- Email: [email protected]
A survey of academic surgeons: Work, stress, and research
A survey of academic surgeons: Work, stress, and research Nikunj K. Chokshi, MD,a Dianne M. Simeone, MD,b Ravi S. Chari, MD, MBA,c Fred Dorey, PhD,a Yigit S. Guner, MD,a and Jeffrey S. Upperman, MD,a Los Angeles, CA, Ann Arbor, MI, and Nashville, TN
Background. An academic surgeon’s workweek is divided among patient care, administrative duties, education, and research. The time available for research activities may change as a surgeon’s career evolves. We sought to determine involvement of academic surgeons in research and to assess how this research endeavor was affected by demographic and workplace characteristics. Methods. We constructed a survey to explore the following 4 domains: demographics, time allotment, research activities, and effects of stressors. We distributed the survey to members of the Society of University Surgeons. In addition to performing descriptive statistics, we defined an active researcher as someone with a funding source who devoted 15% or more work hours to research. Using this definition, we performed statistical analyses to assess the significance of independent variables on research. Stress factors were evaluated on a Likert scale with responses ranging from 1 (not at all) to 5 (extremely). Results. We received 314 completed surveys (response rate 23%). Of the respondents, 274 (87%) stated that they were involved in some kind of research activity; however, only 143 (46%) were active researchers. Using univariate logistic regression analysis, younger respondents and surgeons who practiced for more than 10 years were more likely to be active researchers (odds ratio [OR]: 1.93, confidence interval [CI]: 1.51--2.46 and OR: 2.06, CI: 1.64--2.59, respectively). Males were less likely than females to be active researchers (OR: 0.32, CI: 016--0.67); however, by multivariate analysis, we found that the ‘‘years in practice’’ of an active researcher was the most significant predictor of research activity, whereas age and sex were not. In regard to stress, most respondents reported scores of 1--3 for all 7 stressors, which is consistent with minimal to moderate stress. Conclusion. Academic surgeons are involved actively in research; however, this involvement decreases as other professional responsibilities increase. To optimize the surgical research environment, departments should invest time and resources in young investigators to prevent them from decreasing their research activities. (Surgery 2009;146:462-8.) From the Department of Pediatric Surgery, Children Hospital Los Angeles,a Los Angeles, CA; the Department of Surgery, University of Michigan,b Ann Arbor, MI; and the Department of Surgery, Vanderbilt University Medical Center,c Nashville, TN
DURING
THE SPAN OF AN ACADEMIC SURGEON’S CAREER,
change. Such changes, whether because of professional or personal reasons, invariably have an important impact on the surgeon’s time allotment and the activities that he or she chooses to pursue. An academic surgeon’s workweek is divided among patient care, administrative duties, educational activities, and research. Juggling these varied responsibilities successfully can be difficult and often unwieldy.
RESPONSIBILITIES
AND
PRIORITIES
Accepted for publication February 27, 2009. Reprint requests: Jeffrey S. Upperman, MD, Department of Pediatric Surgery, Children Hospital Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, Mailstop #72, Los Angeles, CA 90027. E-mail: jupperman@ chla.usc.edu. 0039-6060/$ - see front matter Ó 2009 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2009.02.015
462 SURGERY
Basic or clinical science research activities are the typical mainstays of academic surgeons. Past contributions of surgeon scientists to modern medicine show clearly the success of many of these research endeavors. The incorporation of dedicated research time in many surgery residency programs is a testament to the recognition of the importance of surgery research. Indeed, although no recent studies are available, older studies have shown that most individuals who perform research during training continue to do so at the onset of their professional career.1 The research activities of these individuals, however, may change over time. Not surprisingly, a growing clinical practice or increasing administrative duties may slowly erode into the time available for surgery research, either basic science or clinical. Basic science research continues to increase in complexity and expense. The inability to devote time and dedication to staying abreast of
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current scientific advancements can lead quickly to investigative obsolescence. In addition, the inability to secure or retain long-term funding may compound this problem even more. Some young surgeons have trouble initiating an academic career because surgeons have both a lesser application rate as well as less success rates in competing for National Institutes of Health (NIH) career development awards (K-awards) when compared with non-surgery applicants.2 Perceptions of stress in the workplace play a role on academic productivity and may also affect the success of research endeavors. Increased stress may also lead to physician burnout, which is defined by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishments. Young surgeons are more likely to experience burnout,3 which may impact adversely their inclination to engage in surgery research because they may not experience much success initially despite their efforts. The decreased availability of government funding may make it even more difficult to initiate a research career. The primary outcome measure we sought to determine was the involvement of academic surgeons in research activities. We also examined how such involvement changed with advancing career stages and whether demographic variables or stressors in the workplace correlated with research activity. To conduct this analysis, we developed a survey instrument that addressed these questions. In the survey, we did not require respondents to define their research endeavors, so the term may be applied broadly to any investigations or intellectual pursuits respondents partake in as academic surgeons. METHODS Survey design and population. We constructed a survey instrument in concordance with similar published studies2-6 (available online as supplemental material). We explored the following 4 domains in this survey: demographics, time allotment at work, research activities and funding, as well as effects of workplace stressors on research. The survey was piloted prior to distribution to a sample set of university surgeons for assessment of clarity and content validation. These respondents were not included in the final analysis. Based on their comments, the survey was edited to ease use and adjust queries. We distributed the survey electronically to all members of the Society of University Surgeons (SUS) with e-mail addresses inviting them to participate in a survey of academic surgeons. Data were collected by an anonymous Internet survey
Chokshi et al 463
