- Email: [email protected]
A Model for a Formal Mentorship Program in Surgical Residency
j o u r n a l o f s u r g i c a l r e s e a r c h n o v e m b e r 2 0 1 9 ( 2 4 3 ) 6 4 e7 0
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
A Model for a Formal Mentorship Program in Surgical Residency Katherine Bingmer, MD,a Charles M. Wojnarski, MD, MS,a Justin T. Brady, MD,a Sharon L. Stein, MD,a Vanessa P. Ho, MD,b and Emily Steinhagen, MDa,* a b
Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, Ohio Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
article info
abstract
Article history:
Background: Mentorship is a key component in preventing burnout and attrition in surgical
Received 29 January 2019
training, yet many residencies lack a formal program, one method used to establish suc-
Received in revised form
cessful mentor relationships. We aimed to measure the difference in resident perceptions
8 April 2019
and experience after the implementation of a mentorship program.
Accepted 25 April 2019
Methods: An anonymous survey was distributed to all general surgery residents at a single
Available online 30 May 2019
academic institution before and after implementation of a year-long mentorship program that involved assigned mentors, two social events, and recommended mentorship meet-
Keywords:
ings. Responses were recorded on a five-point Likert scale.
Surgery residency
Results: Half of respondents (n ¼ 17, 53%) attended at least one event, and 66% (n ¼ 21) had
Surgical education
at least one mentor meeting. The proportion of residents who identified a faculty mentor
Mentorship
increased from 59% to 75%. Residents with two or more mentor meetings (n ¼ 12, 38%) were
Wellness
more likely to report faculty were interested in mentoring and cared about their development (3.5 versus 4.6, 3.6 versus 4.6, P < 0.001). They were more likely to identify faculty approachable for resident performance (3.8 versus 4.6, P < 0.02) and outside of work concerns (3.2 versus 4.3, P < 0.01) and were more likely to be satisfied with the amount of mentorship received (2.8 versus 4.0 P < 0.001). Conclusions: Implementation of a formal mentorship program resulted in an improvement in resident perception of faculty involvement and support. Meeting with a mentor resulted in a significant improvement in resident perception. Implementation of a mentorship program can improve resident experience, and few interactions are needed to affect the change. ª 2019 Elsevier Inc. All rights reserved.
This article has been accepted for presentation at Academic Surgical Congress meeting in February 2019, Houston, TX. * Corresponding author. Division of Colorectal, Department of Surgery, Associate Program Director, General Surgery Residency, 11100 Euclid Avenue, Cleveland, OH 44122. Tel.: þ216 844 5025; fax: (216) 844-5957. E-mail address: [email protected] (E. Steinhagen). 0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.04.068
bingmer et al surgical residency mentorship program
Introduction Mentorship has been proposed as one way to confront general surgery trainee burnout and attrition. Burnout, a condition characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment, is pervasive throughout the medical profession. A national survey from 2012 found 45.8% of U.S. physicians reported suffering from at least one of the three components of burnout.1 Studies of general surgery residents have found 50%-82%2-5 of residents test positive for some degree of burnout. Attrition is one potential consequence of burnout for training programs. However, it is challenging to identify those residents most at risk and administrators often underestimate the scope of the problem.6 Furthermore, effective ways to prevent and address burnout and to help those residents at risk for attrition are not well defined. The presence of a mentor has been shown to be a protective factor against burnout, fatigue, and attrition.3 Unfortunately, in surveys, only two-thirds of general surgery residents identify a mentor.7 Formal mentorship programs may be able to affect resident well-being by fostering these relationships. One national survey found the presence of a formal mentorship program to be associated with lower rates of burnout among surgical residents,3 and other surgical subspecialties have seen a reduction in burnout with the implementation of a formal mentorship program.8 A formal resident-to-resident mentorship program was instituted as an overall wellness initiative at one program at a cost of $30,000 annually.9 However, less than 25% of residents reported meeting with their mentor, there were no differences in preburnout and postburnout or psychological well-being scores, and most residents found the program to be only “somewhat valuable.” Financial, time, and efficacy issues have limited the implementation of mentorship programs. Previously described programs may be viewed as logistically difficult to replicate because of prohibitive costs and need for dedicated time.9,10 It is unknown which elements of these programs are most effective at improving resident wellness. It is also unknown whether a minimal-commitment, low-cost, formal mentorship program can positively affect resident wellness. We hypothesized that a formal mentorship program can be effective in improving resident experience.
Methods A formal mentorship program was instituted at an academic general surgery residency program during the 2017-2018 academic year. The program involved all categorical and preliminary general surgery residents. Residents in dedicated research time were not included in the study. Before this, no organized extracurricular program focused on fostering faculty-resident interaction existed at this institution. The program paired each junior resident (postgraduate year 1-2) with a senior resident mentor (postgraduate year 3-5). Each pair was assigned a faculty mentor. The surgical faculty for the residency program, involving faculty from three participating institutions, were asked to volunteer for the program.
