Plastic Surgeons’ Satisfaction with Work–Life
Balance: Results from a National Survey
Rachel Streu, M.D., M.S. Mary H. McGrath, M.D., M.P.H. Ashley Gay, B.A. Barbara Salem, M.S.W., M.S. Paul Abrahamse, M.S. Amy K. Alderman, M.D., M.P.H. Ann Arbor, Mich.; and San Francisco, Calif.
Background: Plastic surgery demographics are transforming, with a greater proportion of women and younger physicians who desire balance between their career and personal lives compared with previous generations. The authors’ purpose was to describe the patterns and correlates of satisfaction with work–life balance among U.S. plastic surgeons.
Methods: A self-administered survey was mailed to a random sample of Amer-ican Society of Plastic Surgeons members (n⫽ 708; 71 percent response rate). The primary outcome was satisfaction with work–life balance. Independent variables consisted of surgeon sociodemographic and professional characteris-tics. Logistic regression was used to evaluate correlates of satisfaction with work–life balance.
Results: Overall, over three-fourths of respondents were satisfied with their career; however, only half were satisfied with their time management between career and personal responsibilities. Factors independently associated with diminished satisfaction with work–life balance were being female (odds ratio⫽ 0.63; 95 percent CI, 0.42 to 0.95), working more than 60 hours per week (versus⬍ 60 hours per week; odds ratio ⫽ 0.44; 95 percent CI, 0.28 to 0.72), having emergency room call responsibilities (versus no emergency room call, odds ratio⫽ 0.42; 95 percent CI, 0.27 to 0.67), and having a primarily recon-structive practice (versus primarily aesthetic practice; odds ratio ⫽ 0.53; 95 percent CI, 0.30 to 0.93).
Conclusions: While generational differences were minimal, surgeons who were female, worked longer hours, and had emergency room call responsibilities and primarily reconstructive practices were significantly less satisfied with their work–life balance. (Plast. Reconstr. Surg. 127: 1713, 2011.)
T
he face of the plastic surgery workforce is changing. More women are entering this sur-gical field than ever before. Over the past 20 years, the percentage of female physicians in all specialties has risen from 11.6 to 27.8 percent.1Women consist of half of all students currently enrolled in U.S. medical schools,2 make up over
one-third of the first-year resident complement in general surgery,3and account for one-quarter of
first-year residents in plastic surgery.4In addition,
a generational shift is occurring with the emer-gence of Generation X and Y into the physician workforce. These younger generational groups (born from the 1960s to the early 1990s) com-pared with their baby boomer predecessors have notably shifted their priorities toward family and work–life balance.5,6
Work–life balance is described as the per-ceived sufficiency of time available for work and social life.7Little is known about the impact of the
above demographic changes on satisfaction with work–life balance among plastic surgeons. To un-derstand these workforce changes, both academic medical and surgical specialties are paying more attention to the factors that influence physicians’
From the Section of Plastic Surgery, Department of Surgery, The University of Michigan Medical Center; Department of General Surgery, St. Joseph Mercy Hospital; Department of Plastic and Reconstructive Surgery, University of California, San Francisco; and Division of General Medicine, Depart-ment of Internal Medicine, University of Michigan. Received for publication February 13, 2010; accepted August 4, 2010.
Presented at the American College of Surgeons Clinical Con-gress, in Chicago, Illinois, October 15, 2009.
Copyright ©2011 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e318208d1b3
Disclosure: The authors have no financial interest
abilities to successfully balance careers with family responsibilities.8 –10 Female physicians are
partic-ularly vulnerable, as they are more likely to uphold the societal role of wife and mother and are more likely to shoulder the majority of child-rearing responsibilities.11–15 Likewise, younger physicians
tend to value the balance between personal and professional responsibilities more than older generations.5,6 This younger cohort of physicians
is also being educated in a dramatically different training environment that mandates a more bal-anced lifestyle through strongly regulated work-hour restrictions.16 It is unclear how these
physi-cians will adapt after residency once they enter a demanding surgical practice with unregulated work hours.