(SurveyMonkey.com) from May to August 2007. During the recruitment period, 2 reminder e-mails were sent to SUS members to increase the sample size. The survey responses were anonymous in regard to respondent’s name, institution, and location. Independent variables. We collected data on sex, age, marital status, practice setting, practice duration, training, and hospital coverage. We asked respondents how many hours they worked in an average week and to divide that total into percentages spent on various activities, including clinical duties, administrative tasks, teaching, research, and billing. We sought to determine which stress factors impacted their work environment. Possibilities included departmental politics, billing issues, department and hospital deficits, intradepartmental faculty turnover, extradepartmental faculty turnover, sexual harassment, and malpractice issues (prevention or litigation). For all stressors, we gave respondents a 5-point Likert scale, with responses ranging from ‘‘not at all’’ to ‘‘extremely.’’ Explanatory variables. We defined an ‘‘active researcher’’ as an individual who was involved in research, had a funding source, and reported spending a minimum of 15% of their work time on research activities. We felt that this last criterion was important for determining who was involved actively in research, as opposed to overseeing or advising on departmental research. We divided the active researchers into those with NIH funding and those with funding from other sources. Outcome variables. The primary outcome variable was the involvement in clinical or basic science research. A secondary outcome included the status of research funding. We asked whether the surgeon had applied for and received NIH K-awards or NIH R-01 grants. We also asked whether he or she had procured other research funding sources such as philanthropic foundation awards, private industry grants, or intramural support. Last, we queried whether the surgeon had served as an ad-hoc or permanent member of an NIH Study Section. Study sample and data analysis. Survey invitations were sent to 1,381 members of the Society of University Surgeons. Statistical analyses were performed by the Children Hospital Los Angeles’ Pediatric Surgery Clinical Research Center, using the Stata software package, version 9 (Stata Corp., College Station, TX). We characterized the demographics of the study sample using descriptive statistics. We performed univariate analysis to analyze time allotment, research activities, and the effects of stressors on academic surgeons. In addition, we applied a
464 Chokshi et al
bivariate analysis to determine whether a relationship existed between the independent variables and their research activities. Next, we performed logistic regression analysis to examine the impact of the variables of interest on the outcome of ‘‘active researcher’’ and to control for potential confounding variables or effect modifiers. A multivariate logistic regression model was built incorporating variables with univariate associations with the outcome of ‘‘active researcher’’ (P < .2). We divided respondents into 3 age groups: 35--44 years, 45--54 years, and $55 years. We performed Spearman’s rank correlation (rho coefficient, for ordinal data) to assess the effect of age on the time allotment or perceived stressors and an analysis of variance (ANOVA) to determine the differences among these groups to assess the impact of age. For all statistical analyses, P values of less than .05 were considered statistically significant. In addition, we have rounded all percentages to whole numbers for clarity. RESULTS The survey was sent to 1,381 academic surgeons, and we received 314 responses for a response rate of 23%. Participant characteristics. Among respondents, most were male (88%), married (91%), between 35 and 54 years old (68%), and practicing for 6--20 years (58%); most respondents were employed in an academic setting (97%) (see Table I). Most respondents work at a single institution (61%) and have either 2 or 3 attendings for every resident on their service (2 attendings, 28%; 3 attendings, 26%). Most surgeons in this sample practice in an urban setting (80%) with a population over 350,000 people (74%). With regard to self-reported work hours, 30% (n = 91) of the respondents averaged 60--70 h per week, and 26% (n = 79) averaged more than 80 h per week. Only 7% (n = 20) stated that they worked 40--50 hours per week. When taking into account all activities they perform in a given workweek, respondents’ time was divided as follows (data are presented as percent time ± standard deviation): 38% ± 26 on clinical duties; 18% ± 20 on research activities; 15% ± 18 on administrative tasks; 11% ±11 on teaching; and 3% ± 4 on billing. When we performed a Spearman’s rank correlation to assess the impact of age on time allotment, we found that the younger groups (ages 35--44 years and 45--54 years) spent more time on clinical activities than their older (>55 years) counterparts (42% and 41% vs 29%, P = .0008). The youngest group also spent the most time on
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Table I. Respondent demographics Sex Male Female Age (years) 35--44 45--54 55--64 65--74 $75 Years in practice #5 6--10 11--20 21--30 >30 Academic practice Yes No Not applicable City population <25K 25--350K >350K Relationship status Married Domestic partnership Single Divorced Widowed
N = 311
Valid %
275 36
88 12
77 133 45 39 14
25 43 15 13 5
16 73 108 58 59
5 23 34 19 19
302 6 3
97 2 1
13 69 232
4 26 74
205 2 8 7 3
91 1 4 3 1
research activities, almost twice as much as those more than 45 years (Spearman’s Rho = 0.39, P = .0000). A positive correlation was found between age and percentage of time spent on administrative duties (Spearman’s Rho = 0.14, P = 0.018), which implies that older respondents have more administrative responsibilities or at least a greater percentage of their total work time allotted for such duties (see Table II). Stress factors: For all stressors, we measured responses on a 5-point Likert scale, with responses ranging from 1 (not at all) to 5 (extremely). The responders gave responses of 1--3 for all 7 stressors, which is consistent with minimal to moderate stress (Figure). Departmental and hospital deficits were chosen as the most common stressor, with this category having the greatest frequency of ‘‘4’’ or ‘‘5’’ responses, with 110 individuals (36%) stating that this stressor affected their professional life greatly. Departmental politics had the next greatest response rate, with 94 (34%) giving responses of ‘‘4’’ or ‘‘5.’’ Interestingly, sexual harassment was not cited as a frequent stressor, with only 7 (2%) stating it played a substantive role (Figure).
Chokshi et al 465
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Table II. Time allotment Percentage of total time Activity
35--44 years (n = 77)
Clinical duties Administrative time Teaching time Research activities
42% 9% 9% 33%
± ± ± ±
45--54 years (n = 133)
22% 7% 7% 21%
41% 15% 10% 18%
± ± ± ±
26% 16% 7% 16%
$55 years (n = 97) 29% 20% 13% 16%
± ± ± ±
28 24% 16% 22%
Spearman’s Rho
P value
0.191 +0.135 +0.080 0.390
.001* .018* .1611 <.000*
Respondents were divided into 3 age groups, and responses for time allotments (as percentage of total work time) were analyzed. A Spearman rank correlation test was performed, with negative correlations indicating the younger groups invest more time (as a percentage) in the activity analyzed. A positive correlation indicates the older groups invest more time (as a percentage) in the activity analyzed. *P values of <.05 were considered as statistically significant.
