North American research from the 1980s predicted an explosive growth in the number of general surgeons, with physicians expected to exceed population needs by the year 2000.1–3 However, over the last two decades the opposite has occurred.2,3 The Association of American Medical Colleges and the Canadian Medical Association have reported a decline in the number of practicing general surgeons,4,5 which has created a workforce crisis that is impacted by low recruitment, poor retention, and early retirement. For instance, between 1981 and 2005, there was a steady decline of general surgical manpower across the United States on a per capita basis: from 7.68 to 5.69 general surgeons per 100,000 persons.6 In Canada, the Canadian Residency Matching Service reported a decline in the number of first-choice applicants to general surgery between 1996 and 2001, as well as an increasing number of general surgeons pursuing surgical specialty fellowships.5 An increasing number of Canadian general surgery residents were also failing to complete their training programs.5 In the United States, the average age of practicing general surgeons exceeds that of other surgical specialties, with over half of general surgeons between 50 and 62 years old. Further, this cohort is anticipated to retire almost a decade earlier than previous generations.4,6,7 Most concerning is the knowledge that during the next 20 years, the general surgery workload in North America is expected to increase because the number of people over the age of 65 will double, and those over 85 years will triple.8,9
The greatest impact of this looming crisis in the general surgery workforce is being observed in rural communities where access to lifesaving surgical services has been profoundly affected.10 A rural area is defined as one where the population is fewer than 150,000 persons. U.S. research has estimated general surgeon manpower in rural areas to be in the range of 4.67 general surgeons per 100,000 persons.11 The general surgeon shortage has reached critical proportions in some communities where the lack of general surgeon availability threatens the survival of local hospitals. General surgeons are essential to the stability of these hospitals because, without their service, emergency departments cannot remain open and family physicians are left without a means to secure even basic surgical consultations.8 The recruitment and retention of general surgeons in such sites is increasingly difficult, as a community of practice with a reasonable cohort of practitioners to share on-call and other service demands is rapidly evaporating.9 Furthermore, in the United States, as much as 40% of hospital revenues arise from general surgical practice, and, without this income stream, these small hospitals face the threat of closure.6
The declining workforce in general surgery has been well documented, particularly in the United States,11 where attrition has been linked to career dissatisfaction. Descriptive survey research has demonstrated that low career satisfaction in general surgery is impacted by lack of control over work hours, lack of financial incentives, the need for additional training, and geographic isolation.12–15 We sought to advance this current understanding of career satisfaction and attrition among general surgeons by conducting a qualitative exploration of the experiences of Canadian general surgeons and, moreover, by comparing and contrasting the experiences of those in rural and urban areas. Qualitative methods provide a rich narrative account which complements previous survey findings and permits an exploration of the more complex dimensions of career satisfaction and how they impact recruitment, retention, and early retirement among general surgeons. Our objective was to understand what personal, professional, and environmental factors, either alone or in combination, influence career satisfaction among urban and rural general surgeons. We intend findings from this research to inform the creation of a solutions-oriented approach to this human resource problem.
This was a qualitative interview study. Qualitative research methods are ideally suited to explore poorly understood phenomena related to choices and complex behaviors.16 Approval was received from the research ethics board at St. Michael’s Hospital Research Institute, University of Toronto. Informed consent was obtained from study participants.
Recruitment and participants
We obtained contact and demographic information for general surgeons from the Canadian Association of General Surgeons database. Between August 2009 and June 2010, we sent out 401 e-mail invitations using a purposeful, criterion-based, maximum-variation frame sampling approach.16 Our goal was to establish a participant cohort of urban and rural general surgeons with varied experiences with respect to subspecialty interests, years in practice, and practice location across Canada. This approach was used to increase the conceptual generalizability of the results.17 Response to the initial e-mail invitation was low, and a second round of e-mails was sent.
Data collection and analysis
We conducted 32 telephone interviews. The interviews lasted 40 minutes on average and were audio-recorded. We collected demographic data about participants’ gender, years in practice, and rural or urban location. Two trained interviewers (M.C., B.K.) followed a semistructured interview guide, starting with general open-ended questions, followed by probes to stimulate more in-depth responses from participants. The interview process was a dynamic one. Not all questions or probes were asked as participants’ responses determined how and which questions were posed.18 See Table 1 for interview questions and follow-up probes.
