Factors associated with career satisfaction and burnout among US neurosurgeons: results of a nationwide survey

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OBJECT

The object of this study was to identify and quantify predictors of burnout and career satisfaction among US neurosurgeons.

METHODS

All US members (3247) of the American Association of Neurological Surgeons (AANS) were invited to participate in a survey between September and December 2012. Responses were evaluated through univariate analysis. Factors independently associated with burnout and career satisfaction were determined using multivariable logistic regression. Subgroup analysis of academic and nonacademic neurosurgeons was performed as well.

RESULTS

The survey response rate was 24% (783 members). The majority of respondents were male, 40–60 years old, in a stable relationship, with children, working in a group or university practice, and trained in a subspecialty. More than 80% of respondents reported being at least somewhat satisfied with their career, and 70% would choose a career in neurosurgery again; however, only 26% of neurosurgeons believed their professional lives would improve in the future, and 52% believed it would worsen. The overall burnout rate was 56.7%. Factors independently associated with both burnout and career satisfaction included achieving a balance between work and life outside the hospital (burnout OR 0.45, satisfaction OR 10.0) and anxiety over future earnings and/or health care reform (burnout OR 1.96, satisfaction OR 0.32). While the burnout rate for nonacademic neurosurgeons (62.9%) was higher than that for academic neurosurgeons (47.7%), academicians who had practiced for over 20 years were less likely to be satisfied with their careers.

CONCLUSIONS

The rates of burnout and career satisfaction were both high in this survey study of US neurosurgeons. The negative effects of burnout on the lives of surgeons, patients, and their families require further study and probably necessitate the development of interventional programs at local, regional, and even national levels.

ABBREVIATIONSAANS = American Association of Neurological Surgeons; AUC = area under the curve; CSNS = Council of State Neurosurgical Societies; MBI = Maslach Burnout Inventory; PPACA = Patient Protection and Affordable Care Act.

Medicine combines scientific discovery with the opportunity to care for patients with a diverse range of disease. Physicians, however, are subject to a number of stressors and challenges that may lead to an unhealthy level of dissatisfaction, and even burnout. “Burnout” has been defined as a clinical syndrome characterized by emotional exhaustion, depersonalization, and a decreased sense of accomplishment.9 A definition of burnout is included in the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10 Version:2010, http://apps.who.int/classifications/icd10) as a drawback related to life-management difficulty combined with a state of vital exhaustion. Symptoms include fatigue, poor judgment, cynicism, guilt, feelings of ineffectiveness, and disconnection with coworkers or patients.1,9,34 Maslach et al. defined burnout among health care providers as a psychological process whereby human service professionals attempting to positively impact the lives of others become overwhelmed and frustrated by unforeseen stressors related to their jobs.30

Burnout and dissatisfaction with one's career are pervasive problems in medicine that can negatively affect a physician's personal, physical, and mental well-being. They are associated with interpersonal relationship dysfunction, substance abuse, suicidal ideation, and a desire by young surgeons to retire early.2,11,35 More medical errors have also been reported among surgeons who experience higher levels of burnout.36,47,48 Patients who are treated by physicians suffering from burnout are more often dissatisfied with their level of care and are more likely to participate in malpractice suits.2

Many studies have gauged the level of burnout in various medical subspecialties. In a landmark study, Shanafelt and colleagues surveyed 7905 surgeons in an effort to identify personal and professional characteristics that may predict burnout.37 They found that specialty practice area,7 number of nights on call per week,5 h ours worked per week,5 younger age,25 and compensation based entirely on billing were factors associated with surgeon burnout.37 Further studies report that surgeons who are female,16 work in private practice,7 or report not having enough time for family or personal life4,38 have higher levels of burnout. Conversely, surgeons who are older,25 work in academia,7 have sufficient time for non–patient care activities,6,25 and spend more time in the operating room37 are typically more satisfied with their career choice.

While previous studies have included a small sample of neurosurgeons, there is little research dedicated to career satisfaction or burnout in what is arguably one of the most intense fields in medicine. We recently published our results from a pilot study in which 85 neurosurgeons completed a 107-item questionnaire.23 After partnering with the Council of State Neurosurgical Societies (CSNS), we conducted a nationwide study using a modified and shortened version of our original questionnaire. The primary objective of this study was to better define within neurosurgery the level of burnout and career satisfaction and their predictive factors.

Methods

A shorter, modified online version (SurveyMonkey) of the pilot study questionnaire was used to improve participation (Appendix). An e-invitation to complete the survey was sent to all US members of the American Association of Neurological Surgeons (AANS) on behalf of the CSNS on 4 separate occasions between September and December 2012. Electronic communication to potential survey respondents included a link to the survey, as well as a cover letter outlining the purpose of the survey. Participation was voluntary and data were de-identified by the survey administrator (S.M.) prior to analysis. We combined responses from this survey with those from our previous pilot study as we assumed that those neurosurgeons who participated in the pilot survey were not likely to complete the updated survey.

Definitions and Statistical Analysis

Descriptive summary statistics were used to describe the overall group of respondents. Select survey responses were combined into categories for the purposes of statistical analysis based on previous literature and number of responses within the original selections. All categories were determined prior to completing any statistical analysis. For example, responses to specific questions regarding professional perceptions that were believed to have a large impact on the desired outcome were converted from a Likert-type scale to dichotomous variables. The number of age categories was collapsed from 7 to 3 to approximate the early (up to and including age 45 years), middle (46–55 years), and later (> 55 years) stages of a person's career, with each stage selected to represent an approximate 10-year period.

We decided a priori to identify and quantify predictors of 2 survey outcomes: 1) burnout and 2) career satisfaction. Burnout was measured using the validated Maslach Burnout Inventory (MBI) that assesses emotional exhaustion (9 questions), depersonalization (5 questions), and personal accomplishment (8 questions). Using the same definition as Shanafelt et al. and the cutoff values specific for those who work in medicine as set forth in the MBI manual, burnout was defined as having high scores for emotional exhaustion or depersonalization on the MBI.30,37 Respondents were classified as being satisfied with their career if they selected “very satisfied” or “somewhat satisfied” on Question 1 of the professional satisfaction section of the survey. Subgroup analysis evaluating the same outcomes in respondents who described their job as “academic” versus those who did not was also performed.

After conducting univariate analysis, forward multivariable logistic regression was undertaken to assess independent associations related to the dichotomous variables of burnout and career satisfaction. Variables with p < 0.2 in the univariate analysis were placed in the logistic regression model initially. The same methodology was used for the subgroup analysis of academic and nonacademic neurosurgeons. Two-tailed statistical tests were performed, and p ≤ 0.05 was determined to represent statistical significance in the univariate and multivariable analysis. The level of statistical significance for multiple comparisons was not adjusted. Results were reported as adjusted odds ratio with corresponding 95% confidence intervals. All data were analyzed using SPSS software (IBM SPSS Statistics for Windows, Version 21.0, Released 2012, IBM Corp.).

