Silence is deadly: The importance of communication in addressing wellness and burnout in surgical residency

Walk in the shoes of a junior surgery resident for a day. Wake up at 4:30 am to another dark morning and drive to work. Do a chart check and note the pertinent data on the list for the team. The chief resident, exhausted after being called in overnight, is irritated that information is missing from the list and chides you to be more thorough. Pre-round with the team. The nursing staff is annoyed that their 6:00 am pages and orders have yet to be addressed. Rush to the preoperative holding area to receive consent from a patient who is vexed that he hasn’t spoken to the attending and wants assurance that the attending, not a resident, will perform the operation. Scurry to write notes and place orders from pre-rounding as the patient is rolled into the operating room (OR).

As you finish up and respond to pages, the attending walks in and is peeved that the patient isn’t positioned and prepped yet. During the procedure, your attending allows you to perform some portions of the operation but takes over at the critical portion without explaining why or offering suggestions on how you could improve your technique. Your pager goes off multiple times, and the sighs emanating from the circulating nurse make it clear that he is irritated about answering your pages. Scrub out and rush to finish the brief postop note and orders while returning several more pages. The anesthesia team is now irritated that you are sitting at the computer instead of helping to transfer the patient to the postoperative acute care unit (PACU) bed. You leave the paperwork incomplete and go to PACU with your patient.

Next, you run off to a consult and check on a few floor patients, complete the preoperative consult on the next patient, and return to the OR in time to prep and position the patient to avoid upsetting the attending again. Notify your chief resident of the consult and plan, but you don’t hear back until you’re scrubbed in; scrub out. Your chief is annoyed that you didn’t meet her to see the consult. Your attending wants to round, so you tell the chief and finalize the consult plan together after rounds. The night float intern sends you a text at 7:00 pm, expressing concern that he is getting paged about patients whom you have yet to discharge. Respond to the pages and finish your notes and orders. At 9:00 pm, you finally sign out. Head home in the dark with reading to do for the next day. Never mind food, exercise, or any other method of self-care. Never mind that you need to vent, haven’t spoken to your friends and family in a week, and have neither the time nor energy to make those phone calls. Instead, you finish your reading, and get four hours of sleep until the alarm wakes you at 4:30 am. Rinse and repeat.

These daily slights, whether nonverbal (sighs or eye rolls) or verbal, are noticeable. How we communicate within our teams, among our fellow residents, with our attendings, the OR staff, and our patients, directly affects every aspect of our professional lives. Brief, negative interactions add up. As medical students, many of us were taught that the patient’s needs should take priority over our own. This mantra is reinforced throughout surgical training. Expressing our needs—whether physical, emotional, or spiritual—can result in backlash from our colleagues within the surgical community.

In her 2018 Academic Surgical Congress presidential address, Taylor S. Riall, MD, PhD, FACS, discussed the fallacy of how we romantically or heroically view our surgical culture of “strength and invincibility,” commenting that “it is even more flawed in its assertion that a surgeon who allows himself or herself to be vulnerable is unworthy of being a trusted and respected colleague.”¹

This article reviews the effect of communication on resident wellness and offers evidence-based solutions to encourage transparency and disrupt the culture of silence in a positive manner.

The power of positive self-talk

One of the foundations of cognitive behavioral therapy is self-instructional training—the process of identifying negative self-talk and reframing these statements into positive thoughts.² This method of cognitive behavioral modification has been used to treat many mental health conditions, including anxiety, attention deficit disorder, and depression. Neuroimaging studies have shown that forms of self-talk, such as third-person self-talk, can help an individual regulate emotional responses to stressful situations.³ In sports psychology, positive self-talk has been associated with improved performance. In a 1995 study, Van Raalte and colleagues instructed participants to say, “You can do it,” “You cannot do it,” or nothing at all before throwing darts. Study subjects who said “You can do it” displayed a statistically significant more accurate performance than individuals who said “You cannot do it” or those who said nothing.⁴ Recently, the idea of positive self-talk has been further classified into two distinct categories: motivational self-talk, such as “I’ve got this,” and instructional self-talk like “watch the finish line.”

