Distress and Career Satisfaction Among 14 Surgical Specialties, Comparing Academic and Private Practice Settings

Charles M. Balch, MD; Tait D. Shanafelt, MD; Jeffrey A. Sloan, PhD; Daniel V. Satele, BS; Julie A. Freischlag, MD.

Disclosures

Annals of Surgery. 2011;254(4):558-568. 

In This Article

Results

Demographic and Outcomes for Individual Surgical Specialties

The demographics, work characteristics, distress incidence and career satisfaction for each of the 14 surgical subspecialties are described below in approximate order of distress parameters. The ranking for burnout, screen + for depression, low mental QOL and career satisfaction is listed in Table 1.

Trauma Surgeons

The majority of the 345 respondents were located in an academic practice (68.7%). The mean age was 48 years (rank 11th among the 14 specialties) and 17.8% were women (rank 4th). Compared to the other 13 surgical specialties, they reported the highest workload of all surgical specialties, with 65% working >70 hours/week, and a mean workweek of 72.8 hours/week (rank 1st) and an average of 2.3 nights on call per week (rank 11th). On the other hand, they reported the lowest number of hours in the operating room at 12 hours/week (rank 14th). With regard to distress parameters, they had the highest incidence of burnout (51.6%), the lowest mental QOL score with a mean score of 46.9, and 36.7% having low QOL score that was half a standard deviation below the population norm (rank 1st), and the highest rate of work/home conflict (62.3%). They had a positive depression screen of 33.9% (rank 3rd), and a suicide ideation rate of 7.0% (rank 3rd). With regard to career satisfaction, 26.7% would not be a surgeon again (rank 8th of 14 specialties), whereas 42% would not recommend a medical career to their children (rank 10th).

Vascular Surgeons

The majority of the 463 respondents were located in a private practice (54%). The mean age was 52.9 years (rank 6th) and 6.1% were women (rank 10th). Compared to the other 13 surgical specialties, they reported an average workload, with 35.5% working >70 hours/week, a mean workweek of 61.6 hours/week (rank 7th), and an average of 2.7 nights on call per week (rank 5th). They reported a high number of hours in the OR at 20 hours/week (rank 2nd). With regard to distress parameters, they had the second highest incidence of burnout (44%), a lower mental QOL score of 48.7, with 29.1% having low QOL score (rank 6th), and an average rate of work/home conflict (51.9%; rank 7th). They ranked 5th in having a positive depression screen (30.4%), and reported the highest incidence of suicide ideation rate at 7.7% (rank 1st). Vascular surgeons reported the lowest level of career satisfaction, with 36% stating they would not be a surgeon again (rank 1st), whereas 54.4% would not recommend a medical career to their children (rank 1st).

Transplant Surgeons

The vast majority of the 123 respondents were located in an academic practice (78%). They were one of the youngest groups, with a mean age of 47.9 years (rank 13th) and 10.6% were women (rank 8th). Compared to the other 13 surgical specialties, they reported a high workload, with 48.8% working >70 hours/week, a mean workweek of 68.8 hours/week and an average of 4.3 nights on call per week (rank 1st). They reported an average number of hours in the OR at 16.5 hours/week (rank 9th). With regard to distress parameters, they had the highest rate of having a positive depression screen (36.7%), an average incidence of burnout (39.8%; rank 6th), and a lower mental QOL score at 47.7, with 30.8% having low QOL score (rank 2nd). They reported a high rate of work/home conflict (59.3%; rank 3rd). Suicide ideation rate was relatively low at 4.1% (rank 13th). Transplant surgeons reported a high level of career satisfaction, with only 15.7% stating they would not be a surgeon again (rank 13th), whereas 37.7% would not recommend a medical career to their children (rank 13th).

