Women surgical residents suffer more mistreatment than men, which leads to a higher burnout rate and more suicidal thoughts among female residents, reports a new Northwestern Medicine study that surveyed trainees in all accredited 260 U.S. general surgical residency programs.
But when the study authors adjusted for the occurrence of mistreatment (discrimination, harassment, abuse), the rates of burnout were similar for men and women residents.
“The biggest driver of burnout was whether you experienced discrimination, abuse or harassment. The more you experienced it, the more likely you were to be burned out,” said senior author Dr. Karl Bilimoria. "Mistreatment among female residents is what seems to explain their higher rates of burnout."
Bilimoria is the director of the Surgical Outcomes and Quality Improvement Center at Northwestern Medicine and the John B. Murphy Professor of Surgery at Northwestern University Feinberg School of Medicine.
The paper was published Oct. 28 in the New England Journal of Medicine.
While verbal abuse primarily arose from other surgeons, gender and racial discrimination came mostly from patients and their families, the survey showed.
Patients frequently mistook the female physician for a nurse. Or patients thought the female physician wasn’t qualified enough and wanted to see a male resident or student who may have been be more junior, the researchers found. Patients often refused to see residents of a certain racial background or made racially demeaning comments to the resident physicians.
Sexual harassment, verbal/physical abuse and pregnancy/childcare discrimination primarily came from the attending surgeons and other residents.
Female residents were told they should not have children during the residency training. Sexual harassment by patients included suggestive comments and inappropriate touching and jokes.
“I’m struck by the frequency of this mistreatment and how much of an impact it has on resident burnout,” Bilimoria said, noting this mistreatment is a problem throughout medicine and society. “Clearly, there is a tremendous need to improve the learning environment to protect the well-being of our trainees.”
Some symptoms of burnout examined on the survey are: feeling fatigued when you get up in the morning and have to face another day on the job; feeling you’ve become more callous toward people since you began residency; not caring what happens to some patients; and treating some patients as if they were impersonal objects.
An estimated 7,400 residents from all 262 residency programs across the U.S. took the survey (a striking 99% response rate), which was appended to the annual American Board of Surgery In-Training Exam.
Among the study findings:
- More than 50% of all general surgery residents reported some form of mistreatment.
- 65% of women reported gender discrimination
- 20% of women reported sexual harassment
- 5.3% of women surgical residents had suicidal thoughts in the last year compared to 3.9% of men (~2.5% in general population)
- 17% of residents reported racial discrimination
“This is a pretty high percentage of people experiencing mistreatment, and this is detrimental to the development of emotionally healthy surgeons who function effectively. We need them to get the best training to become great doctors,” Bilimoria said. “We need to improve in each one of these areas.”
On a positive note, some residency programs had low rates of mistreatment events, the survey showed.
“That suggests improvement is possible,” Bilimoria said. “Some programs are doing this well and others can learn from them.”
‘You have the worst harassment in the country’
The residency programs won’t find out how they fared in this research, but a new study will change that. The second trial, for which Bilimoria and colleagues have recruited more than 200 programs, will give half the programs their performance data. Then, investigators will give program leaders an evidence-based toolkit to improve. The toolkit will be based on the investigators' visits of up to 40 programs to see what they do well to reduce these issues.
“We will give residency programs a report that shows their performance, and they may find they have the highest rate of burnout or sexual harassment in the country,“ Bilimoria said. “Then they will be able to use that data to focus improvement efforts. Programs are not uniformly good or bad. Just because you have a high rate of sexual harassment doesn’t mean you have a high rate of gender discrimination. Hopefully, giving programs these data will allow them to focus on their weaknesses and really improve.”
Dr. Yue-Yung Hu and Dr. Ryan Ellis are first co-authors on the paper.
The study was supported by funding from the American College of Surgeons, Accreditation Council for Graduate Medical Education and the American Board of Surgery.