- Email: [email protected]
Grit as a predictor of risk of attrition in surgical residency
Accepted Manuscript Grit as a predictor of risk of attrition in surgical residency Arghavan Salles, Dana Lin, Cara Liebert, Micaela Esquivel, James N. Lau, Ralph S. Greco, Claudia Mueller PII:
S0002-9610(16)30927-8
DOI:
10.1016/j.amjsurg.2016.10.012
Reference:
AJS 12179
To appear in:
The American Journal of Surgery
Received Date: 5 April 2016 Revised Date:
2 September 2016
Accepted Date: 20 October 2016
Please cite this article as: Salles A, Lin D, Liebert C, Esquivel M, Lau JN, Greco RS, Mueller C, Grit as a predictor of risk of attrition in surgical residency, The American Journal of Surgery (2016), doi: 10.1016/ j.amjsurg.2016.10.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Grit as a Predictor of Risk of Attrition in Surgical Residency Authors: Arghavan Salles, MD, PhD1, 2
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Dana Lin, MD1 Cara Liebert, MD1 Micaela Esquivel, MD1
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James N. Lau, MD1
Claudia Mueller, PhD, MD1 Corresponding Author: Arghavan Salles, MD, PhD Telephone: (650) 387-5275
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Ralph S. Greco, MD1
1Stanford
Health Care
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Email: [email protected]
300 Pasteur Drive, MC H3591
author’s current address:
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2Corresponding
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Stanford, CA 94305
Washington University in St. Louis Department of Surgery 660 S. Euclid Box 8109 St. Louis, MO 63110
None of the authors have relevant financial disclosures to report
1
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Abstract Background: Grit, a measure of perseverance, has been shown to predict resident wellbeing. In this study we assess the relationship between grit and attrition.
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Methods: We collected survey data from residents in a single institution over two
consecutive years. All residents in general surgery were invited to participate (N=115). Grit and psychological well-being were assessed using validated measures. Risk of attrition was
SC
measured using survey items.
Results: 73 residents participated (63% response rate). Grit was positively correlated with
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general psychological well-being (r=0.30, p<0.05) and inversely correlated with depression (r=-0.25, p<0.05) and risk of attrition (r=-0.37, p<0.01). In regression analyses, grit was positively predictive of well-being (B=0.77, t=2.96, p<0.01) and negatively predictive of depression (B=-0.28 t=-2.74, p<0.01) and attrition (B=-0.99, t=-2.53, p<0.05).
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Conclusions: Attrition is a costly and disruptive problem in residency. Grit is a quick,
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study.
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reliable measure which appears to be predictive of attrition risk in this single institution
2
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Summary This study examines the relationship between grit, a measure of perseverance, and resident well-being as well as attrition. The key findings are that grit is positively
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associated with better psychological well-being and negatively associated with risk of
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attrition.
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Keywords: grit, attrition, well-being, depression, burnout
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Introduction Surgical residency is a stressful and grueling period in medical training. Surgery residents experience burnout and depression to a greater degree than do members of the
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general public.1 The long hours,2 lack of control over one’s schedule, and acuity of patients are all factors that may make residency training particularly challenging. For these and other reasons, the attrition rate in general surgery is higher than that of other specialties at
SC
approximately 20%.3-6
Attrition is costly to both individuals and the programs in which they matriculate.7
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Previous research has shown that fatigue8 and poor well-being, such as depression, may be contributors to attrition.9-10 Specifically, those who have more positive feelings are less likely to quit their jobs and experience burnout.10-11 Conversely, workplace stress is associated with absenteeism and reduced productivity.9 Thus, it may be that improving
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resident well-being can improve retention.
Grit, defined as perseverance and passion for long-term goals,12 may also be associated with lower rates of attrition. This could happen in two ways. First, previous data
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has suggested that grit is positively associated with psychological well-being13 which may
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thus in turn be associated with lower rates of attrition. Second, grit may directly make it less likely that someone would quit residency. In this study, we aim to understand whether grit, in and of itself, may be a predictor
of one’s desire to quit residency. In addition, we aim to replicate prior findings that have shown a positive correlation between grit and psychological well-being. We hypothesize that grit will be positively associated with psychological well-being and that it will be a predictor of risk of attrition.