We analyzed data inductively using an iterative, constant-comparison coding technique.19 The interviewers began to identify recurrent themes and incidents in the transcripts at the start of the data collection period. They met regularly with the primary investigator (N.A.) to discuss these themes, to compare and contrast them across interviews, and to generate probes to direct further data collection. This process continued until thematic saturation was reached—that is, when no new themes were emerging from the data. Subsequently, four authors (N.A., M.C., B.K., L.G.C.) independently reviewed the transcripts to triangulate the data and improve the trustworthiness of the findings.20 Differences in any coding among investigators were discussed until consensus was reached. We used NVivo software Version 8 (Cambridge, Massachusetts) to manage the data.
From the two rounds of e-mail invitations, we successfully recruited a total of 32 participants. Participant demographic details are summarized in Table 2. Our findings revealed a number of common themes among all participants, across urban and rural categories, and across gender and career stage.
What influences career satisfaction?
Gratification: Work is its own reward. Of most salience to participants’ positive career satisfaction was the gratification they experienced through their work, defined by both their passion for the hands-on clinical work and their professional and patient relationships. Participants described gratification in being able to take care of patients’ problems “expeditiously,” “fixing things quite quickly,” and seeing the immediate outcome of a procedure and its impact on the patient’s quality of life. This sense of instant gratification functioned to raise the level of satisfaction by reinforcing the meaningfulness of participants’ technical abilities, particularly as they pertained to treating patients within a relatively short time frame. As explained by one participant:
The thing I like about surgery is you are actually fixing or doing something right there, right now and you get to see immediately how things are advancing. [0–8 years in practice, female, urban]
Across our demographic categories, participants described having a passion for their work that made the long hours involved inconsequential, as one comment shows:
I didn’t really care how many hours I worked because I just enjoyed what I was doing and I could really see myself doing that for the rest of my life. [>15 years in practice, female, urban]
Also raising career satisfaction was the influence of relationships. The “close personal relationships” with patients were identified as one of the rewards of the work that overrode its challenges. Accordingly, both urban and rural surgeons viewed themselves as fortunate to play a meaningful role in their patient’s care trajectory, which this comment exemplifies:
I see my … cancer [patients] ’till the six-month mark and give them back to their family doctors and they give you a big hug before they go, you know, that’s really good. You have to remember all those good things and forget the one bad thing that’s happened ’cause 90% of [people] are really good people and we are very privileged to be able to be a part of these people’s lives. [0–8 years in practice, female, rural]
Professional relationships: People are important. Feeling connected to surgical colleagues was important for creating a supportive workplace culture. Participants in both urban and rural settings described how continuously learning from others kept them engaged and satisfied in their practice. One participant commented:
Every day I go to work and I really enjoy the guy I work with and I’ve known him since I was a kid and I feel privileged to still learn things from him. [0–8 years in practice, male, rural]
Collegial relationships built on mutual dependence, trust, and respect raised the level of satisfaction. These factors created opportunities for effective teamwork, continuity of patient care, and emotional support. For some, they overrode frustrations such as limited access to operating room (OR) time, as is shown by one participant’s comment:
I’m very lucky to be with a group that’s so supportive of what I do. I have three colleagues and they’re [an] extremely reliable, extremely helpful group. If you have bad colleagues then it doesn’t matter, everything else is a waste, no matter how much OR time and everything else you get, if your colleagues are not trustworthy, you won’t do well. [0–8 years in practice, male, urban]
Indeed, one participant attributed his plans to leave his current institution in part to a lack of collegiality and support:
Like, for example, the chief of surgery is a very negative fellow and the only time he ever talks to me is to tell me I’ve done something wrong. So we never talk other than to be told, you know there’s something wrong that you’ve done, or whatever, or there’s a complaint or this or that. [>15 years in practice, male, urban]
What contributes to career dissatisfaction?
