- Email: [email protected]
Measuring determinants of career satisfaction of anesthesiologists: validation of a survey instrument
Journal of Clinical Anesthesia (2013) 25, 289–295
Original Contribution
Measuring determinants of career satisfaction of anesthesiologists: validation of a survey instrument☆,☆☆ Anoushka M. Afonso MD (Clinical Instructor)a , James H. Diaz MD, DrPH (Professor) b , Corey S. Scher MD (Associate Professor)c , Robbie A. Beyl BS, MS (Doctoral Candidate in Biostatistics)d , Singh R. Nair MD (Director, Clinical Research Anesthesia)e , Alan David Kaye MD, PhD (Professor and Chairman)b,⁎ a
Department of Anesthesiology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA Department of Anesthesiology, Louisiana Health Sciences University, New Orleans, New Orleans, LA 70112, USA c Department of Anesthesiology, New York University Langone Medical Center, New York, NY 10016, USA d School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA e Department of Anesthesiology, Montefiore Medical Center, Bronx, NY 10467, USA b
Received 20 July 2012; revised 1 January 2013; accepted 17 January 2013
Keywords: Anesthesiologists: aging; Burnout; Career satisfaction; Practice; Survey
Abstract Study Objective: To measure the parameter of job satisfaction among anesthesiologists. Design: Survey instrument. Setting: Academic anesthesiology departments in the United States. Subjects: 320 anesthesiologists who attended the annual meeting of the ASA in 2009 (95% response rate). Measurements and Main Results: The anonymous 50-item survey collected information on 26 independent demographic variables and 24 dependent ranked variables of career satisfaction among practicing anesthesiologists. Mean survey scores were calculated for each demographic variable and tested for statistically significant differences by analysis of variance. Questions within each domain that were internally consistent with each other within domains were identified by Cronbach’s alpha ≥ 0.7. P-values ≤ 0.05 were considered statistically significant. Cronbach’s alpha analysis showed strong internal consistency for 10 dependent outcome questions in the practice factor-related domain (α = 0.72), 6 dependent outcome questions in the peer factor-related domain (α = 0.71), and 8 dependent outcome questions in the personal factor-related domain (α = 0.81). Although age was not a variable, full-time status, early satisfaction within the first 5 years of practice, working with respected peers, and personal choice factors were all significantly associated with anesthesiologist job satisfaction. Conclusions: Improvements in factors related to job satisfaction among anesthesiologists may lead to higher early and current career satisfaction. © 2013 Elsevier Inc. All rights reserved.
☆
Supported by departmental funds only. Presented in part at the annual meeting of the American Society of Anesthesiologists, San Diego, CA, Oct. 16-20, 2010. ⁎ Correspondence: Alan David Kaye, MD, PhD, Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, Room 656, 1542 Tulane Ave., New Orleans, LA 70112, USA. Tel: + 1 504 568-2319; fax: + 1 504 568-2317. E-mail address: [email protected] (A.D. Kaye). ☆☆
0952-8180/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jclinane.2013.01.007
290
1. Introduction Anesthesiology has been recognized as a high-stress occupation; job stress and burnout have been significantly correlated with job dissatisfaction among anesthesiologists, gastroenterologists, psychiatrists, primary care practitioners, and other specialists [1-4]. While certain independent predictors of job dissatisfaction differ among the medical specialties, some remain constant across the specialties, including unexpected complications, increasing workloads, decreasing time off, reduced reimbursements, and malpractice suits [1-3]. Physicians who are satisfied with their careers have been shown to provide better health care and to have more satisfied patients [3]. Dissatisfaction among physicians leads to declining numbers of medical graduates entering that specialty, increasing rates of medical errors, and exodus from the specialty or the medical profession [3]. Since prior investigations have not examined the impact of advancing age and other demographics on job satisfaction among anesthesiologists, a cross-sectional survey study was designed to investigate 1) the impact of advancing age on the selection of anesthesiology as a satisfying career early or later in one’s career, and 2) the impact of several other demographic, practice, personnel, peer, financial, personal, and health-related factors on job satisfaction among practicing anesthesiologists over the span of their careers.
2. Materials and methods A focus group of practicing anesthesiologists was convened in the summer of 2009 at the Mt. Sinai Medical Center's Department of Anesthesiology in New York City, New York, in order to develop a survey on job satisfaction among anesthesiologists attending the 2009 American Society of Anesthesiologists (ASA) Annual Meeting in New Orleans, LA, October 16-19, 2009. Based on the recommendations of the focus group, job satisfaction was divided into 4 areas: practice-related, peer-related, personal health, and financially related. The subsequent survey study was designed to test the following null hypotheses: 1) that advancing age has no impact on the assessment of anesthesiology as a satisfying career early or later in one’s career as a practicing anesthesiologist; and that 2) demographics, practice-related factors, personnel and peer-related factors, personal and health-related factors, and financial factors have no impact on job satisfaction among practicing anesthesiologists. The 50-item survey was designed to collect information on 26 demographic factors as independent variables and 24 ranked variables of career satisfaction or not. The final analyzed survey consisted of 26 independent demographic variables and 24 dependent outcome variables, which were divided into the following three domains based on the professional recommendations of the focus group: 1)
A.M. Afonso et al. practice-related factors, 2) personnel and peer-related factors, and 3) personal and health-related factors [Table 1]. To test the associations between advancing age and other demographic factors on job satisfaction, a power analysis was conducted to determine the number of study subjects needed to be surveyed to achieve 90% statistical power to detect a true correlation of 0.3 at a 5% significance level [5]. The correlation coefficient value of 0.3 was chosen because this value is generally accepted to represent a moderate degree of association [5]. The sample size analysis indicated that 113 study subjects would need to be surveyed to achieve 90% statistical power. Since a listing of registered ASA meeting attendees was not available to the investigators, a nonrandomized convenience sample of meeting attendees was surveyed as randomized selection of survey subjects was not possible. The job satisfaction surveys were specifically designed for numerical coding to assure anonymity and confidentiality when administered to consenting anesthesiologists. Following Institutional Review Board (IRB) approval, the job satisfaction surveys were distributed to 320 ASA meeting attendees in the following 2 ways: 1) by practicing anesthesiologists, anesthesiology residents, and medical students attending a survey booth area at the ASA convention near the conference hall cafeteria; and 2) by practicing anesthesiologists, anesthesiology residents, and medical students directly handing out the surveys for completion by anesthesiologists from the conference hall cafeteria. To obtain a representative sample of the ASA Table 1
Stratification of the domains tested
Domain
Question (#)
Practice-related
Boring work (14), Excessive work (15) Intellectual stimulation (23) Case variety (24) Case complexity (25) Less OR time (26) Call difficulty (29) Selling calls (30) Learning new skills (39) Malpractice threats (40) Case competition (18) Schedule control (19) Surgeon staff interaction (20) Anesthesiologist staff interaction (21) House staff interaction (22) Younger competitors (27) Medical health (31) Mental health (32) Physical health (33) Sexual health (34) Relationships (35) Parental role (36) Alcohol use (37) Controlled substance use (38)
Personnel/peer-related
Personal/health-related
OR=operating room.
