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Tulunay-Ugur OE, Sinclair CF, Chen AY. Assessment of Gender Differences in Perceptions of Work-Life Integration Among Head and Neck Surgeons. JAMA Otolaryngol Head Neck Surg. 2019;145(5):453–458. doi:10.1001/jamaoto.2019.0104
What are the factors that may contribute to gender discrepancies among attending surgeons?
In this web-based survey study including 261 head and neck surgeons, a statistically significant difference in rank distribution was noted, with fewer women in higher academic ranks ranks compared with men. Female head and neck surgeons were more likely to be single, to have fewer children than male colleagues, and to have been treated for mental health issues.
Despite improvements in work hours and gender balance in residency programs, there continues to be a discrepancy in the number of female surgeons with senior academic rankings and equitable levels of family life and well-being; further improvements are needed.
The factors that contribute to gender discrepancies among attending head and neck surgeons have yet to be fully characterized.
To evaluate the association of gender difference with the perceived quality of life of head and neck oncological surgeons.
Design, Setting, and Participants
Following approval from the American Head and Neck Society (AHNS) review board, a web-based survey study of 37 questions, mainly assessing daily lifestyle and quality of life, was sent to the entire membership.
Main Outcomes and Measures
The main outcome assessed was perceived quality of life among female and male surgeons.
A total of 261 members (13.0%) responded, 71 women (27.2%) and 190 men (72.8%). In all, 66 female (92.5%) and 152 male (80%) surgeons worked at an academic institution. A greater percentage of women were at the associate professor level than men (20/64 [31%] vs 37/152 [24%]; difference, 6.9%; 95% CI, −5.6% to 20.5%) and a greater percentage of men were at the professor level than women (72/152 [47%] vs 18/64 [28%]; difference, 19%; 95% CI, 4.9% to 31.6%). This discrepancy was evident in administrative roles as well, with 4 female (6.2%) vs 23 male (17.6%) department chairs (difference, 11.3%; 95% CI, 0.9%-19.6%). Of the 71 women, 18 (25%) were not in a long-term relationship or were divorced, as opposed to 6 (3.2%) men (difference, 22%; 95% CI, 12.8%-33.5%). Women had a mean (median) 1.18 (1) children, whereas men had 2.29 (2) children. Mean age that participating women had their first child was 35.1 years, whereas the man age for men was 31.9 years. Overall, 117 men (61.9%) and 45 women (67.2%) found their family time limited compared with other otolaryngological subspecialties. Despite these results, 101 men (53.4%) vs 37 women (55.2%) stated that they had a good work-life balance. Six women vs 8 men indicated they would choose a different subspecialty if they could.
Conclusions and Relevance
Despite improvements in work hours and gender balance in residency programs, discrepancy in the number of female surgeons with senior academic rankings continues. However, female and male head and neck surgeons appear equally content with their subspecialty choice.
It has been 55 years since the Equal Pay Act passed in the United States, aiming to abolish pay disparity based on sex. Although huge strides have been made toward greater gender equality in the workplace since the passing of this act, there remain many ongoing disparities, as evidenced by the frequency of discussions in the media regarding a woman’s role in science, technology, medicine, and day-to-day life. In Medicine, although 50% of graduating medical students are women, subsequent recruitment of women to surgical subspecialties continues to be challenging. Female medical students frequently cite an inability to maintain a satisfactory work-life balance as a surgeon as one of the main reasons that deters them from pursuing a surgical subspecialty.1-3 Other possible contributing factors include a lack of female role models, “boys club” mentality,4,5 and fear of discrimination based on gender.6 For those women who do choose to join the surgical workforce, subsequent attrition rates in surgical specialties are higher for women than men. According to the Association of American Medical Colleges (AAMC) 2014 report,7 64% of instructors in otolaryngology–head and neck surgery are women; however, as academic ranking increases, the numbers of women decrease considerably. Only 32% of assistant professors, 27% of associate professors, and 12% of professor in otolaryngology are reported to be women, and the percentage of female department chairs and deans is even lower, at 2.3%.
To date, there have been a number of studies in various surgical subspecialty fields evaluating factors that may contribute to gender discrepancies among attending surgeons. However, surprisingly few studies have been conducted in the specialty of otolaryngology–head and neck surgery. With the ever-increasing emphasis on physician burn-out and quality of life, the current study was designed to specifically evaluate how gender differences are associated with perceived quality of life and work-life balance in a highly demanding surgical field, head and neck oncological surgery. Both male and female members the American Head and Neck Society were surveyed with the primary objective being to determine whether female head and neck surgeons were as satisfied with their lifestyle and work-life balance as their male counterparts.
