Only few surveys have been conducted among pediatric surgeons to evaluate their satisfaction with professional activities and the work-life balance. Published papers show that traditional figures have changed. Private life has become as equally important as professional achievements. The trend of feminization among surgeons has been noticed lately. All other issues – legislative, financial, and interpersonal – have become eligible for investigation and improvement. Our study collected a sample of 44 among 72 regular members of Croatian pediatric surgeons. Collected data clearly pointed to a major area of satisfaction, but also highlighted areas that need improvement.
The average age of the participants was 46 years and almost 60% of the participants were in the age group 40–60 years, the most productive and creative period. This data suggest that employment policy is appropriate, and that the present situation provides for a competent service of pediatric surgery in Croatia. Same figures can be found in the reports of Bouchard and Laberge 1 and Katz 2. M/F ratio showed only 11% of the female pediatric surgeons in our study, but in the group under the age of 40, the recent trend of feminization was evident, as in this group women represent almost 40% of the participants. The same trend has been shown in recent surveys in the USA 2 and the UK 3. Studies 4–6 among the overall population of surgeons in the USA show approximately the same figures; the proportion of female surgeons varies from 13 to 20%. The reported proportion is significantly lower than the participation of women (50%) in the overall physician population 7,8. This data confirm traditional notions about surgery as a male profession.
The average work volume/week in Croatia was 52 h, which is same as the average working week reported for American physicians 8. This is slightly less than the average working week of 57 h reported for pediatric surgeons in Canada 1, but significantly shorter than that reported for surgeons in the USA (60–65 h/week) 4,6. American surgeons actually stated a 50-h working week as the desired goal 4. Croatian pediatric surgeons work 45–47 weeks/year, which is same for pediatric surgeons in Canada 1. Reported off duty/vacation time for American surgeons 4 is 28 available working days/year, but is effectively taken 20 days/year. The collected data show that working time among countries could differ considerably, whereas the vacation among surgeons in the cited studies is in the same range.
In 76% of the participants, satisfaction with professional activities and daily working tasks were rated high or very high. Studies among pediatric surgeons in Canada 1, USA 2 and UK 3 reported similar figures. Intrinsic factors of satisfaction (reward of helping others, professional activities, decisive nature, intellectual challenge) were found to be the reasons why the vast majority of the participants in our study, as well as a similar proportion of participants in comparable studies 3–5, would choose the same profession again or even recommend specialization to their own children 4,5. The importance of good interpersonal relationship was rated high among Croatian pediatric surgeons. Recent studies 9,10 demonstrated effective communication and support of the departmental chairperson as crucial for supportive environment. In contrast, low operative volume and poor task allocation could be a strong cause for dissatisfaction 9. Major reasons for dissatisfaction in our study included excessive administrative work and too many working hours. Complaints about extensive administrative work and inadequate secretarial support were same among pediatric 1,2, as well as among general surgeons 5,7. Dissatisfaction due to too many working hours was clearly expressed in the studies by Cannino 2, Troppmann et al. 4, and Shanafelt et al. 5. Better control over the schedule and working hours, as well as departmental organization, could probably help in tackling this problem.
In our study, 66% of the participants had experienced some symptoms or signs of professional burn out (emotional exhaustion, apathy, or sad mood) during the last year. The widespread professional and emotional exhaustion was also demonstrated in a survey among Spanish paediatric surgeons 11. Surveys among American 5,7 and British surgeons 6 showed the presence of professional burn out in a moderate range. Serious professional stress and clinical depression were reported in some studies 6,7; in addition, these studies demonstrated the demanding nature of surgery.
All the analyzed structural issues (medical facilities, technical support and equipment, and information technology) in our study are in need of improvement. It is well documented that poor practice conditions could be a reason for professional dissatisfaction or relocation 10, whereas we need further investigation to document how poor working conditions influence physician performance and professional score.
Despite favorable figures concerning publishing and conference attending, a strong dissatisfaction with the work conditions for educational activities still persists. The major issue is a lack of protected study time. The factors hindering scholarly or academic development were reported in several studies 2,3, and research time was rarely a part of the routine working schedule 7. One of the reasons for serious concern was the fact that more than half of the participants rated their training program as insufficient, and thus its parts, program, and mentorship role should be evaluated and promptly improved. According to some studies, most American and Canadian pediatric surgeons find themselves well prepared at the end of the learning process 12,13, although almost half of them desire some additional training 12.
Our future plans for improvement are as follows.
Additional training program in minimally invasive surgery must be provided to pediatric surgeons. As laparoscopic techniques have become an integral part of the operative management in virtually every realm of pediatric surgery, the Croatian Society of Pediatric Surgeons organizes training in minimal access surgery for every resident since 2009 to ensure the safe performance of such operations. The purpose of the training guided by Aesculap Academy is to foster the integration of advanced laparoscopic surgical training into the curriculum of the surgery residency. As the utilization of minimal access procedures increases, residents will more readily acquire the skills necessary to accomplish these operations safely. Basic laparoscopic procedures include laparoscopic cholecystectomy, laparoscopic appendectomy, and diagnostic laparoscopy. All other laparoscopic operations are defined as ‘advanced’. Before performing advanced laparoscopic procedures, the resident must be familiar with and experienced in basic laparoscopic skills.
