A Questionnaire-Based Prospective Study to Assess Professional and Personal Satisfaction amongst Endocrine Surgeons in India

Abstract

Background: 

Endocrine surgery (ES) has been a well-recognised surgical carrier option for trainees across the globe. With the successful running of Magister Chirurgiae (MCh) training programmes at various premiere medical institutions, it is rapidly gaining popularity in India. This study was conducted to assess multiple aspects of practising endocrine surgeons in India such as financial well-being, career satisfaction, and work-life balance.

Materials and Methods: 

A questionnaire-based survey was circulated amongst the members of the Indian Association of Endocrine Surgeons. The questionnaire included questions on various professional and personal fronts of practising endocrine surgeons in India such as training in ES, contentment/satisfaction with the field, teaching/training scenario of ES in India and comparison with opportunities outside India, rating in surgical calibre as well as choices regarding change of sector, change of speciality, etc.

Results: 

Seventy-three endocrine surgeons participated in the study. 46.6% were ES faculties working in different medical institutes, 26% were consultants in private practice, 16.4% were ES residents training under the MCh curriculum, and 11% were general surgeons practising ES. 35.6% had less than five years of experience, 27.4% had an experience of 5–10 years and 37% had more than 10 years of experience. 79.5% said ES was their first choice. 26% had beforehand exposure to other specialities before joining ES. Academic satisfaction was found to be fulfilling in 54.8%, overall work satisfaction in 71%, surgical work satisfaction in 54.8%, financial satisfaction in 43.8%, and personal life satisfaction in 71.2%. 60.3% felt burnt out once every six months, 35.6% felt it every three months and 4.1% felt the same every month. 61.6% said that it was difficult to balance their personal and professional lives. 61.6% believed that ES training in India was better or at par compared to training outside Indian territories. 58.9% felt their surgical skill calibre was equivalent, while 27.4% claimed to be superior to their peers in other surgical specialities. 63% felt confident by the end of their training period in handling all spectrum of surgeries about ES. 82.2% had no thoughts of changing specialities, whereas 52.1% opted for a change of sector. 61.6% felt there was no gender bias in this field.

Conclusion: 

This study is the first of its kind done among practising endocrine surgeons in India, and shows that overall surgeon satisfaction was high, wherein academic surgeons had higher career satisfaction when compared with those private practice surgeons. The quality of life of endocrine surgeons should be improved to ensure better work-life balance which can help in strengthening the cause of ES as a separate super speciality while turning the spotlight on for the younger surgeons to see.

INTRODUCTION

What started as a small seedling once blossomed into a magnificent tree today, such is the subspeciality of endocrine surgery (ES). It has gained recognition worldwide and India hasn’t been an exception to the same. This is apparent due to the fact that several academic bodies especially those dealing with ES, have emerged over the years.

Today there is an International Association of Endocrine Surgeons, the British Association of Endocrine and Thyroid Surgeons, the American Association of Endocrine Surgeons (AAES), the European Society of Endocrine, and the Indian Association of Endocrine Surgeons (IAES), to name a few.^[1] Magister Chirurgiae (MCh) training program in ES has been started at various renowned medical institutions all across India like—All India Institute of Medical Sciences, Delhi (five candidates), Christian Medical College, Vellore (two candidates), King George’s Medical University, Lucknow (two candidates), Madras Medical College, Chennai (two candidates) and Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow (four candidates). ES has developed as a subspeciality of the parent branch of General Surgery owing to the grouping of various diseases under the umbrella of endocrine biology. This evolution helps to provide excellence in terms of holistic management, teaching, and research in the ES field.

This study was conducted to assess multiple aspects of practising endocrine surgeons in India such as financial well-being, career satisfaction, and work-life balance. We aimed to delve deep into the lifestyle of super-speciality-trained endocrine surgeons. To do so, a survey was done on the practising endocrine surgeons. Their practice patterns and work-related satisfaction levels were analysed. A PubMed search was conducted using the keywords “Endocrine Surgeons”, “Quality of Life”, “Burnout” and “Satisfaction”. No studies were found concerning endocrine surgeons of India. This study is the first of its kind done among practising endocrine surgeons in India. The survey about various aspects of an endocrine surgeon’s career serves as an important benchmark for evaluating their satisfaction in individual areas and in general as well. It was seen that multiple domains affect surgeons of different factions differently, as the scenarios are unique to every professional group. This can be used to ensure better work-life balance and can help in strengthening the cause of ES as a separate speciality while turning the spotlight on for the younger surgeons to see.

