- Email: [email protected]
What a Shame: Increased Rates of OMS Resident Burnout May Be Related to the Frequency of Shamed Events During Training
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ANESTHESIA/FACIAL PAIN
What a Shame: Increased Rates of OMS Resident Burnout May Be Related to the Frequency of Shamed Events During Training Michael C. Shapiro, DDS, MA,* Sowmya R. Rao, PhD,y Jason Dean, MD,z and Andrew R. Salama, DDS, MDx
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Purpose:
Shame is an ineffective tool in residency education that often results in depression, isolation, and worse patient care. This study aimed to assess burnout, depersonalization, and personal achievement levels in current oral and maxillofacial surgery (OMS) residents, to assess the prevalence of the use of shame in OMS residency training, and to determine whether there is a relation between shame exposure and resident burnout, depersonalization, and personal achievement levels.
Materials and Methods:
An anonymous 20-question cross-sectional survey was developed incorporating the Maslach Burnout Index and a previously validated shame questionnaire and sent to all OMS program directors affiliated with the American Association of Oral and Maxillofacial Surgeons for distribution among their respective residents in 2016. Univariate analyses were used to determine the distribution of the predictor (shame) and outcome (burnout) by gender and by frequency of shaming events. Multivariable logistic regression analysis was used to assess the relation of shame to burnout. A 2-sided P value less than .05 was considered statistically significant.
Results:
Two hundred seventeen responses were received; 82% of respondents were men (n = 178), 95% were 25 to 34 years old (n = 206), and 58% (n = 126) were enrolled in a 4-year program. Frequently shamed residents were more likely to have depression (58 vs 22%; P < .0001), isolation (55 vs 22%; P < .0001), and poor job performance (50 vs 30%; P < .0001). Residents who were frequently shamed were more likely to experience moderate to severe burnout (odds ratio = 4.6; 95% confidence interval, 2.1-10.0; P < .001) and severe depersonalization (odds ratio = 5.1; 95% confidence interval, 2.1-12.0; P < .0001) than residents who had never or infrequently been shamed.
Conclusion:
There is a clear relation between the number of shame events and burnout and depersonalization levels. It is important to understand the negative impact that the experience of shame has on residents, including its unintended consequences. Ó 2016 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-9, 2016
*Resident, Department of Oral and Maxillofacial Surgery, Boston
Address correspondence and reprint requests to Dr Shapiro:
Medical Center and Boston University School of Dental Medicine,
Department of Oral and Maxillofacial Surgery, Boston Medical
Boston, MA.
Center, 100 East Newton Street, Suite G-407, Boston, MA 02118;
ySenior Statistician, Department of Surgery, Boston University
e-mail: [email protected]
Medical Center, and MGH Biostatistics Center, Massachusetts
Received April 26 2016
General Hospital, Boston, MA.
Accepted August 24 2016
zResident, Department of Psychiatry, Brigham and Women’s
Ó 2016 Published by Elsevier Inc on behalf of the American Association of Oral
Hospital and Harvard Medical School, Boston, MA. xResidency Director, Department of Oral and Maxillofacial
and Maxillofacial Surgeons
Surgery, Boston Medical Center; Assistant Professor, Boston
http://dx.doi.org/10.1016/j.joms.2016.08.040
0278-2391/16/30774-1
University School of Dental Medicine, Boston, MA. This report has been accepted for publication as an oral abstract and will be presented at the 98th Annual Meeting of the American Association of Oral and Maxillofacial Surgeons.
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RESIDENT BURNOUT AND RATE OF SHAMED EVENTS
Emotional burnout, depersonalization, and lack of selfconfidence are common during residency training. These factors have been studied and quantified by Maslach et al.1 Maslach et al defined burnout as a syndrome involving chronic fatigue, emotional exhaustion, and fatigue at the very idea of work. Depersonalization was defined as a ‘‘dehumanization in interpersonal relations,’’ in which the clinician becomes detached from others. In depersonalization, the clinician experiences a lack of empathy for patients, guilt, and withdraws from social contact. If unaddressed, burnout and depersonalization can lead to a perceived decrease in personal achievement, in which the clinician doubts his or her abilities and capacity for success. The available literature on burnout in residency education involves residents in internal medicine, anesthesiology, surgery, orthopedic surgery, and family practice.2-11 Several studies have found high rates of burnout, depersonalization, and depression among residents. Campbell et al11 found that 78% of medical residents experienced at least 1 episode of burnout during training. A survey of general surgery residents found that 28% reported weekly experiences of depersonalization, 28% reported weekly feelings of emotional exhaustion, 32% noted a personal-andprofessional balance that was ‘‘very poor’’ or ‘‘not great,’’ 67% reported reflecting on satisfaction from being a surgeon at least weekly, and 1 in 7 considered leaving their residency at least once a week.12 The Intern Health Study by Sen et al13 followed a cohort of internal medicine interns and found that the prevalence of a major depressive episode during the intern year was approximately 20%. Although the Accreditation Council for Graduate Medical Education implemented duty hour restrictions in 2011 to address the alarmingly high rates of burnout and depression in residency, these changes do not appear to have improved quality of life. In fact, Sen et al14 surveyed a new cohort of internal medicine residents training after the duty hour changes and found no meaningful improvement in depressive symptoms or well-being. The persistence of burnout and depression implies that, in addition to the quantitative factor of the number of hours worked, one must address the qualitative factors of residency training that affect quality of life. It might not be the number of hours worked that causes burnout, but rather the psychological effects of residency and its effects on interpersonal relationships.15 In particular, experiences of shame and humiliation during residency also have been found to affect quality of life and well-being. In a recent study, McMains et al16 surveyed otolaryngology residents and found that 50% of residents had been shamed by senior
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residents or attendings. They also found that exposure to shame resulted in increased rates of depression, decreased self-confidence, and led to decreased job performance. The purpose of this study was to answer 3 specific questions. First, what is the prevalence of burnout, depersonalization, and decreased personal achievement as defined by the Maslach Burnout Index (MBI) in current oral and maxillofacial surgery (OMS) residents? Second, what is the prevalence of shame and humiliation as an educational tool in current OMS residents according to a previously validated shame questionnaire? Third, what is the association, if any, between shame exposure and resident burnout?