Results

Survey Results

Of the 3247 US neurosurgeons invited to complete the survey, 783 responded (24%). Responses from 33 physicians were excluded due to incompleteness on the 22-question MBI, yielding 750 completed surveys.

The majority of respondents were male, between the ages of 40 and 60 years, in a stable relationship with children, and working in a group or university practice with subspecialty training. Most worked more than 50 hours per week, took call 6 or more days per month, and completed over 200 cases annually. Just over half indicated that they had not been involved in any malpractice suits over the last 5 years (2008–2012). A detailed summary of personal and practice characteristics of the 750 survey participants is provided in Table 1.

TABLE 1

Demographic information on 750 survey respondents

CharacteristicNo. (%)
Male655 (87.3)
Age (yrs)
 ≤4090 (12.0)
 41–45142 (18.9)
 46–50135 (18.0)
 51–55145 (19.3)
 56–60121 (16.1)
 61–6574 (9.9)
 >6543 (5.7)
Relationship status
 Stable partner/married683 (91.1)
 Single67 (8.9)
 Divorced*68 (9.1)
Children667 (88.9)
Practice type
 Group286 (38.1)
 University191 (25.5)
 Private w/ academic affiliation114 (15.2)
 Solo94 (12.5)
 Other42 (5.6)
 Health care management organization12 (1.6)
 Veterans Affairs/government11 (1.5)
Academic/university affiliation308 (41.1)
Duration of practice (yrs)
 <573 (9.7)
 5–10121 (16.1)
 11–15153 (20.4)
 16–20117 (15.6)
 20–25124 (16.5)
 >25162 (21.6)
Any subspecialty training418 (55.7)
 Spine132 (17.6)
 Pediatrics76 (10.1)
 Cerebrovascular55 (7.3)
 Skull base58 (7.7)
 Functional & stereotactic44 (5.9)
 Other53 (7.1)
Hours worked per week
 <4015 (2.0)
 41–5083 (11.1)
 51–60202 (26.9)
 61–70242 (32.3)
 71–80106 (14.1)
 >80102 (13.6)
On-call days per month
 <360 (8.0)
 3–5129 (17.2)
 6–10333 (44.4)
 >10228 (30.4)
Cases completed annually
 <200221 (29.5)
 201–300312 (41.6)
 301–400160 (21.3)
 >40057 (7.6)
Malpractice cases over the last 5 yrs (2008–2012)
 0407 (54.3)
 1–5333 (44.4)
 >510 (1.3)

Percentage of total population (n = 750) who stated they had been through a divorce during career.

A breakdown of responses for the survey sections on professional stressors, satisfaction, and quality of life is shown in Figs. 13. Too much call (59.2%), uncertainty about future earnings/health care reform (75.2%), inadequate administration time (46.9%), low salary (48.8%), and too little vacation time (43.7%) had at least a moderate impact on neurosurgeons' professional careers (Fig. 1). Participants were satisfied with the location of their practice (75.1%) and their neurosurgical colleagues (65.1%), but were dissatisfied with the time allowed for personal growth/development (44.6%) and believed that reimbursement should be improved (69.6%; Figs. 2 and 3).

FIG. 1.
FIG. 1.

Response to questions for Professional Stressors (Appendix, Section 2). Figure is available in color online only.

FIG. 2.
FIG. 2.

Response to questions for Professional Satisfaction (Appendix, Section 3). Figure is available in color online only.

FIG. 3.
FIG. 3.

Response to questions for Quality of Professional Life (Appendix, Section 4). Figure is available in color online only.

Selected questions from each of the 3 sections—professional stressors, satisfaction, and quality of life—and from the general questions section of the survey are shown in Table 2. More than 80% cited that they were satisfied with their career as a neurosurgeon. Strong responses by participants included being intellectually challenged by their work (77.3%), having a spouse that understood their demanding work schedule (73.5%), and being concerned about future earnings and health care reform (53.5%). Only 36.5% believed that they had adequate time for personal growth/development, and 48.1% had achieved a balance between work and life. Although almost 70% of respondents would choose a career in neurosurgery again, only 35.5% would recommend neurosurgery as a career to their children.

TABLE 2

Professional perceptions among surveyed neurosurgeons

PerceptionNo. (%)
Satisfied w/ career as a neurosurgeon*609 (81.2)
Adequate time for personal development274 (36.5)
Challenged at work580 (77.3)
Good work/life balance361 (48.1)
Spouse understands when they work extra hours551 (73.5)
Would choose to be a neurosurgeon again512 (68.3)
Would recommend neurosurgery as a career to their children266 (35.5)
Uncertain of future earnings/health care reform401 (53.5)

Respondents answered “very satisfied” or “somewhat satisfied” with the factors surveyed.

Respondents answered “strongly agree” or “agree” that they were satisfied with the factors surveyed.

Respondents answered that the factors surveyed impact their practice to an “extreme amount” or a “large amount.”

When asked if they felt their professional life would improve, only 26% of neurosurgeons agreed. Moreover, when asked if they felt their professional life would worsen, 52% agreed, whereas only 24.8% did not. The direction neurosurgeons believe their careers will take in the future is depicted graphically in Fig. 4.

FIG. 4.
FIG. 4.

Perceptions among neurosurgeons on the future direction of their career. Figure is available in color online only.

The burnout rate overall was 56.7% (Table 3). High emotional exhaustion was reported in 35.1% of neurosurgeons, high depersonalization in 31.3%, and a low sense of personal accomplishment in 28.4%.

TABLE 3

Burnout indices among 750 neurosurgeons*

Burnout IndicesMedian Score (IQR)No. (%)
Emotional exhaustion21 (11–31)
 Low score (≤18)322 (42.9)
 Moderate score165 (22.0)
 High score (≥27)263 (35.1)
Depersonalization6 (3–11)
 Low score (≤5)349 (46.5)
 Moderate score166 (22.1)
 High score (≥10)235 (31.3)
Personal accomplishment38 (31–43)
 Low score (≤33)312 (28.4)
 Moderate score201 (26.8)
 High score (≥40)336 (44.8)
Burned out425 (56.7)

All data are listed as median (25%–75% interquartile range [IQR]) unless otherwise noted.

High score on emotional exhaustion and/or depersonalization subscales (see Methods).

