Editor’s Spotlight/Take 5: Is Grit Associated with Burnout and Well-being in Orthopaedic Resident and Faculty Physicians? A Multi-institutional Longitudinal Study Across Training Levels

Perhaps you’ve heard of an experiential learning program called Outward Bound [12]. If so, you may associate it with arduous backcountry experiences, long hikes, and skill building in challenging outdoor environments.

But you may not know of its origins. The program dates to the 1930s, but a key part of it developed in the early years of World War II. Sir Lawrence Holt, the owner of a merchant shipping company in the United Kingdom, noticed an unusual survival curve among his seamen when their ships were torpedoed: Younger sailors were dying in their lifeboats, while older ones were not. It was not a function of training; the newbies had lots of that. It wasn't physical fitness, either, since youth has its advantages there, too. It seems the younger sailors who perished seemed to lack what we’d now call resilience. The old salts, some of whom were veterans of the Great War, had it in abundance. Holt and a colleague created a training program—which they named Outward Bound—to try to cultivate just that quality in the younger merchant marines [11].

Today, we might call it grit. In a popular book by the same name, as well as in her scholarly work, psychologist Angela Duckworth defines grit as perseverance and passion for long-term goals [3]. Those who lack it seem to be at risk for another term that’s having a cultural moment: burnout.

Burnout even appears in the International Classification of Diseases (ICD-11), though it’s listed as an occupational phenomenon rather than a medical condition. The ICD-11 defines it as having three dimensions: energy depletion or exhaustion, mental distance from or negativism toward one’s job, and reduced professional efficacy [19].

In this month’s Clinical Orthopaedics and Related Research®, a large, multicenter study group lead by Donald H. Lee MD, of Vanderbilt University in Tennessee, found an inverse relationship between grit and burnout among orthopaedic residents, fellows, and faculty [7]. They’re not the first to do so, although this is one of the more ambitious efforts I’ve seen on the topic—an interim report on a 5-year longitudinal study—and after controlling for relevant confounding variables, the effect size they uncovered was large. Where to go with findings like these?

Sir Lawrence Holt, Dr. Angela Duckworth, and Professor Donald Lee all seem to agree on one thing: Grit can, and should, be taught.

I’m not spotlighting Dr. Lee’s study because I agree with that, though I don’t know if I disagree. Certainly, his study is robust and the findings are intuitively sensible. But the truth is, I’m struggling with this whole set of concepts, and I’m hoping for a conversation about them—starting here in the Take 5 section of CORR® immediately following this Editor’s Spotlight commentary, but also beyond.

They say that the person who writes about his experience is not the same person who had it. Even so, as I look back, it feels to me like my level of grittiness, as best as I can characterize it, has changed with time (and not always in one direction). It’s certainly changed with context. At times, I’ve been a gritty surgeon, at other times much less so [8]. I have the same sense about my varying grit levels as an athlete, father, and husband, despite reasonable levels of “passion and perseverance” in all of those domains.

Perhaps more importantly, thoughtful people have wondered whether grit is the right construct at all. Grit doesn’t consider the possibility that dogged persistence may be the wrong reaction and a well-timed pivot the right one, depending on circumstances [17]. Grit certainly can smack of blaming the victim; by suggesting that insufficient grit is the reason physicians succumb to burnout, we may miss opportunities to fix healthcare systems that many have characterized as all-but-impossible to thrive in. One clinician wrote: “Burnout is a normal human response under excessive stress. Anything that is exposed to undue amounts of stress will break. People are no different. Clinicians are no different. We are not unbreakable” (emphasis hers) [15]. Another, more colorfully, derided the idea that we should create better-adapted canaries (clinicians) to send into ever-worse coal mines (healthcare systems that treat those clinicians as disposable resources) [2]. And it seems clear enough that the playing field, at least in our specialty, is not completely level—not even close—in terms of factors like gender [18] and race [14]. Expecting aspirants and practicing surgeons to overcome discrimination and harassment with grit is quite simply, wrong.

Finally, it would seem to be difficult if not frankly uncharitable to characterize our residents (and partners) as anything but gritty. To get where they’ve gotten has taken an amazing amount of passion and perseverance: They represent a thin slice (acing college) of a thin slice (kicking butt in medical school) of a thin slice (making it into an orthopaedic residency). They can’t make up more than a small part of the right-hand tail of the grit curve. Is it possible to make them still-grittier in the setting of a 5-year program during which they also have to learn how to miss the popliteal artery while cutting tibias?