65
Faculty who responded in the affirmative were assigned mentorship positions. Each mentee and mentor completed a brief survey on outside interests to assist in the matching process. Mentors were assigned by the mentorship program directors without input from either the mentor or mentee; factors considered for pairing included outside interests, strengths and weaknesses of the trainees and mentees, clinical/specialty interests, and clinical rotation site overlap. All residents and involved faculty were invited to two voluntary events over the course of the academic year. In addition, it was recommended participants arrange a minimum of three meetings during the year. There were no mandatory events, although participants were periodically reminded to check in with their mentor or mentee. This intervention was considered a quality improvement study and therefore was considered exempt from institutional review board approval. A 35-question multiple choice electronic survey was administered. Responses were anonymous. The presurvey was administered in May 2017 and the postsurvey in June 2018. The survey was a combination of demographics questions and inquiries relating to resident perception of faculty support, resident support, and personal fit within the program. A five-point Likert scale was used with each answer being assigned a numerical value 1 to 5, corresponding to Strongly Disagree, Disagree, Neutral, Agree, and Strongly Agree. A bivariate analysis was performed using Pearson’s chi square test for categorical variables and Student’s t-test for continuous variables. Average Likert responses were compared using the unpaired t-test. A subgroup analysis was performed comparing responses between residents who had two or more meetings with their mentors compared with those who had less than two meetings. A P value < 0.05 was used to determine statistical significance. All analyses were performed using Stata 15.1 software.
Results Demographics Among 46 residents, 29 (66%) residents responded to the presurvey and 32 (70%) responded to the postsurvey. There was a similar breakdown of residents by age, postgraduate year, and gender. Although the results did not reach statistical significance, there was a trend toward more residents expressing interest in pursuing research (41% versus 56%, P ¼ 0.25) and fellowship (69% versus 81%, P ¼ 0.05) at the completion of the program. (Table 1).
Implementation of the program Attendance at the voluntary social events was self-reported. Half of participants did not attend either event, whereas 50% attended at least one event and 25% attended both events. Among the respondents to the survey, 34% never met with their mentor, 44% met 1 or 2 times, and 22% met 3 or more times. Overall, the residents surveyed were split when asked directly whether the program had a positive impact on their residency experience (56% neutral versus 44% agree or strongly
66
j o u r n a l o f s u r g i c a l r e s e a r c h n o v e m b e r 2 0 1 9 ( 2 4 3 ) 6 4 e7 0
Table 1 e Demographics. Demographics
Before
After
n ¼ 29
n ¼ 32
P-value*
n
%
n
%
Male
18
62
23
72
Female
11
38
9
28
Junior
14
48
13
41
Senior
15
52
19
59
PGY1
9
31
8
25
PGY2
5
17
5
16
PGY3
5
17
6
19
PGY4
5
17
7
22
PGY5
5
17
3
9
25-30
12
41
15
47
31-35
13
45
14
44
4
14
3
9
Gender 0.42
Resident level 0.55
0.98
Age
>35
0.83
Plans after residency Pursuing fellowship
20
69
26
81
0.05
Academic
13
45
17
53
0.22
Community Unsure
5
17
9
28
11
38
6
19
Mentor Identify a mentor
17
59
24
75
0.17
Mentor identifying you
9
31
20
63
0.01
Have a senior mentor?
7
24
10
31
0.15
Have a junior mentor?
4
14
11
34
0.07
Significant values (P < 0.05) bolded. * Chi-squared test.
agree); however, none of the residents felt that the mentorship program had a negative impact.
Overall effect on mentorship Residents were more likely to report that they could identify a mentor at the completion of the program (59% pre versus 75% post, P ¼ 0.174), and significantly more residents felt that their mentors identified them as their mentee (31% versus 63%, P < 0.05). The proportion of female residents who could identify a mentor improved from 36% to 67% (P ¼ 0.178); male residents improved from 72% to 78% (P ¼ 0.655). There was no significant change in resident satisfaction with the amount of mentorship they received; however, significantly more residents agreed that they received sufficient feedback on their performance as a resident (2.8 pre versus 3.5 post, P < 0.05). Only 7 residents (22%) would request the same mentor again.
Overall effect on resident perception In the survey, there were five questions designed to assess resident perception of both faculty involvement and fellow
resident support. The average Likert scores of the presurvey and postsurvey are shown (Table 2). Average scores increased at the completion of the program for all but one item, although only one reached statistical significance (I receive sufficient feedback on my performance as a resident, pre 2.8 versus post 3.5, P < 0.05).
Predictors of positive outcomes There was a significant difference in resident perception based on the number of meetings residents had with their mentors. Responses were compared between residents who met less than two times with their mentor (n ¼ 20, 63.5%) and those who met two or more times (n ¼ 12, 37.5%). Residents who met with their mentor two or more times were more likely to feel faculty were interested in mentoring and cared about their development (3.5 versus 4.6; 3.6 versus 4.6, both P < 0.001). They were more likely to identify faculty they could speak to about work performance (3.8 versus 4.6, P < 0.02) and outside of work (3.2 versus 4.3, P < 0.01) concerns. These residents were also more likely to be satisfied with the amount of mentorship (2.8 versus 4.0, P < 0.001) received, as well as their
67
bingmer et al surgical residency mentorship program
Table 2 e Average Likert scores for select questions on the presurvey and postsurvey and a separate comparison of postsurvey results based on number of mentor meetings. Survey question
All Pre (29)
P-value
Mentor meetings <2 (20)
Post (32)
P-value
2 (12)
Having a mentor is important for my success
4.4
4.7
0.15
4.6
4.8
I am satisfied with the amount of mentorship I receive
3.5
3.7
0.34
2.8
4
<0.001
0.16
My clinical and operative skills are appropriate for my level
3.5
3.7
0.34
3.5
4.1
<0.02
I fit in well in my program
4
4.1
0.87
3.9
4.4
<0.05
I receive sufficient feedback on my performance as a resident
2.8
3.5
<0.05
3.3
3.8
0.13
Faculty members are interested in mentoring me
3.4
3.9
0.05
3.5
4.6
<0.001
Faculty members care about my development as a surgeon
3.8
3.9
0.44
3.6
4.6
<0.001
There are faculty members I can speak to about academic or clinical concerns/questions
4.1
4.3
0.34
4.2
4.6
0.19
There are faculty members who I can speak to regarding concerns about my performance as a resident
3.7
4.1
0.15
3.8
4.6
<0.02
There are faculty members I can speak to about concerns regarding my life outside of residency
3.2
3.6
0.17
3.2
4.3
<0.01
I am satisfied with my professional relationships with other residents within the program
4.2
4.2
0.45
4.2
4.4
0.32
I am friends with other residents in the program
4.3
4.4
0.52
4.4
4.4
0.75
There are co-residents who I can speak to about academic or clinical concerns/questions
4.4
4.5
0.69
4.5
4.5
0.79
There are co-residents who I can speak to regarding concerns about my performance as a resident
4.1
4.3
0.49
4.3
4.2
0.62
There are co-residents who I can talk to about concerns regarding my life outside of residency
4.3
4.2
0.59
4.2
4.3
0.84
operative and clinical skill levels (3.5 versus 4.1, P < 0.02) (Table 2, Figure).