A meta-analysis of the effect of self-talk on sports and task performance identified three points that translate well to surgical residency. First, instructional self-talk has a greater impact on fine motor skills than on gross motor tasks. Second, although it leads to improvement in both well-learned and novel tasks, self-talk has a higher impact on novel task performance. Finally, training subjects in positive self-talk results in more immediate results and a larger effect (see Table 1).⁵ Because operating requires fine motor skills, the ability to adapt to unexpected findings, and an expectation of leadership during stressful situations both in and out of the OR, surgical residents may benefit from training in positive self-talk.

Interpersonal communication

Despite the 80-hour per week duty-hour limits, surgical residents still spend most of their time at work. We often spend more time with our colleagues than with our families and friends. As most practicing surgeons can attest, this way of life extends well beyond residency. Therefore, our daily interactions at work certainly can affect our well-being both in and out of the hospital.

One of the more frequent interactions residents have is with nursing staff and other nonphysician team members. Several studies explore interprofessional communication between physicians and other health care professionals, including physical therapists, occupational therapists, and social workers. In one case study comparing hospitalists and consultant internists at community hospitals, three themes were identified as playing a significant role in positive communication dynamics. First, in-house hospitalists were more available, leading to improved, more efficient communication. In contrast, consultants were less likely to have developed long-term relationships with the other health care team members, leading to more formality and even reduced communication. Finally, team members felt that consultant units were physician-centered and did not foster a collaborative environment.⁶

In a similar study of two urban teaching hospitals, interprofessional communication was found to be poor between physicians, nursing, and allied health staff. Intraprofessional rounds were prioritized over interprofessional rounds, and during these rounds the most frequent communication was between physicians and other team members, without mutual discussion of patients. Unscheduled interactions that occurred outside of rounds were infrequent and tended toward abrupt question-answer formats between physicians and nurses rather than the more extensive exchange of ideas between nurses and allied health care professionals.⁷

Multiple studies have examined the communication patterns between surgical residents and nurses. In a 2016 study of 31 nurses and 18 surgical trainees at two Canadian academic medical centers, researchers reported multiple themes that impaired interprofessional communication. The surgical residents experienced nurses as territorial and disrespectful of their clinical knowledge, whereas nurses felt residents were inattentive to their clinical concerns and had a poor understanding of the nurses’ role on the team.⁸ However, another 2016 study of 38 surgical interns and 11 nursing students found that participation in an eight-hour interprofessional training session improved attitudes toward collaboration in both groups. Postsession interviews revealed that both groups gained clarity regarding the roles of both interns and nurses on the team.⁹ These studies shed light on several ways that we, as residents, can improve communication and engage in more positive and effective interactions with our colleagues, including the following:

• Be available and attentive
• Develop positive relationships
• Foster a collaborative team environment
• Respect others’ training and expertise

Several studies have explored communication patterns between surgeons and other physicians, with general surgeons tending to exhibit more aggressive verbal communication.^10,11 As a result, there has been a push for culture change.¹² A 2015 qualitative study of communication between surgeons and intensivists defined “good” and “bad” communication.¹²

Good communication occurred when both teams felt they were heard and were working toward a mutual goal for the patient. This communication was possible despite multiple barriers that can exist between surgical and intensive care unit (ICU) teams, including cultural differences and the presence of closed ICUs, wherein decisional authority is limited to the intensivist.

Poor communication occurred when team members felt their knowledge and experience were undervalued and seemed to stem, in part, from discrepancies between how clinicians rated their own experience versus how other health care professionals viewed their experience. In an outpatient setting, a survey of primary care physicians (PCPs) and specialists demonstrated disparate perceptions as well.¹³ Specialists believed they effectively communicated results back to PCPs but did not receive adequate information in the referral, whereas PCPs believed they effectively communicated information regarding the consultation but did not receive follow-up information from the referrals. Through continued research and identification of discordant perceptions that surgeons and physician colleagues have of each other, we can begin addressing the problem through team-building simulation and training.

One of the most significant examples of surgeon-team communication occurs in the OR, where surgeons are viewed as leaders. Using a validated scoring system, a 2017 retrospective review of surgeon behavior during complex operations shed light on how a task-focused leadership style is less effective than a team-oriented approach.¹⁴ Different types of behavior affected scoring of surgeon leadership, including exhibiting specific voice behavior, allowing a safe space for team members to vocalize concerns, encouraging cooperative behavior, fostering a collaborative environment, and sharing knowledge. The highest-scoring surgeon engaged all team members in the room upon entering the OR, discussed the plan for the case with the anesthesiologist, allowed the surgical resident to offer input on the case, and maintained enthusiasm throughout the operation.

