In this episode, Dr. Jamie Coleman is joined by Carter Lebares, MD, FACS, from the Department of Surgery, University of California San Francisco. They discuss Dr. Lebares’ recent study at 16 academic general surgery training programs, in which residents indicated a perceived lack of value congruence with leadership regarding occupational well-being. Program directors expressed variable alignment with these perceptions. Value congruence was significantly associated with individual resident global well-being.
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Episode Transcript
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(00:01):
Welcome to The Operative Word,
a podcast brought to you by the
Journal of the American College of
Surgeons.
I'm Dr. Jamie Coleman.
And throughout this series, Dr.
Dante Yeh and I will speak with
recently published authors about the
motivation behind their latest
research and the clinical
implications it has for the
practicing surgeon.
(00:22):
The opinions expressed in this
podcast are those of the
participants and not necessarily
that of the American College of
Surgeons.
Welcome to The Operative Word, a
podcast from the Journal of the
American College of Surgeons.
I'm Dr. Jamie Coleman, one of your
hosts for this series.
In this episode, I am joined by
(00:43):
Dr. Carter Lebares, and we'll
be taking an in-depth look into her
current article, Operationalizing
the Culture of Burnout and
Well-Being, A Multicenter Study
of Value Congruence and Flourishing
in General Surgery Residency.
Dr. Lebares is an associate
Professor of Surgery and Director of
the Center for Mindfulness in
Surgery at the University of
California, San Francisco.
(01:05):
Dr. Lebares, welcome to The
Operative Word.
Hi, thanks for having me.
Before we begin, do you have any
conflicts of interest to disclose?
This study was funded by
an Association for Surgical
Education Foundation Platinum
Grant.
But other than that, no disclosures.
Great.
(01:26):
Well, first, I just would like to
say what a pleasure it is to have
you on The Operative Word with this
paper.
It's a much-needed step in
addressing resident burnout.
I know when I go and I give talks
regarding wellness, the number one
question I get asked is,
So what do we do about it?
And this paper takes a huge step
in helping to provide those answers
(01:47):
of what works and what doesn't.
So thank you again for being here.
Yeah, my pleasure.
All right. Well, let's start off
actually with a phrase that I think
many surgeons may not be familiar
with (01:58):
this concept of
value congruence.
Can you define that for our
listeners? And why is this so
important when we talk about
burnout?
Yeah. So value congruence
is a pretty interesting concept
and it's one that has its roots
in
Marylène Gagné's work around
workplace motivation.
(02:20):
And this is getting
into the
heart of the matter.
But I think it's important in terms
of thinking about
how do we really address and
understand what matters
to people in making their work
satisfying, meaningful
and something that they want to do
for the long term.
(02:41):
Those are things that we want from
physicians, that we want from
surgeons, we want from surgeons in
training.
So in Gagné's work,
she talks about two kinds of
motivation, one being extrinsic,
which is sort of like getting money
or public praise.
And then the other source
of motivation is being intrinsic.
(03:01):
And that has to do with things like
purpose, meaning and fulfillment.
So if we think about those
intrinsic motivators, no
one really gives those to us.
Those are things that we
create or have within ourselves.
And yet we know that one's
sense of purpose can be influenced
(03:22):
by the outside.
So value congruence is
a concept that begins
to get at that sense of
purpose or
satisfaction or value from one's
work.
And it's a really interesting
concept because it takes
into account individuals
thoughts and feelings about what
(03:42):
they do and what matters to them.
It also looks at systems because
it's comparing how
our values, our thoughts, our
feelings about our work resonate
with those of our employer
or boss or institution.
And so simply put,
it's the degree
of alignment between worker
(04:03):
and workplace values.
What that ends up looking like is
predominantly, do
I feel like the things that matter
to me that motivate me
on an internal level to
do hard work, are respected
and represented and
shared by the people who employ me?
(04:24):
So it's a really powerful motivator
and it is kind of at the
intersection of individual
personality and needs
as well as systems, how your
workplace works, and then
cultural values like what matters
to the people that you work for.
And I think it was so interesting,
too, just to highlight
(04:45):
the fact that you really
you went down the perception
of value congruence you
what you didn't do is you didn't do
a direct comparison of
self-reported values.