A web-based survey of 37 questions was designed, comprising 7 domains to assess demographics, academic status, mentorship experience, daily lifestyle, family life, personal health, and job satisfaction (Supplement). The study was approved by the board of the American Head and Neck Society. Participants were not compensated. The questions included current academic rank and institution type, work hours, type of practice and types of cases performed, call and leave quantity, relationship status, number of children and the age at which the first child was born or adopted, time spent on maternity or paternity leave, and how household chores were divided. Personal health was assessed by evaluating smoking and drinking status, amount of weekly exercise, self-perceived assessment of current health, mental health issues and, if present, type of treatment employed. Participants were asked if they were satisfied with their career choice and if they would pursue head and neck surgery again if they were given the choice of changing specialties. The survey was distributed via email to all members of the American Head and Neck Society. The surveys were anonymous, no identifiers were collected. The surveys were sent out at 2 time points. After the first distribution, which resulted in a 12% response rate, a second reminder was sent during the major academic meeting of the year.
Completed surveys were analyzed and answers recorded. Male and female responses to each item were compared using χ2 testing for continuous variables and paired t tests for categorical variables.
A total of 261 members (13%) responded to the survey , including 71 women (27.2%) and 190 men (72.8%). Four female and 1 male respondent were excluded from final analysis because they were not head and neck surgeons. Overall, 38 female (71%) and 93 male (49%) respondents were aged between 30 and 50 years. One woman was older than 60 years, whereas 34 men (18%) were aged between 60 to 70 years and 6 (3.2%) were older than 70 years. Demographic details are summarized in Table 1.
Of 256 respondents, 5 female (7.5%) and 38 male (20%) surgeons did not work at an academic institution. Of the women practicing in academia, 20 (30.8%) held an associate professor ranking, and 18 (27.8%) a professor rank. Seventy-two (41.6%) men practicing in academia ranked as professor, and 37 (21.3%) as associate professor. There were 4 (6.2%) female and 23 (17.6%) male department chairs, and 4 female (6.2%) and 26 male (19.8%) department vice chairs. Thirty-one (46.3%) women and 54 (28.6%) men in academia stated that they did not carry a leadership role (Table 2).
To qualify respondents’ daily practices, they were asked to stratify the amount of time divided between ablative, reconstructive, microvascular, and endocrine surgery as well as general otolaryngology. These results are summarized in Table 3.
Seventeen (25%) of 67 female respondents were either not married/in a long-term relationship or were divorced, as opposed to 6 (3.2%) of 189 male respondents (difference, 20.8%; 95% CI, 11.6%-32%). All except 1 of these women were older than 40 years. Women surgeons had a mean (median) 1.18 (1) children per family. Men had a mean (median) 2.29 (2) children. One woman (1.5%) had 4 children, and none had more than 4. Twenty-six men (13.8%) had 4 or more children. The mean age that women gave birth or adopted their first child was 35.1 years compared with 31.9 years for men. Also, 9 female (13%) respondents reported that they were on bed rest prior to delivery owing to preeclampsia.
Female respondents took a mean of 19.6 days of vacation per year compared with a mean of 21.1 days for men. Overall, 89 (34.8%) respondents stated that they felt pressured not to take vacation owing to pressure from the department chair or hospital administration (15.3%), pressure from patients (41.4%), or a perceived need to generate income (37%). When asked about their health, 7 surgeons (2.7%) rated it as poor or very poor, whereas 200 surgeons (78.5%) stated they exercised regularly. Twenty-one female (31.3%) and 30 male (15.9%) respondents had been treated for mental health issues, mostly a combination of couples and individual therapy.
When asked whether they found their family time limited by their subspecialty compared with other subspecialties of otolaryngology, 117 men (61.9%) and 45 women (67.2%) responded yes. Despite this, 101 men (53.4%) and 37 (55.2%) women stated they had a good work-life-balance. Six women (9%) and 8 men (4.2%) indicated that they would choose a different subspecialty if they could.
Recruitment and retention of women in surgical specialties continues to be a topical issue and there are few studies to date focusing on the issues facing women in otolaryngology–head and neck surgery. The current study investigated the association of gender differences with workplace demographics and job satisfaction in head and neck oncological surgery. Significant gender-specific findings included: a discrepancy in seniority of academic rankings between men and women; a higher number of female respondents were not married, in a relationship, or were divorced (25%) compared with male colleagues (3.2%); fewer children per family for female compared with male surgeons (median, 1 vs 2 children per family, respectively); and twice the rate of treatment for mental health issues among female (31.3%) compared with male (15.9%) respondents.
However, despite the above gender discrepancies, more than half of all respondents, both male and female, felt that they had a good work-life balance, with few of either gender indicating they would choose a different subspecialty if they had to make that choice again.
