Is Grit Associated with Burnout and Well-being in Orthopaedic Resident and Faculty Physicians? A Multi-institution Longitudinal Study Across Training Levels

Abstract

Background

Grit has been defined as “perseverance and passion for long-term goals” and is characterized by maintaining focus and motivation toward a challenging ambition despite setbacks. There are limited data on the impact of grit on burnout and psychologic well-being in orthopaedic surgery, as well as on which factors may be associated with these variables.

Questions/purposes

(1) Is grit inversely correlated with burnout in orthopaedic resident and faculty physicians? (2) Is grit positively correlated with psychologic well-being in orthopaedic resident and faculty physicians? (3) Which demographic characteristics are associated with grit in orthopaedic resident and faculty physicians? (4) Which demographic characteristics are associated with burnout and psychologic well-being in orthopaedic resident and faculty physicians?

Methods

This study was an institutional review board–approved interim analysis from the first year of a 5-year longitudinal study of grit, burnout, and psychologic well-being in order to assess baseline relationships between these variables before analyzing how they may change over time. Orthopaedic residents, fellows, and faculty from 14 academic medical centers were enrolled, and 30% (335 of 1129) responded. We analyzed for the potential of response bias and found no important differences between sites in low versus high response rates, nor between early and late responders. Participants completed an email-based survey consisting of the Duckworth Short Grit Scale, Maslach Burnout Inventory-Human Services (Medical Personnel) Survey, and Dupuy Psychological Well-being Index. The Short Grit Scale has been validated with regard to internal consistency, consensual and predictive validity, and test-retest stability. The Psychological Well-being Index has similarly been validated with regard to reliability, test-retest stability, and internal consistency, and the Maslach Burnout Inventory has been validated with regard to internal consistency, reliability, test-retest stability, and convergent validity. The survey also obtained basic demographic information such as survey participants’ age, gender, race, ethnicity, marital status, current year of training or year in practice (as applicable), and region of practice. The studied population consisted of 166 faculty, 150 residents, and 19 fellows. Beyond the expected age differences between sub-populations, the fellow population had a higher proportion of women than the faculty and resident populations did. Pearson correlations and standardized β coefficients were used to assess the relationships of grit, burnout, psychologic well-being, and continuous participant characteristics.

Results

We found moderate, negative relationships between grit and emotional exhaustion (r = -0.30; 95% CI -0.38 to -0.21; p < 0.001), depersonalization (r = -0.34; 95% CI -0.44 to -0.23; p < 0.001), and the overall burnout score (r = -0.39; 95% CI -0.48 to -0.31; p < 0.001). The results also showed a positive correlation between grit and personal accomplishment (r = 0.39; 95% CI 0.29 to 0.48; p < 0.001). We also found a moderate, positive relationship between grit and psychologic well-being (r = 0.39; 95% CI 0.30 to 0.49; p < 0.001). Orthopaedic surgeons with 21 years or more of practice had higher grit scores than physicians with 10 to 20 years of practice. Orthopaedic surgeons in practice for 21 years or more also had lower burnout scores than those in practice for 10 to 20 years. Married physicians had higher psychologic well-being than unmarried physicians did.

Conclusion

Among orthopaedic residents, fellows, and faculty, grit is inversely related to burnout, with lower scores for emotional exhaustion and depersonalization and higher scores for personal accomplishment as grit increases.

Clinical Relevance

The results suggest that grit could be targeted as an intervention for reducing burnout and promoting psychologic well-being among orthopaedic surgeons. Other research has suggested that grit is influenced by internal characteristics, life experiences, and the external environment, suggesting that there is potential to increase one’s grit. Residency programs and faculty development initiatives might consider measuring grit to assess for the risk of burnout, as well as offering curricula or training to promote this psychologic characteristic.

Introduction

Psychologists have extensively focused on not only intelligence but also the qualities or characteristics that are involved in fully using or maximizing one’s intelligence for achievements or accomplishments [11]. Grit has been identified as an attribute that is shared by leaders in diverse fields. Extensively studied by prominent psychologist Angela Duckworth PhD, the concept of grit has been widely shared in her book Grit as well as in her popular TED Talk on the subject [8, 9]. Grit has been defined as “perseverance and passion for long-term goals” and is characterized by working toward a challenging ambition, maintaining focus and enthusiasm on this goal, and sustaining motivation for long periods of time despite setbacks [11]. Grit has been correlated with achievement and perseverance in a wide variety of rigorous pursuits, including the military and the United States National Spelling Bee [11]. In the medical field, grit has been associated with a lower risk of attrition during residency training [32]. With a grit scale developed and validated by Duckworth in a range of populations, grit may contribute to achievement and success [11, 12].