Anesthesiologists' career satisfaction Table 2
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Demographic characteristics of survey responders
Survey Responders Board-certified yes no Age (yrs) 20-30 31-40 41-50 51-60 N 60 Gender male female U.S. medical school yes no Practice Type academic private other Full-time or part-time status full-time part-time Region of practice New England Mid-Atlantic South Atlantic East North Central East South Central West North Central West South Central Mountain Pacific Hours worked per week b 40 40-50 50-60 60-70 N 70 Years of experience 0-5 5-10 10-20 20-30 30-40 40-50 N 50 ASA member Yes No Income b$50,000 $50,00-$99,000 $100,00-$149,999 $150,00-$199,999 $200,00-$249,999 $250,00-$299,999
Number (%)
Satisfaction [mean (SD)]
237 (77.70%) 68 (22.30%)
5.57 (1.27) 5.63 (1.45)
31 69 74 90 40
(10.16%) (22.62%) (24.26%) (29.51%) (13.11%)
5.70 5.65 5.52 5.47 5.80
(1.32) (1.32) (1.30) (1.35) (1.29)
236 (77.38%) 68 (22.30%)
5.61 (1.31) 5.53 (1.35)
193 (63.28%) 110 (36.07%)
5.50 (1.40) 5.74 (1.15)
133 (45.24%) 107 (36.39%) 54 (18.37%)
5.58 (1.27) 5.69 (1.29) 5.39(1.46)
281 (93.36%) 20 (6.64%)
5.56 (1.32) 5.80 (1.28)
17 81 42 28 19 11 35 8 20
(6.51%) (31.03%) (16.09%) (10.73%) (7.28%) (4.21%) (13.41%) (3.07%) (7.66%)
5.65 5.36 5.65 5.75 5.84 5.73 5.60 5.13 5.40
(1.32) (1.30) (1.37) (1.32) (1.17) (0.90) (1.31) (1.81) (1.39)
22 66 119 78 18
(7.26%) (21.78%) (39.27%) (25.74%) (5.94%)
5.45 5.47 5.57 5.70 5.72
(1.77) (1.32) (1.25) (1.27) (1.41)
82 46 60 79 28 6 1
(27.15%) (15.23%) (19.87%) (26.16%) (9.27%) (1.99%) (0.33%)
5.62 5.65 5.28 5.57 6.00 5.50 7.00
(1.35) (1.16) (1.38) (1.35) (1.31) (0.55) (.)
271 (89.14%) 33 (10.86%) 15 40 12 19 33 31
(5.30%) (14.13%) (4.24%) (6.71%) (11.66%) (10.95%)
5.55 (1.33) 5.88 (1.11) 6.07 5.45 5.83 5.47 5.30 5.58
(1.33) (1.38) (1.03) (1.90) (1.36) (1.34)
Table 2 (continued) Survey Responders $300,00-$399,999 $400,00-$499,999 N$500,000
Number (%) 72 (25.44%) 43 (15.19%) 18 (6.36%)
Satisfaction [mean (SD)] 5.80 (1.05) 5.44 (1.28) 6.00 (0.97)
active, nonresident membership, surveys were distributed only to practicing board-certified and board-eligible anesthesiologists. Study subjects were instructed to leave a question blank if they felt that none of the ranked response choices expressed how they felt or if the question did not apply to them or their practice pattern. The demographic factors of all respondents were considered as the independent or predictor indicators of job satisfaction versus dissatisfaction in a linear regression model and included age, gender, U.S. versus international medical school graduate, board certification, academicprivate-government practice, region of practice, hours worked per week, years in practice, ASA membership, early satisfaction in the first 5 years of practice, and income levels. For ease of administration, the independent demographic questions and the ranked survey outcome questions were combined into one 50-question instrument, but the independent and dependent variables were initially analyzed separately and then combined in a linear regression model. Mean (standard deviation) survey scores were calculated for each demographic predictor and satisfaction outcome variable and tested for statistically significant differences by analysis of variance (ANOVA). Two other statistical methods were applied to the survey results: 1) Cronbach’s alpha calculations for survey outcome questions per domain; and 2) linear regression of independent predictors of satisfaction on the dependent outcomes of career satisfaction or not. Cronbach’s alpha coefficients, which measure the internal consistency of a set of responses, were computed for every nondemographic survey question response and for the 4 domains of the survey: practicerelated, peer-related, personal health, and financially related. Questions within each domain that correlated and were internally consistent with each other were identified by a domain Cronbach’s alpha of 0.7 or greater. All dependent variables analyzed for internal consistency by Cronbach’s alpha were scored dichotomously (yes/no) or ranked on an ordinal, Likert scale. A linear regression model was used to correlate the independent demographic predictor variables with the individual domain scores of the practice-related, peerrelated, and personal-related domains on the dependent outcomes of satisfaction versus dissatisfaction. Regression (correlation) coefficients were then compared for statistically significant differences in the impact of the predictor variables on the outcomes of satisfaction versus dissatisfaction. SAS version 9.2 (SAS, Inc., Cary, NC, USA) was used for all data
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analysis. P-values less than or equal to 0.05 were considered to be statistically significant.