5
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Materials & Methods After obtaining approval from the Stanford University Institutional Review Board, in the context of a larger longitudinal study we administered a survey to assess residents’
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perseverance, burnout, psychological well-being, depression, and risk of attrition. The Short Grit Scale14 was used to measure perseverance. Burnout was measured using the Maslach Burnout Inventory (MBI).15-16 Psychological well-being was measured using the
SC
Dupuy Psychological General Well-Being (PGWB) scale.17 Depression was measured using the short form of the Beck Depression Inventory (BDI).18 Risk of attrition was measured
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using two items: “At this point in time, how likely is it that you will complete residency training in your current specialty?” and “In the past month, how often have you thought about leaving your current residency program?” These two items have face validity as measures of risk of attrition but have not undergone explicit validation studies. We also
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measured true attrition as residents left training during the period of the study. Residents in the general surgery program (including preliminary residents going into orthopedics, plastic surgery, urology, neurosurgery and those who were non-
EP
designated preliminary residents; N=115) were invited to participate in the study in the
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spring of 2014 and the spring of 2015. Participants were recruited during mandatory department education meetings. Some participants responded to both surveys. Rather than including these individuals in analyses twice, we retained data from their first set of responses only.
Our analytic strategy was to combine data from all three types of residents (categorical general surgery, designated preliminary residents, and non-designated preliminary residents) for outcome measures which showed no differences by group. This
6
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was the case for all measures except for the item regarding likelihood of completing residency. On this item, non-designated preliminary residents had significantly lower scores than did either categorical general surgery or designated preliminary residents.
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Given that the non-designated preliminary residents had only temporary contracts, this would be expected. Analyses regarding this item included only categorical general surgery
analyses in Stata 10.1. Results
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Well-being
SC
and preliminary residents. Data were analyzed using correlations and linear regression
Seventy-three unique residents participated (63% response rate) in the study. Table 1 shows the demographic data for the participants. We first analyzed the descriptive data. We then sought to understand the relationship between grit and well-being. The
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relationships we found were consistent with our hypotheses. As shown in Figure 1, we found that there was a significant positive association between grit and general psychological well-being (r=0.30, p<0.05). Figures 2 and 3 show that there was a significant
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negative association between grit and the depersonalization scale of the MBI (r=-0.24,
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p=0.05) as well as the BDI (r=-0.25, p<0.05). There was no significant association between grit and the emotional exhaustion scale of the MBI (r=-0.21, p=.09). In regression analyses, controlling for age, gender, ethnicity, and marital status, we
found that grit was a significant positive predictor of general psychological well-being (B=0.77, t=2.96, p<0.01). Grit was not a significant predictor of depersonalization (B=-0.57, t=-1.33, p=0.19) or emotional exhaustion (B=-0.76, t=-1.82, p=0.08). Grit was significantly negatively predictive of depression (B=-0.28, t=-2.74, p<0.01). For both general
7
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psychological well-being and depression, gender was also a significant predictor (B=-0.59, t=-2.65, p<0.05; B=0.18, t=2.10, p<0.05) such that women were associated with lower general psychological well-being and higher levels of depression than men. (This
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association was only found in these regressions. Direct comparisons [t tests] did not reveal a significant difference in any well-being measure by gender.) The interaction terms (gender x grit) in the regressions were not significant, nor were any other variables.
SC
Attrition
We then evaluated the relationship between grit and risk of attrition as measured
M AN U
by our two survey items. We found a significant positive correlation between grit and how likely residents thought they were to complete their current residency (r=0.31, p<0.05) along with a significant negative correlation between grit and how often residents thought about leaving their residency (r=-0.37, p<0.01).
