November 21, 2024 • 28 mins
In this episode, Lillian Erdahl, MD, FACS, is joined by Jessica Ching, MD, from the Baylor College of Medicine. They discuss Dr Ching’s recent article, “Protective Effects of Authenticity Against Depression, Suicide, and Burnout among Surgeons,” in which the authors found that authenticity may protect against burnout, depression, and suicide, pointing to a vital intervention opportunity. This research highlights the importance of cultivating a culture that prioritizes mental health to foster a resilient, fulfilled surgical community.
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Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:03):
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Lillian Erdahl,and throughout this series, Dr Tom
Varghese and I will speak with recently
published authors about the motivationbehind their latest research
and the clinical implicationsit has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants,
(00:26):
and not necessarily that of the AmericanCollege of Surgeons.
Hello, and welcome back to The Operative
Word, the podcast of the Journalof the American College of Surgeons.
I am your host, Dr Lillian Erdahl.
And today I am joined by Dr Jessica Ching,who is an associate
professor of surgery at the BaylorCollege of Medicine in Houston.
(00:48):
Welcome, Dr Ching.
Thank you so much for having me today.
Dr Ching,
do you have anything to discloserelated to this publication?
No, I have no disclosures.
We're going to talk about the workyou did with your colleagues
called “Protective Effects of Authenticityagainst Depression,
Suicide, and Burnout among Surgeons.”
And before we get into that topic,because this is a sensitive topic,
(01:12):
I do want to mentionto any of our listeners
that the National Alliance onMental Illness has a helpline you can text
or call 988 for any emergenciesor concerns that you have.
So, Dr Ching, do you want to tell usjust a little bit about the background
that made you and your colleaguesinterested in this research topic?
Yeah.
So what got me interested in this was,
(01:35):
I had as a medical student,resident, fellow, faculty,
I'd seen people around me strugglewith burnout and depression,
whether or notthey were able to articulate it or we just
you were able to observethat they were struggling.
But whenI was a faculty, it came to a head.
I had a, a close work colleague
(01:56):
who committed suicide in April of 2020,
and I had just worked with her,
two days before, the daybefore she committed suicide.
And I remember thinking, didI miss something?
Was there somethingI should have picked up on?
Was there were there signsthat would have,
you know, led me to act differentlyor alerted, to what was to come?
(02:21):
And the reality was there wasthere was nothing really
that I personally observed or witnessed.
And, that was frustratingto feel helpless in that.
But then, you know,
watching the outpouring of responseafter she committed suicide and the
the way that people reactedemotionally was very touching.
(02:45):
And after a few weeks that subsided
and ultimately everythingkind of went back to business as usual.
And I just kept thinking,
can we really go back to normalafter this?
Is this really going to preventsomebody else
committing suicideor having these struggles?
(03:07):
And I kept thinking,there has to be something better.
There has to be something morethat we could do.
So I started looking at doing
qualitative research, actually to tryto catalog the stories and struggles.
I was listening to the Dr Lorna BreenFoundation, speak out
on, physician suicide and mental healthand the stigma associated with it.
(03:30):
And I was listening to,the stories of Dr Kara Cunningham as well
speak out on this.
And I kept thinking, man these storiesare so powerful, let's catalog them.
So I actually started firstwith qualitative research, looking at,
what the physicians aroundus are going through.
And even if they don'twant to own the stories, personally,
(03:51):
I it's called the, anonymous.
Excuse me,it's called the Authentic Doctor Survey.
And it is anonymous.
If you go to AuthenticDoctorSurvey.com,you'll find it there.
And so through that toolI was able to capture and chronologically
these anonymous, responsesto the struggles
and stories of physiciansall over the U.S.
(04:12):
I analyzed those and realizedthat we really needed quantitative data.
So that's how the current study wasborn, was trying to quantitatively,
validate what we could see qualitativelyand what we knew
from the stories of those around usthat we had personally witnessed. So.
(04:33):
Well,
thank you for sharing your personal story.
And, I also, unfortunately,
have had colleagues die by suicide.
And, and I think you're not there'sno normal about it.
You know,I appreciate you saying that.
That business as usual,
(04:56):
doesn't feel good.
And, you know, how
touching to hear you honor your colleague
by taking that seriously and seeing,you know, if you can do something to help
someone else to prevent others from,
you know, from sufferingloss of their loved ones
and colleagues,but also, you know, can we help our peers,
(05:20):
do better and survivein what is really a stressful job?
And Ithink that, you know, some of the numbers
that you found in your study,you know, speak to this,
but there are also national numberslooking at the rates of burnout
and suicidal ideationamong physicians and surgeons.
The Medscape surveythat you quote said 49% of all respondents
(05:43):
and 45% of general surgeonsin 2024 reported symptoms of burnout.
And,
I you know, I think those numbersare staggering to me.
Half of our workforceis coming to work every day
not feeling well.
We're not overall feeling well,which, as you mentioned, you know,
(06:03):
sometimes is related to the work itself,but not entirely.
May be related to other things likethe struggle of being a professional and,
you know, a caregiver at home, as well.
But,really, those numbers, I think, should
call our attention,
that we have and in, you know,
(06:24):
another survey 70% of surgical traineesreporting burnout.
I mean, these are staggering numbers.
