The face of the plastic surgery workforce is SPECIAL TOPIC. Plastic Surgeons Satisfaction with Work Life Balance: Results from a National Survey

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1 SPECIAL TOPIC Plastic Surgeons Satisfaction with Work Life Balance: Results from a National Survey Rachel Streu, M.D., M.S. Mary H. McGrath, M.D., M.P.H. Ashley Gay, B.A. Barbara Salem, M.S.W., M.S. Paul Abrahamse, M.S. Amy K. Alderman, M.D., M.P.H. Ann Arbor, Mich.; and San Francisco, Calif. Background: Plastic surgery demographics are transforming, with a greater proportion of women and younger physicians who desire balance between their career and personal lives compared with previous generations. The authors purpose was to describe the patterns and correlates of satisfaction with work life balance among U.S. plastic surgeons. Methods: A self-administered survey was mailed to a random sample of American Society of Plastic Surgeons members (n 708; 71 percent response rate). The primary outcome was satisfaction with work life balance. Independent variables consisted of surgeon sociodemographic and professional characteristics. Logistic regression was used to evaluate correlates of satisfaction with work life balance. Results: Overall, over three-fourths of respondents were satisfied with their career; however, only half were satisfied with their time management between career and personal responsibilities. Factors independently associated with diminished satisfaction with work life balance were being female (odds ratio 0.63; 95 percent CI, 0.42 to 0.95), working more than 60 hours per week (versus 60 hours per week; odds ratio 0.44; 95 percent CI, 0.28 to 0.72), having emergency room call responsibilities (versus no emergency room call, odds ratio 0.42; 95 percent CI, 0.27 to 0.67), and having a primarily reconstructive practice (versus primarily aesthetic practice; odds ratio 0.53; 95 percent CI, 0.30 to 0.93). Conclusions: While generational differences were minimal, surgeons who were female, worked longer hours, and had emergency room call responsibilities and primarily reconstructive practices were significantly less satisfied with their work life balance. (Plast. Reconstr. Surg. 127: 1713, 2011.) The face of the plastic surgery workforce is changing. More women are entering this surgical field than ever before. Over the past 20 years, the percentage of female physicians in all specialties has risen from 11.6 to 27.8 percent. 1 Women consist of half of all students currently enrolled in U.S. medical schools, 2 make up over one-third of the first-year resident complement in general surgery, 3 and account for one-quarter of From the Section of Plastic Surgery, Department of Surgery, The University of Michigan Medical Center; Department of General Surgery, St. Joseph Mercy Hospital; Department of Plastic and Reconstructive Surgery, University of California, San Francisco; and Division of General Medicine, Department of Internal Medicine, University of Michigan. Received for publication February 13, 2010; accepted August 4, Presented at the American College of Surgeons Clinical Congress, in Chicago, Illinois, October 15, Copyright 2011 by the American Society of Plastic Surgeons DOI: /PRS.0b013e318208d1b3 first-year residents in plastic surgery. 4 In addition, a generational shift is occurring with the emergence of Generation X and Y into the physician workforce. These younger generational groups (born from the 1960s to the early 1990s) compared with their baby boomer predecessors have notably shifted their priorities toward family and work life balance. 5,6 Work life balance is described as the perceived sufficiency of time available for work and social life. 7 Little is known about the impact of the above demographic changes on satisfaction with work life balance among plastic surgeons. To understand these workforce changes, both academic medical and surgical specialties are paying more attention to the factors that influence physicians Disclosure: The authors have no financial interest to declare in relation to the content of this article

2 Plastic and Reconstructive Surgery April 2011 abilities to successfully balance careers with family responsibilities Female physicians are particularly vulnerable, as they are more likely to uphold the societal role of wife and mother and are more likely to shoulder the majority of child-rearing responsibilities Likewise, younger physicians tend to value the balance between personal and professional responsibilities more than older generations. 5,6 This younger cohort of physicians is also being educated in a dramatically different training environment that mandates a more balanced lifestyle through strongly regulated workhour restrictions. 