BTK_Burnout_Vascular

Hey everyone. Welcome back to the behind the knife podcast. I'm Drew Brate here along with the other members of the vascular surgery subspecialty team, doctors, Bobby Beaulieu and Frank Davis. We're very excited to be back with you for another episode. And today we're actually going to switch it up a little bit, and we're going to discuss some recent publications on the topic of burnout within vascular surgery trainees.

I know that this is a bit of a curve ball from the journal, journal articles in vascular surgery that we typically cover. However, I, I really do think that this topic applies to everyone in medicine and really even more so than most of the publications that come out of vascular surgery and certainly the ones that we've discussed.

So there's also some pretty unique aspects of vascular training that I think make the discussion of burnout even a little bit more interesting. So even if you're not a vascular trainee or a vascular surgeon, I think that you can still learn a lot from these papers. And that's whether you're a medical student, trainee, program director, or just an attending, you know, burnout's a really important concept to understand,

be able to recognize and be aware of the tools to help you manage it.

Okay, so with that out of the way, why don't we start with some basic definitions. Bobby, you're the program director, so I'm sure you've seen some, or have some experience with talking to trainees about this. Can you tell us what defines burnout? Awesome, thanks for the intro, Drew, and I can't stress how much I agree that burnout is such a critical issue to understand and discuss.

I'm really happy to see the increased focus regarding burnout and appreciate how much this increased focus has actually led towards increased research as well. And then finally, the opportunity to discuss it on a platform like this, you know, burnout is pretty tough. It's almost defined as the lack of something else, which is like wellness, but that's not an easy thing to study.

So we have more formal definitions and that's a burnout is a syndrome that's defined by emotional exhaustion, depersonalization, and a sense of. low personal accomplishment in physicians. We often see this as no longer finding meaning in work,

feeling ineffective and the tendency to view patients, students, colleagues as objects rather than other human beings.

Physician burnout is linked to both negative patient outcomes. and negative effects on career attrition. So it's more important to note that burnout is not limited to physicians. However, physicians have been found to suffer from much higher burnout than other fields and the general population. Burnout specifically in vascular surgeons and vascular surgery trainees has recently gotten a lot of attention.

In the most recent report from the SVS Wellness Task Force, 30 percent of practicing vascular surgeons met criteria for burnout. And in a survey from the APDVS, which is the Association of Program Directors in Vascular Surgery, more than 60 percent of vascular trainees reported feeling burnout at least once a week.

Frank, you've been through a vascular surgery residency, and now you're an attending vascular surgeon. What do we know about

burnout specific to vascular surgery? For instance, what's it associated with? What's the impact on our workforce and on our trainees? Thanks, Bobby. And wow, I mean, that just kind of put the numbers into perspective.

I never knew burnout was that big of a problem. And to be honest, I didn't think it was so, so prevalent. So for vascular surgeon, vascular trainees may be predisposed to increased burnout specifically from physical pain and work home conflicts. And studies have shown by Davila et al. that looked into this in the 2019 JVS paper entitled Physical Discomfort, Professional Satisfaction, and Burnout in Vascular Surgeons.

And they found that 40 percent of vascular surgeons reported a current muscle skeletal discomfort and almost all experienced pain during their procedures. They also found that most vascular surgeons perform surgery and or interventional procedures at least three days each week, and almost 20 percent of them are working eight or more hours per day on those on those given days.

An additional study published in JVS in 2024 by

Pilotto et al. The title reported pain at work is a risk factor for vascular surgery trainee burnout. And they found an association of physical pain and burnout in vascular trainees. In addition, they also found that 38 percent of trainees reported moderate to severe pain after a full day of work.

For those of you who are vascular surgeons or have scrubbed vascular surgery procedures, things like wearing lead, lead glasses, headlights, and the sheer length of some of the vascular surgery cases likely contribute to the high rates of physical discomfort amongst vascular surgeons. A hot topic of research and actually a focus of one of the papers we will discuss has to do with identifying predictors of burnout, which we can potentially help guide our interventions to prevent and treat burnout within vascular surgery trainees and on into faculty and attendings.

Research suggests that older trainees and those who possess advanced degrees are more likely to report burnout. An additional survey data has shown that the lack of mentorship or the lack of social events within a program or a violation of duty hours as would be expected are associated with burnout for amongst the

trainees.