A study from 20128 examining the evolution of racial, ethnic, and gender diversity in US otolaryngology residency programs reported a promising growth trend for women. Nonetheless, they found that both women and certain racial and ethnic minority groups were historically and currently underrepresented in otolaryngology–head and neck surgery residency programs. A study9 from Canada noted that female representation in otolaryngology had doubled over 27 years from 20% to 40%. Similarly, in the United States, the proportion of female otolaryngology residents is increasing, with an estimated 36.3% of otolaryngology residents being women according to the 2015 AAMC report.10 However, despite this increased intake of women in residency, the current study suggests that academic rankings of female surgeons in head and neck oncological surgery are considerably lower than for male surgeons. It should be noted that, some of the findings may be owing to differing career goals between female and male surgeons. A prior study11 assessing gender disparity in scholarly activity in academic otolaryngology departments evaluated 92 academic institutions in the United States. They reported that 24% of assistant professors, 20% of associate professors, and 12% of professors were women. These percentages are inclusive of all subspecialties of otolaryngology and are notably lower than the corresponding percentages observed in our study. It should be noted that the distribution in this cohort is reflective of the population responding to the survey and not the general population. On the other hand, we believe this discrepancy may, in part, be explained by a decrease in the attrition rates of female head and neck surgeons from academic institutions compared with female otolaryngologists in general such that the head and neck surgeons continue to increase in rank over the course of their career. This hypothesis is supported by the finding that only 7% of female head and neck surgeons responding to the current survey practiced outside of an academic institution. It suggests that female head and neck surgeons are more inclined to remain in an academic setting, an outcome that is not surprising given that the complexity of the cases seen in head and neck oncological surgery frequently necessitate a multidisciplinary approach that is most available in an academic setting. Another possible explanation for the greater proportion of women with senior academic titles in the current study is that head and neck oncological surgery may offer greater opportunity for the research and teaching work necessary to advance in academic rank compared with some other otolaryngology subspecialties.
With regard to research productivity as a predictor of academic title, Eloy et al11 noted that women had lower scientific productivity rates early in their careers when at the assistant or associate professor level. However, at a professor level, this trend in productivity (measured by the h-index) reversed, with women being the more productive gender. Lower productivity for women early in their careers is likely multifactorial and lack of mentorship and greater involvement in family responsibilities are frequently cited as important contributors.11-13 With regard to mentorship, in the current study only 25% of female respondents stated that they were lacking or had lacked a good mentor. However, most respondents in this study were fellowship trained and their decision to pursue a fellowship was likely, at least in part, reinforced by male and female role models. This may be one explanation for the lower percentage of female respondents claiming to have lacked a good mentor compared with prior studies. Future studies are needed to assess the status of mentorship in the different subspecialties of otolaryngology by the various professional subspecialty organizations. The importance of effective mentorship should not be underestimated because it has been shown to play a crucial role in academic success as well as professional growth and development.14 Formal mentorship programs (FMP) for residents have been shown to significantly increase quality of life measures. In 1 study reporting on the implementation of FMP at the University of Alberta Department of Otolaryngology, the participating residents had significantly lower perceived stress levels, lower emotional scores and levels of depersonalization, with significant improvement in physical and psychological health and social relationships.15 The AHNS Women in Surgery Committee is working on implementing an FMP for its members in hopes of increasing perceived quality of life measures and the numbers of women in higher academic ranks.
Greater involvement in family responsibilities by female compared with male physicians is another possible reason for decreased productivity in the early years of a female surgeon’s career.11,16,17 Although the current study did not specifically address this issue, it is important to note that female head and neck surgeons had fewer children compared with male surgeons and were older when they welcomed the first child. Hypothetically, these findings may indicate that occupation-related demands and constraints make having larger families at a younger age very difficult for female surgeons. A number of studies in various surgical subspecialties such as plastic18 and orthopedic19 surgery have shown increased complication rates during pregnancy, including miscarriages and preeclampsia, and increased elective abortion and infertility rates for female surgeons compared with the general population. In our study, we had similar findings. Whether these findings are related to the highly demanding nature of the occupation having a negative impact on forming and keeping long-term relationships for female surgeons was not directly assessed. However, of note, 62% of men and 67% of women who had long-term relationships and/or children believed that their family time was limited compared with other otolaryngology subspecialties.