Predictors of Satisfaction and Burnout

The results of univariate analysis are shown in Table 4. Factors that were independently associated with career satisfaction and burnout are listed in Table 5. Six factors were predictive of burnout and 7 for career satisfaction. Being accused of malpractice (OR 1.6) and having uncertainty regarding future earnings/health care reform (OR 1.96) significantly increased the odds of being burned out, while 4 other practice characteristics or perceptions were protective. Four of the 7 factors independently associated with career satisfaction were positive correlations, including having children (OR 2.4) and a good work/life balance (OR 10.0). Achieving a balance between work and life and anxiety over future earnings/health care reform were factors shown to significantly impact the odds of both outcomes. The presence of burnout reduced the odds of being satisfied with one's career almost 6-fold (OR 0.17).

TABLE 4

Univariate analysis of burnout and satisfaction among neurosurgeons

CharacteristicNo. (%)
 SatisfiedBurned Out
 NoYesp ValueNoYesp Value
No. of respondents141609325425
Age (yrs)
 <4548 (34.0)184 (30.2)0.3896 (29.5)136 (32.0)0.47
 46–5548 (34.0)232 (38.1)0.37130 (40.0)150 (35.3)0.19
 >5545 (31.9)193 (31.7)0.9699 (30.5)139 (32.7)0.51
Female26 (18.4)68 (11.2)0.01932 (9.8)62 (14.6)0.052
Relationship status
 Stable relationship/married299 (92.0)384 (90.4)0.43
 Single26 (8.0)41 (9.6)0.43
Children116 (82.3)551 (90.5)0.005295 (90.8)372 (87.5)0.16
Academic affiliation41 (29.1)267 (43.8)0.001161 (49.5)147 (34.6)<0.001
Career duration
 ≤10 yrs32 (22.7)162 (26.6)0.3482 (25.2)112 (26.4)0.73
 11–20 yrs44 (31.2)226 (37.1)0.19120 (36.9)150 (35.3)0.65
 >20 yrs65 (46.1)221 (36.3)0.03123 (37.8)163 (38.4)0.89
Subspecialty training66 (46.8)353 (58.0)0.02190 (58.5)229 (53.9)0.21
 Cerebrovascular7 (5.0)47 (7.7)0.2525 (7.7)29 (6.8)0.65
 Functional/stereotactic7 (5.0)37 (6.1)0.6124 (7.4)20 (4.7)0.12
 Pediatrics7 (5.0)69 (11.3)0.0237 (11.4)39 (9.2)0.32
 Spine24 (17.0)109 (17.9)0.8156 (17.2)77 (18.1)0.75
 Skull base12 (8.5)46 (7.6)0.7026 (8.0)32 (7.5)0.81
 Other9 (6.4)45 (7.4)0.2622 (6.8)31 (7.3)0.77
Productivity
 On call >10 days/mo48 (34.0)180 (29.6)0.3092 (28.3)136 (32.0)0.28
 Performs >300 cases/yr29 (20.6)188 (30.9)0.015100 (30.8)117 (27.5)0.33
 Work >70 hrs/wk36 (25.5)173 (28.4)0.4989 (27.4)120 (28.2)0.80
Accused of malpractice70 (49.6)273 (44.8)0.30121 (37.2)222 (52.2)<0.001
Professional perceptions
 Adequate time for personal development7 (5.0)267 (43.8)<0.001174 (53.5)100 (23.5)<0.001
 Challenged at work62 (44.0)518 (85.1)<0.001284 (87.4)296 (69.6)<0.001
 Good work/life balance10 (7.1)351 (57.6)<0.001216 (66.5)145 (34.1)<0.001
 Spouse understands extra work hrs91 (64.5)460 (75.5)0.008259 (79.7)292 (68.7)0.001
 Uncertain of future earnings/health care reform114 (81.4)287 (47.4)<0.001128 (39.5)273 (64.8)<0.001
Would choose neurosurgery again33 (23.6)479 (79.2)<0.001284 (87.9)228 (54.0)<0.001
TABLE 5

Multivariable logistic regression analysis of 750 survey respondents

CharacteristicOR95% CIp Value
Burnout*
 Accused of malpractice1.601.16–2.200.004
 Academic affiliation0.690.49–0.960.03
 Professional perceptions
  Uncertain of future earnings/health care reform1.961.41–2.72<0.001
  Challenged at work0.600.39–0.930.02
  Good work/life balance0.450.31–0.65<0.001
  Adequate time for personal development0.570.39–0.840.005
Satisfaction
 Having children2.41.2–4.80.01
 Completing >300 cases/yr1.771.03–3.030.04
 Professional perceptions
  Uncertain of future earnings/health care reform0.320.19–0.55<0.001
  Challenged at work4.62.9–7.4<0.001
  Good work/life balance10.04.9–20.3<0.001
 Burned out0.170.08–0.32<0.001
 Practiced for >20 yrs0.610.38–0.970.04

The sex of the respondent and the perception of having a spouse who understands the need for expanded work hours did not predict outcome. The area under the receiver operating characteristic curve (AUC) = 0.89 (95% CI 0.87–0.92).

The sex of the respondent, specialty training, academic affiliation, perception of adequate time for development or a spouse who understands the need for expanded work hours did not predict outcome. The AUC = 0.74 (95% CI 0.71–0.78).

Academic Versus Nonacademic Neurosurgeons

Characteristics of academic and nonacademic neurosurgeons are shown in Table 6. Variables that were independently associated with career satisfaction and burnout among academic and nonacademic neurosurgeons are shown in Tables 7 and 8, respectively.

TABLE 6

Univariate analysis of burnout and satisfaction among academic versus nonacademic neurosurgeons*