16 It is unclear how these physicians will adapt after residency once they enter a demanding surgical practice with unregulated work hours. Our purpose was to describe satisfaction with work life balance among a national sample of plastic surgeons. In particular, we evaluated the association between surgeons personal characteristics (such as age and gender) and professional characteristics (such as practice mix, work hours, and call responsibilities) with surgeons satisfaction with work life balance. METHODS Study Population and Data Collection A written, self-administered survey was sent to a national sample of plastic surgeons in the United States to evaluate satisfaction with work life balance. The study sample was selected from a random sample of members from the American Society of Plastic Surgeons (708 total; 354 men and 354 women). Sampling was not based on age or geographical region. Women, however, were oversampled to provide an equal gender distribution of respondents. We estimated that a sample size of 200 for both men and women would provide adequate power to avoid type 2 error and allow us to detect small differences in physicians satisfaction. Surgeons were mailed an anonymous survey containing a $10 cash incentive gift, which is a standard survey technique to improve response rates. 17,18 We used the Dillman method to maximize response rates, which involved mailing nonresponders a reminder letter and questionnaire within 4 weeks of initial contact. 19,20 Follow-up letters were sent to responders with missing questions to improve the completeness of the data set. The response rate was 71 percent (n 505) and included 250 male and 255 female surgeons. The study protocol was reviewed and approved by the Institutional Review Board of the University of Michigan. Measures The surgeon questionnaire was developed based on a conceptual model. The primary outcome was surgeon satisfaction with work life balance. A satisfaction scale was developed from the following items: (1) I have too much work to do everything well, (2) I am satisfied with my career, and (3) I am satisfied with my time management between career and personal responsibilities. The first item was derived from the General Social Survey questionnaire. 21 The other two items were designed by the authors to further assess satisfaction with work life balance. Each item used a fivepoint Likert response, ranging from 1 (highly dissatisfied) to 5 (highly satisfied). For analytical purposes, responses were dichotomized into satisfied (4 or 5) versus dissatisfied (1, 2, or 3). Applying different categorizations did not alter the results significantly. The independent variables included (1) surgeon characteristics (age, gender, marital status, employment of spouse, number of children, and childrearing responsibilities) and (2) professional characteristics (practice mix, practice size, resident teaching responsibility, and professional time commitments). Surgeon age was categorized into four groups: less than 40, 41 to 50, 51 to 60, and more than 60 years. Surgeon gender was a two-level categorical variable. Marital status was grouped as married/partnered, single divorced, and single never married. Full-time employment of a spouse was dichotomized into yes versus no. Number of children was categorized into four groups: none, 1, 2 to 3, and more than 3. Surgeon age at the birth of their first child was a continuous variable described in years. Level of training at the birth of the surgeon s first child was categorized into three groups: before training, during training, and after training completed. Primary caregiver of child was dichotomized into yes versus no. Practice mix was categorized by the percentage of aesthetic cases a surgeon performed, for which less than 25 percent was considered primarily reconstructive, 25 to 75 percent was considered mixed practice, and more than 75 percent was considered primarily aesthetic. Practice size was dichotomized into solo versus group with two or more physicians. Participation in resident training was dichotomized: yes versus no. Emergency room call was dichotomized into none versus one or more calls per month. Work hours were dichotomized into 60 or fewer versus more than 60 hours per week. 1714

3 Volume 127, Number 4 Satisfaction with Work Life Balance Analysis Descriptive We first described the distribution of our sample by surgeon gender and surgeon age across all independent variables. We also described the family characteristics of the sample by surgeon gender. Pearson chi-square was used for the bivariate analyses for the comparisons between categorical variables, and Student t tests were used for analyses of continuous variables. Multivariate Regression We then performed a multivariate logistic regression to evaluate factors associated with satisfaction with work life balance among plastic surgeons. Variables related to child responsibilities were excluded from the final regression model because a large proportion of the sample did not have children. The Wald test and the likelihood ratio test were used to test the significance of individual predictive variables, and the model chisquare statistic was applied to test the overall