And lastly, as Drew mentioned earlier, burnout is associated with negative outcomes both by patients and providers. Burnout has been linked to attrition within the surgical residency and in general surgery programs, attrition rates range from three to five percent. And although attrition rates for vascular surgery integrated residencies are lower, they still are one to three percent, which should not be taken lightly for our junior trainees.

And many programs have it between one or two vascular trainees a year. So a loss of any resident within an integrated program is a profound impact on that program. And burnout has been associated with suicidal ideation. Unfortunately, around 5 percent of vascular surgery trainees have reported suicidal ideation.

And alarming practicing vascular surgeons have the highest rate of suicidal ideation amongst any surgical sub specialty. Well, I got to say those, those are really alarming statistics. And I think that really highlights the importance of further research into burnout. And really highlights, you know, why it's important that we're talking about this on this platform here.

And actually, you know,

that kind of segues perfectly into the two articles that we're going to discuss today. So, the first paper we're going to discuss is titled, Modifiable Risk Factors for Burnout in Vascular Surgery Trainees. This was written by Heckman et al. on behalf of the APDVS Issues Committee, and it was published actually in 2021 in the Journal of Vascular Surgery.

So the objective of this paper was to use the annual training survey, which is issued by the APDVS, to evaluate coping strategies as potentially modifiable risk factors for burnout among vascular surgery trainees. In this study, the authors leveraged this training survey, which was sent to a total of about 630 vascular surgery trainees.

And this actually included both integrated vascular surgery residents and fellows. And to identify causative factors, they included questions that addressed motivation, mentorship,

and stress coping. So as you'd expect, you know, there's the response rate on surveys, especially amongst Busy VA trainees is never perfect.

But they actually had a response rate of around 55%, which is pretty good. 70% of responders were male and the median age of responders was 30. A majority of those who responded described their programs as quaternary or tertiary care centers, and a majority described their training program as academic.

So in this cohort, alarmingly, 45% of of those who responded reported burnout. And there was no statistically significant difference between the groups regarding gender, sex, age, program type, or training level. But the authors did find a significant difference between burnout and no burnout groups in the balance between integrating learning and clinical productivity in the operating room.

So, to look at that a little bit in more detail, 68 percent of the no burnout group reported that they felt that there was a

good balance between learning and clinical productivity in the OR, Whereas only 50 percent reported that there was good balance in the burnout group. So the burnout group and no burnout groups also differed significantly in the response to feeling appropriately challenged by the faculty, which I think was really interesting.

So 96 percent of the no burnout group felt like they were appropriately challenged by their faculty and only 78 percent in the burnout group felt the same way. And then they also looked at the supportiveness of the learning environment. And they found that that seemed to drive burnout too. So 12 percent of the no burnout group felt unsupported.

So the vast majority of them are feeling supported by in their training and 33 percent of the burnout group felt unsupported. So significantly higher. And then finally they, the no burnout group was also more likely to report good availability of mentorship opportunities and longitudinal mentorship than the burnout group.

Okay. And then lastly, they also looked at some coping

mechanisms. So the burnout group was more likely to report self distraction, substance use, disengagement, self blame and humor rather than the no burnout group. And the burnout group was also significantly less likely to report being satisfied with their training programs.

at 60 percent versus 88 percent in the no burnout group. So lots of data there. Bobby, Frank, you guys are attendings. You know, what do you make of all this data? How can it use, how can this be used to help? Yeah. I mean, I think you hit the nail on the head because nobody wants to feel burnt out. And frankly, some people are getting burnt out of the conversation around burnout.

That doesn't really give you many actionable items. And so I think this paper was really helpful in that regard because it helped to identify some of the things that we could look at now, and in particular, the importance of the learning environment. The authors do a great job of discussing it in the paper, so I highly recommend linking to the show notes and seeing the paper itself.

But it seems like the feeling of

being appropriately challenged, appropriately integrated learning and content, Clinical productivity and having a supportive learning environment were protective factors against burnout, you know This isn't a new topic. This is something we've seen time and time again when you look at Productivity and people reaching to new heights and accomplishment.

I mean, this is the idea of flow the knee high chicks at knee high idea that you get pushed a little bit outside your comfort zone. And that's where you find meaning and evolution of your skills. And so it's so cool to see that this can go on with a longitudinal aspect of how long it takes to become a surgery resident.

You know, also about three or four years ago, there was a big bend on this idea of psychological safety and feeling like you could bring something up in your learning environment in a way that That allowed you to have a question that didn't, you know, make you look like an ignorant person. I think that really is part of what's mentioned here, too.