In her book, Duckworth wrote about increasing grit from within and without. She identified four major psychologic assets that gritty people have in common: interest, practice, purpose, and hope [9]. Duckworth included hope as part of the major psychologic assets involved in grit, and specifically equated hope with a growth mindset. She found that students with a growth mindset are grittier than those with a fixed mindset [9]. Nurturing and emphasizing these psychologic factors in medical professionals could similarly encourage them to build grit. Regarding building grit from the outside in, Duckworth commented on the importance of pursuing activities that are designed to cultivate interest, practice, purpose, and hope, as well as the importance of following through with completing challenging tasks. Using examples from professional sports and the military, Duckworth also highlighted the value of culture on shaping personal perseverance and passion [9]. In a team-based profession such as medicine, this cultural influence may be similarly important.

Burnout, a three-pronged syndrome of exhaustion, depersonalization, and decreased feelings of professional efficacy [25], has become an important consideration of the medical profession. The medical training process and subsequent practice can be grueling and stressful. More than half of physicians in the United States report symptoms of burnout [35, 37]. Burnout is an important topic in medicine because of its potential impact on physicians’ health as well as on their medical practice and quality of care [35, 37]. In addition to the psychologic impact on physicians, burnout is correlated with increased medical errors and may increase disruptive workplace behaviors [2, 14, 36]. Further, burnout is associated with a surgeon’s likelihood of reporting a recent major medical error [36]. For the healthcare system, physician turnover and lost clinical hours related to burnout cost an estimated USD 4.6 million annually [17]. Because of the negative ramifications of burnout, an emerging body of research has focused on positive factors such as grit and resilience, which may be negatively associated with burnout [7, 15, 16, 19, 31, 44]. The long-term purpose of our research was to provide a foundation for future interventional studies on building and fostering grit in orthopaedic surgeons throughout their careers. Although small studies have found that orthopaedic surgeons have higher grit than the population of the United States at large [3, 11, 22], we still believe that these associations are important to study in this population in order to set the stage for future studies aimed at increasing grit.

Research targeted at the interactions of grit and burnout in medical professionals has largely been limited to cross-sectional studies, studies with short longitudinal follow-up [1, 7, 16, 31, 34, 42], or studies on residents in training [1, 6, 7, 16, 34]. These studies have found that grit is negatively correlated with burnout and is positively correlated with psychologic well-being [7, 31]. However, most prior research in this area has focused on a single-timepoint analysis of only one or two levels of medical professionals and not how these factors may change over the course of an individual’s medical career [1, 6, 7, 16, 31, 34, 42]. Additionally, there is limited information comparing these measures across a spectrum of levels of training or careers. Although there are studies of grit in orthopaedic residency applicants [3, 21], there are no studies of the relationships among grit, burnout, and psychologic well-being across the training spectrum of orthopaedic residents, fellows, and faculty surgeons. An analysis of the relationships among these variables is necessary to provide a baseline level of knowledge upon which to build future interventional studies to cultivate grit and potentially mitigate the development of burnout in orthopaedic surgeons.

Therefore, we asked, (1) Is grit inversely correlated with burnout in orthopaedic resident and faculty physicians? (2) Is grit positively correlated with psychologic well-being in orthopaedic resident and faculty physicians? (3) Which demographic characteristics are associated with grit in orthopaedic resident and faculty physicians? (4) Which demographic characteristics are associated with burnout and psychologic well-being in orthopaedic resident and faculty physicians?

Materials and Methods

Study Design and Setting

This study was a cross-sectional, interim analysis of the first year of a multicenter, 5-year longitudinal study of grit, burnout, and psychologic well-being in orthopaedic resident and faculty surgeons at 14 academic medical centers. We intended to provide a baseline understanding of the associations between these variables before analyzing how their relationships may change over time. Study data were collected and managed using REDCap electronic data capture tools hosted at Vanderbilt University Medical Center [14, 15]. REDCap is a secure, internet-based software platform designed to support data capture for research studies [14, 15].