Our purpose was to describe satisfaction with work–life balance among a national sample of plastic surgeons. In particular, we evaluated the association between surgeons’ personal character-istics (such as age and gender) and professional characteristics (such as practice mix, work hours, and call responsibilities) with surgeons’ satisfac-tion with work–life balance.
METHODS
Study Population and Data Collection
A written, self-administered survey was sent to a national sample of plastic surgeons in the United States to evaluate satisfaction with work–life bal-ance. The study sample was selected from a ran-dom sample of members from the American So-ciety of Plastic Surgeons (708 total; 354 men and 354 women). Sampling was not based on age or geographical region. Women, however, were over-sampled to provide an equal gender distribution of respondents. We estimated that a sample size of 200 for both men and women would provide ad-equate power to avoid type 2 error and allow us to detect small differences in physicians’ satisfaction. Surgeons were mailed an anonymous survey con-taining a $10 cash incentive gift, which is a stan-dard survey technique to improve response rates.17,18 We used the Dillman method to
maxi-mize response rates, which involved mailing non-responders a reminder letter and questionnaire within 4 weeks of initial contact.19,20Follow-up
let-ters were sent to responders with missing ques-tions to improve the completeness of the data set. The response rate was 71 percent (n⫽ 505) and included 250 male and 255 female sur-geons. The study protocol was reviewed and ap-proved by the Institutional Review Board of the University of Michigan.
Measures
The surgeon questionnaire was developed based on a conceptual model. The primary out-come was surgeon satisfaction with work–life bal-ance. A satisfaction scale was developed from the following items: (1) I have too much work to do everything well, (2) I am satisfied with my career, and (3) I am satisfied with my time management between career and personal responsibilities. The first item was derived from the General Social Survey questionnaire.21The other two items were
designed by the authors to further assess satisfac-tion with work–life balance. Each item used a five-point Likert response, ranging from 1 (highly dis-satisfied) to 5 (highly dis-satisfied). For analytical purposes, responses were dichotomized into sat-isfied (4 or 5) versus dissatsat-isfied (1, 2, or 3). Ap-plying different categorizations did not alter the results significantly.
The independent variables included (1) sur-geon characteristics (age, gender, marital status, employment of spouse, number of children, and childrearing responsibilities) and (2) professional characteristics (practice mix, practice size, resi-dent teaching responsibility, and professional time commitments). Surgeon age was categorized into four groups: less than 40, 41 to 50, 51 to 60, and more than 60 years. Surgeon gender was a two-level categorical variable. Marital status was grouped as married/partnered, single– divorced, and single–never married. Full-time employment of a spouse was dichotomized into yes versus no. Number of children was categorized into four groups: none, 1, 2 to 3, and more than 3. Surgeon age at the birth of their first child was a continuous variable described in years. Level of training at the birth of the surgeon’s first child was categorized into three groups: before training, during train-ing, and after training completed. Primary care-giver of child was dichotomized into yes versus no. Practice mix was categorized by the percentage of aesthetic cases a surgeon performed, for which less than 25 percent was considered “primarily reconstructive,” 25 to 75 percent was considered “mixed practice,” and more than 75 percent was considered “primarily aesthetic.” Practice size was dichotomized into solo versus group with two or more physicians. Participation in resident training was dichotomized: yes versus no. Emergency room call was dichotomized into none versus one or more calls per month. Work hours were dichoto-mized into 60 or fewer versus more than 60 hours per week.
Analysis
Descriptive
We first described the distribution of our sam-ple by surgeon gender and surgeon age across all independent variables. We also described the fam-ily characteristics of the sample by surgeon gen-der. Pearson chi-square was used for the bivariate analyses for the comparisons between categorical variables, and Student t tests were used for analyses of continuous variables.
