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

a
Division of General Surgery, Stanford Hospital & Clinics, 300 Pasteur Drive, MC H3591, Palo Alto, CA 94305, USA;
b
Stanford University Graduate School of Education, Stanford, CA, USA; cDivision of Pediatric Surgery, Lucile Packard
Children’s Hospital, Palo Alto, CA, USA

KEYWORDS: Abstract
Grit; BACKGROUND: The well-being of residents in general surgery is an important factor in their success
Burnout; within training programs. Consequently, it is important to identify individuals at risk for burnout and
Well-being low 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 for
long-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 Maslach
Burnout Inventory (B 5 2.20, P 5 .05) and as measured by the Psychological General Well-Being
Scale (B 5 .27, P , .01).
CONCLUSIONS: Measuring grit may identify those who are at greatest risk for poor psychological
well-being in the future. These residents may benefit from counseling to provide support and improve
coping skills.
Ó 2013 Elsevier Inc. All rights reserved.

Residency is a difficult period in physician training
across specialties. One recent survey noted that residents
rate the majority of their working days as being between 4
and 5 on a 5-point, Likert-type scale of stress, with 5
representing ‘‘extremely stressful.’’1 This constant degree
of pressure can lead to feelings of discouragement and dis-
satisfaction, which may ultimately result in the desire to
leave a training program.
The growing concern about the toll stress can have on
the professional and personal lives of residents has led to an
The authors declare no conflicts of interest.
* Corresponding author. Tel.: 11-650-387-5275; fax: 11-650-736-
1663.
E-mail address: arghavan@stanford.edu
Manuscript received May 7, 2013; revised manuscript August 23, 2013
increased focus on their well-being. However, the factors
that contribute to residents’ ability to sustain themselves
and maintain well-being through the rough patches in their
training 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 in
6 studies of different populations. They defined a new con-
struct, grit, as perseverance and passion for long-term
goals. 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 of
achievement, even when taking into account prior measures
such as IQ and grade point average.
In addition, research has shown that those who are
happier are more likely to graduate from college, less likely

0002-9610/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2013.09.006
2 The American Journal of Surgery, Vol -, No -, - 2013

to leave their jobs, and less likely to experience burnout.3 In
essence, 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 between
grit and measures of well-being in residents of several sur-
gical specialties. We proposed that residents who are higher
in grit would also display higher levels of well-being.
Methods
In the context of a larger longitudinal study, we combined
several previously validated scales to assess residents’ per-
severance, burnout, and psychological well-being. We used
the 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 different
one.’’ The Maslach Burnout Inventory (MBI)5,6 was used
as a measure of burnout. One representative item from this
scale is ‘‘I feel emotionally drained from my work.’’ We
also included a broad measure of psychological well-being,
the Dupuy Psychological General Well-Being Scale
(PGWB).7 Two sample items from this scale are ‘‘Have
you felt so sad, discouraged, hopeless, or had so many prob-
lems that you wondered if anything was worthwhile during
the past month?’’ and ‘‘I was emotionally stable and sure of
myself during the past month.’’
After obtaining approval from the Stanford University
Institutional Review Board, we administered the survey twice
to residents across 9 surgical specialties (cardiothoracic sur-
gery, general surgery, neurosurgery, ophthalmology, orthope-
dic surgery, otolaryngology head and neck surgery, plastic
surgery, vascular surgery, and urology). Survey sessions were
separated by 6 months. Informed consent was obtained, and
the data were deidentified and kept confidential.
Scores were created for each scale by averaging the
responses to individual items within the scale. The sign was
reversed as appropriate for the wording of each item. The
MBI is composed of 3 subscales: emotional exhaustion,
depersonalization, and personal accomplishment. An over-
all score for burnout was created by reverse coding the
personal accomplishment subscale and then adding all 3
scales together. MBI data were analyzed using this com-
posite score as well as each of the subscales. The Short Grit
Scale and the PGWB were not broken down into further
subscales. For all 3 scales, the MBI, PGWB, and the Short
Grit Scale, all items were included in the analyses below.
Items on the MBI had 7 answer choices, items on the
PGWB had 6 answer choices, and items on the Short Grit
Scale had 5 answer choices.
Data were analyzed using correlations and linear regres-
sion analyses in Stata version 10.1 (StataCorp LP, College
Station, TX).
Results
One hundred forty-one residents (52 women; response
rate, 84%) participated in the study. See Table 1 for a break-
down of age, gender, and response rate by specialty. We first
examined the data to see whether grit was a stable measure
over the period of study. In keeping with previous data,2
the participants’ grit scores were highly positively correlated
across time points (r 5 .71, P , .01; baseline mean, 3.65 6
.53; follow-up mean, 3.64 6 .53). The average level of burn-
out at baseline was 3.05 6 .84 on a 7-point scale. The average
level of psychological well-being at baseline was 4.54 6 .70
on a 6-point scale. These values are quite similar to the
follow-up values for burnout and psychological well-being
(r 5 .76, P , .01, and r 5 .72, P , .01, respectively).
Tables 2 and 3 show the variation of grit, burnout, and
psychological well-being at baseline among the different
surgical specialties and among different years in training,
respectively. Analysis of variance examining differences
in grit, burnout, and psychological well-being by specialty
showed no significant differences (P values ..62). A sim-
ilar analysis for variation by year in training showed that
grit 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 levels
of burnout than more junior residents (F 5 2.17, P , .05).

