Surgical training is often described as a test of technical precision, stamina, and decision-making under pressure. A qualitative study published in JAMA Network Open adds another, less visible demand to that list: the constant effort some residents make to assess whether their identities could expose them to professional risk. The study characterizes this experience as “vigilance,” a form of continuous psychological and cognitive monitoring in which residents watch their surroundings, interpret social signals, adjust how they present themselves, and calculate when it may be safe to speak, ask for help, or reveal personal information. Although vigilance can help trainees navigate potentially threatening situations, the researchers found that maintaining it may carry a substantial emotional cost, contributing to fatigue, burnout, and, for some residents, thoughts of leaving surgery altogether.
In this context, vigilance is more than ordinary awareness in a demanding clinical environment. Surgical residents already monitor patients’ vital signs, operative anatomy, instrument handling, and the decisions of the operating team. Identity-related vigilance adds another layer of surveillance directed at the social environment. Residents may assess whether a comment is hostile or merely joking, whether a mistake will be interpreted as an individual failure or as confirmation of a stereotype, and whether an aspect of their identity could affect how colleagues, supervisors, or patients perceive their competence. These judgments can occur rapidly and repeatedly, often without being visible to others. The result is a parallel workload that exists alongside the formal requirements of surgical education.
The researchers describe three connected elements of this process. First, residents perceived threats linked to aspects of their identities, including the possibility of bias, exclusion, stereotyping, or mistreatment. Second, they adapted their self-presentation in response, deciding how much of themselves to disclose and how closely to conform to expectations within the surgical workplace. Third, they monitored the environment for signs of risk, evaluating people, interactions, and institutional settings for evidence that could signal safety or danger. Together, these behaviors resemble a form of threat detection. In psychological terms, the residents were not simply responding to isolated incidents; they were preparing for the possibility that an interaction could carry consequences for belonging, credibility, or career progression.
That preparation may be especially demanding in surgery because the specialty is organized around high-stakes performance, steep hierarchies, and public evaluation. Residents learn in environments where their technical skills and judgment are observed continuously, often by more senior physicians whose assessments influence advancement. Under those conditions, identity-related concerns can become intertwined with professional performance. A resident who is worried about being judged through a stereotype may devote mental resources to appearing confident, avoiding behaviors that could be interpreted negatively, or deciding whether to challenge a decision. Such self-monitoring can compete with attention that would otherwise be directed toward learning, communication, and patient care. The study therefore presents vigilance as a hidden component of the training experience rather than as a personal weakness or an isolated coping style.
The cognitive science behind this burden is consistent with what is known about sustained threat monitoring. The brain’s attention systems are designed to detect potentially important changes in the environment, but maintaining that readiness over long periods can consume working memory and increase stress. Repeatedly scanning for danger may activate physiological stress responses even when no overt event occurs. Over time, the combination of emotional regulation, social calculation, and clinical responsibility can contribute to mental exhaustion. The study does not frame every instance of vigilance as harmful; awareness can help residents protect themselves and make informed decisions. The concern is that when monitoring becomes persistent, unavoidable, and unsupported, it may produce a chronic demand that institutions fail to recognize.
Participants linked this demand to fatigue and burnout, conditions that are already widespread across medical training. Burnout is commonly associated with emotional exhaustion, detachment, and a reduced sense of professional effectiveness. In surgical residency, these symptoms can be intensified by long hours, sleep disruption, emergency cases, and the pressure of acquiring complex procedural skills. Vigilance may add a distinct pathway to the same outcome. A resident who spends the day managing clinical tasks while also regulating speech, appearance, disclosure, and reactions may finish a shift depleted even if no dramatic conflict occurred. The energy required to remain guarded can accumulate quietly, making it difficult to distinguish ordinary workload from the additional strain created by an unsafe or unpredictable social climate.
The findings also raise questions about retention in surgery. Some participants reported that vigilance contributed to thoughts of leaving the specialty, suggesting that career decisions may reflect more than operative workload or lifestyle concerns. A resident may question whether the professional environment permits long-term belonging, advancement, or psychological safety. When that calculation is repeated, the loss is potentially broader than the departure of one trainee. Surgical programs invest years in recruiting and educating residents, and departures can affect workforce capacity, team stability, and the diversity of future leadership. The study consequently links an individual psychological experience to an institutional problem: a training culture that requires some residents to spend substantial effort protecting themselves may undermine the very workforce it is trying to develop.
At the same time, the residents identified opportunities for intervention at the programmatic level. The study points toward the importance of changing conditions rather than placing the responsibility entirely on individuals to become more resilient. Programs could examine how concerns are reported and addressed, whether residents trust supervisory systems, and how faculty respond to bias, exclusion, or identity-based mistreatment. Clear accountability, confidential channels for support, and consistent responses to harmful behavior may reduce the uncertainty that drives monitoring. Mentorship and sponsorship can also matter when they provide residents with trusted people who understand the risks of disclosure and can help them navigate difficult interactions. These measures would not eliminate every source of stress, but they could reduce the need for continuous defensive self-surveillance.
The study’s qualitative design is particularly suited to revealing experiences that may be difficult to capture through standard burnout surveys. Quantitative instruments can measure exhaustion, depression, discrimination, or intent to leave, but they may not show how these phenomena develop during ordinary moments in training. Interviews and other qualitative approaches can illuminate the decisions hidden behind a resident’s behavior: why someone remained silent, altered their presentation, avoided a social setting, or hesitated to request assistance. Those details help explain how institutional culture becomes embodied as cognitive and emotional labor. The authors, led by Jamila K. Picart, MD, MSc, at the University of Michigan, present vigilance as an important concept for understanding the lived experience of surgical residents and for designing more effective interventions.
The implications extend beyond surgery. Many workplaces require people whose identities are marginalized or questioned to perform a second job alongside their formal duties: anticipating bias, managing impressions, and determining whether an environment is safe enough for authenticity. In medicine, where collaboration and speaking up are central to patient safety, the consequences can be particularly serious. A resident who is preoccupied with social risk may have less capacity to participate fully in teaching, communicate concerns, or seek help during a difficult case. By making vigilance visible, the study offers programs a way to reconsider burnout not only as an outcome of workload, but also as a possible signal of unequal psychological demands. Creating training environments in which residents can learn without constantly defending their legitimacy could improve well-being, strengthen retention, and support safer care for patients.
Subject of Research: Identity-related vigilance, psychological stress, burnout, and retention among surgical residents.
Web References: https://doi.org/10.1001/jamanetworkopen.2026.28776
References: Picart JK et al. Qualitative study of vigilance among surgical residents. JAMA Network Open. DOI: 10.1001/jamanetworkopen.2026.28776.
Keywords: surgical residency, surgery, physician workforce, physician scientists, vigilance, identity-related threat, psychological stress, cognitive load, burnout, fatigue, medical education, retention, mental health, workplace safety, qualitative research