Multivariate Regression
We then performed a multivariate logistic re-gression to evaluate factors associated with satis-faction with work–life balance among plastic sur-geons. Variables related to child responsibilities were excluded from the final regression model because a large proportion of the sample did not have children. The Wald test and the likelihood ratio test were used to test the significance of in-dividual predictive variables, and the model chi-square statistic was applied to test the overall significance of the model. All analyses were per-formed with STATA version 8.0 (College Station, Texas).
RESULTS
Table 1 describes personal and professional characteristics of the study sample by surgeon gen-der. Our sample consisted of a slightly older fe-male population, as only 43 percent of fefe-male surgeons were less than 50 years of age compared with 57 percent of men (p ⬍ 0.001). Compared with their male colleagues, female plastic surgeons were more likely to have been divorced (8 versus 14 percent, respectively) or never married (2 ver-sus 13 percent, respectively; p ⬍ 0.001). There were no significant differences in operative case mix and practice size by surgeon gender. Male compared with female surgeons, however, were more likely to work more than 60 hours per week (26 versus 19 percent, respectively, p ⫽ 0.051), take emergency room calls (72 versus 60 percent, respectively, p ⫽ 0.004), and participate in resi-dent education (36 versus 25 percent, p ⫽ 0.01). Figure 1 displays the family characteristics of the surgeon sample. One-third of female plastic surgeons indicated that they had no children ver-sus only 7 percent of male plastic surgeons (p ⬍ 0.001). Of those with children, male surgeons were more likely to have two or more children compared with female surgeons (81 versus 58 per-cent, respectively; p ⬍ 0.001). Female surgeons appeared to be more likely to delay having chil-dren. Seventy-one percent of male surgeons
indi-cated that their first child was born before or dur-ing their surgical traindur-ing years compared with 46 percent of female surgeons (p ⬍ 0.001). For the entire study sample, 81 percent of plastic surgeons were married with children, but only 15 percent of respondents indicated that they were the primary caregiver to their child(ren). Female surgeons were more likely to indicate that they were their child(ren)’s primary caregiver compared with their male counterparts (25 versus 5 percent, re-spectively, p ⬍ 0.001). In addition, female sur-geons who were married were more likely to be married to a spouse who worked full time, as com-pared with their male colleagues (74 versus 29 percent, respectively; p⬍ 0.001).
Table 2 describes the sample population by surgeon age. The younger surgeons (ⱕ50 years) compared with the older cohort (⬎50 years) had a significantly larger proportion of men (57 versus 42 percent, respectively; p ⫽ 0.001), were more likely to be in a group practice (50 versus 37 per-cent, respectively; p⫽ 0.002), and were more likely to take emergency room call (74 versus 58 percent, respectively, p⬍ 0.001). There were no significant differences between the two age groups with re-gard to marital status, practice mix, participation in resident education, or work hours per week. Table 1. Sample Characteristics by Surgeon Gender
Men (nⴝ 250) No. (%)* Women (nⴝ 255) No. (%)* p Personal characteristics Age ⬍0.001 ⬍40 years 25 (10.1) 7 (2.8) 41–50 years 117 (47.2) 101 (40.0) 51–60 years 95 (38.3) 124 (49.0) ⬎60 years 11 (4.4) 8 (8.3) Marital status ⬍0.001 Married/partnered 227 (90.8) 184 (72.4) Single–divorced 19 (7.6) 36 (14.2) Single–never married 4 (1.6) 34 (13.4) Professional characteristics Practice mix 0.370 Primarily aesthetic 68 (27.4) 84 (33.2) Mixed 111 (44.8) 105 (41.5) Primarily reconstructive 69 (27.8) 64 (25.3) Practice size 0.770 Solo 143 (57.2) 142 (56.0) Group (ⱖ2) 107 (42.8) 112 (44.1) Participate in training residents 0.010 Yes 88 (35.6) 63 (25.0)
Emergency room call
days/month 0.004 None 70 (28.0) 102 (40.3) ⱖ1 180 (72.0) 150 (59.7) Work hours/week 0.051 ⱕ60 182 (74.0) 204 (81.3) ⬎60 64 (26.0) 47 (18.7) *Column percentage.