Table 1 Demographic data by specialty

Range of
Number of respondents Age postgraduate Response
Specialty (number of women) (mean) year rate
Cardiothoracic 5 (1) 30.2 1–4 63%
General surgery 40 (20) 31.6 1–5 85%
Neurosurgery 13 (2) 31.7 1–5 76%
Plastic surgery 17 (7) 30.9 1–6 85%
Ophthalmology 11 (5) 33.8 2–4 100%
Orthopedic surgery 21 (5) 30.3 1–5 81%
Otolaryngology head and neck 18 (6) 31.3 1–5 100%
surgery
Urology 14 (5) 30.6 1–5 82%
Vascular surgery 2 (1) 27 1–2* 67%
*The vascular surgery program had residents only in postgraduate years 1 to 3 at the time of the study.
A. Salles et al. Grit and resident well-being 3

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

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

After these descriptive analyses, we assessed whether
grit, as measured at the first time point, was predictive of
later psychological health. In a multivariate linear regres-
sion controlling for gender and baseline burnout, we
found that, on average, those with more grit at baseline
had significantly lower rates of burnout 6 months later
than those with less grit (B 5 2.20, P 5 .01). The same
pattern was true for the emotional exhaustion and deper-
sonalization subscales of the MBI when controlling for
the 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, on
average, significantly higher levels of general psychological
well-being 6 months later than those with less grit (B 5 .27,
P , .01), again controlling for gender and baseline psycho-
logical well-being.
We repeated these analyses including only residents in
general surgery, because this is the specialty that is thought
to have the highest rate of attrition. Although the relation-
ship between grit and overall burnout was similar to that in
the overall sample, the relationship did not reach statistical
significance (B 5 2.36, P 5 .12). The relationship between
grit and the emotional exhaustion subscale was also similar
in the general surgery sample compared with the total
sample (B 5 2.51, P 5 .12) but again did not reach statis-
tical significance. There was no statistically significant
relationship between grit and depersonalization, personal
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 of
psychological health in a sample of 141 surgical residents.
This suggests that measuring grit may be one way to
identify those who are at risk for burnout or lower overall
well-being. Thus, program directors could use grit as a
measure to identify residents who could benefit from
additional support throughout their training. Although this
could also be done by administering the MBI and the
PGWB directly, these instruments contain sensitive ques-
tions. Residents may not want their program directors to be
aware of their responses to the items contained in these
surveys. The Short Grit Scale, however, does not contain
such sensitive items and takes less time to administer (it
contains only 8 items, compared with 22 each for the MBI
and the PGWB).
Furthermore, burnout and low levels of psychological
well-being may be related to why some residents choose to
leave residency rather than complete it. Given the shortage of
physicians, and surgeons in particular,8 in this country, it is
important 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 among
studies, the generally accepted figure is that 1 of 5 general

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

Year in Number of Psychological
training respondents Grit Burnout well-being
1 26 3.67 6 .52 3.12 6 .78 4.56 6 .66
2 29 3.67 6 .64 3.02 6 .90 4.52 6 .71
3 25 3.59 6 .50 3.34 6 .87 4.40 6 .66
4 21 3.61 6 .49 3.12 6 .81 4.55 6 .71
5 22 3.81 6 .51 2.63 6 .71 4.66 6 .74
6* 3 3.96 6 .31 2.70 6 .51 4.73 6 .49
Research 15 3.44 6 .42 3.05 6 .96 4.56 6 .86
*Only 1 of the residency programs has 6 clinical years; this program has 3 residents per year.
4 The American Journal of Surgery, Vol -, No -, - 2013
surgery residents leaves residency.10–12 This attrition is
costly for both the individuals affected and their training pro-
grams.13 Although there are a number of factors that are
likely to contribute to attrition, including lifestyle and inter-
est in another specialty or career,10,13 we propose that grit
might be a measurable identifier for this important career
outcome.
Similarly, grit might be a useful measure for program
directors to incorporate into their residency screening
process. However, there are some constraints we must
consider. First, our data show grit to be relatively stable
over only a short period of time, 6 months. Previous studies
have shown that grit increases with age.2 Given the length
of residency training programs, residents’ grit may change
within the course of their training. In addition, it would be
difficult to find a single session in which to administer the
survey. One could have applicants complete the survey on
the day they interview; however, that is an emotionally
charged day. Furthermore, residents’ responses might be
influenced by the context of the interviews, which could re-
sult in inaccuracies in measurement.
There are several important overall limitations to this
study. First, it is unclear why these relationships were not
upheld when we restricted the analyses to the 40 residents
in general surgery. It may be that the relationship between
grit and psychological health is different among this
subgroup. It is also possible that this is due to the sample
size, which is much smaller than the overall sample.
Additional investigation is needed within this department
to elucidate these findings.
Another limitation is that the study took place at only
1 institution, which may limit its generalizability. Further-
more, this study is correlational in nature and does not
suggest a causal relationship of any kind. Finally, the time
frame of the study was too short to measure the outcome of
greatest interest, attrition itself. We plan to follow these
residents over the next few years to be able to relate grit to
attrition directly rather than the surrogate measures used
here. We also hope to collaborate with other institutions to
see if the pattern of data seen here is similar elsewhere.
Only then will we know whether the statistically significant
differences found here will translate into meaningful
differences in residency outcomes.
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