Systems issues: Barriers to patient care. Our findings revealed that despite being fulfilled by the work itself and the relationships this entailed, both urban and rural participants felt they had inadequate access to and control over resources. This negatively impacted their morale and ability to provide timely and high-quality patient care. Participants perceived their need for increased access to and control over the organizational aspects of OR resources and desire to provide efficient care to be in conflict with hospital administrations’ mandate to manage hospital budgets. One participant commented:
All that everybody wants to do is to cut operating time because it costs the [Canadian] system money to run the OR. Nobody looks and says, it’s somebody’s mother or somebody’s daughter or husband or whatever. They just look at the accounting side of it and that’s it. [0–8 years in practice, male, rural]
Among urban general surgeons, satisfaction was lowered by frustration due to lack of access to OR resources during daylight hours, and the routine practice of delaying urgent operations. Rural general surgeons were frustrated by the large “call burden” and volume of patients due to the large geographic catchment areas their hospitals served. Indeed, the call structure influenced one participant to leave his current position:
The other thing that’s getting me down, and why I’m leaving, is the call. It’s a very, very busy place callwise, you know, it’s not just [this city] we take care of. Remember most of the other hospitals [in this area] don’t have general surgeons or they don’t have anything and so if you have appendicitis in someplace like that, well you come here to have it done. [>15 years in practice, male, rural]
Rural general surgeons were also frustrated by the poor alignment between patient care needs and fiscal concerns, which pitted surgeons against hospital administrators. One participant described this as a “culture of the administrators that is absolutely out of touch with the reality of patient care.” The administrative focus on budget was believed to take precedence over patients’ needs, amounting simply to “a lot of nice talk about how to restructure and how to improve patient care but little action taken.” Neither urban nor rural participants felt well supported by their hospitals. The “increase[ing] bureaucracy” was experienced as a sense of alienation from hospital leadership, and it lowered satisfaction and morale among our participants. Furthermore, dissatisfaction related to the lack of control over scheduling and organizational aspects of resources was very common. As one participant explained,
When the hospital makes it difficult for you to do things efficiently, you’re kind of dissatisfied at the end of the day. [0–8 years in practice, male, rural]
Work–life balance: Lack of control over lifestyle. Among all participants, career satisfaction was also influenced by perceptions of work–life balance. Both male and female, junior and senior general surgeons described having made certain personal “sacrifices” to achieve their professional goals. Indeed, some senior general surgeons believed that achieving balance was not realistic as a general surgeon. For example, one seasoned participant stated, “There’s no way there’s a balance between work and nonwork as a general surgeon, there just isn’t.” Sacrificing time spent with family, young children in particular, was viewed as a consequence of this imbalance. As explained by one male respondent,
You’re not going to be able to make every one of your kids’ extracurricular events. [>15 years in practice, male, rural].
Another participant related this perspective:
Other than OB/GYN, I would say we have the hardest lifestyle because we do a lot of after-hour work, which affects your family life. Not only that day, but several days after. We also admit patients who don’t need things done that night but other nights down the road in two or three days. So that’s another night away from your family. [8–15 years in practice, female, rural]
Yet, some participants believed it was possible to achieve a reasonable work–life balance, if the necessary supports were in place. In addition to the administrative supports, these included a collegial and available clinical practice group, and an understanding and supportive spouse and family structure. One participant’s comments are illustrative:
I think first and foremost is my surgical colleagues, particularly the ones I work closest with, who definitely add a quality of life to my day-to-day practice. We’re mutually dependent on each other as well to achieve that balance between life and practice because mutual coverage is intrinsic to someone’s satisfaction. So that is one of the factors that without good immediate surgical colleagues I would find it virtually impossible to find a balance. [9–15 years in practice, male, urban]
Discussion and Conclusions
Our qualitative investigation of career satisfaction among urban and rural general surgeons makes a number of contributions to what is already known about this topic. First, despite the geographic disparity between them, career satisfaction among urban and rural general surgeons is impacted both positively and negatively in a similar way. All participants in our study described career satisfaction as elevated by the ability to cultivate their passion for the everyday work they do for patients, and to do it alongside colleagues who share an appreciation for and dedication to the altruistic and humanistic value of their work. At all career stages, we found these values among general surgeons to be present and firm.