Materials and Methods STUDY DESIGN AND SAMPLE
The research proposal was approved by the institutional review board of Boston University (Boston, MA). To address the research purpose, the authors designed and implemented a 20-question survey using the Qualtrics (https://www.qualtrics.com/) online platform incorporating the MBI and a previously validated shame questionnaire16 and emailed it to oral and maxillofacial program directors affiliated with the American Association of Oral and Maxillofacial Surgeons (AAOMS) for distribution among their respective residents. The initial email request was followed by 1 additional email encouraging participation, and the survey link was available for completion for a total of 30 days. Survey responses were completely anonymous. The study population was composed of all trainees attending AAOMS-affiliated OMS training programs. To be included in the study, subjects had to be enrolled in an AAOMS-affiliated OMS training program in the United States or its territories. Respondents were excluded as study subjects if their survey consisted of incomplete responses to any question other than demographic data. STUDY VARIABLES
The primary predictor variable was the number of perceived shamed events, which was divided into 3 groups (0, 1 to 5, and >5 shamed events; Table 1). The shame questionnaire developed by McMains Q2 et al16 was used to assess the perception of shame. The questionnaire consists of 14 questions that assess the perception of, and effects stemming from, shame and humiliation. Content validity was established by a modified subject matter expert rater method, and this survey has been used to assess shame in otolaryngology resident training programs in the United States.16,17 Shame was defined and limited to Q3
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SHAPIRO ET AL
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Table 1. DISTRIBUTION OF STUDY VARIABLES VERSUS THE PREDICTOR VARIABLE
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Number of Shamed Events, n (%Col) Variable Age in categories
Gender Program, level of training
Categories
0
1-5
>5
1. 25-34 yr 2. 35-44 yr 3. 45-54 yr 1. women 2. men 1. 4-yr program, first year 2. 4-yr program, second and third years 3. 4-yr program, fourth year 4. 6-yr program, first year 5. 6-yr program, second to fourth years 6. 6-yr program, fifth and sixth years
65 (98.5) 1 (1.5) 0 (0.0) 15 (22.7) 51 (77.3) 11 (16.4) 15 (22.4)
83 (94.3) 5 (5.7) 0 (0.0) 10 (11.4) 78 (88.6) 15 (17.2) 30 (34.5)
58 (93.5) 3 (4.8) 1 (1.6) 13 (21.0) 49 (79.0) 8 (13.1) 21 (34.4)
9 (13.4) 4 (6.0) 19 (28.4)
7 (8.0) 7 (8.0) 17 (19.5)
10 (16.4) 3 (4.9) 7 (11.5)
9 (13.4)
11 (12.6)
12 (19.7)
P Value
.3734
.1325 .3358
Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
banishment from the operating room, being yelled at, being called names, being called ‘‘stupid,’’ or being threatened. No other behaviors were included as shame behaviors in this study. STUDY OUTCOMES
The primary outcome variable was burnout, which was determined using the MBI. The MBI is a validated 22-item questionnaire that is generally considered the gold standard measurement for burnout.18 The inventory asks respondents to indicate on a 7-point Likert scale the frequency with which they experience certain feelings related to their work. The MBI evaluates 3 domains of burnout: 1) emotional exhaustion, which is measured with a subscale of 9 items (eg, ‘‘I feel emotionally drained from my work’’); 2) depersonalization, which is measured with a subscale of 5 items (eg, ‘‘I feel I look after certain patients/clients impersonally, as if they are objects’’); and 3) personal accomplishment, which is measured with 8 items (eg, ‘‘I accomplish many worthwhile things in this job’’). Based on the MBI responses, independent subscale scores were calculated for each of the 3 domains of burnout (mild, moderate, and severe).
years) and was used this for analysis where possible because of the sample size constraints. Bivariate analysis were conducted to test whether shaming, burnout, depersonalization, and personal achievement levels varied meaningfully by gender (men vs women), program type and level of training (4-yr program, first year; 4-yr program, second and third years; 4-yr program, fourth year; 6-yr program, first year; 6-yr program, second to fourth years; 6-yr program, fifth and sixth years), and the intensity of shaming events (0, 1 to 5, and >5) using the Fisher exact test. Similar analyses were conducted to assess the relation of shame to burnout, depersonalization, and personal achievement. Furthermore, odds ratios (ORs) and 95% confidence intervals (CIs) were obtained from multivariable logistic regression models to evaluate the association of shame to moderate to severe burnout, personal achievement, and severe depersonalization accounting for gender, number of shamed events, and program and level of training. For the model to predict severe depersonalization, the model included the program (4 or 6 yr) instead of program and level of training owing to small samples. A 2-sided P value less than .05 was considered significant.
OTHER VARIABLES
The other variables of interest included age, gender (men vs women), program type (4 vs 6 year program), and level of training (by postgraduate year). STATISTICAL ANALYSES
A variable was created that combined program type (4 vs 6 yr) and postgraduate year (first to sixth
Results In total, 217 responses were eligible for inclusion in the study. Responses were received from 29 of 37 states or territories that possess an OMS training program. The male-to-female response ratio was 82:18, which closely approximates the actual 85:15 ratio of current OMS residents.17 Seven percent of
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RESIDENT BURNOUT AND RATE OF SHAMED EVENTS
shame event (Fig 5) had decreased self-esteem (P < .0001) and were significantly more likely to have isolation (P < .001) and depression (P = .037). Regarding resident burnout, 51% of OMS residents had moderate to severe emotional exhaustion, 85.7% had moderate to severe depersonalization, and 53% had moderate to severe feelings of inefficacy (Fig 6). There was no statistically meaningful difference in the burnout rates of male and female respondents. Residents who were frequently shamed (>5 shame events) were more likely to experience moderate to severe burnout (OR = 4.6; 95% CI, 2.1-10.0; P < .001; Table 3) and severe depersonalization (OR = 5.1; 95% CI, 2.1-12.0; P < .0001) than residents who were shamed less frequently or never shamed.
respondents stated that shame was a necessary or effective tool, 70% of respondents stated that they had been shamed during residency, and 82% reported witnessing the shaming of a fellow resident. Eighty percent of residents reported that an attending performed the shaming, and the most common location for a shame event was the operating room (67%). There was no statistically relevant difference in shame rates between male and female respondents (Table 2). When residents were frequently shamed (Figs 1-4), they were more likely to be shamed because of surgical error (41 vs 19%; P < .001), incorrect response to questioning (84 vs 66%; P < .01), and disagreement regarding clinical care (58 vs 28%; P < .001). They also were more likely to have depression (58 vs 22%; P < .0001), isolation (55 vs 22%; P < .0001), and poor job performance (50 vs 30%; P < .0001). In addition, residents who were frequently shamed were more likely to report having been shamed by a senior-level resident (76 vs 50%; P < .01). Those who were exposed to fewer than 5 shame events were more likely to report that the shame event had no effect on them (33 vs 18%; P < .05). Women who were exposed to just a single
Discussion The purpose of the present study was to assess burnout, depersonalization, and personal achievement levels in current OMS residents, to assess the prevalence of burnout in current OMS residents, to assess the prevalence of shame and humiliation as an educational tool in current OMS residents, and model
Table 2. DISTRIBUTION OF STUDY VARIABLES AND NUMBER OF SHAMED EVENTS BY OUTCOMES
Outcomes, n (%) Burnout
Variable
Moderate to High Level
Age (yr) 25-34 106 (96.4) 35-44 3 (2.7) 45-54 1 (0.9) Gender Women 22 (20.0) Men 88 (80.0) Program/level of training 4 yr/first year 24 (22.0) 4 yr/second and 29 (26.6) third years 4 yr/fourth year 14 (12.8) 6 yr/first year 9 (8.3) 6 yr/second to 18 (16.5) fourth years 6 yr/fifth and 15 (13.8) sixth years Number of shamed events 0 26 (23.6) 1-5 39 (35.5) >5 45 (40.9)
Low Level
Depersonalization P Value
High Level
Low to Moderate Level
100 (94.3) 135 (97.1) 6 (5.7) .3257 3 (2.2) 0 (0.0) 1 (0.7)
70 (92.1) 6 (7.9) 0 (0.0)
16 (15.1) 28 (20.1) 90 (84.9) .3755 111 (79.9)
10 (13.2) 66 (86.8)
10 (9.4) 37 (34.9)
26 (18.8) 40 (29.0)
8 (10.5) 26 (34.2)
12 (11.3) .0980 5 (4.7) 25 (23.6)
19 (13.8) 11 (8.0) 24 (17.4)
7 (9.2) 3 (3.9) 19 (25.0)
17 (16.0)
18 (13.0)
13 (17.1)
41 (38.3) 49 (45.8) .0002 17 (15.9)
35 (25.2) 51 (36.7) 53 (38.1)
31 (40.3) 37 (48.1) 9 (11.7)
Personal Achievement P Value
.0703
.2620
.2663
<.0001
Moderate to High Level
Low Level
P Value
111 (96.5) 3 (2.6) 1 (0.9)
90 (93.8) 6 (6.3) .3056 0 (0.0)
25 (21.7) 90 (78.3)
12 (12.5) 84 (87.5) .1016
16 (14.0) 38 (33.3)
16 (16.7) 28 (29.2)
16 (14.0) 7 (6.1) 21 (18.4)
10 (10.4) .9224 7 (7.3) 20 (20.8)
16 (14.0)
15 (15.6)
27 (23.5) 47 (40.9) 41 (35.7)
37 (38.1) 39 (40.2) .0262 21 (21.6)
Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
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FIGURE 1. Shame-provoking event (by number of shamed events). Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
the risk of burnout as a sequela of shame, if such an association indeed exists. The authors hypothesized that residents who were exposed to an increased number of shamed events would have a higher burnout rate than those who were shamed less frequently.
