The American Journal of Surgery (2013) -, -–-

The relationship between grit and resident well-being

Arghavan Salles, M.D.a,b,*, Geoffrey L. Cohen, Ph.D.b, Claudia M. Mueller, M.D., Ph.D.c

aDivision of General Surgery, Stanford Hospital & Clinics,b

300 Pasteur Drive, MC H3591, Palo Alto, CA 94305, USA;Stanford University Graduate School of Education, Stanford, CA, USA; cDivision of Pediatric Surgery, Lucile PackardChildren’s Hospital, Palo Alto, CA, USA

KEYWORDS:Grit;Burnout;Well-being

The authors declare no conflicts of i

* Corresponding author. Tel.: 11-6

1663.

E-mail address: arghavan@stanford.

Manuscript received May 7, 2013; re

0002-9610/$ - see front matter � 2013

http://dx.doi.org/10.1016/j.amjsurg.20

AbstractBACKGROUND: The well-being of residents in general surgery is an important factor in their success

within training programs. Consequently, it is important to identify individuals at risk for burnout andlow levels of well-being as early as possible. The aim of this study was to test the hypothesis that res-ident well-being may be related to grit, a psychological factor defined as perseverance and passion forlong-term goals.

METHODS: One hundred forty-one residents across 9 surgical specialties at 1 academic medical cen-ter were surveyed; the response rate was 84%. Perseverance was measured using the Short Grit Scale.Resident well-being was measured with (1) burnout using the Maslach Burnout Inventory and (2) psy-chological well-being using the Dupuy Psychological General Well-Being Scale.

RESULTS: Grit was predictive of later psychological well-being both as measured by the MaslachBurnout Inventory (B 5 2.20, P 5 .05) and as measured by the Psychological General Well-BeingScale (B 5 .27, P , .01).

CONCLUSIONS: Measuring grit may identify those who are at greatest risk for poor psychologicalwell-being in the future. These residents may benefit from counseling to provide support and improvecoping skills.� 2013 Elsevier Inc. All rights reserved.

Residency is a difficult period in physician trainingacross specialties. One recent survey noted that residentsrate the majority of their working days as being between 4and 5 on a 5-point, Likert-type scale of stress, with 5representing ‘‘extremely stressful.’’1 This constant degreeof pressure can lead to feelings of discouragement and dis-satisfaction, which may ultimately result in the desire toleave a training program.

The growing concern about the toll stress can have onthe professional and personal lives of residents has led to an

nterest.

50-387-5275; fax: 11-650-736-

edu

vised manuscript August 23, 2013

Elsevier Inc. All rights reserved.

13.09.006

increased focus on their well-being. However, the factorsthat contribute to residents’ ability to sustain themselvesand maintain well-being through the rough patches in theirtraining are not as yet understood.

In this report, we focus on an individual trait, persever-ance, which has not yet been considered in this context.Duckworth et al2 showed the importance of perseverance in6 studies of different populations. They defined a new con-struct, grit, as perseverance and passion for long-termgoals. In studies with people ranging from West Point ca-dets and Ivy League students to national spelling bee partic-ipants, they found that grit was an independent predictor ofachievement, even when taking into account prior measuressuch as IQ and grade point average.

In addition, research has shown that those who arehappier are more likely to graduate from college, less likely

2 The American Journal of Surgery, Vol -, No -, - 2013

to leave their jobs, and less likely to experience burnout.3 Inessence, happiness or well-being may increase the likeli-hood that people will persevere and achieve their goals.In this study, we aimed to examine the relationship betweengrit and measures of well-being in residents of several sur-gical specialties. We proposed that residents who are higherin grit would also display higher levels of well-being.

Methods

In the context of a larger longitudinal study, we combinedseveral previously validated scales to assess residents’ per-severance, burnout, and psychological well-being. We usedthe Short Grit Scale4 as a measure of perseverance. This in-cludes items such as ‘‘Setbacks don’t discourage me’’ and‘‘I often set a goal but later choose to pursue a differentone.’’ The Maslach Burnout Inventory (MBI)5,6 was usedas a measure of burnout. One representative item from thisscale is ‘‘I feel emotionally drained from my work.’’ Wealso included a broad measure of psychological well-being,the Dupuy Psychological General Well-Being Scale(PGWB).7 Two sample items from this scale are ‘‘Haveyou felt so sad, discouraged, hopeless, or had so many prob-lems that you wondered if anything was worthwhile duringthe past month?’’ and ‘‘I was emotionally stable and sure ofmyself during the past month.’’

