Distribution of surgeons by year after graduation.
Distribution of the study population by marital status and sex.
Differences between fellows and practicing surgeons in ratings of issues on a Likert-type scale (with scores from 1 [least concerning] to 5 [most concerning]). Significant differences (P<.05) exist for the issues listed.
Differences between men and women in ratings of issues on a Likert-type scale (with scores from 1 [least concerning] to 5 [most concerning]). Women were significantly (P<.05) more concerned than men about the issues listed.
Gabram SGA, Hoenig J, Schroeder JW, Mansour A, Gamelli R. What Are the Primary Concerns of Recently Graduated Surgeons and How Do They Differ From Those of the Residency Training Years?. Arch Surg. 2001;136(10):1109-1114. doi:10.1001/archsurg.136.10.1109
Graduated surgeons have differences in concerns when comparisons are made between fellows and practicing surgeons, practicing surgeons and residents, and male and female surgeons.
Design and Setting
A survey was distributed to surgeons who graduated from 17 New England residency programs from 1993 to 1996, consisting of 9 demographic questions and 33 items coded on a Likert-type scale (with scores from 1 [least concerning] to 5 [most concerning]).
Surgical fellows and practicing surgeons recently graduated from general surgical residency programs in New England who had participated in a previous study as residents.
Distribution and completion of the survey.
Main Outcome Measure
Personal and career-oriented concerns of recently graduated surgical residents.
Personal issues continue to rank high for graduated residents, but the areas of greatest concern became more financially and career oriented. The top concerns of fellows were personal finances (mean score, 3.2), child rearing (mean score, 3.1), salary (mean score, 3.1), postponing family plans (mean score, 3.0), availability of role models (mean score, 2.9), and number of work hours (mean score, 2.8). The top concerns of practicing surgeons were salary (mean score, 3.2), personal finances (mean score, 3.1), number of referrals (mean score, 3.0), support for research (mean score, 2.7), child rearing (mean score, 2.7), and availability of role models (mean score, 2.7). Differences existed between men and women for child rearing, initiating personal relationships, maintaining personal relationships, maternity leave, and promotional advancement. Women were more concerned than men.
Assistance with career planning and job selection during the residency years should be enhanced to diminish the concerns about financial issues and the availability of role models after graduation. Many of the concerns among male and female graduates are still reflective of larger societal expectations, but some, such as promotional advancement, may be attenuated through guidance and mentoring of residents before job selection.
THE RESIDENCY training years represent a major pinnacle of achievement that surgeons encounter in their lifetime. Ironically, despite the fact that surgical residencies are more demanding from a physical and emotional perspective, surgical residents remain just as satisfied as residents in other areas of medicine.1 Some studies2 indicate that the stress and pace of surgical residencies actually attract students who find this lifestyle "good" or "exhilarating." However, although studies surrounding the rigors of surgical residencies are plentiful, there is a paucity of literature on understanding the issues and concerns that face newly graduated surgeons after their residency training years.
In 1993, residents were surveyed to determine issues and concerns specific to their residency experience.3 For those responding, work hours was ranked as the most concerning issue, followed by personal finances, quantity and quality of education, postponing family plans, and maintaining personal relationships. Items that one would expect as sources of stress and concern for residents, such as patient perception of residents' credibility, relationship/interaction with colleagues, and assignment of operative cases, were ranked as some of the least-concerning issues. Interestingly, significant differences between the concerns of men and women were found to exist for the subjects of mentor availability, comfort with expressing emotions at work, initiating and maintaining personal relationships, having children, and postponing family plans.
Every year, about 10004 surgeons embark on their surgical careers, but what becomes of their concerns? To answer this question, we developed a follow-up questionnaire for the group of residents surveyed in 1993. This study was specifically designed to quantify the level of concern recent surgical graduates have for certain career and personal issues, to determine if surgeons in practice have different concerns than those in fellowship training, to compare these concerns with those identified during the residency training years, and to determine if men and women differ on the issues they find most concerning.
In 1997, the program directors of 22 New England surgical residencies were contacted for the addresses of residents who graduated between 1993 and 1996. This same group of residents was surveyed immediately after the 1993 American Board of Surgery In-Service Training Examination.3 Seventeen of the 22 New England surgical residency programs returned the requested information, allowing for the distribution of 227 follow-up surveys. A second mailing to the nonrespondents occurred to enhance the response rate. The surgeons were assured of anonymity.