MATERIALS AND METHODS

The study was conducted as a questionnaire-based survey, created on Google forms, which was circulated by the investigators amongst the members of the IAES. Questions were floated in May 2021 and responses were recorded as replies. The snowball sampling method was used to circulate it widely throughout India using various social media handles. Indian citizens, who happened to be practising endocrine surgeons, as well as members of the IAES, were chosen to be subjects for the study.

Upon choosing to participate in the study, the online link first opened up to the question of informed consent. Following this, the questionnaire consisted of various inquiries devised on various aspects of professional and personal fronts of endocrine surgeons in India such as academic satisfaction, surgical satisfaction, financial satisfaction, personal life satisfaction, overall satisfaction, and burnout frequency. Questions were divided into different sections, where each section focused on a particular aspect such as training in ES, contentment/satisfaction with the field, teaching/training scenario of ES in India and the subsequent comparison with available opportunities outside India, rating of surgical calibre as well as choices regarding change of sector, change of speciality and whether gender bias was prominent or not.

All responses were evaluated using standard biostatistical analysis done with the help of International Business Machines Corporation (IBM) Statistical Package for Social Sciences v23 software (IBM, USA). Standard descriptive analysis tests were applied. All procedures complied with the ethical standards of human experimentation and the Helsinki declaration (rev. 2013).

RESULTS

A total of 73 endocrine surgeons participated in the study by filling out Google forms (n = 73). Out of 73, 34 (46.6%) were ES faculties working in different medical institutes, 19 (26%) were consultants in private practice, 12 (16.4%) were ES residents training under the MCh (ES) curriculum; and 8 (11%) were general surgeons practising ES [Figure 1a]. When their experience of practice in ES was considered, 26 (35.6%) individuals had less than five years of experience, 20 (27.4%) had an experience of 5–10 years and the remaining 27 (37%) had more than 10 years of experience in the field [Figure 1b]. About 80% of the participants were high-volume endocrine surgeons. The rest are in the system of high-volume surgery centres.

Figure 1: General information of the participants: (a) current designation; (b) experience (in years) in endocrine surgery (ES); (c) preference of choosing ES; (d) wish to join any other surgical speciality post-MS-before MCh; (e) whether any prior work exposure in any other super-speciality before joining ES; (f) whether any prior work exposure in ES post-MS-before MCh; (g) Mode of receiving basic training in ES

On being questioned whether ES was their first choice of speciality while applying for their MCh, 58 (79.5%) responded positively and the remainder 15 (20.5%) confirmed it was their second or third choice [Figure 1c]. Thirty (41.1%) participants said that they wished to join some other speciality, however, later got inclined to join ES due to various reasons. A singular response (1.4%) was that of a general surgeon who wanted to pursue no further specialisation [Figure 1d]. The respective choices of the candidates who had wished for a different speciality have been listed along with the frequency in Table 1.

Table 1: Speciality desired by candidates (other than endocrine surgery) along with a number of responses and percentage of candidates

It was found that 19 (26%) participants had beforehand exposure to other specialities before joining ES [Figure 1e]. The specialities of such participants are shown in Table 2.

Table 2: Speciality in which candidates had exposure before joining endocrine surgery along with a number of responses and percentage of candidates

Twenty-three (34%) participants had received training and exposure in ES during the post-MS (before joining MCh) period [Figure 1f]. Regarding the basic training in ES, 55 (76%) received it during their MCh tenure, 4 (5.6%) in fellowship/observership courses in India, 2 (2.8%) in fellowship/observership courses outside India, 1 (1.4%) claimed to be self-taught via courses, conferences, and hospital visits and the rest 10 (13.9%) had a special interest in ES although working in general surgery department [Figure 1g].