significance of the model. All analyses were performed with STATA version 8.0 (College Station, Texas). Table 1. Sample Characteristics by Surgeon Gender Men (n 250) Women (n 255) Personal characteristics Age years 25 (10.1) 7 (2.8) years 117 (47.2) 101 (40.0) years 95 (38.3) 124 (49.0) 60 years 11 (4.4) 8 (8.3) Marital status Married/partnered 227 (90.8) 184 (72.4) Single divorced 19 (7.6) 36 (14.2) Single never married 4 (1.6) 34 (13.4) Professional characteristics Practice mix Primarily aesthetic 68 (27.4) 84 (33.2) Mixed 111 (44.8) 105 (41.5) Primarily reconstructive 69 (27.8) 64 (25.3) Practice size Solo 143 (57.2) 142 (56.0) Group ( 2) 107 (42.8) 112 (44.1) Participate in training residents Yes 88 (35.6) 63 (25.0) Emergency room call days/month None 70 (28.0) 102 (40.3) (72.0) 150 (59.7) Work hours/week (74.0) 204 (81.3) (26.0) 47 (18.7) *Column percentage. RESULTS Table 1 describes personal and professional characteristics of the study sample by surgeon gender. Our sample consisted of a slightly older female population, as only 43 percent of female surgeons were less than 50 years of age compared with 57 percent of men (p 0.001). Compared with their male colleagues, female plastic surgeons were more likely to have been divorced (8 versus 14 percent, respectively) or never married (2 versus 13 percent, respectively; p 0.001). There were no significant differences in operative case mix and practice size by surgeon gender. Male compared with female surgeons, however, were more likely to work more than 60 hours per week (26 versus 19 percent, respectively, p 0.051), take emergency room calls (72 versus 60 percent, respectively, p 0.004), and participate in resident education (36 versus 25 percent, p 0.01). Figure 1 displays the family characteristics of the surgeon sample. One-third of female plastic surgeons indicated that they had no children versus only 7 percent of male plastic surgeons (p 0.001). Of those with children, male surgeons were more likely to have two or more children compared with female surgeons (81 versus 58 percent, respectively; p 0.001). Female surgeons appeared to be more likely to delay having children. Seventy-one percent of male surgeons indicated that their first child was born before or during their surgical training years compared with 46 percent of female surgeons (p 0.001). For the entire study sample, 81 percent of plastic surgeons were married with children, but only 15 percent of respondents indicated that they were the primary caregiver to their child(ren). Female surgeons were more likely to indicate that they were their child(ren) s primary caregiver compared with their male counterparts (25 versus 5 percent, respectively, p 0.001). In addition, female surgeons who were married were more likely to be married to a spouse who worked full time, as compared with their male colleagues (74 versus 29 percent, respectively; p 0.001). Table 2 describes the sample population by surgeon age. The younger surgeons ( 50 years) compared with the older cohort ( 50 years) had a significantly larger proportion of men (57 versus 42 percent, respectively; p 0.001), were more likely to be in a group practice (50 versus 37 percent, respectively; p 0.002), and were more likely to take emergency room call (74 versus 58 percent, respectively, p 0.001). There were no significant differences between the two age groups with regard to marital status, practice mix, participation in resident education, or work hours per week. p 1715

4 Plastic and Reconstructive Surgery April 2011 Fig. 1. The family characteristics of the surgeon sample. Table 2. Sample Characteristics by Surgeon Age Generation X/Y (Age <50 years; n 250) Baby Boomers (Age >50 years; n 238) Personal characteristics Gender Male 142 (56.8) 106 (42.2) Female 108 (43.2) 145 (57.8) Marital status Married/partnered 208 (83.5) 201 (80.1) Single divorced 21 (8.4) 32 (12.8) Single never married 20 (8.0) 18 (7.2) Professional characteristics Practice mix Primarily aesthetic 70 (28.1) 80 (32.3) Mixed 102 (41.0) 112 (45.2) Primarily reconstructive 77 (30.9) 56 (22.6) Practice size Solo 124 (49.6) 158 (63.2) Group ( 2) 126 (50.4) 92 (36.8) Participate in training residents Yes 76 (30.7) 73 (29.6) Emergency call days/month None 66 (26.4) 104 (41.8) (73.6) 145 (58.2) Work hours/week (74.7) 200 (80.7) (25.3) 48 (19.4) *Column percentage. p Overall, 29.8 percent of all respondents were satisfied with their career; however, 80.9 percent felt that they had too much work to do everything well, and only 52 percent were satisfied with their time management between career and personal responsibilities. Table 3 shows the independent association of covariates of plastic surgeons satisfaction with work life balance. The results are re- 1716