CharacteristicAcademic NeurosurgeonsNonacademic Neurosurgeons
 SatisfiedBurned OutSatisfiedBurned Out
 NoYesNoYesNoYesNoYes
No. of neurosurgeons41267161147100342164278
Age in yrs
 ≤4515 (36.6)107 (40.1)61 (37.9)61 (41.5)33 (33)77 (22.5)35 (21.3)75 (27)
 46–5514 (34.1)92 (34.5)58 (36.0)48 (32.7)34 (34)140 (40.9)72 (43.9)102 (36.7)
 >5512 (29.3)68 (25.5)42 (26.1)38 (25.9)33 (33)125 (36.5)57 (34.8)101 (36.3)
Female7 (17.1)38 (14.2)19 (11.8)26 (17.7)19 (19.0)30 (8.8)13 (7.9)36 (12.9)
Relationship status
 Stable relationship/married38 (92.7)242 (90.6)147 (91.3)133 (90.5)90 (90)313 (91.5)152 (92.7)251 (90.3)
 Single3 (7.3)25 (9.4)14 (8.7)14 (9.5)10 (10)29 (8.5)12 (7.3)27 (9.7)
Children33 (80.5)233 (87.3)144 (89.4)122 (83.0)83 (83)318 (93.0)151 (92.1)250 (89.9)
Career duration
 ≤10 yrs10 (24.4)74 (27.7)45 (48)39 (26.5)22 (22)88 (25.7)37 (22.6)73 (26.3)
 11–20 yrs11 (26.8)108 (40.4)64 (39.8)55 (37.4)33 (33.0)118 (34.5)56 (34.1)95 (34.2)
 >20 yrs42 (48.8)85 (31.8)52 (32.3)53 (36.1)45 (45)136 (39.8)71 (43.3)110 (39.6)
Subspecialty training27 (65.9)206 (77.2)119 (73.9)114 (77.6)39 (39)147 (43)71 (43.3)115 (41.4)
Productivity
 On call >10 days/mo11 (26.8)57 (21.3)34 (21.1)34 (23.1)37 (37)123 (36)58 (35.4)102 (36.7)
 Performs >300 cases/yr6 (14.6)73 (27.3)46 (28.6)33 (22.4)23 (23)115 (33.6)54 (32.9)84 (30.2)
 Work >70 hrs/wk15 (36.6)85 (31.8)47 (29.2)53 (36.1)21 (21)88 (25.7)42 (25.6)67 (24.1)
Accused of malpractice17 (41.5)115 (43.1)57 (35.4)75 (51.0)53 (53)158 (46.2)64 (39)147 (52.9)
Professional perceptions
 Adequate time for personal development2 (4.9)125 (46.8)93 (57.8)34 (23.1)5 (5)142 (41.5)81 (49.4)66 (23.7)
 Challenged at work23 (56.1)245 (91.8)148 (91.9)120 (81.6)39 (39)273 (79.8)136 (82.9)176 (63.3)
 Good work/life balance4 (9.8)157 (58.8)108 (67.1)53 (36.1)6 (6)194 (56.7)108 (65.9)92 (33.1)
 Spouse understands extra work hours30 (73.2)201 (75.3)124 (77)107 (72.8)61 (61)259 (75.7)135 (82.3)185 (66.5)
 Uncertain of future earnings/health care reform26 (65.0)104 (39.1)50 (31.3)80 (54.8)88 (88)183 (54)78 (47.6)193 (70.2)

Values expressed as number (%).

Included in multivariable logistic regression due to p value < 0.2.

TABLE 7

Multivariable logistic regression analysis of 308 academic neurosurgeons

CharacteristicOR95% CIp Value
Burnout*
 Professional perceptions
  Uncertain of future earnings/health care reform2.031.23–3.340.005
  Adequate time for personal development0.370.20–0.680.001
  Good work/life balance0.550.30–0.990.04
Satisfaction
 Professional perceptions
  Good work/life balance7.472.4–23.70.001
  Challenged at work5.682.3–14.0<0.001
 Practiced >20 yrs0.340.15–0.780.01
 Burned out0.0740.02–0.26<0.001

The sex of the respondent, having children, working more than 70 hours/week, being accused of malpractice, and being challenged at work did not predict outcome. The AUC = 0.73 (95% CI 0.67–0.78).

Caseload, uncertainty about future earning potential due to health care reform, the perception of having adequate time for personal growth, and subspecialty training did not predict outcome. The AUC = 0.89 (95% CI 0.85–0.94).

TABLE 8

Multivariable logistic regression analysis of 442 nonacademic neurosurgeons

CharacteristicOR95% CIp Value
Burnout*
 Accused of malpractice1.691.11–2.580.15
 Professional perceptions
  Good work/life balance0.340.22–0.52<0.001
  Challenged at work0.490.29–0.810.005
  Uncertain of future earnings/health care reform1.961.28–3.020.002
Satisfaction
 Having children4.751.91–11.820.001
 Professional perceptions
  Good work/life balance11.994.80–29.93<0.001
  Challenged at work4.702.63–8.37<0.001
  Uncertain of future earnings/health care reform0.190.86–0.41<0.001
 Burned out0.230.10–0.530.001

The sex of the respondent, working more than 70 hours/week, an age < 46 years, the perception of having adequate time for personal growth, and the perception of having a spouse who understands extra work hours did not predict outcome. The AUC = 0.73 (95% CI 0.68–0.78).

Caseload, the perception of having adequate time for personal growth, an age < 46 years, the sex of the respondent, and the perception of having a spouse who understands the need for expanded work hours did not predict outcome. The AUC = 0.88 (95% CI 0.85–0.91).

Discussion

Study Findings

Neurosurgery has been—and will remain—a stressful yet rewarding profession. This survey study represents the most comprehensive attempt to identify and quantify sources of satisfaction and burnout in neurosurgeons. Among all survey participants, factors shown to independently increase the odds of being satisfied with a career in neurosurgery included being surgically productive, having children, being intellectually stimulated, and achieving balance between career and life outside of work. The burnout rate overall was 56.7% (35.1% emotional exhaustion and 31.3% depersonalization), which is one of the highest reported rates among surgical8,25,33,37,44,45 and nonsurgical specialties,10,13,14,26,27,31,32,40 including those in previously published reports for neurosurgeons (Table 9).7,23,37 Burnout was associated with malpractice litigation and uncertainty regarding future earnings and health care reform, which was also shown to decrease the odds of being satisfied with neurosurgery.

TABLE 9

Burnout rates for various surgical and nonsurgical specialties

SpecialtyBurnout Rate (%)No. of Participants (Response Rate)
Neurosurgery (current)57783 (24%)
Neurosurgery (pilot)232785 (50%)
Plastic surgery4529505 (71%)*
Orthopedic surgery3328264 (24%)
Surgical oncology2528549 (36%)
British colorectal and vascular surgeons4432501 (59%)
Transplant surgery838259 (35%)
American surgeons37407905 (32%)
Clinical oncology40451490 (50%)
NICU physicians3215204 (not given)§
Switzerland ICU physicians3131465 (69%)
Italian psychiatrists104981 (70%)
Emergency medicine2632193 (43%)
New Zealand public hospital radiologists2723136 (51%)
Ophthalmology chairs139101 (77%)
Infectious disease14441840 (46%)

ICU = intensive care unit; NICU = neonatal ICU.

Participants were offered a cash gift for completion.

Response rate was 55.6% for colorectal surgeons and 62.3% for vascular surgeons.

Participants were offered a free American Society of Clinical Oncology educational product for completion.

Response rate only given for entire study population, of which NICU physicians accounted for only 10%.

Burnout

The study of burnout and career satisfaction is immensely important in today's health care system with effects that permeate many different aspects of health care delivery. Physician burnout has been shown to lead to medical errors,19,36,39,47,48 early retirement,11,22,43 diminished patient satisfaction with care,20,28 and increased malpractice suits.21 Surgeons from every specialty are at very high risk for burnout.7,37 The current study and prior pilot study are the only studies, to our knowledge, that have been designed specifically to garner feedback from neurosurgeons. Despite a high burnout rate among the neurosurgeons who participated in the survey, the overall career satisfaction response rate was 81.2%. Similar studies have found this seemingly paradoxical finding,7,25 which supports the innate subjectivity of burnout assessment. Burnout can occur in transient or periodic episodes, thus causing physicians to suffer from burnout at some point in their career while still being satisfied overall. Interestingly, a physician's perception of his or her own life seems to play a significant role in the relative impact of burnout on career satisfaction.