3. Results Of the 320 anesthesiologists surveyed, 304 survey subjects returned completed surveys, for a survey response rate of 95%, providing the study with more than adequate statistical power to detect associations of moderate strength among those completing the survey. Completed surveys were returned either to the survey booth or to clearly identified survey workers. Demographic characteristics of the survey respondents are shown in Table 2. The mean age of the study subjects (45.3 yrs) was similar to the mean age of the ASA membership (47.5 yrs) at the time. Initial statistical tests showed that the only demographic variable that affected the mean satisfaction scores was whether the anesthesiologist was practicing full-time or part-time (F = 4.33, P = 0.039) [Table 3]. Of the 26 satisfaction outcome questions, the only questions that had a statistically significant impact on the satisfaction scores were Question 32, practice affected their mental health (F = 3.28, P = 0.023), and Question 36, practice affected their role as a parent (F = 2.78, P = 0.043) [Table 4]. Initial Cronbach’s alpha analyses prior to survey distribution demonstrated strong (N 0.70) internal consistency for 10 dependent outcome questions in the practice factorrelated domain, 6 dependent outcome questions in the peer factor-related domain, and 8 dependent outcome questions in the personal factor-related domain for a total of 24 ranked survey outcome questions. Subsequently, the final Cronbach’s alpha analyses, by demonstrating that those questions were internally consistent among survey respondents confirmed that this part of the survey instrument was reliable. The 24-item survey outcome questions demonstrated strong internal consistency by domains on initial and subsequent analyses by Cronbach’s alpha and validated the
Table 3
Analysis of variance of demographic data
Demographic question
F-statistic
P-value
Board-certified Age Gender U.S. medical school Practice type Full-time or part-time status Region of country Hours per week Years of experience ASA member Income
0.31 1.91 0.55 2.76 1.55 4.33 0.61 0.89 0.46 0.17 1.22
0.5813 0.0941 0.4588 0.0984 0.2156 0.0387 ⁎ 0.7664 0.4737 0.8354 0.6766 0.2870
⁎ P ≤ 0.05 (statistically significant difference).
findings from the focus group in measuring career satisfaction by domains among practicing anesthesiologists. Overall, three questions in the practice factor domain that were not internally consistent were removed for the final survey. Likewise, two questions in the initial personal factor domain that were not internally consistent were removed from the final survey. The linear regression model used to predict the career satisfaction scores, based on the independent demographic variables as well as the three domains, was formed from the 26 predictor questions. Advancing age and many other predictors had no impact on career satisfaction among practicing anesthesiologists [Table 5]. The only statistically significant predictors of career satisfaction among anesthesiologists included the following variables: 1) graduation from a U.S. medical school (P = 0.019); 2) full-time practice of anesthesiology (P = 0.032); 3) early satisfaction with the profession within the first 5 years of practice (P b 0.0001); and 4) working with respected peers (P = 0.03); and personal-health choice factors on career satisfaction (P = 0.004) [Table 5]. The Cronbach's alpha coefficient for the personal-health choices domain was 0.81, reflecting high internal consistency among the 8 survey questions in that domain. In the multivariate analysis of all responses to nondemographic survey questions, only the two questions that addressed the adverse effects of career choice on mental health (Q32) and on parenting (Q36) achieved statistically significant differences from all other survey question responses. Therefore, questions addressing career impact on mental health and parenting contributed to the significant predictive capability (P = 0.004) of personal-health choice factors in the regression model to a greater extent than other domainspecific responses and should be included in job satisfaction surveys for anesthesiologists [Table 4].
4. Discussion This survey study was designed to examine the impact of advancing age and other factors related to job satisfaction among practicing anesthesiologists attending the 2009 Annual Meeting of the American Society of Anesthesiologists. The study was conducted and analyzed in accordance with the recommendations for reporting survey results [6]. The demographic characteristics of the 304 survey responders mirrored the demographic characteristics of the ASA membership when compared with the ASA membership at that time with a mean age of the study subjects (45.3 yrs) similar to the mean age of the ASA membership (47.5 yrs). In addition, the sample gender representation in the study population (77.4% men) nearly matched that of the ASA membership (77.6% men). The external validity of this study was supported by the high survey response rate to a focus group pretested survey
Anesthesiologists' career satisfaction Table 4
293
Analysis of variance of survey outcome data
Question (#)
F-statistic
P-value
Working as an anesthesiologist is boring (14) Work hours (15) Impediments to promotion (16) Inadequate compensation (17) Sense of competition with younger anesthesiologists (18) Lack control over my schedule (19) Professional interactions with surgeons (20) Professional interactions with other attending anesthesiologists (21) Professional interactions with house staff (22) Adequate intellectual stimulation at work (23) Clinical cases lack variety (24) Being “phased out” and assigned less complex cases (25) Being “phased out” and assigned less operating room time (26) Feel threatened when new, young attendings join the service (27) Gained prestige over course of my career (28) Taking call is more difficult now (29) Have been selling calls (30) Affected my medical health (31) Affected my mental health (32) Affected my physical health (33) Affected having a faithful relationship (34) Affected a relationship with a significant other (35) Affected my role as a parent (36) Excessive alcohol consumption (37) Use of controlled substances (38) Difficult to learn new skills or to learn to use new technology (39) Concerned with threatening malpractice arena (40)
1.79 0.54 0.87 0.35 1.67
0.1522 0.6580 0.4592 0.7884 0.1749
1.66 0.95 1.96
0.1779 0.4169 0.1227
0.57 0.52 0.24 0.64
0.6365 0.6679 0.8675 0.5913
0.52
0.6678
1.45
0.2299
0.54 0.12 0.56 0.45 3.28 0.96 2.15 1.57 2.78 0.48 1.17 1.64
0.6551 0.9510 0.4566 0.7144 0.0226 ⁎ 0.4121 0.0957 0.1983 0.0427 ⁎ 0.6998 0.3221 0.1834
0.66
0.5792
⁎ P ≤ 0.05 (statistically significant difference).