And I thought that that was huge
because I think there is a lot of
conflation or confusion about
burnout. Is that...and
I'm going to quote this from your
(05:06):
paper, because I think this was just
so key that individual
perceptions
are powerful influences of
behavior, regardless
of objective fact.
And I think sometimes as surgeons,
we we focus
on the facts or the data
or this or that, you know,
for programs well, but they're
(05:27):
always under their hours, You know,
what's the issue.
Whereas it's really about how
people feel and their perceptions
of how
they feel and what they value aligns
with where they work.
I just I thought that that was a
brilliant aspect.
Yeah, it's really interesting.
(05:48):
In the first part of the study,
I'm jumping ahead a little bit, but
in the first part of the study we
did a survey
of residents at I think
it was 16 different institutions
and we ended up getting
about
250 respondents.
And amongst
(06:09):
those
we asked both
objective questions using standard
measures and surveys.
That's kind of what you're talking
about.
But then we also asked open ended
questions.
What are some of the main things
that influence your well-being or
detract from your well-being?
And what we noticed from those
responses to the open ended
(06:30):
questions was
that people were making comments
that seemed to speak
to this idea of
feeling uncared
for, of feeling
that they weren't being valued
or taken care of
or even considered in
the machinery and the operation of
(06:51):
their residency program.
And so this was intriguing to us,
partly because we thought these are
really powerful statements.
I mean, we didn't ask list all the
things you're unhappy about.
We said, tell us the thing
that is the most antagonistic to
your well-being right now and
what the majority many
of the people chose to focus
on were things around this
(07:12):
sense of being
not taken seriously, being taken
advantage of, not being cared for,
questionable motives on the part of
their department
or surgery program.
And that's really potent.
You know, that speaks to perception,
but it also speaks to, frankly,
mistrust.
(07:33):
And so we dug into that
a little bit deeper and
also wondered if there would be
a synergy or
a disconnect between how
program directors
see these same issues.
So after we got that initial
survey data, we did interviews
(07:53):
with nine of the program directors
involved in the larger
group of programs we had
surveyed and really
asked them questions about
how they conceive of their
well-being, programing, what their
goals and purposes are, and
then what they think or know about
how residents are experiencing
things.
And what was really interesting
(08:14):
about that part of the study was
that it revealed
in most instances
the program directors were aware
of the kind of negative perceptions
that residents were having, and
they understood why.
Many of those negative perceptions
the program directors shared.
So, for instance,
(08:36):
feeling somewhat
handicapped by this
recognition that some of the
problems around burnout are systemic
and lie outside the scope of
influence of a program director.
And so while
residents might be blaming the
program, the program director saw,
Look, your complaint is legitimate.
(08:57):
I'm just incapable of
doing anything about it.
But what was also interesting is
that program directors in
fewer instances
saw some of the issues that
residents raised as being
kind of unreasonable or
as being the result
of residents coming from a different
(09:19):
perspective. The perspective of
novices, not people
who have been in the field for years
or decades.
And so to me, that was actually one
of the most exciting findings
In the end, we followed
up with a second national survey
to the residents in that same 16
institution consortium,
(09:39):
and we decided to use an objective
measure that's
used widely in high reliability
organizations nationally
to assay directly
this idea of value congruence.
And then we compared
that to measures of flourishing,
which is kind of global well-being.
And what we found was that they are
(10:00):
correlated so that when people
feel a higher level of value
congruence, they are
more likely to be flourishing.
So it just kind of makes a
tight package suggesting that this
area of transparency
and alignment and trust
is really important.
Absolutely. I mean, I think the
(10:21):
trust is
this huge because again, you know,
we've talked about previously,
but you never know what's
going to happen. And I think, again,
the timing of your study in 2021
or the beginning of your first
parts of it, you know,
clearly no one anticipated
the pandemic, so you never know
(10:41):
what's going to happen. But feeling
that you trust your leaders, that
regardless of what happens,
they will value you,
they will take care of you.
They may not be able to control
everything, but they will support
you. And I think that's
just such a big perspective, and I
think it sometimes gets lost when
that gets discussed.
(11:03):
And like you said, you
know, not unsurprisingly, you know,
you found that residents who
perceived value congruence with
their program had higher
scores of individual global
well-being.
But for the residents who did
perceive this lack of value
congruence, they were not aligned
with their programs.