Sources of Satisfaction and Dissatisfaction

In almost all models for satisfaction and burnout, neurosurgeons have indicated that they enjoy being challenged at work. The data presented suggest that neurosurgeons are content when they are in the early-to-middle portion of their career, are consistently challenged, and spend considerable time in the operating room. In a previous cross-sectional study, Dyrbye and colleagues examined how the stage in a physician's career affects burnout and satisfaction.17 Physicians from all specialties in the US were analyzed and showed that the lowest satisfaction occurs at 2 times during their careers. First, during the early stages of their careers, physicians were dissatisfied with their overall career choice (that is, being a physician) because of work/home conflicts and feelings of depersonalization. Second, during the midstages of their careers, they were dissatisfied with their specialty career choice because of excessive work demands (that is, working long hours and taking overnight call).17 This finding is contrary to data in the current study. We hypothesize that the typical neurosurgeon experiences excitement and energy in practicing independently during the early part of their career and then may achieve a “professional peak” in terms of skill level, experience, or impact during the middle portion of their career. It is reasonable to infer that the latter stage of their career may be negatively affected by greater administrative duties, less operating room time, and increased physical fatigue or personal health issues. Such challenges may contribute to the pessimistic and unfavorable outlook held by some neurosurgeons regarding their future career (Fig. 4). Age, by itself, was not predictive of burnout or achieving career satisfaction.

It is equally clear that neurosurgeons desire a good work/life balance. The professional perception of a good work/life balance was significant in all multivariable analyses. The long hours and hard work required of a neurosurgeon make it difficult to achieve a satisfactory balance. Numerous studies have addressed the impact of work/home conflicts on medical professionals and have shown that physicians with career and family imbalance, recent work/home conflicts, and recent conflicts resolved in favor of work typically have higher rates of burnout.11,16,18 However, if a neurosurgeon perceives a good balance between work and personal life, then career satisfaction may be higher and risk of burnout may be lower.

Neurosurgeons, as with all health care workers, have been impacted in recent years by health care reform. As new measures of the Patient Protection and Affordable Care Act (PPACA) continue to be unveiled, uncertainty about the impact of health care reform may have adverse effects on the well-being of physicians. It has been suggested that health care reform poses an increased risk for burnout by augmenting physician workload, decreasing autonomy, and potentially disrupting physician work/life balance.15 The economic implications of health care reform on a neurosurgeon's practice should also be considered as a source of anxiety. To our knowledge, no previous study has assessed this issue despite the potential for changes in the US health care system to exacerbate burnout. Our data revealed that career satisfaction among US neurosurgeons is strongly impacted by the uncertainty of future earnings and health care reform. More importantly, those who feel this uncertainty in their practice have an increased risk for burnout.

Medical malpractice was another important characteristic associated with burnout. Malpractice, which was not addressed by the PPACA, has been shown to strongly influence physician burnout, depression, and suicidal ideation among surgeons.3 Physicians who had experienced medical malpractice were more likely to score a higher burnout level in all 3 domains assessed by the MBI.12 Even though less than half of the polled neurosurgeons were involved in malpractice suits over a 5-year period (2008–2012), malpractice was still found to be associated with an increased risk of burnout and can affect patient care.

Academic Versus Nonacademic Neurosurgeons

Another intriguing aspect of the present study was our comparison of academic and nonacademic neurosurgeons. Many of the predictors of satisfaction and burnout were shared between the 2 groups. Both were more likely to be satisfied if they felt challenged at work and perceived themselves as having a good work/life balance. They were less likely to be satisfied if they were considered burned out. Academic neurosurgery had a lower rate of burnout than nonacademic neurosurgery (47.7% vs 62.9%). These results were similar to those in previous studies in which private-practice general surgeons and oncologists had a greater burnout risk and lower career satisfaction rate.7,40 Previous research has suggested that nonacademic surgeons may be at greater risk because of the higher average number of call days, the longer hours worked per week, or earnings based entirely on billing.37 In contrast to their academic colleagues, who are more likely to be salaried, nonacademic neurosurgeons in our study also had lower levels of career satisfaction when they reported uncertainty about future earnings and health care reform.

Interestingly, academic neurosurgeons were less likely to be satisfied with their careers if they had practiced as a neurosurgeon for more than 20 years. This finding suggests that while burnout may be an overall problem for nonacademic neurosurgeons, it may be a bigger problem for more senior academicians. Academia presents unique stressors, such as administrative and teaching responsibilities, tenure applications, and research requirements. These additional obligations may promote burnout as the number of years that such stressors are experienced increases and by leaving inadequate time for personal development, which, as found in our study, decreases satisfaction. It is also possible that more specialized academic neurosurgeons may be at an increased risk of burnout given the impact of repetition and decreased operative variability.40

Study Limitations

Our response rate of 24% was reasonable but on the lower end of the spectrum compared with the rates in other studies listed in Table 9. We did not offer any incentive(s) to participate as others have, although doing so may have improved our response rate. This study may suffer from selection bias whereby individuals who completed the survey may be different as a group compared with those who did not complete the survey. For example, those who currently suffer from burnout or career dissatisfaction may be less likely to take the time to complete a voluntary survey, which would underestimate the prevalence of both outcomes, or vice versa.23 Another example of selection bias relates to the results of our earlier pilot study. That study had 85 respondents, most of whom were in academics or had an academic affiliation (73%). The senior author (P.K.) personally asked many of them to participate in the pilot study, resulting in a higher response rate (50%). On virtually all measures, the pilot study respondents seemed to be a “happier” group than the 750 neurosurgeons in the present study (which includes the 85 in the pilot study). For example, the neurosurgeons in the pilot study had a lower burnout rate (27% vs 57%), higher overall satisfaction (96% vs 81.2%), greater work/life balance (74% vs 48.1), and greater likelihood of choosing neurosurgery again as a career (88% vs 68.3%). While results of the present study are internally valid, the results may not be completely generalizable to surgeons who did not complete the survey. Nonetheless, we think that the 750 survey respondents in the current study are probably a more representative sample of US neurosurgeons than the 85 participants in the pilot study, and thus the full sample provides a more accurate assessment of burnout and job satisfaction.