The survey consisted of 9 demographic questions and 33 items. The demographic questions recorded the participants' practice settings, specialty choice, years in practice, age, sex, marital status, and number of children. The surgeons were asked to code each of the 33 items on a Likert-type scale (with scores from 1 [least concerning] to 5 [most concerning]). The 33 items surveyed ranged from issues directly concerning the graduates' surgical careers to issues concerning their personal lives and finances. The 1993 questionnaire was used and expanded after discussion with the senior authors (S.G.A.G., A.M., and R.G.) of this study.
The data gathered from the returned surveys were analyzed using a 2-tailed t test for equality of means (with equal variances assumed) on a personal computer with statistical analysis software (Statistical Package for the Social Sciences; SPSS Inc, Chicago, Ill).
Of the 227 surveys sent to graduated residents in this study, 111 (49%) responded. The mean age of the respondents was 35 years (range, 29-40 years); 85 (77%) were men and 26 (23%) were women. Forty-one surgeons were in a fellowship program in their first through fourth years, and 69 were in private practice (there was one nonrespondent for this demographic variable) (Figure 1). Nearly 67% of the respondents were specialized, 26.1% were practicing general surgery, and 7.2% did not respond to the question about their specialty (percentages total >100 because of rounding) (Table 1). The most common practice setting was academic, although this did include fellows, followed by private group practice (Table 2). Overall, most respondents were married, but the proportion of men who were married (66 [78%]) was significantly higher than the proportion of women who were married (14 [54%]) (Figure 2).
First, we analyzed issues of concern for fellows and practicing surgeons. These results are listed in Table 3 and Table 4, respectively. On a Likert-type scale, with scores ranging from 1 to 5, fellows ranked personal finances as the most concerning issue, followed by child rearing, salary level, postponing family plans, availability of role models, and number of work hours (Table 3). Practicing surgeons ranked salary level as most concerning, followed by personal finances, number of referrals from practitioners, support for clinical or basic science research, child rearing, and availability of role models (Table 4). Significant differences (P<.05) between the concerns of fellows and practicing surgeons exist for board certification, process of grievances, verbal harassment, physical harassment, operating room accessibility, and referrals from other practitioners (Figure 3). The first 4 issues were more concerning for fellows, and the latter 2 were more concerning for practicing surgeons.
A summary of the results of present fellows' and surgeons' responses compared with the 1993 survey3 of the same physicians as residents is presented in Table 5.
The concerns of men and women differed significantly (P<.05) for 5 of the 33 items surveyed. Women were significantly more concerned than men about the following issues: child rearing, initiating personal relationships, maintaining personal relationships, maternity leave, and promotional advancement (Figure 4). There were no issues or concerns identified that male fellows and surgeons ranked significantly higher than female fellows and surgeons.
To better help surgical residents as they make the transition from "students" of surgery to practicing surgeons, program directors and chairpersons of surgical residencies must be aware of the issues and concerns that these residents are facing after graduation. Once these issues and concerns are quantified, changes can be implemented to assist with career selection and to improve the educational experience during the residency years. It is important to guarantee the success of these young role models in surgery, since we need to encourage a continued supply of highly qualified candidates, motivating medical students to enter surgical disciplines.5
Since the survey used for this study was only sent to residency programs in New England, the data gathered from these fellows and surgeons may be more representative of the Northeast than of the entire United States. This may explain the higher proportion of graduates pursuing fellowships and the higher proportion of surgeons in academic settings. Despite this limitation of sample pool, some of the demographic features of this population of surgeons are similar to those found on a national level. Comparing our results with those of the recently published longitudinal study of surgical residents,4 the mean age of our respondents was 35 years (our group excludes obstetrics/gynecology and ophthalmology residents), whereas the mean age of graduates of all core specialties (includes obstetrics/gynecology and ophthalmology residents) in 1996 was 33 years. In the longitudinal study, women make up 14% of graduating residents, compared with 23% found in our study of New England graduates. Another difference that was found in our study compared with national data was the percentage of graduates who specialize compared with those who pursue general surgery alone. In the longitudinal study, 60% specialize and 40% are in general surgery, and in our study, 26% stated they were practicing general surgery alone. These differences may be explained by the fact that the sample pool was limited to the Northeast. Last, compared with national averages, a higher percentage of residents in our study pursued academic careers. This may be because of the high concentration of academic institutions in the Northeast.
Salary and personal finances rank high as a concern for fellows and practicing surgeons. This is consistent with today's medical economic environment and with the challenges of reimbursement for patient care. With the average debt of public medical school graduates increasing by 59.2% and the average debt of private medical school graduates increasing by 64.2% from 1985 to 1995,6 it is no surprise that money is a major issue for recently graduated residents. However, it is possible that better planning throughout the residency years and preparation during the practicing years can lighten this burden. Organized approaches to educating surgical residents on the topics of debt management may prove to lessen financial anxieties as residents make their way into practice.