You kind of found these themes and
(11:23):
you grouped them into four
categories of inaccessibility
inconsiderateness,
inauthenticity, and
insufficiency.
Can you expand upon that and
even maybe give us some examples of
those?
Yeah. So.
All of those categories are
(11:44):
themes that arose within
the context of asking
what do you what are your thoughts,
perceptions and experiences
around the wellbeing interventions
in specific and the wellbeing
program in general at your
institution, whatever
that might look like?
And so we are trying to get at
(12:07):
the fact that the majority
of institutions these days
are working hard, giving
a very sincere effort
to address well-being.
We have very little evidence to go
on in terms of what works
or even what to do.
And so understandably,
there's a bit of a shotgun approach
going on and people often
(12:30):
invest precious time
and money in offering
something to residents that has
worked for them personally
or that they simply think sounds
reasonable or legitimate or is
feasible, which
is understandable,
but is
not the most efficient or directed
or evidence based evidence based
(12:51):
way to approach things.
So what we were trying to understand
is when
we ask residents what's working for
you, where can we start to see
patterns about things that
the rest of us might learn from and
then start using
preferentially going forward?
Secondly, we've been trying to
(13:13):
understand when
we when we come to
identify something that matters to
residents, let's say, for instance,
a bit more control over their lives.
When that comes up as an objective
finding that has a strong
correlation to measures
of well-being, what exactly
(13:33):
does that mean?
Right? So we can say like control is
really important or the magnitude
of demand on a resident is really
important.
But literally, what does that mean?
How do we operationalize that?
And so that was at the heart of this
development of themes and this
specific categorization of the
themes that we found.
So in regard
(13:54):
to the themes that you mentioned
when it came to inaccessibility,
what that referred to was residents
repeated mention of
good wellbeing programs, good
interventions being
impossible for them to use.
And so specifically speaking,
for instance, wellness half days.
(14:16):
So a lot of programs are
implementing wellness half days,
residents get to leave and go take
care of, you know, a veterinary
appointment, dental appointment,
maybe a yoga class, whatever they
want, something that helps them
take care of themselves.
And while people really appreciated
this and thought it was a great idea
and when they did get to use it
found it very useful,
(14:37):
It was often provided
in a way that was in direct conflict
with other
duties and responsibilities.
So for instance, for senior
residents missing the entire
morning rounds on a day in
the middle of the week left them
feeling like they were completely
blind to what was going on in their
service, which both
led to a pile up of work
(14:58):
when they returned from their
wellness half day, sort of erasing
the benefits of their
wellness morning
and or a real sense of
internal conflict about
their sense of duty and
responsibility.
So here we we want
residents to feel like they own the
service and that they're responsible
for what they do.
But then we're asking them to
(15:20):
pause that for a moment without
really helping them
understand or manage
the fact that things will be taken
care of in their absence.
So that was inaccessibility, a good
idea that's provided in such a way
that it can't really be taken
advantage of.
The second category was
inconsiderateness, and I found
(15:41):
this one to be particularly
interesting because
residents are not children.
Right? Even though they come into
surgery,
almost 100% naive to what
the field really is about.
They are adults.
They're adult learners.
Many of them are married, married
and divorced and married again, or
have children or have had careers
(16:03):
that have spanned years.
And frequently
these adult learners will say
it's insulting to be told what
to do for our own well-being.
And this was really interesting.
And this particular category
really was expanded
on in the program director
interviews, because
(16:24):
what we learned was that often
residents felt that being
told something is mandatory seemed
kind of infantilizing.
They also felt that being
told that they needed to invest in
skills when what they really wanted
was just a moment to breathe,
felt like their true needs were
being ignored.
(16:45):
What the program directors reflected
on, and this was where they had
an entirely different perspective
based on their years of experience,
was that often making something
mandatory was the only way that they
could make it protected.
So in a sense, addressing
category number one inaccessibility
required that they made something
mandatory.
That's, that way, no
(17:07):
other attendings, you know, no other
staff in the hospital could wonder
why the resident wasn't at their
post and they were doing something
else, and
residents didn't really seem to see
that.
So that really can be remedied
through better communication.
Right? A better explanation of
people's motivations.
Absolutely.
The other part of it that program
(17:29):
directors were often saying you need
to build a skill set, not just
have the pop off valve
had to do with program directors,
really insightfully describing how,
you know, a resident might feel like
what they need to do in their free
hours is work on their notes
or go for a hard run.