Participants

We enrolled orthopaedic residents, fellows, and faculty surgeons who are currently employed at the aforementioned participating institutions for a 5-year longitudinal study between 2019 and 2024.

Demographics, Description of Study Population

During the first year of the survey, 30% of those invited (335 of 1129) responded. Individual site response proportions varied from 14% (16 of 113) to 95% (19 of 20). Because of the low response proportion, we investigated bias by comparing responses of sites with higher (≥ 75%) and lower (< 36%) response proportions (Appendix Table 1; http://links.lww.com/CORR/A628) and participants who responded earlier (≤ 2 weeks after invitation) and later (> 2 weeks after invitation) (Appendix Table 2; http://links.lww.com/CORR/A629). We were unable to directly compare the demographics of participants who did not respond because sites were unable to disclose the demographic characteristics of nonresponders. These analyses found no meaningful differences in the outcomes or exposure variables in this study, and very few demographic differences between groups. These analyses indicate that although sample bias should be considered a limitation of this study because of the low response proportion, we did not find specific indicators of bias in the analyses we could perform.

The sample included 150 orthopaedic residents, 19 orthopaedic fellows, and 166 orthopaedic faculty (Table 1). Overall, 78% (260 of 335) were men. This percentage was similar across the faculty and residents. However, a higher proportion of the fellows were women (eight of 19 respondents). Most respondents in each group were married (overall: 74%; 245 of 333), with residents reporting the lowest percentage of married status (53%; 80 of 150). Most were white, ranging from 14 of 19 fellows to 83% (137 of 166) of faculty. Overall, there was a fairly even distribution among levels of training and years in practice (postgraduate year [PGY] 1: 11%; PGY 2 to 3: 19%; PGY 4 to 6: 21%; 0 to 9 years in practice as an attending: 17%; 10 to 21 years in practice as an attending: 16%; and greater than 21 years in practice as an attending: 16%) (Table 1).

Table 1.

Demographic characteristics by physician status

Demographic characteristics	Faculty (n = 166)	Resident (n = 150)	Fellow (n = 19)
Age in years, mean ± SD	49 ± 11	30 ± 3	33 ± 1
Gender
Men	79 (130)	79 (118)	58 (11)
Women	21 (35)	21 (32)	42 (8)
Marital status
Married	93 (152)	54 (80)	63 (12)
Single, never married, or divorced	7 (12)	46 (67)	37 (7)
Race
White	83 (137)	77 (116)	74 (14)
Black	2 (3)	1 (2)	11 (2)
Native American or American Indian	1 (2)	0 (0)	5 (1)
Asian or Pacific Islander	10 (16)	12 (18)	5 (1)
Other or prefer not to answer	4 (7)	9 (14)	5 (1)
Ethnicity
Latino or Hispanic	4 (7)	5 (7)	11 (2)
Not Latino or Hispanic	96 (150)	95 (133)	89 (17)
Current level of experience
PGY 1	0 (0)	24 (36)	0 (0)
PGY 2-3	0 (0)	41 (62)	0 (0)
PGY 4-6 or above	0 (0)	35 (52)	100 (19)
0-9 years in practice	35 (57)	0 (0)	0 (0)
10-20 years in practice	33 (54)	0 (0)	0 (0)
21 years or more in practice	32 (53)	0 (0)	0 (0)

Data are presented as % (n), unless stated otherwise. The sample was missing age (for three physicians), marital status (for four), and ethnicity (for 18). Additionally, one respondent did not denote their status (faculty, resident, or fellow). PGY = postgraduate year.

Description of Experiment, Treatment, or Surgery

Email-based REDCap survey invitations were sent to orthopaedic residents, fellows, and faculty surgeons at each participating institution. Participants who responded to the survey invitation were asked to review and sign a REDCap-based electronic informed consent document. Three rounds of enrollment invitations were sent over a 6-week period. The REDcap survey comprises Angela Duckworth’s Short Grit Scale [9, 12], the Maslach Burnout Inventory-Human Services (Medical Personnel) Survey [24, 25], and the Dupuy Psychological Well-being Index [13].