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In regression analyses controlling for age, gender, ethnicity, and marital status, we found that grit was not significantly predictive of likelihood of completing residency (B=0.49, t=1.81, p=0.08) but was significantly negatively predictive of frequency of
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thoughts of leaving residency (B=-0.99, t=-2.53, p<0.05). There was no statistically
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significant relationship between grit and true attrition (B=85.83, z=0.00, p=0.999). Interestingly, there was no statistically significant difference between those who quit and all other residents for grit (t=0.37, p=0.71), psychological well-being (t=-0.11, p=0.91), depersonalization (t=-0.66, p=0.51), emotional exhaustion (t=-0.40, p=0.69), depression (t=0.66, p=0.51), likelihood of completing residency (t=1.20, p=0.23), or frequency of thoughts of leaving (t=-1.96, p=0.055). Discussion
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The findings of this study are similar to prior data which have shown that grit is predictive of psychological health in surgical residents.13 Unlike the previous study, we did not find a significant relationship between grit and the emotional exhaustion subscale of
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the MBI. However, similar to the prior study we did find a significant negative relationship between grit and the depersonalization subscale of the MBI in correlational analyses.
Although this relationship was not persistent in regression analyses, this may be due to the
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smaller number of participants in this study. Further investigation will have to be done to see if this relationship exists and we did not detect it here or if, rather, there is no
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significant relationship between burnout and grit.
We found grit to be positively predictive of general psychological well-being and negatively predictive of depression as measured by the BDI. These findings are consistent with our previous data. The finding that gender is associated with psychological well-being
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and depression is new in this study and is of unclear significance. Population studies have shown no difference in general psychological well-being between men and women.17 Prior data has suggested that women are more prone to depression than men.19 However, more
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recent data suggests that this does not reflect a difference in the incidence of depression,
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rather that it is more likely to be diagnosed in women than in men.20 The absolute levels of psychological well-being and depression were not statistically different between men and women in this study. Thus, it is difficult to draw any meaningful conclusions without further data.
With regard to attrition, we found data supporting the idea that those with more grit are less likely to quit. This was true in the well-being data which suggests that those who have more grit have better well-being and may thus be at lower risk for attrition. This was
9
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also true for the questions assessing risk of attrition since we found that those with more grit were more likely to think they would complete their current residency. Those with more grit also thought about leaving their residency less often. While the relationship
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between grit and likelihood of completing residency was not significant in regression
analyses (p=0.08), the trend was in the expected direction. It is possible that with a larger number of participants grit would have been predictive of this outcome as well. Thus, it
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does seem that grit is associated with a lower risk of attrition, although it is hard to say whether this is a direct effect or is mediated by well-being. Admittedly, the two questions
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we used in the survey to assess risk of attrition are only an approximation and have not been validated.
There was not a significant relationship between grit and actual measured attrition. This is likely because of the small number of residents who have quit in this period of time
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(n=5). Although there were no statistically significant differences between these five and the remaining residents, there was a trend suggesting that those who left may have had more frequent thoughts of leaving. Longer studies with a larger number of participants will
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need to be done to determine whether this measure or grit can predict actual attrition.
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This study is limited by the fact that it was performed at a single institution. In addition, the small number of participants limits our ability to detect significant relationships among the variables. The most important limitation is the correlational nature of the study which prohibits any causal inferences. It has previously been suggested that grit might be a useful tool in identifying residents who may be at risk for poor well-being or possibly higher risk of attrition. However, we would caution against using grit as a high-stakes screening tool. As Dr.
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Duckworth, who developed the scale, has said, it was intended as a research tool, not for high-stakes decision making.21 Duckworth and Yeager have argued that the same is true for other non-cognitive assessments such as mindset (growth vs. fixed) and self-control.22
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Thus, we advocate that grit could potentially be used as an aid to identify individuals who may benefit from additional support as they strive to become surgeons. Conclusions
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This work extends our previous work on the relationship of grit and well-being. We found further evidence that there is an association such that more grit is associated with
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better well-being. We also found that those with more grit were less likely to have thoughts of leaving their current residency. We did not find a relationship between grit and true attrition. Further work is needed to try to understand whether there is a causal relationship between grit and well-being. In addition, it would be useful to design an
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causal in nature.