(95%); the demographic consistency of the study subjects with the general membership of the ASA; the similarity of independent survey responses when stratified by demographics, and by the selection of the same validated practice, personnel/peer, personal/health, and financial domains as used in other survey investigations of job satisfaction among practicing physicians in other specialties [1-4]. Therefore, the completed and returned surveys comprised a representative sample of responses from the ASA membership target population and were assumed to reflect the opinions of practicing anesthesiologists at large. Advancing age and many other independent predictors had no statistically significant impact on career satisfaction among practicing anesthesiologists [Table 5]. The only statistically significant predictors of career satisfaction among anesthesiologists included the following variables: 1) graduation from a U.S. medical school (P = 0.019); 2) fulltime practice of anesthesiology (P = 0.032); 3) early satisfaction with the profession within the first 5 years of
practice (P b 0.0001); 4) working with respected peers (P = 0.03); and personal-choice factors (P = 0.004) [Table 5]. In 2011, Koshy and co-investigators reported the results of a survey study of job satisfaction and stress among Indian anesthesiologists and identified good interactions with surgical colleagues as stress preventers; our results supported their findings [7]. The results of this investigation have demonstrated that advancing age, gender, board certification, academicprivate-government practice, region of practice, hours worked per week, years in practice, ASA membership, and income levels had no statistically significant effect on career satisfaction among practicing anesthesiologists compared to full-time practice by U.S. graduates expressing satisfaction with their career choice in the first 5 years of practice. Gender and location of practice have been shown previously not to influence job satisfaction among practicing anesthesiologists, and this study confirmed those findings [8,9].
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Table 5 Linear regression model: predictors of career satisfaction among anesthesiologists P-value Variable Board-certified Age Gender U.S. medical school Practice type Full-time or part-time Region of the country Hours per week Years of experience ASA member Satisfaction with profession in first few yrs of practice Domain Income Practice factor Peer factor Personal factor
0.9712 0.0859 0.4893 0.0193 ⁎ 0.4516 0.0319 ⁎ 0.8542 0.2500 0.6321 0.7027 b 0.0001 ⁎
0.6092 0.5525 0.0300 ⁎ 0.0036 ⁎
⁎ P ≤ 0.05 (statistically significant).
In 2006, Fernandez Torres and co-investigators measured predictors for burnout among Spanish anesthesiologists using the Maslach Burnout Inventory, and reported no significant differences in burnout scores in relation to gender or region and type of practice [8]. Andrade and coinvestigators also demonstrated that gender had no significant effects on the measurement of burnout and stress levels as surrogates for job satisfaction among practicing anesthesiologists using previously validated survey instruments [9]. This study confirmed the findings of the prior investigations that both gender and regional location of practice had no statistically significant impact on career satisfaction among practicing anesthesiologists using a survey instrument designed to assess job satisfaction specifically among practicing anesthesiologists. There was no intention to leave or change specialty careers detected in this study. However, to date only one other study has addressed early career changes among anesthesiologists compared with other medical specialists. In 1982, Seltzer and Veloski reported changes in specialty choices among 1,151 graduates of the same medical school over the period 1968 - 1976 [10]. Of 31 graduates choosing anesthesiology as a career, 26 (84%) remained in anesthesiology, and 9 changed to other medical specialties [10]. The authors concluded that the ability of anesthesiology to retain physicians who originally planned to specialize in anesthesiology, or to gain physicians who switched to anesthesiology from other specialties, was no different from that found in the other specialties studied [10]. This survey study confirmed the earlier findings reported by Seltzer and Veloski [1]. Although this survey study was not designed to address specialty retention or reasons for retirement, it identified the interactions of career and personal health-
related issues and career and parental roles as significant contributors to career satisfaction that, if further addressed, may improve career recruitment, retention, and decisions regarding early retirement [3-13]. The design limitations of this study, which should be addressed in future investigations, included: 1) using a crosssectional survey design with convenience sampling that relied only on self-reported data, thereby introducing the possibility of recall bias for some survey items; 2) not using a previously validated survey instrument of job satisfaction, such as the Maslach Burnout Inventory or the Social Support and Personal Coping Survey; and 3) not readministering the survey to another different group of anesthesiologist to confirm test-retest reliability [10-12]. In conclusion, this survey study confirmed several findings of previous studies of job satisfaction among anesthesiologists using previously validated survey instruments [7-13]. As in a 2009 study with surveys mailed to 1,208 active and retired ASA members in Northern New England, this survey study found that chronological age is not a strong correlate of an individual’s practice pattern, behavior, or performance [13]. Designed specifically for anesthesiologists, the newly designed survey tool validated in this study also identified several other factors associated with career satisfaction among anesthesiologists. Full-time status, early satisfaction within the first 5 years of practice, working with respected peers and personal-health choice factors were all significantly associated with anesthesiologists’ job satisfaction. Job satisfaction among anesthesiologists was significantly influenced by a set of factors that could be targeted for improvement in order to increase career satisfaction among anesthesiologists. Further investigations that measure and confirm the significant predictors of job satisfaction among anesthesiologists using a validated survey instrument may increase career retention and career specialty choice of anesthesiology by medical graduates.
Acknowledgments The authors would like to thank Amit P. Prabhakar, BS, MS, Senior Medical Student and Research Associate, Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, LA; and Patrick Torres, BS, Medical Student and Research Associate, Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, for help with manuscript preparation.
References [1] Jenkins K, Wong D. A survey of professional satisfaction among Canadian anesthesiologists. Can J Anaesth 2001;48:637-45. [2] Keswani RN, Taft TH, Coté GA, Keefer L. Increased levels of stress and burnout are related to decreased physician experience and to
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interventional gastroenterology career choice: findings from a US survey of endoscopists. Am J Gastroenterol 2011;106:1734-40. DeMello JP, Deshpande SP. Career satisfaction of psychiatrists. Psychiatr Serv 2011;62:1013-8. Landon BE, Reschovsky J, Blumenthal D. Changes in career satisfaction among primary care and specialist physicians, 19972001. JAMA 2003;289:442-9. Cohen J. Statistical Power for the Behavioral Sciences. 2nd ed. Hillsdale (NJ): Lawrence Erlbaum Publishers; 1988. p. 6-17. Story DA, Gin V, na Ranong V, Poustie S, Jones D; ANZCA Trials Group. Inconsistent survey reporting in anesthesia journals. Anesth Analg 2011;113:591-5. Koshy RC, Ramesh B, Khan S, Sivaramakrishnan A. Job satisfaction and stress levels among anesthesiologists of south India. Indian J Anesthesiol 2011;55:513-7. Fernández Torres B, Roldán Pérez LM, Guerra Vélez A, Roldán Rodríguez T, Gutiérrez Guillén A, De las Mulas Béjar MM.