Variables, Outcome Measures, Data Sources, and Bias

The Short Grit Scale is an eight-item, validated instrument for measuring grit [12]. Its score is based on respondents’ agreements with statements related to enduring interest and lasting effort. Grit scores range from 1 to 5, with higher scores indicating higher levels of grit. The Maslach Burnout Inventory-Human Services (Medical Personnel) Survey is a validated 22-item instrument to measure burnout in medical professionals, particularly as professionals relate to patients [24]. It includes three components of burnout: emotional exhaustion, depersonalization, and personal accomplishment, and was adapted from the Maslach Burnout Inventory, which is considered a gold-standard measure of burnout [25]. Burnout overall and subscale scores range from 0 to 6, with higher scores indicating higher levels of burnout, emotional exhaustion, depersonalization, and personal accomplishment. The Dupuy Psychological Well-being Index is a 22-item questionnaire on a 6-point (0 to 5) Likert scale. Burnout and grit scores are based on the mean of the answer point values and psychologic well-being on a percentage calculation, with questions reverse-scored as appropriate [12, 24, 31]. The survey also obtained basic demographic information such as the survey respondents’ age, gender, ethnicity, marital status, current year of training or year in practice (collected as PGY for fellows and residents, and years in practice for attendings and faculty members, which were subsequently grouped into the categories of PGY 1, PGY 2 to 3, PGY 4 to 6, and years in practice as attending of 0 to 9, 10 to 20, and 21 years or more), and region of practice.

Ethical Approval

The ethical review board of our institution approved this study, including the interim analysis described in this article.

Statistical Analysis, Study Size

Descriptive data are provided as frequencies, precentages, means, and SDs. Pearson correlation coefficients with bootstrapped 95% CIs were used to assess bivariate correlations among the Short Grit Scale and the Maslach Burnout Inventory-Human Services (Medical Personnel) Survey scores and Dupuy Psychological Well-being Index. The absolute values of Pearson correlations were interpreted as weak (< 0.30), moderate (0.30-0.50), or strong (> 0.50) [5]. A series of multivariable linear regressions were used to assess the impact of the Short Grit Scale on the outcomes while adjusting for age, gender, marital status, race, current practice level, and region of the United States. Standardized β values are reported as a measure of the effect size and are interpreted similar to Pearson correlations as weak, moderate, and strong associations, as outlined above. Adjusted r² values are reported to assess the overall amount of variance explained in each of the the outcomes. A p value of < 0.05 was considered significant for all comparisons. All analyses were conducted using SPSS, version 27 (IBM Corp.).

Results

Is Grit Inversely Correlated with Burnout in Orthopaedic Resident and Faculty Surgeons?

Grit was negatively correlated with burnout. Pearson correlation coefficients demonstrated moderate, negative relationships between grit and emotional exhaustion (r = -0.30; 95% CI -0.38 to -0.21; p < 0.001), depersonalization (r = -0.34; 95% CI -0.44 to -0.23; p < 0.001), and the overall burnout score (r = -0.39; 95% CI -0.48 to -0.31; p < 0.001). The results also showed a positive correlation between grit and personal accomplishment (r = 0.39; 95% CI 0.29 to 0.48; p < 0.001). After controlling for potential confounding variables such as age, marital status, and race, we found that grit was strongly associated with overall burnout and all three burnout subscales (Table 2). Higher grit was associated with higher personal accomplishment (β = 0.49; 95% CI 0.35 to 0.64; p < 0.001) and lower overall burnout (β = -0.64; 95% CI -0.82 to -0.45; p < 0.001), emotional exhaustion (β = -0.69; 95% CI -0.98 to -0.41; p < 0.001), and depersonalization (β = -0.77; 95% CI -1.02 to -0.52; p < 0.001). The standardized β suggested that grit was moderately associated with overall burnout (standardized β = -0.35), personal accomplishment (standardized β = 0.35), and depersonalization (standardized β = -0.30), and weak for the relationship between grit and emotional exhaustion (standardized β = -0.26) when including covariates in the regression analyses.

Table 2.