Discussion This study demonstrates that active participation in a formal mentorship program with a low time commitment requirement can result in an improvement in resident perception of faculty involvement and support. Residents who met with their mentor as few as two times consistently rated faculty involvement higher than those who did not, suggesting that a personal relationship with a mentor is an effective way to positively impact resident experience. When comparing the preimplementation and postimplementation responses among all residents, there was a significant improvement in the proportion of residents who felt they received adequate feedback on their performance. There was also a positive correlation with resident rating of faculty involvement and approachability; however, these did not reach statistical significance. The small sample size of this study limits statistical significance, but positive trends are notable in many areas. This study is unique in its program simplicity. Previous mentor interventions in surgical residency have been relatively time-consuming, which can be taxing for both the
mentors and the mentees. One program was designed to be module-based over the course of 2 y and a structured group mentorship relationship.10 The program was designed around eight 3-h modules with varied themes and associated supplemental reading. Overall, residents rated the program as having a neutral or positive impact on residency life and their motivation to pursue individual mentor relationships. A comprehensive wellness program instituted at another hospital system, which included a mentorship component, cost $30,000 to implement.9 This program addressed physical, psychological, and social well-being, as well as mentorship and leadership. Junior and senior residents were paired, and quarterly lunch meetings were provided to promote regular meetings. Compared with these examples, the present study demonstrates that it is possible to create a successful program with minimal costs and a more limited time commitment on the part of both mentors and mentees. Just two meetings over the course of an academic year was associated with improved perceptions in multiple domains, suggesting that even faculty with limited time to mentor have the potential for an important impact on trainees. Up to 80% of general surgery residents suffer from burnout,5 and this pervasive problem has been challenging to solve. It is difficult to identify residents at risk for burnout as it does not appear to correlate with age, postgraduate year,
68
j o u r n a l o f s u r g i c a l r e s e a r c h n o v e m b e r 2 0 1 9 ( 2 4 3 ) 6 4 e7 0
Fig e Likert scores on postsurveys based on the number of meetings with mentors. (Color version of figure is available online.)
marriage, children, or academic performance.3,11 A variety of possible solutions to burnout have been proposed. Hour restrictions and work hour regulations have had a mixed effect on resident burnout scores, and positive studies show only modest improvements.5 Effective mentorship may be one solution to the burnout epidemic; the presence of a mentor has been previously associated with lower burnout scores,3 yet only two-thirds of residents nationally can identify a mentor.7 The program in this study improved the number of residents identifying a mentor at our institution from 59% to 75% and improved the number of residents who felt their mentor identified them as their mentee from 31% to 63%.
Among the 19 residents who met with their mentor at least once, almost all identified a mentor. In addition to burnout, general surgery residency has a relatively high attrition rate: 12%-19.5% of residents choose to leave general surgery residencies,12-16 and up to 44% consider dropping out.3 Structured interviews of 19 residents who left general surgery training revealed four main themes: low priority on education, no safe space to voice personal concerns, few role models, and negative interactions with program leaders.17 Female residents in particular appear to be more likely to be affected by burnout and attrition3,18; this becomes increasingly relevant as the number of female general surgery
bingmer et al surgical residency mentorship program
residents continues to rise. Similarly, female residents have reported more thoughts of leaving training than men,19 and higher rates of female attrition have been observed in some studies.18 Women in particular report a lack of mentors and available role models, possibly because of few women in leadership roles.20 As the percentage of female general surgery residents continues to rise, from 32.3% in 200821 to 38.5% in 2016,22 there becomes an increasingly urgent need to address burnout and attrition. Female surgical residents are more likely to report violating duty hours and experiencing fatigue20 and are significantly more likely to meet criteria for burnout than men.3 If mentors and role models are protective against burnout and attrition, it makes sense that a group of residents suffering from a lack of the former have higher rates of the latter. In this study, 36% of female residents identified a mentor before the program compared with 72% of male residents. After the program, this improved to 67% for women and 78% for men. Although these improvements do not reach statistical significance, the program resulted in a notable improvement in the number of female residents receiving mentorship. A formal mentorship program may be one way to improve burnout and attrition among female residents in particular. There are several limitations to this study. This is a small, single-institution study. Many of our data points did not reach statistical significance at least partially because of small sample size. Although this study demonstrated an improvement in residents’ subjective scoring of their experience, it was not designed to collect objective data regarding resident burnout, and formal assessment of burnout was not included in this study. Although it is encouraging that there is an association between participation in the program and higher resident satisfaction, the authors note that possibly those residents who are most proactive and involved are more inclined to respond positively in the survey. This leads to the question: are the residents who are most at risk for burnout being missed with this program? Surveys of surgical leadership demonstrate that even in formal mentorship programs within surgical departments designed to benefit attending surgeons, mentors and mentees receive little training, and a majority of the pairings were assigned by a third party.23 Suggestions made to improve the effectiveness of programs by Kibbe et al. included allowing mentees to choose their mentors and providing formal training for mentors.23 Including these improvements in our program will be a consideration in our program going forward, with the hope of improving outcomes. Despite these limitations, our findings suggest that trainees respond positively to small changes in support. General surgery residents suffer from long work hours, high rates of burnout, and attrition. Introduction of a formal mentorship program is one way programs can protect training physicians from the toll of a grueling residency. Our study suggests that an effective formal mentorship program does not need to be time-consuming for participants or expensive for the residency program to affect a positive impact, but does require a small amount of participation from both the mentee and mentor. It remains to be seen whether this will translate into improvement in resident burnout scores or reduction in attrition rates.
