff.
Dr. Brosious: Every surgical resident will experience burnout at some point. All residents need to know there are options for help when they burn out – not if they burn out. Burnout is inevitable, and it needs to be planned for.
Dr. Mehta is PGY-4 at the University of Las Vegas.