Overall, 29.8 percent of all respondents were satisfied with their career; however, 80.9 percent felt that they had too much work to do everything well, and only 52 percent were satisfied with their
time management between career and personal responsibilities. Table 3 shows the independent association of covariates of plastic surgeons’ satis-faction with work–life balance. The results are re-Fig. 1. The family characteristics of the surgeon sample.
Table 2. Sample Characteristics by Surgeon Age
Generation X/Y (Age <50 years; nⴝ 250) No. (%)* Baby Boomers (Age >50 years; nⴝ 238) No. (%)* p Personal characteristics Gender 0.001 Male 142 (56.8) 106 (42.2) Female 108 (43.2) 145 (57.8) Marital status 0.287 Married/partnered 208 (83.5) 201 (80.1) Single–divorced 21 (8.4) 32 (12.8) Single–never married 20 (8.0) 18 (7.2) Professional characteristics Practice mix 0.108 Primarily aesthetic 70 (28.1) 80 (32.3) Mixed 102 (41.0) 112 (45.2) Primarily reconstructive 77 (30.9) 56 (22.6) Practice size 0.002 Solo 124 (49.6) 158 (63.2) Group (ⱖ2) 126 (50.4) 92 (36.8) Participate in training residents
Yes 76 (30.7) 73 (29.6) 0.791 Emergency call days/month ⬍0.001
None 66 (26.4) 104 (41.8) ⱖ1 184 (73.6) 145 (58.2) Work hours/week 0.113 ⱕ60 183 (74.7) 200 (80.7) ⬎60 62 (25.3) 48 (19.4) *Column percentage.
ported using odds ratios and associated 95 percent confidence intervals. The odds ratio measures the odds of being satisfied for the indicated category relative to the reference group. Odds ratios less than 1.0 are considered to be associated with di-minished satisfaction with work–life balance and those greater than 1.0 are associated with in-creased satisfaction with work–life balance. Fac-tors independently associated with diminished sat-isfaction with work–life balance were being female (odds ratio ⫽ 0.63, 95 percent CI, 0.42 to 0.95), working more than 60 hours per week (versusⱕ60 hours per week, odds ratio⫽ 0.44, 95 percent CI, 0.28 to 0.72), and having emergency room call re-sponsibilities (versus no emergency room call, odds ratio⫽ 0.42, 95 percent CI, 0.27 to 0.67). In ad-dition, having a primarily reconstructive practice (i.e., less than 25 percent aesthetic surgery) was associated with lower satisfaction with work–life balance (versus primarily aesthetic practice mix, odds ratio ⫽ 0.53, 95 percent CI, 0.30 to 0.93). Surgeon age, marital status, size of practice and
involvement in resident education did not con-tribute to plastic surgeon satisfaction with work– life balance.
DISCUSSION
In this national survey, we did not find satis-faction with work–life balance to vary significantly with surgeon age. Plastic surgeons under the age of 50 (from Generation X/Y) work a similar num-ber of hours per week as those over the age of 50 (from the baby boomer generation). This is con-sistent when compared with a recent study by Rohrich et al. that addressed work hours per week in plastic surgeons over age 50.22 Younger
sur-geons, however, take more emergency room calls and have proportionally more physicians in group practice compared with solo practice. We did, however, find a very significant association be-tween surgeon gender and satisfaction with work– life balance. Female plastic surgeons report sig-nificantly less favorably about the competing requirements of career and personal life. Other factors associated with surgeons having less satis-faction with work–life balance included practicing primarily reconstructive surgery, working more than 60 hours/week, and having emergency room call responsibilities.