After obtaining approval from the Stanford UniversityInstitutional Review Board, we administered the survey twiceto residents across 9 surgical specialties (cardiothoracic sur-gery, general surgery, neurosurgery, ophthalmology, orthope-dic surgery, otolaryngology head and neck surgery, plasticsurgery, vascular surgery, and urology). Survey sessions wereseparated by 6 months. Informed consent was obtained, andthe data were deidentified and kept confidential.

Scores were created for each scale by averaging theresponses to individual items within the scale. The sign wasreversed as appropriate for the wording of each item. TheMBI is composed of 3 subscales: emotional exhaustion,depersonalization, and personal accomplishment. An over-all score for burnout was created by reverse coding the

Table 1 Demographic data by specialty

SpecialtyNumber of respondents(number of women)

Cardiothoracic 5 (1)General surgery 40 (20)Neurosurgery 13 (2)Plastic surgery 17 (7)Ophthalmology 11 (5)Orthopedic surgery 21 (5)Otolaryngology head and necksurgery

18 (6)

Urology 14 (5)Vascular surgery 2 (1)

*The vascular surgery program had residents only in postgraduate years 1

personal accomplishment subscale and then adding all 3scales together. MBI data were analyzed using this com-posite score as well as each of the subscales. The Short GritScale and the PGWB were not broken down into furthersubscales. For all 3 scales, the MBI, PGWB, and the ShortGrit Scale, all items were included in the analyses below.Items on the MBI had 7 answer choices, items on thePGWB had 6 answer choices, and items on the Short GritScale had 5 answer choices.

Data were analyzed using correlations and linear regres-sion analyses in Stata version 10.1 (StataCorp LP, CollegeStation, TX).

Results

One hundred forty-one residents (52 women; responserate, 84%) participated in the study. See Table 1 for a break-down of age, gender, and response rate by specialty. We firstexamined the data to see whether grit was a stable measureover the period of study. In keeping with previous data,2

the participants’ grit scores were highly positively correlatedacross time points (r 5 .71, P , .01; baseline mean, 3.65 6.53; follow-up mean, 3.646 .53). The average level of burn-out at baselinewas 3.056 .84 on a 7-point scale. The averagelevel of psychological well-being at baseline was 4.546 .70on a 6-point scale. These values are quite similar to thefollow-up values for burnout and psychological well-being(r5 .76, P , .01, and r 5 .72, P , .01, respectively).

Tables 2 and 3 show the variation of grit, burnout, andpsychological well-being at baseline among the differentsurgical specialties and among different years in training,respectively. Analysis of variance examining differencesin grit, burnout, and psychological well-being by specialtyshowed no significant differences (P values ..62). A sim-ilar analysis for variation by year in training showed thatgrit and psychological well-being did not differ signifi-cantly by year in training (P values ..45). As might be ex-pected from Table 3, burnout did differ by year in training,with those further along (years 5 and 6) having lower levelsof burnout than more junior residents (F 5 2.17, P , .05).

Age(mean)

Range ofpostgraduateyear

Responserate

30.2 1–4 63%31.6 1–5 85%31.7 1–5 76%30.9 1–6 85%33.8 2–4 100%30.3 1–5 81%31.3 1–5 100%

30.6 1–5 82%27 1–2* 67%

to 3 at the time of the study.

Table 2 Grit, burnout, and psychological well-being at baseline by specialty

Specialty Grit BurnoutPsychologicalwell-being

Cardiothoracic 3.78 6 .48 2.69 6 .66 4.84 6 .69General surgery 3.63 6 .40 2.96 6 .81 4.57 6 .63Neurosurgery 3.61 6 .59 2.77 6 .74 4.79 6 .53Plastic surgery 3.51 6 .51 2.90 6 .86 4.54 6 .77Ophthalmology 3.72 6 .73 3.32 6 1.12 4.31 6 .75Orthopedic surgery 3.80 6 .52 3.26 6 .83 4.48 6 .72Otolaryngology head and neck surgery 3.64 6 .72 3.10 6 .76 4.35 6 .87Urology 3.59 6 .50 3.27 6 .91 4.45 6 .94Vascular surgery 3.5 6 .18 3.46 6 .65 4.39 6 .93

Data are expressed as mean 6 SD.

A. Salles et al. Grit and resident well-being 3

After these descriptive analyses, we assessed whethergrit, as measured at the first time point, was predictive oflater psychological health. In a multivariate linear regres-sion controlling for gender and baseline burnout, wefound that, on average, those with more grit at baselinehad significantly lower rates of burnout 6 months laterthan those with less grit (B 5 2.20, P 5 .01). The samepattern was true for the emotional exhaustion and deper-sonalization subscales of the MBI when controlling forthe corresponding baseline values. There was no statisti-cally significant relationship between grit and the per-sonal accomplishment subscale of the MBI (B 5 2.12,P 5 .30).