On analysing the participants’ overall work satisfaction in ES speciality, a majority of 52 (71%) individuals claimed they were fully satisfied, while 21 (29%) had partially satisfactory feedback [Figure 2a]. Academic satisfaction (seminars, journal clubs, national/international conferences) was found to be fulfilling in 40 (54.8%) cases and partial in 33 (45.2%) cases [Figure 2b]. For surgical work satisfaction (workload, surgical spectrum, working hours), there were 40 (54.8%) responses stating that they were fully satisfied, 31 (42.5%) responses claiming partial satisfaction and yet 2 (2.7%) were completely dissatisfied [Figure 2c]. When concerns about financial satisfaction were brought into question, there were mixed responses with 32 (43.8%) being satisfied, 34 (46.6%) with partial satisfaction, and the remaining 7 (9.6%) being unsatisfied [Figure 2d]. Pondering over the surgeons’ personal life satisfaction, a majority of 52 (71.2%) were found to be completely satisfied, while the other 21 (28.8%) reported being partially satisfied [Figure 2e].

Figure 2: Domains of satisfaction of the participants: (a) overall satisfaction; (b) academic satisfaction; (c) surgical satisfaction; (d) financial satisfaction; (e) personal life satisfaction; (f) frequency of burnout; (g) preference of marrying someone from same speciality; (h) whether balancing personal and professional lives becomes difficult

“Burnout” at any workplace is a crucial issue to address, and a total of 44 (60.3%) responses stated feeling burnt out once every six months, 26 (35.6%) felt it every three months, while 3 (4.1%) felt the same every month [Figure 2f]. On being offered a hypothetical choice of marrying someone specialising in ES, 7 (9.6%) subjects agreed, 53 (72.6%) disagreed and 13 (17.8%) were unsure about the matter [Figure 2g]. As many as 45 (61.6%) participants confirmed that it was sometimes difficult to balance their personal and professional lives while 4 (5.5%) stated that it was difficult quite often [Figure 2h]. 24 (32.9%) candidates also said that they never faced difficulty in balancing their personal life and career [Figure 2h].

Mentoring plays an essential role in all surgical specialities. Fifty-five (75.3%) participants admitted to having constant mentorship available during their ES tenure, while 12 (16.4%) participants had mentors only during the initial training phase [Figure 3a]. An impressive number of 61 (83.6%) voted unanimously that faculties and consultants were very committed to teaching and training programmes [Figure 3b]. An estimate of 48 (65.8%) participating individuals felt satisfied with the available opportunities for ES training in India [Figure 3c], and an overwhelming 45 (61.6%) respondents believed that ES training in India was better or at par compared to training outside Indian territories [Figure 3d]. 37 (50.7%) entrants had exposure to training in an international ES centre [Figure 3e], and 48 (65.8%) entries were of the opinion that such training is mandatory for academic growth [Figure 3f].

Figure 3: Perception of participants: (a) presence of constant mentorship during training; (b) attitude of endocrine surgery (ES) consultants towards teaching; (c) satisfaction with available ES training options in India; (d) ES training: better in India or internationally; (e) prior international exposure in ES; (f) whether international ES exposure should be mandated for Indians pursuing ES

The applicants were asked to rank their surgical skills, in comparison to those of their peers in other surgical specialities. To this, 43 (58.9%) felt their surgical skill calibre was equivalent, while 20 (27.4%) claimed to be superior to their peers in other surgical specialities [Figure 4a]. We also analysed the proportion of independent operations a budding surgeon should perform, to feel confident about their psychomotor skills. The response to the former was 40 (54.8%) participants felt that they should get at least 30% surgeries as first and second assistants in the initial years and at least 40% independent surgeries towards their last year of the training period; as many as 18 (24.7%) felt the need of performing 30% surgeries both as first assistants and independently and 40% as 2^nd assistant; while the rest 15 (20.5%) believed that 50% and 30% surgeries to be allocated as first and second assistants respectively during the initial phase and 20% independent surgeries towards the final years [Figure 4b]. A considerable number of 46 (63%) respondents felt confident by the end of their training period in handling all spectrum of surgeries about ES [Figure 4c]. When asked about how the participants thought they would get rated by their peers/colleagues of other specialities: 36 (49.3%) stated to be at par, 17 (23.3%) felt they were superior, 1 (1.4%) argued to be inferior whereas the remainder were indecisive [Figure 4d].