Multivariable logistic regression analyses showed that frequently shamed residents were more likely to experience moderate to severe burnout and severe depersonalization than residents who were shamed less frequently or never shamed.
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SHAPIRO ET AL
FIGURE 2. Shaming environment (by number of shamed events). Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
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RESIDENT BURNOUT AND RATE OF SHAMED EVENTS
FIGURE 3. Person responsible for shaming (by number of shamed events). Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
This study documents a persistent culture of ‘‘individually oriented shame and blame’’ in residency education,19 and the results of this study suggest that there is prevalent use of shame as an educational tool in OMS training. Incorrect response to questioning and disagreement regarding clinical care were the most commonly cited reasons for shaming a resident, and as the frequency of shaming increased, residents experienced increased rates of depression, isolation, and poor job performance. The results of this study suggest that women are more likely to respond with isolation and depression to a shamed event. The results of this study also suggest that attendings and senior-level OMS residents are responsible for the performance of shaming events.
Eighty-two percent of respondents witnessed the shaming of a colleague, and nearly 70% experienced at least 1 shame event. These figures are substantially increased when compared with a study of shame prevalence among otolaryngology residents (70 and 50%, respectively); however, a mere 7% of ear, nose, and throat and OMS residents believed that shame was a useful or effective tool in residency training, indicating a near universal rejection of the use of shame in residency training.16 According to some, shame is the emotional response to a feeling of personal defect or failure.19 Throughout development, each individual internalizes a personal ideal, and when an individual fails to live up to that personal ideal, the response is a feeling of shame. This state of deficiency and failure is experienced subjectively as emotional depletion, fatigue, and a lack of empathy. The depletion of the self causes a pervasive feeling of emptiness and lack of vitality, which can lead to what has been called ‘‘guiltless depression.’’20 The psychological understanding of shame as the subjective experience of a defective and depleted self correlates with the concepts of burnout, depersonalization, and lack of personal achievement described by Maslach et al.16 These entities represent 3 areas of functioning that are affected by a depleted sense of self. Interestingly, experiencing shame even a few times among the thousands of interactions with superiors has a dramatic effect on subjective quality of life. In the free-text responses, many residents reported a constant feeling of dread related to the fear of being shamed, including a ‘‘fear of impending doom
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FIGURE 4. Result of shaming (by number of shamed events). Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
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FIGURE 5. Result of shaming (by gender). Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
when walking into the hospital.’’ An important implication of the data is that even 1 experience of shame, or even seeing a colleague shamed, can lead to a pervasive feeling of shame and deficiency despite thousands of neutral or even positive interactions. Repeated exposure to shaming results in high levels of moderate to severe burnout and severe depersonalization (Tables 2,3, Fig 6). To defend against the painful reality of work, residents dissociate and ‘‘check out.’’ Although in the short term dissociation might mitigate the pain of fully engaging in work, in the long term it leads to a secondary lack of vitality, emotional burnout, and depression. This phenomenon also could explain the considerable decrease in self-esteem, in addition to the isolation, depression, and worse job performance, found in residents exposed to repeated shame events (Fig 4). As 1
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SHAPIRO ET AL
FIGURE 6. Distribution of burnout (by number of shamed events). Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
respondent wrote, ‘‘I feel like I can’t do anything correctly. I have minimal confidence in myself, my surgical skills, my didactic knowledge, and it affects my psyche daily.’’ Dissociation as a defense against shame also might explain the finding that residents with mild shame (1 to 5 events) were more likely to report that shame had no effect on them (Fig 4). Low levels of shame might lead to dissociation, in which the painful effects of shame are minimized through the narrative of ‘‘I don’t care.’’ In contrast, severe shame is so painful that the defense mechanism of dissociation breaks down, and the feelings of shame and depression leap forward. This model, in which dissociation (depersonalization) is a direct response to and defense against shame and emotional burnout, depression, and lack of personal efficacy are the secondary results of this dissociated state, also might explain why more residents suffer more from depersonalization than burnout. Dissociation and depersonalization precede burnout and thus can be considered the milder form of the same syndrome. Thus, although 85% of residents had severe depersonalization, only 50% had from moderate to severe burnout (Fig 6). The large number of oral surgery residents who develop severe depersonalization is alarming because it has detrimental effects on patient care. In a multivariable logistic regression analysis from 1 cross-sectional study, residents with high depersonalization were 8 times more likely to self-report monthly or weekly suboptimal patient practices and 4 times more likely to report suboptimal attitudes toward their patients.2 Gender is an important risk factor for burnout.21,22 Although this study suggests that there is no gender Q5 predilection for burnout, depersonalization, and
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RESIDENT BURNOUT AND RATE OF SHAMED EVENTS
Table 3. ODDS RATIOS (95% CONFIDENCE INTERVALS) OBTAINED FROM LOGISTIC REGRESSIONS TO PREDICT BURNOUT, DEPERSONALIZATION, AND PERSONAL ACHIEVEMENT AMONG ALL RESPONDENTS
Burnout (n = 214) Variable
OR (95% CI)
Number of shamed events 0 1-5 >5 Gender Women Men Program/level of training 4 yr/first year 4 yr/second and third years 4 yr/fourth year 6 yr/first year 6 yr/second to fourth years 6 yr/fifth and sixth years Program 6 yr 4 yr
P Value*
Depersonalization (n = 214) OR (95% CI)
#.001 1.0 1.31 (0.66-2.60) 4.56 (2.08-10.00)
P Value*
OR (95% CI)
#.001 1.27 (0.66-2.45) 5.07 (2.13-12.02)
.54 1.0 0.79 (0.37-1.68)
Personal Achievement (n = 209) P Value* .04 1.88 (0.95-3.73) 2.64 (1.24-5.61)
.24 0.61 (0.27-1.39)
.05 0.45 (0.21-1.00)
.08
.93
1.0 0.27 (0.11-0.68) 0.39 (0.13-1.20) 0.74 (0.19-2.88) 0.32 (0.12-0.85) 0.29 (0.10-0.86)
1.37 (0.57-3.25) 1.64 (0.56-4.84) 1.00 (0.28-3.60) 1.25 (0.48-3.22) 1.03 (0.37-2.87) .47 1.0 1.25 (0.69-2.26)
Abbreviations: CI, confidence interval; OR, odds ratio. * Based on Wald c2 tests obtained from multivariable models that included all variables in the table. Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