Dr. Donald Lee thinks so. Join me as we go behind the discovery with Dr. Lee in the Take 5 interview that follows, and please send in your own questions—I promise to pass them along—as letters to the editor (eic@clinorthop.org).

Take 5 Interview with Donald H. Lee MD, senior author of “Is Grit Associated with Burnout and Well-being in Orthopaedic Resident and Faculty Physicians? A Multi-institution Longitudinal Study Across Training Levels”

Seth S. Leopold MD: Congratulations on this fascinating study, though I know it’s only the first moment in time on a 5-year journey with these study participants. So maybe change over time is a good place to begin: As I mentioned, my own levels of resilience, perseverance, and passion have not been stable quantities across settings and seasons of life, so perhaps my grit isn’t, either. What are you hoping to learn in the longitudinal part of your study—both from trainees and also in fully fledged surgeons—and, more importantly, how are you hoping to use what you learn?

Donald H. Lee MD: Thank you for the opportunity to further discuss this topic. We agree that like some other psychological attributes, grit is not a static factor. Influenced by both individual characteristics as well as by external experiences, grit can be dynamic as our lives and careers evolve. While most studies demonstrate that grit increases with age and experience, we would like to further delineate when and why these changes occur within a career trajectory. A medical career requires frequent role transitions and changes—from medical student to resident (and then perhaps fellow) to attending physician. Even after beginning practice, substantial transitions occur from early career to mid and late-career, and then to retirement.

Each of these transitions has its own unique stressors and challenges. Grit, it appears, may help modulate individuals’ responses to these situations. Furthermore, each of these transitions carries unique risks for psychological distress and burnout. For example, changes in call schedules throughout the course of residency or practice may lead to fluctuations in burnout. We hope to better understand when and why these changes are occurring. This longitudinal study is intended to provide the baseline relationships of grit, burnout, and psychological well-being as well as the dynamic changes in these relationships during a surgical career.

We hope to build upon this study to investigate how grit can be bolstered in orthopaedic surgeons with the intention of reducing burnout and psychological distress. Although there are existing data on the benefits of resilience training, we lack evidence on interventions that might increase grit in medical professionals. We hope to find ways to increase grit in orthopaedic surgeons.

Dr. Leopold: Given what I’ve suggested about physicians [8] and certainly orthopaedic surgeons being at the top of the grit pyramid to start with, how reasonable is it to try to engritten them further, and how possible is it to do this within the context of either an already stuffed 5-year residency or our already overpacked workdays as surgeons after graduation from residency?

Dr. Lee: As mentioned in our manuscript, several small studies have reported that orthopaedic surgery residents score in the 65^th to 70^th percentiles of grit as compared to the general population. Despite higher-than-average grit scores, orthopaedic residency is grueling. Traits that may actually contribute to orthopaedic surgeons’ success (such as perfectionism) can also drive deleterious psychological outcomes such as burnout. We believe that despite higher-than-average grit, the demonstrated associations between grit, burnout, and wellbeing warrant further thought on bolstering grit to reduce burnout and psychological distress. Additionally, as previously mentioned, there is precedent that resilience training can be beneficial and can be done in a relatively short time period. The Pennsylvania resilience training program was administered to Chinese medical students for 10 weeks, with weekly training sessions lasting 90 to 120 minutes. The surgical resident training programs also required about 6 to 8 weeks, with classes lasting approximately 90 to 120 minutes [6]. The Master Resilience Training in the US Army is taught over a 9-day period. These training programs do not require an inordinate amount of time. However, as with any program, continued maintenance and enhancement of the principles of the resilience training program are needed for ongoing benefits.

Dr. Leopold: Grit may have a dark side, namely that people with lots of it may hold themselves and others to unrealistically high standards [9]. Perfectionism can be associated with some real harms, and one study correlated grit with “adaptive grandiose narcissism” [5], which is not an unalloyed good. I don’t see too much clinical research in surgeons focusing on the problems of excessive perfectionism. What are we missing?

Dr. Lee: Burnout, as coined by American psychologist Herbert Freudenberger, typically occurs in goal-oriented achievers or idealists [4]. These individuals are dedicated and commitment-oriented both in their personal and especially in their professional lives. As Dr. Freudenberger points out, burnout is virtually impossible in the underachiever. As such, many of these characteristics are seen in successful surgeons. These individuals tend to become victims of their own over-commitment or over-dedication. They are intensely driven people who strive hard to achieve goals. They tend to burn out because they have pushed themselves too hard for too long. These individuals’ high aspirations, which may or may not come to fruition, also contribute to their symptoms of burnout such as exhaustion or loss of energy. This leads to symptoms of detachment, depersonalization, or cynicism characterized by moving away from people, events, and situations, acting as a self-protective mechanism to minimize pain. Finally, there is a sense of decreased personal accomplishment accompanied by feelings of negativism and cynicism.

