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Patients with substance use disorders (SUDs) who undergo valve repair or replacement are often readmitted to the hospital after discharge secondary to recidivism. These "dread to treat" patients pose a unique dilemma for cardiac surgeons who often must make the extremely difficult decision of whether to perform a valve replacement in a recidivist patient with SUDs. This editorial focuses on illuminating strategies which surgeons can administer to patients with SUDs to improve quality of care and reduce provider distress. K E Y W O R D S behavioral interventions, intravenous drug abuse, substance use disorders, surgeon wellness, valve repair/replacement Among the most difficult types of surgical patients to treat are those who struggle with substance addiction. Often complicating their hemodynamic and cardiovascular management after cardiac surgery are challenges with pain management and Cardiac Surgical Intensive Care Unit (CSICU)behavior. These issues impact the primary decision of basic management

Background International medical graduates (IMGs) have less burnout than U. S. medical school graduates (USMGs) during residency training. This study evaluates possible correlates of differences in burnout rates between USMGs and IMGs. Methods We surveyed 375 first-year residents at orientation in June/July 2017. We assessed burnout using the Copenhagen Burnout Inventory (CBI) and used validated scales to measure stress, quality of life (QoL), mastery, and spirituality. We collected data on gender, place of graduation, language fluency, and specialty. We compared CBI scores between USMGs and IMGs, performed a multivariate linear regression analysis of relationships between covariates and CBI subscales, and logistic regression analysis for our categorical definition of burnout. Results Two hundred twenty-two residents responded for a response rate of 59%. Personal, work or patient- related burnout was common among residents, particularly among USMGs. The most common form of burnout was work-related. Forty nine percent of USMGs have work burnout compared to 26% of IMGs (p < 0.01). In multivariate analysis, being an IMG reduced odds of work-related and of total burnout by 50% (OR 0.5 C.I 0.25-0.99). Perceived mastery was associated with reductions in all subscales of burnout (p < 0.05). Stress and low QoL related to personal and work burnout scores (p < 0.01). Conclusion Work-related burnout is more common among USMGs than in IMGs. Although mastery, QoL and stress were correlates of burnout among all residents, these factors did not explain the difference. Future studies should evaluate the role of medical school structure and curriculum on differences in burnout rates between the two groups.