Fellows and practicing surgeons identified the availability of role models/mentors as a significant concern. Interestingly, this was not ranked as highly for residents during their training years. In this survey, queries about role models and mentors were grouped together; however, the definition of each is unique. Role models are surgeons who display certain enviable characteristics. From a graduated surgeon's perspective, this may be an individual with strengths in clinical performance, educational talents, research credibility, or general academic achievement. It is an individual who is perceived as successful in his or her given career path. A mentor may be a role model to students, residents, and other surgeons but, in addition, is usually an individual with a lot of experience and knowledge who provides guidance to a younger chosen protégé. Mentors play a variety of roles that include a teacher, facilitator, and sponsor, and are often tasked with inspiring, supporting, and investing in their protégé's future career.7 There has been a paradigm shift of mentorship from mentors displaying paternalistic, authoritarian, strict, and protective behaviors to the more acceptable characteristics of empowering, inspiring, and liberating.8 Instead of the traditional mentoree or protégé playing a subservient role, the charge to today's mentoree is to acquire independence and self-assurance over time. Role models and mentors are vital not only during the residency years but also during the early years of surgical practice. As residents identify their job selection, it is key that faculty members in departments of surgery instruct them on the importance of identifying a role model or mentor regardless of whether the graduated resident is pursuing a fellowship, an academic career, or a private practice career. Surgical faculty who provide this guidance need continuing educational support to strengthen their mentoring skills and recognition for the important function they provide (documentation as a part of their academic achievement during annual faculty review sessions or monetary rewards).
Fellows and new surgeons in practice ranked child rearing (such as supervisory issues) as 1 of their top 5 highest-ranked concerns. Work-life balances are increasingly becoming issues for medical and nonmedical professions. Dual-career couples and women representing a higher proportion of the medical school class are 2 reasons this issue may be such a concern. Residents should be advised to consider their own work-life balance needs in selecting their ultimate career path in surgery. Practice opportunities exist in which better work-life balances are achievable.
Practicing surgeons also ranked support for clinical and basic science research as 1 of their top 5 concerns. With clinical productivity becoming a more significant issue in surgical academic practice, the time available to write grants for funding research initiatives is becoming more limited. When interviewing for jobs, future academic surgeons need to be encouraged to negotiate for protected time or to identify a mature research setting where there is senior faculty support (in clinical or basic science) to assist the young faculty member with this process.
Some of the differences between the concerns of fellows and newly practicing surgeons are explainable, for the most part, given the practice environment of the graduated surgeon. For instance, board certification and the process of raising grievances concern fellows significantly more than practicing surgeons, whereas the number of patient referrals and operating room accessibility concern newly practicing surgeons significantly more than fellows. However, fellows are more significantly concerned about verbal and physical harassment than practicing surgeons. This difference in concern about harassment is not as easily understandable, and further work must be done to identify the nature, source, and level of harassment for fellows to develop any means of eliminating it.
For 5 of the 33 issues, women were more concerned than men. These issues included initiating personal relationships, maintaining personal relationships, time off for maternity leave, child rearing, and promotional advancement. Two items were similar to the 1993 female residents' concerns: initiating and maintaining personal relationships.3 In either survey, there were no items for which men were more concerned than women. Time off for maternity leave was not included in the 1993 survey and is a significant issue for graduated female surgeons. In 1993, the level of concern for "process of resident promotion" was similar for male and female residents. In this study, promotional advancement has become a significant issue for women as they embark on a surgical career.
Women represent nearly 50% of graduating medical school classes. In the 1993 survey,3 it was shown that a higher percentage of women are choosing general surgery (in lieu of the surgical subspecialties) compared with the percentage of men selecting general surgery. To ensure recruitment of the "best and the brightest,"5 surgical program directors have to make sure that their surgical residencies are attracting talented women and that the environment is such that women will stay in the field. Understanding the needs of residents and newly graduated surgeons provides opportunity for guidance when assisting women with their surgical career choices.
Major societal stereotypes or expectations require change to address issues such as maternity leave and child rearing. In the many years it may take for these changes to occur, there are some opportunities related to having children that can be encouraged in the interim. Female residents can be encouraged to have their children during the residency training years when "sabbatical" time is available. With concerns about the work hours and intensity of work during the clinical years, women should seek sabbatical time by enrolling in several years of research training embedded within their residency. Maternity leave is easier to schedule in this setting, and there are less physical stresses in a laboratory research program. While graduation from the residency is delayed, time off in the research setting will only enhance a resident's future surgical career and benefits will eventually occur.