Agreed.
I think one interesting thingthat we found in our data is that along
the lines of burnout is that burnoutdid not change with professional rank.
So that means residents and fellows,the training group, the junior faculty
(06:47):
and the senior faculty group,which senior faculty was defined
as being more than ten years.
In practice,the burnout rate was equivocal.
There was no clinical.
There was no statistical significance.
So what does that mean?
Well, that means it doesn't get betteras you get further along,
because what do you tell yourselfwhen you're a student,
when you're a resident,when you're starting a practice?
(07:07):
Is that if I make it to the next step,it's going to be better, right?
That's what we tell ourselves.
That's what we tell our loved ones. Right?
But I think the reality isit doesn't automatically.
And like by knowing that
while it is
disappointing to realizethat that's the case, at least you're
(07:30):
we're not blindly proceeding along a path
thinking that it's automaticallygoing to be better, realizing
that we have to make intentional choicesto make it better.
And your study, in order
to look at the numbersbetter, was looking at one institution.
So when you talk about that, these resultsare from a single institution,
(07:51):
although again, there are other studieslooking at burnout.
One of the interesting findingsthat that, I noted from your research
was that there was no sexor gender difference,
in some of these symptoms,whereas other studies have suggested
there might be a difference for womenphysicians,
suffering more burnout or depression.
(08:13):
Right. And, you know, it was,
single center by choice, one to control,
like for a local politicaland systemic factors.
Because in addition to this work,we did proceed on looking
at other specialtieswithin our college of medicine.
And so we were able to compareacross that.
(08:34):
So the gender and the,
you know, those differences, we did seesome of those in other specialties,
but they did not show upin this surgical department.
Interesting.
And tell us a little bit about,you know, some of the specific factors
that you were looking at.
I've learned a lot of termsfrom your study.
(08:55):
You know, I learned about authentic livingscores, but can you tell us a little bit
about authenticity and some of the metricsthat you were looking at?
Yeah, sure.
I think it's always helpful to startwith, the operational definition
for authenticity because it can feela little fuzzy and subjective.
So authenticity is
(09:16):
I define it as being true to one's coreself in all situations, relationships, and
roles you may take on.
So it's a consistent outwardexpression of your values
regardless of what you're doingor who you're with.
And it's a spectrum.
And the other important conceptto understand with authenticity
(09:37):
on the other side of thatspectrum is inauthenticity.
So inauthenticityis compartmentalizing yourself
and your life into different scenarios orto different roles that you may take on.
It's inconsistent and it's not alwayscongruent with your internal values.
Vs authenticity is a completeintegration of self and life.
(10:00):
And it's consistent.
So it's a spectrumwith two different sides.
And while we all would like to think weare on the authenticity side all the time.
It's really somethingwe oscillate between,
while aiming toward the authenticity side
so that we can have those positiveand protective benefits.
(10:21):
Yeah.
And when you were talkingabout authenticity
and in reading this research,I thought a lot about,
what we hear from different individualsabout editing themselves in the workplace,
you know, feeling thatmaybe they have to dress differently
to be accepted as a professional,you know, as well as their behavior.
So I think, that that was kind of
(10:42):
what came up for me was, you know,are you able to present yourself,
authentically just when you come into workor, you know, just people feel
they have to moderate their behaviorand and have a, you know,
an inauthentic presentationof who they really are.
Another term that comes up with
that is, professionalism.
(11:04):
Right?
That's the termthat we hear early on in medical school
and all the way throughout aboutwhat is professionalism.
And a lot of uswere taught to associate that
with a certain austerepresentation of ourselves.
That is in a lot of ways impersonal
(11:25):
and inherently compartmentalizing,because we're
putting on this professional personain order to be a doctor.
Yeah.
So I, I think that’s somethingthat we learn early in our training to do
and it becomes very integratedinto how we are
(11:50):
as we move through our, our trainingand into our practices.
So, it is definitely somethingthat's embedded deep early on.
Tell me a little bit about the survey,you know, tools that you use.
Because again, I want to be mindful.
Sometimes people look at researchlike this and don't see it as rigorous.
(12:11):
And, you know, you used validated toolsand this is,
you know, rigorous science hereto kind of try to get at this question.
Correct. We did use validated tools.
There were four, validated toolsin this survey.
There was, the authenticity scale,
which is a 12 question.
Validated tool.
(12:32):
It assessesauthenticity across three domains.
The Authentic Living Score,which you mentioned earlier, looks at how
well you live out your values,in accordance and consistency.
And then, so that's a positive metricand also talks about
it also reports itin, accepting external influence,
(12:54):
which is how much the opinionsor fear of judgment of others impact
you being able to liveout your authentic self.
And then lastly, self-alienation score,
which is basically a scoreof internal disconnectedness.
Where do you understandhow you feel on the inside?
Are you in touch with that?
(13:15):
Do you know what your values are?
Or have you not had a chanceto think about that?
And that would be captured in that score.
And so it reports the three scoresseparately for, the authenticity scale.
And so that allowed us to do
a lot of the analysisthat you'll see in my article.
The other three survey tools we used
(13:38):
were the PHQ9, which is a patient healthquestionnaire, it's
a validated tool for depressionthat's commonly used in primary care.