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Prevalence of burnout among anesthesiologists at Hospital Universitario Virgen Macarena de Sevilla. Rev Esp Anestesiol Reanim 2006;53:359-62. Andrade AN, de Albuquerque MA, Andrade A. Assessment of the stress level of anesthesiologists of the Sergipe anesthesiologists cooperative. Rev Brasil Anestesiol 2011;61:486-94. Seltzer JL, Veloski J. Changing specialties: do anesthesiologists differ from other physicians? Anesth Analg 1982;61:504-6. Travis KW, Mihevc NT, Orkin FK, Zeitlin GL. Age and anesthetic practice: a regional perspective. J Clin Anesth 1999; 11:175-86. Morais A, Maia P, Azevedo A, Amaral C, Tavares J. Stress and burnout among Portuguese anesthesiologists. Eur J Anaesthesiol 2006;23:433-9. Agnetti B, Pino O, Antonioni M. Sources of stress and burn-out in anesthesiologists. Reality and perspectives. Minerva Anestesiol 1989;55:277-81.
Original Contribution
Measuring determinants of career satisfaction of anesthesiologists: validation of a survey instrument☆,☆☆ Anoushka M. Afonso MD (Clinical Instructor)a , James H. Diaz MD, DrPH (Professor) b , Corey S. Scher MD (Associate Professor)c , Robbie A. Beyl BS, MS (Doctoral Candidate in Biostatistics)d , Singh R. Nair MD (Director, Clinical Research Anesthesia)e , Alan David Kaye MD, PhD (Professor and Chairman)b,⁎ a
Department of Anesthesiology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA Department of Anesthesiology, Louisiana Health Sciences University, New Orleans, New Orleans, LA 70112, USA c Department of Anesthesiology, New York University Langone Medical Center, New York, NY 10016, USA d School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA e Department of Anesthesiology, Montefiore Medical Center, Bronx, NY 10467, USA b
Received 20 July 2012; revised 1 January 2013; accepted 17 January 2013
Keywords: Anesthesiologists: aging; Burnout; Career satisfaction; Practice; Survey
Abstract Study Objective: To measure the parameter of job satisfaction among anesthesiologists. Design: Survey instrument. Setting: Academic anesthesiology departments in the United States. Subjects: 320 anesthesiologists who attended the annual meeting of the ASA in 2009 (95% response rate). Measurements and Main Results: The anonymous 50-item survey collected information on 26 independent demographic variables and 24 dependent ranked variables of career satisfaction among practicing anesthesiologists. Mean survey scores were calculated for each demographic variable and tested for statistically significant differences by analysis of variance. Questions within each domain that were internally consistent with each other within domains were identified by Cronbach’s alpha ≥ 0.7. P-values ≤ 0.05 were considered statistically significant. Cronbach’s alpha analysis showed strong internal consistency for 10 dependent outcome questions in the practice factor-related domain (α = 0.72), 6 dependent outcome questions in the peer factor-related domain (α = 0.71), and 8 dependent outcome questions in the personal factor-related domain (α = 0.81). Although age was not a variable, full-time status, early satisfaction within the first 5 years of practice, working with respected peers, and personal choice factors were all significantly associated with anesthesiologist job satisfaction. Conclusions: Improvements in factors related to job satisfaction among anesthesiologists may lead to higher early and current career satisfaction. © 2013 Elsevier Inc. All rights reserved.
☆
Supported by departmental funds only. Presented in part at the annual meeting of the American Society of Anesthesiologists, San Diego, CA, Oct. 16-20, 2010. ⁎ Correspondence: Alan David Kaye, MD, PhD, Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, Room 656, 1542 Tulane Ave., New Orleans, LA 70112, USA. Tel: + 1 504 568-2319; fax: + 1 504 568-2317. E-mail address: [email protected] (A.D. Kaye). ☆☆
0952-8180/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jclinane.2013.01.007
290
1. Introduction Anesthesiology has been recognized as a high-stress occupation; job stress and burnout have been significantly correlated with job dissatisfaction among anesthesiologists, gastroenterologists, psychiatrists, primary care practitioners, and other specialists [1-4]. While certain independent predictors of job dissatisfaction differ among the medical specialties, some remain constant across the specialties, including unexpected complications, increasing workloads, decreasing time off, reduced reimbursements, and malpractice suits [1-3]. Physicians who are satisfied with their careers have been shown to provide better health care and to have more satisfied patients [3]. Dissatisfaction among physicians leads to declining numbers of medical graduates entering that specialty, increasing rates of medical errors, and exodus from the specialty or the medical profession [3]. Since prior investigations have not examined the impact of advancing age and other demographics on job satisfaction among anesthesiologists, a cross-sectional survey study was designed to investigate 1) the impact of advancing age on the selection of anesthesiology as a satisfying career early or later in one’s career, and 2) the impact of several other demographic, practice, personnel, peer, financial, personal, and health-related factors on job satisfaction among practicing anesthesiologists over the span of their careers.