Adjusted effect of grit (GRIT-S) on each outcome after controlling for demographic characteristics

Model	Outcome	Primary predictor: GRIT-S, β (95% CI)	Standardized β	p value	Adjusted r2 of model	Covariates associated with outcome
Regression 1	Total score: MBI-HSS	-0.64 (-0.82 to -0.45)	-0.35	< 0.001	0.21	Race, years in practice
Regression 2	Emotional exhaustion (MBI-HSS)	-0.69 (-0.98 to -0.41)	-0.26	< 0.001	0.11	Years in practice
Regression 3	Depersonalization (MBI-HSS)	-0.77 (-1.02 to -0.52)	-0.30	< 0.001	0.23	Race, years in practice
Regression 4	Personal accomplishment (MBI-HSS)	0.49 (0.35 to 0.64)	0.35	< 0.001	0.19	None
Regression 5	Dupuy Psychological Well-being Index	10.01 (6.96 to 13.16)	0.33	< 0.001	0.18	Marital status

Covariates included in each multivariable regression model were age, gender, married versus not married status, non-white versus white, and years in practice (PGY1, PGY2-3, PGY4-6, 0 to 9 years in practice, 10 to 20 years in practice, or 21 years or more in practice). Standardized β is a marker of effect size, with values from 0.3 to 0.5 considered a relationship of moderate strength [5]. MBI-HSS = Maslach Burnout Inventory-Human Services Survey; GRIT-S = Short Grit Scale; PGY = postgraduate year.

Is Grit Positively Correlated with Psychologic Well-being in Orthopaedic Resident and Faculty Surgeons?

Pearson correlation demonstrated a moderate, positive relationship between grit and psychologic well-being (r = 0.39; 95% CI 0.30 to 0.49; p < 0.001). After controlling for potential confounding variables such as age, marital status, and race, we found that grit was strongly associated with overall psychologic well-being (β = 10.01; 95% CI 6.96 to 13.16; p < 0.001). The standardized β suggested that grit was moderately associated with psychologic well-being (adjusted β = 0.33) when including covariates (Table 2).

Which Demographic Characteristics are Associated with Grit in Orthopaedic Resident and Faculty Surgeons?

After controlling for age, gender, marital status, race, and current year of training or year in practice, we found that surgeons with 10 to 20 years of practice had lower grit than those with greater than 21 years of practice (β = -0.32; 95% CI -0.59 to -0.05; p = 0.02) (Table 3). However, the effect size for this relationship was weak (standardized β = -0.24). There were no differences in grit by age, gender, marital status, or race.

Table 3.

Multivariable linear regression analysis of factors associated with grit (GRIT-S)

Dependent variable	Covariates	Regression coefficient β (95% CI)	Standardized β	p value
GRIT-S	Age	0.001 (-0.01 to 0.01)	0.02	0.92
	Women (reference: men)	0.02 (-0.12 to 0.14)	0.01	0.82
	Married (reference: not married)	0.04 (-0.10 to 0.18)	0.04	0.55
	Non-white (reference: white)	-0.05 (-0.18 to 0.09)	-0.04	0.48
	Current level: 21 years or more in practice	Reference value
	PGY 1	-0.20 (-0.69 to 0.30)	-0.13	0.44
	PGY 2-3	-0.25 (-0.71 to 0.22)	-0.20	0.30
	PGY 4-6 or more	-0.09 (-0.53 to 0.34)	-0.08	0.68
	0 to 9 years in practice	-0.28 (-0.65 to 0.08)	-0.22	0.12
	10 to 20 years in practice	-0.32 (-0.59 to -0.05)	-0.24	0.02

Full regression model: F (9, 317) = 2.25; p < 0.02; the percentage of variance in GRIT-S scores explained by all of the covariates together is 3% (adjusted r² = 0.03). The standardized β is a marker of effect size, with values from 0.3 to 0.5 considered a relationship of moderate strength [5]. None of the associations here reached that level of effect size. GRIT-S = Short Grit Scale; PGY = postgraduate year.

Which Demographic Characteristics are Associated with Burnout and Psychologic Well-being in Orthopaedic Resident and Faculty Surgeons?