Our findings illustrate importantly that when general surgeons struggle with a lack of resource control, collegiality, and work–life balance, this contributes tremendously to their sense of dissatisfaction, whether in urban or rural settings. General surgeons are tied almost entirely to hospital-based practice to deliver patient care, and a good deal of the care they provide is emergency in nature. As a result, they are affected by hospital and system-wide policies to a greater extent than other physician groups. Participants in this study described this lack of influence over resources as an impediment to the delivery of the efficient and effective patient care that they have devoted themselves to. General surgeons felt that these systemic issues also impact the imbalance in their personal and professional lives. These findings echo what Balch and Shanafelt21 have recently described as the primary factor leading to decreased career satisfaction and burnout among both male and female surgeons: work–life conflict. Among the general surgeons in our study, there was a desire for greater control over their work–life balance. They did not de facto accept that the status quo cannot be improved on. They expressed a wish to regain some control over their professional time and struggled with overloaded on-call systems and hospitals that function inefficiently. This evolving ethos among the general surgeons we interviewed is an area that requires further exploration because it redefines and reprioritizes the need for general surgeons to have influence over resources and time in a way that should not be disregarded.
For general surgeons in this study, satisfaction was lowered when system constraints, such as limited access to OR time, impeded the delivery of surgical care. There was a clear sense that a gap exists between the motivations and goals of these general surgeons and those of health care administrators, and that the values and priorities among these two groups are in conflict. The gap between professional and institutional goals has been previously identified as an obstacle to the achievement of professional fulfillment for physicians practicing in academic health centers.22 Lieff22has shown that realizing one’s values and motivations as a physician, and constructing a meaningful career and identity from that individual vision, is a primary determinant of professional fulfillment and career satisfaction. Yet, to ultimately achieve this, there must be an alignment with the directions and values of one’s environment. Our research suggests that a misalignment of surgeons’ and their institutions’ values is in fact present among both urban and rural general surgeons, in both academic and nonacademic settings. This can only be expected to intensify if effective solutions to this trend are not introduced.
A potential solution may be found in the newly evolving model of acute care surgery (ACS), a group practice model which allows for the separation of emergency and elective surgical care, thereby eliminating the competition between the two services for institutional and human resources and decreasing the burden of work on any one general surgeon. This model has become increasingly popular in academic environments, having been shown to improve provider satisfaction by reorganizing the clinical workload such that it becomes more manageable for any one individual.23,24 It has also been shown to improve productivity and patient outcomes25–27 as well as enhance educational experiences for trainees.28 Although academic trauma centers were among the first to implement trauma/ACS teams, this model is gaining wider interest among nonacademic and rural general surgeons. In nonacademic settings, this model will require a different organizational structure and could include solutions such as the enhancement of existing networks among community hospitals and coalescence of call groups. Additional solutions to alleviate the amount of work required by general surgeons could include the routine involvement of nonsurgeon health care providers. Primary care physicians, nurse practitioners, physician extenders, and patient care navigators are among those whose knowledge and skill could aid in preserving a surgeon’s time and energy so that they are able to invest these into those activities where their expertise is uniquely needed.
The limitations of our study include the inability to conduct in-person interviews due to the geographic distribution of participants. Consequently, we could not assess nonverbal cues (facial expression, body language, etc.). A second possible limitation may be the small sample size of 32. However, because we employed qualitative methods, our goal was to reach data saturation rather than achieve any statistical significance.
It is imperative to understand how to better foster career success and satisfaction among this important group of care providers. The work of urban and rural general surgeons is essential to the health of populations because these professionals provide specialized care for clinical problems that run the gamut from injury and injury prevention to surgical oncology and cancer research to transplantation and immunobiology. The current generation is more family-centric and team-oriented and, although still achievement-oriented, is less interested in personal sacrifices to achieve career success or financial rewards. These trends, combined with the sociologic realities related to the change in family structures (single-parent families, two-professional-parent families), the protection of personal time, and a more tangible way to achieve work–life balance, are becoming increasingly important pragmatic considerations for all professionals. This is an area for further qualitative exploration. Our findings reveal the common difficulty that urban and rural general surgeons face in actualizing their needs in everyday clinical settings, which is significantly influencing attrition among them. Because general surgery practice is necessarily tied to hospitals, general surgeons need to feel that they are able to participate in the creation of a culture that prioritizes patient care and that recognizes the importance of the balance between professional obligations and personal time.
Acknowledgments: The authors wish to thank Dr.Anand Pandya for assisting with the initial study design.
Other disclosures: None.
Ethical approval: This study was approved by the institutional review board of St. Michael’s Hospital Research Institute, University of Toronto.
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