2. Materials and methods A focus group of practicing anesthesiologists was convened in the summer of 2009 at the Mt. Sinai Medical Center's Department of Anesthesiology in New York City, New York, in order to develop a survey on job satisfaction among anesthesiologists attending the 2009 American Society of Anesthesiologists (ASA) Annual Meeting in New Orleans, LA, October 16-19, 2009. Based on the recommendations of the focus group, job satisfaction was divided into 4 areas: practice-related, peer-related, personal health, and financially related. The subsequent survey study was designed to test the following null hypotheses: 1) that advancing age has no impact on the assessment of anesthesiology as a satisfying career early or later in one’s career as a practicing anesthesiologist; and that 2) demographics, practice-related factors, personnel and peer-related factors, personal and health-related factors, and financial factors have no impact on job satisfaction among practicing anesthesiologists. The 50-item survey was designed to collect information on 26 demographic factors as independent variables and 24 ranked variables of career satisfaction or not. The final analyzed survey consisted of 26 independent demographic variables and 24 dependent outcome variables, which were divided into the following three domains based on the professional recommendations of the focus group: 1)
A.M. Afonso et al. practice-related factors, 2) personnel and peer-related factors, and 3) personal and health-related factors [Table 1]. To test the associations between advancing age and other demographic factors on job satisfaction, a power analysis was conducted to determine the number of study subjects needed to be surveyed to achieve 90% statistical power to detect a true correlation of 0.3 at a 5% significance level [5]. The correlation coefficient value of 0.3 was chosen because this value is generally accepted to represent a moderate degree of association [5]. The sample size analysis indicated that 113 study subjects would need to be surveyed to achieve 90% statistical power. Since a listing of registered ASA meeting attendees was not available to the investigators, a nonrandomized convenience sample of meeting attendees was surveyed as randomized selection of survey subjects was not possible. The job satisfaction surveys were specifically designed for numerical coding to assure anonymity and confidentiality when administered to consenting anesthesiologists. Following Institutional Review Board (IRB) approval, the job satisfaction surveys were distributed to 320 ASA meeting attendees in the following 2 ways: 1) by practicing anesthesiologists, anesthesiology residents, and medical students attending a survey booth area at the ASA convention near the conference hall cafeteria; and 2) by practicing anesthesiologists, anesthesiology residents, and medical students directly handing out the surveys for completion by anesthesiologists from the conference hall cafeteria. To obtain a representative sample of the ASA Table 1
Stratification of the domains tested
Domain
Question (#)
Practice-related
Boring work (14), Excessive work (15) Intellectual stimulation (23) Case variety (24) Case complexity (25) Less OR time (26) Call difficulty (29) Selling calls (30) Learning new skills (39) Malpractice threats (40) Case competition (18) Schedule control (19) Surgeon staff interaction (20) Anesthesiologist staff interaction (21) House staff interaction (22) Younger competitors (27) Medical health (31) Mental health (32) Physical health (33) Sexual health (34) Relationships (35) Parental role (36) Alcohol use (37) Controlled substance use (38)
Personnel/peer-related
Personal/health-related
OR=operating room.
Anesthesiologists' career satisfaction Table 2
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Demographic characteristics of survey responders
Survey Responders Board-certified yes no Age (yrs) 20-30 31-40 41-50 51-60 N 60 Gender male female U.S. medical school yes no Practice Type academic private other Full-time or part-time status full-time part-time Region of practice New England Mid-Atlantic South Atlantic East North Central East South Central West North Central West South Central Mountain Pacific Hours worked per week b 40 40-50 50-60 60-70 N 70 Years of experience 0-5 5-10 10-20 20-30 30-40 40-50 N 50 ASA member Yes No Income b$50,000 $50,00-$99,000 $100,00-$149,999 $150,00-$199,999 $200,00-$249,999 $250,00-$299,999
Number (%)
Satisfaction [mean (SD)]
237 (77.70%) 68 (22.30%)
5.57 (1.27) 5.63 (1.45)
31 69 74 90 40
(10.16%) (22.62%) (24.26%) (29.51%) (13.11%)
5.70 5.65 5.52 5.47 5.80
(1.32) (1.32) (1.30) (1.35) (1.29)
236 (77.38%) 68 (22.30%)
5.61 (1.31) 5.53 (1.35)
193 (63.28%) 110 (36.07%)
5.50 (1.40) 5.74 (1.15)
133 (45.24%) 107 (36.39%) 54 (18.37%)
5.58 (1.27) 5.69 (1.29) 5.39(1.46)
281 (93.36%) 20 (6.64%)
5.56 (1.32) 5.80 (1.28)
17 81 42 28 19 11 35 8 20
(6.51%) (31.03%) (16.09%) (10.73%) (7.28%) (4.21%) (13.41%) (3.07%) (7.66%)
5.65 5.36 5.65 5.75 5.84 5.73 5.60 5.13 5.40
(1.32) (1.30) (1.37) (1.32) (1.17) (0.90) (1.31) (1.81) (1.39)
22 66 119 78 18
(7.26%) (21.78%) (39.27%) (25.74%) (5.94%)
5.45 5.47 5.57 5.70 5.72
(1.77) (1.32) (1.25) (1.27) (1.41)
82 46 60 79 28 6 1
(27.15%) (15.23%) (19.87%) (26.16%) (9.27%) (1.99%) (0.33%)
5.62 5.65 5.28 5.57 6.00 5.50 7.00
(1.35) (1.16) (1.38) (1.35) (1.31) (0.55) (.)
271 (89.14%) 33 (10.86%) 15 40 12 19 33 31
(5.30%) (14.13%) (4.24%) (6.71%) (11.66%) (10.95%)
5.55 (1.33) 5.88 (1.11) 6.07 5.45 5.83 5.47 5.30 5.58
(1.33) (1.38) (1.03) (1.90) (1.36) (1.34)
Table 2 (continued) Survey Responders $300,00-$399,999 $400,00-$499,999 N$500,000
Number (%) 72 (25.44%) 43 (15.19%) 18 (6.36%)
Satisfaction [mean (SD)] 5.80 (1.05) 5.44 (1.28) 6.00 (0.97)
active, nonresident membership, surveys were distributed only to practicing board-certified and board-eligible anesthesiologists. Study subjects were instructed to leave a question blank if they felt that none of the ranked response choices expressed how they felt or if the question did not apply to them or their practice pattern. The demographic factors of all respondents were considered as the independent or predictor indicators of job satisfaction versus dissatisfaction in a linear regression model and included age, gender, U.S. versus international medical school graduate, board certification, academicprivate-government practice, region of practice, hours worked per week, years in practice, ASA membership, early satisfaction in the first 5 years of practice, and income levels. For ease of administration, the independent demographic questions and the ranked survey outcome questions were combined into one 50-question instrument, but the independent and dependent variables were initially analyzed separately and then combined in a linear regression model. Mean (standard deviation) survey scores were calculated for each demographic predictor and satisfaction outcome variable and tested for statistically significant differences by analysis of variance (ANOVA). Two other statistical methods were applied to the survey results: 1) Cronbach’s alpha calculations for survey outcome questions per domain; and 2) linear regression of independent predictors of satisfaction on the dependent outcomes of career satisfaction or not. Cronbach’s alpha coefficients, which measure the internal consistency of a set of responses, were computed for every nondemographic survey question response and for the 4 domains of the survey: practicerelated, peer-related, personal health, and financially related. Questions within each domain that correlated and were internally consistent with each other were identified by a domain Cronbach’s alpha of 0.7 or greater. All dependent variables analyzed for internal consistency by Cronbach’s alpha were scored dichotomously (yes/no) or ranked on an ordinal, Likert scale. A linear regression model was used to correlate the independent demographic predictor variables with the individual domain scores of the practice-related, peerrelated, and personal-related domains on the dependent outcomes of satisfaction versus dissatisfaction. Regression (correlation) coefficients were then compared for statistically significant differences in the impact of the predictor variables on the outcomes of satisfaction versus dissatisfaction. SAS version 9.2 (SAS, Inc., Cary, NC, USA) was used for all data
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analysis. P-values less than or equal to 0.05 were considered to be statistically significant.