69
Acknowledgment Authors’ contributions: E.S., V.P.H., J.T.B., and C.M.W. designed and implemented the study, and performed data collection. E.S. and K.B. performed data analysis. The manuscript was written by K.B., E.S., S.L.S., and V.P.H. All authors reviewed the final manuscript.
Disclosure Dr. Sharon L Stein is a consultant in Merck Sharp and Dohme Corporation and Covidien. There are no other author disclosures to report.
references
1. Romani M, Ashkar K. Burnout among physicians. Libyan J Med. 2014;9. https://doi.org/10.3402/ljm.v9.23556. 2. Riall TS, Teiman J, Chang M, et al. Maintaining the fire but avoiding burnout: implementation and evaluation of a resident well-being program. J Am Coll Surg. 2018;226:369e379. 3. Elmore LC, Jeffe DB, Jin L, Awad MM, Turnbull IR. National survey of burnout among US general surgery residents. J Am Coll Surg. 2016;223:440e451. 4. Lin DT, Liebert CA, Tran J, Lau JN, Salles A. Emotional intelligence as a predictor of resident well-being. J Am Coll Surg. 2016;223:352e358. 5. Lindeman BM, Sacks BC, Hirose K, Lipsett PA. Multifaceted longitudinal study of surgical resident education, quality of life, and patient care before and after july 2011. J Surg Educ. 2013;70:769e776. 6. Williford ML, Scarlet S, Meyers MO, et al. Multiple-institution comparison of resident and faculty perceptions of burnout and depression during surgical training. JAMA Surg. 2018;153:705e711. 7. Delisle M, Rivard J, Hebbard P, McCarthy B, Wirtzfeld D. National survey of mentorship in Canadian general surgery residency programs: where are we and what do we need? Can Med Educ J. 2017;8:e42ee53. 8. Zhang H, Isaac A, Wright ED, Alrajhi Y, Seikaly H. Formal mentorship in a surgical residency training program: a prospective interventional study. J Otolaryngol Head Neck Surg. 2017;46:13. 9. Salles A, Liebert CA, Esquivel M, Greco RS, Henry R, Mueller C. Perceived value of a program to promote surgical resident well-being. J Surg Educ. 2017;76:921e927. 10. Champion C, Bennett S, Carver D, et al. Providing mentorship support to general surgery residents: a model for structured group facilitation. Can J Surg. 2015;58:372e373. 11. Cofer KD, Hollis RH, Goss L, Morris MS, Porterfield JR, Chu DI. Burnout is associated with emotional intelligence but not traditional job performance measurements in surgical residents. J Surg Educ. 2018;75:1171e1179. 12. Yeo H, Bucholz E, Ann Sosa J, et al. A national study of attrition in general surgery training: which residents leave and where do they go? Ann Surg. 2010;252:529e534. 13. Yaghoubian A, Galante J, Kaji A, et al. General surgery resident remediation and attrition: a multi-institutional study. Arch Surg. 2012;147:829e833. 14. Everett CB, Helmer SD, Osland JS, Smith RS. General surgery resident attrition and the 80-hour workweek. Am J Surg. 2007. https://doi.org/10.1016/j.amjsurg.2007.08.033.
70
j o u r n a l o f s u r g i c a l r e s e a r c h n o v e m b e r 2 0 1 9 ( 2 4 3 ) 6 4 e7 0
15. Naylor RA, Reisch JS, Valentine RJ. Factors related to attrition in surgery residency based on application data. Arch Surg. 2008;143:647e651. 16. Kwakwa F, Jonasson O. Attrition in graduate surgical education: an analysis of the 1993 entering cohort of surgical residents. J Am Coll Surg. 1999;189:602e610. 17. Bongiovanni T, Yeo H, Sosa JA, et al. Attrition from surgical residency training: perspectives from those who left. Am J Surg. 2015;210:648e654. 18. Yeo HL, Abelson JS, Symer MM, et al. Association of time to attrition in surgical residency with individual resident and programmatic factors. JAMA Surg. 2018;153:511e517. 19. Yeo H, Viola K, Berg D, et al. Attitudes, training experiences, and professional expectations of US general surgery residents: a national survey. JAMA. 2009;302:1301e1308.