More men than women are married during the residency years and the early years of surgical practice. This could be one of the reasons that women are more concerned than men about their ability to initiate and maintain personal relationships. This is another area in which societal expectations need to be adjusted to make an impact. Female partners of male surgeons may be more accommodating of the lifestyle demands of surgical careers than male partners of female surgeons. It is anticipated that with time these differences will not exist as dual-career couples increase and non–work-related daily tasks become more equitable.
It is interesting to recognize items for which men and women did not differ in their responses. Although 36% of the fourth-year medical students at the University of Toronto, Toronto, Ontario,9 and 96% of the female respondents of a similar study at The Johns Hopkins University School of Medicine, Baltimore, Md,10 reported that surgery was discriminatory or unfavorable to their sex, in our survey of graduated surgeons, there were no sex differences in the level of concern for the issues of verbal and physical harassment. A study published in the Journal of the American Medical Association in 1998 by Daugherty et al1 reports that, for all types of residencies, male residents were overall significantly more satisfied with their experience than female residents, and the difference between male and female satisfaction was most pronounced in family practice and surgery. We did not inquire about the overall level of satisfaction of graduated residents. However, since we found no significant difference between male and female concerns about verbal and physical harassment, there is good reason to believe that such sex discrepancies in the level of satisfaction with surgical residencies are not due to a sex bias in verbal and physical harassment. Future data in this particular area should be explored.
The final issue of concern for which differences exist for men and women is promotional advancement. In 1993,3 female residents were more concerned than male residents about the availability of role models and mentors, an issue that was of equal concern for the graduated surgeons. These 2 issues are dependent on each other and are vitally linked. In a recent survey by Colletti et al,11 academic female surgeons provide advice to a higher mean number of students compared with their male counterparts. This is most likely reflective of a limited number of female surgeons available to function as role models and mentors. On the other hand, Colletti and colleagues documented that many of the issues related to mentoring and balancing work/personal life responsibilities were similar for men and women. However, these issues do coincide with our findings: promotional advancement is still more of a concern for the graduated female surgeons in our survey. Perhaps it is due to perceptions of inequities that have been identified in other surveys. Women perceive that clerical support, start-up funds (but not research start-up funds), and technical research support are not adequate to a greater extent than their male counterparts.11 Assisting women in negotiating for these areas of support when they interview for jobs is one way to begin to address promotional advancement and to provide the support necessary to achieve appropriate milestones.
There are still deep-rooted societal expectations, such as the expectation that women handle the responsibility of child rearing to a greater extent than men, that will take longer to change and could still affect the ability of women to be promoted in an acceptable time frame. As described by Jonasson,12 "clock stopping" is a program that lengthens tenure-probationary periods for various reasons, family considerations being one such example. Such advancements should be implemented for women and men in surgical disciplines to eliminate sex-based disadvantages.
One of the limitations of this study is the sample size and response rate. There were 501 responses to the 1993 survey3 and only 111 to this follow-up survey. In 1993, on average, residents of all 5 years were surveyed, and, in the present study, a follow-up was performed at the 4-year interval. Only residents graduating from the general surgery programs were surveyed, excluding those in the surgical subspecialties for technical reasons. Some of these technical reasons were also responsible for the differences in response rates. In 1993, most surveys were distributed and collected on the day of the annual American Board of Surgery In-Service Training Examination. For the follow-up survey, obtaining the names and addresses from all of the surgical programs in New England and relying on surveys to be returned via the mail system definitely affected the absolute number of responses. We still obtained an acceptable response rate (49%), and because of this, we believe the results are representative. Residents who graduated from New England surgical programs made up the study group, and it is unknown whether responses would be the same or different for another region in the country. One of the intents of the study was to compare changes over time for graduated surgical residents. Because of a heightened awareness about certain issues and in trying to identify issues pertinent to the graduated resident, some of the items surveyed in this study were unique and not surveyed in the prior group. Most items were similar, and comparisons could be made.
In conclusion, the focus of top issues and concerns for recently graduated surgeons has shifted to a more financial perspective. Work-life balances, especially in child rearing, rank high for graduated surgeons in fellowships and practice settings. The consistent concerns about mentor availability suggest that career planning and job selection at the resident level could be enhanced. Differences still persist for male and female surgeons; some are controllable through job selection (such as promotional advancement) and some are still reflective of societal expectations. Whether the latter are controllable may only be learned after such measures as clock-stopping advancements have been given their due course.
Presented at the meeting of the Association for Surgical Education, Boston, Mass, April 7-10, 1999.
Corresponding author and reprints: Sheryl G. A. Gabram, MD, MBA, Department of Surgery, Loyola University Medical Center, 2160 S First Ave, Maywood, IL 60153 (e-mail: firstname.lastname@example.org).