Neurosurgeons are constantly asked to participate in various surveys, which leads to apathy or “survey fatigue,” making it difficult to conduct such studies. The results may not be applicable to neurosurgeons outside the US, although it is reasonable to assume that there is some degree of universality in terms of sources of stress and satisfaction among all neurosurgeons, regardless of practice location. As with any survey study, some of the questions may not have been clearly understood by all participants. For example, the divorce rate of the neurosurgeons sampled was only 9.1%. This is significantly lower than previously published rates, suggesting that miscommunication probably occurred at some level of survey administration.16,37 Shortening the survey was necessary to improve our response rate; however, doing so resulted in less information in comparison with that in the pilot study. Nonetheless, we believe that the shortened survey was able to capture the important aspects of a career that have direct relevance on satisfaction, stress, and burnout.

Future Studies

To safely and reliably provide for the needs of the increasing patient population in the US, it is essential that individual and organizational interventions be created to diminish the potency of potential stressors in all medical specialties that can lead to unhealthy levels of stress and burnout.29,41,42 Such programs could be tailored to practice types (for example, academic vs private vs hospital based) based on research that would further clarify predictors of job satisfaction and burnout. Some researchers have already begun work on programs to reduce stress and burnout.24,46 An intervention involving facilitated physician discussion groups around mindfulness, reflection, shared experience, and small-group learning has shown increased empowerment and engagement at work, decreased rates of depersonalization, and decreased overall burnout among participating physicians.46 Another intervention that offered an educational course on mindfulness meditation, self-awareness, and meaningful clinical narratives was shown to improve scores for mindfulness, burnout, depersonalization, personal accomplishment, and empathy.24 Finally, it would be interesting to repeat this study in the future to ascertain the full impact of health care reform.

Conclusions

Neurosurgery is a rewarding career choice, but there are many challenges and stressors that can lead to lower levels of satisfaction and dangerously increased levels of burnout. This may translate into negative medical experiences for surgeons, patients, and their families. Factors independently associated with burnout and career satisfaction were identified for all study participants, including academic and nonacademic neurosurgeons. Neurosurgeons desire intellectual and technical challenges and a positive balance between work and life. Uncertainty regarding future earnings and health care reform are major sources of discontent and burnout. We hope these results will generate discussion, raise awareness, stimulate further studies, and lead to programs designed to mitigate excessive stress and burnout within neurosurgery.

Acknowledgment

We thank Andrew J. Gienapp for technical and copy editing, preparation of the manuscript and figures for publishing, and publication assistance with this manuscript.

Author Contributions

Conception and design: Klimo, Ragel, McCartney, DeCuypere, Cheng, Boop. Acquisition of data: McCartney. Analysis and interpretation of data: Klimo. Drafting the article: Klimo, McAbee. Critically revising the article: Klimo, McAbee. Reviewed submitted version of manuscript: Klimo, McAbee, Jones, Michael, DeCuypere, Boop. Approved the final version of the manuscript on behalf of all authors: Klimo. Statistical analysis: Jones. Administrative/technical/material support: McCartney, Cheng. Study supervision: Klimo.

References

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    Balch CMFreischlag JAShanafelt TD: Stress and burnout among surgeons: understanding and managing the syndrome and avoiding the adverse consequences. Arch Surg 144:3713762009

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    Balch CMOreskovich MRDyrbye LNColaiano JMSatele DVSloan JA: Personal consequences of malpractice lawsuits on American surgeons. J Am Coll Surg 213:6576672011

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    Balch CMShanafelt TD: Burnout among surgeons: whether specialty makes a difference. Arch Surg 146:3853862011

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    Balch CMShanafelt TDDyrbye LSloan JARussell TRBechamps GJ: Surgeon distress as calibrated by hours worked and nights on call. J Am Coll Surg 211:6096192010

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    Balch CMShanafelt TDSloan JSatele DVKuerer HM: Burnout and career satisfaction among surgical oncologists compared with other surgical specialties. Ann Surg Oncol 18:16252011

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    Balch CMShanafelt TDSloan JASatele DVFreischlag JA: Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Ann Surg 254:5585682011

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    Bertges Yost WEshelman ARaoufi MAbouljoud MS: A national study of burnout among American transplant surgeons. Transplant Proc 37:139914012005

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    Bittner JG IVKhan ZBabu MHamed O: Stress, burnout, and maladaptive coping: strategies for surgeon well-being. Bull Am Coll Surg 96:17222011

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    Bressi CPorcellana MGambini OMadia LMuffatti RPeirone A: Burnout among psychiatrists in Milan: a multicenter survey. Psychiatr Serv 60:9859882009

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    Campbell DA JrSonnad SSEckhauser FECampbell KKGreenfield LJ: Burnout among American surgeons. Surgery 130:6967052001

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    Chen KYYang CMLien CHChiou HYLin MRChang HR: Burnout, job satisfaction, and medical malpractice among physicians. Int J Med Sci 10:147114782013

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    Cruz OAPole CJThomas SM: Burnout in chairs of academic departments of ophthalmology. Ophthalmology 114:235023552007

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    Deckard GJHicks LLHamory BH: The occurrence and distribution of burnout among infectious diseases physicians. J Infect Dis 165:2242281992

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    Dyrbye LNShanafelt TD: Physician burnout: a potential threat to successful health care reform. JAMA 305:200920102011

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    Dyrbye LNShanafelt TDBalch CMSatele DSloan JFreischlag J: Relationship between work-home conflicts and burnout among American surgeons: a comparison by sex. Arch Surg 146:2112172011

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    Dyrbye LNVarkey PBoone SLSatele DVSloan JAShanafelt TD: Physician satisfaction and burnout at different career stages. Mayo Clin Proc 88:135813672013

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    Dyrbye LNWest CPSatele DSloan JAShanafelt TD: Work/home conflict and burnout among academic internal medicine physicians. Arch Intern Med 171:120712092011

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    Firth-Cozens JGreenhalgh J: Doctors' perceptions of the links between stress and lowered clinical care. Soc Sci Med 44:101710221997

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    Haas JSCook EFPuopolo ALBurstin HRCleary PDBrennan TA: Is the professional satisfaction of general internists associated with patient satisfaction?. J Gen Intern Med 15:1221282000

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    Jones JWBarge BNSteffy BDFay LMKunz LKWuebker LJ: Stress and medical malpractice: organizational risk assessment and intervention. J Appl Psychol 73:7277351988

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    Kent GGJohnson AG: Conflicting demands in surgical practice. Ann R Coll Surg Engl 77:5 Suppl2352381995

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    Klimo P JrDeCuypere MRagel BTMcCartney SCouldwell WTBoop FA: Career satisfaction and burnout among U.S. neurosurgeons: a feasibility and pilot study. World Neurosurg 80:e59e682013

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    Krasner MSEpstein RMBeckman HSuchman ALChapman BMooney CJ: Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 302:128412932009