In a conceptual model of disruptive surgeon behavior in the OR, participants (nurses, scrub technicians, medical students, residents, and anesthesiologists) identified four coping strategies:¹⁵

• Speaking with others for support
• Externalizing the behavior so that it is taken less personally
• Avoiding the surgeon
• Warning others as an altruistic effort to prevent similar episodes of disruptive behavior

Similar to the study of interprofessional training for surgical interns and nursing students mentioned previously,⁹ Awad and colleagues instituted medical team training using multiple instructional modalities and followed implementation of the learned skills on preoperative briefings.¹⁶ Surgery and anesthesia personnel rated improved perception of communication between team members after four months of enacting these preoperative briefings. Numerous other publications have highlighted interventions to improve the atmosphere in the OR and team dynamics. The key to all of these enhancements is communication.

Ultimately, communication has the most meaningful impact on the patient. By far the most important interaction that surgical residents have on a daily basis is the time spent with patients and families. However, as all residents know, patients and their families commonly assume that “the doctor” has not rounded on them until the attending shows up, despite how often a resident has rounded on the patient throughout the day. How residents communicate with patients can affect the treatment they receive from patients, nurses, attendings, and other members of the health care team. Multiple simulated models assess and intervene on resident-patient interactions. Senior residents tend to score higher on these evaluations, suggesting that communication skills improve over time.^17-20 Objective, structured clinical exams with standardized patients are commonly administered in medical school and during the Step 2 Clinical Skills portion of the U.S. Medical Licensing Exam; however, these assessments are no longer performed when surgical residency begins. Published simulation models and validated patient-centered assessment tools clearly demonstrate the importance of early education and continued assessment of resident-patient communication skills.

Surgical residents often are reluctant to speak up and may fall prey to the culture of silence because of the hierarchical nature of our field.²¹ In an attempt to address this code of silence and encourage residents to voice their concerns, one group studied the “two-challenge rule” as a method for residents to communicate concerns in a nonthreatening manner during a debriefing session.²²

Anesthesia residents were subjects in two simulated cases in which a faculty anesthesiologist, an attending surgeon, and a circulating nurse introduced communication challenges. After the first case, a debriefing session allowed residents to reflect on their responses or lack thereof. They were then taught the two-challenge rule, which calls for using advocacy-inquiry language, such as, “I see that you want to administer succinylcholine to this patient. She has a 40 percent total body surface area (TBSA) burn. Can you clarify the choice of medication?” If the first challenge is ignored or insufficiently answered, the resident is encouraged to repeat with their critical thinking. “I see that you want to administer succinylcholine to this patient with a 40 percent TBSA burn. I have learned that this medication is contraindicated and may cause fatal hyperkalemia. Should we use vecuronium as an alternative?” The analysis was notable for increased verbalization on the behalf of the resident using “crisp advocacy-inquiry language” to relay concerns to the attending surgeon and faculty anesthesiologist following the debriefing session between Case A and Case B, with no significant change in communication patterns between the resident and nurse. This finding highlights the benefits of the two-challenge rule as an effective means of improving communication between trainee and faculty by overcoming potential hierarchy-related barriers to improve teamwork when patient safety is the concern.

As stated previously, how we communicate throughout the day affects every aspect of our lives. The positive interactions we have with others can lead to a sense of personal fulfillment and community; conversely, negative interactions lead to a sense of frustration, anger, loneliness, or despair. Training residents in evidence-based communication and leadership skills, with amplification of the resident voice, can improve morale, provide a sense of belonging, and remind residents that they are valued members of the patient care team.

When communication fails

When team communication breaks down, patients are the first to be affected, and residents often are next. When plans are made during morning rounds, the most junior resident typically is tasked with completing the orders, writing the notes, and seeing the consults, despite the fact that he or she may have the least knowledge regarding the drugs ordered or the procedures performed. Often, even if there is a question about the utility of a certain drug or the reason for the treatment plan, no time is allotted to critically think and discuss the situation with the senior resident. Similarly, senior residents are too busy managing rounds and rushing to the OR to engage in a discourse with the attendings. This lack of communication can lead not only to a failed learning opportunity, but also to patient harm or provider self-harm.