Malpractice Issues
85
107
Sexual Harassment
72
248
13
30 40
11 2 5
Institutional Faculty Turnover
81
Departmental Faculty Turnover
106
67
Departmental & Hospital Deficits
96
42
Billing Issues 22
0%
82
76 71
Departmental Politics
83
84
83
89
20%
83
40% 1
3
80% 4
10 26
45 58
60% 2
5
49
78
75
29
18 36
100%
5
Figure. Professional stressors
To assess the impact of age on identified stress factors, we again performed a Spearman’s rank correlation. We divided respondents into the 3 age groups discussed previously. We found that departmental politics and malpractice issues affected the younger more than the older age group. The older age groups had no stressors that affected them more than the younger age groups (Table III). Research activities: Among the study cohort, 274 (87%) respondents stated that they are involved actively in research at their institution. In total, 303 (96%) stated that they had active or expired funding for research. Of these, 4 (1%) stated that they had only intramural funding with no external grants. When we queried responders about grant applications and their funding status, we found that 116 (36%) had applied for an NIH career development award (K01, K07, K08, K23, or K24). The success rate was 42% (n = 49), with 26 active and 23 expired K-awards at the time of this survey (22% and 20% of the total applications, respectively; 8% and 7% of survey respondents, respectively). Most (n = 37, 82%) of those with K-awards
received the K08, with 3 each for the K01 and K23, and 1 each for the K07 and K24. With regard to NIH R01 funding, we found that 165 (60%) respondents had applied for this award. The success rate was 56% (n = 92), with 60 active and 32 expired R01 grants at the time of this survey (36% and 19% of the total applications, respectively; 19% and 10% of survey respondents, respectively). As for other funding sources, 46% had active intramural support (an additional 21% had expired), and 59% had active nongovernmental grants (an additional 19% had expired). Of the total respondents, 9% (n = 27) had been or are actively on an NIH Study Section (SS). These included sections as varied as follows: the Cancer Immunopathology and Immunotherapy SS; the Atherosclerosis and Inflammation of the Cardiovascular System SS; and the Clinical and Integrative Gastrointestinal Pathobiology SS. As noted previously, we divided respondents into the following 3 categories: those who devoted <15% of their time to research or had no active financial support (group 1), those who devoted >15% of their time on research and had NIH funding (group 2), and those who devoted >15% of their time on research, with non-NIH funding sources (group 3). Using these criteria, 171 respondents (55%) were not active researchers, 76 (24%) were NIH funded researchers, and 67 (21%) were non-NIH funded researchers. Applying ANOVA, we found that active researchers (groups 2 and 3), when compared with others (group 1) were affected more by departmental politics (P = .048) and less by hospital turnover (P = .049) and malpractice issues (P = .042). The Pearson Chi-squared analysis showed that of demographic and practice variables, respondents younger than 54 years of age, in practice fewer than 10 years, and females (see Table IV) were more likely to be active researchers (P < .001). There was also a trend for those who worked
466 Chokshi et al
Surgery September 2009
Table III. The effect of age on stress factors Mean Likert score (5 point) Professional stressors Malpractice issues Sexual harassment Institutional faculty turnover Departmental faculty turnover Departmental and hospital deficits Billing issues Departmental politics
35--44 years (n = 76)
45--54 years (n = 130)
2.25 1.37 2.10 2.36 2.88 2.05 3.07
2.53 1.26 2.32 2.62 3.11 3.01 3.28
± 1.10 ± 0.79 ± 1.11 ± 1.02 ± 1.10 ± 2.83 ±1.09
± ± ± ± ± ± ±
1.10 0.65 0.98 1.10 1.23 3.23 1.14
$55 years (n = 95) 1.98 1.20 2.23 2.32 2.68 2.23 2.67
± ± ± ± ± ± ±
1.05 0.52 0.96 1.14 1.19 4.59 1.17
Spearman’s Rho
P value
0.116 0.093 +0.058 0.027 0.075 0.039 0.14
.044* .107 .322 .646 .197 .581 .022*
Respondents were divided into 3 age groups, and responses for level of stress were analyzed. A 5-point Likert scale was used for stressors, with 1 = ‘‘Not at all’’ and 5 = ‘‘Extremely.’’ A Spearman rank correlation was performed; negative correlations indicated the younger groups gave the stressor a greater score. A positive correlation indicates the older groups gave the stressor a greaer score. *P values of <.05 were considered as statistically significant.
Table IV. Do women have increased involvement in research? No active research (group 1) NIH-funded active researcher (group 2) Non-NIH funded active researcher (group 3)
Men
Women
Total
159 (57.8%)
12 (30.8%)
171 (54.5%)
57 (20.7%)
19 (48.7%)
76 (24.2%)
59 (21.5%)
8 (20.5%)
67 (21.3%)
Based on the Pearson Chi-squared test, without correcting for confounding demographic variables, women are more involved in research (P = .001).
more hours to be active researchers (P = .066). A univariate logistic regression analysis showed similar findings. Those who had been in practice for less time were more likely to be active researchers (odds ratio [OR]: 2.06, confidence interval [CI]: 1.64--2.59; P = .001). The same relationship was shown for age; for younger respondents, active researcher status increased (OR: 1.93, CI: 1.51--2.46; P = .001). With regard to sex, males were less likely than females to be active researchers (OR: 0.32, CI: 0.16--0.67; P = .002). To delineate the impact of these variables even more, we performed a multivariate logistic regression analysis. When assessing demographic and practice variables, ‘‘years in practice’’ retained significance (OR: 1.83, CI: 1.20--2.80, P = .005), whereas age and sex became nonsignificant when correlated with active research (Table V). No other demographic or practice variables were shown to differ among the 3 groups after correcting for confounders using logistic regression. DISCUSSION The SUS represents a body of surgeons who have achieved a certain academic standing as defined by their publications, grant funding,
institutional and organizational positions, and previous membership in the Association for Academic Surgery.7 Within the respondents to our SUS survey, we found that the demographics are consistent with the general surgeon workforce in the United States based on the American Medical Association Physician Masterfile data set.8 Previous member surveys from the American Association for the Surgery of Trauma, the Eastern Association for the Surgery of Trauma, and the Western Trauma Association all showed a similar demographic pattern, including over half of their respondents practiced in university trauma centers.9 We hypothesized that a survey of the SUS would give us insight into the practice and research patterns of academic surgeons, which one would assume are different from nonacademic surgeons. Academic surgeons are practicing in an environment that is different from that observed even a decade ago.1 Changes in requirements for residency work hours and the health care environment may have forced surgeons to increase clinical time to maintain revenues10 and the quality of patient care. For academic surgery departments, maintaining the revenue stream is often of paramount importance, which forces the
Chokshi et al 467
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Table V. Logistic regression for years in practice and age Involvement in active research
Univariate <10 years in practice <54 years old Male sex Multivariate <10 years in practice <54 years old Male sex
OR
95% CI
P value
2.06 1.93 0.32
1.64–2.59 1.51–2.46 0.16-0.67
<.001* <.001* .002*
1.83 1.07 0.47
1.20–2.80 0.69–1.67 0.21–1.04
.005* .753 .064
A logistic regression with a 95% CI gives a significant P value in those denoted with an asterisk. The upper portion shows variables found to be significant on univariate logistic regression. The lower portion shows results of the multivariate logistic regression. Only <10 years in practice remains significant. *P values of <.05 were considered as statistically significant.