3. Results Of the 320 anesthesiologists surveyed, 304 survey subjects returned completed surveys, for a survey response rate of 95%, providing the study with more than adequate statistical power to detect associations of moderate strength among those completing the survey. Completed surveys were returned either to the survey booth or to clearly identified survey workers. Demographic characteristics of the survey respondents are shown in Table 2. The mean age of the study subjects (45.3 yrs) was similar to the mean age of the ASA membership (47.5 yrs) at the time. Initial statistical tests showed that the only demographic variable that affected the mean satisfaction scores was whether the anesthesiologist was practicing full-time or part-time (F = 4.33, P = 0.039) [Table 3]. Of the 26 satisfaction outcome questions, the only questions that had a statistically significant impact on the satisfaction scores were Question 32, practice affected their mental health (F = 3.28, P = 0.023), and Question 36, practice affected their role as a parent (F = 2.78, P = 0.043) [Table 4]. Initial Cronbach’s alpha analyses prior to survey distribution demonstrated strong (N 0.70) internal consistency for 10 dependent outcome questions in the practice factorrelated domain, 6 dependent outcome questions in the peer factor-related domain, and 8 dependent outcome questions in the personal factor-related domain for a total of 24 ranked survey outcome questions. Subsequently, the final Cronbach’s alpha analyses, by demonstrating that those questions were internally consistent among survey respondents confirmed that this part of the survey instrument was reliable. The 24-item survey outcome questions demonstrated strong internal consistency by domains on initial and subsequent analyses by Cronbach’s alpha and validated the
Table 3
Analysis of variance of demographic data
Demographic question
F-statistic
P-value
Board-certified Age Gender U.S. medical school Practice type Full-time or part-time status Region of country Hours per week Years of experience ASA member Income
0.31 1.91 0.55 2.76 1.55 4.33 0.61 0.89 0.46 0.17 1.22
0.5813 0.0941 0.4588 0.0984 0.2156 0.0387 ⁎ 0.7664 0.4737 0.8354 0.6766 0.2870
⁎ P ≤ 0.05 (statistically significant difference).
findings from the focus group in measuring career satisfaction by domains among practicing anesthesiologists. Overall, three questions in the practice factor domain that were not internally consistent were removed for the final survey. Likewise, two questions in the initial personal factor domain that were not internally consistent were removed from the final survey. The linear regression model used to predict the career satisfaction scores, based on the independent demographic variables as well as the three domains, was formed from the 26 predictor questions. Advancing age and many other predictors had no impact on career satisfaction among practicing anesthesiologists [Table 5]. The only statistically significant predictors of career satisfaction among anesthesiologists included the following variables: 1) graduation from a U.S. medical school (P = 0.019); 2) full-time practice of anesthesiology (P = 0.032); 3) early satisfaction with the profession within the first 5 years of practice (P b 0.0001); and 4) working with respected peers (P = 0.03); and personal-health choice factors on career satisfaction (P = 0.004) [Table 5]. The Cronbach's alpha coefficient for the personal-health choices domain was 0.81, reflecting high internal consistency among the 8 survey questions in that domain. In the multivariate analysis of all responses to nondemographic survey questions, only the two questions that addressed the adverse effects of career choice on mental health (Q32) and on parenting (Q36) achieved statistically significant differences from all other survey question responses. Therefore, questions addressing career impact on mental health and parenting contributed to the significant predictive capability (P = 0.004) of personal-health choice factors in the regression model to a greater extent than other domainspecific responses and should be included in job satisfaction surveys for anesthesiologists [Table 4].
4. Discussion This survey study was designed to examine the impact of advancing age and other factors related to job satisfaction among practicing anesthesiologists attending the 2009 Annual Meeting of the American Society of Anesthesiologists. The study was conducted and analyzed in accordance with the recommendations for reporting survey results [6]. The demographic characteristics of the 304 survey responders mirrored the demographic characteristics of the ASA membership when compared with the ASA membership at that time with a mean age of the study subjects (45.3 yrs) similar to the mean age of the ASA membership (47.5 yrs). In addition, the sample gender representation in the study population (77.4% men) nearly matched that of the ASA membership (77.6% men). The external validity of this study was supported by the high survey response rate to a focus group pretested survey
Anesthesiologists' career satisfaction Table 4
293
Analysis of variance of survey outcome data
Question (#)
F-statistic
P-value
Working as an anesthesiologist is boring (14) Work hours (15) Impediments to promotion (16) Inadequate compensation (17) Sense of competition with younger anesthesiologists (18) Lack control over my schedule (19) Professional interactions with surgeons (20) Professional interactions with other attending anesthesiologists (21) Professional interactions with house staff (22) Adequate intellectual stimulation at work (23) Clinical cases lack variety (24) Being “phased out” and assigned less complex cases (25) Being “phased out” and assigned less operating room time (26) Feel threatened when new, young attendings join the service (27) Gained prestige over course of my career (28) Taking call is more difficult now (29) Have been selling calls (30) Affected my medical health (31) Affected my mental health (32) Affected my physical health (33) Affected having a faithful relationship (34) Affected a relationship with a significant other (35) Affected my role as a parent (36) Excessive alcohol consumption (37) Use of controlled substances (38) Difficult to learn new skills or to learn to use new technology (39) Concerned with threatening malpractice arena (40)
1.79 0.54 0.87 0.35 1.67
0.1522 0.6580 0.4592 0.7884 0.1749
1.66 0.95 1.96
0.1779 0.4169 0.1227
0.57 0.52 0.24 0.64
0.6365 0.6679 0.8675 0.5913
0.52
0.6678
1.45
0.2299
0.54 0.12 0.56 0.45 3.28 0.96 2.15 1.57 2.78 0.48 1.17 1.64
0.6551 0.9510 0.4566 0.7144 0.0226 ⁎ 0.4121 0.0957 0.1983 0.0427 ⁎ 0.6998 0.3221 0.1834
0.66
0.5792
⁎ P ≤ 0.05 (statistically significant difference).