Residents with more grit at baseline also had, onaverage, significantly higher levels of general psychologicalwell-being 6 months later than those with less grit (B5 .27,P , .01), again controlling for gender and baseline psycho-logical well-being.

We repeated these analyses including only residents ingeneral surgery, because this is the specialty that is thoughtto have the highest rate of attrition. Although the relation-ship between grit and overall burnout was similar to that inthe overall sample, the relationship did not reach statisticalsignificance (B 52.36, P 5 .12). The relationship betweengrit and the emotional exhaustion subscale was also similarin the general surgery sample compared with the totalsample (B 5 2.51, P 5 .12) but again did not reach statis-tical significance. There was no statistically significantrelationship between grit and depersonalization, personal

Table 3 Grit, burnout, and psychological well-being at baseline by

Year intraining

Number ofrespondents Grit

1 26 3.67 62 29 3.67 63 25 3.59 64 21 3.61 65 22 3.81 66* 3 3.96 6Research 15 3.44 6

*Only 1 of the residency programs has 6 clinical years; this program has 3

accomplishment, or the PGWB (P values ..25). Notably,there were only 40 residents in this sample.

Comments

The data presented here show that grit was predictive ofpsychological health in a sample of 141 surgical residents.This suggests that measuring grit may be one way toidentify those who are at risk for burnout or lower overallwell-being. Thus, program directors could use grit as ameasure to identify residents who could benefit fromadditional support throughout their training. Although thiscould also be done by administering the MBI and thePGWB directly, these instruments contain sensitive ques-tions. Residents may not want their program directors to beaware of their responses to the items contained in thesesurveys. The Short Grit Scale, however, does not containsuch sensitive items and takes less time to administer (itcontains only 8 items, compared with 22 each for the MBIand the PGWB).

Furthermore, burnout and low levels of psychologicalwell-being may be related to why some residents choose toleave residency rather than complete it. Given the shortage ofphysicians, and surgeons in particular,8 in this country, it isimportant to understand the factors that affect attrition. Nu-merous studies have looked at attrition rates in surgical resi-dencies.9–12 Although the exact number varies amongstudies, the generally accepted figure is that 1 of 5 general

year in training

BurnoutPsychologicalwell-being

.52 3.12 6 .78 4.56 6 .66

.64 3.02 6 .90 4.52 6 .71

.50 3.34 6 .87 4.40 6 .66

.49 3.12 6 .81 4.55 6 .71

.51 2.63 6 .71 4.66 6 .74

.31 2.70 6 .51 4.73 6 .49

.42 3.05 6 .96 4.56 6 .86

residents per year.

4 The American Journal of Surgery, Vol -, No -, - 2013

surgery residents leaves residency.10–12 This attrition iscostly for both the individuals affected and their training pro-grams.13 Although there are a number of factors that arelikely to contribute to attrition, including lifestyle and inter-est in another specialty or career,10,13 we propose that gritmight be a measurable identifier for this important careeroutcome.

Similarly, grit might be a useful measure for programdirectors to incorporate into their residency screeningprocess. However, there are some constraints we mustconsider. First, our data show grit to be relatively stableover only a short period of time, 6 months. Previous studieshave shown that grit increases with age.2 Given the lengthof residency training programs, residents’ grit may changewithin the course of their training. In addition, it would bedifficult to find a single session in which to administer thesurvey. One could have applicants complete the survey onthe day they interview; however, that is an emotionallycharged day. Furthermore, residents’ responses might beinfluenced by the context of the interviews, which could re-sult in inaccuracies in measurement.

There are several important overall limitations to thisstudy. First, it is unclear why these relationships were notupheld when we restricted the analyses to the 40 residentsin general surgery. It may be that the relationship betweengrit and psychological health is different among thissubgroup. It is also possible that this is due to the samplesize, which is much smaller than the overall sample.Additional investigation is needed within this departmentto elucidate these findings.

Another limitation is that the study took place at only1 institution, which may limit its generalizability. Further-more, this study is correlational in nature and does notsuggest a causal relationship of any kind. Finally, the timeframe of the study was too short to measure the outcome ofgreatest interest, attrition itself. We plan to follow theseresidents over the next few years to be able to relate grit to

attrition directly rather than the surrogate measures usedhere. We also hope to collaborate with other institutions tosee if the pattern of data seen here is similar elsewhere.Only then will we know whether the statistically significantdifferences found here will translate into meaningfuldifferences in residency outcomes.

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