Marital status was weakly associated with psychologic well-being. Married surgeons had higher psychological well-being than those who were not married (β = 5.16; 95% CI 1.27 to 9.06; standardized β = 0.15; p = 0.01). Race, compared between white and non-white participants, was weakly associated with overall burnout and depersonalization. Non-white participants had lower overall burnout (β = -0.23; 95% CI -0.45 to -0.01; standardized β = -0.10; p = 0.045) and lower depersonalization (β = -0.31; 95% CI -0.62 to -0.01; standardized β = -0.10; p = 0.045) than white participants did. There were differences among the current year of practice in overall burnout, emotional exhaustion, and depersonalization. Residents in their second to third year had more overall burnout (β = 0.87; 95% CI 0.10 to 1.64; standardized β = 0.38; p = 0.03) and more depersonalization (β = 1.23; 95% CI 0.18 to 2.28; standardized β = 0.39; p = 0.02) than surgeons with 21 years or more of practice. These associations were considered moderately strong based on the standardized β values. Residents in their fourth year of residency or higher reported higher depersonalization (β = 1.08; 95% CI 0.10 to 2.06; standardized β = 0.36; p = 0.03) than did surgeons with 21 years of practice or more, which represented a moderate-strength association. Surgeons with 0 to 9 years in practice reported higher overall burnout (β = 0.66; 95% CI 0.06 to 1.26; standardized β = 0.28; p = 0.03), emotional exhaustion (β = 0.95; 95% CI 0.02 to 1.87; standardized β = 0.28; p = 0.04), and depersonalization (β = 0.85; 95% CI 0.02 to 1.67; standardized β = 0.26; p = 0.04) than surgeons with 21 years or more of practice did. These associations are weak in strength. Finally, surgeons with 10 to 20 years of practice reported higher overall burnout (β = 0.47; 95% CI 0.02 to 0.92; standardized β = 0.19; p = 0.04) than did surgeons with 21 years of practice or more, which represented weak associations based on the standardized β values. Neither age nor gender was associated with any of the five outcomes (Appendix Table 3; http://links.lww.com/CORR/A630).

Discussion

Burnout is exceedingly common in medicine [26] and is associated with detrimental consequences for patient care, health system productivity, and physician well-being and health [27, 36, 43]. The concept of grit, defined by Duckworth [11] as passion and perseverance, has been noted to be inversely related to burnout in residents and physicians of multiple specialties [6, 7, 16, 32, 34, 42]. The present study was designed to investigate the associations among grit, burnout, and well-being in orthopaedic surgery residents, fellows, and faculty surgeons to provide groundwork for further interventional studies in building grit and reducing burnout. Although these concepts have been studied in numerous medical and surgical specialties, we believe this study was warranted to explore these characteristics specifically in an orthopaedic population, including a spectrum of residents, fellows, and faculty surgeons. A 2020 JAMA Surgery article [40] on retired surgeons’ reflections on their lives and careers found that 12.7% of the surgeons wished they had chosen a different surgical specialty, with orthopaedic surgery being one of the top three most desired choices. Furthermore, our recent unpublished data for orthopaedic surgeons found that 28.5% of orthopaedic surgeons wished they had done something different in their life and career as a surgeon, compared with 52.4% of general surgeons in that JAMA Surgery article. Different specialties face different challenges in terms of call, board requirements, and financial compensation, and these surgeons have different perspectives on their careers. Therefore, each deserves separate investigation. Here, among orthopaedic surgeons, we found an inverse correlation between grit scores and burnout. The present study also found a positive correlation between grit scores and psychologic well-being. These results suggest that future interventions to boost grit in the orthopaedic surgeon population may reduce burnout and encourage psychologic well-being.

Limitations

This study has several limitations. The most important is the potential for response bias. We could only evaluate those who responded to the survey, so the study population was a self-selecting group. The overall response proportion in the study population was 30%, but we were unable to further divide into differential response proportions by gender, race, or other factors. We compared proxy response variables by site response rates (low versus high response rate) and by early versus late responders. There were no differences in outcomes between low and high response sites (Appendix Table 1; http://links.lww.com/CORR/A628) or between early and late responders (Appendix Table 2; http://links.lww.com/CORR/A629).

Another limitation is that the study is likely underpowered to detect differences based on gender or race. Prior orthopaedic research [33] found some differences in burnout and its subscales based on race and gender. However, our survey population is more diverse (in terms of both women and non-white participants) than the overall United States orthopaedic surgeon population [4]. Although we used an anonymous online survey, there is undoubtedly some degree of social desirability bias, with participants wishing to portray or view themselves as gritty or psychologically well individuals. This limitation is true of most psychologic instruments, and we posit that the interactions are still valuable to study even if there is some degree of inflation in the grittiness or psychologic wellness of some participants. True associations, whether stronger or weaker, likely cannot be fully measured with this survey. Similar to most characteristics, grit is intangible and cannot be fully encompassed by a short multiple-choice questionnaire. However, the demonstrated associations between these variables (both in this study as well as in others) suggest that grit is indeed a potential factor that modulates well-being and burnout. Additionally, the Short Grit Scale has been rigorously validated with demonstrations of its internal consistency, consensual and predictive validity, and test-retest stability, as well as its associations with various achievements or outcomes [12].