We can only speculate why female compared with male plastic surgeons struggle more with a balance between work and personal responsibili-ties. This study, along with others,11–15 indicates
that female surgeons assume more of the family responsibilities compared with their male col-leagues. Female surgeons are more likely to report being their children’s primary care provider. A striking finding is that three-fourths of the spouses of women plastic surgeons work full time whereas less than one-third of the spouses of male surgeons are employed full-time. This means that outside help for childcare is required in a far larger pro-portion of families in which the woman is a sur-geon. The dual-career burden of work and home, and the perception that one cannot perform ei-ther as expertly as if both were not present, might negatively affect these surgeons’ satisfaction with their ability to maintain balance in their lives. Our previous work has shown that satisfaction with the decision to become a plastic surgeon does not vary by surgeon gender.23Thus, female surgeons are
satisfied with their choice of profession. The pres-ent study shows something additional, namely, that they struggle with the integration of their chosen profession and personal lives.
Family structure varies significantly by surgeon gender. Female plastic surgeons are more likely to Table 3. Correlates of Plastic Surgeon Satisfaction
with Work–Life Balance
Satisfaction with Work–Life Balance Adjusted Odds Ratio 95% CI Personal characteristics Gender Male 1 — Female 0.63 0.42–0.95 Age ⬍40 years 1 — 41–50 years 1.14 0.51–2.53 51–60 years 1.26 0.56–2.85 ⬎60 years 1.70 0.53–5.43 Marital status Single–never married 1 — Single–divorced 0.59 0.23–1.50 Married/partnered 0.55 0.25–1.18 Professional characteristics Case mix Primarily aesthetic 1 — Mixed 0.75 0.46–1.21 Primarily reconstructive 0.53 0.30–0.93 Practice size Solo 1 — Group 0.97 0.64–1.47 Participate in training residents No resident training 1 — Resident training 1.39 0.88–2.19 Emergency room call
days/month None 1 — ⱖ1 0.42 0.27–0.67 Work hours/week ⱕ60 1 — ⬎60 0.44 0.28–0.72
be single or divorced, are more likely to delay childbearing, and are more likely to have fewer children compared with their male colleagues. It is unclear whether the differences in family struc-ture (i.e., marital and parental status) by surgeon gender is a result of surgeon preferences or if female surgeons face more barriers to developing their personal lives compared with their male col-leagues. This difference in family structure by sur-geon gender appears to be long-standing. Over a decade ago, Capek et al. found female plastic sur-geons to be less likely to be married and, if mar-ried, more likely to have no children or fewer children compared with their male colleagues.24
Interestingly, professional and practice character-istics did not differ by surgeon gender in Capek’s study; this is unlike our findings that women work fewer hours per week, take fewer emergency room calls, and participate less in training residents. It is possible that this change in practice by female sur-geons over the past 10 years is a reflection of their effort to try to achieve better work–life balance. Un-fortunately, it appears that these changes in practice have not been sufficient to mitigate women’s per-ception of their ability to balance the pressures of clinical practice with family responsibilities.
Reconstructive surgeons appear to be strug-gling with their satisfaction with work–life balance. Our previous work found reconstructive surgeons to have diminished satisfaction with their career choice,23and the additional data from this study
suggest that reconstructive surgeons also struggle with finding balance between personal and pro-fessional responsibilities. Several factors may be responsible for these outcomes. Reconstructive surgery can be disruptive to a surgeon’s schedule due to the time urgency associated with many reconstructive cases, the complexity of coordinat-ing care with other surgeons, and the long oper-ative times often associated with these complex procedures. In addition, these patients frequently require intensive postoperative monitoring and are at a higher risk for developing postoperative complications compared with elective aesthetic surgeries. This association between satisfaction with work–life balance and a surgeon’s control over work hours and weekly schedule has been well-documented in other surgical fields.10,25
Limitations
Our findings should be interpreted in the con-text of some limitations. Our analyses may be sub-ject to a nonresponse bias. However, given our high response rate for a physician survey (71
per-cent), we believe that our sample was highly rep-resentative of the national population of U.S. plas-tic surgeons. Also, our data were derived from self-report and were subject to respondent recall and interpretation biases. We have no reason to suspect, however, that these potential biases would vary by surgeon gender and practice type. Lastly, our study was performed during a unique economic climate in the United States, which may have influenced re-sponses. The economic recession may have dimin-ished the clinical demand of some surgeons and potentially dampened the magnitude of work–life imbalance reported by surgeons.