department leadership to provide less support for educational and research pursuits on a daily basis.11 Our results show that even among this group of research-oriented surgeons, more than twice as much time is spent on clinical activities compared with research. This observation likely results from the need to maintain the financial viability of the department. In addition, increasing the frequency of call and clinic coverage adds substantially to the amount of time devoted to clinical care. Because of these increasing responsibilities, the academic surgeon may be at risk for decreasing academic pursuits and possibly leaving the academic setting. Physician burnout is an increasing concern in today’s medical environment.3-6,12 Burnout is characterized by emotional exhaustion, depersonalization, cynicism, and perceived ineffectiveness.12 We did not ask questions that gauged burnout specifically as defined here. We do, however, feel that some inferences can be made from our questions regarding stress on these surgeons. The expectations and demands placed on modern surgeons can become overwhelming. Based on the responses to our survey, departmental and hospital deficits were the principal causes of stress in respondents’ professional lives. Stress is often caused by the pressure to achieve a certain goal, imposed either internally or externally. Our data suggest that the financial viability of the department or hospital is important to all surgeons, and the need to maintain financial solvency may place a large burden on academic surgeons. Today’s academic surgeon is dealing not only with the increasing clinical and financial pressures but also with an increasingly complicated research
environment. Among this group of surgeons who have chosen an academic career path, 87% state that they are involved in research; however, only 46% of all respondents have sufficient time commitment and financial resources to be considered active researchers. For a researcher to maintain his/her productivity, it is important that he/she have appropriate mentors and collaborators in addition to adequate resources.13 In the current academic milieu, having the time and resources to succeed in research of either clinical or basic science requires a plan.14 This balance can be achieved only with the assistance of a departmental chair or similarly powerful mentor who understands the time and financial needs of a fledgling surgical scientist and can create a goal-oriented schedule for them. Importantly, the mentor must be honest with the mentee with regard to what the individual should be able to achieve. Setting unattainable goals will not benefit either party. As noted in our results, under univariate analysis, female respondents seem to be more involved in research. Although this finding did not retain statistical significance under multivariate analysis, it does suggest an interesting question. Our respondents were overwhelmingly male (88%), and perhaps if there were more females, this variable would have retained significance. As to why female academic surgeons may be more research oriented, we would need to look specifically at what drives people to perform research and how these variables may differ based on demographics, including sex. This would indeed be an interesting question for a follow-up survey of academic surgeons. Although these survey results are thought provoking, we recognize that the data set collected has certain limitations. Whereas our response rate was appropriate for an online survey, the limited sample size may have created a selection bias. Nonresponse bias and socially desirable response bias may also influence results, with those more interested in academic surgery and research being more likely to participate in the survey. We did not encourage perspective respondents with financial or equivalent inducements. All data were selfreported voluntarily. As such, the data on time, stress, research activities, grant applications, and successes reflect only the respondent’s perceptions and did not require corroboration. It is likely that some respondents overestimated their time allotment or grant status, as well as some who underestimated these measures. We do feel that perceptions in these regards, in particular when discussing stress and workplace prioritization, are important endpoints.
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In conclusion, academic surgeons face many pressures in the current practice environment, and the feasibility of maintaining research activities may be in jeopardy. High clinical demands, as well as stressors in the work place, limit the amount of time available for research. To increase research endeavors in surgery departments, departmental and institutional leaders need to promote these activities with policies and programs geared toward research success. REFERENCES 1. Ko CY, Whang EE, Longmire WP Jr, McFadden DW. Improving the Surgeon’s participation in research: is it a problem of training or priority? J Surg Res 2000;91:5-8. 2. Rangel SJ, Moss RL. Recent trends in the funding and utilization of NIH career development awards by surgical faculty. Surgery 2004;136:232-9. 3. Campbell DA Jr, Sonnad SS, Eckhauser FE, Campbell KK, Greenfield LJ. Burnout among American surgeons. Surgery 2001;130:696-702. 4. Bertges Yost W, Eshelman A, Raoufi M, Abouljoud MS. A national study of burnout among American transplant surgeons. Transplant Proc 2005;37:1399-401.
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5. Gabbe SG, Melville J, Mandel L, Walker E. Burnout in chairs of obstetrics and gynecology: diagnosis, treatment, and prevention. Am J Obstet Gynecol 2002;186:601-12. 6. Johns MM III, Ossoff RH. Burnout in academic chairs of otolaryngology: head and neck surgery. Laryngoscope 2005;115:2056-61. 7. Geller. SUS membership guidlines. In: Taskforce SMC, editor. Maitland, FL: Society of University Surgeons; 2005. 8. Thompson MJ, Lynge DC, Larson EH, Tachawachira P, Hart LG. Characterizing the general surgery workforce in rural America. Arch Surg 2005;140:74-9. 9. Esposito TJ, Leon L, Jurkovich GJ. The shape of things to come: results from a national survey of trauma surgeons on issues concerning their future. J Trauma 2006;60:8-16. 10. Chinoy MR, Moskowitz J, Wilmore DW, Souba WW. Basic science faculty in surgical departments: advantages, disadvantages and opportunities. J Surg Res 2005;123:153-7. 11. Souba WW. The Achilles’ heels of an academic surgeon: a leadership tale. J Surg Res 2005;123:320-7. 12. Spickerd A, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA 2002;288:144750. 13. Brennan MF. Lessons learned. Ann Surg Oncol 2006;13: 1322-8. 14. Staveley-O’Carroll K, Pan M, Meier A, Han D, McFadden D, Souba W. Developing the young academic surgeon. J Surg Res 2005;128:238-42.
Erratum Because the TRICLOSAN coating of the Vicryl suture used in the study is not an antibiotic substance in its true sense, but an antibacterial substance, the title of ‘‘Antibiotic coating of abdominal closure sutures and wound infection,’’ by Christoph Justinger, Mohammed Reza
Moussavian, Christian Schlueter, Berit Kopp, Otto Kollmar, and Martin Karl Schilling, which appeared in Surgery, Vol. 145, No. 3:330--4, 2009, should have read ‘‘Antibacterial coating of abdominal closure sutures and wound infection.’’ The authors apologize for this oversight.