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intervention aimed at improving grit to determine whether the observed relationships are
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Acknowledgements
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We would like to thank Jennifer Tran for her assistance in collecting data for this study.
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References 1. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014; 89(3): 443-451.
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2. Antiel RM, Reed DA, Van Arendonk KJ, et al. Effects of Duty Hour Restrictions on Core Competencies, Education, Quality of Life, and Burnout Among General Surgery Interns. JAMA Surg. 2013 May; 148(5): 448-55.
States. Surg Clin N Am. 2007; 87: 811-823.
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3. Bell RH, Banker MB, Rhodes RS, et al. Graduate medical education in surgery in the United
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4. Kennedy KA, Brennan MC, Rayburn WF, Brotherton SE. Attrition rates between residents in obstetrics and gynecology and other clinical specialties, 2000-2009. J Grad Med Educ. 2013 Jun; 5(2): 267-71.
5. Longo WE, Seashore J, Duffy A, Udelsman R. Attrition of categoric general surgery residents:
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Results of a 20-year audit. Am J Surg. 2009; 197(6): 774-8.
6. Yeo H, Bucholz E, Sosa JA, et al. A National Study of Attrition in General Surgery Training Which Residents Leave and Where Do They Go? Ann Surg. 2010 Sep; 252(3): 529-36.
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7. Longo WE. Attrition: Our biggest continuing challenge. Am J Surg. 2007; 194: 567-575. 8. Gifford E, Galante J, Kaji AH, et al. . Factors Associated With General Surgery Residents'
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Desire to Leave Residency Programs: A Multi-institutional Study (vol 149, pg 948, 2014). JAMA Surg. 2014 Oct; 149(10): 948-953. 9. Danna K, Griffin RW. Health and Well-being in the Workplace. A Review and Synthesis of the Literature. J Manage. 1999; 25(3): 357-384. 10. Harter JK, Schmidt FL, Keyes CL. Well-being in the workplace and its relationship to business outcomes: A review of the Gallup studies. In Keyes CL and Haidt J, editors.
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Flourishing: The positive person and the good life. Washington, D.C.: American Psychological Association; 2002. p. 205-224.
lead to success? Psych Bull. 2005; 131: 803-855.
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11. Lyubomirsky S, King L, Diener E. The benefits of frequent positive affect: Does happiness
12. Duckworth AL, Peterson C, Matthews MD, Kelly DR. Grit: Perseverance and passion for long-term goals. J Pers Soc Psych. 2007; 9: 1087-1101.
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13. Salles A, Cohen GL, Mueller CM. The relationship between grit and resident well-being. Am J Surg, 2014; 207(2): 251-254.
Pers Ass, 2009; 91: 166-174.
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14. Duckworth AL, Quinn PD. Development and validation of the Short Grit Scale (Grit-S). J
15. Maslach C, Jackson SE. The measurement of experienced burnout. J Occ Behav. 2001; 2: 99113.
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16. Maslach C, Jackson SE. Maslach Burnout Inventory—Human Services Survey (MBI-HSS). In Maslach C, Jacskon SE, Leiter MP, editors. MBI manual (3rd ed.), Mountain View, CA: CPP, Inc; 1996.
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17. Dupuy HJ. The psychological general well-being index. In Wenger NK, Mattson ME, Furburg CD, Elinson J, editors. Assessment of quality of life in clinical trials of cardiovascular
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therapies; 1984. p. 170-183.
18. Beck AT, Rial WY, Rickels K. Short form of depression inventory: Cross-validation. Psych Rep, 1974; 34: 1184-1186.
19. Blazer DG, Kessler RC, McGonagle KA, Swartz MS. The prevalence and distribution of major depression in a national community sample: The National Comorbidity Sample. Am J Psych, 1994; 151(7): 979-986.
