Introduction
Surgical educators have in recent years begun to emphasize the importance of wellness in our training programs in response to widespread concerns for burnout and resident distress. Wellness interventions often focus on supporting duty hour restrictions, mindfulness and mental health, or mentorship.1 While these are essential interventions, there has not yet been significant focus on the physical wellness of surgical trainees. The long work hours, significant time constraints, intense physical demands, and psychosocial stressors associated with residency training of our physicians create working conditions that can affect their level of physical fitness as well.
Several studies have found that physical fitness declines during medical residency training.2–7 Olson et al2 evaluated the rate of burnout among internal medicine residents and its relation to physical activity and found that 79% of residents had a decline in physical activity after starting residency. Residents with less physical activity were more likely to report burnout.
Suskin et al3 found that rotations with high clinical workloads during medical residency were associated with a decrease in aerobic fitness, measured as decreased oxygen consumption during exercise, which can predict long-term mortality.4 Arora et al5 found a decline in all training activities of military physicians during residency, including push-ups, sit-ups, and 2-mile run times. This decline was most notable in residents with higher levels of fitness at the start of their residency. Daneshvaret al6 showed that internal medicine residents reported significant decreases in physical activity and fitness. The residents’ mean fitness age was 5.6 years higher than their mean chronological age.
There is only one study that investigated physical fitness during surgery residency training. Perrin et al7 compared the fitness characteristics of surgical and nonsurgical medical residents and found that surgical residents had a greater BMI, a higher body fat percentage and lower aerobic fitness than nonsurgical residents. Surgical residents fell in the 20th percentile for recommended aerobic fitness compared the 70th percentile for non-surgical residents. Surgical residents worked more hours each week than nonsurgical residents.
Given the paucity of evidence regarding physical fitness during surgical residency training, our study examined the fitness perspectives of surgical residents.
Methods
From March to November of 2022, we conducted four voluntary 45-minute focus groups consisting of a total of 32 surgical residents of post-graduate years 1, 2, 4, and 5. Participating residents were rotating at the VA Boston Healthcare System from 2 affiliated academic training programs.
Focus groups were conducted using three open-ended questions (Table 1) that were pilot tested with residents not involved in the study.
With participant permission, focus group sessions were audio-recorded. Transcripts were created from the audio recordings. All identifiers were removed. De-identified transcripts were then manually analyzed using open coding to develop thematic categories.
This study was reviewed and deemed exempt by our Institutional Review Board. When invited to participate, residents were reassured that their decision to participate in the study and their discussions will be de-identified and will not be used in their resident performance evaluations.
Results
Demographics
A total of 32 surgical residents participated in the study. The number of participants in each focus group ranged from 6 to 10, with an average of 8 participants. The demographic characteristics of the participants are shown in Table 2.
Qualitative Analysis
A total of 3 themes were identified, each with several sub-themes. The themes were: the state of current resident physical fitness, barriers to maintaining physical fitness, and interventions recommended for improving resident fitness.
The state of current resident physical fitness
Residents acknowledged that there has been an increased focus on overall resident wellness from their residency programs, including providing access to an off-site physical fitness facility. However, all participating residents rated their current physical fitness as “suboptimal” and commented about how “challenging” has been for them to maintain their physical fitness once they started their surgical training: “As a medical student, I was able to go for a run or go to the gym at least 2-3 times a week … once I started residency, I go weeks in a row without any significant physical exercise. It is like a day and night change”.
They also report the decrease in physical exercise is only worsened by a diet that has become “unhealthier”: “I am afraid to weigh myself, as I keep putting more and more weight. It is so frustrating to exercise less and eat more junk food”.
Barriers to maintaining physical fitness
Residents identified several barriers to maintaining and improving their physical fitness, including time constraints, physically demanding workload, lack of adequate workplace fitness infrastructure, and lack of at-work fitness curriculum. Representative resident quotes are shown in Table 3.