Background. An academic surgeon’s workweek is divided among patient care, administrative duties, education, and research. The time available for research activities may change as a surgeon’s career evolves. We sought to determine involvement of academic surgeons in research and to assess how this research endeavor was affected by demographic and workplace characteristics. Methods. We constructed a survey to explore the following 4 domains: demographics, time allotment, research activities, and effects of stressors. We distributed the survey to members of the Society of University Surgeons. In addition to performing descriptive statistics, we defined an active researcher as someone with a funding source who devoted 15% or more work hours to research. Using this definition, we performed statistical analyses to assess the significance of independent variables on research. Stress factors were evaluated on a Likert scale with responses ranging from 1 (not at all) to 5 (extremely). Results. We received 314 completed surveys (response rate 23%). Of the respondents, 274 (87%) stated that they were involved in some kind of research activity; however, only 143 (46%) were active researchers. Using univariate logistic regression analysis, younger respondents and surgeons who practiced for more than 10 years were more likely to be active researchers (odds ratio [OR]: 1.93, confidence interval [CI]: 1.51--2.46 and OR: 2.06, CI: 1.64--2.59, respectively). Males were less likely than females to be active researchers (OR: 0.32, CI: 016--0.67); however, by multivariate analysis, we found that the ‘‘years in practice’’ of an active researcher was the most significant predictor of research activity, whereas age and sex were not. In regard to stress, most respondents reported scores of 1--3 for all 7 stressors, which is consistent with minimal to moderate stress. Conclusion. Academic surgeons are involved actively in research; however, this involvement decreases as other professional responsibilities increase. To optimize the surgical research environment, departments should invest time and resources in young investigators to prevent them from decreasing their research activities. (Surgery 2009;146:462-8.) From the Department of Pediatric Surgery, Children Hospital Los Angeles,a Los Angeles, CA; the Department of Surgery, University of Michigan,b Ann Arbor, MI; and the Department of Surgery, Vanderbilt University Medical Center,c Nashville, TN
DURING
THE SPAN OF AN ACADEMIC SURGEON’S CAREER,
change. Such changes, whether because of professional or personal reasons, invariably have an important impact on the surgeon’s time allotment and the activities that he or she chooses to pursue. An academic surgeon’s workweek is divided among patient care, administrative duties, educational activities, and research. Juggling these varied responsibilities successfully can be difficult and often unwieldy.
RESPONSIBILITIES
AND
PRIORITIES
Accepted for publication February 27, 2009. Reprint requests: Jeffrey S. Upperman, MD, Department of Pediatric Surgery, Children Hospital Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, Mailstop #72, Los Angeles, CA 90027. E-mail: jupperman@ chla.usc.edu. 0039-6060/$ - see front matter Ó 2009 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2009.02.015
462 SURGERY
Basic or clinical science research activities are the typical mainstays of academic surgeons. Past contributions of surgeon scientists to modern medicine show clearly the success of many of these research endeavors. The incorporation of dedicated research time in many surgery residency programs is a testament to the recognition of the importance of surgery research. Indeed, although no recent studies are available, older studies have shown that most individuals who perform research during training continue to do so at the onset of their professional career.1 The research activities of these individuals, however, may change over time. Not surprisingly, a growing clinical practice or increasing administrative duties may slowly erode into the time available for surgery research, either basic science or clinical. Basic science research continues to increase in complexity and expense. The inability to devote time and dedication to staying abreast of
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current scientific advancements can lead quickly to investigative obsolescence. In addition, the inability to secure or retain long-term funding may compound this problem even more. Some young surgeons have trouble initiating an academic career because surgeons have both a lesser application rate as well as less success rates in competing for National Institutes of Health (NIH) career development awards (K-awards) when compared with non-surgery applicants.2 Perceptions of stress in the workplace play a role on academic productivity and may also affect the success of research endeavors. Increased stress may also lead to physician burnout, which is defined by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishments. Young surgeons are more likely to experience burnout,3 which may impact adversely their inclination to engage in surgery research because they may not experience much success initially despite their efforts. The decreased availability of government funding may make it even more difficult to initiate a research career. The primary outcome measure we sought to determine was the involvement of academic surgeons in research activities. We also examined how such involvement changed with advancing career stages and whether demographic variables or stressors in the workplace correlated with research activity. To conduct this analysis, we developed a survey instrument that addressed these questions. In the survey, we did not require respondents to define their research endeavors, so the term may be applied broadly to any investigations or intellectual pursuits respondents partake in as academic surgeons. METHODS Survey design and population. We constructed a survey instrument in concordance with similar published studies2-6 (available online as supplemental material). We explored the following 4 domains in this survey: demographics, time allotment at work, research activities and funding, as well as effects of workplace stressors on research. The survey was piloted prior to distribution to a sample set of university surgeons for assessment of clarity and content validation. These respondents were not included in the final analysis. Based on their comments, the survey was edited to ease use and adjust queries. We distributed the survey electronically to all members of the Society of University Surgeons (SUS) with e-mail addresses inviting them to participate in a survey of academic surgeons. Data were collected by an anonymous Internet survey