Working on their notes or going for
(17:49):
a hard run is not going to prepare
them for how to manage
medical malpractice litigation in
the future.
It's not going to prepare them for
the stress of having a patient die
or their first complication where
they truly harm someone with their
own hands.
And so the
phrase that came out of that for us
(18:09):
was this contrast
between immediate survival
and preparedness.
And so that's a theme, an idea
that we're digging into deeper
in subsequent work, because it's
fascinating and seems important.
To speed things up a little bit,
the inauthenticity component
(18:30):
was also something that's really
concerning.
This was residents speaking to the
idea that what they're being told
and what is actually happening
are not the same thing.
So, for instance,
being told that they're heroes and
getting mugs and t shirts
and public applause
for working during the
pandemic or,
(18:53):
you know, providing something that's
above and beyond, but then things
that actually
help them like mental health
services or
the time off to counteract
extra time spent working
were not being provided.
And so it made them feel like they
were being the words coming
(19:13):
out of their leaders mouths were
one thing, whereas the
intention underneath those actual
actions was something else.
And this inauthenticity
is also highly concerning.
Much work and occupational science
shows us that when mistrust
between workers and leaders
finds roots, it can be
(19:34):
destructive, very destructive.
And then the last part insufficiency
is probably the simplest, which is
just residents think
some of this stuff is really good,
but we need more.
No, that's great.
Thank you so much.
All right. So we got time
for one last question, and I really
want this to
(19:56):
again, speak to your work, which is
operationalizing.
So for all my program directors out
there and really for
any leaders of surgeons,
because I think so much of this work
applies to not just residents
but to attendings as well.
What are some specific changes or
interventions they can begin today
(20:16):
to reduce burnout and really show
that their residents, their
trainees, their surgeons
are indeed that they are indeed
together value congruent.
Yeah. So I think
probably
one of the most powerful, powerful
things people can do is
(20:37):
talk to residents about this
very question, you know, or
or faculty.
What's the one thing that's most
getting in the way of your
well-being?
And listen to the answer.
Because while this group of
people proposed
the things that we address in this
paper, they're not going to be the
same for every
(20:57):
institution and every group of
individuals across the country.
So I think just embracing this idea
that we want evidence based
practices, but that doesn't mean
that we all get to or need
the same intervention, and that
requires us to ask and listen.
That idea around communication,
I think better communication
(21:17):
also extends to
explaining why we do certain things.
In surgery, it's so common for us to
say, Cut that, do that, stop
that. And in the right context,
that's appropriate.
But I think this is an example
of where we need to say, listen, the
reason we make this mandatory is so
that you're able to do it.
(21:38):
It's not an insult.
It's actually trying to help you.
And I think any reasonable
adult when they're told that
would say, oh, okay, I understand
that makes more sense and thereby
can diffuse some of that friction.
The inauthenticity part is going to
be tough because I think that
that sense that we're being told
(21:58):
one thing while something else is
going on behind the scenes
has some validity to it.
I don't think that's imagined.
And I think of
all of these issues that's going
to be the hardest to address because
it's not going to just
be resolved by a
local leader.
(22:18):
It's going to involve us addressing
our institutions and saying,
You are responsible to us.
Like why are you making the choices
you're making?
Why are you asking me to do one
thing while I see you
in leadership doing something else?
And that's always a hard
conversation.
(22:39):
The insufficiency part.
I think we can start
sharing more information, using more
scientific method to understand
what works and then publish
and tell each other about it.
Make it known at meetings.
Yeah, no, I really do think that's
key because we we've all in this
space, we've all kind of done the
shotgun approach because,
(23:01):
one, we need data.
We need data to inform what works
and what doesn't. And we don't have
it. And we need to create a
body of data
so that then we can figure it out.
And so I think we're we're
definitely starting to shift now
in this literature with
amazing work like yours on this
paper, which everybody just needs to
read.
(23:22):
And it's just
such good information and practical
information, which is pretty new
for us in this space.
So thank you again so
much Dr Lebares, for taking the time
to discuss this amazing
article and thank you to our
listeners as well.
If you have any feedback for us here
at the operative word, please drop
(23:42):
us a line at postmaster@facs.org.
Thank you for listening to the
Journal of the American College of
Surgeons Operative Word Podcast.