Cardiothoracic Surgeons

Over half of the 488 respondents were located in an academic practice (54%). The mean age was 53 years (rank 5th) and 6% were women (rank 11th). Compared to the other 13 surgical specialties, they reported a high workload, with 47.8% working >70 hours/week, a mean workweek of 65.3 hours/week (rank 4th), and an average of 3.5 nights on call per week (rank 2nd). They reported the highest number of hours in the OR at 24.9 hours/week (rank 1st). With regard to distress parameters, they had a higher positive depression screen at 34.5% (rank 2nd), a lower mental QOL score of 48.5, with 29.3% having low mental QOL score (rank 4th), but a lower incidence of burnout at 34.8% (rank 11th), and an average rate of work/home conflict (52.7%; rank 5th). They also reported a higher incidence of suicide ideation rate at 7.3% (rank 2nd). Cardiothoracic surgeons reported an average level of career satisfaction, with 27.5% stating they would not be a surgeon again (rank 5th), whereas 49.1% would not recommend a medical career to their children (rank 12th).

Urologic Surgeons

The majority of the 315 respondents were located in a private practice (61.6%). The mean age was somewhat older at 54.5 years (rank 3rd), and only 3.5% were women (rank 13th). Compared to the other 13 surgical specialties, they reported a somewhat lower workload, with 22.8% working >70 hours/week, a mean workweek of 55.5 hours/week (rank 11th), an average of 2.7 nights on call per week (rank 5th), and a lower number of hours in the operating room at 12.3 hours/week (rank 13st). With regard to distress parameters, they ranked 3rd in burnout rate (42.9%), had an average rate of a positive depression screen at 28.8% (rank 6th), a lower mental QOL score of 49.4, with 26.3% having low QOL score (rank 10th), a lower rate of work/home conflict (43.3%; rank 12th) and a low incidence of suicide ideation rate (4.5%; rank 11th). Urologic surgeons reported an average level of career satisfaction, with 25.9% stating they would not be a surgeon again (rank 9th), whereas 47.6.1% would not recommend a medical career to their children (rank 12th).

General Surgeons

The majority of the 3233 respondents were located in a private practice (63.6%). The mean age was 51.6 years (rank 8th) and 12.8% were women (rank 7th). Compared to the other 13 surgical specialties, they reported an average workload, with 28.4% working >70 hours/week, and a mean workweek of 58.8 hours/week (rank 9th), an average of 2.6 nights on call per week (rank 8th), but a higher number of hours in the operating room at 18.1 hours/week (rank 5th). With regard to distress parameters, they had a higher positive depression screen (32.8%; rank 4th), and burnout rate at 41% (rank 5th), a lower mental QOL score of 48.5, with 29.6% having low QOL score (rank 3rd), and an average rate of work/home conflict (50%; rank 9th). They reported a higher incidence of suicide ideation rate of 6.9% (rank 4th). General surgeons reported a lower level of career satisfaction, with 31.8% stating they would not be a surgeon again (rank 3rd), whereas 53.6% would not recommend a medical career to their children (rank 2nd).

Colorectal Surgeons

The majority of the 302 respondents were located in a private practice (56.3%). The mean age was the youngest of all specialties at 47.7 years (rank 1st), whereas 19.3% were women (rank 2nd). Compared to the other 13 surgical specialties, they reported an above average workload, with 31.8% working >70 hours/week, a mean workweek of 62.2 hours/week (rank 6th), an average of 2.7 nights on call per week (rank 5th), and an average number of hours in the operating room at 17.9 hours/week (rank 7th). With regard to distress parameters, they ranked 7th in burnout rate (39.7%), had an average rate of a positive depression screen at 28.6% (rank 7th), a lower mental QOL score of 48.3, with 29.2% having low QOL score (rank 5th), a higher rate of work/home conflict (59.5%; rank 2nd), and a suicide ideation rate of 6% (rank 7th). Colorectal surgeons reported a lower level of career satisfaction, with 31% stating they would not be a surgeon again (rank 4th of 14 specialties), whereas 45.8% would not recommend a medical career to their children (rank 7th).