There is also the Copenhagen
Burnout Inventory,which is a validated tool for burnout.
There's a lot of different scaleswithin that.
We took the work section.
(13:59):
There's three typical ones, butthere are some other adaptations of them.
We focused on the work section sincethat was the, the, focus of the study.
So there were some questions...
You were trying to capture.
How is burnout, related to your work?
Exactly, exactly.
You know,
there's different types of burnoutthat you can assess with that tool.
(14:20):
Yeah.
And then the last one was calledthe Ask-Suicide Screening Questions,
and I did with it's a four,excuse me, five question survey.
We use the first four.
And the last question was omittedbecause it was, it's about
if you're holding someone on site, like,as an individual, face to face,
(14:42):
and you're asking if they have a suicideplan that they're going
to act on to try to determineif they're safe to leave the premises.
So that question wasn't relevantto this particular application.
Okay.
You found overall, again,you know, rates of depression
and burnoutI think that are concerning to me.
Tell me a little bit about youknow, what you found. Just generally.
(15:05):
So in general
the the results did parallel
what is is
reported by largernational data each year, which validates
the application of the findings as well,because we're right
within the typical population distributionfor this.
But in general,we found that authentic living
(15:29):
story scores correlatedwith reduced burnout and depression.
Accepting external influence scores
and the self-alienation scores,increased burnout and depression,
as well as self-alienationscores, increased
suicidal ideation risk as well.
(15:52):
In general, we saw that with ranklooking at rank and authenticity,
we found that over timethat the accepting external influence
and the self-alienationscores decreased with rank, which is
meaning that the furtherthat they were advanced in their career
(16:12):
and out of training, it improved.
Some of those scores,
you know, the accepting external influence
tended to jump quite a bitand improve from a resident
to a just beginning,beginning a junior faculty,
and then not as much change between juniorand senior faculty.
The self-alienation scorewas more of a gradual decrease.
(16:37):
And the authentic living score, over time
tended to improve, with rank.
Did you did that make sense to you?
I mean, did you,
you know, I guess it it seems,
makes sense to me that people,as they move up in their career
may feel more confident or less,need to rely on the input of others
(17:02):
about how they should behaveor who they should be.
Yes, absolutely.
It definitely made sense for that
to improve, I think, with time.
The other thing, you know,that, you know, was kind of inherent
is this in this is the hierarchical natureof the training model.
Right?
So the accepting external influence
(17:23):
being high or even the self validationbeing high may,
you know, also be influenced by the modelthat they're in, the training model.
So
that's just one other consideration.
Yeah.
And you talked a little bitin the discussion too,
about the fact that, you know,we certainly, could be missing people who,
(17:46):
who left.
You know, people talk about the leakypipeline that we lose, people
along the wayin training for a variety of reasons.
And so there may be peoplewho are who had,
different results,who just aren't represented
because they didn'tget to the senior faculty rank.
Instead, they, were burned outand left, or they left for other reasons.
(18:06):
Yeah, like a selection bias, I guess, yes.
You know, definitely true.
And there's and, it's,it's difficult to say, but.
Yeah, definitely a possibility.
And, and this work looks at one aspect,
what may help peoplehave talked about resilience as well
(18:27):
in research around burnout, depressionand, physician suicidal ideation.
How does this
factor of authenticitykind of add to our working knowledge and
how might we use itin, you know, both talking to individuals
as well as systems, you know, or peoplein charge of systems, to make change.
(18:48):
You know, I think authenticityis a really widespread,
you know,there's a lot of applicability to it.
One, you know,obviously there's an individual component
in at the choice or the the recognition
to be aware of authenticityand to attempt to strive for it.
So that's one aspect.
But you're right, there'sa whole component of the system around us.
(19:12):
And, it's an interesting interplay.
The current research directionthat I've been working in is actually
to try to studythat interplay more, with this
and so trying to better understand
what kind of environment, whether that be,you know, your immediate colleague
(19:32):
group, your department,the local hospital system.
But what kind of environmentis going to foster authenticity?
What are the factors in thator in the peer-to-peer relationships
that we have or team dynamicsthat are going to foster authenticity
and then what kind of things do not?
(19:54):
And there are some thingsthat are really obvious
and that that we can all namethat are helpful
or that are not helpful in that regard.
But trying to quantify which things
are actually correlated, that we can then,
replicate, I think is really important.
But, you know, there's still that,that element of the individual.
(20:15):
So, one thing that is, well, is
documented too, if you start looking at,you know, the literature,
literature for this topic,one thing that you'll notice is that,
there's a termcalled psychological safety,
which I think is really interesting,
talking about the environmentin which you work and,
(20:35):
and most of the data for psychologicalsafety is not about physicians.
And so trying to improve that environment
to be a psychologically safe environment,this is really,
has the potential to be really impactful.
And what we've seenin the early data collection
for the next segment of our work inan improving authenticity and individuals
(20:59):
and thus affecting the risk of burnout,depression and suicide. So,
well, and and the,
the term that came up as well,which is a term I've heard elsewhere,
recently was,you know, this culture of belonging and,
and and it's actually on the,hierarchy of needs.
Belonging is a pretty fundamentalhuman need.