personal achievement, 100% of female respondents who were exposed to just a single shame event (Fig 5) had decreased self-esteem (P < .0001) and were significantly more likely to experience isolation (P < .001) and depression (P = .037). In a study of shame prevalence among otolaryngology residents,16 shame events were roughly twice as likely to result in professional isolation among female trainees, which is consistent with the data obtained by this study (60 vs 30%). These findings highlight the specific emotional challenges women face in residency, because women have an increased lifetime risk of developing depression,21 and shame in residency seems to trigger a precocious presentation of depressive symptoms in female residents. One female respondent addressed this emotional challenge in her free-text response: ‘‘I felt hopeless. At times I felt suicidal—I felt I wanted to quit the program but could not due to the fact that I am a female and they already view women as weak, when in reality—I wanted to quit to save myself from becoming the way they are. I gained weight, I became clinically depressed, and I was short fused .’’ Senior-level OMS residents have an important role in shaming; residents who experienced more than 5 shame events were more likely to report having been shamed by a senior-level resident (76 vs 50%; P < .01). Despite the near universal rejection of shame as an effective tool in OMS training regardless
of postgraduate year, senior-level OMS residents are responsible for perpetuating the very behavior they steadfastly reject. Some junior-level respondents described their senior residents as ‘‘malicious’’ and ‘‘passive aggressive.’’ One junior-level resident stated that in addition to other forms of disrespect and shaming, he had been physically struck by a senior resident. Although the role of the senior resident in the perpetuation of shame in residency is clear, it is the attending physician who is responsible for the bulk of the shaming. McMains et al16 reported that attendings were responsible for the vast majority of shame events. The present data suggest a similar trend, because more than 80% of men and women who reported exposure to a shame event reported that it was performed by an attending, and the most likely setting of the shame event was the operating room (Fig 2). As described by 1 resident, ‘‘we were in the operating room and I had forgotten something about cranial nerve seven. I was humiliated and told to scrub out. I was told I was pathetic, stupid and that they didn’t think I was good enough to be a resident.’’ A senior-level resident stated plainly that he had ‘‘grown to hate the field of OMS because of my attendings.’’ The results of this study should be viewed within the limitations of the data. The survey was emailed to all OMS program directors to distribute to their
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current trainees. Because participation was voluntary, it is possible that a number of program directors chose not to send the survey link to their respective residents. It is impossible to know the number of residents who had access to the survey link, and thus the generalizability of responses beyond the survey respondents is uncertain. The distribution method also lends itself to voluntary response bias, given that trainees who have had memorably bad experiences might be more likely to respond. In conclusion, repeated shame exposure appears to be associated with an increased likelihood of resident burnout. The results of this study suggest that it is important to consider qualitative factors that could act synergistically with quantitative factors to cause high rates of resident burnout, depression, and poor quality of life. Future studies should survey the perception and attitudes of the use of shame of OMS attendings. Because attendings are most responsible for shame events, it is likely that they were exposed to shame events as residents and are simply perpetuating a behavior that might appear normal to them. In addition, although there are several studies that have assessed the prevalence of decreased burnout, depersonalization, and personal achievement levels in resident education, very little attention has been paid to resident shame in the scientific literature.
References 1. Maslach C, Jackson SE, Leiter MP: Maslach Burnout Inventory, in Zalaquett CP, Wood RJ (eds): Evaluating Stress: A Book of Resources (ed 3). Lanham, MD, Rowman & Littlefield Publishers, 1997, pp 191–218 2. Shanafelt TD, Bradley KA, Wipf JE, et al: Burnout and selfreported patient care in an internal medicine residency program. Ann Intern Med 136:358, 2002 3. Linzer M, Visser MR, Oort FJ, et al: Predicting and preventing physician burnout: Results from the United States and the Netherlands. Am J Med 111:170, 2001 4. Campbell DA Jr, Sonnad SS, Eckhauser FE, et al: Burnout among American surgeons. Surgery 130:696, 2001
5. Tzischinsky O, Zohar D, Epstein R, et al: Daily and yearly burnout symptoms in Israeli shift work residents. J Hum Ergol (Tokyo) 30:357, 2001 6. Collier VU, McCue JD, Markus A, et al: Stress in medical residency: Status quo after a decade of reform? Ann Intern Med 136:384, 2002 7. Purdy RR, Lemkau JP, Rafferty JP, et al: Resident physicians in family practice: Who’s burned out and who knows? Fam Med 19:203, 1987 8. Biaggi P, Peter S, Ulich E: Stressors, emotional exhaustion and aversion to patients in residents and chief residents—What can be done? Swiss Med Wkly 133:339, 2003 9. Nyssen AS, Hansez I, Baele P, et al: Occupational stress and burnout in anaesthesia. Br J Anaesth 90:333, 2003 10. Sargent MC, Sotile W, Sotile MO, et al: Stress and coping among orthopaedic surgery residents and faculty. J Bone Joint Surg Am 86A:1579, 2004 11. Campbell J, Prochazka AV, Yamashita T, et al: Predictors of persistent burnout in internal medicine residents: A prospective cohort study. Acad Med 85:1630, 2010 12. 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 148:448, 2013 13. Sen S, Kranzler HR, Krystal JH, et al: A prospective cohort study investigating factors associated with depression during medical internship. Arch Gen Psychiatry 67:557, 2010 14. Sen S, Kranzler HR, Didwania AK, et al: Effects of the 2011 duty hour reforms on interns and their patients: A prospective longitudinal cohort study. JAMA Intern Med 173:657, 2013 15. Dean J: JAMA and jammies: The work-life balance of an intern. Acad Psychiatry 40:117, 2016 16. McMains KC, Peel J, Weitzel EK, et al: Perception of shame in otolaryngology-head and neck surgery training. Otolaryngol Head Neck Surg 153:786, 2015 17. American Association of Oral and Maxillofacial Surgeons: OMS program, resident and faculty summary report. Available at: http://aaoms.org/docs/education_research/edu_training/ aaoms_faculty_resident_summary.pdf. Published 2016 Q6 18. Thomas NK: Resident burnout. JAMA 292:2880, 2004 19. Lin L, Liang BA: Reforming residency: Modernizing resident education and training to promote quality and safety in healthcare. J Health Law 38:203, 2005 20. Morrison AP: Shame, ideal self, and narcissism. Contemp Psychoanal 19:295, 1983 21. Bertakis KD, Helms LJ, Callahan EJ, et al: Patient gender differences in the diagnosis of depression in primary care. J Womens Health Gend Based Med 10:689, 2001 22. Dyrbye LN, Shanafelt TD, Balch CM, et al: Relationship between work-home conflicts and burnout among American surgeons: A comparison by sex. Arch Surg 146:211, 2011
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ANESTHESIA/FACIAL PAIN
What a Shame: Increased Rates of OMS Resident Burnout May Be Related to the Frequency of Shamed Events During Training Michael C. Shapiro, DDS, MA,* Sowmya R. Rao, PhD,y Jason Dean, MD,z and Andrew R. Salama, DDS, MDx
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Purpose:
Shame is an ineffective tool in residency education that often results in depression, isolation, and worse patient care. This study aimed to assess burnout, depersonalization, and personal achievement levels in current oral and maxillofacial surgery (OMS) residents, to assess the prevalence of the use of shame in OMS residency training, and to determine whether there is a relation between shame exposure and resident burnout, depersonalization, and personal achievement levels.
