{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,5]],"date-time":"2026-08-05T00:50:14Z","timestamp":1785891014432,"version":"3.56.0"},"reference-count":31,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,8,1]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVE<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>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 = \u22120.58, p &lt; 0.001).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/2026.4.focus26103","type":"journal-article","created":{"date-parts":[[2026,7,29]],"date-time":"2026-07-29T00:01:53Z","timestamp":1785283313000},"page":"E2","source":"Crossref","is-referenced-by-count":0,"title":["The burden of grief and moral injury in neurosurgery residency compared with other high-risk specialties"],"prefix":"10.3171","volume":"61","author":[{"given":"Catherine","family":"Veilleux","sequence":"first","affiliation":[{"name":"Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Alberta;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brij S.","family":"Karmur","sequence":"additional","affiliation":[{"name":"Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Alberta;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Skarsgard","sequence":"additional","affiliation":[{"name":"Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Alberta;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Heather","family":"Rossong","sequence":"additional","affiliation":[{"name":"Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Alberta;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana","family":"Sepulveda","sequence":"additional","affiliation":[{"name":"Department of Surgery, Section of General Surgery, University of Calgary, Alberta;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qadeem S.","family":"Salehmohamed","sequence":"additional","affiliation":[{"name":"Department of Critical Care Medicine, University of Calgary, Alberta; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dirk","family":"Chisholm","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Calgary, Alberta, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jay","family":"Riva-Cambrin","sequence":"additional","affiliation":[{"name":"Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Alberta;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"5","key":"b1","series-title":"J Palliat Med","first-page":"459","article-title":"Educating medical residents in end-of-life care: insights from a multicenter survey","volume":"12","author":"Schroder C","year":"2009","unstructured":"Schroder C, Heyland D, Jiang X, Rocker G, Dodek P. Educating medical residents in end-of-life care: insights from a multicenter survey. J Palliat Med. 2009;12(5):459\u2013470. doi:10.1089\/jpm.2008.0280"},{"issue":"11","key":"b2","series-title":"PLoS One","first-page":"e0224325","article-title":"Being there: A scoping review of grief support training in medical education","volume":"14","author":"Sikstrom L","year":"2019","unstructured":"Sikstrom L, Saikaly R, Ferguson G, Mosher PJ, Bonato S, Soklaridis S. Being there: A scoping review of grief support training in medical education. PLoS One. 2019;14(11):e0224325. doi:10.1371\/journal.pone.0224325"},{"key":"b3","series-title":"Health Serv Insights","first-page":"11786329251344772","article-title":"Hidden in plain sight: a scoping review of professional grief in healthcare and charting a path for change","volume":"18","author":"Phillips CS","year":"2025","unstructured":"Phillips CS, Trainum K, Thomas Hebdon MC. Hidden in plain sight: a scoping review of professional grief in healthcare and charting a path for change. Health Serv Insights. 