(95%); the demographic consistency of the study subjects with the general membership of the ASA; the similarity of independent survey responses when stratified by demographics, and by the selection of the same validated practice, personnel/peer, personal/health, and financial domains as used in other survey investigations of job satisfaction among practicing physicians in other specialties [1-4]. Therefore, the completed and returned surveys comprised a representative sample of responses from the ASA membership target population and were assumed to reflect the opinions of practicing anesthesiologists at large. Advancing age and many other independent predictors had no statistically significant impact on career satisfaction among practicing anesthesiologists [Table 5]. The only statistically significant predictors of career satisfaction among anesthesiologists included the following variables: 1) graduation from a U.S. medical school (P = 0.019); 2) fulltime practice of anesthesiology (P = 0.032); 3) early satisfaction with the profession within the first 5 years of
practice (P b 0.0001); 4) working with respected peers (P = 0.03); and personal-choice factors (P = 0.004) [Table 5]. In 2011, Koshy and co-investigators reported the results of a survey study of job satisfaction and stress among Indian anesthesiologists and identified good interactions with surgical colleagues as stress preventers; our results supported their findings [7]. The results of this investigation have demonstrated that advancing age, gender, board certification, academicprivate-government practice, region of practice, hours worked per week, years in practice, ASA membership, and income levels had no statistically significant effect on career satisfaction among practicing anesthesiologists compared to full-time practice by U.S. graduates expressing satisfaction with their career choice in the first 5 years of practice. Gender and location of practice have been shown previously not to influence job satisfaction among practicing anesthesiologists, and this study confirmed those findings [8,9].
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Table 5 Linear regression model: predictors of career satisfaction among anesthesiologists P-value Variable Board-certified Age Gender U.S. medical school Practice type Full-time or part-time Region of the country Hours per week Years of experience ASA member Satisfaction with profession in first few yrs of practice Domain Income Practice factor Peer factor Personal factor
0.9712 0.0859 0.4893 0.0193 ⁎ 0.4516 0.0319 ⁎ 0.8542 0.2500 0.6321 0.7027 b 0.0001 ⁎
0.6092 0.5525 0.0300 ⁎ 0.0036 ⁎
⁎ P ≤ 0.05 (statistically significant).
In 2006, Fernandez Torres and co-investigators measured predictors for burnout among Spanish anesthesiologists using the Maslach Burnout Inventory, and reported no significant differences in burnout scores in relation to gender or region and type of practice [8]. Andrade and coinvestigators also demonstrated that gender had no significant effects on the measurement of burnout and stress levels as surrogates for job satisfaction among practicing anesthesiologists using previously validated survey instruments [9]. This study confirmed the findings of the prior investigations that both gender and regional location of practice had no statistically significant impact on career satisfaction among practicing anesthesiologists using a survey instrument designed to assess job satisfaction specifically among practicing anesthesiologists. There was no intention to leave or change specialty careers detected in this study. However, to date only one other study has addressed early career changes among anesthesiologists compared with other medical specialists. In 1982, Seltzer and Veloski reported changes in specialty choices among 1,151 graduates of the same medical school over the period 1968 - 1976 [10]. Of 31 graduates choosing anesthesiology as a career, 26 (84%) remained in anesthesiology, and 9 changed to other medical specialties [10]. The authors concluded that the ability of anesthesiology to retain physicians who originally planned to specialize in anesthesiology, or to gain physicians who switched to anesthesiology from other specialties, was no different from that found in the other specialties studied [10]. This survey study confirmed the earlier findings reported by Seltzer and Veloski [1]. Although this survey study was not designed to address specialty retention or reasons for retirement, it identified the interactions of career and personal health-
related issues and career and parental roles as significant contributors to career satisfaction that, if further addressed, may improve career recruitment, retention, and decisions regarding early retirement [3-13]. The design limitations of this study, which should be addressed in future investigations, included: 1) using a crosssectional survey design with convenience sampling that relied only on self-reported data, thereby introducing the possibility of recall bias for some survey items; 2) not using a previously validated survey instrument of job satisfaction, such as the Maslach Burnout Inventory or the Social Support and Personal Coping Survey; and 3) not readministering the survey to another different group of anesthesiologist to confirm test-retest reliability [10-12]. In conclusion, this survey study confirmed several findings of previous studies of job satisfaction among anesthesiologists using previously validated survey instruments [7-13]. As in a 2009 study with surveys mailed to 1,208 active and retired ASA members in Northern New England, this survey study found that chronological age is not a strong correlate of an individual’s practice pattern, behavior, or performance [13]. Designed specifically for anesthesiologists, the newly designed survey tool validated in this study also identified several other factors associated with career satisfaction among anesthesiologists. Full-time status, early satisfaction within the first 5 years of practice, working with respected peers and personal-health choice factors were all significantly associated with anesthesiologists’ job satisfaction. Job satisfaction among anesthesiologists was significantly influenced by a set of factors that could be targeted for improvement in order to increase career satisfaction among anesthesiologists. Further investigations that measure and confirm the significant predictors of job satisfaction among anesthesiologists using a validated survey instrument may increase career retention and career specialty choice of anesthesiology by medical graduates.
Acknowledgments The authors would like to thank Amit P. Prabhakar, BS, MS, Senior Medical Student and Research Associate, Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, LA; and Patrick Torres, BS, Medical Student and Research Associate, Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, for help with manuscript preparation.
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