Additionally, these interactions involve correlations; no causation was demonstrated in this study. The concepts may be difficult to separate from one another. In other words, seeing oneself as a gritty individual may also boost one’s psychologic well-being. Additionally, although the characteristics of grit are generally assumed to be healthy and helpful, they may not always be appropriate in all situations, or may become unhealthy in some circumstances. It is impossible for a survey to fully address the nuances required in complex decision-making and interactions. For example, although a gritty individual may be less prone to quit tasks, sometimes it is entirely appropriate and healthy to cease a certain activity. Another limitation is that the surveyed surgeons are all in academic practice; as such, these findings may not be generalizable to those in private practices. Most data on grit in physicians have, likewise, been collected from academic physicians. However, a study of both rural and non-rural primary care and specialty physicians in Idaho found no difference in overall grit based on practice location, suggesting that perhaps practice setting does not impact grit [29]. As the first year of a longitudinal study, these data were collected at a static timepoint, providing information on the baseline relationships among these variables. However, we cannot yet analyze how their interactions may change over time. We believe this study lays the groundwork for ongoing research into the evolution of the dynamic associations among these variables.

Further, as a purely correlational analysis, we cannot yet comment on whether grit can be increased or modulated with various interventions. Another potential limitation is that orthopaedic surgeons may already possess a high level of grit, which may skew these results. A small study of orthopaedic surgery residency applicants found that the surveyed applicants were in the 70th percentile for grit compared with the overall United States adult population [3, 18]. Similarly, a study of orthopaedic residents reported that the residents’ grit scores were in the 65th percentile compared with the scores of the general population [22]. Although interventions used in the general population can also be implemented in surgeon populations, we recognize that surgeons face unique stresses and challenges that may require nuanced modifications. We also recognize that the above-average grit scores of orthopaedic surgeons may blunt the magnitude of changes associated with any potential interventions. However, given the demonstrated associations among grit, well-being, and burnout, we believe that grit remains an important variable to study, regardless of the population’s average level of grit. Finally, although this study demonstrated differences in grit, psychologic well-being, and burnout based on several different demographic variables, it remains unclear what magnitude of difference is actually meaningful or important because minimal clinically important differences were not calculated for these metrics.

Is Grit Inversely Correlated with Burnout in Orthopaedic Resident and Faculty Surgeons?

Grit was negatively correlated with burnout in our study population of orthopaedic resident and faculty surgeons. One study [31] reported on a survey of 141 residents across nine surgical specialties at one academic medical center. Grit was similarly inversely related to burnout as measured by the Maslach Burnout Inventory [31]. Similar inverse relationships between grit and burnout have been noted in emergency medicine, internal medicine, neurosurgery, and general surgery residents [1, 6, 7, 34]. A few interesting nuances were discovered as part of these studies. In the study of neurosurgical residents, increased social or personal stressors were associated with increased levels of burnout and decreased levels of grit and resilience, which suggests that these characteristics may fluctuate depending on stress level [34]. A single-institution, 3-year longitudinal survey of 55 general surgery residents found an increased risk of burnout in the third clinical year [6]. Grit remained stable in that study population during the 3-year time period, leading the authors to suggest that grit levels at the beginning of residency may predict the development of burnout during vulnerable periods of training [6].

Is Grit Positively Correlated with Psychologic Well-being in Orthopaedic Resident and Faculty Surgeons?