2025;18:11786329251344772. doi:10.1177\/11786329251344772"},{"key":"b4","series-title":"Front Surg","first-page":"898274","article-title":"The impact of patient deaths on general surgeons\u2019 psychosocial well-being and surgical practices","volume":"9","author":"Akyol C","year":"2022","unstructured":"Akyol C, Celik SU, Koc MA,  The impact of patient deaths on general surgeons\u2019 psychosocial well-being and surgical practices. Front Surg. 2022;9:898274. doi:10.3389\/fsurg.2022.898274"},{"issue":"2","key":"b5","series-title":"J Surg Educ","first-page":"452","article-title":"\"You remember those days\"\u2014a qualitative study of resident surgeon responses to complications and deaths","volume":"79","author":"Bamdad MC","year":"2022","unstructured":"Bamdad MC, Vitous CA, Rivard SJ,  \"You remember those days\"\u2014a qualitative study of resident surgeon responses to complications and deaths. J Surg Educ. 2022;79(2):452\u2013462. doi:10.1016\/j.jsurg.2021.09.011"},{"issue":"7408","key":"b6","series-title":"BMJ","first-page":"185","article-title":"Doctors\u2019 emotional reactions to recent death of a patient: cross sectional study of hospital doctors","volume":"327","author":"Redinbaugh EM","year":"2003","unstructured":"Redinbaugh EM, Sullivan AM, Block SD,  Doctors\u2019 emotional reactions to recent death of a patient: cross sectional study of hospital doctors. BMJ. 2003;327(7408):185. doi:10.1136\/bmj.327.7408.185"},{"issue":"1","key":"b7","series-title":"Arch Surg","first-page":"87","article-title":"Unexpected intraoperative patient death: the imperatives of family- and surgeon-centered care","volume":"143","author":"Taylor D","year":"2008","unstructured":"Taylor D, Hassan MA, Luterman A, Rodning CB. Unexpected intraoperative patient death: the imperatives of family- and surgeon-centered care. Arch Surg. 2008;143(1):87\u201392. doi:10.1001\/archsurg.2007.27"},{"key":"b8","series-title":"Can J Neurol Sci","article-title":"Complications during neurosurgical training: how does one not succumb?","author":"Veilleux C","unstructured":"Veilleux C, Karmur BS, Yang MMH. Complications during neurosurgical training: how does one not succumb?. Can J Neurol Sci. Published online January 23, 2025. doi:10.1017\/cjn.2025.4"},{"issue":"4","key":"b9","series-title":"Keio J Med","first-page":"203","article-title":"Residency training in emergency medicine: the challenges of the 21st century","volume":"53","author":"Williams AL","year":"2004","unstructured":"Williams AL, Blomkalns AL, Gibler WB. Residency training in emergency medicine: the challenges of the 21st century. Keio J Med. 2004;53(4):203\u2013209. doi:10.2302\/kjm.53.203"},{"issue":"13","key":"b10","series-title":"J Gen Intern Med","first-page":"3404","article-title":"How internal medicine residents deal with death and dying: a qualitative study of transformational learning and growth","volume":"37","author":"Ibrahim H","year":"2022","unstructured":"Ibrahim H, Harhara T. How internal medicine residents deal with death and dying: a qualitative study of transformational learning and growth. J Gen Intern Med. 2022;37(13):3404\u20133410. doi:10.1007\/s11606-022-07441-4"},{"issue":"6","key":"b11","series-title":"BMJ Open","first-page":"e072530","article-title":"Interventions to support medical trainee well-being when dealing with patient death: a scoping review protocol","volume":"13","author":"Ibrahim H","year":"2023","unstructured":"Ibrahim H, Vetter CJ, West K, Oyoun Alsoud L, Sorrell S. Interventions to support medical trainee well-being when dealing with patient death: a scoping review protocol. BMJ Open. 2023;13(6):e072530. doi:10.1136\/bmjopen-2023-072530"},{"issue":"6","key":"b12","series-title":"Acad Psychiatry","first-page":"451","article-title":"End-of-life care education for psychiatric residents: attitudes, preparedness, and conceptualizations of dignity","volume":"33","author":"Tait GR","year":"2009","unstructured":"Tait GR, Hodges BD. End-of-life care education for psychiatric residents: attitudes, preparedness, and conceptualizations of dignity. Acad Psychiatry. 2009;33(6):451\u2013456. doi:10.1176\/appi.ap.33.6.451"},{"issue":"2","key":"b13","series-title":"J Med Ethics","first-page":"97","article-title":"Ethical decision making in intensive care units: a burnout risk factor? Results from a multicentre study conducted with physicians and nurses","volume":"40","author":"Teixeira C","year":"2014","unstructured":"Teixeira C, Ribeiro O, Fonseca AM, Carvalho AS. Ethical decision making in intensive care units: a burnout risk factor? Results from a multicentre study conducted with physicians and nurses. J Med Ethics. 