Brown, Judith Belle PhD; Fluit, Meghan MSc; Lent, Barbara MA, MD, FCFP; Herbert, Carol MD, FCFP
The literature is replete with studies reporting factors influencing medical students' choice of a surgical career. For example, concerns about work–life balance are cited as a deterrent to choosing a surgical specialty, whereas positive role models, either a family member or faculty, and career opportunities were viewed as positive influences on students' decision making.1–5
The percentage of women choosing a surgical career is increasing,6,7 and there has been a growing interest among researchers, practitioners, and educators in the challenges faced by women surgeons.6–12 Studies have examined the barriers in choosing a surgical career as well as the obstacles to pursuing academic positions in surgery for women, such as childbearing and child care, lifestyle issues, lack of mentors, and workload.6,7,9,10,12 However, it seems that male surgeons also struggle with attaining a work–life balance.13 Assuming an academic position can place even greater strain on the ability to find a balance between personal and professional obligations.
For this reason, understanding the experiences of both men and women surgeons' academic career trajectories has been cited as important in recruiting competitive candidates and fostering their retention in academic departments of surgery.6 New recruits to the surgical academy are likely to be younger and starting their families.13 At the same time, they are expected to establish their program of research and record of publications in order to attain promotion. The purpose of this study is to describe the experiences of recently recruited academic surgeons in seeking a balance between their personal and professional lives.
In 2002, the Department of Surgery at the Schulich School of Medicine and Dentistry at the University of Western Ontario had 55 full-time clinical faculty, 2 of whom were women. Between 2002 and 2009, 24 new faculty were recruited with equal distribution of men and women.
In 2009, we invited all 24 recently recruited faculty to participate in this study through an e-mail outlining the purpose of the study. Faculty could indicate interest in participating with a return e-mail. The project coordinator (M.F.) then contacted interested participants to arrange a time and location for an interview. During the data collection, two potential participants left their academic positions, one declined for personal reasons, and four did not respond to the e-mail invitation, resulting in a final sample of 17 participants.
The University of Western Ontario research ethics board for health sciences research involving human subjects approved this study.
This phenomenological study used in-depth, individual, semistructured interviews to explore the participants' experiences of seeking a balance between their personal and professional lives.14,15 An interpretive phenomenological approach allows examination of the unique and personal experiences of participants, including, for example, their motivations, affect, values, and perceptions. Interviews were conducted by one of two of the researchers (J.B.B. or M.F.) and lasted approximately 45 to 60 minutes. The interview questions explored participants' work–life balance, support systems, and impact of their careers on their personal lives.
All interviews were audiotaped and transcribed verbatim. In the first phase of the analysis, all four researchers independently reviewed each transcript to identify the key concepts and phrases emerging from the data. We then met to compare and contrast our independent reviews, culminating in a consensus that informed the development of the coding template which evolved over the course of the analysis. All the coded transcripts were entered into NVivo 8 software (QSR International, Cambridge, Massachusetts). We then met for further synthesis and interpretation of the themes using the techniques of immersion and crystallization.16 Immersion involves researchers' complete engrossment in the data, allowing them to become sensitive to the tone, range, mood, and context of the data during the analysis. Crystallization reflects the ultimate synthesis of the central themes as expressed by participants. Theme saturation was achieved by the 12th interview. The five remaining interviews reinforced the emergent themes and conceptualizations of the data. Credibility and trustworthiness of the data were enhanced through the following: verbatim transcripts, field notes generated after each interview, and independent and team analysis. Also, reflexivity, the awareness of the researcher's contribution to the construction of meanings throughout the research process,14 was promoted throughout the analysis. As the researchers came from different backgrounds (two academic family physicians, one PhD researcher, and one MSc researcher), we each reflected on the ways in which our own values and experiences shaped the interpretation of the data.
