#KeyLIMEPodcast 249: Nurture or Torture? Time to Redesign Training to End Mistreatment of Trainees

It is no secret that health professions trainees are subject to high rates of burnout, depression, addictions, and suicide. This week’s article asks: is it simply due to the nature of the job – long hours, intense nature of the work – or does it also have a correlation to mistreatment on the job? The study examined types of mistreatment, who were the perpetrators, and its staggering impact on trainees. Listen in and learn more.


KeyLIME Session 249

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Hu et. al., 2019.Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training N Engl J Med. 381(18):1741-1752.


Jason R. Frank (@drjfrank)


Health professions trainees suffer from shockingly high rates of burnout, depression, addictions, and suicide. Previously on KeyLIME, we have reviewed a number of papers related to wellness, burnout, and the impact on patient care (Episode 206 Physician Burnout). Why does this happen? One theory is the long work hours. Another is the intense nature of our work, caring for and witnessing others’ suffering. Another hypothesis is that we simply choose the wrong people for the health professions—how many times have I heard certain leaders say that “trainees are too weak to be here”? Perhaps it is time to look at whether the learning environment itself is to blame. Does training, with its power hierarchy,  have an environment of psychological safety?


Enter Hu et al in the Halloween issue of the NEJM 2019. The authors set out to examine if self-reported incidents of mistreatment among US General Surgery residents correlated with standardized measures of burnout and suicidal ideation. They state this is the first large-scale study to characterize the prevalence of mistreatment and its correlation to burnout.

Key Points on the Methods

This cleverly simple survey study was sent to all General Surgery residents participating in the 2018 American Board of Surgery practice examination (ABSITE). There were no incentives to participate.

The survey was derived from previously published instruments, pilot tested and revised. Mistreatment items were scored as a frequency. Burnout was measured using the modified Maslach Burnout Inventory (we have critiqued this in past episodes). Burnout was defined as at least weekly symptoms of ANY of the 6 elements of the MBI.

Responses were de-identified and shared with the investigators. 837 residents were excluded (inactive, only 1 resident in program, missing responses). They also excluded 2 programs that had no women.

Multi-variable logistic-regression models were used to examine the relationship between the variables. Note that point estimates were not corrected for multiple comparisons.

Lastly, the authors report that this study was exempted from REB as not being human subjects research(!).

Key Outcomes

There was a 99.3% response rate among 7409 trainees from all 262 training programs in the US.  The staggering prevalence of reported mistreatment revealed includes:

  • 9% discrimination based on gender overall (65.1% of women!);
  • 6% reported racial discrimination;
  • 3% reported verbal or physical abuse;
  • 3% reported sexual harassment, 19.9% in women.

Who did the harassing? Gender and racial issues were from patients and their families about half the time (43.6%, 47.4% respectively). Attending surgeons were the most frequent sources of abuse (51.9%) and sexual harassment (27.2%). These findings had huge variability by site, from 0-66.7% for verbal abuse, and 0-100% for gender discrimination, for example.

The impact is staggering:

  • Weekly burnout symptoms in 28.5% of residents;
  • At least once a week: 38.5% of trainees;
  • Burnout was highest in PGY1s
  • 5% report suicidal thoughts recently.

If a trainee experiences mistreatment, the OR for burnout was 2.94, for suicidal ideation 3.07. There was no difference by gender once exposure to mistreatment was adjusted for.

The silver lining: the majority of trainees reported no violations of duty hours rules (66.5% men, 52.7% women).

Key Conclusions

The authors conclude that mistreatment is overwhelmingly frequent among US surgical residents, especially women. This environment contributes to burnout and suicidality in our youngest colleagues.

We must do better. We as leaders of #meded and health professions education must consider how to redesign the system to respond. This is intolerable.

The low rates of mistreatment in a substantial minority of programs shows us there is a way forward.

Spare Keys – other take home points for clinician educators

  1. This is a great example of a simple survey that can have a great impact on #meded.
  2. 20% of this paper is dedicated to the methods section, something all of us should consider, as a good methods section helps to get credibility with the reader.

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