2014;40(2):97\u2013103. doi:10.1136\/medethics-2012-100619"},{"issue":"4","key":"b14","series-title":"AEM Educ Train","first-page":"e11009","article-title":"Bereavement scheduling policy for emergency medicine residents: a descriptive pilot study","volume":"8","author":"Kelly TD","year":"2024","unstructured":"Kelly TD, de Venecia BT, Pang PS, Turner JS, Reed KD, Pettit KE. Bereavement scheduling policy for emergency medicine residents: a descriptive pilot study. AEM Educ Train. 2024;8(4):e11009. doi:10.1002\/aet2.11009"},{"issue":"1","key":"b15","series-title":"World Psychiatry","first-page":"96","article-title":"Validation of the new DSM-5-TR criteria for prolonged grief disorder and the PG-13-Revised (PG-13-R) scale","volume":"20","author":"Prigerson HG","year":"2021","unstructured":"Prigerson HG, Boelen PA, Xu J, Smith KV, Maciejewski PK. Validation of the new DSM-5-TR criteria for prolonged grief disorder and the PG-13-Revised (PG-13-R) scale. World Psychiatry. 2021;20(1):96\u2013106. doi:10.1002\/wps.20823"},{"issue":"4","key":"b16","series-title":"JAMA Psychiatry","first-page":"277","article-title":"Prolonged grief disorder diagnostic criteria\u2014helping those with maladaptive grief responses","volume":"79","author":"Prigerson HG","year":"2022","unstructured":"Prigerson HG, Shear MK, Reynolds CF III. Prolonged grief disorder diagnostic criteria\u2014helping those with maladaptive grief responses. JAMA Psychiatry. 2022;79(4):277\u2013278. doi:10.1001\/jamapsychiatry.2021.4201"},{"issue":"5","key":"b17","series-title":"J Relig Health","first-page":"2323","article-title":"Identifying moral injury in healthcare professionals: the Moral Injury Symptom Scale-HP","volume":"59","author":"Mantri S","year":"2020","unstructured":"Mantri S, Lawson JM, Wang Z, Koenig HG. Identifying moral injury in healthcare professionals: the Moral Injury Symptom Scale-HP. J Relig Health. 2020;59(5):2323\u20132340. doi:10.1007\/s10943-020-01065-w"},{"issue":"1","key":"b18","series-title":"BMC Psychiatry","first-page":"556","article-title":"Psychometric properties of the moral injury symptom scale among Chinese health professionals during the COVID-19 pandemic","volume":"20","author":"Zhizhong W","year":"2020","unstructured":"Zhizhong W, Koenig HG, Yan T,  Psychometric properties of the moral injury symptom scale among Chinese health professionals during the COVID-19 pandemic. BMC Psychiatry. 2020;20(1):556. doi:10.1186\/s12888-020-02954-w"},{"issue":"1","key":"b19","series-title":"Int J Behav Med","first-page":"92","article-title":"You want to measure coping but your protocol\u2019s too long: consider the brief COPE","volume":"4","author":"Carver CS","year":"1997","unstructured":"Carver CS. You want to measure coping but your protocol\u2019s too long: consider the brief COPE. Int J Behav Med. 1997;4(1):92\u2013100. doi:10.1207\/s15327558ijbm0401_6"},{"issue":"6","key":"b20","series-title":"Psychosomatics","first-page":"613","article-title":"An ultra-brief screening scale for anxiety and depression: the PHQ-4","volume":"50","author":"Kroenke K","year":"2009","unstructured":"Kroenke K, Spitzer RL, Williams JB, Lowe B. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics. 2009;50(6):613\u2013621. doi:10.1176\/appi.psy.50.6.613"},{"key":"b21","series-title":"R: A Language and Environment for Statistical Computing","unstructured":"R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing. https:\/\/www.R-project.org\/"},{"issue":"5","key":"b22","series-title":"Nurs Ethics","first-page":"590","article-title":"Moral injury in healthcare professionals: a scoping review and discussion","volume":"28","author":"\u010cartolovni A","year":"2021","unstructured":"\u010cartolovni A, Stolt M, Scott PA, Suhonen R. Moral injury in healthcare professionals: a scoping review and discussion. Nurs Ethics. 2021;28(5):590\u2013602. doi:10.1177\/0969733020966776"},{"issue":"9","key":"b23","series-title":"Fed Pract","first-page":"400","article-title":"Reframing clinician distress: moral injury not burnout","volume":"36","author":"Dean W","year":"2019","unstructured":"Dean W, Talbot S, Dean A. Reframing clinician distress: moral injury not burnout. Fed Pract. 2019;36(9):400\u2013402."