So we see it in a lot of different ways and a lot of different avenues

outside of Vassar and it's cool to see that some of those things apply. You know, trainees really want to feel appropriately challenged by the faculty member. Which demonstrates the importance of this burnout conversation at both the faculty and the trainee level and getting that buy in.

And it really comes from the top down, from your sectional, your divisional, your departmental, and your programmatic leadership. And even the chief residents, too, are an important part of that conversation. It all comes down to balance. Programs that lean more heavily towards clinical productivities may not allow for the trainees to complete their adequate place cases and then Really look back over what they just did in a productive way Conversely a program that favors learning over productivity May not allow trainees to cultivate the necessary technical skills that really require the practice both in and out of the operating room.

So that balancing act can be difficult and it's probably specific to each person and program,

but to achieve the best outcome in both your technical skills and remain the most well rounded person, you need to look at that balance as best as you can. And this is probably one of the aspects of the upcoming entrustable professional activities or EPAs that you may actually see as being quite helpful.

How do we meaningfully examine the work that we do without adding a lot of burden to having to do that examination in the first place? Yeah, great points, Bobby, on kind of the intrustable professional activities and how we meaningfully examine that. I think one aspect of this specific manuscript that really stuck out to me and resonated with me personally was kind of mentorship.

Within surgical training and more importantly, mentorship over a longitudinal fashion was found to be protective against burnout. I mean, when I think back over my surgical training, it was the mentors that I, that I worked with during that time that allowed me to get through both the highs and the lows of surgical training.

It's really important to have that relationship. with somebody who you can trust and kind of learn from in that process.

And a focus on mentorship has actually been proposed as a way to address physician shortages and to improve representation of underrepresented groups in academic surgery. In the modern surgery training paradigm, mentorship is the most successful when mentees select their mentors and the relationship is continued over an extended period of time.

However, as you can expect, there are challenges to successful mentorship within surgery. Many attending surgeons in this manuscript, or even just within life, has busy lives balancing not only the challenges of busy clinical practice, patient care, but also life outside the hospital. So just like trainees struggle with burnout and trying to learn to be a productive surgical resident, attendings are struggling with it from a more faculty level.

Also in the operating room, there are pressures for fast, accurate decision making, which can impact patient care. And although it's often said, often easier said than done, mentorship remains a key to ensuring that we are adequately training the next generation of vascular surgeons or any surgeon in general.

So, I got to interject here, not to get too sentimental, but You know,

you both have truly been important mentors throughout my journey and this stems back to even when I was a medical student and a junior resident and you know, back way back in the day when you two were trainees with me and I was just starting out.

So, I mean, I have to admit and throughout this time, you know, and you guys have been mentors to me for, for Years now it both. It seemed like it was natural. It seemed that you guys are just professional and natural. So what's the secret? I mean, how do you approach being a good mentor? Yeah, I mean, I think it's a tough aspect to be a good mentor.

And I mean, Bobby and I are always learning how to perfect that aspect within our own training and teaching. I think The big key part when I consider a trainee and working with them is I always want to try to meet that trainee where they're at. So I think it's an important part of a mentorship is you're not trying to create the trainee in your image.

You're trying to allow that trainee to learn and develop their own persona, their own surgical mantra. their own skill set and you want to meet them where their skills are at and push them like Bobby was appropriately saying

to get outside their comfort zone a little bit so that they can grow and see how much they can blossom into.

But again, you don't want to make that trainee within your image. You want them to develop and find their true passion. Yeah. And I think I'd say one of the things that I've always appreciated in mentors and have tried to mentorship is this you know, idea of vulnerability. You know, we've all been through some training programs and seen how difficult it can be and all too often it actually kind of becomes easier to forget about how difficult it was when you're mentoring anybody who hasn't gone through that yet.

And so that can include chief residents, mentoring younger residents, younger residents, mentoring medical students and faculty members, mentoring residents in general. And I think if you approach these conversations with an idea of Man, that could be me struggling, or it was me struggling, and you helped to point that out.

It introduces that aspect that we talked about earlier of people feeling connected and belonging to a program. It also is honestly quite

therapeutic for the mentor too, because sometimes you feel like you can't be a good mentor unless you're on this pedestal of achievement, either in one realm or another, or you're doing well in the operating room.