Overall, 101 men (53%) and 37 women (55%) stated that they had a good work-life balance. The most common detractors of personal life brought forward were the burdens of electronic medical record keeping, too many commitments in one’s institution and national societies, and institutional demand to produce more work-relative value units. These findings are similar to those raised in another study20 where the strongest predictors of burnout were dissatisfaction with the balance between personal and professional life, low self-efficacy, inadequate research time, and inadequate administration time. Unfortunately, it is difficult in the current health care environment to see how physician dissatisfaction and burnout will improve in upcoming years as administration duties continue to escalate, protected research time loses its protection, and the focus of most major tertiary centers shifts further away from an emphasis on physician-patient relations toward financial gain. A recent systematic review21 investigating surgeon burnout among different subspecialties found that, of the 33 studies that specifically reported on gender, 9 correlated female sex with an increased risk for burnout, depression, and lesser career satisfaction. One study21 suggested that male surgeons have an increased risk for burnout and 9 studies found no statistically significant difference by sex for poorer quality of life or burnout. In the studies specifically evaluating burnout in otolaryngology, high burnout was reported among 3% to 41% of attending surgeons and 4% to 10% of residents. Factors correlating with burnout and higher emotional exhaustion from these and other studies include the number of hours worked per week, inadequate administration time, number of children in the home, female gender, inability to care for personal health, and poor perception of control over professional life.20-25 Results from the current study, although not solely focusing on mental health and burnout, show that mental health issues are prevalent in the head and neck oncological community with 31.3% of female and 15.9% of male respondents having been treated for mental health issues at some stage in their career. The National Institutes of Health for the United States reports 6.7% of the US population has at least 1 major depressive episode in a year and suggests that mental health issues are an ongoing source of occupational stress and career dissatisfaction.26 Importantly, only 9% of women and 4% of men in the current study indicated that they would choose a different subspecialty if they could. This is in contrast to an earlier study combining 14 surgical specialties, where 30.5% of respondents stated they would not become surgeons again23 and suggests that there are positive attributes of working in the head and neck oncological field that outweigh the detractors for many surgeons. However, these results may also reflect a bias in the survey population where survey respondents were more satisfied with their occupations than the general head and neck community.
Efforts to improve the climate include mentorship and coaching; however, sponsorship plays an indispensable role for equity. Whereas mentorship often centers on personal and professional development (eg, skill building and goal setting), sponsorship focuses on enhancing the visibility, credibility, and professional networks of talented individuals.27 Gottlieb and Travis27 report in their article that not only are men more likely to benefit from sponsors, who are also men. High-performing women often lack visibility and would benefit from wide-scale sponsorship to improve their advancement.27 Shah et al28 report that it is incumbent on institutional leadership to understand and improve faculty vitality. They state institutions need to provide their members with an appropriate level of security and respect to stimulate vitality.28,29 Vitality of a faculty body reflects engagement, productivity, and stability.30 Their article suggests a contextual framework to study these often competing forces in improving engagement and vitality.28
This study’s greatest strength is that it is a query of a single subspecialty of otolaryngology–head and neck surgery. Whereas, it may not be generalizable to all surgical fields, the fact that head and neck surgery is demanding of training and of lifestyle may help these results inform other fields. A higher response rate would have been desired and in particular, the low representation of underrepresented minorities in the sample may belie the additional obstacles they face.
To our knowledge, this is the first study looking in depth at the lifestyle and quality of life of surgeons in a highly demanding postfellowship subspecialty of otolaryngology–head and neck surgery. The issues raised by this study are in accord with those raised by prior studies in this and other surgical specialties. Despite improvements in work hours and gender balance in residency programs, there continues to be a discrepancy in the number of female surgeons with senior academic rankings. In addition, female head and neck surgeons are more likely to be single, to have fewer children than male colleagues, and to be treated for mental health issues. However, overall, female and male head and neck surgeons appear equally content with their subspecialty choice. It should be recognized that although some of the risk factors for physician burnout appear linked to female gender, in general these factors affect both female and male surgeons and need to be prioritized at the individual and institutional level to prevent escalating rates of occupational dissatisfaction, emotional fatigue, physician burnout, and a reduced physician workforce.
Corresponding Author: Ozlem E. Tulunay-Ugur, MD, Division of Laryngology, Department of Otolaryngology–Head and Neck Surgery, 4301 W Markham St, Slot 543, Little Rock, AR, 72205 (firstname.lastname@example.org).
Accepted for Publication: January 19, 2019.
Published Online: March 21, 2019. doi:10.1001/jamaoto.2019.0104
Author Contributions: Dr Tulunay-Ugur had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Tulunay-Ugur, Sinclair.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Tulunay-Ugur.
Obtained funding: Chen.
Administrative, technical, or material support: Sinclair, Chen.
Study supervision: Sinclair, Chen.
Meeting Presentation: This study was presented as part of a panel discussion at the 2018 American Head and Neck Society Annual Meeting; April 19, 2018; National Harbor, Maryland.
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