Learning Resilience

Physician burnout costs the U.S. health care system about $4.6 billion annually. Almost 40% of that amount—$1.7 billion—can be attributed to surgeon burnout, according to a widely cited analysis (Ann Intern Med 2019;170[11]:784-790).

Estimates of burnout among surgeons vary depending on the definitions and measures used, but one point is clear: The telltale symptoms of emotional exhaustion, cynicism and diminished sense of purpose are common and growing more prevalent during the COVID-19 pandemic (JAMA Surg 2020;155[11]:1043-1049; JAMA Netw Open 2020;3[3]:e203976).

At its core, Carter Lebares, MD, said, “burnout is really a surrogate marker of profound stress and distress.”

The good news is that not all stress is bad, Dr. Lebares said during a presentation on Resilience Training for Surgeons at the virtual 2020 American College of Surgeons (ACS) Clinical Congress (abstract PS431). Research shows that experiencing small bursts of stress-fueled adrenaline can actually enhance a person’s energy level and motivation.

“Surgeons are already familiar with this experience, and many of us were drawn to surgery because of it,” Dr. Lebares, an assistant professor of surgery and the director of the Center for Mindfulness in Surgery at the University of California, San Francisco, told General Surgery News. “But what if surgeons could be taught a set of cognitive skills that would make stress less painful and could increase performance under stress more reliably?”

In her ACS talk, Dr. Lebares detailed her efforts to answer this question, focusing on one approach: enhanced stress resilience training (ESRT). Over the past five years, she has adapted and studied this tailored version of mindfulness-based cognitive training to determine whether surgeons benefit from these skills.

Building the Evidence Base

A long-standing body of research shows that training in mindfulness curbs stress and enhances performance and mood. Learning these cognitive skills, for instance, can help students score higher on exams and professional athletes get in the “zone” during clutch moments of a game (Front Psychol 2019;10:1875; Dev Psychol 2015;51:[1]:44-51).

Dr. Lebares recognized how this training could benefit surgeons but, in 2016, no studies existed in this population. That year, she launched UCSF’s Center for Mindfulness in Surgery to begin studying how training in these cognitive skills may improve surgeons’ mental health and performance.

Her first clue that ESRT could work for surgeons came from a national survey exploring why some general surgery residents are more resilient to burnout (J Am Coll Surg 2018;226[1]:80-90). After analyzing the data, she found that certain surgeons naturally exhibited mindfulness tendencies—greater self-awareness and an ability to regulate their emotions—and these traits lowered their risk for burnout, suicidal thoughts and depression.

“These results suggested that purposefully building mindfulness skills in surgeons could have a similar effect and help a broader set of people,” she said.

Dr. Lebares began testing this theory in surgery residents. First, she needed to see whether integrating formal mindfulness-based training in surgical education would be feasible and whether residents would be on board with it.

“One concern is that surgeons may get caught up in the misconceptions and jargon surrounding mindfulness and miss the core idea,” Dr. Lebares noted. “That’s why, during training sessions, I start by explaining the goal of ESRT. We’re not trying to create Buddhas or yoga teachers; we’re just teaching a set of cognitive skills that help surgeons recognize when a stressor arises, and teaches us to turn our reactions into responses. This simple shift in perspective can totally change how we handle stress and how we feel in general.”

In Dr. Lebares’ Mindful Surgeon pilot study, 21 surgical interns volunteered to be randomized to an early iteration of ESRT training, which involved two-hour sessions of breathing, counting and meditation exercises over eight weeks, and a logistically similar control scenario (JAMA Surg 2018;153[10]:e182734).

Initial interviews confirmed that integrating ESRT into surgical training was indeed feasible, and the training improved surgeons’ ability to handle stressful situations at work and at home. A follow-up analysis showed that participants continued to practice these skills a year later. ESRT participants had higher mindfulness scores, better scores on tests of executive function, and fewer stress and depressive symptoms than the control group (JAMA Netw Open 2019;2[5]:e194108).

