The burden of grief and moral injury in neurosurgery residency compared with other high-risk specialties.

OBJECTIVE

Residents in specialties with frequent exposure to patient death, catastrophic outcomes, and morally complex decisions may be more vulnerable to emotional distress. While burnout is well described in residency training, grief and moral injury remain less explored. This study aimed to examine grief symptoms, moral injury, coping strategies, psychological distress, and perceived program support across neurosurgery and other surgical and acute-care medical specialties.

METHODS

A cross-sectional, anonymous, web-based survey of resident physicians and fellows in neurosurgery, general surgery, emergency medicine, oncology, and critical care at a single academic center was conducted. Validated instruments were used to assess prolonged grief (Prolonged Grief Disorder Scale), moral injury (Moral Injury Symptoms Scale for Health Professionals), coping strategies (Brief Coping Orientation to Problems Experienced questionnaire), and psychological distress (Patient Health Questionnaire-4), alongside items evaluating perceived program support and culture. Multivariable median regression was used to examine associations between specialty group and outcome measures, adjusting for sex, age, and level of training. Exploratory unadjusted analyses comparing neurosurgery and general surgery trainees were also conducted.

RESULTS

Forty-five (46.4%) of 97 eligible trainees responded. Neurosurgery trainees reported exposure to a median of 1.5 deaths and 1.5 devastating outcomes weekly, which was in the higher range compared with other specialties. Neurosurgery and general surgery trainees demonstrated significantly higher median grief scores than medical trainees after adjustment (p = 0.043). Moral injury scores were also higher among surgical trainees (p = 0.032). Among surgical specialties, neurosurgery residents reported lower grief scores than general surgery residents in unadjusted analyses. There was no difference in maladaptive coping among surgical and medical trainees (p = 0.11). Adaptive coping was significantly lower among male and mid-level trainees (p = 0.026 and p = 0.029, respectively). Perceived program support was inversely correlated with moral injury (rho = -0.58, p < 0.001).

CONCLUSIONS

Grief symptoms and moral injury are prevalent among residents in high-risk training environments, particularly within surgical specialties, including neurosurgery. Differences in grief burden among surgical disciplines suggest that perceived preventability and professional identity may shape emotional responses to adverse outcomes. Importantly, the association between higher perceived program support and lower moral injury indicates that training culture is modifiable and may serve as a key lever for intervention.