There was a total of 848 survey respondents. Of these respondents, 682 (81%) completed all the questions and were thus used for further data analysis. This response rate surpassed our calculated minimal sample size requirement of 383. The demographic details about the participants are presented in Table 1.
Table 1
Demographic characteristics of survey respondents
Variable | N | % | CD-RISC* Mean + SD | P Value |
Gender | Female | 383 | 56 | 71 ± 12 | 0.014 |
| Male | 299 | 44 | 74 ± 13 | |
Age (years) | Younger than 35 | 601 | 88 | 72 ± 12 | 0.093 |
| 35 or older | 81 | 12 | 75 ± 13 | |
Ethnicity | Caucasians | 458 | 67 | 73 ± 12 | 0.107 |
| Asian / Pacific Islander | 113 | 17 | 71 ± 13 | |
| Hispanic | 47 | 7 | 75 ± 12 | |
| Multiple ethnicity / Other | 36 | 5 | 69 ± 11 | |
| African American | 27 | 4 | 74 ± 9 | |
| American Indian or Alaskan Native | 1 | < 1 | | |
Relationship | Married/ Partnership | 452 | 66 | 73 ± 12 | 0.560 |
| Single, never married | 208 | 31 | 71 ± 12 | |
| Separated/ Divorced/ Widow | 22 | 3 | 73 ± 10 | |
*CD-RISC = Connor-Davidson Resilience Scale |
The responders had almost equal gender distribution women (N = 383, 56%) as compared to men (N = 299, 44%). The majority (N = 601, 88%) were in 25–34 years of age, Caucasians (N = 458, 67%), and married or in a long-term partnership (N = 452, 66%). Gender distribution among training level is depicted in Fig. 1 and reflects the increasing number of graduating medical students, and subsequently residents, being female.
Figure 1. Gender distribution across post graduate year (PGY) training levels
Legend Fig. 1. Males labeled in blue, females labeled in orange. PGY1 = residents in first year of postgraduate training, PGY2 = residents in the second year of postgraduate training, PGY3 = residents in the third year of postgraduate training, PGY4 = residents in the fourth year of postgraduate training, PGY5 = residents in the fifth year of postgraduate training, PGY6 = residents in the sixth year of postgraduate training, PGY7 = residents in the seventh year of postgraduate training, PGY8 = residents in the eighth year of postgraduate training.
Table 2 describes the specialty distribution of the survey respondents. Three quarters, (N = 509, 75%) were in medical specialties while the remainder were surgical residents. A comparison of all residents, reflected in the 2019 AAMC resident distribution by specialty data, indicates that the respondents on the survey were broadly representative of all residents in the U.S.
Table 2
Specialty Distribution of Respondents versus All Residents in U.S.
| Survey Respondents | 2019 AAMC Data |
Specialty | Men | % | Women | % | Total | Men | % | Women | % | Total |
Anesthesiology | 22 | 56 | 17 | 44 | 39 | 4023 | 66 | 2034 | 34 | 6057 |
Child Neurology | 2 | 22 | 7 | 78 | 9 | 123 | 32 | 266 | 68 | 389 |
Dermatology | 3 | 50 | 3 | 50 | 6 | 562 | 39 | 877 | 61 | 1439 |
Diagnostic Radiology / Nuclear Medicine | 4 | 50 | 4 | 50 | 8 | 4 | 67 | 2 | 33 | 6 |
Emergency Medicine | 31 | 61 | 20 | 39 | 51 | 4941 | 65 | 2720 | 36 | 7661 |
Emergency Medicine/ Family Medicine | 2 | 100 | 0 | 0 | 2 | 18 | 50 | 18 | 50 | 36 |
Family Medicine | 17 | 32 | 37 | 69 | 54 | 5735 | 46 | 6663 | 54 | 12398 |
Family Medicine / Preventive Medicine | 1 | 100 | 0 | 0 | 1 | 10 | 50 | 10 | 50 | 20 |
Internal Medicine | 21 | 46 | 25 | 54 | 46 | 15389 | 58 | 11284 | 42 | 26673 |
Internal Medicine / Emergency Medicine | 1 | 50 | 1 | 50 | 2 | 85 | 64 | 47 | 36 | 132 |
Internal Medicine / Medical Genetics | 0 | 0 | 1 | 100 | 1 | 4 | 80 | 1 | 20 | 5 |
Internal Medicine / Pediatrics | 4 | 29 | 10 | 71 | 14 | 606 | 41 | 874 | 59 | 1480 |
Internal Medicine / Preventive Medicine | 1 | 100 | 0 | 0 | 1 | 14 | 48 | 15 | 52 | 29 |