The treatment for burnout starts with a recognition that burnout is occurring. Following recognition is the personal desire to change, action of the necessary steps to change, followed by the change itself. Although perhaps underrecognized in surgeons, the very characteristics (such as perfectionism) that are essential for excellent patient care can be maladaptive in other situations and may lead to burnout. An unhealthy obsession with or adherence to a goal could certainly be seen as an excessive or harmful amount of grit. Although there is always the potential for too much of a good thing, we do not broadly see grit as a perfectionist characteristic, but rather as one that simply spurs individuals to persevere toward their goals despite challenges. Moreover, we believe that this study and others demonstrate that grit can play a role in promoting psychological well-being and reducing burnout, including in highly successful individuals.

Dr. Leopold: As you sense, I’m a little unsure about these concepts; you can count me as agnostic, or maybe “grit-curious.” Still, others are all-in, including the military; you alluded to the Army’s Master Resilience Trainer course [16], Duckworth’s work was done with military partners [3], and the Special Forces have been trafficking in grit for a long, long time. I also couldn’t help but notice that your study’s finding on age (more grit among older surgeons) paralleled that of the founders of Outward Bound more than 80 years ago [6]. What can we learn from those who’ve been teaching these concepts—perhaps using different terms—for a long time?

Dr. Lee: There tends to be an increase in grit, resilience, and wisdom with age. Experience has been shown to be a predictor of mental toughness in athletics and business. Through targeted development, coaching, mentoring, or simply life events, experience brings a positive effect on mental toughness. Using a Mental Toughness Index, Percy et al. [13] found that staff surgeons scored higher than residents in all areas of mental toughness domains (self-belief, attention and emotion regulation, success mindset, buoyancy, optimism, adversity capacity). Similar to Duckworth’s findings, Marchant et al. [10] found that mental toughness generally increased with age and was also higher in more senior managerial positions. They postulated that an increased exposure to important life events may have a positive developmental effect on mental toughness. Another study similarly demonstrated, perhaps not surprisingly, that adults over the age of 51 years are wiser than college students [1]. This study suggested that growth in wisdom requires a combination of cognition, self-reflection, openness to all kinds of experiences, and the recognition and acceptance of uncertainty [1].

Similar to these more-recent studies, the Outward Bound founders and those involved in related programs have demonstrated that enhancing grit (or similar factors) often involves a combination of life experience as well as targeted instruction or coaching. Analogous to the age-old nature versus nurture debate, grit is related both to internal factors and external experiences.

Dr. Leopold: Burnout. Depression. Emotional distress. Career dissatisfaction. Gritopenia (OK, I made that last one up). To what degree are these separate entities or formes frustes of the same thing, and how much do the Venn diagrams overlap? My father’s response to job-related agita used to be “that’s why they call it work and not play.” When does job-related stress become burnout, and if it does, why not make a change?

Dr. Lee: True depression, which is frequently associated with feelings of guilt, tends to pervade all areas of a person’s life, including appetite, sex life, and sleep, and can be accompanied by suicidal thoughts. Burnout is often characterized by feelings of anger. The depressive-like feelings of burnout are more temporary and tend to pertain more specifically to one area of life, predominantly work. Emotional distress and career dissatisfaction are components of burnout, but they can certainly exist in and of themselves, separate from burnout.

Donald H. Lee MD

Change can take many forms including personal change (change in self), change in condition (job or occupation), and change in location (moving one’s home or business). First of all, most orthopaedic surgeons are relatively happy with their career choice. In our recent unpublished survey of recently retired orthopaedic surgeons, 72% were happy with their chosen profession of orthopaedics. Orthopaedic surgeons do not often change their occupations. In addition to the sunk costs of becoming an orthopaedic surgeon (time, money, effort), the loss of substantial income tends to preclude orthopaedists from changing careers.

I believe that if burnout is happening, a personal change often is the better alternative for the surgeon affected. As mentioned previously, it may be difficult to change external factors but it is usually possible to make positive changes within one’s self. Of course, there certainly are sometimes external factors, such as an oppressive or hostile work environment, that do require making a change in condition or location.