Implications
Surgeons’ ability to successfully balance work and personal responsibilities has important impli-cations for the plastic surgeon workforce and qual-ity of care. Diminished work–life balance is highly correlated with professional burnout.26 –28
Further-more, physicians who score high on professional burnout measures are at risk of delivering poor-quality patient care.29 –31
Our study suggests that female plastic sur-geons and reconstructive sursur-geons are at greater risk for diminished satisfaction with work–life bal-ance. Efforts should focus on specific mechanisms that facilitate these surgeons’ ability to reconcile the competing demands of work and family. The challenge is not unique to the practice of plastic surgery, and the solutions will need to address lifestyle issues at various points in a surgeon’s life. During surgical training, flexible parental leave policies would facilitate pregnancy among female surgical residents and potentially diminish infer-tility and obstetrical complications due to ad-vanced maternal age.3,32–34 Innovative job-sharing
opportunities during and after training may facil-itate work–life balance and be desirable to both male and female surgeons. Professional families would also greatly benefit from on-site hospital-sponsored day care with extended operating hours that correspond to surgical work-hours. In regard to practice structure, reconstructive sur-geons may benefit from creating larger group practices that are better able to distribute clinical and on-call responsibilities.
SUMMARY
Future efforts must be directed at continued monitoring of plastic surgeons’ satisfaction with work–life balance. The struggle of balance be-tween work and family, however, is not an isolated problem within plastic surgery. We must develop
global strategies and collaborative efforts to assist all physicians in the struggle to achieve balance between a demanding profession and personal responsibilities.
Amy K. Alderman, M.D., M.P.H.
Plastic and Reconstructive Surgery University of Michigan 2130 Taubman Center 1500 East Medical Center Drive Ann Arbor, Mich. 48109-0340 [email protected]
REFERENCES
1. American Medical Association. Physician characteristics and distribution in the U.S. 2008. Available at: http://www.ama- assn.org.proxy.lib.umich.edu/ama/pub/about-ama/our-people/member-groups-sections/women-physicians-congress/ statistics-history/table-1-physicians-gender-excludes-students. shtml. Accessed March 2009.
2. Association of American Medical Colleges (AAMC). Women in academic medicine statistics and medical school benchmarking 2004 –2005. Available at: http://www.ama-assn.org.proxy.lib. umich.edu/ama/pub/about-ama/our-people/member-groups-sections/women-physicians-congress/statistics-history/ table-2-women-medical-school-applicants.shtml. Accessed March 2009.
3. Frangou C. Critical mass: With stakes high, women may as-sume crucial role in surgery’s future. Gen Surg News 2008; 35:1–12.
4. American Society of Plastic Surgeons Administrative Offices. Personal communication; November 2009.
5. Moody J. Recruiting generation X physicians. N Engl J Med. 2002. Accessed September 2002.
6. Jovic E, Wallace JE, Lemaire J. The generation and gender shifts in medicine: An exploratory survey of internal medi-cine physicians. BMC Health Serv Res. 2006;6:55. Available at: http://www.biomedcentral.com/1472-6963/6/55. Accessed November 10, 2009.
7. Gropel P, Kuhl J. Work–life balance and subjective well-being: the mediating role of need fulfilment. Br J Psychol. 2009;100(Pt. 2):365–375.
8. Quinlan RM. Gender and the surgical workforce. Arch Surg. 2007;142:321–328.
9. Levinson W, Tolle SW, Lewis C. Women in academic med-icine: Combining career and family. N Engl J Med. 1989;321: 1511–1157.
10. Troppmann KM, Palis BE, Goodnight JE, Ho HS, Trop-pmann C. Career and lifestyle satisfaction among surgeons: What really matters? The National Lifestyles in Surgery To-day Survey. J Am Coll Surg. 2009;209:160–169.