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20. Martin LA, Neighbors HW, Griffith DM. The experience of symptoms of depression in men vs. women: Analysis of the National Comorbidity Survey replication. JAMA Psych, 2013; 70(10): 1100-1106.
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21. Duckworth A. Don’t grade schools on grit. New York Times. 2016 Mar 27; page SR5.
Accessed online at http://www.nytimes.com/2016/03/27/opinion/sunday/dont-grade-schools-ongrit.html?_r=0 on 3/29/2016.
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22. Duckworth A, Yeager DS. Measurement matters: Assessing personal qualities other than
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cognitive ability for educational purposes. Educ Res, 2015; 44(4): 237-251.
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Table 1. Demographic data.* Gender Number (%) Male 42 (58) Female 31 (42) Post-graduate year (PGY) PGY 1 45 (62) PGY 2 10 (14) PGY 3 9 (12) PGY 4 4 (5) PGY 5 2 (3) Research 3 (4) Marital Status Married 27 (42) Widowed 0 (0) Divorced 3 (5) Separated but married 0 (0) Single, never married 34 (53) Ethnicity White 33 (52) Black or African-American 1 (2) Hispanic or Latino 3 (5) Native American 0 (0) Middle Eastern 0 (0) Asian/Pacific Islander 23 (37) Mixed Race 3 (5) Other 0 (0) Specialty Categorical General Surgery 32 (52) Designated Preliminary Resident 22 (36) Non-Designated Preliminary 7 (11) Resident *Not all totals add up to 73 because not all participants answered all demographic questions
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Figure 1. The relationship between grit and psychological well-being. Figure 2. The relationship between grit and depersonalization.
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Figure 3. The relationship between grit and depression.
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S0002-9610(16)30927-8
DOI:
10.1016/j.amjsurg.2016.10.012
Reference:
AJS 12179
To appear in:
The American Journal of Surgery
Received Date: 5 April 2016 Revised Date:
2 September 2016
Accepted Date: 20 October 2016
Please cite this article as: Salles A, Lin D, Liebert C, Esquivel M, Lau JN, Greco RS, Mueller C, Grit as a predictor of risk of attrition in surgical residency, The American Journal of Surgery (2016), doi: 10.1016/ j.amjsurg.2016.10.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Grit as a Predictor of Risk of Attrition in Surgical Residency Authors: Arghavan Salles, MD, PhD1, 2
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Dana Lin, MD1 Cara Liebert, MD1 Micaela Esquivel, MD1
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James N. Lau, MD1
Claudia Mueller, PhD, MD1 Corresponding Author: Arghavan Salles, MD, PhD Telephone: (650) 387-5275
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Ralph S. Greco, MD1
1Stanford
Health Care
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Email: [email protected]
300 Pasteur Drive, MC H3591
author’s current address:
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2Corresponding
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Stanford, CA 94305
Washington University in St. Louis Department of Surgery 660 S. Euclid Box 8109 St. Louis, MO 63110
None of the authors have relevant financial disclosures to report
1
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Abstract Background: Grit, a measure of perseverance, has been shown to predict resident wellbeing. In this study we assess the relationship between grit and attrition.
RI PT
Methods: We collected survey data from residents in a single institution over two
consecutive years. All residents in general surgery were invited to participate (N=115). Grit and psychological well-being were assessed using validated measures. Risk of attrition was
SC
measured using survey items.
Results: 73 residents participated (63% response rate). Grit was positively correlated with
M AN U
general psychological well-being (r=0.30, p<0.05) and inversely correlated with depression (r=-0.25, p<0.05) and risk of attrition (r=-0.37, p<0.01). In regression analyses, grit was positively predictive of well-being (B=0.77, t=2.96, p<0.01) and negatively predictive of depression (B=-0.28 t=-2.74, p<0.01) and attrition (B=-0.99, t=-2.53, p<0.05).
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Conclusions: Attrition is a costly and disruptive problem in residency. Grit is a quick,
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study.