5 Volume 127, Number 4 Satisfaction with Work Life Balance Table 3. Correlates of Plastic Surgeon Satisfaction with Work Life Balance Satisfaction with Work Life Balance Adjusted Odds Ratio 95% CI Personal characteristics Gender Male 1 Female Age 40 years years years years Marital status Single never married 1 Single divorced Married/partnered Professional characteristics Case mix Primarily aesthetic 1 Mixed Primarily reconstructive Practice size Solo 1 Group Participate in training residents No resident training 1 Resident training Emergency room call days/month None Work hours/week ported using odds ratios and associated 95 percent confidence intervals. The odds ratio measures the odds of being satisfied for the indicated category relative to the reference group. Odds ratios less than 1.0 are considered to be associated with diminished satisfaction with work life balance and those greater than 1.0 are associated with increased satisfaction with work life balance. Factors independently associated with diminished satisfaction with work life balance were being female (odds ratio 0.63, 95 percent CI, 0.42 to 0.95), working more than 60 hours per week (versus 60 hours per week, odds ratio 0.44, 95 percent CI, 0.28 to 0.72), and having emergency room call responsibilities (versus no emergency room call, odds ratio 0.42, 95 percent CI, 0.27 to 0.67). In addition, having a primarily reconstructive practice (i.e., less than 25 percent aesthetic surgery) was associated with lower satisfaction with work life balance (versus primarily aesthetic practice mix, odds ratio 0.53, 95 percent CI, 0.30 to 0.93). Surgeon age, marital status, size of practice and involvement in resident education did not contribute to plastic surgeon satisfaction with work life balance. DISCUSSION In this national survey, we did not find satisfaction with work life balance to vary significantly with surgeon age. Plastic surgeons under the age of 50 (from Generation X/Y) work a similar number of hours per week as those over the age of 50 (from the baby boomer generation). This is consistent when compared with a recent study by Rohrich et al. that addressed work hours per week in plastic surgeons over age Younger surgeons, however, take more emergency room calls and have proportionally more physicians in group practice compared with solo practice. We did, however, find a very significant association between surgeon gender and satisfaction with work life balance. Female plastic surgeons report significantly less favorably about the competing requirements of career and personal life. Other factors associated with surgeons having less satisfaction with work life balance included practicing primarily reconstructive surgery, working more than 60 hours/week, and having emergency room call responsibilities. We can only speculate why female compared with male plastic surgeons struggle more with a balance between work and personal responsibilities. This study, along with others, indicates that female surgeons assume more of the family responsibilities compared with their male colleagues. Female surgeons are more likely to report being their children s primary care provider. A striking finding is that three-fourths of the spouses of women plastic surgeons work full time whereas less than one-third of the spouses of male surgeons are employed full-time. This means that outside help for childcare is required in a far larger proportion of families in which the woman is a surgeon. The dual-career burden of work and home, and the perception that one cannot perform either as expertly as if both were not present, might negatively affect these surgeons satisfaction with their ability to maintain balance in their lives. Our previous work has shown that satisfaction with the decision to become a plastic surgeon does not vary by surgeon gender. 23 Thus, female surgeons are satisfied with their choice of profession. The present study shows something additional, namely, that they struggle with the integration of their chosen profession and personal lives. Family structure varies significantly by surgeon gender. Female plastic surgeons are more likely to 1717

6 Plastic and Reconstructive Surgery April 2011 be single or divorced, are more likely to delay childbearing, and are more likely to have fewer children compared with their male colleagues. It is unclear whether the differences in family structure (i.e., marital and parental status) by surgeon gender is a result of surgeon preferences or if female surgeons face more barriers to developing their personal lives compared with their male colleagues. This difference in family structure by surgeon gender appears to be long-standing. Over a decade ago, Capek et al. found female plastic surgeons to be less likely to be married and, if married, more likely to have no children or fewer children compared with their male colleagues. 