Grit was positively correlated with psychologic well-being in our population of orthopaedic resident and faculty surgeons. A number of studies have similarly demonstrated a positive relationship between grit and psychologic well-being in medical personnel; for example, a 2-year single-institution study of residents in general surgery found that grit was positively correlated with psychologic well-being as measured by the Dupuy Psychological General Well-being Scale and inversely correlated with depression as measured by the Beck Depression Inventory [32]. In that study, grit was positively associated with well-being and negatively predictive of depression. Specifically, even after controlling for baseline psychologic well-being, residents with more baseline grit had higher psychologic well-being when assessed 6 months later than did those with a lower amount grit [31]. A multicenter study of emergency medicine residents similarly found that grit was positively correlated with psychologic well-being, as measured by the WHO-5 Well-being Index [7]. Some studies have suggested that grit should be assessed in residents to identify those who may be more at risk for burnout or poor psychologic outcomes so these residents could be provided with additional support or counseling [6, 31, 34]. These findings suggest that a grit assessment may identify those who are at the greatest risk of having poor psychologic well-being in the future and that these physicians may benefit from counseling to provide support and improve their coping skills during a stressful career [31]. However, despite the rapid rise of positive psychology, some have recently called contemporary behavioral science into question. Notably, The Quick Fix: Why Fad Psychology Can’t Cure Our Social Ills [38] has particularly indicted popular psychology concepts, including grit, as a superficial way of dealing with problems rather than addressing the societal structures and root causes that drive them. This book and other similar essays [39, 41] emphasize the importance of cautiously interpreting studies on psychologic constructs, as well as the necessity of a more comprehensive assessment of the deeper factors that influence these constructs and their resultant behaviors.

Which Demographic Characteristics are Associated with Grit in Orthopaedic Resident and Faculty Surgeons?

We found that individuals with 21 years or more in practice had higher grit scores than those with 10 to 20 years of practice, suggesting that grit increases with experience. An alternative explanation is that those with lower grit may have chosen not to remain in the field of orthopaedic surgery. Although our study is unable to comment on surgeons who may have already left the field, our findings are concordant with prior research. Duckworth has found that grit increases with age and has suggested that this may be a function of the cultural era that one grows up in [9]. That is, older adults might be grittier because of a higher past cultural emphasis on sustained passion and perseverance compared with the culture of a younger generation. An alternative theory is that people mature over time and that people develop the capacity for long-term passion and perseverance as they age. Cross-sectional research from the British medical system also suggests that senior physicians have more grit than trainee physicians [16, 42]. Similar to all traits, grit is influenced by personal (nature) and environmental (nurture) factors [9], making it challenging to fully delineate the contributions of each to an individual’s grit.

Which Demographic Characteristics are Associated with Burnout and Psychologic Well-being in Orthopaedic Resident and Faculty Surgeons?

Married surgeons had higher psychologic well-being, suggesting that marriage may provide a social support system that can be important for psychologic wellness. Surgeons with greater than 21 years of practice had less burnout than those with 10 to 20 years of practice. The 2020 Medscape National Physician Burnout and Suicide Report noted a generational divide in burnout, with Generation X physicians reporting higher burnout than Millennial or Baby Boomer physicians did [26]. These findings are believed to reflect mid-career burnout, as well as external pressures that physicians of Generation X may be facing, including caring for both children and elderly parents [26]. The nuances of demographic characteristics related to grit, burnout, and psychologic well-being emphasize that each of these factors are multifactorial and require individualized consideration for each surgeon. The interplay between these factors undoubtedly changes and fluctuates over time in response to work and personal stressors and experiences, although we could not elucidate this from the single-year nature of this analysis.

Conclusion

The present study found a positive association between grit and psychologic well-being and a negative association between grit and burnout in orthopaedic surgeons. With ever-increasing rates of burnout in medicine, early identification and support of at-risk trainees and practicing surgeons could reduce burnout’s detrimental downstream effects, including reduced well-being, suicide, medical errors, and economic costs. Interventions for increasing resilience have been successfully implemented in other stressful careers such as the Master Resilience Trainer course of the United States Army, and similar training might be able to augment grit in medical professionals [30]. A study of middle school students found that students whose schools emphasized mastery (prioritizing academic improvement) instead of performance (competition and social comparison) were more likely to increase students’ grit during the school year [28]. The results suggest that residency or fellowship cultures could similarly affect trainees’ development of grit [28]. Duckworth [9] has developed foundational principles (interest, practice, purpose, and hope) for increasing grit, and these principles could be applied or emphasized in residency training or faculty development. Although some authors have proposed that grit be used as a metric in the increasingly competitive selection process for medical school and residency [20, 23], Duckworth [10] emphasized that grit should not be a high-stakes metric, but is rather intended for research and self-discovery. However, despite the potential utility of grit in wellness and in subsequent personal and professional development, there are no interventional data that speak to the impact of programming or training to increase grit. Hence, although the present findings of the relationships of grit, burnout, and psychologic well-being provide a baseline level of knowledge of these variables in an orthopaedic surgeon population, further interventional research will be required to determine whether there is causality in these relationships, as well as to assess their degree of malleability during a medical career.