If you've enjoyed today's episode,
spread the word on social media by
using the hashtag
#JACSOperativeWord.
Subscribe to The Operative Word
(24:03):
wherever podcasts are available
or listen on the American College of
Surgeons website at
FACS.org/podcast.
Welcome to The Operative Word,
a podcast brought to you by the
Journal of the American College of
Surgeons.
I'm Dr. Jamie Coleman.
And throughout this series, Dr.
Dante Yeh and I will speak with
recently published authors about the
motivation behind their latest
research and the clinical
implications it has for the
practicing surgeon.
(00:22):
The opinions expressed in this
podcast are those of the
participants and not necessarily
that of the American College of
Surgeons.
Welcome to The Operative Word, a
podcast from the Journal of the
American College of Surgeons.
I'm Dr. Jamie Coleman, one of your
hosts for this series.
In this episode, I am joined by
(00:43):
Dr. Carter Lebares, and we'll
be taking an in-depth look into her
current article, Operationalizing
the Culture of Burnout and
Well-Being, A Multicenter Study
of Value Congruence and Flourishing
in General Surgery Residency.
Dr. Lebares is an associate
Professor of Surgery and Director of
the Center for Mindfulness in
Surgery at the University of
California, San Francisco.
(01:05):
Dr. Lebares, welcome to The
Operative Word.
Hi, thanks for having me.
Before we begin, do you have any
conflicts of interest to disclose?
This study was funded by
an Association for Surgical
Education Foundation Platinum
Grant.
But other than that, no disclosures.
Great.
(01:26):
Well, first, I just would like to
say what a pleasure it is to have
you on The Operative Word with this
paper.
It's a much-needed step in
addressing resident burnout.
I know when I go and I give talks
regarding wellness, the number one
question I get asked is,
So what do we do about it?
And this paper takes a huge step
in helping to provide those answers
(01:47):
of what works and what doesn't.
So thank you again for being here.
Yeah, my pleasure.
All right. Well, let's start off
actually with a phrase that I think
many surgeons may not be familiar
with (01:58):
this concept of
value congruence.
Can you define that for our
listeners? And why is this so
important when we talk about
burnout?
Yeah. So value congruence
is a pretty interesting concept
and it's one that has its roots
in
Marylène Gagné's work around
workplace motivation.
(02:20):
And this is getting
into the
heart of the matter.
But I think it's important in terms
of thinking about
how do we really address and
understand what matters
to people in making their work
satisfying, meaningful
and something that they want to do
for the long term.
(02:41):
Those are things that we want from
physicians, that we want from
surgeons, we want from surgeons in
training.
So in Gagné's work,
she talks about two kinds of
motivation, one being extrinsic,
which is sort of like getting money
or public praise.
And then the other source
of motivation is being intrinsic.
(03:01):
And that has to do with things like
purpose, meaning and fulfillment.
So if we think about those
intrinsic motivators, no
one really gives those to us.
Those are things that we
create or have within ourselves.
And yet we know that one's
sense of purpose can be influenced
(03:22):
by the outside.
So value congruence is
a concept that begins
to get at that sense of
purpose or
satisfaction or value from one's
work.
And it's a really interesting
concept because it takes
into account individuals
thoughts and feelings about what
(03:42):
they do and what matters to them.
It also looks at systems because
it's comparing how
our values, our thoughts, our
feelings about our work resonate
with those of our employer
or boss or institution.
And so simply put,
it's the degree
of alignment between worker
(04:03):
and workplace values.
What that ends up looking like is
predominantly, do
I feel like the things that matter
to me that motivate me
on an internal level to
do hard work, are respected
and represented and
shared by the people who employ me?
(04:24):
So it's a really powerful motivator
and it is kind of at the
intersection of individual
personality and needs
as well as systems, how your
workplace works, and then
cultural values like what matters
to the people that you work for.
And I think it was so interesting,
too, just to highlight
(04:45):
the fact that you really
you went down the perception
of value congruence you
what you didn't do is you didn't do
a direct comparison of
self-reported values.
And I thought that that was huge
because I think there is a lot of
conflation or confusion about
burnout. Is that...and
I'm going to quote this from your
(05:06):
paper, because I think this was just
so key that individual
perceptions
are powerful influences of
behavior, regardless
of objective fact.