24 Interestingly, professional and practice characteristics did not differ by surgeon gender in Capek s study; this is unlike our findings that women work fewer hours per week, take fewer emergency room calls, and participate less in training residents. It is possible that this change in practice by female surgeons over the past 10 years is a reflection of their effort to try to achieve better work life balance. Unfortunately, it appears that these changes in practice have not been sufficient to mitigate women s perception of their ability to balance the pressures of clinical practice with family responsibilities. Reconstructive surgeons appear to be struggling with their satisfaction with work life balance. Our previous work found reconstructive surgeons to have diminished satisfaction with their career choice, 23 and the additional data from this study suggest that reconstructive surgeons also struggle with finding balance between personal and professional responsibilities. Several factors may be responsible for these outcomes. Reconstructive surgery can be disruptive to a surgeon s schedule due to the time urgency associated with many reconstructive cases, the complexity of coordinating care with other surgeons, and the long operative times often associated with these complex procedures. In addition, these patients frequently require intensive postoperative monitoring and are at a higher risk for developing postoperative complications compared with elective aesthetic surgeries. This association between satisfaction with work life balance and a surgeon s control over work hours and weekly schedule has been well-documented in other surgical fields. 10,25 Limitations Our findings should be interpreted in the context of some limitations. Our analyses may be subject to a nonresponse bias. However, given our high response rate for a physician survey (71 percent), we believe that our sample was highly representative of the national population of U.S. plastic surgeons. Also, our data were derived from self-report and were subject to respondent recall and interpretation biases. We have no reason to suspect, however, that these potential biases would vary by surgeon gender and practice type. Lastly, our study was performed during a unique economic climate in the United States, which may have influenced responses. The economic recession may have diminished the clinical demand of some surgeons and potentially dampened the magnitude of work life imbalance reported by surgeons. Implications Surgeons ability to successfully balance work and personal responsibilities has important implications for the plastic surgeon workforce and quality of care. Diminished work life balance is highly correlated with professional burnout Furthermore, physicians who score high on professional burnout measures are at risk of delivering poorquality patient care Our study suggests that female plastic surgeons and reconstructive surgeons are at greater risk for diminished satisfaction with work life balance. Efforts should focus on specific mechanisms that facilitate these surgeons ability to reconcile the competing demands of work and family. The challenge is not unique to the practice of plastic surgery, and the solutions will need to address lifestyle issues at various points in a surgeon s life. During surgical training, flexible parental leave policies would facilitate pregnancy among female surgical residents and potentially diminish infertility and obstetrical complications due to advanced maternal age. 3,32 34 Innovative job-sharing opportunities during and after training may facilitate work life balance and be desirable to both male and female surgeons. Professional families would also greatly benefit from on-site hospitalsponsored day care with extended operating hours that correspond to surgical work-hours. In regard to practice structure, reconstructive surgeons may benefit from creating larger group practices that are better able to distribute clinical and on-call responsibilities. SUMMARY Future efforts must be directed at continued monitoring of plastic surgeons satisfaction with work life balance. The struggle of balance between work and family, however, is not an isolated problem within plastic surgery. We must develop 1718

7 Volume 127, Number 4 Satisfaction with Work Life Balance global strategies and collaborative efforts to assist all physicians in the struggle to achieve balance between a demanding profession and personal responsibilities. Amy K. Alderman, M.D., M.P.H. Plastic and Reconstructive Surgery University of Michigan 2130 Taubman Center 1500 East Medical Center Drive Ann Arbor, Mich aalder@umich.edu REFERENCES 1. American Medical Association. Physician characteristics and distribution in the U.S Available at: statistics-history/table-1-physicians-gender-excludes-students. shtml. Accessed March Association of American Medical Colleges (AAMC). Women in academic medicine statistics and medical school benchmarking Available at: umich.edu/ama/pub/about-ama/our-people/membergroups-sections/women-physicians-congress/statistics-history/ table-2-women-medical-school-applicants.shtml. Accessed March Frangou C. Critical mass: With stakes high, women may assume crucial role in surgery s future. 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