20. Dahlke AR, Johnson JK, Greenberg CC, et al. Gender differences in utilization of duty-hour regulations, aspects of burnout, and psychological well-being among general surgery residents in the United States. Ann Surg. 2018;268:204e211. 21. Sexton KW, Hocking KM, Wise E, et al. Women in academic surgery: the pipeline is busted. J Surg Educ. 2012;69:84e90. 22. Association of American Medical Colleges. Report on residents; 2016. https://www.aamc.org/download/449978/ data/reportonresidentsexecutivesummary.pdf. Accessed January 29, 2019. 23. Kibbe MR, Pellegrini CA, Townsend CM, Helenowski IB, Patti MG. Characterization of mentorship programs in departments of surgery in the United States. JAMA Surg. 2016;151:900e906.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
A Model for a Formal Mentorship Program in Surgical Residency Katherine Bingmer, MD,a Charles M. Wojnarski, MD, MS,a Justin T. Brady, MD,a Sharon L. Stein, MD,a Vanessa P. Ho, MD,b and Emily Steinhagen, MDa,* a b
Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, Ohio Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
article info
abstract
Article history:
Background: Mentorship is a key component in preventing burnout and attrition in surgical
Received 29 January 2019
training, yet many residencies lack a formal program, one method used to establish suc-
Received in revised form
cessful mentor relationships. We aimed to measure the difference in resident perceptions
8 April 2019
and experience after the implementation of a mentorship program.
Accepted 25 April 2019
Methods: An anonymous survey was distributed to all general surgery residents at a single
Available online 30 May 2019
academic institution before and after implementation of a year-long mentorship program that involved assigned mentors, two social events, and recommended mentorship meet-
Keywords:
ings. Responses were recorded on a five-point Likert scale.
Surgery residency
Results: Half of respondents (n ¼ 17, 53%) attended at least one event, and 66% (n ¼ 21) had
Surgical education
at least one mentor meeting. The proportion of residents who identified a faculty mentor
Mentorship
increased from 59% to 75%. Residents with two or more mentor meetings (n ¼ 12, 38%) were
Wellness
more likely to report faculty were interested in mentoring and cared about their development (3.5 versus 4.6, 3.6 versus 4.6, P < 0.001). They were more likely to identify faculty approachable for resident performance (3.8 versus 4.6, P < 0.02) and outside of work concerns (3.2 versus 4.3, P < 0.01) and were more likely to be satisfied with the amount of mentorship received (2.8 versus 4.0 P < 0.001). Conclusions: Implementation of a formal mentorship program resulted in an improvement in resident perception of faculty involvement and support. Meeting with a mentor resulted in a significant improvement in resident perception. Implementation of a mentorship program can improve resident experience, and few interactions are needed to affect the change. ª 2019 Elsevier Inc. All rights reserved.
This article has been accepted for presentation at Academic Surgical Congress meeting in February 2019, Houston, TX. * Corresponding author. Division of Colorectal, Department of Surgery, Associate Program Director, General Surgery Residency, 11100 Euclid Avenue, Cleveland, OH 44122. Tel.: þ216 844 5025; fax: (216) 844-5957. E-mail address: [email protected] (E. Steinhagen). 0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.04.068
bingmer et al surgical residency mentorship program
Introduction Mentorship has been proposed as one way to confront general surgery trainee burnout and attrition. Burnout, a condition characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment, is pervasive throughout the medical profession. A national survey from 2012 found 45.8% of U.S. physicians reported suffering from at least one of the three components of burnout.1 Studies of general surgery residents have found 50%-82%2-5 of residents test positive for some degree of burnout. Attrition is one potential consequence of burnout for training programs. However, it is challenging to identify those residents most at risk and administrators often underestimate the scope of the problem.6 Furthermore, effective ways to prevent and address burnout and to help those residents at risk for attrition are not well defined. The presence of a mentor has been shown to be a protective factor against burnout, fatigue, and attrition.3 Unfortunately, in surveys, only two-thirds of general surgery residents identify a mentor.7 Formal mentorship programs may be able to affect resident well-being by fostering these relationships. One national survey found the presence of a formal mentorship program to be associated with lower rates of burnout among surgical residents,3 and other surgical subspecialties have seen a reduction in burnout with the implementation of a formal mentorship program.8 A formal resident-to-resident mentorship program was instituted as an overall wellness initiative at one program at a cost of $30,000 annually.9 However, less than 25% of residents reported meeting with their mentor, there were no differences in preburnout and postburnout or psychological well-being scores, and most residents found the program to be only “somewhat valuable.” Financial, time, and efficacy issues have limited the implementation of mentorship programs. Previously described programs may be viewed as logistically difficult to replicate because of prohibitive costs and need for dedicated time.9,10 It is unknown which elements of these programs are most effective at improving resident wellness. It is also unknown whether a minimal-commitment, low-cost, formal mentorship program can positively affect resident wellness. We hypothesized that a formal mentorship program can be effective in improving resident experience.
Methods A formal mentorship program was instituted at an academic general surgery residency program during the 2017-2018 academic year. The program involved all categorical and preliminary general surgery residents. Residents in dedicated research time were not included in the study. Before this, no organized extracurricular program focused on fostering faculty-resident interaction existed at this institution. The program paired each junior resident (postgraduate year 1-2) with a senior resident mentor (postgraduate year 3-5). Each pair was assigned a faculty mentor. The surgical faculty for the residency program, involving faculty from three participating institutions, were asked to volunteer for the program.
65
Faculty who responded in the affirmative were assigned mentorship positions. Each mentee and mentor completed a brief survey on outside interests to assist in the matching process. Mentors were assigned by the mentorship program directors without input from either the mentor or mentee; factors considered for pairing included outside interests, strengths and weaknesses of the trainees and mentees, clinical/specialty interests, and clinical rotation site overlap. All residents and involved faculty were invited to two voluntary events over the course of the academic year. In addition, it was recommended participants arrange a minimum of three meetings during the year. There were no mandatory events, although participants were periodically reminded to check in with their mentor or mentee. This intervention was considered a quality improvement study and therefore was considered exempt from institutional review board approval. A 35-question multiple choice electronic survey was administered. Responses were anonymous. The presurvey was administered in May 2017 and the postsurvey in June 2018. The survey was a combination of demographics questions and inquiries relating to resident perception of faculty support, resident support, and personal fit within the program. A five-point Likert scale was used with each answer being assigned a numerical value 1 to 5, corresponding to Strongly Disagree, Disagree, Neutral, Agree, and Strongly Agree. A bivariate analysis was performed using Pearson’s chi square test for categorical variables and Student’s t-test for continuous variables. Average Likert responses were compared using the unpaired t-test. A subgroup analysis was performed comparing responses between residents who had two or more meetings with their mentors compared with those who had less than two meetings. A P value < 0.05 was used to determine statistical significance. All analyses were performed using Stata 15.1 software.
