You are listening to The Operative Word, a podcast brought to you by the Journal of the American College of Surgeons. I'm Dr Lillian Erdahl, and throughout this series, Dr Tom Varghese and I will speak with recently published authors about the motivation behind their latest research and the clinical implications it has for the practicing surgeon. The opinions expressed in this podcast are those of the participants, and not necessarily that of the American College of Surgeons.
Hello, and welcome back to The Operative Word, the podcast of the Journal of the American College of Surgeons. I am your host, Dr Lillian Erdahl. And today I am joined by Dr Jessica Ching, who is an associate professor of surgery at the Baylor College of Medicine in Houston. Welcome, Dr Ching. Thank you so much for having me today. Dr Ching, do you have anything to disclose related to this publication? No, I have no disclosures.
We're going to talk about the work you did with your colleagues called “Protective Effects of Authenticity against Depression, Suicide, and Burnout among Surgeons.” And before we get into that topic, because this is a sensitive topic, I do want to mention to any of our listeners that the National Alliance on Mental Illness has a helpline you can text or call 988 for any emergencies or concerns that you have.
So, Dr Ching, do you want to tell us just a little bit about the background that made you and your colleagues interested in this research topic? Yeah. So what got me interested in this was, I had as a medical student, resident, fellow, faculty, I'd seen people around me struggle with burnout and depression, whether or not they were able to articulate it or we just you were able to observe that they were struggling. But when I was a faculty, it came to a head.
I had a, a close work colleague who committed suicide in April of 2020, and I had just worked with her, two days before, the day before she committed suicide. And I remember thinking, did I miss something? Was there something I should have picked up on? Was there were there signs that would have, you know, led me to act differently or alerted, to what was to come? And the reality was there was there was nothing really that I personally observed or witnessed.
And, that was frustrating to feel helpless in that. But then, you know, watching the outpouring of response after she committed suicide and the the way that people reacted emotionally was very touching. And after a few weeks that subsided and ultimately everything kind of went back to business as usual. And I just kept thinking, can we really go back to normal after this? Is this really going to prevent somebody else committing suicide or having these struggles?
And I kept thinking, there has to be something better. There has to be something more that we could do. So I started looking at doing qualitative research, actually to try to catalog the stories and struggles. I was listening to the Dr Lorna Breen Foundation, speak out on, physician suicide and mental health and the stigma associated with it. And I was listening to, the stories of Dr Kara Cunningham as well speak out on this.
And I kept thinking, man these stories are so powerful, let's catalog them. So I actually started first with qualitative research, looking at, what the physicians around us are going through. And even if they don't want to own the stories, personally, I it's called the, anonymous. Excuse me, it's called the Authentic Doctor Survey. And it is anonymous. If you go to AuthenticDoctorSurvey.com, you'll find it there.
And so through that tool I was able to capture and chronologically these anonymous, responses to the struggles and stories of physicians all over the U.S. I analyzed those and realized that we really needed quantitative data. So that's how the current study was born, was trying to quantitatively, validate what we could see qualitatively and what we knew from the stories of those around us that we had personally witnessed. So. Well, thank you for sharing your personal story.
And, I also, unfortunately, have had colleagues die by suicide. And, and I think you're not there's no normal about it. You know, I appreciate you saying that. That business as usual, doesn't feel good.
And, you know, how touching to hear you honor your colleague by taking that seriously and seeing, you know, if you can do something to help someone else to prevent others from, you know, from suffering loss of their loved ones and colleagues, but also, you know, can we help our peers, do better and survive in what is really a stressful job?
And I think that, you know, some of the numbers that you found in your study, you know, speak to this, but there are also national numbers looking at the rates of burnout and suicidal ideation among physicians and surgeons. The Medscape survey that you quote said 49% of all respondents and 45% of general surgeons in 2024 reported symptoms of burnout. And, I you know, I think those numbers are staggering to me. Half of our workforce is coming to work every day not feeling well.
We're not overall feeling well, which, as you mentioned, you know, sometimes is related to the work itself, but not entirely. May be related to other things like the struggle of being a professional and, you know, a caregiver at home, as well. But, really, those numbers, I think, should call our attention, that we have and in, you know, another survey 70% of surgical trainees reporting burnout. I mean, these are staggering numbers. Agreed.
I think one interesting thing that we found in our data is that along the lines of burnout is that burnout did not change with professional rank. So that means residents and fellows, the training group, the junior faculty and the senior faculty group, which senior faculty was defined as being more than ten years. In practice, the burnout rate was equivocal. There was no clinical. There was no statistical significance. So what does that mean?