Figure 4: Attitude of participants: (a) ranking of participants’ surgical calibre in comparison to peers; (b) partitioning of surgical skills during endocrine surgery (ES) training; (c) certainty to operate individually on the entire spectrum of ES surgeries; (d) perception of colleagues about participants’ surgical skill; (e) satisfaction with exposure to newer techniques/technologies; (f) level of confidence while performing challenging thyroid, adrenal, and parathyroid surgeries

Having updated knowledge about recent advancements is also very vital for any surgeon. A great number of 40 (54.8%) entrants felt satisfied with exposure to newer techniques, technologies, and instruments [Figure 4e]. After joining as a consultant, an immense number of 53 (72.6%) participants were confident in carrying out difficult thyroid, parathyroid and adrenal surgeries, whereas 18 (24.7%) admitted to consulting a fellow/senior colleague for the purpose of challenging surgeries and 2 (2.7%) respondents preferred referring the difficult cases to other centres [Figure 4f].

If given the option to change their speciality, an enormous number of 60 (82.2%) people promptly chose not to do so [Figure 5a]. The participants were offered an imaginary choice to change their practising setup from a government sector to a private one or vice versa and 38 (52.1%) candidates wished to opt for the change [Figure 5b].

Figure 5: Miscellaneous: (a) perception of participants if a hypothetical choice is offered to change speciality; (b) perception of participants if a hypothetical choice is offered to change sector; (c) perception of participants regarding the role of gender in choosing a speciality; (d) whether the participants would recommend endocrine surgery to other colleagues

An individual record for each of the four groups of participants (ES faculty, ES residents, consultants in private practice, and general surgery faculty) and their associated satisfaction trends along with tendencies to change their jobs/sectors is depicted in Table 3.

Table 3: An individual record for each of the four participant groups [endocrine surgery (ES) faculty, ES residents, consultants in private practice, and general surgery faculty] including information on satisfaction patterns and propensity to switch jobs/sectors

Forty-five (61.6%) individuals felt that there was no gender bias and that both males and females dominated the field equally. However, 18 (24.7%) responses indicated that the male gender does have an inclination for choosing ES [Figure 5c]. A high count of 62 (84.9%) participants voted to recommend ES speciality to their junior colleagues as well [Figure 5d].

DISCUSSION

More than half of fellowship-trained endocrine surgeons exhibit a wish to have a more speciality-oriented path. However, an analysis of practising fellowship-trained endocrine surgeons demonstrates that maintaining a totally focused scope of surgical specialisation is not always feasible.^[2–5] Given the growing complexity and range of patient treatment, fellowship training may be required every so often. To expand the constantly growing understanding of endocrine illnesses and to provide patients with high-quality surgical therapy, endocrine specialists must go through advanced training.^[6]

Regarding the number of years each participant had devoted to practising ES in their lifetime, nearly a third of the participants had an experience of over 10 years. It was also noted that many of the aforementioned surgeons were faculty members. While as many as 80% of individuals had taken up ES as their choice of profession voluntarily, there were others who had joined the speciality as a secondary option, with immediate interests lying in other surgical specialities. Many participants also revealed that they had joined training courses in ES before pursuing their specialisation via MCh and were thus acclimatised to some of the procedures performed from their earlier days, although nearly 75% of the responses agreed that their basic knowledge of ES and its procedures were derived from their tutelage at MCh. In a survey conducted by Tsinberg M et al.^[5] where participants were members of AAES, the respondents were classified into three groups: “young” (<3 years in practice), “middle” (3–5 years), and “older” (>5 years). It was found that more of the “young” surgeons had academic practices (92%) versus “older” surgeons (67%).