Materials and Methods:
An anonymous 20-question cross-sectional survey was developed incorporating the Maslach Burnout Index and a previously validated shame questionnaire and sent to all OMS program directors affiliated with the American Association of Oral and Maxillofacial Surgeons for distribution among their respective residents in 2016. Univariate analyses were used to determine the distribution of the predictor (shame) and outcome (burnout) by gender and by frequency of shaming events. Multivariable logistic regression analysis was used to assess the relation of shame to burnout. A 2-sided P value less than .05 was considered statistically significant.
Results:
Two hundred seventeen responses were received; 82% of respondents were men (n = 178), 95% were 25 to 34 years old (n = 206), and 58% (n = 126) were enrolled in a 4-year program. Frequently shamed residents were more likely to have depression (58 vs 22%; P < .0001), isolation (55 vs 22%; P < .0001), and poor job performance (50 vs 30%; P < .0001). Residents who were frequently shamed were more likely to experience moderate to severe burnout (odds ratio = 4.6; 95% confidence interval, 2.1-10.0; P < .001) and severe depersonalization (odds ratio = 5.1; 95% confidence interval, 2.1-12.0; P < .0001) than residents who had never or infrequently been shamed.
Conclusion:
There is a clear relation between the number of shame events and burnout and depersonalization levels. It is important to understand the negative impact that the experience of shame has on residents, including its unintended consequences. Ó 2016 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-9, 2016
*Resident, Department of Oral and Maxillofacial Surgery, Boston
Address correspondence and reprint requests to Dr Shapiro:
Medical Center and Boston University School of Dental Medicine,
Department of Oral and Maxillofacial Surgery, Boston Medical
Boston, MA.
Center, 100 East Newton Street, Suite G-407, Boston, MA 02118;
ySenior Statistician, Department of Surgery, Boston University
e-mail: [email protected]
Medical Center, and MGH Biostatistics Center, Massachusetts
Received April 26 2016
General Hospital, Boston, MA.
Accepted August 24 2016
zResident, Department of Psychiatry, Brigham and Women’s
Ó 2016 Published by Elsevier Inc on behalf of the American Association of Oral
Hospital and Harvard Medical School, Boston, MA. xResidency Director, Department of Oral and Maxillofacial
and Maxillofacial Surgeons
Surgery, Boston Medical Center; Assistant Professor, Boston
http://dx.doi.org/10.1016/j.joms.2016.08.040
0278-2391/16/30774-1
University School of Dental Medicine, Boston, MA. This report has been accepted for publication as an oral abstract and will be presented at the 98th Annual Meeting of the American Association of Oral and Maxillofacial Surgeons.
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RESIDENT BURNOUT AND RATE OF SHAMED EVENTS
Emotional burnout, depersonalization, and lack of selfconfidence are common during residency training. These factors have been studied and quantified by Maslach et al.1 Maslach et al defined burnout as a syndrome involving chronic fatigue, emotional exhaustion, and fatigue at the very idea of work. Depersonalization was defined as a ‘‘dehumanization in interpersonal relations,’’ in which the clinician becomes detached from others. In depersonalization, the clinician experiences a lack of empathy for patients, guilt, and withdraws from social contact. If unaddressed, burnout and depersonalization can lead to a perceived decrease in personal achievement, in which the clinician doubts his or her abilities and capacity for success. The available literature on burnout in residency education involves residents in internal medicine, anesthesiology, surgery, orthopedic surgery, and family practice.2-11 Several studies have found high rates of burnout, depersonalization, and depression among residents. Campbell et al11 found that 78% of medical residents experienced at least 1 episode of burnout during training. A survey of general surgery residents found that 28% reported weekly experiences of depersonalization, 28% reported weekly feelings of emotional exhaustion, 32% noted a personal-andprofessional balance that was ‘‘very poor’’ or ‘‘not great,’’ 67% reported reflecting on satisfaction from being a surgeon at least weekly, and 1 in 7 considered leaving their residency at least once a week.12 The Intern Health Study by Sen et al13 followed a cohort of internal medicine interns and found that the prevalence of a major depressive episode during the intern year was approximately 20%. Although the Accreditation Council for Graduate Medical Education implemented duty hour restrictions in 2011 to address the alarmingly high rates of burnout and depression in residency, these changes do not appear to have improved quality of life. In fact, Sen et al14 surveyed a new cohort of internal medicine residents training after the duty hour changes and found no meaningful improvement in depressive symptoms or well-being. The persistence of burnout and depression implies that, in addition to the quantitative factor of the number of hours worked, one must address the qualitative factors of residency training that affect quality of life. It might not be the number of hours worked that causes burnout, but rather the psychological effects of residency and its effects on interpersonal relationships.15 In particular, experiences of shame and humiliation during residency also have been found to affect quality of life and well-being. In a recent study, McMains et al16 surveyed otolaryngology residents and found that 50% of residents had been shamed by senior
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residents or attendings. They also found that exposure to shame resulted in increased rates of depression, decreased self-confidence, and led to decreased job performance. The purpose of this study was to answer 3 specific questions. First, what is the prevalence of burnout, depersonalization, and decreased personal achievement as defined by the Maslach Burnout Index (MBI) in current oral and maxillofacial surgery (OMS) residents? Second, what is the prevalence of shame and humiliation as an educational tool in current OMS residents according to a previously validated shame questionnaire? Third, what is the association, if any, between shame exposure and resident burnout?