(21:21):
And so, you know, I heard a talk by DrJulie Silver about that, but,
you brought that upin the discussion as well, you know,
how can we fosterbelonging in the workplace?
Yeah, it's really important.
So if you think about itwith authenticity, in order to have
meaningful personal relationships,you have to feel known
(21:43):
as an individual by that other person,and you have to feel like you know them.
So if you're never ableto be authentically who you are, it's
hard to form a meaningful relationshipbecause they never really get to know you,
and you don't really get to know them.
And so it really underpins having thatsense of belonging and connectedness
and having the ability then if, you know,if you choose to be vulnerable
(22:07):
with, and build on that relationshipand have trust.
So I think that, soyeah, it's, it's a really foundational,
concept
to form relationships and have belonging.
I think the other thing that struck me in
reading this, and in looking at other,
(22:28):
discussions of physician depressionand burnout from a, from a workforce
as well as an individual standpoint,is removing the stigma around,
having anything
that's a struggle,you know, whether it qualifies as,
you know, mental health or qualifiesas, you know, workplace stress.
(22:49):
However we talk about it,that we need to make it easy
for physicians to get the helpand support that they need.
And you talked about thatin terms of access to that, you know,
within our workplacesand particularly being in healthcare.
But, you know,it seems to me simple in some respects
(23:10):
that we should have accessto mental health care for physicians.
But I do think that there'sa lot of stigma around
saying that you need helpor that you're struggling, as well as,
you know, some of the licensing concernsand the way
that credentialing committeesask questions about mental health as well.
So the other piecethat, is important to me to talk about
(23:32):
is how to make it easy for physiciansto get the help they need.
And as you mentioned, Dr KaraCunningham spoke about this as well.
But that we need to tell our colleaguesit's okay
to ask for help, and to be openif you need,
if you want to be open,if that's part of authenticity for you.
Right.
(23:52):
And normalizingthat the, the struggles and,
making it something like you said,that's not a stigma.
Well,you know, one thing that has come up in,
some of the datanot reported in this particular, article,
but some of our other research is,
we found that the, the rate,
(24:15):
so looking at the validated tools,burnout, depression and suicidal risk,
but particularly focusingon burnout and, and depression
lookedat had them take the validated tools
and looked at the self-reported data.
So when asked if they are burned outand how burned out they are, they
(24:37):
are they really burned out or not?
Mild? Moderate? Severe.
And then looked at the,
the, depressionif they think they're depressed or not.
We found that the,
physicians typically underreportby 2 to 3 times,
like under what the actual iswhen they take a validated tool.
(25:00):
And so it begs the question,why the discrepancy?
These are obviously very adeptand very smart individuals.
So why would it be so, so different?
And, you know, in thinking about it,
it may be that they are unaware.
They think that this is theirthat this is normal for everyone.
(25:22):
This is how it's supposed to be.
This is the baseline,
which I think a lot of us have gone
through, that we look aroundand we see everyone,
especially when you're training,you look around,
you're like, well, everyone'shas it tough.
So this is how it is.
Or are they ignoring it?
Are they saying like, I'll dealwith this later, it'll be better later.
I know that I'm burnt out,but it's going to get better.
(25:43):
Or are they just
being stoic, willfully saying,
yes, I am burnt out,but I'm not going to think about right.
That right now.
I'm going to keep goingand I'm going to do this.
I'm just going to push this aside,and I'm going to keep going.
And so I can picture any of those three.
And probably a combinationbeing true for a lot of people that,
(26:07):
you know, that we work with
and at times even, you know,I can think of myself
having thought those same thoughtsabout life and what I was experiencing.
So but it's definitely interestingthinking about the underreporting
may not even bebecause of a fear of stigma.
It may be from what I just described.
(26:28):
Oh yeah.
Well,and I certainly can say I experienced
a culture where stoicism was encouraged,
in my training and I'm sure that I also,you know, have done that myself.
And perhaps, you know,
asked that of other individualsto be stoic at a time when what they
really needed was a break or to be ableto, to, say, you know, I'm not okay.
(26:52):
And that's where the culture change,
you know, can come into play that,
that we allow peopleto get the help that they need
or admit that they need help and encourageit rather than pushing through.
And it's not just for,what you bring up.
I mean, I think for physical illnessas well. Right.
You know,
as long as
you don't have a positive Covid test,you can put on a mask and come to work.
(27:15):
Right?
We don't necessarily encourageor I don't think workplaces
tell people to come to work sick,but you're rewarded
for showing up to work and pushing throughand getting that work done.
100 percent.
Yeah.
Well, thank you, for spending some timesharing your findings
with The Operative Word audience.
Dr Ching, and thank you for continuingto do this work that is so meaningful.
(27:40):
Clearly to you personally,but to our profession and our colleagues.
And I look forward to learning morein your next publication.
Thank you so much.
I really enjoyed speaking with you.
Thank you for taking an interest in this.
I think it says a lotthat such a renowned organization
would put this on their radar and really,you know, own it.
(28:02):
So I really appreciate thatfrom the Journal of the American College
of Surgeons.
And, you know,this work is meant to advocate ultimately.
And the data, is meant to be
to help advance things and improve things.
So I hope that we'll continueto be able to partner as we move forward.
So thank you. Thank you.