},{"issue":"1","key":"b24","series-title":"Ann Palliat Med","first-page":"70","article-title":"Surgeon and medical student response to patient death","volume":"12","author":"Wiemann B","year":"2023","unstructured":"Wiemann B, Ketteler E, Fahy B. Surgeon and medical student response to patient death. Ann Palliat Med. 2023;12(1):70\u201380. doi:10.21037\/apm-22-885"},{"issue":"1","key":"b25","series-title":"BMJ Open","first-page":"e076218","article-title":"How do they cope? A national cross-sectional study of coping in hospital doctors in Ireland","volume":"14","author":"Doherty A","year":"2024","unstructured":"Doherty A, Prihodova L, Walsh G, Hayes B. How do they cope? A national cross-sectional study of coping in hospital doctors in Ireland. BMJ Open. 2024;14(1):e076218. doi:10.1136\/bmjopen-2023-076218"},{"issue":"1","key":"b26","series-title":"Omega (Westport)","first-page":"59","article-title":"A proposed model of health professionals\u2019 grieving process","volume":"41","author":"Papadatou D","year":"2000","unstructured":"Papadatou D. A proposed model of health professionals\u2019 grieving process. Omega (Westport). 2000;41(1):59\u201377. doi:10.2190\/TV6M-8YNA-5DYW-3C1E"},{"issue":"5","key":"b27","series-title":"Psychooncology","first-page":"698","article-title":"Acute empathy decline among resident physician trainees on a hematology-oncology ward: an exploratory analysis of house staff empathy, distress, and patient death exposure","volume":"26","author":"McFarland DC","year":"2017","unstructured":"McFarland DC, Malone AK, Roth A. Acute empathy decline among resident physician trainees on a hematology-oncology ward: an exploratory analysis of house staff empathy, distress, and patient death exposure. Psychooncology. 2017;26(5):698\u2013703. doi:10.1002\/pon.4069"},{"issue":"8","key":"b28","series-title":"Acad Med","first-page":"996","article-title":"Empathy decline and its reasons: a systematic review of studies with medical students and residents","volume":"86","author":"Neumann M","year":"2011","unstructured":"Neumann M, Edelh\u00e4user F, Tauschel D,  Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86(8):996\u20131009. doi:10.1097\/ACM.0b013e318221e615"},{"key":"b29","series-title":"BMC Med Educ","first-page":"108","article-title":"\"That\u2019s not what you expect to do as a doctor, you know, you don\u2019t expect your patients to die.\" Death as a learning experience for undergraduate medical students","volume":"16","author":"Smith-Han K","year":"2016","unstructured":"Smith-Han K, Martyn H, Barrett A, Nicholson H. \"That\u2019s not what you expect to do as a doctor, you know, you don\u2019t expect your patients to die.\" Death as a learning experience for undergraduate medical students. BMC Med Educ. 2016;16:108. doi:10.1186\/s12909-016-0631-3"},{"issue":"5","key":"b30","series-title":"CMAJ Open","first-page":"E1006","article-title":"The impact of patient death experiences early in training on resident physicians: a qualitative study","volume":"11","author":"Ye WQW","year":"2023","unstructured":"Ye WQW, Griffin C, Sverdlichenko I, Vegas DB. The impact of patient death experiences early in training on resident physicians: a qualitative study. CMAJ Open. 2023;11(5):E1006\u2013E1011. doi:10.9778\/cmajo.20230011"},{"key":"b31","series-title":"MedEdPORTAL","first-page":"10809","article-title":"Empowering residents to process distressing events: a debriefing workshop","volume":"15","author":"Govindan M","year":"2019","unstructured":"Govindan M, Keefer P, Sturza J, Stephens MR, Malas N. Empowering residents to process distressing events: a debriefing workshop. MedEdPORTAL. 2019;15:10809. doi:10.15766\/mep_2374-8265.10809"}],"container-title":["Neurosurgical Focus"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/neurosurg-focus\/61\/2\/article-pE2.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/neurosurg-focus\/61\/2\/article-pE2.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/neurosurg-focus\/61\/2\/article-pE2.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,5]],"date-time":"2026-08-05T00:01:19Z","timestamp":1785888079000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/neurosurg-focus\/61\/2\/article-pE2.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,1]]},"references-count":31,"journal-issue":{"issue":"2"},"URL":"https:\/\/doi.org\/10.3171\/2026.4.focus26103","relation":{},"ISSN":["1092-0684"],"issn-type":[{"value":"1092-0684","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,1]]}}}