Internal Medicine/ Psychiatry | 2 | 100 | 0 | 0 | 2 | 56 | 53 | 49 | 47 | 105 |
Interventional Radiology - Integrated | 2 | 40 | 3 | 60 | 5 | 172 | 80 | 43 | 20 | 215 |
Medical Genetics and Genomics | 0 | 0 | 1 | 100 | 1 | 22 | 34 | 43 | 66 | 65 |
Neurology | 9 | 69 | 4 | 31 | 13 | 1516 | 55 | 1266 | 46 | 2782 |
Neurological Surgery | 9 | 82 | 2 | 18 | 11 | 1218 | 83 | 259 | 18 | 1477 |
Obstetrics and Gynecology | 7 | 12 | 54 | 89 | 61 | 886 | 17 | 4495 | 84 | 5381 |
Ophthalmology | 8 | 47 | 9 | 53 | 17 | 794 | 60 | 538 | 40 | 1332 |
Orthopedic Surgery | 18 | 75 | 6 | 25 | 24 | 3353 | 85 | 610 | 15 | 3963 |
Otolaryngology-Head and Neck Surgery | 2 | 40 | 3 | 60 | 5 | 1025 | 64 | 581 | 36 | 1606 |
Pathology -Anatomic and Clinical | 4 | 31 | 9 | 69 | 13 | 1125 | 50 | 1120 | 50 | 2245 |
Pediatrics | 19 | 25 | 57 | 75 | 76 | 2461 | 28 | 6419 | 72 | 8880 |
Pediatrics / Anesthesiology | 1 | 100 | 0 | 0 | 1 | 13 | 34 | 25 | 66 | 38 |
Pediatrics / Physical Medicine and Rehabilitation | 0 | 0 | 2 | 100 | 2 | 2 | 17 | 10 | 83 | 12 |
Pediatrics / Psychiatry / Child and Adolescent Psychiatry | 0 | 0 | 3 | 100 | 3 | 22 | 24 | 71 | 76 | 93 |
Physical Medicine and Rehabilitation | 8 | 57 | 6 | 43 | 14 | 843 | 63 | 503 | 37 | 1346 |
Plastic Surgery | 2 | 100 | 0 | 0 | 2 | 142 | 69 | 63 | 31 | 205 |
Plastic Surgery - Integrated | 1 | 33 | 2 | 67 | 3 | 524 | 59 | 372 | 42 | 896 |
Preventive Medicine | 4 | 50 | 4 | 50 | 8 | 142 | 49 | 146 | 51 | 288 |
Psychiatry | 21 | 35 | 39 | 65 | 60 | 2934 | 50 | 2943 | 50 | 5877 |
Psychiatry / Family Medicine | 2 | 50 | 2 | 50 | 4 | 18 | 35 | 33 | 65 | 51 |
Radiation Oncology | 10 | 67 | 5 | 33 | 15 | 519 | 70 | 225 | 30 | 744 |
Radiology - Diagnostic | 12 | 44 | 15 | 56 | 27 | 3194 | 73 | 1178 | 27 | 4372 |
Surgery - General | 21 | 53 | 19 | 48 | 40 | 5384 | 59 | 3789 | 41 | 9173 |
Thoracic Surgery - Integrated | 1 | 100 | 0 | 0 | 1 | 158 | 73 | 59 | 27 | 217 |
Transitional Year | 8 | 57 | 6 | 43 | 14 | 798 | 63 | 464 | 36 | 1262 |
Urology | 14 | 74 | 5 | 26 | 19 | 1009 | 75 | 342 | 25 | 1351 |
Vascular Surgery - Integrated | 5 | 71 | 2 | 0.3 | 7 | 212 | 67 | 107 | 34 | 319 |
Total | 299 | 44 | 383 | 56 | 682 | 60,056 | 54 | 50,564 | 46 | 110,620 |
Descriptive statistics for the Connor-Davidson Resilience Scale showed a mean value of 72 with a median of 72 and a mode of 65. Data analysis demonstrated a normal distribution of scores which allows the use of parametric statistical testing21. There were no significant differences in CD-RISC scores based on age, ethnicity, or marital status (Table 1). However, female residents were significantly less resilient (F = 6.103, p = 0.014) when compared to their male counterparts, with a score of 71 and 74, respectively.
No significant differences in resilience were found among participants from academic versus community hospital-based training program (F = 2.031, p = 0.13) or geographic regions (F = 2.522, p = 0.06). The residents in the upper level of training had significantly higher CD-RISC scores when compared to the junior residents (F = 2.145, p = 0.04) with residents from postgraduate years six to eight (PGY 6–8) being the most resilient with CD-RISC = 80.1 (13.4), followed by the residents from postgraduate year four and five (PGY 4–5) with CD-RISC = 74.1(11.3) and postgraduate year one to three (PGY 1–3) with CD-RISC = 71.6 (12.5).
Specialty distribution was also not found to be correlated to with resilience (F 1.176, p = 0.24). However, when comparing the medical and surgical specialties, surgical residents scored higher in resilience than medical residents (F = 7.169, p = 0.008; CD-RISC = 74.5 (11.5) versus 71.7 (12.3).
There was a significant and positive correlation between family support and higher resilience (F = 16.941, p < 0.001; Table 3).