EP
reliable measure which appears to be predictive of attrition risk in this single institution
2
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Summary This study examines the relationship between grit, a measure of perseverance, and resident well-being as well as attrition. The key findings are that grit is positively
RI PT
associated with better psychological well-being and negatively associated with risk of
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EP
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M AN U
SC
attrition.
3
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Keywords: grit, attrition, well-being, depression, burnout
4
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Introduction Surgical residency is a stressful and grueling period in medical training. Surgery residents experience burnout and depression to a greater degree than do members of the
RI PT
general public.1 The long hours,2 lack of control over one’s schedule, and acuity of patients are all factors that may make residency training particularly challenging. For these and other reasons, the attrition rate in general surgery is higher than that of other specialties at
SC
approximately 20%.3-6
Attrition is costly to both individuals and the programs in which they matriculate.7
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Previous research has shown that fatigue8 and poor well-being, such as depression, may be contributors to attrition.9-10 Specifically, those who have more positive feelings are less likely to quit their jobs and experience burnout.10-11 Conversely, workplace stress is associated with absenteeism and reduced productivity.9 Thus, it may be that improving
TE D
resident well-being can improve retention.
Grit, defined as perseverance and passion for long-term goals,12 may also be associated with lower rates of attrition. This could happen in two ways. First, previous data
EP
has suggested that grit is positively associated with psychological well-being13 which may
AC C
thus in turn be associated with lower rates of attrition. Second, grit may directly make it less likely that someone would quit residency. In this study, we aim to understand whether grit, in and of itself, may be a predictor
of one’s desire to quit residency. In addition, we aim to replicate prior findings that have shown a positive correlation between grit and psychological well-being. We hypothesize that grit will be positively associated with psychological well-being and that it will be a predictor of risk of attrition.
5
ACCEPTED MANUSCRIPT
Materials & Methods After obtaining approval from the Stanford University Institutional Review Board, in the context of a larger longitudinal study we administered a survey to assess residents’
RI PT
perseverance, burnout, psychological well-being, depression, and risk of attrition. The Short Grit Scale14 was used to measure perseverance. Burnout was measured using the Maslach Burnout Inventory (MBI).15-16 Psychological well-being was measured using the
SC
Dupuy Psychological General Well-Being (PGWB) scale.17 Depression was measured using the short form of the Beck Depression Inventory (BDI).18 Risk of attrition was measured
M AN U
using two items: “At this point in time, how likely is it that you will complete residency training in your current specialty?” and “In the past month, how often have you thought about leaving your current residency program?” These two items have face validity as measures of risk of attrition but have not undergone explicit validation studies. We also
TE D
measured true attrition as residents left training during the period of the study. Residents in the general surgery program (including preliminary residents going into orthopedics, plastic surgery, urology, neurosurgery and those who were non-
EP
designated preliminary residents; N=115) were invited to participate in the study in the
AC C
spring of 2014 and the spring of 2015. Participants were recruited during mandatory department education meetings. Some participants responded to both surveys. Rather than including these individuals in analyses twice, we retained data from their first set of responses only.
Our analytic strategy was to combine data from all three types of residents (categorical general surgery, designated preliminary residents, and non-designated preliminary residents) for outcome measures which showed no differences by group. This
6
ACCEPTED MANUSCRIPT
was the case for all measures except for the item regarding likelihood of completing residency. On this item, non-designated preliminary residents had significantly lower scores than did either categorical general surgery or designated preliminary residents.