Assessing the satisfaction levels of various aspects of an endocrine surgeon was one of the main aims of this study. The number of participants with partial overall satisfaction was comparatively more in the Private Consultants group. In a study by Tsinberg M et al.,^[5] 42 surgeons (75%) graded their ES training as 5 on a five-point scale while 14 (25%) rated it as 4. While none of the groups reported nil satisfaction with regard to academics, the private consultants and residents were again found to have high percentages in terms of partial satiety: 63.2% and 50% respectively, owing probably to the long and rigorous working hours, disturbed work-life balance and insufficient financial compensation. The average week of labour for the International Association of Endocrine Surgeons in a survey conducted by them was 55 ± 15 h, and they averaged 17 h in the operating room.^[7] In a survey conducted by Chen H et al.^[8] in 2002 among medical students, it was concluded that the students had observed significantly lower thyroidectomies, parathyroidectomies, and adrenalectomies, in comparison to other subspeciality surgeries such as mastectomies, coronary bypasses and laparoscopic cholecystectomies. Out of these prospective future general surgery residents, 34% failed to see even one thyroid resection, 42% missed a parathyroidectomy, and 65% missed an adrenalectomy. Finally, prospective general surgery residents appear to see a diversity of surgical cases. However, most students had little to no experience with ES. This lack of surgical exposure may have significant implications for both schooling and career. Their health-related quality of life (QoL) was also close to that of other British professionals.^[9] In a similar study by Mahoney ST et al.^[10] comparing the job satisfaction of academic surgeons and private practice surgeons, it was found that the former spent more weekly hours doing non-clinical work and were also more satisfied with their profession and earnings. Solorzano C et al.,^[11] in their study on ES surgeons, arrived at the revelation that general surgery residents who train at centres with experienced attending ES faculties, well-equipped hospitals, and increased research opportunities are more likely to enter the speciality, as mentorship, increased number of surgical procedures and research play an important role. The highest level of total surgical satisfaction was seen in ES faculty members while as many as two-thirds of private consultants remained only partially satisfied. The reason for the same could be attributed to the dual nature of work which falls under the aegis of academic endocrine surgeons, that is the task of teaching and training younger surgeons as well as of performing surgeries. This merger exposes the individual to lifelong learning along with advanced knowledge, all the while performing the typical procedures on a day-to-day basis, but with reduced workloads, thus leading to greater satisfaction levels. One more aspect that cannot be denied is that satisfaction may be affected while working in a team. Having a cooperative team of endocrine surgeons may help in referring cases, making up the surgical volume, and hence helping in improving surgical satisfaction. Similarly, working with general surgeons, radiologists, etc., presents opportunities to discuss difficult cases and decide the road map, which further helps in boosting confidence, and also adds to the knowledge and surgical skills, which ultimately leads to an upliftment of professional satisfaction.^[12]

Another interesting aspect that has surfaced during our practice and further discussion with fellow endocrine surgeons is the aspect of diabetic foot disorder patients in India. India is said to be the diabetic capital of the world, with roughly 62 million diabetics in the country in the year 2017.^[13] Having said that, there are more numbers of important neglected diabetic patients with complications like diabetic foot disorders, diabetic kidney diseases, atherosclerosis, etc., Out of the 62 million diabetics in the country in 2017, 25% had gone on to develop diabetic foot ulcers. Hospitalisation was required in nearly 50% of these patients, where 20% had required amputation of diabetic foot forms one of the major surgical parts of the endocrine system, also shared by general surgeons who practice ES. As these wounds are chronic and difficult to heal, and often require multimodality care, they may often burden in high-volume endocrine centres where only advanced ES is being practised. Still, these patients require specialist care and multiple visits where the endocrine system forms an irreplaceable pillar. As the Indian system of referral improves or gradually the number of practising endocrine surgeons increases, then only this burden of a diabetic foot can be reduced in society and on the clinical practitioners. Hence, the high volume of diabetic foot cases in an advanced ES centre may lead to an increased load on the existing system, thus decreasing the overall satisfaction of the endocrine surgeons. This can also be improved by channelising more of these patients to be operated on by general surgeons and plastic and reconstructive surgeons.

Negligible financial satisfaction was reported by 8.8%, 15.8% and 12.5% of ES faculty, private consultants, and general surgery faculty respectively. This could be because of the increase in workload, which could be why the respondents don’t feel they’re financially rewarded in equal amounts to the work they perform and the stress they endure, due to which the work-life balance ends up getting disrupted. Tsinberg M et al.^[5] studied satisfaction concerning financial allowance, the younger faction scored an average of 3.2 on a four-point scale, in contrast to their older colleagues, who managed an average of 2.9 out of 4.