And I think sometimes as surgeons,
we we focus
on the facts or the data
or this or that, you know,
for programs well, but they're
(05:27):
always under their hours, You know,
what's the issue.
Whereas it's really about how
people feel and their perceptions
of how
they feel and what they value aligns
with where they work.
I just I thought that that was a
brilliant aspect.
Yeah, it's really interesting.
(05:48):
In the first part of the study,
I'm jumping ahead a little bit, but
in the first part of the study we
did a survey
of residents at I think
it was 16 different institutions
and we ended up getting
about
250 respondents.
And amongst
(06:09):
those
we asked both
objective questions using standard
measures and surveys.
That's kind of what you're talking
about.
But then we also asked open ended
questions.
What are some of the main things
that influence your well-being or
detract from your well-being?
And what we noticed from those
responses to the open ended
(06:30):
questions was
that people were making comments
that seemed to speak
to this idea of
feeling uncared
for, of feeling
that they weren't being valued
or taken care of
or even considered in
the machinery and the operation of
(06:51):
their residency program.
And so this was intriguing to us,
partly because we thought these are
really powerful statements.
I mean, we didn't ask list all the
things you're unhappy about.
We said, tell us the thing
that is the most antagonistic to
your well-being right now and
what the majority many
of the people chose to focus
on were things around this
(07:12):
sense of being
not taken seriously, being taken
advantage of, not being cared for,
questionable motives on the part of
their department
or surgery program.
And that's really potent.
You know, that speaks to perception,
but it also speaks to, frankly,
mistrust.
(07:33):
And so we dug into that
a little bit deeper and
also wondered if there would be
a synergy or
a disconnect between how
program directors
see these same issues.
So after we got that initial
survey data, we did interviews
(07:53):
with nine of the program directors
involved in the larger
group of programs we had
surveyed and really
asked them questions about
how they conceive of their
well-being, programing, what their
goals and purposes are, and
then what they think or know about
how residents are experiencing
things.
And what was really interesting
(08:14):
about that part of the study was
that it revealed
in most instances
the program directors were aware
of the kind of negative perceptions
that residents were having, and
they understood why.
Many of those negative perceptions
the program directors shared.
So, for instance,
(08:36):
feeling somewhat
handicapped by this
recognition that some of the
problems around burnout are systemic
and lie outside the scope of
influence of a program director.
And so while
residents might be blaming the
program, the program director saw,
Look, your complaint is legitimate.
(08:57):
I'm just incapable of
doing anything about it.
But what was also interesting is
that program directors in
fewer instances
saw some of the issues that
residents raised as being
kind of unreasonable or
as being the result
of residents coming from a different
(09:19):
perspective. The perspective of
novices, not people
who have been in the field for years
or decades.
And so to me, that was actually one
of the most exciting findings
In the end, we followed
up with a second national survey
to the residents in that same 16
institution consortium,
(09:39):
and we decided to use an objective
measure that's
used widely in high reliability
organizations nationally
to assay directly
this idea of value congruence.
And then we compared
that to measures of flourishing,
which is kind of global well-being.
And what we found was that they are
(10:00):
correlated so that when people
feel a higher level of value
congruence, they are
more likely to be flourishing.
So it just kind of makes a
tight package suggesting that this
area of transparency
and alignment and trust
is really important.
Absolutely. I mean, I think the
(10:21):
trust is
this huge because again, you know,
we've talked about previously,
but you never know what's
going to happen. And I think, again,
the timing of your study in 2021
or the beginning of your first
parts of it, you know,
clearly no one anticipated
the pandemic, so you never know
(10:41):
what's going to happen. But feeling
that you trust your leaders, that
regardless of what happens,
they will value you,
they will take care of you.
They may not be able to control
everything, but they will support
you. And I think that's
just such a big perspective, and I
think it sometimes gets lost when
that gets discussed.
(11:03):
And like you said, you
know, not unsurprisingly, you know,
you found that residents who
perceived value congruence with
their program had higher
scores of individual global
well-being.
But for the residents who did
perceive this lack of value
congruence, they were not aligned
with their programs.
You kind of found these themes and
(11:23):
you grouped them into four
categories of inaccessibility
inconsiderateness,
inauthenticity, and
insufficiency.
Can you expand upon that and
even maybe give us some examples of
those?