Plastic Surgeons

The majority of the 458 respondents were located in a private practice (67.9%). The mean age was 50.8 years (rank 10th), whereas 14.7% were women(rank 6th). Compared to the other 13 surgical specialties, they reported a lower average workload, with 17.5% working >70 hours/week, a mean workweek of 54.6 hours/week (rank 12th), an average of 2.8 nights on call per week (rank 4th), and a higher number of hours in the operating room at 19.7 hours/week (rank 3rd). With regard to distress parameters, they had a burnout rate of 37.4% (rank 9th), a positive depression screen of 28.4% (rank 8th), a mental QOL score of 49.4, with 27.1% having low QOL score (rank 9th), and an average rate of work/home conflict (50%; rank 9th). They reported a higher incidence of suicide ideation rate (6.8%; rank 5th). Plastic surgeons reported a lower level of career satisfaction, with 32.7% stating they would not be a surgeon again (rank 2nd), whereas 48.6% would not recommend a medical career to their children (rank 4th).

Neurologic Surgeons

The majority of the 184 respondents were located in a private practice. The mean age was somewhat older at 54.3 years (rank 4th), whereas 6% were women (rank 12th). Compared to the other 13 surgical specialties, they reported a mean workweek of 61.5 hours/week (rank 8th), with 37.7% working >70 hours/week, an average of 2.4 nights on call per week (rank 10th), and 18 hours/week in the operating room (rank 6th). With regard to distress parameters, they had a burnout rate of 38.5% (rank 8th), a 21.3% rate of a positive depression screen (rank 12th), a mental QOL score of 49.8, with 25.3% having a low QOL score (rank 12th), a work/home conflict rate of 41.5% (rank 13th), and a suicide ideation rate of 4.4% (rank 12th). Neurosurgeons reported an average level of career satisfaction, with 28.3% stating they would not be a surgeon again (rank 6th), whereas 44.2% would not recommend a medical career to their children (rank 8th).

Otolaryngology/Head and Neck Surgeons

The majority of the 371 respondents were located in a private practice (54.7%). The mean age was 51.5 years (rank 7th) and 9.2% were women (rank 9th). Compared to the other 13 surgical specialties, they reported a mean workweek of 54.3 hours/week (rank 13th), with 12.8% working >70 hours/week, an average of 2.3 nights on call per week (rank 11th), and a lower number of hours in the operating room at13.3 hours/week (rank 10th). With regard to distress parameters, they had a higher burnout rate of 41.3% (rank 4th), but a lower positive depression screen at 23.3% (rank 11th), a mental QOL score of 50.4, with 20.9% having low QOL score (rank 13th), a 51.8% rate of work/home conflict (rank 8th), and a suicide ideation rate of 4.6% (rank 10th). Otolaryngology/Head and Neck surgeons reported an average level of career satisfaction, with 30.5% stating they would not be a surgeon again (rank 5th of 14 specialties), whereas 45.5% would not recommend a medical career to their children (rank 8th).

Surgical Oncology

The majority of the 407 respondents were located in an academic practice (59.5%). The mean age was younger at 49.9 years (rank 11th) and they represented the highest proportion of women (26.4%). Compared to the other 13 surgical specialties, they reported a high workload, with 36.1% working >70 hours/week, a mean workweek of 62.6 hours/week (rank 5th), but a lower 2.1 nights on call per week (rank 13th), and 17.7 hours/week hours in the operating room (rank 8th). With regard to distress parameters, they had a lower rate of burnout at 36.1% (rank 10th), a positive depression screen rate of 24.3% (rank 10th), and a mental QOL score of 48.9, with 26.2% having low QOL score (rank 11th). They reported a 55.2% rate of work/home conflict (rank 6th), and a suicide ideation rate at 4.9% (rank 9th). Surgical Oncologists reported a higher level of career satisfaction, with 24.9% stating they would not be a surgeon again (rank 10th), whereas 30.5% would not recommend a medical career to their children (rank 12th).