The sample consisted of nine women and eight men who ranged in age from 32 to 48 (mean = 38). The men and women were comparable in age. All were at the rank of assistant professor except two, who were associate professors. The two associate professors were men, and they had been affiliated with the department for the longest period of time. Participants' subspecialties varied and included, for example, cardiothoracic, orthopedics, colorectal, and plastics. We obtained no specific information regarding participants' academic productivity, yet all participants anticipated promotion. All participants were currently in committed heterosexual relationships. Of the six women participants with children, four had partners who were actively engaged in professional careers, and the two others had partners whose career status provided flexibility in assuming child care responsibilities. For the six male participants with children, their partners assumed the majority of child care and household responsibilities. Most of the participants' children were under the age of four.
All participants expressed a passion and commitment to academic surgery; at the same time, their stories revealed the complexity of making choices in seeking a balance between their personal and professional lives. As Figure 1 illustrates, this process of making choices was filtered through the values that influenced the participants' lives, which in turn determined how they set boundaries to protect their personal time from the demands of their professional obligations. Intertwined in this process were the trade-offs they had to make in order to seek balance. Inevitably, some choices, boundary-setting strategies, and trade-offs were dictated by gender. Finally, the process of making choices and seeking balance was not static. Instead, it was both dynamic and cyclical, requiring reexamination throughout their life cycle and over their career trajectory.
The choices that set the participants' career trajectories in motion were, of course, first to become a surgeon and then to become an academic surgeon. Making the choice to become a surgeon was sometimes influenced by an individual's family of origin: “My Dad is a surgeon so he really inspired me.” The choice to become a surgeon was also influenced by mentors encountered during medical school, as one participant recalled:
When I was in medical school I had the opportunity to work with some surgeons and they were great mentors to me … that's when I fell in love with cardiac surgery.
The strong belief that they could make a difference in their patients' lives, expressed as the impact on patient outcomes, also influenced their specialty choice. One participant reflected that “You make a tremendous difference in the person's functional life.… It's very gratifying to do the work.” The ability to cure was also motivating: “I think surgery is a specialty that can cure things in just one moment compared to other specialties where you control the disease.”
All participants voiced a passion for their work, as illustrated succinctly by this individual: “If there was no passion, I couldn't do my job.” Many expressed satisfaction with their choice of an academic career, commenting, for example, that “I really like the mix of research and clinical. I'm extremely happy.” But, often, balancing their multiple responsibilities was a challenge. As one participant articulated:
It's very difficult.… I have Tuesday mornings where I try to focus on things (research) but the reality is it never happens. There's a problem with a patient on the floor, there's an admission … so you look after your patients first and … the research comes secondarily.
The participants' choices were filtered through influential values which reflected their personal beliefs about life and work. For example, in discussing the care of postsurgical patients, a participant articulated a commitment to be available should complications arise, based on his personal values:
I don't think that everyone, even in my generation, would ascribe to my ideals. But I don't begrudge people that don't, that's their choice. This is just the way I am as a person.
All participants exhibited a very strong work ethic, which could result in some distress when work demands were extreme. As one participant shared,
I'm a person that feels totally uncomfortable when I don't do my work 100%.… Right now my schedule is a bit crazy. And I don't live well with the fact that things are hanging at 75%.
For many participants, work was an integral component of how they defined themselves, yet at the same time the value they assigned to their personal lives influenced their choice-making. One participant remarked that “I love my work. It's what makes me, me, but it's not worth sacrificing everything personal for it.”
Collectively, participants observed a shift in gender roles, with men in the discipline valuing time with family and being more actively involved in child rearing than their predecessors. For example, “There's lots of males who take child rearing responsibilities very seriously and … who play a very active role in their child's life.” Some men participants acknowledged the unique challenges faced by their women colleagues: “I can't imagine [being] a woman in surgery, there's a lot more stresses than as a man…. I've got a very supportive wife and somebody who can look after the home.” The women participants who had children struggled with the role conflict they experienced as they highly valued their roles both at home and at work. As one woman put it,
Although they [males] want to understand the gender difference.… I don't think men can understand the stress on the woman surgeon to be [a] woman at home and [a] woman at work.
