Why Surgical Residents Stay Silent: New Review Exposes Psychological Safety Crisis in the OR

Operating rooms are among the most hierarchical environments in modern medicine, and a sweeping new review suggests that this hierarchy, combined with harassment and structural inequities, is quietly undermining the well-being of the surgeons of tomorrow. A narrative review published in Global Surgical Education, the journal of the Association for Surgical Education, synthesizes 54 studies published between 2014 and 2026 to map the barriers to and facilitators of psychological safety in surgical training. The authors, Andrada Diaconescu, Tania K. Arora, and Brenessa Lindeman of the University of Alabama at Birmingham, argue that psychological safety, the shared confidence that speaking up, admitting mistakes, or raising concerns will be met with support rather than humiliation or punishment, is not a soft luxury but a foundational requirement for equitable training, resident well-being, and even patient outcomes.

The concept of psychological safety originated in the business literature, first described by organizational psychologist Edgar Schein and later popularized by Harvard professor Amy Edmondson, whose 1999 research showed that teams learn better when members feel safe to take interpersonal risks. The idea migrated into graduate medical education alongside competency-based training, interprofessional education, and the growing emphasis on diversity, equity, and inclusion. A parallel concept, the microaggression, was first defined by psychiatrist Chester Pierce in 1970 and popularized by psychologist Derald Sue in 2007, who described these as brief, everyday exchanges that send denigrating messages to individuals because of their group membership. The review underscores that microaggressions directly corrode psychological safety, silencing the very diverse perspectives that inclusive programs claim to want. In 2023, the Accreditation Council for Graduate Medical Education formally elevated psychological safety to a core principle of residency training, giving the concept regulatory weight.

The stakes are far from abstract. A widely cited 2018 survey found that 38.5 percent of residents experienced burnout symptoms weekly and 4.5 percent reported suicidal thoughts within the previous year. Residents who faced discrimination, abuse, or harassment at least a few times per month were significantly more likely to experience both burnout and suicidal ideation. The review also draws on evidence linking psychological safety to measurable performance: psychologically safe learning environments improve resident performance and have been associated with better patient outcomes both inside and outside the operating room. In surgery, where a junior team member’s hesitation to question a supervising surgeon can mean the difference between a caught error and a patient harm, the clinical consequences of silence are particularly acute.

To assemble the evidence base, the authors conducted a three-phase PubMed search covering US-based literature from 2014 to 2026, following the SANRA guidelines for narrative reviews. The first search targeted psychological safety in surgery and yielded 17 included articles from 88 abstracts; the second examined the intersection of well-being, DEI, and surgery, contributing 9 articles; and the broadest search on DEI in surgery added 20 more, with 8 additional studies identified through reference mining. The final synthesis comprised 12 quantitative surveys, 4 qualitative studies, 6 mixed-methods studies, 4 cohort or database studies, and 12 review articles, with the remainder consisting of perspective papers and program descriptions. The authors acknowledge the inherent limitations of the narrative design, including single-reviewer screening and the possibility of selection bias, but argue that the heterogeneity of the field, dominated by qualitative and perspective work, makes narrative synthesis the appropriate tool.

The barriers the review identifies cluster into three interlocking systems. The first is hierarchical culture. A qualitative interview study of surgical trainees identified four recurring threats to psychological safety: public humiliation, tension around questioning attendings, the culture fostered by faculty, and flawed system factors such as operating room staffing and leadership instability. A national survey confirmed that residents’ comfort in raising concerns to attendings varies with post-graduate year, program culture, and prior experiences with specific supervisors. Even morbidity and mortality conferences, designed as learning forums, can devolve into blame and shame when discussions are unstructured, discouraging trainees from engaging openly. When junior members fear retribution for speaking up, near misses go unreported and the entire team’s performance suffers.

The second barrier is harassment and discrimination, and the numbers are stark. In a national survey, patients and their families were the most frequent sources of gender and racial discrimination, reported by 46.3 percent and 47.4 percent of residents respectively, but attending surgeons were the most frequent sources of sexual harassment and abuse, at 27.2 percent and 51.9 percent. Overall, 72.2 percent of surgery residents reported experiencing microaggressions, most commonly from patients, followed by staff, faculty, and co-residents. Nearly one-third said microaggressions negatively affected their training, and 14.1 percent considered leaving residency because of them. In one national survey, 30.8 percent of residents who reported mistreatment experienced retaliation. Female trainees face implicit biases that actively discourage them from surgery, with higher expectations but fewer role models, mentors, and sponsors, while LGBTQ+ trainees report similar discriminatory experiences that leave them feeling unsupported.