Obstetrics/Gynecology

Of the 105 respondents, 48.6% were located in a private practice. The mean age was 54.8 years (rank 2nd), whereas 18.3% were women (rank 3rd). Compared to the other 13 surgical specialties, they reported a mean workweek of 57.0 hours/week (rank 10th), with 29.1% working >70 hours/week, an average of 3.4 nights on call per week (rank 3rd), and a lower number of hours in the operating room at 13.0 hours/week (rank 12th). With regard to distress parameters, they had a lower rate of burnout at 33.7% (rank 12th), a lower rate of positive depression screen at 19.6% (rank 13th), and an average mental QOL score of 50.1, with 27.5% having low QOL score (rank 7th). They reported a lower rate of work/home conflict at 44.1% (rank 11th), and the lowest rate of suicide ideation at 3.8% (rank 14th). Responding Obstetrics/Gynecologists reported an average level of career satisfaction, with 22.1% stating they would not be a surgeon again (rank 11th), but a higher 47.5% would not recommend a medical career to their children (rank 6th).

Orthopedic Surgeons

The majority of the 155 respondents were located in a private practice (61%). They were the oldest group with a mean age was 58.9 years (rank 1st), whereas only 3.3% were women (rank 14th). Compared to the other 13 surgical specialties, they reported a lower mean workweek of 51.1 hours/week (rank 14th), with 18.5% working >70 hours/week (rank 12th), an average of 1.8 nights on call per week (rank 14th), and a lower number of hours in the OR at 13.2 hours/week (rank 11th). With regard to distress parameters, they had one of the lowest burnout rates of 32% (rank 13th), the lowest rate of a positive depression screen at 20.8% (rank 14th), a higher mental QOL score of 51.7, with only 20.4% having low QOL score (rank 14th), and the lowest rate of work/home conflict at 39.5% (rank 14th). The responding orthopedic surgeons reported an high level of career satisfaction, with only 20.1% stating they would not be a surgeon again (rank 12th), whereas 44.2% would not recommend a medical career to their children (rank 9th).

Pediatric Surgeons

The majority of the 243 respondents were located in an academic practice (61.6%). The mean age was 51.2 years (rank 9th), whereas 16.5% were women (rank 5th). Compared to the other 13 surgical specialties, they reported a high workload, with a mean workweek of 65.8 hours/week (rank 3rd), 42.7% working >70 hours/week (rank 4th), 2.6 nights on call per week (rank 8th), and a higher number of hours in the operating room at 19.4 hours/week (rank 4th). With regard to distress parameters, they had the lowest rate of burnout at 31.4% (rank 14th), a lower depression screen rate of 28% (rank 9th), and an average mental QOL score of 49.0, with 27.3% having low QOL score (rank 8th). They reported a higher rate of work/home conflict at 56.4% (rank 4th), and a suicide ideation rate of 6.3% (rank 6th). Pediatric surgeons reported the highest level of career satisfaction, with only 15.6% stating they would not be a surgeon again (rank 14th), and only 33.3% would not recommend a medical career to their children (rank 14th).

Multivariate Analysis of Distress Parameters and Career Satisfaction

Independent factors relating to burnout were analyzed in a MV analysis. In this model, the practice setting was included as a variable and the surgical subspecialties were compared to general surgery. After accounting for all the variables, the practice setting was an independent variable, with surgeons in a private practice setting having a greater burnout risk compared to an academic practice setting (OR 1.172, P = 0.0212). Compared to general surgery, the subspecialties with a higher risk of burnout were trauma (OR 1.413, P = 0.0088), urology (OR 1.350, P = 0.0222) and otolaryngology/head and neck surgery (OR 1.282, P = 0.0397), while those with a relatively lower risk of burnout were pediatric surgery (OR 0.670, P = 0.0135) and cardiothoracic surgery (OR 0.776, P = 0.0284) after accounting for all other factors. As reported previously,[2] the other independent factors associated with burnout were hours worked per week, nights on call per week, incentive based pay, years in practice, younger age, having younger children and spouse working (Table 2).

Independent factors relating to career satisfaction included the practice setting in this analysis. Surgeons in a private practice setting had a lower career satisfaction response relative to those in an academic practice setting (OR 0.527, P < 0.0001). Compared to general surgery, the surgical subspecialties with a higher degree of career satisfaction were otolaryngology/head and neck surgery (OR 2.664, P < 0.001), transplant surgery (OR 2.212, P = 0.0060), plastic surgery (OR 2.000, P < 0.0001), pediatric surgery (OR1.794, P = 0.0068), urology (OR 1.869, P = 0.0002), and orthopedic surgery (OR 1.756, P = 0.0360), whereas vascular surgeons had a lower degree of career satisfaction compared to general surgeons (OR 0.746, P = 0.0200). As reported previously (Shanafelt, 2009), the other independent factors associated positively with career satisfaction were hours in the operating room per week, older age, nonpatient care activities and negatively with nights on call per week and burnout (Table 2).