Rates of major depressive disorder (MDD) and death by suicide are higher among physicians than in the general population. It is estimated that 300 to 400 physicians die each year from suicide, double the rate of the general population.²³ Risk factors for MDD and suicide include work demands, sleep deprivation, poor nutrition and fitness, desensitization to illness and death in the workplace, increased administrative oversight, access to medication, and burnout.²⁴ A survey of members of the American College of Surgeons demonstrated that suicidal ideation is associated with burnout, symptoms of depression, and perceived medical error in the last three months. Unfortunately, of the 7 percent of survey respondents who expressed suicidal ideation in the previous 12 months, only 26 percent sought help.²⁵

Barriers to physicians seeking help include the stigma of mental illness, concern for negative consequences on medical licensing and insurance coverage, and the perception that others will find them less competent.^24,26,27 Consequently, many physicians, including surgeons, suffer in silence, missing out on the opportunity to connect with colleagues who are having similar experiences, as well as the opportunity to engage with people who may be able to connect them with available resources. Studies have shown that 40–50 percent of patients who die by suicide have seen a primary care physician within one month of their death, and 17 percent within one week; however, they did not discuss their symptoms, suicidal ideation, or plans.²⁸

Communication is paramount for identifying and addressing burnout, depressive symptoms, and suicide risk. Prompting conversation, commiserating, and sharing experiences is the first step toward identifying distress and reducing stigma within the medical community. Once the doors of communication are opened, referrals to the appropriate resources can follow.

When communication is valued

Wellness among trainees and faculty has become a major discussion point in surgery, and more studies are needed to determine root causes and appropriate interventions. Several surgical residency programs are paving the way and leading by example.

After a beloved surgical colleague committed suicide just months after completing residency, the Stanford University, CA, surgical residency program director and multiple residents collaborated to develop the Balance in Life program in 2011 to address key factors affecting resident physician well-being.²⁹ In this program, residents are provided with the following resources: 24-hour access to healthy snacks and drinks, an after-hours guide to the city, scheduled group counseling, a senior-to-junior resident mentorship program, elected class representatives who express concerns to the program director at regularly scheduled meetings, and sponsored group social events. Objective measures, such as burnout and general psychological well-being, were not significantly different after introducing this program, but the surveyed residents expressed generally positive responses to all six of the program’s resource areas. Furthermore, most of the residents attended the psychological counseling sessions and felt that debriefing with colleagues who shared similar experiences was of value. Although a stigma is still attached to counseling, with many residents hesitant to express personal emotions in a group setting, what we glean from Stanford’s intervention is that training programs should create the physical space and time for commiserating and sharing to occur.

Similarly, the University of Arizona, Tucson, general surgery program implemented the Energy Leadership Well-Being and Resiliency Program developed by a professional coach along with the residents and program leadership.³⁰ In this program, residents attend monthly interactive sessions during protected educational time, and topics such as leadership, team building, and communication are addressed. Although objective measures did not show statistically significant decreases in burnout (similar to the findings of the Stanford University program), components of burnout, such as emotional exhaustion, professional efficacy, and perceived stress, did improve. Positive trends also were demonstrated in areas such as self-rated satisfaction with communication skills, leadership ability, and work relationships. Ultimately, program satisfaction in the annual Accreditation Council for Graduate Medical Education survey increased to 96 percent from 80 percent.

More local and national programs are being developed out of the concern for, and personal experiences with, physician burnout and depression. After suffering from both conditions, Michael Weinstein, MD, FACS, an acute care surgeon in Philadelphia, PA, started the LiveWell Physicians program.³¹ This weekly physician peer support group provides a safe forum for the confidential expression of stress and negative emotions, while also providing the skills to recognize and address symptoms of burnout and depression. The program seeks to destigmatize seeking counseling from mental health professionals.

Conclusion

Communication is the common thread that is intricately woven into every aspect of our daily lives as physicians. From evaluating the impact of positive self-talk to examining the methods in which we positively (or negatively) communicate among ourselves and with other health care professionals, it is clear that the effects on our well-being cannot be ignored. Failure to effectively communicate on one level can compound on multiple additional levels, with significant and long-lasting consequences. Understanding and appreciating the value of effective communication is, without question, an important factor in physician wellness and, ultimately, in maintaining career satisfaction and minimizing burnout. Ensuring the ready availability of training resources for teaching effective communication skills and implementing wellness-focused initiatives are paramount to moving the needle forward in this increasingly important area in order to preemptively address small issues before they manifest into larger and potentially fatal outcomes.

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