Well, that means it doesn't get better as you get further along, because what do you tell yourself when you're a student, when you're a resident, when you're starting a practice? Is that if I make it to the next step, it's going to be better, right? That's what we tell ourselves. That's what we tell our loved ones. Right? But I think the reality is it doesn't automatically.
And like by knowing that while it is disappointing to realize that that's the case, at least you're we're not blindly proceeding along a path thinking that it's automatically going to be better, realizing that we have to make intentional choices to make it better. And your study, in order to look at the numbers better, was looking at one institution. So when you talk about that, these results are from a single institution, although again, there are other studies looking at burnout.
One of the interesting findings that that, I noted from your research was that there was no sex or gender difference, in some of these symptoms, whereas other studies have suggested there might be a difference for women physicians, suffering more burnout or depression. Right. And, you know, it was, single center by choice, one to control, like for a local political and systemic factors.
Because in addition to this work, we did proceed on looking at other specialties within our college of medicine. And so we were able to compare across that. So the gender and the, you know, those differences, we did see some of those in other specialties, but they did not show up in this surgical department. Interesting. And tell us a little bit about, you know, some of the specific factors that you were looking at. I've learned a lot of terms from your study.
You know, I learned about authentic living scores, but can you tell us a little bit about authenticity and some of the metrics that you were looking at? Yeah, sure. I think it's always helpful to start with, the operational definition for authenticity because it can feel a little fuzzy and subjective. So authenticity is I define it as being true to one's core self in all situations, relationships, and roles you may take on.
So it's a consistent outward expression of your values regardless of what you're doing or who you're with. And it's a spectrum. And the other important concept to understand with authenticity on the other side of that spectrum is inauthenticity. So inauthenticity is compartmentalizing yourself and your life into different scenarios or to different roles that you may take on. It's inconsistent and it's not always congruent with your internal values.
Vs authenticity is a complete integration of self and life. And it's consistent. So it's a spectrum with two different sides. And while we all would like to think we are on the authenticity side all the time. It's really something we oscillate between, while aiming toward the authenticity side so that we can have those positive and protective benefits.
Yeah. And when you were talking about authenticity and in reading this research, I thought a lot about, what we hear from different individuals about editing themselves in the workplace, you know, feeling that maybe they have to dress differently to be accepted as a professional, you know, as well as their behavior.
So I think, that that was kind of what came up for me was, you know, are you able to present yourself, authentically just when you come into work or, you know, just people feel they have to moderate their behavior and and have a, you know, an inauthentic presentation of who they really are. Another term that comes up with that is, professionalism. Right? That's the term that we hear early on in medical school and all the way throughout about what is professionalism.
And a lot of us were taught to associate that with a certain austere presentation of ourselves. That is in a lot of ways impersonal and inherently compartmentalizing, because we're putting on this professional persona in order to be a doctor. Yeah. So I, I think that’s something that we learn early in our training to do and it becomes very integrated into how we are as we move through our, our training and into our practices. So, it is definitely something that's embedded deep early on.
Tell me a little bit about the survey, you know, tools that you use. Because again, I want to be mindful. Sometimes people look at research like this and don't see it as rigorous. And, you know, you used validated tools and this is, you know, rigorous science here to kind of try to get at this question. Correct. We did use validated tools. There were four, validated tools in this survey. There was, the authenticity scale, which is a 12 question. Validated tool.
It assesses authenticity across three domains. The Authentic Living Score, which you mentioned earlier, looks at how well you live out your values, in accordance and consistency. And then, so that's a positive metric and also talks about it also reports it in, accepting external influence, which is how much the opinions or fear of judgment of others impact you being able to live out your authentic self.
And then lastly, self-alienation score, which is basically a score of internal disconnectedness. Where do you understand how you feel on the inside? Are you in touch with that? Do you know what your values are? Or have you not had a chance to think about that? And that would be captured in that score. And so it reports the three scores separately for, the authenticity scale. And so that allowed us to do a lot of the analysis that you'll see in my article.
The other three survey tools we used were the PHQ9, which is a patient health questionnaire, it's a validated tool for depression that's commonly used in primary care. There is also the Copenhagen Burnout Inventory, which is a validated tool for burnout. There's a lot of different scales within that. We took the work section. There's three typical ones, but there are some other adaptations of them. We focused on the work section since that was the, the, focus of the study.