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(SurveyMonkey.com) from May to August 2007. During the recruitment period, 2 reminder e-mails were sent to SUS members to increase the sample size. The survey responses were anonymous in regard to respondent’s name, institution, and location. Independent variables. We collected data on sex, age, marital status, practice setting, practice duration, training, and hospital coverage. We asked respondents how many hours they worked in an average week and to divide that total into percentages spent on various activities, including clinical duties, administrative tasks, teaching, research, and billing. We sought to determine which stress factors impacted their work environment. Possibilities included departmental politics, billing issues, department and hospital deficits, intradepartmental faculty turnover, extradepartmental faculty turnover, sexual harassment, and malpractice issues (prevention or litigation). For all stressors, we gave respondents a 5-point Likert scale, with responses ranging from ‘‘not at all’’ to ‘‘extremely.’’ Explanatory variables. We defined an ‘‘active researcher’’ as an individual who was involved in research, had a funding source, and reported spending a minimum of 15% of their work time on research activities. We felt that this last criterion was important for determining who was involved actively in research, as opposed to overseeing or advising on departmental research. We divided the active researchers into those with NIH funding and those with funding from other sources. Outcome variables. The primary outcome variable was the involvement in clinical or basic science research. A secondary outcome included the status of research funding. We asked whether the surgeon had applied for and received NIH K-awards or NIH R-01 grants. We also asked whether he or she had procured other research funding sources such as philanthropic foundation awards, private industry grants, or intramural support. Last, we queried whether the surgeon had served as an ad-hoc or permanent member of an NIH Study Section. Study sample and data analysis. Survey invitations were sent to 1,381 members of the Society of University Surgeons. Statistical analyses were performed by the Children Hospital Los Angeles’ Pediatric Surgery Clinical Research Center, using the Stata software package, version 9 (Stata Corp., College Station, TX). We characterized the demographics of the study sample using descriptive statistics. We performed univariate analysis to analyze time allotment, research activities, and the effects of stressors on academic surgeons. In addition, we applied a
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bivariate analysis to determine whether a relationship existed between the independent variables and their research activities. Next, we performed logistic regression analysis to examine the impact of the variables of interest on the outcome of ‘‘active researcher’’ and to control for potential confounding variables or effect modifiers. A multivariate logistic regression model was built incorporating variables with univariate associations with the outcome of ‘‘active researcher’’ (P < .2). We divided respondents into 3 age groups: 35--44 years, 45--54 years, and $55 years. We performed Spearman’s rank correlation (rho coefficient, for ordinal data) to assess the effect of age on the time allotment or perceived stressors and an analysis of variance (ANOVA) to determine the differences among these groups to assess the impact of age. For all statistical analyses, P values of less than .05 were considered statistically significant. In addition, we have rounded all percentages to whole numbers for clarity. RESULTS The survey was sent to 1,381 academic surgeons, and we received 314 responses for a response rate of 23%. Participant characteristics. Among respondents, most were male (88%), married (91%), between 35 and 54 years old (68%), and practicing for 6--20 years (58%); most respondents were employed in an academic setting (97%) (see Table I). Most respondents work at a single institution (61%) and have either 2 or 3 attendings for every resident on their service (2 attendings, 28%; 3 attendings, 26%). Most surgeons in this sample practice in an urban setting (80%) with a population over 350,000 people (74%). With regard to self-reported work hours, 30% (n = 91) of the respondents averaged 60--70 h per week, and 26% (n = 79) averaged more than 80 h per week. Only 7% (n = 20) stated that they worked 40--50 hours per week. When taking into account all activities they perform in a given workweek, respondents’ time was divided as follows (data are presented as percent time ± standard deviation): 38% ± 26 on clinical duties; 18% ± 20 on research activities; 15% ± 18 on administrative tasks; 11% ±11 on teaching; and 3% ± 4 on billing. When we performed a Spearman’s rank correlation to assess the impact of age on time allotment, we found that the younger groups (ages 35--44 years and 45--54 years) spent more time on clinical activities than their older (>55 years) counterparts (42% and 41% vs 29%, P = .0008). The youngest group also spent the most time on
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Table I. Respondent demographics Sex Male Female Age (years) 35--44 45--54 55--64 65--74 $75 Years in practice #5 6--10 11--20 21--30 >30 Academic practice Yes No Not applicable City population <25K 25--350K >350K Relationship status Married Domestic partnership Single Divorced Widowed
N = 311
Valid %
275 36
88 12
77 133 45 39 14
25 43 15 13 5
16 73 108 58 59
5 23 34 19 19
302 6 3
97 2 1
13 69 232
4 26 74
205 2 8 7 3
91 1 4 3 1
research activities, almost twice as much as those more than 45 years (Spearman’s Rho = 0.39, P = .0000). A positive correlation was found between age and percentage of time spent on administrative duties (Spearman’s Rho = 0.14, P = 0.018), which implies that older respondents have more administrative responsibilities or at least a greater percentage of their total work time allotted for such duties (see Table II). Stress factors: For all stressors, we measured responses on a 5-point Likert scale, with responses ranging from 1 (not at all) to 5 (extremely). The responders gave responses of 1--3 for all 7 stressors, which is consistent with minimal to moderate stress (Figure). Departmental and hospital deficits were chosen as the most common stressor, with this category having the greatest frequency of ‘‘4’’ or ‘‘5’’ responses, with 110 individuals (36%) stating that this stressor affected their professional life greatly. Departmental politics had the next greatest response rate, with 94 (34%) giving responses of ‘‘4’’ or ‘‘5.’’ Interestingly, sexual harassment was not cited as a frequent stressor, with only 7 (2%) stating it played a substantive role (Figure).
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Table II. Time allotment Percentage of total time Activity
35--44 years (n = 77)
Clinical duties Administrative time Teaching time Research activities
42% 9% 9% 33%
± ± ± ±
45--54 years (n = 133)
22% 7% 7% 21%
41% 15% 10% 18%
± ± ± ±
26% 16% 7% 16%
$55 years (n = 97) 29% 20% 13% 16%
± ± ± ±
28 24% 16% 22%
Spearman’s Rho
P value
0.191 +0.135 +0.080 0.390
.001* .018* .1611 <.000*
Respondents were divided into 3 age groups, and responses for time allotments (as percentage of total work time) were analyzed. A Spearman rank correlation test was performed, with negative correlations indicating the younger groups invest more time (as a percentage) in the activity analyzed. A positive correlation indicates the older groups invest more time (as a percentage) in the activity analyzed. *P values of <.05 were considered as statistically significant.
