Karl Y. Bilimoria

Studies show that burnout is common among health care professionals.^1,2 Burnout is characterized by emotional exhaustion, depersonalization, and low personal accomplishment³ and is associated with medical errors, suicide, attrition, and substance abuse.^4-6 Trainees, particularly in surgery, are at heightened risk for burnout, duty hour violations, and mistreatment.^1,2,7-9 Mistreatment, long hours, poor compensation, and job-related stress may contribute to resident physician burnout.^2,10,11

Burnout in medicine is receiving considerable attention owing to its detrimental effect on health care professionals and their patients.^1-4 The hardships and stress experienced during general surgery residency can disproportionately compromise wellness among surgical residents compared with other specialties.^5,6 Moreover, resident attrition (leaving a training program) has long been a concern in surgery.⁷ The general surgery resident attrition rate is greater than that of other surgical specialties.^8-11 Historical audits and recent studies report 1 in 5 categorical general surgery residents will leave to pursue an alternative career.^11-13 Finally, and most concerning, among all residents training at Accreditation Council for Graduate Medical Education (ACGME)–accredited programs across all specialties, suicide is the leading cause of death in male residents and the second most common cause of death overall.¹⁴

This Viewpoint discusses updates to the Hospital Quality Star Ratings issued by the Centers for Medicare & Medicaid Services (CMS), including changes design

Background: Patient utilization of public reporting has been suboptimal despite attempts to encourage use. Lack of utilization may be due to discordance between reported metrics and what patients want to know when making health care choices. Objective: The objective of this study was to identify measures of quality that individuals want to be presented in public reporting and explore factors associated with researching health care. Research Design: Patient interviews and focus groups were conducted to develop a survey exploring the relative importance of various health care measures. Subjects: Interviews and focus groups conducted at local outpatient clinics. A survey administered nationally on an anonymous digital platform. Measures: Likert scale responses were compared using tests of central tendency. Rank-order responses were compared using analysis of variance testing. Associations with binary outcomes were analyzed using multivariable logistic regression. Results: Overall, 4672 responses were received (42.0% response rate). Census balancing yielded 2004 surveys for analysis. Measures identified as most important were hospital reputation (considered important by 61.9%), physician experience (51.5%), and primary care recommendations (43.2%). Unimportant factors included guideline adherence (17.6%) and hospital academic affiliation (13.3%, P<0.001 for all compared with most important factors). Morbidity and mortality outcome measures were not among the most important factors. Patients were unlikely to rank outcome measures as the most important factors in choosing health care providers, irrespective of age, sex, educational status, or income. Conclusions: Patients valued hospital reputation, physician experience, and primary care recommendations while publicly reported metrics like patient outcomes were less important. Public quality reports contain information that patients perceive to be of relatively low value, which may contribute to low utilization.

Hospital safety culture has been defined as the individual and organizational perceptions and behaviors that determine commitment to patient safety.^1,2 The link between hospital safety culture, quality of care, and patient outcomes has been well documented.^3-7 Given the current focus on quality of care in the United States health care system, an increasing emphasis has been placed on improving hospital safety culture.⁸ Previous interventions aimed at improving the delivery of care in operating rooms and intensive care units, such as teamwork training and implementation of checklists, have been linked to both improved perception of safety culture and decreased morbidity and mortality rates.^8-13 However, many of these interventions have been implemented in specific clinical areas, rather than across an entire department or hospital. Less is known regarding the effects of interventions designed to influence department- or hospital-wide safety culture. Therefore, statewide quality improvement (QI) collaboratives provide an ideal mechanism for implementing and evaluating strategies aimed at improving safety culture on a larger scale.^8,11,14

