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.


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

In This Article


If strategies are to be developed at the local level to prevent or mitigate stress and burnout…by the individual surgeon and at the organizational level…it is important to understand the contributing factors that, in combination, are associated with relatively higher and lower degrees of risk for distress to improve personal wellness and to optimize the quality of patient care. Each surgeon brings to the issue of personal wellness a complex array of risks factors, whereas each medical institution, surgical practice groups, and surgical specialty corporations face a complex array of workplace issues that may contribute to burnout. Our results highlight the importance of accounting for the diverse influences within each surgical specialty, the practice setting (private practice and academic practice) and their association with both surgeon distress and career satisfaction. Such information would be helpful to individuals and supervisors to target programs for surgeons that are more specific to the underlying factors associated with distress in their workplace environment, especially for those surgeons who are at particularly higher risk for stress, burnout and depression.[5,16,17] For example, those surgeons who work more than 80 hours a week and/or have 2 or more nights on call per week was associated with a detrimental impact on surgeons in almost every setting, both professionally and personally.[18] On the other hand, some surgical specialties independently correlated with burnout, both positively and negatively, even after accounting for these factors (Table 2a).

These results illustrate the dichotomy of issues that could impact on an individual surgeon and their workplace environment. Among these 14 surgical subspecialties, there was great variability in their demographics, age, gender, time in the operating room, workload, nonpatient activities, and practice setting. There were also differences in the incidence of burnout, depression, lower quality of life—issues that impact on personal wellness. These 3 indices of distress did not necessarily align together when comparing 1 surgical subspecialty to another. For example, otolaryngology/head and neck surgeons ranked in the upper third for burnout and the lower third for depression and lower mental QOL, and conversely, cardiothoracic surgeons ranked in the lower third for burnout and in the upper third for depression and low mental QOL. Although there was a general correlation between increased distress and lower career satisfaction, this was not always the case. For example, transplant surgeons reported a higher level of distress, but a relatively high level of career satisfaction compared to other surgical specialties. Trauma surgery consistently ranked in the highest third of distress parameters, and was an independent variable after accounting for all other factors relative to the distress parameters of general surgery. At the other end of the spectrum, the specialty of pediatric surgery consistently ranked among the lowest third of distress parameters and was also identified as an independent variable.

When practice setting (private practice vs. academic practice) was inserted into the MV model, it was identified as an independent factor associated with burnout and with career satisfaction. As a result, we performed an in depth analysis comparing the demographics, distress parameters, and career satisfaction based on the practice setting. In these analyses, different surgical subspecialties were associated with burnout (both positively and negatively) and with career satisfaction (both positively and negatively). The results demonstrated that most, but not all, surgical specialties that rank at the highest and lowest levels of distress parameters correlate reciprocally with relatively higher and lower levels of career satisfaction.

The results from this analysis have some limitations. First, the sample size for some of the specialties (eg, orthopedics and obstetrics/gynecology) represents a minority of the practicing surgeons in these specialties. It is unknown whether the stress factors and career satisfaction is representative of the larger group of certain subspecialties. That would have to be confirmed with validated surveys targeted to these specialties. On the other hand, the information reported here is consistent with other published studies for these surgical subspecialties.[1,2,4] We would encourage the leadership of these subspecialties to conduct surveys of their constituents to gain more insights about both incidence of and factors associated with burnout and career satisfaction, such as has been performed selectively for otolaryngology/head and neck surgery as well as surgical oncology.[17,19] Second, this type of survey does not infer cause and effect relationship but only statistical associations. Many of these circumstances are bi-directional influences; for example, medical errors can contribute to burnout among some surgeons whereas the converse is true in other circumstances. Third, this survey was performed in June 2008 and represents a "snapshot" of distress factors and career satisfaction at that time. The American College of Surgeons has performed a second survey in October 2010 and the results from this should reveal interesting trends that will provide further insights at a second point in time. These may be impacted by national health care policy and economics that have occurred since 2008.

With these results, as well as those previously published, individual surgeons and group practices of specific specialty surgeons should be able to better understand the relative risk for distress for them personally and for their colleagues. Although it is important for all surgeons to address the issues of personal wellness, it is particularly important for those who are at increased risk based on combinations of increased workload, specific surgical specialty, practice environment, age, family responsibilities and work-home conflict resolution that, in the aggregate, span a spectrum of risk for burnout, depression and low mental quality of life. With this information, medical students and residents can better select their specialty choice and practice environment that is in better congruence with their life style, personal and professional expectations and stress tolerance. With this information, individual surgeons can understand the importance of addressing proactively their personal wellness, especially those that are at increased risk based on combinations of personal and professional factors. With this information, leaders of group practices, surgery departments and medical organizations can better calibrate their programs for personal wellness and a supportive workplace environment, especially among those surgeons both at the individual and specialty level who are at increased risk for burnout and depression. With this information, researchers can better understand the complex variables that can impact on the professional and personal life of surgeons and other physician specialties in designing increasingly sophisticated approaches to identify successful methods for preventing or mitigating the consequences of burnout and other adverse effects on personal wellness and quality patient care.

Just as the approaches to "personalized medicine" take into account the individual variability of a disease state, the genetic background of the host, and their quality of life, so too do the solutions of preventing or treating burnout, depression and low mental quality of life among surgeons require solutions at the individual level and the individual surgical practice environment.


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