So there were some questions... You were trying to capture. How is burnout, related to your work? Exactly, exactly. You know, there's different types of burnout that you can assess with that tool. Yeah. And then the last one was called the Ask-Suicide Screening Questions, and I did with it's a four, excuse me, five question survey. We use the first four.
And the last question was omitted because it was, it's about if you're holding someone on site, like, as an individual, face to face, and you're asking if they have a suicide plan that they're going to act on to try to determine if they're safe to leave the premises. So that question wasn't relevant to this particular application. Okay. You found overall, again, you know, rates of depression and burnout I think that are concerning to me.
Tell me a little bit about you know, what you found. Just generally. So in general the the results did parallel what is is reported by larger national data each year, which validates the application of the findings as well, because we're right within the typical population distribution for this. But in general, we found that authentic living story scores correlated with reduced burnout and depression.
Accepting external influence scores and the self-alienation scores, increased burnout and depression, as well as self-alienation scores, increased suicidal ideation risk as well. In general, we saw that with rank looking at rank and authenticity, we found that over time that the accepting external influence and the self-alienation scores decreased with rank, which is meaning that the further that they were advanced in their career and out of training, it improved.
Some of those scores, you know, the accepting external influence tended to jump quite a bit and improve from a resident to a just beginning, beginning a junior faculty, and then not as much change between junior and senior faculty. The self-alienation score was more of a gradual decrease. And the authentic living score, over time tended to improve, with rank. Did you did that make sense to you?
I mean, did you, you know, I guess it it seems, makes sense to me that people, as they move up in their career may feel more confident or less, need to rely on the input of others about how they should behave or who they should be. Yes, absolutely. It definitely made sense for that to improve, I think, with time. The other thing, you know, that, you know, was kind of inherent is this in this is the hierarchical nature of the training model. Right?
So the accepting external influence being high or even the self validation being high may, you know, also be influenced by the model that they're in, the training model. So that's just one other consideration. Yeah. And you talked a little bit in the discussion too, about the fact that, you know, we certainly, could be missing people who, who left. You know, people talk about the leaky pipeline that we lose, people along the way in training for a variety of reasons.
And so there may be people who are who had, different results, who just aren't represented because they didn't get to the senior faculty rank. Instead, they, were burned out and left, or they left for other reasons. Yeah, like a selection bias, I guess, yes. You know, definitely true. And there's and, it's, it's difficult to say, but. Yeah, definitely a possibility.
And, and this work looks at one aspect, what may help people have talked about resilience as well in research around burnout, depression and, physician suicidal ideation. How does this factor of authenticity kind of add to our working knowledge and how might we use it in, you know, both talking to individuals as well as systems, you know, or people in charge of systems, to make change. You know, I think authenticity is a really widespread, you know, there's a lot of applicability to it.
One, you know, obviously there's an individual component in at the choice or the the recognition to be aware of authenticity and to attempt to strive for it. So that's one aspect. But you're right, there's a whole component of the system around us. And, it's an interesting interplay.
The current research direction that I've been working in is actually to try to study that interplay more, with this and so trying to better understand what kind of environment, whether that be, you know, your immediate colleague group, your department, the local hospital system. But what kind of environment is going to foster authenticity?
What are the factors in that or in the peer-to-peer relationships that we have or team dynamics that are going to foster authenticity and then what kind of things do not? And there are some things that are really obvious and that that we can all name that are helpful or that are not helpful in that regard. But trying to quantify which things are actually correlated, that we can then, replicate, I think is really important. But, you know, there's still that, that element of the individual.
So, one thing that is, well, is documented too, if you start looking at, you know, the literature, literature for this topic, one thing that you'll notice is that, there's a term called psychological safety, which I think is really interesting, talking about the environment in which you work and, and most of the data for psychological safety is not about physicians.
And so trying to improve that environment to be a psychologically safe environment, this is really, has the potential to be really impactful. And what we've seen in the early data collection for the next segment of our work in an improving authenticity and individuals
and thus affecting the risk of burnout, depression and suicide. So, well, and and the, the term that came up as well, which is a term I've heard elsewhere, recently was, you know, this culture of belonging and, and and it's actually on the, hierarchy of needs. Belonging is a pretty fundamental human need. And so, you know, I heard a talk by Dr Julie Silver about that, but, you brought that up in the discussion as well, you know, how can we foster belonging in the workplace?
Yeah, it's really important. So if you think about it with authenticity, in order to have meaningful personal relationships, you have to feel known as an individual by that other person, and you have to feel like you know them. So if you're never able to be authentically who you are, it's hard to form a meaningful relationship because they never really get to know you, and you don't really get to know them.