Results Demographics Among 46 residents, 29 (66%) residents responded to the presurvey and 32 (70%) responded to the postsurvey. There was a similar breakdown of residents by age, postgraduate year, and gender. Although the results did not reach statistical significance, there was a trend toward more residents expressing interest in pursuing research (41% versus 56%, P ¼ 0.25) and fellowship (69% versus 81%, P ¼ 0.05) at the completion of the program. (Table 1).
Implementation of the program Attendance at the voluntary social events was self-reported. Half of participants did not attend either event, whereas 50% attended at least one event and 25% attended both events. Among the respondents to the survey, 34% never met with their mentor, 44% met 1 or 2 times, and 22% met 3 or more times. Overall, the residents surveyed were split when asked directly whether the program had a positive impact on their residency experience (56% neutral versus 44% agree or strongly
66
j o u r n a l o f s u r g i c a l r e s e a r c h n o v e m b e r 2 0 1 9 ( 2 4 3 ) 6 4 e7 0
Table 1 e Demographics. Demographics
Before
After
n ¼ 29
n ¼ 32
P-value*
n
%
n
%
Male
18
62
23
72
Female
11
38
9
28
Junior
14
48
13
41
Senior
15
52
19
59
PGY1
9
31
8
25
PGY2
5
17
5
16
PGY3
5
17
6
19
PGY4
5
17
7
22
PGY5
5
17
3
9
25-30
12
41
15
47
31-35
13
45
14
44
4
14
3
9
Gender 0.42
Resident level 0.55
0.98
Age
>35
0.83
Plans after residency Pursuing fellowship
20
69
26
81
0.05
Academic
13
45
17
53
0.22
Community Unsure
5
17
9
28
11
38
6
19
Mentor Identify a mentor
17
59
24
75
0.17
Mentor identifying you
9
31
20
63
0.01
Have a senior mentor?
7
24
10
31
0.15
Have a junior mentor?
4
14
11
34
0.07
Significant values (P < 0.05) bolded. * Chi-squared test.
agree); however, none of the residents felt that the mentorship program had a negative impact.
Overall effect on mentorship Residents were more likely to report that they could identify a mentor at the completion of the program (59% pre versus 75% post, P ¼ 0.174), and significantly more residents felt that their mentors identified them as their mentee (31% versus 63%, P < 0.05). The proportion of female residents who could identify a mentor improved from 36% to 67% (P ¼ 0.178); male residents improved from 72% to 78% (P ¼ 0.655). There was no significant change in resident satisfaction with the amount of mentorship they received; however, significantly more residents agreed that they received sufficient feedback on their performance as a resident (2.8 pre versus 3.5 post, P < 0.05). Only 7 residents (22%) would request the same mentor again.
Overall effect on resident perception In the survey, there were five questions designed to assess resident perception of both faculty involvement and fellow
resident support. The average Likert scores of the presurvey and postsurvey are shown (Table 2). Average scores increased at the completion of the program for all but one item, although only one reached statistical significance (I receive sufficient feedback on my performance as a resident, pre 2.8 versus post 3.5, P < 0.05).
Predictors of positive outcomes There was a significant difference in resident perception based on the number of meetings residents had with their mentors. Responses were compared between residents who met less than two times with their mentor (n ¼ 20, 63.5%) and those who met two or more times (n ¼ 12, 37.5%). Residents who met with their mentor two or more times were more likely to feel faculty were interested in mentoring and cared about their development (3.5 versus 4.6; 3.6 versus 4.6, both P < 0.001). They were more likely to identify faculty they could speak to about work performance (3.8 versus 4.6, P < 0.02) and outside of work (3.2 versus 4.3, P < 0.01) concerns. These residents were also more likely to be satisfied with the amount of mentorship (2.8 versus 4.0, P < 0.001) received, as well as their
67
bingmer et al surgical residency mentorship program
Table 2 e Average Likert scores for select questions on the presurvey and postsurvey and a separate comparison of postsurvey results based on number of mentor meetings. Survey question
All Pre (29)
P-value
Mentor meetings <2 (20)
Post (32)
P-value
2 (12)
Having a mentor is important for my success
4.4
4.7
0.15
4.6
4.8
I am satisfied with the amount of mentorship I receive
3.5
3.7
0.34
2.8
4
<0.001
0.16
My clinical and operative skills are appropriate for my level
3.5
3.7
0.34
3.5
4.1
<0.02
I fit in well in my program
4
4.1
0.87
3.9
4.4
<0.05
I receive sufficient feedback on my performance as a resident
2.8
3.5
<0.05
3.3
3.8
0.13
Faculty members are interested in mentoring me
3.4
3.9
0.05
3.5
4.6
<0.001
Faculty members care about my development as a surgeon
3.8
3.9
0.44
3.6
4.6
<0.001
There are faculty members I can speak to about academic or clinical concerns/questions
4.1
4.3
0.34
4.2
4.6
0.19
There are faculty members who I can speak to regarding concerns about my performance as a resident
3.7
4.1
0.15
3.8
4.6
<0.02
There are faculty members I can speak to about concerns regarding my life outside of residency
3.2
3.6
0.17
3.2
4.3
<0.01
I am satisfied with my professional relationships with other residents within the program
4.2
4.2
0.45
4.2
4.4
0.32
I am friends with other residents in the program
4.3
4.4
0.52
4.4
4.4
0.75
There are co-residents who I can speak to about academic or clinical concerns/questions
4.4
4.5
0.69
4.5
4.5
0.79
There are co-residents who I can speak to regarding concerns about my performance as a resident
4.1
4.3
0.49
4.3
4.2
0.62
There are co-residents who I can talk to about concerns regarding my life outside of residency
4.3
4.2
0.59
4.2
4.3
0.84
operative and clinical skill levels (3.5 versus 4.1, P < 0.02) (Table 2, Figure).
