Demands on surgeons and surgical systems have increased at a rapid rate during the last several decades, primarily related to an aging patient population in need of surgical interventions combined with an understaffed surgical workforce. These factors are in addition to the growing requirements for documentation and data collection for quality assurance mechanisms and pressure to increase surgical volume. Proof of this trend is the fact that the average general surgeon performed 398 cases in 1997 and 533 in 2007, while over the same period of time surgical training programs remained relatively static.1 Further attestation to this trend is the shift in surgical practices away from small surgical practices toward larger group employment models in recent years.2 In addition, new technology, such as minimally invasive surgery, requires surgeons to learn new techniques, which potentially require more time to perform, particularly during the learning curve.3 Finally, achieving professional success in an increasingly competitive environment and maintaining active roles beyond clinical duties has further contributed to the significant strain experienced by surgeons and threatened their ability to provide optimal care. The COVID-19 pandemic has intensified these demands, as systems address the surgical backlog with increasing demand for throughput despite a significant number of surgeons experiencing burnout.4,5 Our surgical systems must proactively address issues that impact well-being and self-actualization of surgeons to effectively address these challenges in the long-term. The question we face will continue to be: How can surgical leaders promote well-being and build surgeon resilience to retain the workforce and optimize their performance?
Integrating a culture of well-being across the healthcare workforce to build resilience is essential to providing quality care for surgical patients. Resilience is one’s ability to adapt well in the face of adversity, trauma, tragedy, or significant stress. Building a resilient surgical workforce requires the promotion of well-being principles, including the importance of providing and sustaining a safe workplace and attention to individual physical, emotional, mental, spiritual, financial, and family well-being. Well-being programs have been integrated into many health systems to address clinician well-being and reduce burnout; however, little is known about the utilization and efficacy of these programs among surgeons. For example, demands on surgeon time and institutional culture might limit surgeon engagement in available resources.
The American College of Surgeons and Ariadne Labs propose a Guide for Building Surgeon Resilience (GBSR) for health systems seeking specific recommendations to preserve and/or improve the physical, mental, emotional, spiritual, family, and financial health of surgeons during the COVID-19 pandemic and beyond (Fig. 1). The foundation of the guide is existing literature regarding workforce support as well as surgical system research performed during the COVID-19 pandemic. The recommendations in the GBSR span multiple principles and provide a starting point for surgical leaders to address surgeon well-being. The guide must be tailored to the local context and adapted to address the specific gaps at individual organizations.
GUIDE FOR BUILDING SURGEON RESILIENCE
The guide starts with the expectation that the surgical leader assumes the role of a well-being role model. It is imperative for surgical leaders to model actions that reflect the principles and values outlined above. These actions demonstrate leadership commitment to a healthy and resilient workforce by supporting both institutional and personal well-being. The surgical leaders must incorporate well-being principles into policies and practice in addition to attending to and acknowledging the importance of their own personal well-being. Leading by example and consistently demonstrating the importance of well-being as a core faculty expectation can help gradually shift the surgical culture at an institution to one that promotes well-being and resilience.
Next, the leader must build a team to develop and support well-being programs at their institution. This multidisciplinary team should reflect the diversity of the surgical department or division, in terms of race and ethnicity, experience, including trainees, gender, personal and professional roles, and other considerations as relevant; the team may be small or large. Ideal surgeons for the team are individuals who can champion well-being initiatives with diverse perspectives and who are relational, emotionally intelligent, and respected by their peers.6,7 Importantly, the team must be sufficiently empowered to enact changes in the organization. The domain of influence of the team should include the scope of well-being related to activities within the hospital and can also be directed to support well-being out of the hospital, such as subsidy for home food delivery, expanded childcare support, and/or resources that promote work-life balance.
Next, the guide addresses the need for the team to evaluate the current state of well-being in the department/division. Seeking input at the individual, departmental, and institutional levels will provide a more holistic view of current conditions and help leaders understand the challenges and needs of surgical teams. In addition, it will provide surgeons with an opportunity to be heard. Evaluation methods can be formal or informal; formal methods include survey tools, such as the well-being index8 or information from human resources about employee turnover. Informal feedback can be solicited through facilitated discussions in departmental meetings, hosting listening sessions or virtual town halls. Using a mix of these methods is often the best approach.