Malpractice Issues
85
107
Sexual Harassment
72
248
13
30 40
11 2 5
Institutional Faculty Turnover
81
Departmental Faculty Turnover
106
67
Departmental & Hospital Deficits
96
42
Billing Issues 22
0%
82
76 71
Departmental Politics
83
84
83
89
20%
83
40% 1
3
80% 4
10 26
45 58
60% 2
5
49
78
75
29
18 36
100%
5
Figure. Professional stressors
To assess the impact of age on identified stress factors, we again performed a Spearman’s rank correlation. We divided respondents into the 3 age groups discussed previously. We found that departmental politics and malpractice issues affected the younger more than the older age group. The older age groups had no stressors that affected them more than the younger age groups (Table III). Research activities: Among the study cohort, 274 (87%) respondents stated that they are involved actively in research at their institution. In total, 303 (96%) stated that they had active or expired funding for research. Of these, 4 (1%) stated that they had only intramural funding with no external grants. When we queried responders about grant applications and their funding status, we found that 116 (36%) had applied for an NIH career development award (K01, K07, K08, K23, or K24). The success rate was 42% (n = 49), with 26 active and 23 expired K-awards at the time of this survey (22% and 20% of the total applications, respectively; 8% and 7% of survey respondents, respectively). Most (n = 37, 82%) of those with K-awards
received the K08, with 3 each for the K01 and K23, and 1 each for the K07 and K24. With regard to NIH R01 funding, we found that 165 (60%) respondents had applied for this award. The success rate was 56% (n = 92), with 60 active and 32 expired R01 grants at the time of this survey (36% and 19% of the total applications, respectively; 19% and 10% of survey respondents, respectively). As for other funding sources, 46% had active intramural support (an additional 21% had expired), and 59% had active nongovernmental grants (an additional 19% had expired). Of the total respondents, 9% (n = 27) had been or are actively on an NIH Study Section (SS). These included sections as varied as follows: the Cancer Immunopathology and Immunotherapy SS; the Atherosclerosis and Inflammation of the Cardiovascular System SS; and the Clinical and Integrative Gastrointestinal Pathobiology SS. As noted previously, we divided respondents into the following 3 categories: those who devoted <15% of their time to research or had no active financial support (group 1), those who devoted >15% of their time on research and had NIH funding (group 2), and those who devoted >15% of their time on research, with non-NIH funding sources (group 3). Using these criteria, 171 respondents (55%) were not active researchers, 76 (24%) were NIH funded researchers, and 67 (21%) were non-NIH funded researchers. Applying ANOVA, we found that active researchers (groups 2 and 3), when compared with others (group 1) were affected more by departmental politics (P = .048) and less by hospital turnover (P = .049) and malpractice issues (P = .042). The Pearson Chi-squared analysis showed that of demographic and practice variables, respondents younger than 54 years of age, in practice fewer than 10 years, and females (see Table IV) were more likely to be active researchers (P < .001). There was also a trend for those who worked
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Table III. The effect of age on stress factors Mean Likert score (5 point) Professional stressors Malpractice issues Sexual harassment Institutional faculty turnover Departmental faculty turnover Departmental and hospital deficits Billing issues Departmental politics
35--44 years (n = 76)
45--54 years (n = 130)
2.25 1.37 2.10 2.36 2.88 2.05 3.07
2.53 1.26 2.32 2.62 3.11 3.01 3.28
± 1.10 ± 0.79 ± 1.11 ± 1.02 ± 1.10 ± 2.83 ±1.09
± ± ± ± ± ± ±
1.10 0.65 0.98 1.10 1.23 3.23 1.14
$55 years (n = 95) 1.98 1.20 2.23 2.32 2.68 2.23 2.67
± ± ± ± ± ± ±
1.05 0.52 0.96 1.14 1.19 4.59 1.17
Spearman’s Rho
P value
0.116 0.093 +0.058 0.027 0.075 0.039 0.14
.044* .107 .322 .646 .197 .581 .022*
Respondents were divided into 3 age groups, and responses for level of stress were analyzed. A 5-point Likert scale was used for stressors, with 1 = ‘‘Not at all’’ and 5 = ‘‘Extremely.’’ A Spearman rank correlation was performed; negative correlations indicated the younger groups gave the stressor a greater score. A positive correlation indicates the older groups gave the stressor a greaer score. *P values of <.05 were considered as statistically significant.
Table IV. Do women have increased involvement in research? No active research (group 1) NIH-funded active researcher (group 2) Non-NIH funded active researcher (group 3)
Men
Women
Total
159 (57.8%)
12 (30.8%)
171 (54.5%)
57 (20.7%)
19 (48.7%)
76 (24.2%)
59 (21.5%)
8 (20.5%)
67 (21.3%)
Based on the Pearson Chi-squared test, without correcting for confounding demographic variables, women are more involved in research (P = .001).
more hours to be active researchers (P = .066). A univariate logistic regression analysis showed similar findings. Those who had been in practice for less time were more likely to be active researchers (odds ratio [OR]: 2.06, confidence interval [CI]: 1.64--2.59; P = .001). The same relationship was shown for age; for younger respondents, active researcher status increased (OR: 1.93, CI: 1.51--2.46; P = .001). With regard to sex, males were less likely than females to be active researchers (OR: 0.32, CI: 0.16--0.67; P = .002). To delineate the impact of these variables even more, we performed a multivariate logistic regression analysis. When assessing demographic and practice variables, ‘‘years in practice’’ retained significance (OR: 1.83, CI: 1.20--2.80, P = .005), whereas age and sex became nonsignificant when correlated with active research (Table V). No other demographic or practice variables were shown to differ among the 3 groups after correcting for confounders using logistic regression. DISCUSSION The SUS represents a body of surgeons who have achieved a certain academic standing as defined by their publications, grant funding,
institutional and organizational positions, and previous membership in the Association for Academic Surgery.7 Within the respondents to our SUS survey, we found that the demographics are consistent with the general surgeon workforce in the United States based on the American Medical Association Physician Masterfile data set.8 Previous member surveys from the American Association for the Surgery of Trauma, the Eastern Association for the Surgery of Trauma, and the Western Trauma Association all showed a similar demographic pattern, including over half of their respondents practiced in university trauma centers.9 We hypothesized that a survey of the SUS would give us insight into the practice and research patterns of academic surgeons, which one would assume are different from nonacademic surgeons. Academic surgeons are practicing in an environment that is different from that observed even a decade ago.1 Changes in requirements for residency work hours and the health care environment may have forced surgeons to increase clinical time to maintain revenues10 and the quality of patient care. For academic surgery departments, maintaining the revenue stream is often of paramount importance, which forces the
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Table V. Logistic regression for years in practice and age Involvement in active research
Univariate <10 years in practice <54 years old Male sex Multivariate <10 years in practice <54 years old Male sex
OR
95% CI
P value
2.06 1.93 0.32
1.64–2.59 1.51–2.46 0.16-0.67
<.001* <.001* .002*
1.83 1.07 0.47
1.20–2.80 0.69–1.67 0.21–1.04
.005* .753 .064
A logistic regression with a 95% CI gives a significant P value in those denoted with an asterisk. The upper portion shows variables found to be significant on univariate logistic regression. The lower portion shows results of the multivariate logistic regression. Only <10 years in practice remains significant. *P values of <.05 were considered as statistically significant.