Materials and Methods STUDY DESIGN AND SAMPLE
The research proposal was approved by the institutional review board of Boston University (Boston, MA). To address the research purpose, the authors designed and implemented a 20-question survey using the Qualtrics (https://www.qualtrics.com/) online platform incorporating the MBI and a previously validated shame questionnaire16 and emailed it to oral and maxillofacial program directors affiliated with the American Association of Oral and Maxillofacial Surgeons (AAOMS) for distribution among their respective residents. The initial email request was followed by 1 additional email encouraging participation, and the survey link was available for completion for a total of 30 days. Survey responses were completely anonymous. The study population was composed of all trainees attending AAOMS-affiliated OMS training programs. To be included in the study, subjects had to be enrolled in an AAOMS-affiliated OMS training program in the United States or its territories. Respondents were excluded as study subjects if their survey consisted of incomplete responses to any question other than demographic data. STUDY VARIABLES
The primary predictor variable was the number of perceived shamed events, which was divided into 3 groups (0, 1 to 5, and >5 shamed events; Table 1). The shame questionnaire developed by McMains Q2 et al16 was used to assess the perception of shame. The questionnaire consists of 14 questions that assess the perception of, and effects stemming from, shame and humiliation. Content validity was established by a modified subject matter expert rater method, and this survey has been used to assess shame in otolaryngology resident training programs in the United States.16,17 Shame was defined and limited to Q3
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Table 1. DISTRIBUTION OF STUDY VARIABLES VERSUS THE PREDICTOR VARIABLE
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Number of Shamed Events, n (%Col) Variable Age in categories
Gender Program, level of training
Categories
0
1-5
>5
1. 25-34 yr 2. 35-44 yr 3. 45-54 yr 1. women 2. men 1. 4-yr program, first year 2. 4-yr program, second and third years 3. 4-yr program, fourth year 4. 6-yr program, first year 5. 6-yr program, second to fourth years 6. 6-yr program, fifth and sixth years
65 (98.5) 1 (1.5) 0 (0.0) 15 (22.7) 51 (77.3) 11 (16.4) 15 (22.4)
83 (94.3) 5 (5.7) 0 (0.0) 10 (11.4) 78 (88.6) 15 (17.2) 30 (34.5)
58 (93.5) 3 (4.8) 1 (1.6) 13 (21.0) 49 (79.0) 8 (13.1) 21 (34.4)
9 (13.4) 4 (6.0) 19 (28.4)
7 (8.0) 7 (8.0) 17 (19.5)
10 (16.4) 3 (4.9) 7 (11.5)
9 (13.4)
11 (12.6)
12 (19.7)
P Value
.3734
.1325 .3358
Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
banishment from the operating room, being yelled at, being called names, being called ‘‘stupid,’’ or being threatened. No other behaviors were included as shame behaviors in this study. STUDY OUTCOMES
The primary outcome variable was burnout, which was determined using the MBI. The MBI is a validated 22-item questionnaire that is generally considered the gold standard measurement for burnout.18 The inventory asks respondents to indicate on a 7-point Likert scale the frequency with which they experience certain feelings related to their work. The MBI evaluates 3 domains of burnout: 1) emotional exhaustion, which is measured with a subscale of 9 items (eg, ‘‘I feel emotionally drained from my work’’); 2) depersonalization, which is measured with a subscale of 5 items (eg, ‘‘I feel I look after certain patients/clients impersonally, as if they are objects’’); and 3) personal accomplishment, which is measured with 8 items (eg, ‘‘I accomplish many worthwhile things in this job’’). Based on the MBI responses, independent subscale scores were calculated for each of the 3 domains of burnout (mild, moderate, and severe).
years) and was used this for analysis where possible because of the sample size constraints. Bivariate analysis were conducted to test whether shaming, burnout, depersonalization, and personal achievement levels varied meaningfully by gender (men vs women), program type and level of training (4-yr program, first year; 4-yr program, second and third years; 4-yr program, fourth year; 6-yr program, first year; 6-yr program, second to fourth years; 6-yr program, fifth and sixth years), and the intensity of shaming events (0, 1 to 5, and >5) using the Fisher exact test. Similar analyses were conducted to assess the relation of shame to burnout, depersonalization, and personal achievement. Furthermore, odds ratios (ORs) and 95% confidence intervals (CIs) were obtained from multivariable logistic regression models to evaluate the association of shame to moderate to severe burnout, personal achievement, and severe depersonalization accounting for gender, number of shamed events, and program and level of training. For the model to predict severe depersonalization, the model included the program (4 or 6 yr) instead of program and level of training owing to small samples. A 2-sided P value less than .05 was considered significant.
OTHER VARIABLES
The other variables of interest included age, gender (men vs women), program type (4 vs 6 year program), and level of training (by postgraduate year). STATISTICAL ANALYSES
A variable was created that combined program type (4 vs 6 yr) and postgraduate year (first to sixth
Results In total, 217 responses were eligible for inclusion in the study. Responses were received from 29 of 37 states or territories that possess an OMS training program. The male-to-female response ratio was 82:18, which closely approximates the actual 85:15 ratio of current OMS residents.17 Seven percent of
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RESIDENT BURNOUT AND RATE OF SHAMED EVENTS
shame event (Fig 5) had decreased self-esteem (P < .0001) and were significantly more likely to have isolation (P < .001) and depression (P = .037). Regarding resident burnout, 51% of OMS residents had moderate to severe emotional exhaustion, 85.7% had moderate to severe depersonalization, and 53% had moderate to severe feelings of inefficacy (Fig 6). There was no statistically meaningful difference in the burnout rates of male and female respondents. Residents who were frequently shamed (>5 shame events) were more likely to experience moderate to severe burnout (OR = 4.6; 95% CI, 2.1-10.0; P < .001; Table 3) and severe depersonalization (OR = 5.1; 95% CI, 2.1-12.0; P < .0001) than residents who were shamed less frequently or never shamed.
respondents stated that shame was a necessary or effective tool, 70% of respondents stated that they had been shamed during residency, and 82% reported witnessing the shaming of a fellow resident. Eighty percent of residents reported that an attending performed the shaming, and the most common location for a shame event was the operating room (67%). There was no statistically relevant difference in shame rates between male and female respondents (Table 2). When residents were frequently shamed (Figs 1-4), they were more likely to be shamed because of surgical error (41 vs 19%; P < .001), incorrect response to questioning (84 vs 66%; P < .01), and disagreement regarding clinical care (58 vs 28%; P < .001). They also were more likely to have depression (58 vs 22%; P < .0001), isolation (55 vs 22%; P < .0001), and poor job performance (50 vs 30%; P < .0001). In addition, residents who were frequently shamed were more likely to report having been shamed by a senior-level resident (76 vs 50%; P < .01). Those who were exposed to fewer than 5 shame events were more likely to report that the shame event had no effect on them (33 vs 18%; P < .05). Women who were exposed to just a single
Discussion The purpose of the present study was to assess burnout, depersonalization, and personal achievement levels in current OMS residents, to assess the prevalence of burnout in current OMS residents, to assess the prevalence of shame and humiliation as an educational tool in current OMS residents, and model
Table 2. DISTRIBUTION OF STUDY VARIABLES AND NUMBER OF SHAMED EVENTS BY OUTCOMES
Outcomes, n (%) Burnout
Variable
Moderate to High Level
Age (yr) 25-34 106 (96.4) 35-44 3 (2.7) 45-54 1 (0.9) Gender Women 22 (20.0) Men 88 (80.0) Program/level of training 4 yr/first year 24 (22.0) 4 yr/second and 29 (26.6) third years 4 yr/fourth year 14 (12.8) 6 yr/first year 9 (8.3) 6 yr/second to 18 (16.5) fourth years 6 yr/fifth and 15 (13.8) sixth years Number of shamed events 0 26 (23.6) 1-5 39 (35.5) >5 45 (40.9)
Low Level
Depersonalization P Value
High Level
Low to Moderate Level
100 (94.3) 135 (97.1) 6 (5.7) .3257 3 (2.2) 0 (0.0) 1 (0.7)
70 (92.1) 6 (7.9) 0 (0.0)
16 (15.1) 28 (20.1) 90 (84.9) .3755 111 (79.9)
10 (13.2) 66 (86.8)
10 (9.4) 37 (34.9)
26 (18.8) 40 (29.0)
8 (10.5) 26 (34.2)
12 (11.3) .0980 5 (4.7) 25 (23.6)
19 (13.8) 11 (8.0) 24 (17.4)
7 (9.2) 3 (3.9) 19 (25.0)
17 (16.0)
18 (13.0)
13 (17.1)
41 (38.3) 49 (45.8) .0002 17 (15.9)
35 (25.2) 51 (36.7) 53 (38.1)
31 (40.3) 37 (48.1) 9 (11.7)
Personal Achievement P Value
.0703
.2620
.2663
<.0001
Moderate to High Level
Low Level
P Value
111 (96.5) 3 (2.6) 1 (0.9)
90 (93.8) 6 (6.3) .3056 0 (0.0)
25 (21.7) 90 (78.3)
12 (12.5) 84 (87.5) .1016
16 (14.0) 38 (33.3)
16 (16.7) 28 (29.2)
16 (14.0) 7 (6.1) 21 (18.4)
10 (10.4) .9224 7 (7.3) 20 (20.8)
16 (14.0)
15 (15.6)
27 (23.5) 47 (40.9) 41 (35.7)
37 (38.1) 39 (40.2) .0262 21 (21.6)
Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
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FIGURE 1. Shame-provoking event (by number of shamed events). Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
the risk of burnout as a sequela of shame, if such an association indeed exists. The authors hypothesized that residents who were exposed to an increased number of shamed events would have a higher burnout rate than those who were shamed less frequently.