(28:27):
Thank you for listening
to the Journal of the American Collegeof Surgeons ‘Operative Word’ Podcast.
If you enjoyed today's episode,spread the word on social media
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Subscribe to the Operative Wordwherever podcasts are available, or
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You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Lillian Erdahl,and throughout this series, Dr Tom
Varghese and I will speak with recently
published authors about the motivationbehind their latest research
and the clinical implicationsit has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants,
(00:26):
and not necessarily that of the AmericanCollege of Surgeons.
Hello, and welcome back to The Operative
Word, the podcast of the Journalof the American College of Surgeons.
I am your host, Dr Lillian Erdahl.
And today I am joined by Dr Jessica Ching,who is an associate
professor of surgery at the BaylorCollege of Medicine in Houston.
(00:48):
Welcome, Dr Ching.
Thank you so much for having me today.
Dr Ching,
do you have anything to discloserelated to this publication?
No, I have no disclosures.
We're going to talk about the workyou did with your colleagues
called “Protective Effects of Authenticityagainst Depression,
Suicide, and Burnout among Surgeons.”
And before we get into that topic,because this is a sensitive topic,
(01:12):
I do want to mentionto any of our listeners
that the National Alliance onMental Illness has a helpline you can text
or call 988 for any emergenciesor concerns that you have.
So, Dr Ching, do you want to tell usjust a little bit about the background
that made you and your colleaguesinterested in this research topic?
Yeah.
So what got me interested in this was,
(01:35):
I had as a medical student,resident, fellow, faculty,
I'd seen people around me strugglewith burnout and depression,
whether or notthey were able to articulate it or we just
you were able to observethat they were struggling.
But whenI was a faculty, it came to a head.
I had a, a close work colleague
(01:56):
who committed suicide in April of 2020,
and I had just worked with her,
two days before, the daybefore she committed suicide.
And I remember thinking, didI miss something?
Was there somethingI should have picked up on?
Was there were there signsthat would have,
you know, led me to act differentlyor alerted, to what was to come?
(02:21):
And the reality was there wasthere was nothing really
that I personally observed or witnessed.
And, that was frustratingto feel helpless in that.
But then, you know,
watching the outpouring of responseafter she committed suicide and the
the way that people reactedemotionally was very touching.
(02:45):
And after a few weeks that subsided
and ultimately everythingkind of went back to business as usual.
And I just kept thinking,
can we really go back to normalafter this?
Is this really going to preventsomebody else
committing suicideor having these struggles?
(03:07):
And I kept thinking,there has to be something better.
There has to be something morethat we could do.
So I started looking at doing
qualitative research, actually to tryto catalog the stories and struggles.
I was listening to the Dr Lorna BreenFoundation, speak out
on, physician suicide and mental healthand the stigma associated with it.
(03:30):
And I was listening to,the stories of Dr Kara Cunningham as well
speak out on this.
And I kept thinking, man these storiesare so powerful, let's catalog them.
So I actually started firstwith qualitative research, looking at,
what the physicians aroundus are going through.
And even if they don'twant to own the stories, personally,
(03:51):
I it's called the, anonymous.
Excuse me,it's called the Authentic Doctor Survey.
And it is anonymous.
If you go to AuthenticDoctorSurvey.com,you'll find it there.
And so through that toolI was able to capture and chronologically
these anonymous, responsesto the struggles
and stories of physiciansall over the U.S.
(04:12):
I analyzed those and realizedthat we really needed quantitative data.
So that's how the current study wasborn, was trying to quantitatively,
validate what we could see qualitativelyand what we knew
from the stories of those around usthat we had personally witnessed. So.
(04:33):
Well,
thank you for sharing your personal story.
And, I also, unfortunately,
have had colleagues die by suicide.
And, and I think you're not there'sno normal about it.
You know,I appreciate you saying that.
That business as usual,
(04:56):
doesn't feel good.
And, you know, how
touching to hear you honor your colleague
by taking that seriously and seeing,you know, if you can do something to help
someone else to prevent others from,
you know, from sufferingloss of their loved ones
and colleagues,but also, you know, can we help our peers,
(05:20):
do better and survivein what is really a stressful job?
And Ithink that, you know, some of the numbers
that you found in your study,you know, speak to this,
but there are also national numberslooking at the rates of burnout
and suicidal ideationamong physicians and surgeons.
The Medscape surveythat you quote said 49% of all respondents
(05:43):
and 45% of general surgeonsin 2024 reported symptoms of burnout.
And,
I you know, I think those numbersare staggering to me.
Half of our workforceis coming to work every day
not feeling well.
We're not overall feeling well,which, as you mentioned, you know,
(06:03):
sometimes is related to the work itself,but not entirely.
May be related to other things likethe struggle of being a professional and,
you know, a caregiver at home, as well.
But,really, those numbers, I think, should
call our attention,
that we have and in, you know,
(06:24):
another survey 70% of surgical traineesreporting burnout.
I mean, these are staggering numbers.
Agreed.
I think one interesting thingthat we found in our data is that along
the lines of burnout is that burnoutdid not change with professional rank.
So that means residents and fellows,the training group, the junior faculty
(06:47):
and the senior faculty group,which senior faculty was defined
as being more than ten years.
In practice,the burnout rate was equivocal.