Participants protected their personal lives by identifying strategies for setting boundaries. Many participants and their partners chose to hire outside help to manage household tasks, which then allowed more quality family time. As one participant explained, “If I have … five or six hours on a Saturday it's much more valuable for me to spend time with my children than cutting my grass.” Others secured help in the home to alleviate their stress levels and seek some balance:
We got a nanny because I was like, “I need a life.” I cannot be the person that is doing all the child care, the groceries, the cleaning, the laundry, and working full-time as a … surgeon, like I'll burn out.
When at home, many participants made a concerted effort to protect their time with family which often meant establishing firm boundaries: “I try to avoid everything work-related when I'm at home. I try to work as efficiently as I can while I'm at work. But I have to protect that time.”
Again, the value they ascribed to family time assisted them in setting boundaries on the time spent at work, as the following participant described: “I try to get home for dinner four times during the week and whenever I am home I spend time with my family.” Setting boundaries was supported when colleagues shared a philosophy similar to the one articulated by this participant:
When … there [is] a four o'clock … hip to be pinned on the board and I'm not on call and somebody says, “Can you do it?” I say, “No, I'm out. I gotta take my son to karate.” I think they [partners] understand that.
But setting boundaries was not easily accomplished, took time to reconcile, and was interwoven with personal and professional trade-offs. One participant recalled,
The first two years I really struggled. I brought my work home and then I brought my work back again. I was frustrated. I was trying to be the primary caregiver, be the worker and I [was] stressed.
For the most part, participants did not view gender as an issue in their work. However, in considering the strategies they used for setting boundaries, gender issues were evident. One woman participant explained the difference between male and female surgeons and the inherent differences experienced in boundary setting:
My male colleagues don't even think twice about, “Okay, I'll be there at 7:00 am rounds,” or “I'll be there at 6:00 pm meetings.” They can do that and they don't have to think about child care.
Although the participants actively set boundaries both at home and at work, there were inevitable trade-offs they had to make to achieve balance. The most prominent was their limited time for self. To make time for other personal and professional obligations, one participant noted, “I don't feel like I do very much for me.” Many had also relinquished former friendships and expressed regret about this loss: “Personal relationships have had to take second priority to my career … so that has been a personal sacrifice.” Although some participants valued the importance of exercise, many reported less time for such activities, like this participant who “used to run every day. I have definitely given that up.”
As noted previously in the theme of setting boundaries, trade-offs did seem to be influenced by gender. The following participant articulated this challenge:
I would never say to my male colleagues … I can't do something because … I have to be home for the kids … because that's always the perception, I think, by men, that women do less work because of their own families.
Making choices, setting boundaries, and reconciling trade-offs were all part of the process of seeking balance between the participants' personal and professional worlds. But for many participants this was an ongoing struggle, and some feared that the imbalance might intensify over time:
I don't [manage work and life balance]. It's terrible. It's horrendous. I have no balance right now. And it keeps getting worse. And I haven't figured out how to slow the train down and that's a major … concern for me.
Others candidly stated that the balance was nonexistent, although they were trying to achieve that equilibrium:
I don't think I'm the correct role model for someone who has been able to balance work [and] life because there is no balance and I'm not sure there can be a balance when you're a surgeon [and] a researcher. It's just a work in progress.
Thus, seeking balance was an ongoing process for all of the participants.
The cyclical nature of seeking balance
The acts of seeking balance between personal and professional lives, as well as deciding which boundaries or trade-offs were deemed acceptable, were not static or permanent. Rather, these decisions seemed to be cyclical, influenced by multiple life cycle events such as completing residency, establishing long-term relationships, having children, and pursuing career opportunities.
As individuals moved through life, their decisions and expectations adjusted to their current reality. One participant explained: “I think as you get older you readjust what you think your expectations are …. I think you adjust what you think can fit into your life as your career develops.”