Using the collected information, the team should identify gaps or critical areas that are impacting surgeon well-being the most and can be feasibly addressed. Teams should look for deficiencies in the system (policy and practice development) as well as at the hospital staff level (activities for the hospital staff that promote and support well-being). This process should involve on-the-ground engagement to identify specific root causes of burnout in the local context and to develop actionable insights into systems and processes driving burnout.
Goals for improvement should be developed based on the identified gaps. Each goal should be prioritized based on the importance of the goal and the feasibility of the solution required to address the identified need. Starting with simple, feasible solutions with clear impact potential can provide new teams with early wins to support sustainment and expansion of future work. Each goal should be specific, measurable, attainable, relevant, and time-based. For each goal, the scope, resource requirements, and timeline should be clearly outlined. Goals should be promoted through a public commitment that underscores the priority of well-being of the department/division members and institutional leadership. This communication can occur through a combination of emails, telephone calls, in meetings, and/or a personal or virtual launch of the well-being program.
Surgeons are often focused on solutions and are eager to quickly move to enact change. The preceding steps are critical to ensuring the success of a well-being program. Urgent situations may require immediate changes, but such abrupt changes may not result in a sustained and holistic improvement. It is only after establishing teams and identifying prioritized goals that programs are truly ready to begin the work of solution implementation that will result in long-term improvements. When developing solutions, the use of a systems lens may help to identify policies and processes that can be modified to promote surgeon well-being specifically related to priority goals. When possible, these policies should be embedded into existing workflows and processes. Developing a pilot program with clear, measurable goals can build support for the work and allows for small scale testing and iterative improvement.
Finally, the key to continued success and sustained improvement in building a well-being program is to reassess measures through meaningful evaluation. Evaluation of program effectiveness using previously identified metrics such as a well-being index can be reviewed on a quarterly or biannual basis considering more frequent measurement when program changes are implemented or health system changes occur. On the basis of these findings the program can be modified or expanded by identifying changes that can address new or remaining gaps. Working with institutional leadership and multidisciplinary stakeholders throughout this process provides the opportunity for the program to have an impact beyond surgeons and extend benefits to other disciplines and to the entire hospital.
The following vignette offers an example of how the GSBR can be implemented to result in a successful well-being program.
Vignette: Building a Surgical Peer Support Program9,10
A surgeon recognized moral distress that they and their trainees experienced after a major intraoperative event. He recognized the lack of a program to support surgeons through these events at his institution. First, he began talking to other surgeons and trainees about the importance of providing support to colleagues going through similar situations (Be a well-being role model). He quickly identified an interested team of surgeons and trainees passionate about this effort (Build a team). Together they performed a survey and found that other surgeons experienced similar distress after major intraoperative events and evaluated existing solutions to address this problem (Evaluate the current state and Identify gaps). Armed with this information the team set a goal to build a peer support program with a launch date in 6 months in the general surgery division with 4 trained peer supporters by the start date (Set goals). With this goal in mind, they made a public commitment with departmental leadership endorsement. There was enthusiastic uptake of this program as surgeons nominated colleagues to be trained after considering, “Who do you turn to when things go wrong?” (Begin the work). Over time a dedicated, balanced and diverse team of peer supporters has undergone training to ensure representation across the department. This group of individuals continues to be engaged due to the small time commitment requested and positive experiences in helping colleagues during difficult times (Reassess and expand/improve).
The most valuable resource at every healthcare institution is the people who work there. A system and culture that supports surgeons in all areas of well-being will thrive by providing the foundation for a strong and resilient surgical workforce. As surgeons consider how to continue to improve surgical care quality, we must address this ongoing and critical need. Surgeons, surgical leaders, health systems, and policy makers must embrace this culture change in surgery to address patient and personal safety and ensure a resilient workforce now and in the future.
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