Table 3
Factors Associated with Resilience (Pearson Correlation of CD-RISC)
| R | P |
Family support | .277** | < 0.001 |
Considering all of this I like my job | 0.505 | < 0.001 |
Compliance with 80 hours restriction | 0.133 | < 0.001 |
Personal achievement | 0.484 | < 0.001 |
Emotional exhaustion | -0.0477 | < 0.001 |
Depersonalization | -0.305 | < 0.001 |
Number of hours of sleep | -0.014 | 0.720 |
Residents with strong family support (always, usually) scored higher than the residents with sporadic or inexistent family support (sometimes, rarely, never). Job satisfaction and residency program support was assessed through five questions and was also found to correlate positively with resilience. There is a positive correlation with the self-affirmation “Considering everything I like my job “ (R = 0.505, p < 0.001), "There is a positive morale at work" (R = 0.395, p < 0.001), "This hospital is a good place to work" (R = 0.364, p < 0.001), "I am proud to work at this hospital" (R = 0.373, p < 0.001)", and "During my residency I feel like being part of a large family" (R = 0.335, p < 0.001). No correlation was found between the resilience index and the number of hours of sleep (R= -0.014, p = 0.72), however the compliance with the 80-hour restriction was a small but significant correlate (R = 0.133, p < 0.001).
Multivariate linear regression showed five significant factors associated with higher resilience (Table 4): family support, geographic location, surgical specialties, autonomy, and agreeing to the question “Considering everything, I like my job“.
Table 4
Multivariate Analysis and Significance (p values)
Analyzed factors | CD-RISC | Personal Achievement | Emotional Exhaustion | Depersonalization |
CD-RISC | | < .0001 | < .0001 | 0.0185 |
Family support | < .0001 | 0.8569 | 0.4868 | 0.8078 |
Autonomy | < .0001 | 0.0003 | 0.4887 | 0.6198 |
Considering everything I like my job | < .0001 | < .0001 | < .0001 | 0.0016 |
Surgical specialties | 0.0003 | 0.4885 | 0.6914 | 0.3615 |
Geography | 0.0037 | 0.7543 | 0.8677 | 0.1863 |
I am proud to work at this hospital | 0.0738 | 0.3552 | 0.0624 | 0.053 |
There is a positive morale at work | 0.108 | 0.9013 | 0.0008 | 0.9985 |
Gender | 0.1753 | 0.1736 | 0.1469 | < .0001 |
Marital Status | 0.2291 | 0.063 | 0.1211 | 0.5113 |
Type of program | 0.2348 | 0.6282 | 0.8455 | 0.6457 |
Age | 0.2881 | 0.0568 | 0.9577 | 0.0178 |
Race | 0.4093 | 0.6977 | 0.0035 | 0.0063 |
Satisfaction with faculty | 0.4493 | 0.2741 | 0.0992 | 0.2761 |
Supervision | 0.5693 | 0.5908 | 0.3262 | 0.4344 |
This hospital is a good place to work | 0.6635 | 0.962 | 0.2189 | 0.0378 |
Compliance with 80 hours rule | 0.7725 | 0.1781 | 0.3947 | 0.5493 |
During my residency I feel being part of a big family | 0.8918 | 0.3026 | 0.6295 | 0.6769 |
The average CD-RISC score for residents that always had family support is 3.4 points higher than that for residents who only usually had family support. The average CD-RISC score for residents that are extremely comfortable being autonomous in making medical decisions is 14.6 points higher than that for residents not at all comfortable in being autonomous. For every one-point increase in Likert scale regarding the question ”Considering everything, I like my job”, the average CD-RISC score increases by 4.5 points. Overall, 64% of the respondents were found to have at least one element of burnout with predominance on emotional exhaustion (58%). Resilience positively correlates with the sense of personal achievement (R = 0.484, p < 0.001) and negatively with emotional exhaustion (R= -0.477, p < 0.001) and depersonalization (R= -0.305, p < 001).
Each element of burnout was examined using multivariate regression. Personal achievement was positively corelated with autonomy, “Considering everything, I like my job”, and having higher resilience score. Emotional exhaustion had four significant factors: race, disagreeing with the questions “Considering everything, I like my job,” “There is a positive morale at work,” and a low CD-RISC. The emotional burnout for White/Caucasians residents was higher than that for Asian/Pacific islander residents (p < 0.001). Although not significant in the multivariate analysis, the emotional exhaustion for residents that were “single/never married” was higher than that for “married/in a partnership” residents (p = 0.04). Residents satisfied with their faculty had experienced less emotional burnout (p = 0.02), whereas residents that had close/direct supervision reported a higher rate of emotional exhaustion (p = 0.04).
We found six significant factors in the multivariate analysis influencing depersonalization: resident under age 35 years (p = 0.018), male gender (p < 0.001), race (p = 0.006), lower CD-RISC (p = 0.018), disagreeing with “Considering everything, I like my job” (p = 0.002), and “This hospital is a good place to work” (p = 0. 038). Caucasians residents reported higher depersonalization when compared to Hispanics (p = 0.007) and African Americans residents (p = 0.003).