There was no clinical.
There was no statistical significance.
So what does that mean?
Well, that means it doesn't get betteras you get further along,
because what do you tell yourselfwhen you're a student,
when you're a resident,when you're starting a practice?
(07:07):
Is that if I make it to the next step,it's going to be better, right?
That's what we tell ourselves.
That's what we tell our loved ones. Right?
But I think the reality isit doesn't automatically.
And like by knowing that
while it is
disappointing to realizethat that's the case, at least you're
(07:30):
we're not blindly proceeding along a path
thinking that it's automaticallygoing to be better, realizing
that we have to make intentional choicesto make it better.
And your study, in order
to look at the numbersbetter, was looking at one institution.
So when you talk about that, these resultsare from a single institution,
(07:51):
although again, there are other studieslooking at burnout.
One of the interesting findingsthat that, I noted from your research
was that there was no sexor gender difference,
in some of these symptoms,whereas other studies have suggested
there might be a difference for womenphysicians,
suffering more burnout or depression.
(08:13):
Right. And, you know, it was,
single center by choice, one to control,
like for a local politicaland systemic factors.
Because in addition to this work,we did proceed on looking
at other specialtieswithin our college of medicine.
And so we were able to compareacross that.
(08:34):
So the gender and the,
you know, those differences, we did seesome of those in other specialties,
but they did not show upin this surgical department.
Interesting.
And tell us a little bit about,you know, some of the specific factors
that you were looking at.
I've learned a lot of termsfrom your study.
(08:55):
You know, I learned about authentic livingscores, but can you tell us a little bit
about authenticity and some of the metricsthat you were looking at?
Yeah, sure.
I think it's always helpful to startwith, the operational definition
for authenticity because it can feela little fuzzy and subjective.
So authenticity is
(09:16):
I define it as being true to one's coreself in all situations, relationships, and
roles you may take on.
So it's a consistent outwardexpression of your values
regardless of what you're doingor who you're with.
And it's a spectrum.
And the other important conceptto understand with authenticity
(09:37):
on the other side of thatspectrum is inauthenticity.
So inauthenticityis compartmentalizing yourself
and your life into different scenarios orto different roles that you may take on.
It's inconsistent and it's not alwayscongruent with your internal values.
Vs authenticity is a completeintegration of self and life.
(10:00):
And it's consistent.
So it's a spectrumwith two different sides.
And while we all would like to think weare on the authenticity side all the time.
It's really somethingwe oscillate between,
while aiming toward the authenticity side
so that we can have those positiveand protective benefits.
(10:21):
Yeah.
And when you were talkingabout authenticity
and in reading this research,I thought a lot about,
what we hear from different individualsabout editing themselves in the workplace,
you know, feeling thatmaybe they have to dress differently
to be accepted as a professional,you know, as well as their behavior.
So I think, that that was kind of
(10:42):
what came up for me was, you know,are you able to present yourself,
authentically just when you come into workor, you know, just people feel
they have to moderate their behaviorand and have a, you know,
an inauthentic presentationof who they really are.
Another term that comes up with
that is, professionalism.
(11:04):
Right?
That's the termthat we hear early on in medical school
and all the way throughout aboutwhat is professionalism.
And a lot of uswere taught to associate that
with a certain austerepresentation of ourselves.
That is in a lot of ways impersonal
(11:25):
and inherently compartmentalizing,because we're
putting on this professional personain order to be a doctor.
Yeah.
So I, I think that’s somethingthat we learn early in our training to do
and it becomes very integratedinto how we are
(11:50):
as we move through our, our trainingand into our practices.
So, it is definitely somethingthat's embedded deep early on.
Tell me a little bit about the survey,you know, tools that you use.
Because again, I want to be mindful.
Sometimes people look at researchlike this and don't see it as rigorous.
(12:11):
And, you know, you used validated toolsand this is,
you know, rigorous science hereto kind of try to get at this question.
Correct. We did use validated tools.
There were four, validated toolsin this survey.
There was, the authenticity scale,
which is a 12 question.
Validated tool.
(12:32):
It assessesauthenticity across three domains.
The Authentic Living Score,which you mentioned earlier, looks at how
well you live out your values,in accordance and consistency.
And then, so that's a positive metricand also talks about
it also reports itin, accepting external influence,
(12:54):
which is how much the opinionsor fear of judgment of others impact
you being able to liveout your authentic self.
And then lastly, self-alienation score,
which is basically a scoreof internal disconnectedness.
Where do you understandhow you feel on the inside?
Are you in touch with that?
(13:15):
Do you know what your values are?
Or have you not had a chanceto think about that?
And that would be captured in that score.
And so it reports the three scoresseparately for, the authenticity scale.
And so that allowed us to do
a lot of the analysisthat you'll see in my article.
The other three survey tools we used
(13:38):
were the PHQ9, which is a patient healthquestionnaire, it's
a validated tool for depressionthat's commonly used in primary care.
There is also the Copenhagen
Burnout Inventory,which is a validated tool for burnout.
There's a lot of different scaleswithin that.
We took the work section.
(13:59):
There's three typical ones, butthere are some other adaptations of them.
We focused on the work section sincethat was the, the, focus of the study.
So there were some questions...
You were trying to capture.
