Shame and Burnout in Oral and Maxillofacial Surgery Resident Education; A Cross Sectional Analysis of 217 Current OMS Residents

There is an unfortunate culture of “shame-and-blame” in traditional residency education. In addition, intense work demands, limited control, and a high degree of work-home interference predisposes residents to burnout. Unfortunately, there is a dearth of literature exploring the use of shame as an educational tool in surgical resident training, as well as a lack of information regarding burnout levels amongst surgical trainees.  A 20-question survey was developed incorporating the Maslach-Burnout-Index (MBI) and a previously-validated shame questionnaire, and sent to all AAOMS affiliated oral and maxillofacial program directors for distribution amongst their respective residents. A total of 217 responses were received (M 82%, F 18%): 7% of respondents felt that shame was a necessary/effective tool, 70% of respondents felt that they had been shamed during residency, and 82% reported witnessing the shaming of a fellow resident. 63% of residents reported that an attending physician performed the shaming, and the most common location for a shame event was the operating room (50 %).  There was no statistically significant difference in shame rates between male and female respondents. When residents are exposed to an increased rate of shame events (5 or more events), they are more likely to be shamed due to surgical error (p < 0.001), incorrect response to questioning (p < 0.01), and disagreement regarding clinical care (p < 0.001), and more likely to experience these increased number of shame events irrespective of environment (p < 0.001). They are also more likely to suffer from depression (p < 0.0001), isolation (p < 0.0001), and poor job performance (p < 0.0001). In addition, residents that experienced greater than 5 shame events were more likely to report having been shamed by a senior level resident (p < 0.01). Interestingly, those that were exposed to less than 5 shame events were more likely to report that the shame event had no effect on them (p < 0.05). Regarding resident burnout, 51% of OMFS residents suffer from moderate/severe emotional exhaustion, 85.7% suffer from moderate/severe depersonalization, and 55.3% suffer from moderate/severe feelings of inefficacy. When post-graduate year (PGY) is considered, PGY-1 residents of both four and six year training programs suffered from the highest rate of both burnout (p < 0.001) and depersonalization (p < 0.001). There was no statistically significant difference in burnout rates between male and female respondents. Residents that are perpetually shamed (> 5 shame events) are more likely to experience moderate/severe burnout (odds ratio, 4.6 [95 % CI, 2.1 to 10.0]; P < 0.001), and severe depersonalization (odds ratio, 5.1 [95 % CI, 2.1 to 12.0]; P < 0.0001) than residents that were never shamed, and also more likely to experience moderate/severe burnout (odds ratio, 3.5 [95 % CI, 1.7 to 7.5]; P < 0.001), and severe depersonalization (odds ratio, 3.9 [95 % CI, 1.7 to 9.0]; P< 0.001) than residents that were shamed less frequently ( 1-5 shame events). In conclusion, despite of its widespread use, shame is an ineffective and counterproductive tool in OMFS residency education that often results in depression, isolation and worse patient care. In addition, the rate of moderate/severe OMFS resident burnout is greater than 50%, and the rate of moderate/severe OMFS depersonalization is a staggering 85%. There is a clear relationship between number of shame events and burnout and depersonalization levels. 

References:

1. McMains KC, Peel J, Weitzel EK, Der-Torossian H, Couch M. Perception of Shame in Otolaryngology-Head and Neck Surgery Training. Otolaryngol Head Neck Surg. 2015 Nov;153(5):786-90 

2. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and Self-Reported Patient Care in an Internal Medicine Residency Program. Ann Intern Med. 2002;136:358-367. doi:10.7326/0003-4819-136-5 200203050-00008