Discussion This study demonstrates that active participation in a formal mentorship program with a low time commitment requirement can result in an improvement in resident perception of faculty involvement and support. Residents who met with their mentor as few as two times consistently rated faculty involvement higher than those who did not, suggesting that a personal relationship with a mentor is an effective way to positively impact resident experience. When comparing the preimplementation and postimplementation responses among all residents, there was a significant improvement in the proportion of residents who felt they received adequate feedback on their performance. There was also a positive correlation with resident rating of faculty involvement and approachability; however, these did not reach statistical significance. The small sample size of this study limits statistical significance, but positive trends are notable in many areas. This study is unique in its program simplicity. Previous mentor interventions in surgical residency have been relatively time-consuming, which can be taxing for both the
mentors and the mentees. One program was designed to be module-based over the course of 2 y and a structured group mentorship relationship.10 The program was designed around eight 3-h modules with varied themes and associated supplemental reading. Overall, residents rated the program as having a neutral or positive impact on residency life and their motivation to pursue individual mentor relationships. A comprehensive wellness program instituted at another hospital system, which included a mentorship component, cost $30,000 to implement.9 This program addressed physical, psychological, and social well-being, as well as mentorship and leadership. Junior and senior residents were paired, and quarterly lunch meetings were provided to promote regular meetings. Compared with these examples, the present study demonstrates that it is possible to create a successful program with minimal costs and a more limited time commitment on the part of both mentors and mentees. Just two meetings over the course of an academic year was associated with improved perceptions in multiple domains, suggesting that even faculty with limited time to mentor have the potential for an important impact on trainees. Up to 80% of general surgery residents suffer from burnout,5 and this pervasive problem has been challenging to solve. It is difficult to identify residents at risk for burnout as it does not appear to correlate with age, postgraduate year,
68
j o u r n a l o f s u r g i c a l r e s e a r c h n o v e m b e r 2 0 1 9 ( 2 4 3 ) 6 4 e7 0
Fig e Likert scores on postsurveys based on the number of meetings with mentors. (Color version of figure is available online.)
marriage, children, or academic performance.3,11 A variety of possible solutions to burnout have been proposed. Hour restrictions and work hour regulations have had a mixed effect on resident burnout scores, and positive studies show only modest improvements.5 Effective mentorship may be one solution to the burnout epidemic; the presence of a mentor has been previously associated with lower burnout scores,3 yet only two-thirds of residents nationally can identify a mentor.7 The program in this study improved the number of residents identifying a mentor at our institution from 59% to 75% and improved the number of residents who felt their mentor identified them as their mentee from 31% to 63%.
Among the 19 residents who met with their mentor at least once, almost all identified a mentor. In addition to burnout, general surgery residency has a relatively high attrition rate: 12%-19.5% of residents choose to leave general surgery residencies,12-16 and up to 44% consider dropping out.3 Structured interviews of 19 residents who left general surgery training revealed four main themes: low priority on education, no safe space to voice personal concerns, few role models, and negative interactions with program leaders.17 Female residents in particular appear to be more likely to be affected by burnout and attrition3,18; this becomes increasingly relevant as the number of female general surgery
bingmer et al surgical residency mentorship program
residents continues to rise. Similarly, female residents have reported more thoughts of leaving training than men,19 and higher rates of female attrition have been observed in some studies.18 Women in particular report a lack of mentors and available role models, possibly because of few women in leadership roles.20 As the percentage of female general surgery residents continues to rise, from 32.3% in 200821 to 38.5% in 2016,22 there becomes an increasingly urgent need to address burnout and attrition. Female surgical residents are more likely to report violating duty hours and experiencing fatigue20 and are significantly more likely to meet criteria for burnout than men.3 If mentors and role models are protective against burnout and attrition, it makes sense that a group of residents suffering from a lack of the former have higher rates of the latter. In this study, 36% of female residents identified a mentor before the program compared with 72% of male residents. After the program, this improved to 67% for women and 78% for men. Although these improvements do not reach statistical significance, the program resulted in a notable improvement in the number of female residents receiving mentorship. A formal mentorship program may be one way to improve burnout and attrition among female residents in particular. There are several limitations to this study. This is a small, single-institution study. Many of our data points did not reach statistical significance at least partially because of small sample size. Although this study demonstrated an improvement in residents’ subjective scoring of their experience, it was not designed to collect objective data regarding resident burnout, and formal assessment of burnout was not included in this study. Although it is encouraging that there is an association between participation in the program and higher resident satisfaction, the authors note that possibly those residents who are most proactive and involved are more inclined to respond positively in the survey. This leads to the question: are the residents who are most at risk for burnout being missed with this program? Surveys of surgical leadership demonstrate that even in formal mentorship programs within surgical departments designed to benefit attending surgeons, mentors and mentees receive little training, and a majority of the pairings were assigned by a third party.23 Suggestions made to improve the effectiveness of programs by Kibbe et al. included allowing mentees to choose their mentors and providing formal training for mentors.23 Including these improvements in our program will be a consideration in our program going forward, with the hope of improving outcomes. Despite these limitations, our findings suggest that trainees respond positively to small changes in support. General surgery residents suffer from long work hours, high rates of burnout, and attrition. Introduction of a formal mentorship program is one way programs can protect training physicians from the toll of a grueling residency. Our study suggests that an effective formal mentorship program does not need to be time-consuming for participants or expensive for the residency program to affect a positive impact, but does require a small amount of participation from both the mentee and mentor. It remains to be seen whether this will translate into improvement in resident burnout scores or reduction in attrition rates.