Multivariable logistic regression analyses showed that frequently shamed residents were more likely to experience moderate to severe burnout and severe depersonalization than residents who were shamed less frequently or never shamed.
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FIGURE 2. Shaming environment (by number of shamed events). Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
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RESIDENT BURNOUT AND RATE OF SHAMED EVENTS
FIGURE 3. Person responsible for shaming (by number of shamed events). Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
This study documents a persistent culture of ‘‘individually oriented shame and blame’’ in residency education,19 and the results of this study suggest that there is prevalent use of shame as an educational tool in OMS training. Incorrect response to questioning and disagreement regarding clinical care were the most commonly cited reasons for shaming a resident, and as the frequency of shaming increased, residents experienced increased rates of depression, isolation, and poor job performance. The results of this study suggest that women are more likely to respond with isolation and depression to a shamed event. The results of this study also suggest that attendings and senior-level OMS residents are responsible for the performance of shaming events.
Eighty-two percent of respondents witnessed the shaming of a colleague, and nearly 70% experienced at least 1 shame event. These figures are substantially increased when compared with a study of shame prevalence among otolaryngology residents (70 and 50%, respectively); however, a mere 7% of ear, nose, and throat and OMS residents believed that shame was a useful or effective tool in residency training, indicating a near universal rejection of the use of shame in residency training.16 According to some, shame is the emotional response to a feeling of personal defect or failure.19 Throughout development, each individual internalizes a personal ideal, and when an individual fails to live up to that personal ideal, the response is a feeling of shame. This state of deficiency and failure is experienced subjectively as emotional depletion, fatigue, and a lack of empathy. The depletion of the self causes a pervasive feeling of emptiness and lack of vitality, which can lead to what has been called ‘‘guiltless depression.’’20 The psychological understanding of shame as the subjective experience of a defective and depleted self correlates with the concepts of burnout, depersonalization, and lack of personal achievement described by Maslach et al.16 These entities represent 3 areas of functioning that are affected by a depleted sense of self. Interestingly, experiencing shame even a few times among the thousands of interactions with superiors has a dramatic effect on subjective quality of life. In the free-text responses, many residents reported a constant feeling of dread related to the fear of being shamed, including a ‘‘fear of impending doom
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FIGURE 4. Result of shaming (by number of shamed events). Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
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FIGURE 5. Result of shaming (by gender). Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
when walking into the hospital.’’ An important implication of the data is that even 1 experience of shame, or even seeing a colleague shamed, can lead to a pervasive feeling of shame and deficiency despite thousands of neutral or even positive interactions. Repeated exposure to shaming results in high levels of moderate to severe burnout and severe depersonalization (Tables 2,3, Fig 6). To defend against the painful reality of work, residents dissociate and ‘‘check out.’’ Although in the short term dissociation might mitigate the pain of fully engaging in work, in the long term it leads to a secondary lack of vitality, emotional burnout, and depression. This phenomenon also could explain the considerable decrease in self-esteem, in addition to the isolation, depression, and worse job performance, found in residents exposed to repeated shame events (Fig 4). As 1
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FIGURE 6. Distribution of burnout (by number of shamed events). Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
respondent wrote, ‘‘I feel like I can’t do anything correctly. I have minimal confidence in myself, my surgical skills, my didactic knowledge, and it affects my psyche daily.’’ Dissociation as a defense against shame also might explain the finding that residents with mild shame (1 to 5 events) were more likely to report that shame had no effect on them (Fig 4). Low levels of shame might lead to dissociation, in which the painful effects of shame are minimized through the narrative of ‘‘I don’t care.’’ In contrast, severe shame is so painful that the defense mechanism of dissociation breaks down, and the feelings of shame and depression leap forward. This model, in which dissociation (depersonalization) is a direct response to and defense against shame and emotional burnout, depression, and lack of personal efficacy are the secondary results of this dissociated state, also might explain why more residents suffer more from depersonalization than burnout. Dissociation and depersonalization precede burnout and thus can be considered the milder form of the same syndrome. Thus, although 85% of residents had severe depersonalization, only 50% had from moderate to severe burnout (Fig 6). The large number of oral surgery residents who develop severe depersonalization is alarming because it has detrimental effects on patient care. In a multivariable logistic regression analysis from 1 cross-sectional study, residents with high depersonalization were 8 times more likely to self-report monthly or weekly suboptimal patient practices and 4 times more likely to report suboptimal attitudes toward their patients.2 Gender is an important risk factor for burnout.21,22 Although this study suggests that there is no gender Q5 predilection for burnout, depersonalization, and
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RESIDENT BURNOUT AND RATE OF SHAMED EVENTS
Table 3. ODDS RATIOS (95% CONFIDENCE INTERVALS) OBTAINED FROM LOGISTIC REGRESSIONS TO PREDICT BURNOUT, DEPERSONALIZATION, AND PERSONAL ACHIEVEMENT AMONG ALL RESPONDENTS
Burnout (n = 214) Variable
OR (95% CI)
Number of shamed events 0 1-5 >5 Gender Women Men Program/level of training 4 yr/first year 4 yr/second and third years 4 yr/fourth year 6 yr/first year 6 yr/second to fourth years 6 yr/fifth and sixth years Program 6 yr 4 yr
P Value*
Depersonalization (n = 214) OR (95% CI)
#.001 1.0 1.31 (0.66-2.60) 4.56 (2.08-10.00)
P Value*
OR (95% CI)
#.001 1.27 (0.66-2.45) 5.07 (2.13-12.02)
.54 1.0 0.79 (0.37-1.68)
Personal Achievement (n = 209) P Value* .04 1.88 (0.95-3.73) 2.64 (1.24-5.61)
.24 0.61 (0.27-1.39)
.05 0.45 (0.21-1.00)
.08
.93
1.0 0.27 (0.11-0.68) 0.39 (0.13-1.20) 0.74 (0.19-2.88) 0.32 (0.12-0.85) 0.29 (0.10-0.86)
1.37 (0.57-3.25) 1.64 (0.56-4.84) 1.00 (0.28-3.60) 1.25 (0.48-3.22) 1.03 (0.37-2.87) .47 1.0 1.25 (0.69-2.26)
Abbreviations: CI, confidence interval; OR, odds ratio. * Based on Wald c2 tests obtained from multivariable models that included all variables in the table. Shapiro et al. Resident Burnout and Rate of Shamed Events. J Oral Maxillofac Surg 2016.