To investigate the long-term effect of flexible duty-hour policies on resident outcomes The Flexibility in Duty Hour Requirements for Surgical Trainees trial showed no significant difference in overall resident well-being between flexible and standard duty-hour policies after 1 year. However, long-term exposure to flexibility could have adverse effects on duty-hour violations, resident satisfaction, and well-being. In 2014, 117 programs were randomized to flexible or standard duty-hour policy. Residents were surveyed annually following the American Board of Surgery In-Training Exam (~3750 residents/yr; response rate 99%). Four-year trends within the flexible policy arm were analyzed using cluster-corrected Chi-squared tests. Differences between study arms were modeled using multivariable logistic regression. Over time, there was a trend toward fewer 80-hour work week violations in the flexible arm (19.8%–17.0%, P = 0.06), and increased satisfaction with flexible duty-hours (91.9%–94.3%, P < 0.05). Although well-being decreased over time (85.1%–81.5%, P = 0.01), this was seen globally with no difference between study arms [odds ratio (OR) 0.96 (0.74–1.25)]. Likewise, at the end of the study period, there was no association between flexible policy and duty-hour violations [OR 1.25 (0.95–1.61)] or satisfaction with duty hours [OR 0.80 (0.55–1.19)] compared to standard policy. Residents in flexible duty-hour programs reported significantly fewer lapses in continuity than standard policy residents, until all programs transitioned to flexibility by 2018. Cumulative time under flexible duty-hour policies had no detrimental effects on duty-hour violations or resident well-being. After multiple years of flexibility, residents continue to report a high rate of satisfaction and positive effects on continuity of care.

Objectives: The aims of this study were to: (1) measure the prevalence of self-reported medical error among general surgery trainees, (2) assess the association between general surgery resident wellness (ie, burnout and poor psychiatric well-being) and self-reported medical error, and (3) examine the association between program-level wellness and objectively measured patient outcomes. Summary of Background Data: Poor wellness is prevalent among surgical trainees but the impact on medical error and objective patient outcomes (eg, morbidity or mortality) is unclear as existing studies are limited to physician and patient self-report of events and errors, small cohorts, or examine few outcomes. Methods: A cross-sectional survey was administered immediately following the January 2017 American Board of Surgery In-training Examination to clinically active general surgery residents to assess resident wellness and self-reported error. Postoperative patient outcomes were ascertained using a validated national clinical data registry. Associations were examined using multivariable logistic regression models. Results: Over a 6-month period, 22.5% of residents reported committing a near miss medical error, and 6.9% reported committing a harmful medical error. Residents were more likely to report a harmful medical error if they reported frequent burnout symptoms [odds ratio 2.71 (95% confidence interval 2.16–3.41)] or poor psychiatric well-being [odds ratio 2.36 (95% confidence interval 1.92–2.90)]. However, there were no significant associations between program-level resident wellness and any of the independently, objectively measured postoperative American College of Surgeons National Surgical Quality improvement Program outcomes examined. Conclusions: Although surgical residents with poor wellness were more likely to self-report a harmful medical error, there was not a higher rate of objectively reported outcomes for surgical patients treated at hospitals with higher rates of burnout or poor psychiatric well-being.

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

Objectives: To empirically describe surgical residency program culture and assess program characteristics associated with program culture. Summary Background Data: Despite concerns about the impact of the learning environment on trainees, empirical data have not been available to examine and compare program-level differences in residency culture. Methods: Following the 2018 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. Survey items were analyzed using principal component analysis to derive composite measures of program culture. Associations between program characteristics and composite measures of culture were assessed. Results: Analysis included 7387 residents at 260 training programs (99.3% response rate). Principal component analysis suggested that program culture may be described by 2 components: Wellness and Negative Exposures. Twenty-six programs (10.0%) were in the worst quartile for both Wellness and Negative Exposure components. These programs had significantly higher rates of duty hour violations (23.3% vs 11.1%), verbal/physical abuse (41.6% vs 28.6%), gender discrimination (78.7% vs 64.5%), sexual harassment (30.8% vs 16.7%), burnout (54.9% vs 35.0%), and thoughts of attrition (21.6% vs 10.8%; all P < 0.001). Being in the worst quartile of both components was associated with percentage of female residents in the program (P = 0.011), but not program location, academic affiliation, size, or faculty demographics. Conclusions: Residency culture was characterized by poor resident wellness and frequent negative exposures and was generally not associated with structural program characteristics. Additional qualitative and quantitative studies are needed to explore unmeasured local social dynamics that may underlie measured differences in program culture.