RI PT
Given that the non-designated preliminary residents had only temporary contracts, this would be expected. Analyses regarding this item included only categorical general surgery
analyses in Stata 10.1. Results
M AN U
Well-being
SC
and preliminary residents. Data were analyzed using correlations and linear regression
Seventy-three unique residents participated (63% response rate) in the study. Table 1 shows the demographic data for the participants. We first analyzed the descriptive data. We then sought to understand the relationship between grit and well-being. The
TE D
relationships we found were consistent with our hypotheses. As shown in Figure 1, we found that there was a significant positive association between grit and general psychological well-being (r=0.30, p<0.05). Figures 2 and 3 show that there was a significant
EP
negative association between grit and the depersonalization scale of the MBI (r=-0.24,
AC C
p=0.05) as well as the BDI (r=-0.25, p<0.05). There was no significant association between grit and the emotional exhaustion scale of the MBI (r=-0.21, p=.09). In regression analyses, controlling for age, gender, ethnicity, and marital status, we
found that grit was a significant positive predictor of general psychological well-being (B=0.77, t=2.96, p<0.01). Grit was not a significant predictor of depersonalization (B=-0.57, t=-1.33, p=0.19) or emotional exhaustion (B=-0.76, t=-1.82, p=0.08). Grit was significantly negatively predictive of depression (B=-0.28, t=-2.74, p<0.01). For both general
7
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psychological well-being and depression, gender was also a significant predictor (B=-0.59, t=-2.65, p<0.05; B=0.18, t=2.10, p<0.05) such that women were associated with lower general psychological well-being and higher levels of depression than men. (This
RI PT
association was only found in these regressions. Direct comparisons [t tests] did not reveal a significant difference in any well-being measure by gender.) The interaction terms (gender x grit) in the regressions were not significant, nor were any other variables.
SC
Attrition
We then evaluated the relationship between grit and risk of attrition as measured
M AN U
by our two survey items. We found a significant positive correlation between grit and how likely residents thought they were to complete their current residency (r=0.31, p<0.05) along with a significant negative correlation between grit and how often residents thought about leaving their residency (r=-0.37, p<0.01).
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In regression analyses controlling for age, gender, ethnicity, and marital status, we found that grit was not significantly predictive of likelihood of completing residency (B=0.49, t=1.81, p=0.08) but was significantly negatively predictive of frequency of
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thoughts of leaving residency (B=-0.99, t=-2.53, p<0.05). There was no statistically
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significant relationship between grit and true attrition (B=85.83, z=0.00, p=0.999). Interestingly, there was no statistically significant difference between those who quit and all other residents for grit (t=0.37, p=0.71), psychological well-being (t=-0.11, p=0.91), depersonalization (t=-0.66, p=0.51), emotional exhaustion (t=-0.40, p=0.69), depression (t=0.66, p=0.51), likelihood of completing residency (t=1.20, p=0.23), or frequency of thoughts of leaving (t=-1.96, p=0.055). Discussion
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The findings of this study are similar to prior data which have shown that grit is predictive of psychological health in surgical residents.13 Unlike the previous study, we did not find a significant relationship between grit and the emotional exhaustion subscale of
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the MBI. However, similar to the prior study we did find a significant negative relationship between grit and the depersonalization subscale of the MBI in correlational analyses.
Although this relationship was not persistent in regression analyses, this may be due to the
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smaller number of participants in this study. Further investigation will have to be done to see if this relationship exists and we did not detect it here or if, rather, there is no
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significant relationship between burnout and grit.
We found grit to be positively predictive of general psychological well-being and negatively predictive of depression as measured by the BDI. These findings are consistent with our previous data. The finding that gender is associated with psychological well-being
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and depression is new in this study and is of unclear significance. Population studies have shown no difference in general psychological well-being between men and women.17 Prior data has suggested that women are more prone to depression than men.19 However, more
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recent data suggests that this does not reflect a difference in the incidence of depression,
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rather that it is more likely to be diagnosed in women than in men.20 The absolute levels of psychological well-being and depression were not statistically different between men and women in this study. Thus, it is difficult to draw any meaningful conclusions without further data.