department leadership to provide less support for educational and research pursuits on a daily basis.11 Our results show that even among this group of research-oriented surgeons, more than twice as much time is spent on clinical activities compared with research. This observation likely results from the need to maintain the financial viability of the department. In addition, increasing the frequency of call and clinic coverage adds substantially to the amount of time devoted to clinical care. Because of these increasing responsibilities, the academic surgeon may be at risk for decreasing academic pursuits and possibly leaving the academic setting. Physician burnout is an increasing concern in today’s medical environment.3-6,12 Burnout is characterized by emotional exhaustion, depersonalization, cynicism, and perceived ineffectiveness.12 We did not ask questions that gauged burnout specifically as defined here. We do, however, feel that some inferences can be made from our questions regarding stress on these surgeons. The expectations and demands placed on modern surgeons can become overwhelming. Based on the responses to our survey, departmental and hospital deficits were the principal causes of stress in respondents’ professional lives. Stress is often caused by the pressure to achieve a certain goal, imposed either internally or externally. Our data suggest that the financial viability of the department or hospital is important to all surgeons, and the need to maintain financial solvency may place a large burden on academic surgeons. Today’s academic surgeon is dealing not only with the increasing clinical and financial pressures but also with an increasingly complicated research
environment. Among this group of surgeons who have chosen an academic career path, 87% state that they are involved in research; however, only 46% of all respondents have sufficient time commitment and financial resources to be considered active researchers. For a researcher to maintain his/her productivity, it is important that he/she have appropriate mentors and collaborators in addition to adequate resources.13 In the current academic milieu, having the time and resources to succeed in research of either clinical or basic science requires a plan.14 This balance can be achieved only with the assistance of a departmental chair or similarly powerful mentor who understands the time and financial needs of a fledgling surgical scientist and can create a goal-oriented schedule for them. Importantly, the mentor must be honest with the mentee with regard to what the individual should be able to achieve. Setting unattainable goals will not benefit either party. As noted in our results, under univariate analysis, female respondents seem to be more involved in research. Although this finding did not retain statistical significance under multivariate analysis, it does suggest an interesting question. Our respondents were overwhelmingly male (88%), and perhaps if there were more females, this variable would have retained significance. As to why female academic surgeons may be more research oriented, we would need to look specifically at what drives people to perform research and how these variables may differ based on demographics, including sex. This would indeed be an interesting question for a follow-up survey of academic surgeons. Although these survey results are thought provoking, we recognize that the data set collected has certain limitations. Whereas our response rate was appropriate for an online survey, the limited sample size may have created a selection bias. Nonresponse bias and socially desirable response bias may also influence results, with those more interested in academic surgery and research being more likely to participate in the survey. We did not encourage perspective respondents with financial or equivalent inducements. All data were selfreported voluntarily. As such, the data on time, stress, research activities, grant applications, and successes reflect only the respondent’s perceptions and did not require corroboration. It is likely that some respondents overestimated their time allotment or grant status, as well as some who underestimated these measures. We do feel that perceptions in these regards, in particular when discussing stress and workplace prioritization, are important endpoints.
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In conclusion, academic surgeons face many pressures in the current practice environment, and the feasibility of maintaining research activities may be in jeopardy. High clinical demands, as well as stressors in the work place, limit the amount of time available for research. To increase research endeavors in surgery departments, departmental and institutional leaders need to promote these activities with policies and programs geared toward research success. REFERENCES 1. Ko CY, Whang EE, Longmire WP Jr, McFadden DW. Improving the Surgeon’s participation in research: is it a problem of training or priority? J Surg Res 2000;91:5-8. 2. Rangel SJ, Moss RL. Recent trends in the funding and utilization of NIH career development awards by surgical faculty. Surgery 2004;136:232-9. 3. Campbell DA Jr, Sonnad SS, Eckhauser FE, Campbell KK, Greenfield LJ. Burnout among American surgeons. Surgery 2001;130:696-702. 4. Bertges Yost W, Eshelman A, Raoufi M, Abouljoud MS. A national study of burnout among American transplant surgeons. Transplant Proc 2005;37:1399-401.
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5. Gabbe SG, Melville J, Mandel L, Walker E. Burnout in chairs of obstetrics and gynecology: diagnosis, treatment, and prevention. Am J Obstet Gynecol 2002;186:601-12. 6. Johns MM III, Ossoff RH. Burnout in academic chairs of otolaryngology: head and neck surgery. Laryngoscope 2005;115:2056-61. 7. Geller. SUS membership guidlines. In: Taskforce SMC, editor. Maitland, FL: Society of University Surgeons; 2005. 8. Thompson MJ, Lynge DC, Larson EH, Tachawachira P, Hart LG. Characterizing the general surgery workforce in rural America. Arch Surg 2005;140:74-9. 9. Esposito TJ, Leon L, Jurkovich GJ. The shape of things to come: results from a national survey of trauma surgeons on issues concerning their future. J Trauma 2006;60:8-16. 10. Chinoy MR, Moskowitz J, Wilmore DW, Souba WW. Basic science faculty in surgical departments: advantages, disadvantages and opportunities. J Surg Res 2005;123:153-7. 11. Souba WW. The Achilles’ heels of an academic surgeon: a leadership tale. J Surg Res 2005;123:320-7. 12. Spickerd A, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA 2002;288:144750. 13. Brennan MF. Lessons learned. Ann Surg Oncol 2006;13: 1322-8. 14. Staveley-O’Carroll K, Pan M, Meier A, Han D, McFadden D, Souba W. Developing the young academic surgeon. J Surg Res 2005;128:238-42.
Erratum Because the TRICLOSAN coating of the Vicryl suture used in the study is not an antibiotic substance in its true sense, but an antibacterial substance, the title of ‘‘Antibiotic coating of abdominal closure sutures and wound infection,’’ by Christoph Justinger, Mohammed Reza
Moussavian, Christian Schlueter, Berit Kopp, Otto Kollmar, and Martin Karl Schilling, which appeared in Surgery, Vol. 145, No. 3:330--4, 2009, should have read ‘‘Antibacterial coating of abdominal closure sutures and wound infection.’’ The authors apologize for this oversight.