And to air out some of the things that make you feel most insecure, either in your role as a vascular surgeon or as a mentor, sometimes give them the room to just dissipate rather than being collected in your head. And so, that vulnerability can really serve to make it so that both the mentor and the mentee are, are good beneficiaries of that conversation.

It's also really important to, to mention when you kind of fall short. You know, like I, I think what really resonated with you is when you, with me is when you talked about our first study that demonstrated some of the things that were associated with burnout when you're talking about how you cope with stress.

I mean, humor, self blame, like these are kind of the hallmarks of how we approach surgery. I mean, think of all the gallows humor that exists, and I'm not here to suggest that that shouldn't be in some element in

surgery. Because I know I'm just as guilty of it. But if we rely on those mechanisms as the only way to say it's healthy to cope with some of the really tough issues Sometimes tragic things that we see in the operating room.

We're pretty poorly equipping the next generation of surgeons to not only be good people, but also to teach whomever they're going to teach, how to be surgeons in a world where the operations are just getting more complex, the answers are just getting harder. It's getting more medical, legally bent, and you feel like you're constantly judged.

And so, I look at my role as a mentor as a way to improve myself in a lot of different ways. And by approaching that, I've actually gained more out of any mentoring relationships. You not being an exception, though you may think you are than, than any of the mentor or mentees have probably gotten from me.

Well, that's amazing insight and good advice. I did take note of your use of humor

in that one, so, tying in our, our articles there. But, but actually on a serious note, I mean, I do really think that, you know, what both of you said really is paralleled in what we talked about in that first paper.

And it really goes to show that good mentorship takes effort on both ends and in the right way. It's beneficial on both sides. So, I appreciate it. And I'll continue to take all the advice you guys give me and run with it. So thanks. So, let's get into our second paper. And this is titled burnout is not associated with training performance on the vascular surgery in training exam.

This was published in the journal of estro surgery in 2024. And I'm really excited to discuss this paper in particular because the two first authors, Dr. Cui and Dr. Riley, are friends of mine. And the senior author, Dr. Coleman, was at one point all of our program directors for each of us. So for those of you who aren't familiar with the vascular surgery in training examination or V site, it's a yearly exam evaluating the

knowledge base of trainees.

And this is fresh in my mind because I just took it two days prior to recording this. Burnout has been identified as a negative predictor of the site test scores. And given the high prevalence of burnout amongst vascular surgery trainees, which we've been talking about You know, understanding the impact of burnout on how trainees score on this exam is really important.

So in this study, the authors used confidential survey data which was administered after the VSITE from 2020 to 2022. So I think at least my scores were probably included in some of this research. The survey was developed from prior existing instruments and has been used in multiple previous publications.

So in this survey, I won't read every question to you although I probably do remember some of them from two days ago. But there are questions about racial and ethnic background, relationship status, family status, what level you are as a resident, your gender and gender identity. And then there's questions

about burnout, emotional exhaustion, depersonalization, and then your learning environment, including your work hours, how much time you have for education, how much clinical sports, belongingness, and your attending trainee relationships, operative time, and autonomy, etc.

There's a lot more detail in the manuscript, so I encourage you to take a look there because it's probably a lot more clear than what I'm explaining. The primary outcome was VSITE score and comparisons were performed for trainees who were above versus below the mean VSITE score. Okay, so I feel like I've been talking entirely too long.

So, Frank, can you tag me out and tell me what they found? Sure, Drew, no problem. Let me jump in there. For the study itself, they had between 630 to 600 trainees took the exam each of the years, with a response rate of 82 to 86 percent. So that's a really good response rate. And anywhere from 64 to 76 percent of those trainees, on a given basis or annual basis, reported burnout.

Burnout data given a grand

total of 1, 300 respondents, which is phenomenal for this type of research. About 45 percent of the trainees reported weekly burnout symptoms, and those who reported weekly burnout symptoms had lower V SITE scores when compared to those who did not. Senior trainees, male trainees, non Hispanic white trainees.

Trainees in relationships and those with children were more likely to score above the mean. Aspects of the learning environment, including no duty hour violations, having meaningful mentorships, and having level appropriate time in the OR were also associated with higher scores. Interestingly on a just analysis, burnout was no longer a significant predictor of V site score.

Rather, senior residents None Hispanic White residents, men without children, larger training programs, trainees and relationships. And trainees who reported a sense of belonging were significantly positive predictors of VSIGHT. Some could argue that sense of belonging could be a correlate of burnout.