Yeah. So.
All of those categories are
(11:44):
themes that arose within
the context of asking
what do you what are your thoughts,
perceptions and experiences
around the wellbeing interventions
in specific and the wellbeing
program in general at your
institution, whatever
that might look like?
And so we are trying to get at
(12:07):
the fact that the majority
of institutions these days
are working hard, giving
a very sincere effort
to address well-being.
We have very little evidence to go
on in terms of what works
or even what to do.
And so understandably,
there's a bit of a shotgun approach
going on and people often
(12:30):
invest precious time
and money in offering
something to residents that has
worked for them personally
or that they simply think sounds
reasonable or legitimate or is
feasible, which
is understandable,
but is
not the most efficient or directed
or evidence based evidence based
(12:51):
way to approach things.
So what we were trying to understand
is when
we ask residents what's working for
you, where can we start to see
patterns about things that
the rest of us might learn from and
then start using
preferentially going forward?
Secondly, we've been trying to
(13:13):
understand when
we when we come to
identify something that matters to
residents, let's say, for instance,
a bit more control over their lives.
When that comes up as an objective
finding that has a strong
correlation to measures
of well-being, what exactly
(13:33):
does that mean?
Right? So we can say like control is
really important or the magnitude
of demand on a resident is really
important.
But literally, what does that mean?
How do we operationalize that?
And so that was at the heart of this
development of themes and this
specific categorization of the
themes that we found.
So in regard
(13:54):
to the themes that you mentioned
when it came to inaccessibility,
what that referred to was residents
repeated mention of
good wellbeing programs, good
interventions being
impossible for them to use.
And so specifically speaking,
for instance, wellness half days.
(14:16):
So a lot of programs are
implementing wellness half days,
residents get to leave and go take
care of, you know, a veterinary
appointment, dental appointment,
maybe a yoga class, whatever they
want, something that helps them
take care of themselves.
And while people really appreciated
this and thought it was a great idea
and when they did get to use it
found it very useful,
(14:37):
It was often provided
in a way that was in direct conflict
with other
duties and responsibilities.
So for instance, for senior
residents missing the entire
morning rounds on a day in
the middle of the week left them
feeling like they were completely
blind to what was going on in their
service, which both
led to a pile up of work
(14:58):
when they returned from their
wellness half day, sort of erasing
the benefits of their
wellness morning
and or a real sense of
internal conflict about
their sense of duty and
responsibility.
So here we we want
residents to feel like they own the
service and that they're responsible
for what they do.
But then we're asking them to
(15:20):
pause that for a moment without
really helping them
understand or manage
the fact that things will be taken
care of in their absence.
So that was inaccessibility, a good
idea that's provided in such a way
that it can't really be taken
advantage of.
The second category was
inconsiderateness, and I found
(15:41):
this one to be particularly
interesting because
residents are not children.
Right? Even though they come into
surgery,
almost 100% naive to what
the field really is about.
They are adults.
They're adult learners.
Many of them are married, married
and divorced and married again, or
have children or have had careers
(16:03):
that have spanned years.
And frequently
these adult learners will say
it's insulting to be told what
to do for our own well-being.
And this was really interesting.
And this particular category
really was expanded
on in the program director
interviews, because
(16:24):
what we learned was that often
residents felt that being
told something is mandatory seemed
kind of infantilizing.
They also felt that being
told that they needed to invest in
skills when what they really wanted
was just a moment to breathe,
felt like their true needs were
being ignored.
(16:45):
What the program directors reflected
on, and this was where they had
an entirely different perspective
based on their years of experience,
was that often making something
mandatory was the only way that they
could make it protected.
So in a sense, addressing
category number one inaccessibility
required that they made something
mandatory.
That's, that way, no
(17:07):
other attendings, you know, no other
staff in the hospital could wonder
why the resident wasn't at their
post and they were doing something
else, and
residents didn't really seem to see
that.
So that really can be remedied
through better communication.
Right? A better explanation of
people's motivations.
Absolutely.
The other part of it that program
(17:29):
directors were often saying you need
to build a skill set, not just
have the pop off valve
had to do with program directors,
really insightfully describing how,
you know, a resident might feel like
what they need to do in their free
hours is work on their notes
or go for a hard run.
Working on their notes or going for
(17:49):
a hard run is not going to prepare
them for how to manage
medical malpractice litigation in
the future.