In addition, CSPS manages postgraduate-level scholarships at accredited academic institutions throughout the world. By implementing some of the world’s most prestigious and innovative scholarship programs in a competitive and transparent manner, the CSPS provides residents with access to leading institutions such as Graz, Cincinnati, and Strasburg. These programs are critical to promoting mutual understanding and developing competitive skills among residents.
Finally, an improvement of facilities is the next important issue. It has been proven that residents who learn in excellent facilities achieve more and are in a better position to gain the qualifications they need.
Dissatisfaction with the reimbursement continues to be an issue among pediatric surgeons despite substantial employee benefits such as retirement packages, health and disability insurance, and paid vacation time. Salary range for the position determined on national level and lack of bonus-based or commission-based programs diminish the motivation of the surgeons. Financial incentives and stimulation for performance still meet strong political opposition and space for improvement is hence limited. Therefore, one-third of pediatric surgeons rely on sources of extra incomes. Despite the fact that the profession provides prestige and reputation in social status, that three-quarters of the participants would not recommend pediatric surgery to their own children could be an important fact in the proper estimation of occupational give/reward ratio.
Statistical analysis demonstrated the importance of regular working time and proper working conditions. Those who depended on an extra income had a lower rate of satisfaction than did the average surgeon. Excessive workload as a factor associated with burnout in our study underlined the importance of the proper allocation of tasks and responsibilities. Underpayment is a well-known risk factor for professional dissatisfaction and usually acts in synergy with other negative factors. No publishing could be one of the symptoms of low energy, lack of motivation, and poor concentration, as could be features that define burnout.
Current data suggest that proper recruiting policy could provide competent service on national level and achieve the fine balance between fear of surplus among pediatric surgeons as well as ensure immediate employment for new graduates. Intrinsic factors are generally the most important factors for job satisfaction; organizational issues, such as work schedule, planning, task allocation, and interpersonal relationships, should promote and not suppress the rewarding nature of surgery as profession. Substantial financial investment in the system is necessary for the improvement in technical insufficiencies, and probably the most efficient way to ensure this goal is a more active participation of our professional society in the national healthcare policy. The educational program needs to be improved urgently. The personal involvement of the mentors should be more supportive and helpful and the curriculum should be adjusted to the current EUPSA syllabus. A large pay-gap continues to exist between expectations and the real income. This data could help fostering more realistic expectations but also promote some real actions to improve payment policy.
Conflicts of interest
There are no conflicts of interest.
1. Bouchard S, Laberge JM. Pediatric surgeons' activities and future plans. J Pediatr Surg 1997; 32:801–805.
2. Katz A, Mallory B, Gilbert JC, Bethel C, Hayes-Jordan AA, Saito JM, et al.. State of the practice for pediatric surgery – career satisfaction and concerns. A report from the American Pediatric Surgical Association Task Force on Family Issues. J Pediatr Surg 2010; 45:1975–1982.
3. Smith NP, Dykes EH, Youngson GS, Losty PD. Is the grass greener? A survey of female pediatric surgeons in the United Kingdom. J Pediatr Surg 2006; 41:1879–1881.
4. Troppmann KM, Palis BE, Goodnight JE, Ho HS, Troppmann C. Career and lifestyle stisfaction among surgeons: what really matters? The National lifestyles in surgery today -survey. J Am Coll Surg 2009; 209:160–169.
5. Shanafelt TD, Balch CM, Bechamps GJ, Russell T, Dyrbye L, Satele D, et al.. Burnout and career satisfaction among American surgeons. Ann Surg 2009; 250:463–471.
6. Sharma A, Sharp DM, Walker LG, Monson JR. Stress and burnout in colorectal and vascular surgical consultants working in the UK National Health Service. Psychooncology 2008; 17:570–576.
7. Kuerer HM, Eberlein TJ, Pollock RE, Huschka M, Baile WF, Morrow M, et al.. Career satisfaction, practice patterns and burnout among surgical oncologists: report on the quallity of life of the Society of Surgical Oncologists. Ann Surg Oncol 2007; 14:3043–3053.
8. Keeton K, Fenner DE, Johnson TR, Hayward RA. Predictors of physitian career satisfaction, work-life balance, and burnout. Obstet Gynecol 2007; 109:949–955.
9. End A, Mittlboeck M, Piza-Katzer H. Professional satisfaction of women in surgery: results of a national study. Arch Surg 2004; 139:1208–1214.
10. Rauch TM. Job satisfaction in the practice of clinical pharmacy. Am J Public Health 1981; 71:527–529.
11. Jiménez Alvarez C, Morales Torres JL, Martínez Martínez C. Study of ‘burnout’ syndrome in Spanish pediatric surgeons. Cir Pediatr 2002; 15:73–78.
12. Parkerton PH, Geiger JD, Mick SS, O’Neill JA Jr. The market for pediatric surgeons: a survey of recent graduates. J Pediatr Surg 1999; 34:931–939.
© 2016 Annals of Pediatric Surgery
13. Emil S, Laberge JM. Canada-trained pediatric surgeons: a cross-border survey of satisfaction and preferences. J Pediatr Surg 2007; 42:878–884.