Similar results were seen

between fellows and integrated residents. Performing below the mean was also associated with increased work life conflict. Trainees who scored below the mean were more likely to report dissatisfaction with their their personal life outside of work, dissatisfaction with their ability to produce.

maintenance and more likely to have thoughts of attrition overall. Thanks, Frank. You know what is really interesting about this is that initially the VSCI scores were higher for trainees who did not experience weekly burnout symptoms. However, after adjusting for trainee and learning environment factors, burnout was no longer significantly associated with VSCI scores.

This really goes, again, to show the importance of what a good learning environment can do for both our trainees and the clinical experience and now in this V Sci realm. On that note, the sense of belongingness within a training program was associated with a 20 point difference in V Sci scores. And interestingly, program size was associated with improved scores.

Both of these may be driven by larger faculty pools. You can kind of identify a mentor that makes

more sense with you. You can get organic relationships that you may not be able to find in small programs. Something actually that a lot of vascular surgery training programs suffer from is being quite small.

So it's not a surprise that Having a bigger connected network can potentially help with your V Sight score. But obviously it's hard to tease this out from this data. I think another point is important to discuss, and that's that there are significant associations between sex, race, and ethnicity on the V Sight performance.

I mean, I don't think this is going to be the first podcast where this breaks, but biases have been reported at nearly every step in the training pathway. And these findings suggest that trainees with different sex, race, ethnicity, etc. may have differences in educational experience of their training. And it's important to highlight that the goal of this study was to understand modifiable risk factors that can help improve trainee education rather than understanding predictors of training.

So it didn't include important factors such as study training time, resource availability, program level, educational support such as do you get a bunch of money for books, do you get a bunch of money for question banks, and other data points that would have been needed to assess. They really conclude that the Differences seen in the study reflect differences in educational experiences of each group, rather than attributing gender and or race as markers of testing outcome.

So I'm gonna say that again, we've recognized that some of these factors listed here can impact your educational experience before you enter a study.

And we're not saying, or nor are the authors saying, that these factors such as gender, race, and ethnicity are markers of who will perform well on the V site. And I think that's a really important point to make sure that potential glancery reads at this won't make a conclusion that could be biased in its own attempt.

So, nonetheless, our, our society and our vascular surgery realm has become more and more diverse. And we're going to have to recognize more and more ways that we help educate our trainees and help them feel the sense of belonging that we've talked about earlier, the sense of being pushed and to reduce burnout, even if it might not have an impact on their V site score.

Yeah, thanks, Bobby. You know, I mean, I've taken the V site five times now, and I've had varying levels of anxiety about each one. And, you know, one thing that I really stood out to me about the second paper was, it was how much the author stress that. V site is supposed to be a low stakes evaluation of your clinical knowledge, just to kind of, you know, a litmus test to see where you're at.

And it's not, it's not meant to predict your surgical competence. It's not been demonstrated to predict surgical competence. And it's certainly not meant to be the sole factor determining whether a resident needs V site. It's to remediate or something like that. And if I'm not mistaken, I think this is actually part of why the

reason or part of the reason that the American board of surgery got rid of percentile scores this past year.

So, you know, I think that that was really stressed by the authors and that actually made me feel a little bit more comfortable after After five years of this and so, you know, I'm really thankful for both you for, for joining for such an awesome discussion about this burnout and more. So I'm really just glad that there's great research and growing research and, and groups like Dr Coleman's group and other groups, certainly from the APDV.

APDVS, who has made this an important thing, an important topic to, to discuss. And I think that as we continue to get research to address this and inform people at all stages, including trainees and attendings about the risk factors, effects, and interventions of burnout, then we can only go up from here.

So as a reminder to all the listeners there's going to be links to all the studies that we mentioned in the show notes. And we really encourage you to take a look cause there's a lot more to unpack than we could kind of cover in this podcast episode. So we really appreciate you for listening and until next

time, dominate the day.

Yeah, and Drew and Frank, I think you'd back me up on echoing this. If anybody listening, trainee, student, or attending otherwise, is feeling burnout symptoms, and or self harm, please report it to somebody you care about. These are the type of things that as a program director, when you hear, you can just activate so many different levels of help that can really put a resident in a much better place.

And so it's everybody's responsibility to not only really look inside themselves and see if they're feeling anything, but to check in with your neighbors, check in with your colleagues, and make sure that those around you are feeling safe and protected from the risk of burnout.