It's not going to prepare them for
the stress of having a patient die
or their first complication where
they truly harm someone with their
own hands.
And so the
phrase that came out of that for us
(18:09):
was this contrast
between immediate survival
and preparedness.
And so that's a theme, an idea
that we're digging into deeper
in subsequent work, because it's
fascinating and seems important.
To speed things up a little bit,
the inauthenticity component
(18:30):
was also something that's really
concerning.
This was residents speaking to the
idea that what they're being told
and what is actually happening
are not the same thing.
So, for instance,
being told that they're heroes and
getting mugs and t shirts
and public applause
for working during the
pandemic or,
(18:53):
you know, providing something that's
above and beyond, but then things
that actually
help them like mental health
services or
the time off to counteract
extra time spent working
were not being provided.
And so it made them feel like they
were being the words coming
(19:13):
out of their leaders mouths were
one thing, whereas the
intention underneath those actual
actions was something else.
And this inauthenticity
is also highly concerning.
Much work and occupational science
shows us that when mistrust
between workers and leaders
finds roots, it can be
(19:34):
destructive, very destructive.
And then the last part insufficiency
is probably the simplest, which is
just residents think
some of this stuff is really good,
but we need more.
No, that's great.
Thank you so much.
All right. So we got time
for one last question, and I really
want this to
(19:56):
again, speak to your work, which is
operationalizing.
So for all my program directors out
there and really for
any leaders of surgeons,
because I think so much of this work
applies to not just residents
but to attendings as well.
What are some specific changes or
interventions they can begin today
(20:16):
to reduce burnout and really show
that their residents, their
trainees, their surgeons
are indeed that they are indeed
together value congruent.
Yeah. So I think
probably
one of the most powerful, powerful
things people can do is
(20:37):
talk to residents about this
very question, you know, or
or faculty.
What's the one thing that's most
getting in the way of your
well-being?
And listen to the answer.
Because while this group of
people proposed
the things that we address in this
paper, they're not going to be the
same for every
(20:57):
institution and every group of
individuals across the country.
So I think just embracing this idea
that we want evidence based
practices, but that doesn't mean
that we all get to or need
the same intervention, and that
requires us to ask and listen.
That idea around communication,
I think better communication
(21:17):
also extends to
explaining why we do certain things.
In surgery, it's so common for us to
say, Cut that, do that, stop
that. And in the right context,
that's appropriate.
But I think this is an example
of where we need to say, listen, the
reason we make this mandatory is so
that you're able to do it.
(21:38):
It's not an insult.
It's actually trying to help you.
And I think any reasonable
adult when they're told that
would say, oh, okay, I understand
that makes more sense and thereby
can diffuse some of that friction.
The inauthenticity part is going to
be tough because I think that
that sense that we're being told
(21:58):
one thing while something else is
going on behind the scenes
has some validity to it.
I don't think that's imagined.
And I think of
all of these issues that's going
to be the hardest to address because
it's not going to just
be resolved by a
local leader.
(22:18):
It's going to involve us addressing
our institutions and saying,
You are responsible to us.
Like why are you making the choices
you're making?
Why are you asking me to do one
thing while I see you
in leadership doing something else?
And that's always a hard
conversation.
(22:39):
The insufficiency part.
I think we can start
sharing more information, using more
scientific method to understand
what works and then publish
and tell each other about it.
Make it known at meetings.
Yeah, no, I really do think that's
key because we we've all in this
space, we've all kind of done the
shotgun approach because,
(23:01):
one, we need data.
We need data to inform what works
and what doesn't. And we don't have
it. And we need to create a
body of data
so that then we can figure it out.
And so I think we're we're
definitely starting to shift now
in this literature with
amazing work like yours on this
paper, which everybody just needs to
read.
(23:22):
And it's just
such good information and practical
information, which is pretty new
for us in this space.
So thank you again so
much Dr Lebares, for taking the time
to discuss this amazing
article and thank you to our
listeners as well.
If you have any feedback for us here
at the operative word, please drop
(23:42):
us a line at postmaster@facs.org.
Thank you for listening to the
Journal of the American College of
Surgeons Operative Word Podcast.
If you've enjoyed today's episode,
spread the word on social media by
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Subscribe to The Operative Word
(24:03):
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