How is burnout, related to your work?
Exactly, exactly.
You know,
there's different types of burnoutthat you can assess with that tool.
(14:20):
Yeah.
And then the last one was calledthe Ask-Suicide Screening Questions,
and I did with it's a four,excuse me, five question survey.
We use the first four.
And the last question was omittedbecause it was, it's about
if you're holding someone on site, like,as an individual, face to face,
(14:42):
and you're asking if they have a suicideplan that they're going
to act on to try to determineif they're safe to leave the premises.
So that question wasn't relevantto this particular application.
Okay.
You found overall, again,you know, rates of depression
and burnoutI think that are concerning to me.
Tell me a little bit about youknow, what you found. Just generally.
(15:05):
So in general
the the results did parallel
what is is
reported by largernational data each year, which validates
the application of the findings as well,because we're right
within the typical population distributionfor this.
But in general,we found that authentic living
(15:29):
story scores correlatedwith reduced burnout and depression.
Accepting external influence scores
and the self-alienation scores,increased burnout and depression,
as well as self-alienationscores, increased
suicidal ideation risk as well.
(15:52):
In general, we saw that with ranklooking at rank and authenticity,
we found that over timethat the accepting external influence
and the self-alienationscores decreased with rank, which is
meaning that the furtherthat they were advanced in their career
(16:12):
and out of training, it improved.
Some of those scores,
you know, the accepting external influence
tended to jump quite a bitand improve from a resident
to a just beginning,beginning a junior faculty,
and then not as much change between juniorand senior faculty.
The self-alienation scorewas more of a gradual decrease.
(16:37):
And the authentic living score, over time
tended to improve, with rank.
Did you did that make sense to you?
I mean, did you,
you know, I guess it it seems,
makes sense to me that people,as they move up in their career
may feel more confident or less,need to rely on the input of others
(17:02):
about how they should behaveor who they should be.
Yes, absolutely.
It definitely made sense for that
to improve, I think, with time.
The other thing, you know,that, you know, was kind of inherent
is this in this is the hierarchical natureof the training model.
Right?
So the accepting external influence
(17:23):
being high or even the self validationbeing high may,
you know, also be influenced by the modelthat they're in, the training model.
So
that's just one other consideration.
Yeah.
And you talked a little bitin the discussion too,
about the fact that, you know,we certainly, could be missing people who,
(17:46):
who left.
You know, people talk about the leakypipeline that we lose, people
along the wayin training for a variety of reasons.
And so there may be peoplewho are who had,
different results,who just aren't represented
because they didn'tget to the senior faculty rank.
Instead, they, were burned outand left, or they left for other reasons.
(18:06):
Yeah, like a selection bias, I guess, yes.
You know, definitely true.
And there's and, it's,it's difficult to say, but.
Yeah, definitely a possibility.
And, and this work looks at one aspect,
what may help peoplehave talked about resilience as well
(18:27):
in research around burnout, depressionand, physician suicidal ideation.
How does this
factor of authenticitykind of add to our working knowledge and
how might we use itin, you know, both talking to individuals
as well as systems, you know, or peoplein charge of systems, to make change.
(18:48):
You know, I think authenticityis a really widespread,
you know,there's a lot of applicability to it.
One, you know,obviously there's an individual component
in at the choice or the the recognition
to be aware of authenticityand to attempt to strive for it.
So that's one aspect.
But you're right, there'sa whole component of the system around us.
(19:12):
And, it's an interesting interplay.
The current research directionthat I've been working in is actually
to try to studythat interplay more, with this
and so trying to better understand
what kind of environment, whether that be,you know, your immediate colleague
(19:32):
group, your department,the local hospital system.
But what kind of environmentis going to foster authenticity?
What are the factors in thator in the peer-to-peer relationships
that we have or team dynamicsthat are going to foster authenticity
and then what kind of things do not?
(19:54):
And there are some thingsthat are really obvious
and that that we can all namethat are helpful
or that are not helpful in that regard.
But trying to quantify which things
are actually correlated, that we can then,
replicate, I think is really important.
But, you know, there's still that,that element of the individual.
(20:15):
So, one thing that is, well, is
documented too, if you start looking at,you know, the literature,
literature for this topic,one thing that you'll notice is that,
there's a termcalled psychological safety,
which I think is really interesting,
talking about the environmentin which you work and,
(20:35):
and most of the data for psychologicalsafety is not about physicians.
And so trying to improve that environment
to be a psychologically safe environment,this is really,
has the potential to be really impactful.
And what we've seenin the early data collection
for the next segment of our work inan improving authenticity and individuals
(20:59):
and thus affecting the risk of burnout,depression and suicide. So,
well, and and the,
the term that came up as well,which is a term I've heard elsewhere,
recently was,you know, this culture of belonging and,
and and it's actually on the,hierarchy of needs.
Belonging is a pretty fundamentalhuman need.
(21:21):
And so, you know, I heard a talk by DrJulie Silver about that, but,
you brought that upin the discussion as well, you know,
how can we fosterbelonging in the workplace?
Yeah, it's really important.
So if you think about itwith authenticity, in order to have
meaningful personal relationships,you have to feel known
(21:43):
as an individual by that other person,and you have to feel like you know them.