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    Kuerer HMEberlein TJPollock REHuschka MBaile WFMorrow M: Career satisfaction, practice patterns and burnout among surgical oncologists: report on the quality of life of members of the Society of Surgical Oncology. Ann Surg Oncol 14:304330532007

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    Kuhn GGoldberg RCompton S: Tolerance for uncertainty, burnout, and satisfaction with the career of emergency medicine. Ann Emerg Med 54:106113.e62009

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    Lim RCPinto C: Work stress, satisfaction and burnout in New Zealand radiologists: comparison of public hospital and private practice in New Zealand. J Med Imaging Radiat Oncol 53:1941992009

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    Linn LSBrook RHClark VADavies ARFink AKosecoff J: Physician and patient satisfaction as factors related to the organization of internal medicine group practices. Med Care 23:117111781985

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    Linzer M: Preventing burnout in academic medicine. Arch Intern Med 169:9279282009

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    Maslach CJackson SELeiter MP: Maslach Burnout Inventory Manual ed 3Palo Alto, CAConsulting Psychologists Press1996

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    Merlani PVerdon MBusinger ADomenighetti GPargger HRicou B: Burnout in ICU caregivers: a multicenter study of factors associated to centers. Am J Respir Crit Care Med 184:114011462011

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    Profit JSharek PJAmspoker ABKowalkowski MANisbet CCThomas EJ: Burnout in the NICU setting and its relation to safety culture. BMJ Qual Saf 23:8068132014

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    Sargent MCSotile WSotile MORubash HBarrack RL: Quality of life during orthopaedic training and academic practice. Part 1: orthopaedic surgery residents and faculty. J Bone Joint Surg Am 91:239524052009

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    Shanafelt TDyrbye L: Oncologist burnout: causes, consequences, and responses. J Clin Oncol 30:123512412012

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    Shanafelt TDBalch CMBechamps GRussell TDyrbye LSatele D: Burnout and medical errors among American surgeons. Ann Surg 251:99510002010

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    Shanafelt TDBalch CMBechamps GJRussell TDyrbye LSatele D: Burnout and career satisfaction among American surgeons. Ann Surg 250:4634712009

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    Shanafelt TDBoone STan LDyrbye LNSotile WSatele D: Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 172:137713852012

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    Shanafelt TDBradley KAWipf JEBack AL: Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 136:3583672002

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    Shanafelt TDGradishar WJKosty MSatele DChew HHorn L: Burnout and career satisfaction among US oncologists. J Clin Oncol 32:6786862014

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Neurosurgeon Career and Lifestyle Satisfaction Survey

Section 1: Demographic Questions

QuestionSurvey Response CategoriesCategories Analyzed*
What is your age (years)?<40

41–45
<46
 46–50

51–55
46–55
 56–60

61–65

>65
>55
What is your gender?Male

Female
No change
What is your marital status?MarriedCurrently married or in a stable relationship
 Stable partner 
 Divorced and remarried 
 Separated

Divorced

Single
Currently single
What is your practice type?Group

University

Private with academic affiliation

Solo
No change
 Health management organization

VA/government hospital

City/county hospital

Other
Other
How many years have you been in practice?<5

5–10
≤10
 11–15

16–20
11–20
 21–25

>25
>20
Have you received formal subspecialty training?None

Cerebrovascular

Functional/stereotactic Pediatrics

Spine

Skull base
No change
 Endovascular

Neurotrauma

Other
Other
On average, how many hours do you work per week?<30

30–40

41–50

51–60

61–70
≤70
 71–80

>80
>70
How many days of call do you take per month?<3

3–5

6–10
<10
 >10No change
On average, how many operative cases do you perform annually?<100

100–150

151–200

201–250

251–300
≤300
 301–350

350–400

>400
>300
Over the last 5 years, how many times have you been named in a mal-practice lawsuit?NoneNo change
 1–5At least once

VA = Veterans Affairs.

Survey response categories were combined into categories for the purposes of statistical analysis based on previously published literature and the number of responses by persons completing the survey. All categories were determined prior to completion of any statistical analysis.

Section 2: Professional Stressors

QuestionTo what extent have the following factors affected you in your practice over the last 12–24 months?
FactorsToo much callSexual harassment
 Inadequate research timeMalpractice issues
 Inadequate administration timeToo many cases
 Inadequate teaching timeToo few cases
 Low salary/incomeToo little vacation time
 Chairman's/Senior Partner's demandsSurgery-related complications
 Hostile or difficult work environmentLoss of coworker/faculty
 Tenure/promotion issuesUncertainty of future earnings/health care reform*
AnswersNot at all Small amountLarge amount Extreme amount
 Moderate amountNot applicable

Respondents selecting “large amount” or “extreme amount” were classified on a dichotomous scale as having the factor of interest (yes) for the purposes of statistical analysis.

Section 3: Professional Satisfaction

QuestionIn relation to your practice, how satisfied are you with the factors listed below?
FactorsOverall career as a neurosurgeon*Intellectually challenged at work*
 Balance between professional and personal life*Neurosurgical colleagues
 Meeting your career expectations/goalsLocation of practice
 Time for personal growth/development*Salary/income
AnswersVery satisfied Somewhat satisfied NeutralSomewhat dissatisfied Very dissatisfied Not applicable

Respondents selecting “very satisfied” or “somewhat satisfied” were classified on a dichotomous scale as having the factor of interest (yes) for the purposes of statistical analysis.

Section 4: Quality of Life

QuestionPlease respond to the following statements below:
FactorsMy spouse/partner understands when I have to work extra hoursMy practice should improve its reimbursement
 My practice should minimize emergency callMy practice should work harder to diminish litigation
 My practice has an unfair call scheduleI would recommend neurosurgery to my child as a career
 My practice/program should increase the number of residents/physician extenders
AnswersStrongly agree Agree NeutralDisagree Strongly disagree Not applicable

Section 5: Maslach Burnout Inventory*

QuestionHow often do you experience the following?
Factors1. I feel emotionally drained from my work
 2. I feel used up at the end of the day
 3. I feel fatigued when I get up in the morning to face another workday
AnswersNever

Few times a year

Monthly

Few times a month
Weekly

Few times a week

Daily

Sample of first 3 questions; the inventory consists of 22 questions total.

Section 6: General Questions

QuestionAnswer
If you were a 4th year medical student, would you still choose to pursue neurosurgery as a career?Yes

No
How likely do you feel that your professional life will improve?*Likely

Somewhat likely

Not sure

Somewhat unlikely

Unlikely
How likely do you feel that your professional life will worsen?*Likely

Somewhat likely

Not sure

Somewhat unlikely

Unlikely
Please provide the most rewarding aspect of your career.Written answer
Please provide the most frustrating aspect of your career.Written answer

Respondents selecting “likely” or “somewhat likely” were classified on a dichotomous scale as having the factor of interest (yes) for the purposes of statistical analysis.