personal achievement, 100% of female respondents who were exposed to just a single shame event (Fig 5) had decreased self-esteem (P < .0001) and were significantly more likely to experience isolation (P < .001) and depression (P = .037). In a study of shame prevalence among otolaryngology residents,16 shame events were roughly twice as likely to result in professional isolation among female trainees, which is consistent with the data obtained by this study (60 vs 30%). These findings highlight the specific emotional challenges women face in residency, because women have an increased lifetime risk of developing depression,21 and shame in residency seems to trigger a precocious presentation of depressive symptoms in female residents. One female respondent addressed this emotional challenge in her free-text response: ‘‘I felt hopeless. At times I felt suicidal—I felt I wanted to quit the program but could not due to the fact that I am a female and they already view women as weak, when in reality—I wanted to quit to save myself from becoming the way they are. I gained weight, I became clinically depressed, and I was short fused .’’ Senior-level OMS residents have an important role in shaming; residents who experienced more than 5 shame events were more likely to report having been shamed by a senior-level resident (76 vs 50%; P < .01). Despite the near universal rejection of shame as an effective tool in OMS training regardless
of postgraduate year, senior-level OMS residents are responsible for perpetuating the very behavior they steadfastly reject. Some junior-level respondents described their senior residents as ‘‘malicious’’ and ‘‘passive aggressive.’’ One junior-level resident stated that in addition to other forms of disrespect and shaming, he had been physically struck by a senior resident. Although the role of the senior resident in the perpetuation of shame in residency is clear, it is the attending physician who is responsible for the bulk of the shaming. McMains et al16 reported that attendings were responsible for the vast majority of shame events. The present data suggest a similar trend, because more than 80% of men and women who reported exposure to a shame event reported that it was performed by an attending, and the most likely setting of the shame event was the operating room (Fig 2). As described by 1 resident, ‘‘we were in the operating room and I had forgotten something about cranial nerve seven. I was humiliated and told to scrub out. I was told I was pathetic, stupid and that they didn’t think I was good enough to be a resident.’’ A senior-level resident stated plainly that he had ‘‘grown to hate the field of OMS because of my attendings.’’ The results of this study should be viewed within the limitations of the data. The survey was emailed to all OMS program directors to distribute to their
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current trainees. Because participation was voluntary, it is possible that a number of program directors chose not to send the survey link to their respective residents. It is impossible to know the number of residents who had access to the survey link, and thus the generalizability of responses beyond the survey respondents is uncertain. The distribution method also lends itself to voluntary response bias, given that trainees who have had memorably bad experiences might be more likely to respond. In conclusion, repeated shame exposure appears to be associated with an increased likelihood of resident burnout. The results of this study suggest that it is important to consider qualitative factors that could act synergistically with quantitative factors to cause high rates of resident burnout, depression, and poor quality of life. Future studies should survey the perception and attitudes of the use of shame of OMS attendings. Because attendings are most responsible for shame events, it is likely that they were exposed to shame events as residents and are simply perpetuating a behavior that might appear normal to them. In addition, although there are several studies that have assessed the prevalence of decreased burnout, depersonalization, and personal achievement levels in resident education, very little attention has been paid to resident shame in the scientific literature.
References 1. Maslach C, Jackson SE, Leiter MP: Maslach Burnout Inventory, in Zalaquett CP, Wood RJ (eds): Evaluating Stress: A Book of Resources (ed 3). Lanham, MD, Rowman & Littlefield Publishers, 1997, pp 191–218 2. Shanafelt TD, Bradley KA, Wipf JE, et al: Burnout and selfreported patient care in an internal medicine residency program. Ann Intern Med 136:358, 2002 3. Linzer M, Visser MR, Oort FJ, et al: Predicting and preventing physician burnout: Results from the United States and the Netherlands. Am J Med 111:170, 2001 4. Campbell DA Jr, Sonnad SS, Eckhauser FE, et al: Burnout among American surgeons. Surgery 130:696, 2001
5. Tzischinsky O, Zohar D, Epstein R, et al: Daily and yearly burnout symptoms in Israeli shift work residents. J Hum Ergol (Tokyo) 30:357, 2001 6. Collier VU, McCue JD, Markus A, et al: Stress in medical residency: Status quo after a decade of reform? Ann Intern Med 136:384, 2002 7. Purdy RR, Lemkau JP, Rafferty JP, et al: Resident physicians in family practice: Who’s burned out and who knows? Fam Med 19:203, 1987 8. Biaggi P, Peter S, Ulich E: Stressors, emotional exhaustion and aversion to patients in residents and chief residents—What can be done? Swiss Med Wkly 133:339, 2003 9. Nyssen AS, Hansez I, Baele P, et al: Occupational stress and burnout in anaesthesia. Br J Anaesth 90:333, 2003 10. Sargent MC, Sotile W, Sotile MO, et al: Stress and coping among orthopaedic surgery residents and faculty. J Bone Joint Surg Am 86A:1579, 2004 11. Campbell J, Prochazka AV, Yamashita T, et al: Predictors of persistent burnout in internal medicine residents: A prospective cohort study. Acad Med 85:1630, 2010 12. 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 148:448, 2013 13. Sen S, Kranzler HR, Krystal JH, et al: A prospective cohort study investigating factors associated with depression during medical internship. Arch Gen Psychiatry 67:557, 2010 14. Sen S, Kranzler HR, Didwania AK, et al: Effects of the 2011 duty hour reforms on interns and their patients: A prospective longitudinal cohort study. JAMA Intern Med 173:657, 2013 15. Dean J: JAMA and jammies: The work-life balance of an intern. Acad Psychiatry 40:117, 2016 16. McMains KC, Peel J, Weitzel EK, et al: Perception of shame in otolaryngology-head and neck surgery training. Otolaryngol Head Neck Surg 153:786, 2015 17. American Association of Oral and Maxillofacial Surgeons: OMS program, resident and faculty summary report. Available at: http://aaoms.org/docs/education_research/edu_training/ aaoms_faculty_resident_summary.pdf. Published 2016 Q6 18. Thomas NK: Resident burnout. JAMA 292:2880, 2004 19. Lin L, Liang BA: Reforming residency: Modernizing resident education and training to promote quality and safety in healthcare. J Health Law 38:203, 2005 20. Morrison AP: Shame, ideal self, and narcissism. Contemp Psychoanal 19:295, 1983 21. Bertakis KD, Helms LJ, Callahan EJ, et al: Patient gender differences in the diagnosis of depression in primary care. J Womens Health Gend Based Med 10:689, 2001 22. Dyrbye LN, Shanafelt TD, Balch CM, et al: Relationship between work-home conflicts and burnout among American surgeons: A comparison by sex. Arch Surg 146:211, 2011
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