11. Yutzie JD, Shellito JL, Helmer SD, Chang FC. Gender dif-ferences in general surgical careers: Results of a post-resi-dency survey. Am J Surg. 2005;190:955–959.
12. Carr PL, Gareis KC, Barnett RC. Characteristics and out-comes for women physicians who work reduced hours. J
Wo-mens Health (Larchmt). 2003;12:399–405.
13. McMurray JE, Linzer M, Konrad TR, Douglas J, Shugerman R, Nelson K. The work lives of women physicians results from
the physician work life study: The SGIM Career Satisfaction Study Group. J Gen Intern Med. 2000;15:372–380.
14. Barnett RC, Gareis KC, Carr PL. Career satisfaction and retention of a sample of women physicians who work re-duced hours. J Womens Health (Larchmt). 2005;14:146–153. 15. Grandis JR, Gooding WE, Zamboni BA, et al. The gender gap
in a surgical subspecialty: Analysis of career and lifestyle factors. Arch Otolaryngol Head Neck Surg. 2004;130:695–702. 16. Accreditation Council for Graduate Medical Education.
Res-ident duty hours in the learning and working environment. Available at: http://www.acgme.org/acWebsite/dutyHours/ dh_ComProgrRequirmentsDutyHours0707.pdf. Accessed May 2009.
17. Bourque L. How to Conduct Self-Administered and Mail Surveys. London: Sage; 1995.
18. Cummings SM, Savitz LA, Konrad TR. Reported response rates to mailed physician questionnaires. Health Serv Res. 2001;35:1347–1355.
19. Dillman D. Mail and Telephone Surveys. New York: Wiley; 1978. 20. Anema MG, Brown BE. Increasing survey responses using the total design method. J Contin Educ Nurs. 1995;26:109–114. 21. University of Chicago. General social survey. Available at: www.
norc.uchicago.edu/projects/gensoc.asp. Accessed November 10, 2009.
22. Rohrich RJ, McGrath MH, Lawrence TW. Plastic surgeons over 50: Practice patterns, satisfaction, and retirement plans. Plast
Reconstr Surg. 2008;121:1458–1474; discussion 1475–1477.
23. Streu RHS, Gay A, Salem B, Alderman AK. Satisfaction with career choice among U.S. plastic surgeons: Results from a national survey. Plast Reconstr Surg. 2009;126:636–642. 24. Capek L, Edwards DE, Mackinnon SE. Plastic surgeons: A
gender comparison. Plast Reconstr Surg. 1997;99:289–299. 25. Keeton K, Fenner DE, Johnson TR, Hayward RA. Predictors
of physician career satisfaction, work–life balance, and burn-out. Obstet Gynecol. 2007;109:949–955.
26. Bertges Yost W, Eshelman A, Raoufi M, Abouljoud MS. A national study of burnout among American transplant sur-geons. Transplant Proc. 2005;37:1399–1401.
27. Campbell DA Jr, Sonnad SS, Eckhauser FE, Campbell KK, Greenfield LJ. Burnout among American surgeons. Surgery 2001;130:696–702; discussion 705.
28. Green A, Duthie HL, Young HL, Peters TJ. Stress in surgeons.
Br J Surg. 1990;77:1154–1158.
29. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358–367.
30. Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med. 1997;44:1017–1022.
31. West CP, Huschka MM, Novotny PJ, et al. Association of per-ceived medical errors with resident distress and empathy: A prospective longitudinal study. JAMA. 2006;296:1071–1078. 32. Lerner LB, Stolzmann KL, Gulla VD. Birth trends and
preg-nancy complications among women urologists. J Am Coll Surg. 2009;208:293–297.
33. Mackinnon SE, Mizgala CL. Pregnancy and plastic surgery residency. Plast Reconstr Surg. 1994;94:186–192.
34. Mackinnon SE, Mizgala CL, McNeill IY, Walters BC, Ferris LE. Women surgeons: Career and lifestyle comparisons among surgical subspecialties. Plast Reconstr Surg. 1995;95: 321–329.