“In our interviews, we also found that residents liked the training, found tons of ways to apply it and, perhaps most importantly, changed how they internalized stressful experiences,” Dr. Lebares said.

Despite the positive findings, she knew convincing practicing surgeons to make time for this training would be a bigger challenge. To appeal to a wider range of surgeons, she streamlined the time commitment—initially to six weeks of 90-minute sessions and later to five weeks of one-hour sessions. A newly published analysis showed that the shorter training program still led to improvements in burnout symptoms and reduced the proinflammatory gene response (Ann Surg 2021;273[3]:424-432).

Outside of formal training, finding time to practice these skills is key. Dr. Lebares recommended carving out spare moments in the day while waiting for the elevator, washing hands or driving home.

“One surgeon described paying attention to her feet touching the pavement as she walks from the hospital to her car,” she said. “This mental routine allows her to leave work and transition to home. Another surgeon said he uses time waiting for lab results or the elevator to meditate, saying it ‘reclaims the moment,’ which I think means just letting go of the stress and frustration of waiting or rushing. We are seeing that doing this kind of informal, anytime micropractice is quite powerful and shows us that surgeons don’t have to become monks to benefit from meditation.”

Beyond ESRT

Last year, ESRT became part of the mandatory curriculum for surgical interns at UCSF. Outside of UCSF, surgeons have been slow to adopt ESRT, but the pandemic has spurred greater interest from programs across the United States, Canada and Europe.

“Over the past six months, I’ve been getting calls and emails from more and more surgery programs who want to make this training part of their academic work and want to teach it,” said Dr. Lebares, who has adapted ESRT training to a remote form, which she now offers across four time zones to ER physicians and surgeons. “We’ve demonstrated that ESRT reduces burnout, and have created a road map to help other institutions implement this training.”

But ESRT training is just one strategy to reframe the culture of surgery at the individual and program levels.

In a complementary ACS session, Lilah F. Morris-Wiseman, MD, FACS, highlighted another approach to improve surgeon well-being (abstract PS324). In July 2016, the University of Arizona in Tucson launched a well-being and resiliency program for general surgery residents, which paired residents and faculty, as a way to facilitate confidential discussions about challenging experiences on the job.

An initial study that assessed the program one year after implementation found perceived stress and emotional exhaustion among 49 surgery residents decreased while their satisfaction with work relationships, communication skills, productivity and work–life balance increased (J Am Coll Surg 2018;226[4]:369-379). A 2020 follow-up analysis found that residents continued to report improvements in team communication and sense of community (J Surg Educ 2020;77[3]:508-519).

“While we may not have the power to change health care systems, we can change our departmental cultures and give our faculty and trainees the tools to succeed in [the] complex environment,” Dr. Morris-Wiseman, a clinical assistant professor of surgery at the University of Arizona in Tucson, said during her presentation.

In the session on surgeon well-being, Yue-Yung Hu, MD, MPH, an assistant professor of pediatric surgery at Northwestern University Feinberg School of Medicine, in Chicago, discussed her team’s efforts to better understand national-level system and cultural issues that affect surgeon experience and burnout.

Part of the problem, Dr. Hu said, is that “most programs have no data about their performance on these issues and lack access to readily available strategies to make improvements.”

These gaps in understanding prompted Dr. Hu and her colleagues to launch the SECOND trial—Surgical Education Culture Optimization through targeted interventions based on National comparative Data—to improve the well-being of residents nationwide and ultimately establish wellness tool kits tailored to different programs.

To measure how resident well-being differs on the local level, Dr. Lebares’ group also recently began a project exploring how the culture of programs influences the types of interventions that are accepted and effective (JAMA Netw Open 2021;4[1]:e2032676).

“Ultimately, we want to provide guidance as to where and how to use our precious resources to engage and prioritize surgeon wellness in different environments,” Dr. Lebares said.

This article is from the March 2021 print issue.