High levels of personal life satisfaction were recorded in ES faculty, residents, and general surgery faculty owing most likely to the reasonable work-hour culture, and a well-maintained QoL, thus ensuring reduced burnout and more satisfaction. According to research, burnout is a syndrome that affects people with demanding professions and those who provide care for others, such as social workers, educators, and medical professionals.^[14] It could eventually lead to more medical blunders and lower job satisfaction, which would ultimately be responsible for their early retirement.^[15] Tsinberg M et al.^[5] described lifestyle satisfaction as being comparable in both groups: 3.6 in young practitioners vs. 3.1 in the older group.

A long-term data review of AAES was undertaken by Borman et al.,^[16] and it was reported that the percentage of general surgery residents opting for fellowships increased from 67% to 77% during 1993–2005. A survey by Jensen M et al.^[17] highlighted the incidence of work-related injuries and musculoskeletal symptoms in endocrine surgeons. Symptoms were found in 199 (90%) of the 220 participants, which included complaints such as pain (91%) and stiffness (81%) over the neck (87%) and shoulders (55%). Women were more likely to be affected. Nearly 41% of the International Association of Endocrine Surgeons’ survey participants reported experiencing discomfort as a result of their surgical practice.^[7] These findings could provide possible reasons for the individuals to feel disinterested enough to opt for a change of speciality/sector if provided.

A surgical career often has its highs and lows. The downsides (to name a few) might include operating in a high-stress environment for unusually long durations, new norms for scrutinising the outcomes, and a struggle to maintain a work-life balance. These factors lead to burnout which is characterised by emotional exhaustion, cynicism, and reduced feelings of personal accomplishment.^[18,19] Surgeon burnout compromises the QoL of doctors, and the delivery of care to patients and decreases the satisfaction associated with the speciality. In a 2011 survey conducted by over 1043 female and 6815 male US surgeons, Dyrbye LN et al.^[20] discovered that despite having equivalent work hours, female surgeons were more likely to experience burnout, depression, work-home conflicts, and depressive symptoms. They were also less able to rely on their spouse for childcare and more likely to believe that their spouse’s career came first. In a systematic review by Pulcrano M et al.,^[19] various surgical specialities were evaluated for the QoL and Burnout rates experienced by their practitioners. Of the 16 included specialities, paediatric surgeons (86%–96%) and endocrine surgeons (96%) had the highest levels of career satisfaction. It was also found that residents across multiple specialities were almost always at greater risk of burnout than the attending surgeons. Resident burnout was often associated with capacious work demands, limited control, and high degrees of work-home interference.^[18] In our survey, 60.3% of respondents stated feeling burnt out once every six months, 35.6% felt it every three months and 4.1% felt the same every month. In a qualitative study, in-depth interviews with 12 Australian women who had chosen to leave surgical training highlighted potentially correctable factors such as lack of leave availability, the distinction between legitimate and invalid reasons for leave, poor mental health, lack of female peer interactions, fear of consequences, and lack of pathways for independent support.^[21]

Despite 84.9% of respondents endorsing ES speciality to junior colleagues, it was shocking to see that 72.6% of respondents refused to marry a fellow practising endocrine surgeon. We feel both are totally different aspects so should be judged on different scales. Advising juniors about their career options and marrying a person in the same field carries different perspectives.

CONCLUSION

This questionnaire-based survey is probably the first of its kind done among practising endocrine surgeons in India and shows that most of the surgeons chose this sub-speciality as their first choice and overall surgeon satisfaction was high. Academic surgeons reported higher career satisfaction in diverse aspects when compared with those private practice surgeons. When given a choice to change their speciality, 10.45% of participants agreed that they would opt for the change. 26.4% of private practitioners were willing to switch to work in government and allied hospitals. The prevailing reasons behind such choices could be extensive and could be explored by undertaking a new survey. This study concludes with the encouraging recommendation that rotations in ES departments should be offered to junior residents of general surgery department training at centres having a separate department of ES. Such exposure could have an imminent role for the general surgery residents to gain further interest, knowledge, and skill in this field, and gauge the pros and cons of pursuing ES as a career in the future. While assessing the satisfaction levels in career, personal and professional well-being, satisfaction assessment metrics using the Likert scale could have been adopted rather than assessed by multiple choice questions, having options as satisfied, or unsatisfied. Although using a Likert scale would’ve led to multiple responses and getting an inference from that in such a sample size would’ve diluted the result.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.