69
Acknowledgment Authors’ contributions: E.S., V.P.H., J.T.B., and C.M.W. designed and implemented the study, and performed data collection. E.S. and K.B. performed data analysis. The manuscript was written by K.B., E.S., S.L.S., and V.P.H. All authors reviewed the final manuscript.
Disclosure Dr. Sharon L Stein is a consultant in Merck Sharp and Dohme Corporation and Covidien. There are no other author disclosures to report.
references
1. Romani M, Ashkar K. Burnout among physicians. Libyan J Med. 2014;9. https://doi.org/10.3402/ljm.v9.23556. 2. Riall TS, Teiman J, Chang M, et al. Maintaining the fire but avoiding burnout: implementation and evaluation of a resident well-being program. J Am Coll Surg. 2018;226:369e379. 3. Elmore LC, Jeffe DB, Jin L, Awad MM, Turnbull IR. National survey of burnout among US general surgery residents. J Am Coll Surg. 2016;223:440e451. 4. Lin DT, Liebert CA, Tran J, Lau JN, Salles A. Emotional intelligence as a predictor of resident well-being. J Am Coll Surg. 2016;223:352e358. 5. Lindeman BM, Sacks BC, Hirose K, Lipsett PA. Multifaceted longitudinal study of surgical resident education, quality of life, and patient care before and after july 2011. J Surg Educ. 2013;70:769e776. 6. Williford ML, Scarlet S, Meyers MO, et al. Multiple-institution comparison of resident and faculty perceptions of burnout and depression during surgical training. JAMA Surg. 2018;153:705e711. 7. Delisle M, Rivard J, Hebbard P, McCarthy B, Wirtzfeld D. National survey of mentorship in Canadian general surgery residency programs: where are we and what do we need? Can Med Educ J. 2017;8:e42ee53. 8. Zhang H, Isaac A, Wright ED, Alrajhi Y, Seikaly H. Formal mentorship in a surgical residency training program: a prospective interventional study. J Otolaryngol Head Neck Surg. 2017;46:13. 9. Salles A, Liebert CA, Esquivel M, Greco RS, Henry R, Mueller C. Perceived value of a program to promote surgical resident well-being. J Surg Educ. 2017;76:921e927. 10. Champion C, Bennett S, Carver D, et al. Providing mentorship support to general surgery residents: a model for structured group facilitation. Can J Surg. 2015;58:372e373. 11. Cofer KD, Hollis RH, Goss L, Morris MS, Porterfield JR, Chu DI. Burnout is associated with emotional intelligence but not traditional job performance measurements in surgical residents. J Surg Educ. 2018;75:1171e1179. 12. Yeo H, Bucholz E, Ann Sosa J, et al. A national study of attrition in general surgery training: which residents leave and where do they go? Ann Surg. 2010;252:529e534. 13. Yaghoubian A, Galante J, Kaji A, et al. General surgery resident remediation and attrition: a multi-institutional study. Arch Surg. 2012;147:829e833. 14. Everett CB, Helmer SD, Osland JS, Smith RS. General surgery resident attrition and the 80-hour workweek. Am J Surg. 2007. https://doi.org/10.1016/j.amjsurg.2007.08.033.
70
j o u r n a l o f s u r g i c a l r e s e a r c h n o v e m b e r 2 0 1 9 ( 2 4 3 ) 6 4 e7 0
15. Naylor RA, Reisch JS, Valentine RJ. Factors related to attrition in surgery residency based on application data. Arch Surg. 2008;143:647e651. 16. Kwakwa F, Jonasson O. Attrition in graduate surgical education: an analysis of the 1993 entering cohort of surgical residents. J Am Coll Surg. 1999;189:602e610. 17. Bongiovanni T, Yeo H, Sosa JA, et al. Attrition from surgical residency training: perspectives from those who left. Am J Surg. 2015;210:648e654. 18. Yeo HL, Abelson JS, Symer MM, et al. Association of time to attrition in surgical residency with individual resident and programmatic factors. JAMA Surg. 2018;153:511e517. 19. Yeo H, Viola K, Berg D, et al. Attitudes, training experiences, and professional expectations of US general surgery residents: a national survey. JAMA. 2009;302:1301e1308.
20. Dahlke AR, Johnson JK, Greenberg CC, et al. Gender differences in utilization of duty-hour regulations, aspects of burnout, and psychological well-being among general surgery residents in the United States. Ann Surg. 2018;268:204e211. 21. Sexton KW, Hocking KM, Wise E, et al. Women in academic surgery: the pipeline is busted. J Surg Educ. 2012;69:84e90. 22. Association of American Medical Colleges. Report on residents; 2016. https://www.aamc.org/download/449978/ data/reportonresidentsexecutivesummary.pdf. Accessed January 29, 2019. 23. Kibbe MR, Pellegrini CA, Townsend CM, Helenowski IB, Patti MG. Characterization of mentorship programs in departments of surgery in the United States. JAMA Surg. 2016;151:900e906.