These patterns are consistent across surgical subspecialties and fall hardest on trainees underrepresented in medicine, or URiM. Among vascular surgery residents, 36.3 percent of Asian and 56.3 percent of Black trainees reported racial discrimination. A multicenter study found URiM general surgery residents had higher anxiety, emotional exhaustion, and depersonalization, and comparable disparities have been documented in otolaryngology, orthopedic surgery, and pediatric surgery. In plastic surgery, 68.8 percent of residents reported microaggressions, with higher rates among female, Asian, and non-heterosexual trainees. The cumulative toll is measurable: URiM trainees reported burnout rates of 76 percent compared with 63 percent among their non-URiM peers. Structural barriers compound the interpersonal ones, including weaker academic support, scarce mentorship, social isolation, and the so-called minority tax, the extra emotional labor and time diverse trainees and faculty spend on diversity work itself.

The consequences extend to attrition, one of the most costly failure modes of surgical training. While the proportion of female residents in surgery has improved over the past 18 years, the percentage of URiM residents has remained essentially unchanged. A study of racial and gender disparities in attrition across surgical specialties found that female and URiM residents had significantly higher relative risk of leaving training, with the highest rates among Black and African American residents: 10.6 percent intended attrition and 5.2 percent unintended attrition, compared with 6.2 percent and 1.8 percent among White residents. A weak sense of belonging, which has been associated with non-White race, lower academic performance, and adverse health outcomes, appears to be a key mediating mechanism, creating a feedback loop in which isolation erodes belonging, which in turn erodes performance and retention.

Yet the review is not merely a catalog of dysfunction; it identifies concrete facilitators that programs can implement. Culturally concordant mentorship, pairing URiM trainees with mentors who share aspects of their background, emerges as a key driver of psychological safety, with institutional, national, and peer mentorship models all showing benefit. Structured mentorship has been proposed as a race-neutral strategy for improving networking, and dedicated roles such as chief residents for diversity and inclusion offer novel advocacy channels. On the curricular side, the review highlights Kimberly Manning’s Five Ds Upstander Training, which teaches individuals to Direct, Distract, Delegate, Delay, and Display Discomfort in response to bias, and the Microaggressions Triangle Model, which addresses microaggressions from the perspectives of recipient, source, and bystander. DEI toolkits for program directors changed recruitment practices for 31 percent of directors who used them. Institutional innovations range from Minority Housestaff Organizations that provide liberated spaces for URiM trainees, to embedded psychiatrists in training programs, to proposed Education Ombudspersons whose primary role is fostering psychological safety.

The authors conclude that creating psychologically safe surgical training environments requires deliberate, multifaceted institutional commitment rather than isolated gestures. Leaders who respond to concerns with gratitude rather than annoyance, teams that emphasize interdependence, and faculty trained in inclusive teaching all contribute to a culture where vulnerability is normalized. Programs must recruit and retain diverse trainees and faculty, distribute diversity work equitably to avoid overburdening the marginalized individuals such initiatives are meant to support, and maintain multiple reporting pathways, including anonymous ones, that trainees can trust. Notably, only 32.4 percent of trainees report receiving formal training on managing microaggressions, and over half have received no training on explicit or implicit bias, suggesting an enormous gap between the evidence and current practice. As the review makes clear, psychological safety is not simply a matter of comfort; it directly shapes resident well-being, retention, performance, and the quality of care patients receive, and closing the gap will require sustained, systemic effort across every level of surgical education.

Subject of Research: Psychological safety, well-being, and diversity, equity, and inclusion in surgical residency training

Article Title: Psychological safety and well-being

Article References: Diaconescu, A., Arora, T. K., & Lindeman, B. (2026). Psychological safety and well-being. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 190. https://doi.org/10.1007/s44186-026-00607-2

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00607-2

Keywords: psychological safety, surgical education, resident well-being, burnout, microaggressions, URiM trainees, mentorship, DEI, harassment, attrition, operating room culture, ACGME