Article Information

Correspondence Paul Klimo Jr., Department of Neurosurgery, Le Bonheur Children's Hospital, 50 N. Dunlap St., Memphis, TN 38103. email: pklimo@semmes-murphey.com.

INCLUDE WHEN CITING Published online February 13, 2015; DOI: 10.3171/2014.12.JNS141348.

DISCLOSURE The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law."

Headings

Figures

References

1

Balch CMCopeland E: Stress and burnout among surgical oncologists: a call for personal wellness and a supportive workplace environment. Ann Surg Oncol 14:302930322007

2

Balch CMFreischlag JAShanafelt TD: Stress and burnout among surgeons: understanding and managing the syndrome and avoiding the adverse consequences. Arch Surg 144:3713762009

3

Balch CMOreskovich MRDyrbye LNColaiano JMSatele DVSloan JA: Personal consequences of malpractice lawsuits on American surgeons. J Am Coll Surg 213:6576672011

4

Balch CMShanafelt TD: Burnout among surgeons: whether specialty makes a difference. Arch Surg 146:3853862011

5

Balch CMShanafelt TDDyrbye LSloan JARussell TRBechamps GJ: Surgeon distress as calibrated by hours worked and nights on call. J Am Coll Surg 211:6096192010

6

Balch CMShanafelt TDSloan JSatele DVKuerer HM: Burnout and career satisfaction among surgical oncologists compared with other surgical specialties. Ann Surg Oncol 18:16252011

7

Balch CMShanafelt TDSloan JASatele DVFreischlag JA: Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Ann Surg 254:5585682011

8

Bertges Yost WEshelman ARaoufi MAbouljoud MS: A national study of burnout among American transplant surgeons. Transplant Proc 37:139914012005

9

Bittner JG IVKhan ZBabu MHamed O: Stress, burnout, and maladaptive coping: strategies for surgeon well-being. Bull Am Coll Surg 96:17222011

10

Bressi CPorcellana MGambini OMadia LMuffatti RPeirone A: Burnout among psychiatrists in Milan: a multicenter survey. Psychiatr Serv 60:9859882009

11

Campbell DA JrSonnad SSEckhauser FECampbell KKGreenfield LJ: Burnout among American surgeons. Surgery 130:6967052001

12

Chen KYYang CMLien CHChiou HYLin MRChang HR: Burnout, job satisfaction, and medical malpractice among physicians. Int J Med Sci 10:147114782013

13

Cruz OAPole CJThomas SM: Burnout in chairs of academic departments of ophthalmology. Ophthalmology 114:235023552007

14

Deckard GJHicks LLHamory BH: The occurrence and distribution of burnout among infectious diseases physicians. J Infect Dis 165:2242281992

15

Dyrbye LNShanafelt TD: Physician burnout: a potential threat to successful health care reform. JAMA 305:200920102011

16

Dyrbye LNShanafelt TDBalch CMSatele DSloan JFreischlag J: Relationship between work-home conflicts and burnout among American surgeons: a comparison by sex. Arch Surg 146:2112172011

17

Dyrbye LNVarkey PBoone SLSatele DVSloan JAShanafelt TD: Physician satisfaction and burnout at different career stages. Mayo Clin Proc 88:135813672013

18

Dyrbye LNWest CPSatele DSloan JAShanafelt TD: Work/home conflict and burnout among academic internal medicine physicians. Arch Intern Med 171:120712092011

19

Firth-Cozens JGreenhalgh J: Doctors' perceptions of the links between stress and lowered clinical care. Soc Sci Med 44:101710221997

20

Haas JSCook EFPuopolo ALBurstin HRCleary PDBrennan TA: Is the professional satisfaction of general internists associated with patient satisfaction?. J Gen Intern Med 15:1221282000

21

Jones JWBarge BNSteffy BDFay LMKunz LKWuebker LJ: Stress and medical malpractice: organizational risk assessment and intervention. J Appl Psychol 73:7277351988

22

Kent GGJohnson AG: Conflicting demands in surgical practice. Ann R Coll Surg Engl 77:5 Suppl2352381995

23

Klimo P JrDeCuypere MRagel BTMcCartney SCouldwell WTBoop FA: Career satisfaction and burnout among U.S. neurosurgeons: a feasibility and pilot study. World Neurosurg 80:e59e682013

24

Krasner MSEpstein RMBeckman HSuchman ALChapman BMooney CJ: Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 302:128412932009

25

Kuerer HMEberlein TJPollock REHuschka MBaile WFMorrow M: Career satisfaction, practice patterns and burnout among surgical oncologists: report on the quality of life of members of the Society of Surgical Oncology. Ann Surg Oncol 14:304330532007

26

Kuhn GGoldberg RCompton S: Tolerance for uncertainty, burnout, and satisfaction with the career of emergency medicine. Ann Emerg Med 54:106113.e62009

27

Lim RCPinto C: Work stress, satisfaction and burnout in New Zealand radiologists: comparison of public hospital and private practice in New Zealand. J Med Imaging Radiat Oncol 53:1941992009

28

Linn LSBrook RHClark VADavies ARFink AKosecoff J: Physician and patient satisfaction as factors related to the organization of internal medicine group practices. Med Care 23:117111781985

29

Linzer M: Preventing burnout in academic medicine. Arch Intern Med 169:9279282009

30

Maslach CJackson SELeiter MP: Maslach Burnout Inventory Manual ed 3Palo Alto, CAConsulting Psychologists Press1996

31

Merlani PVerdon MBusinger ADomenighetti GPargger HRicou B: Burnout in ICU caregivers: a multicenter study of factors associated to centers. Am J Respir Crit Care Med 184:114011462011

32

Profit JSharek PJAmspoker ABKowalkowski MANisbet CCThomas EJ: Burnout in the NICU setting and its relation to safety culture. BMJ Qual Saf 23:8068132014

33

Sargent MCSotile WSotile MORubash HBarrack RL: Quality of life during orthopaedic training and academic practice. Part 1: orthopaedic surgery residents and faculty. J Bone Joint Surg Am 91:239524052009

34

Shanafelt TDyrbye L: Oncologist burnout: causes, consequences, and responses. J Clin Oncol 30:123512412012

35

Shanafelt TSloan JSatele DBalch C: Why do surgeons consider leaving practice?. J Am Coll Surg 212:4214222011

36

Shanafelt TDBalch CMBechamps GRussell TDyrbye LSatele D: Burnout and medical errors among American surgeons. Ann Surg 251:99510002010

37

Shanafelt TDBalch CMBechamps GJRussell TDyrbye LSatele D: Burnout and career satisfaction among American surgeons. Ann Surg 250:4634712009

38

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