Academic Versus Private Practice Setting

Personal and professional characteristics of surgeons working in a private practice setting (N = 4240) and an academic practice setting (N = 2272) are shown in Table 3 and Table 4. Compared to those in an academic practice, community-based surgeons were more likely to be younger (mean age of 50 years vs. age 51 for those in an academic practice), worked fewer hours per week (59.4 hours/week vs. 65.3 hours/week), had more nights on call (3.0 vs. 2.2 nights on call per week), were less likely to be salaried (29.8% vs. 86.5%), and had less nonpatient care activities (17.2% vs.61% had >20% nonpatient care time per week; all P < 0.0001; Table 3 and Table 4). Academic surgeons were less likely to experience burnout compared to those in private practice (37.7% vs. 43.1%), less likely to screen positive for depression (27.6% vs. 33%) or to have suicide ideation (4.7% vs. 7.4%; all P < 0.0001). They were also more likely to have career satisfaction (77.4% of academic surgeons would become a surgeon again vs. 64.9% for those in private practice; P < 0.0001)) and to recommend a medical career to their children (61.3% vs. 43.7%, P < 0.0001; Table 5).

The independent factors associated with burnout and career satisfaction was different for those in an academic practice compared to those in a private practice (Table 6). For academic surgeons, the most significant associations with burnout were: being a trauma surgeon (OR 1.513, P = 0.0059), more nights on call (OR 1.062, P = 0.0123) and hours worked (OR 1.019, P < 0.0001), whereas the negative associations were: having older children (>22 years; OR 0.529, P < 0.0001), being a pediatric surgeon (OR 0.583, P = 0.0053), or a cardiothoracic surgeon (OR 0.626, P = 0.0117), and being male (OR 0.787, P = 0.0491; Table 6a). In a private practice setting, the most significant positive associations with burnout were: being a urologic surgeon (OR 1.497, P = 0.0086), having 31% to 50% time for nonclinical activities (OR 1.404, P = 0.0409), having incentive based pay (OR 1.344, P < 0.0001), more nights on call (OR 1.045, P = 0.0029) and more hours worked (OR 1.015, P < 0.0001), whereas the negative associations were: older children (OR 0.677, P = 0.0001), having a physician spouse (OR 0.753, P = 0.0093), and older age (OR 0.989, P = 0.0158; Table 6c).

With regard to career satisfaction, the most significant positive associations were being a full professor (OR1.398, P < 0.001), having a salary with bonus pay (OR 1.397, P = 0.0061), hours worked per week (OR 1.010, P = 0.0313) and having older children (OR 1.484, P = 0.0407), whereas the negative associations were being burned out (OR 0.214, P < 0.0001), being a vascular surgeon (versus general surgery; OR 0.516, P = 0.0040), and being an assistant professor (OR 0.702, P = 0.0085; Table 6b). The independent factors relating to career satisfaction for surgeons in private practice were different. Thus, the most significant positive associations were the subspecialties of otolaryngology/head and neck surgery (compared to general surgery; OR 2.517, P < 0.0001), plastic surgery (OR 1.906, P < 0.0001), pediatric surgery (OR 2.783, P = 0.0054), urology (OR 1.673, P = 0.0044), and orthopedics (OR 1.811, P = 0.0416) as well as older age (OR 1.029, P < 0.0001), more hours in the operating room (OR 1.016, P < 0.0001), more time for nonpatient activities (OR 1.275, P = 0.0337) and having older children (OR 1.258, P = 0.0416), whereas the 3 negative associations were hours worked per week (OR 0.990, P < 0.0001, nights on call (OR 0.941, P = 0.0001) and being burned out (OR 0.222, P <0.0001; Table 6d).

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