Another participant who recently completed her residency explained:
I finally don't have to study all the time, I finally have a little bit of money.… Now I have breathing room … work is not a killer. You just want to have a few years to enjoy your life before you commit to the next big thing.
Deciding when to have children, or not to have children, was also a pervasive issue with regard to the cyclical nature of seeking balance. In particular, finding the “right” time to start a family was a common concern that engendered tension and was shared by the women participants. One woman participant put it this way:
Do you sort of give up your 20s … focus on your career first and then focus more on your family?… To me in my 20s.… I didn't want to be married and have kids at that point. I was focused on my career.
As new opportunities arose during the participants' careers, they were faced with additional demands on their time. One participant explained: “I just took on the [role of] program director in [specialty] surgery. So that's about a hundred residents a year that come through the program.” For some, this added responsibility was not a choice but an assignment: “We just had a meeting and he said, ‘You’re going to take over that job as of now.'”
Therefore, each life cycle stage prompted different decision points for the participants to negotiate as they continued to seek balance between their personal and professional lives.
This study provides valuable insights into the complexities of seeking work–life balance for both women and men surgeons. This is a cyclical process that initially begins with making choices, which are filtered through influential values, and continues through setting boundaries and making trade-offs.
Factors directing the participants' choice to become an academic surgeon, such as family circumstances and influential mentors, have been previously cited.8,9,17 Most evident in the current study was participants' passion for their work and their conviction that they could make a difference in their patients' lives. As noted in other research, participants spontaneously described having no regrets about their choice of an academic career.7 What our findings reveal is the complexity of their career path, expanding on prior literature.
The study illuminated how the participants' values and beliefs about life and work influence both their choices and boundary setting. For example, value placed on quality family time prompted participants to set discrete boundaries between work and home. Many participants used specific strategies, such as hiring outside help to assist with household tasks and child care responsibilities, to help keep these boundaries in place. Although such strategies have been reported previously, the concept that these strategies are values-driven is new.18 Therefore, new recruits to academic positions may require mentors to assist them in recognizing and reconciling their personal and professional values.9,19
Boundary setting between personal and professional responsibilities continues to be a challenge for women. The women participants shared the long-held belief that they would be “criticized” should they overtly choose to meet family obligations over professional responsibilities.9,18 Of note, the men participants did not seem to endorse this perspective, and their own commitment to setting boundaries between home and work was very apparent. This may reflect a generational shift; yet, the women participants continued to experience setting boundaries, as well as seeking a balance, through a gendered lens.
All the participants described inevitable trade-offs they experienced in seeking balance, especially limited time for self and a loss of relationships. Similar trade-offs have been identified in previous studies of women physicians.20–22 Of importance in this study is how the men surgeons' trade-offs were very similar to those of their women colleagues.
The challenge of women physicians' seeking balance between their personal and professional lives is not new.20–22 Unique to this study is the perspective of surgeons, both women and men, in a discipline that has placed particularly high value on hard work and long hours at work. In this study, balance seemed to be attained over time, and rebalancing was necessary as life cycle events occurred both in participants' personal lives and in their professional lives.
There are, however, limitations to our work. Because the participants were recent recruits at only one surgical department, our findings may not be transferable to a broader group of physicians.
This study enhances the understanding of the complex process by which academic surgeons seek balance in their personal and professional lives. Exploration of this dynamic process revealed the complexity of their choices in their attempts to seek balance. How individuals, who are members of an academic department of surgery, navigate the balance between their personal and professional worlds may provide new insights and understanding for other disciplines striving to enhance the development of the next generation of academics. For example, academic leaders may consider providing explicit permission for setting boundaries between personal and professional domains, offering assistance in reconciling new recruits' value systems with their personal and professional obligations, and examining how the losses associated with trade-offs can be limited, while enhancing new faculty members' satisfaction both at home and at work.
The authors wish to thank the participants for their time and candor. They also thank Dr. John Denstedt for his time and commitment to this project.
Ethics approval was received from the University of Western Ontario research ethics board for health sciences research involving human subjects.