With regard to attrition, we found data supporting the idea that those with more grit are less likely to quit. This was true in the well-being data which suggests that those who have more grit have better well-being and may thus be at lower risk for attrition. This was
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also true for the questions assessing risk of attrition since we found that those with more grit were more likely to think they would complete their current residency. Those with more grit also thought about leaving their residency less often. While the relationship
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between grit and likelihood of completing residency was not significant in regression
analyses (p=0.08), the trend was in the expected direction. It is possible that with a larger number of participants grit would have been predictive of this outcome as well. Thus, it
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does seem that grit is associated with a lower risk of attrition, although it is hard to say whether this is a direct effect or is mediated by well-being. Admittedly, the two questions
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we used in the survey to assess risk of attrition are only an approximation and have not been validated.
There was not a significant relationship between grit and actual measured attrition. This is likely because of the small number of residents who have quit in this period of time
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(n=5). Although there were no statistically significant differences between these five and the remaining residents, there was a trend suggesting that those who left may have had more frequent thoughts of leaving. Longer studies with a larger number of participants will
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need to be done to determine whether this measure or grit can predict actual attrition.
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This study is limited by the fact that it was performed at a single institution. In addition, the small number of participants limits our ability to detect significant relationships among the variables. The most important limitation is the correlational nature of the study which prohibits any causal inferences. It has previously been suggested that grit might be a useful tool in identifying residents who may be at risk for poor well-being or possibly higher risk of attrition. However, we would caution against using grit as a high-stakes screening tool. As Dr.
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Duckworth, who developed the scale, has said, it was intended as a research tool, not for high-stakes decision making.21 Duckworth and Yeager have argued that the same is true for other non-cognitive assessments such as mindset (growth vs. fixed) and self-control.22
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Thus, we advocate that grit could potentially be used as an aid to identify individuals who may benefit from additional support as they strive to become surgeons. Conclusions
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This work extends our previous work on the relationship of grit and well-being. We found further evidence that there is an association such that more grit is associated with
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better well-being. We also found that those with more grit were less likely to have thoughts of leaving their current residency. We did not find a relationship between grit and true attrition. Further work is needed to try to understand whether there is a causal relationship between grit and well-being. In addition, it would be useful to design an
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causal in nature.
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intervention aimed at improving grit to determine whether the observed relationships are
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Acknowledgements
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We would like to thank Jennifer Tran for her assistance in collecting data for this study.
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References 1. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014; 89(3): 443-451.
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2. Antiel RM, Reed DA, Van Arendonk KJ, et al. Effects of Duty Hour Restrictions on Core Competencies, Education, Quality of Life, and Burnout Among General Surgery Interns. JAMA Surg. 2013 May; 148(5): 448-55.
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3. Bell RH, Banker MB, Rhodes RS, et al. Graduate medical education in surgery in the United
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20. Martin LA, Neighbors HW, Griffith DM. The experience of symptoms of depression in men vs. women: Analysis of the National Comorbidity Survey replication. JAMA Psych, 2013; 70(10): 1100-1106.
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21. Duckworth A. Don’t grade schools on grit. New York Times. 2016 Mar 27; page SR5.
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cognitive ability for educational purposes. Educ Res, 2015; 44(4): 237-251.
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Table 1. Demographic data.* Gender Number (%) Male 42 (58) Female 31 (42) Post-graduate year (PGY) PGY 1 45 (62) PGY 2 10 (14) PGY 3 9 (12) PGY 4 4 (5) PGY 5 2 (3) Research 3 (4) Marital Status Married 27 (42) Widowed 0 (0) Divorced 3 (5) Separated but married 0 (0) Single, never married 34 (53) Ethnicity White 33 (52) Black or African-American 1 (2) Hispanic or Latino 3 (5) Native American 0 (0) Middle Eastern 0 (0) Asian/Pacific Islander 23 (37) Mixed Race 3 (5) Other 0 (0) Specialty Categorical General Surgery 32 (52) Designated Preliminary Resident 22 (36) Non-Designated Preliminary 7 (11) Resident *Not all totals add up to 73 because not all participants answered all demographic questions
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Figure 1. The relationship between grit and psychological well-being. Figure 2. The relationship between grit and depersonalization.
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Figure 3. The relationship between grit and depression.
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