So if you're never ableto be authentically who you are, it's
hard to form a meaningful relationshipbecause they never really get to know you,
and you don't really get to know them.
And so it really underpins having thatsense of belonging and connectedness
and having the ability then if, you know,if you choose to be vulnerable
(22:07):
with, and build on that relationshipand have trust.
So I think that, soyeah, it's, it's a really foundational,
concept
to form relationships and have belonging.
I think the other thing that struck me in
reading this, and in looking at other,
(22:28):
discussions of physician depressionand burnout from a, from a workforce
as well as an individual standpoint,is removing the stigma around,
having anything
that's a struggle,you know, whether it qualifies as,
you know, mental health or qualifiesas, you know, workplace stress.
(22:49):
However we talk about it,that we need to make it easy
for physicians to get the helpand support that they need.
And you talked about thatin terms of access to that, you know,
within our workplacesand particularly being in healthcare.
But, you know,it seems to me simple in some respects
(23:10):
that we should have accessto mental health care for physicians.
But I do think that there'sa lot of stigma around
saying that you need helpor that you're struggling, as well as,
you know, some of the licensing concernsand the way
that credentialing committeesask questions about mental health as well.
So the other piecethat, is important to me to talk about
(23:32):
is how to make it easy for physiciansto get the help they need.
And as you mentioned, Dr KaraCunningham spoke about this as well.
But that we need to tell our colleaguesit's okay
to ask for help, and to be openif you need,
if you want to be open,if that's part of authenticity for you.
Right.
(23:52):
And normalizingthat the, the struggles and,
making it something like you said,that's not a stigma.
Well,you know, one thing that has come up in,
some of the datanot reported in this particular, article,
but some of our other research is,
we found that the, the rate,
(24:15):
so looking at the validated tools,burnout, depression and suicidal risk,
but particularly focusingon burnout and, and depression
lookedat had them take the validated tools
and looked at the self-reported data.
So when asked if they are burned outand how burned out they are, they
(24:37):
are they really burned out or not?
Mild? Moderate? Severe.
And then looked at the,
the, depressionif they think they're depressed or not.
We found that the,
physicians typically underreportby 2 to 3 times,
like under what the actual iswhen they take a validated tool.
(25:00):
And so it begs the question,why the discrepancy?
These are obviously very adeptand very smart individuals.
So why would it be so, so different?
And, you know, in thinking about it,
it may be that they are unaware.
They think that this is theirthat this is normal for everyone.
(25:22):
This is how it's supposed to be.
This is the baseline,
which I think a lot of us have gone
through, that we look aroundand we see everyone,
especially when you're training,you look around,
you're like, well, everyone'shas it tough.
So this is how it is.
Or are they ignoring it?
Are they saying like, I'll dealwith this later, it'll be better later.
I know that I'm burnt out,but it's going to get better.
(25:43):
Or are they just
being stoic, willfully saying,
yes, I am burnt out,but I'm not going to think about right.
That right now.
I'm going to keep goingand I'm going to do this.
I'm just going to push this aside,and I'm going to keep going.
And so I can picture any of those three.
And probably a combinationbeing true for a lot of people that,
(26:07):
you know, that we work with
and at times even, you know,I can think of myself
having thought those same thoughtsabout life and what I was experiencing.
So but it's definitely interestingthinking about the underreporting
may not even bebecause of a fear of stigma.
It may be from what I just described.
(26:28):
Oh yeah.
Well,and I certainly can say I experienced
a culture where stoicism was encouraged,
in my training and I'm sure that I also,you know, have done that myself.
And perhaps, you know,
asked that of other individualsto be stoic at a time when what they
really needed was a break or to be ableto, to, say, you know, I'm not okay.
(26:52):
And that's where the culture change,
you know, can come into play that,
that we allow peopleto get the help that they need
or admit that they need help and encourageit rather than pushing through.
And it's not just for,what you bring up.
I mean, I think for physical illnessas well. Right.
You know,
as long as
you don't have a positive Covid test,you can put on a mask and come to work.
(27:15):
Right?
We don't necessarily encourageor I don't think workplaces
tell people to come to work sick,but you're rewarded
for showing up to work and pushing throughand getting that work done.
100 percent.
Yeah.
Well, thank you, for spending some timesharing your findings
with The Operative Word audience.
Dr Ching, and thank you for continuingto do this work that is so meaningful.
(27:40):
Clearly to you personally,but to our profession and our colleagues.
And I look forward to learning morein your next publication.
Thank you so much.
I really enjoyed speaking with you.
Thank you for taking an interest in this.
I think it says a lotthat such a renowned organization
would put this on their radar and really,you know, own it.
(28:02):
So I really appreciate thatfrom the Journal of the American College
of Surgeons.
And, you know,this work is meant to advocate ultimately.
And the data, is meant to be
to help advance things and improve things.
So I hope that we'll continueto be able to partner as we move forward.
So thank you. Thank you.
(28:27):
Thank you for listening
to the Journal of the American Collegeof Surgeons ‘Operative Word’ Podcast.
If you enjoyed today's episode,spread the word on social media
by using the hashtag #JACSOperativeWord.
Subscribe to the Operative Wordwherever podcasts are available, or
listen on the American College of Surgeonswebsite at FACS.org/Podcast.
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