Interventions recommended for improving resident fitness
Several fitness improvement interventions were recommended by the residents: regular assessment of physical fitness, creation of at-work individualized physical fitness curriculum with protected workout time away from work duties, virtual or in-person physical fitness coaching, and establishment of regular fitness challenges. (Table 4)
Discussion
Our study shows that surgical residents report decreased physical activity and poor fitness during their training. In line with findings from several studies on physical fitness of medicine trainees2,8,9 surgical residents reported a significant falloff in their physical activity and fitness from medical school to residency. This identifies the transition to residency as one crucial window of opportunity to implement interventions focused on maintaining and further developing the pre-existing exercise habits and culture of the medical students entering their internship year.
Our findings confirmed prior findings from medicine residents,2,3,8 reporting a lack of time to be the major obstacle to maintaining regular physical activity during residency. Time constraints are even more severe for surgical residents since they generally work more hours than nonsurgical residents.7
Our study participants reported frustration that, in addition to a decrease in physical activity, their wellness is further affected by inadequate nutrition. Maintaining optimal nutrition during residency training is a struggle that is well-acknowledged by graduate medical educators10,11 with lack of time and access to healthy food being the most important barriers to optimal workplace nutrition.
Despite long and busy work hours, it is very important for surgical residency programs to advance strategies to support their trainees achieve optimal physical fitness and nutrition. Residents participating in our study suggested several interventions for improving fitness that combine protected time for at-work physical activities with improved fitness curriculum and coaching. In addition to considering the applicability of these resident recommendations at their individual programs, surgical educators should also explore innovative ways to improve the fitness of their trainees. There are successful reports of motivational fitness curriculum12 and incentivized exercise program13 for medical trainees. Furthermore, there are also examples of mandatory, workplace physical activity programs used by the municipality of Copenhagen, Denmark, and several companies in the Scandinavian countries for employees performing demanding physical tasks.14 Although initially controversial,14 these measures are receiving increasing attention.15 These types of interventions can be considered in surgical trainees, though they require thoughtful consideration in their implementation to be inclusive of all trainees, regardless of physical ability, and to not add additional burden.
Supporting physical fitness programs of our surgical residents not only increases their wellness and resilience during the residency training, but also cultivates healthy and lasting physical exercise habits that would help them better integrate their work and life as practicing surgeons. This is very important because practicing surgeons are known to have suboptimal physical activity and fitness,16,17 placing them at risk for premature exit from practice with significant workforce shortage implications. Harms et al16 showed that 50% of US surgeons experience a major health issue by the age of 50 years and that physical exercise is an important factor influencing the length of a surgeon’s career.
Importantly, physician fitness has also implications on the health of our patients. Not only physically fit physicians can have a better work performance, but they are also in better position to counsel their patient on healthy habits. This correlation is strong as several studies have shown that medical students, residents, and physicians who exercise regularly and maintain normal body mass are more likely to counsel their patients on these issues.18–21
The present study should be considered in the context of its several limitations.
First, residents who agreed to participate in our study may have been more interested in improving their physical fitness, introducing a risk for selection bias. Second, our study could also be subject to social desirability bias, with respondents answering questions with positive and favorable responses to be better received.
Third, the sample size is small, although in line with other focus group studies on surgical education and wellness. However, the study groups were diverse and from two different training programs. Fourth, our study cohorts included surgical residents from only two residency program in the Boston area, and as such, our results may not be generalizable to all surgery residents nationwide.
Fifth, due to the qualitative nature of focus group studies, we cannot exclude inherent researcher bias as well as moderator’s influence on group discussions. To reduce these, we used structured questions and minimized moderator activity. Finally, to maximize anonymity the present study does not include information on individual residency program characteristics.
These limitations notwithstanding, our study brings awareness to the barriers surgical residents face in optimizing their physical fitness. Many of the residents report a change from their previous habits and feel it impacts their health. This study additionally identifies several resident-recommended interventions for improvement. Training programs should consider the implementation of a well-rounded wellness program that includes these recommended interventions to improve physical fitness and nutrition.
Conclusions
Despite an increasing focus on trainee wellness, surgery residents face several barriers in achieving optimal physical fitness. Resident physical wellness remains a casualty of long working hours, and effective physical fitness programs that can be incorporated into the busy workday of our trainees are lacking. Institutional support from ACGME and residency programs, input from residents, and practical applicability are crucial considerations for the implementation of an at-work personalized physical fitness curriculum for surgery residents.
Disclosure Statement
The authors have no conflicts of interest or financial disclosures to declare.