And so it really underpins having that sense of belonging and connectedness and having the ability then if, you know, if you choose to be vulnerable with, and build on that relationship and have trust. So I think that, so yeah, it's, it's a really foundational, concept to form relationships and have belonging.
I think the other thing that struck me in reading this, and in looking at other, discussions of physician depression and burnout from a, from a workforce as well as an individual standpoint, is removing the stigma around, having anything that's a struggle, you know, whether it qualifies as, you know, mental health or qualifies as, you know, workplace stress. However we talk about it, that we need to make it easy for physicians to get the help and support that they need.
And you talked about that in terms of access to that, you know, within our workplaces and particularly being in healthcare. But, you know, it seems to me simple in some respects that we should have access to mental health care for physicians. But I do think that there's a lot of stigma around saying that you need help or that you're struggling, as well as, you know, some of the licensing concerns and the way that credentialing committees ask questions about mental health as well.
So the other piece that, is important to me to talk about is how to make it easy for physicians to get the help they need. And as you mentioned, Dr Kara Cunningham spoke about this as well. But that we need to tell our colleagues it's okay to ask for help, and to be open if you need, if you want to be open, if that's part of authenticity for you. Right. And normalizing that the, the struggles and, making it something like you said, that's not a stigma.
Well, you know, one thing that has come up in, some of the data not reported in this particular, article, but some of our other research is, we found that the, the rate, so looking at the validated tools, burnout, depression and suicidal risk, but particularly focusing on burnout and, and depression looked at had them take the validated tools and looked at the self-reported data. So when asked if they are burned out and how burned out they are, they are they really burned out or not?
Mild? Moderate? Severe. And then looked at the, the, depression if they think they're depressed or not. We found that the, physicians typically underreport by 2 to 3 times, like under what the actual is when they take a validated tool. And so it begs the question, why the discrepancy? These are obviously very adept and very smart individuals. So why would it be so, so different? And, you know, in thinking about it, it may be that they are unaware.
They think that this is their that this is normal for everyone. This is how it's supposed to be. This is the baseline, which I think a lot of us have gone through, that we look around and we see everyone, especially when you're training, you look around, you're like, well, everyone's has it tough. So this is how it is. Or are they ignoring it? Are they saying like, I'll deal with this later, it'll be better later. I know that I'm burnt out, but it's going to get better.
Or are they just being stoic, willfully saying, yes, I am burnt out, but I'm not going to think about right. That right now. I'm going to keep going and I'm going to do this. I'm just going to push this aside, and I'm going to keep going. And so I can picture any of those three. And probably a combination being true for a lot of people that, you know, that we work with and at times even, you know, I can think of myself having thought those same thoughts about life and what I was experiencing.
So but it's definitely interesting thinking about the underreporting may not even be because of a fear of stigma. It may be from what I just described. Oh yeah. Well, and I certainly can say I experienced a culture where stoicism was encouraged, in my training and I'm sure that I also, you know, have done that myself. And perhaps, you know, asked that of other individuals to be stoic at a time when what they really needed was a break or to be able to, to, say, you know, I'm not okay.
And that's where the culture change, you know, can come into play that, that we allow people to get the help that they need or admit that they need help and encourage it rather than pushing through. And it's not just for, what you bring up. I mean, I think for physical illness as well. Right. You know, as long as you don't have a positive Covid test, you can put on a mask and come to work. Right?
We don't necessarily encourage or I don't think workplaces tell people to come to work sick, but you're rewarded for showing up to work and pushing through and getting that work done. 100 percent. Yeah. Well, thank you, for spending some time sharing your findings with The Operative Word audience. Dr Ching, and thank you for continuing to do this work that is so meaningful. Clearly to you personally, but to our profession and our colleagues.
And I look forward to learning more in your next publication. Thank you so much. I really enjoyed speaking with you. Thank you for taking an interest in this. I think it says a lot that such a renowned organization would put this on their radar and really, you know, own it. So I really appreciate that from the Journal of the American College of Surgeons. And, you know, this work is meant to advocate ultimately. And the data, is meant to be to help advance things and improve things.
So I hope that we'll continue to be able to partner as we move forward. So thank you. Thank you. Thank you for listening to the Journal of the American College of Surgeons ‘Operative Word’ Podcast. If you enjoyed today's episode, spread the word on social media by using the hashtag #JACSOperativeWord. Subscribe to the Operative Word wherever podcasts are available, or listen on the American College of Surgeons website at FACS.org/Podcast.