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Practice activities and career satisfaction among fellows of the South Atlantic Association of Obstetricians and Gynecologists
American Journal of Obstetrics
and Gynecology Founded in 1920
volume 169 number 2 part 1
AUGUST
1993
TRANSACTIONS OF THE FIFTY-FIFTH ANNUAL MEETING OF THE SOUTH ATLANTIC ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS Practice activities and career satisfaction among fellows of the South Atlantic Association of Obstetricians and Gynecologists Presidential address Edgar O. Horger III, MD
Columbia, South Carolina OBJECTIVE: The practice activities and career satisfaction of obstetricians and gynecologists in private practice were compared with those in a teaching faculty setting. STUDY DESIGN: The 475 fellOWS of the South Atlantic Association of Obstetricians and Gynecologists were surveyed; 314 responses (66.1 %) were received. Private practice and teaching faculty respondents were compared regarding practice description, factors influencing choice of practice type, practice activities, and career satisfaction. Data were examined by x2 testing and analysis of variance. RESULTS: Patient care involvement was the primary influence in practice choice by 86.0% of private practitioners; interest in teaching was the most important single factor for 58.2% of the teaching faculty. Significantly more teaching faculty than private practitioners had done research work during residency (81.2% vs 53.4%, P < 0.001). There were no differences regarding presentations at medical meetings during residency or publications from work performed during residency. The private practice group recorded more nights on call and more scheduled time off. The teaching faculty showed more publications, continuing medical education credits, hours worked per week, and medical meeting attendance. There were no differences in vacation days, malpractice charges, or expert witness appearances. The group showed no significant differences in their ratings of career satisfaction, but more of the teaching faculty group would elect again to enter obstetrics and gynecology if completing school today (82.4% vs 55.3%, P < 0.001). CONCLUSION: Professional activities of private practice physicians differ from those of teaching faculty physicians. The great majority of both groups are satisfied with their careers. (AM J OBSTET GVNECOL 1993;169:239-44.)
Key words: Survey, practice activities, career satisfaction From the Department of Obstetrics and Gynecology, University of South Carolina School of Medicine. Presented at the Fifth-fifth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Hot Springs, Virginia, January 31-February 3, 1993. Reprint requests: Edgar O. Horger III, MD, Department of Obstetrics and Gynecology, Two Richland Medical Park #208, Columbia, SC 29203. Copyright © 1993 by Mosby-Year Book, Inc. 0002-9378/93 $1.00 + .20 6/6/47755
Delivery of this presidential address is accompanied by a barrage of emotions. Excitement is certainly understandable, but I also have feelings of trepidation from standing before this august body, humility engendered by the addition of my name to your distinguished list of past presidents, and satisfaction gained from the experiences of my entire professional career. Your president completed his residency in obstetrics and
239
240 Horger
gynecology more than 25 years ago and embarked on an academic career involving teaching, research, and patient care. The satisfaction I have had with my career prompted me to look at the career choices made by others in obstetrics and gynecology. I wondered about practice activities, career satisfaction, and just why you chose to do what you do. Why did any of you choose obstetrics and gynecology? The thrill of the birth process, opportunity to perform surgical procedures, primary care of young, generally healthy people, active lifestyle, and financial considerations all are stated to be common factors in the selection of obstetrics and gynecology residency by graduating medical students. I. 2 The choice of obstetrics and gynecology training by graduating students has shown a fairly steady rise during the past decade, from 6.3% in 1981 to 7.1% in 1987 and 8.4% in 1992.3 . 4 On the other hand, many medical students point to the life-style, malpractice risks, and insurance premiums as primary reasons for their rejecting obstetrics and gynecology! Interest in academic careers appears to be increasing among graduating medical students. The graduation questionnaire administered yearly to all graduating seniors at United States medical schools shows academic careers to be about 33% more popular in 1992 than in 1981. This interest has shown a steady rise, from 22.5% in 1981 to 27.7% in 1986 and 30.0% in 1992. Interest in private practice has shown a modest decrease in this period, from 63.5% in 1981 to 54.1 % in 1992 ." 4 Although multiple factors must be operative in one's choice of practice type, interest in research and teaching and satisfaction achieved from patient care are stated most commonly. The South Atlantic Association of Obstetricians and Gynecologists has an excellent mix of private practitioners and academic faculty physicians. The two groups show excellent interaction and cooperation in management of the affairs of the association and in production of the scientific programs. Perhaps this cohesion is the reason I have had such pleasure and stimulation from the meetings of the association over the last 30 years. As a point of reference, I attended my first South Atlantic meeting as a first-year resident in 1964, and I have attended 22 of 30 meetings since that time, including the last 13 meetings in a row. I have appeared on your scientific program 10 times, and I have served on your Executive Board for the past 11 years. The mixture of private practitioners and academic faculty was discussed in 1983 at the first Executive Board meeting that I attended. There was some concern regarding a bylaws limitation of 250 active fellows and a long waiting list for membership. An ad hoc committee proposed a group of distinguished service fellows (primarily the professors) to be split off from the
August 1993 Am J Obstet Gynecol
role of active fellows, thereby allowing room for new initiates. I was pleased when our mixture of private practice and teaching faculty was allowed to remain intact by a simple bylaws amendment raising the number of active fellows to 300. Since that time I have wondered frequently about the differences between private practice doctors and teaching faculty within the South Atlantic Association of Obstetricians and Gynecologists. My questions and concerns prompted a survey of the association's members. Although the stated purposes of the survey were to assess the practice activities and career satisfaction of the fellows, I also wished to compare the private practice group with the teaching faculty group. Material and methods
A 58-point questionnaire was formulated to determine demographic characteristics, residency training, practice description, factors influencing choice of practice type, practice activities, and career satisfaction. The survey was mailed to all active fellows and senior fellows of the association on March 30, 1992. Of 475 surveys mailed, 314 responses (66.1 %) were received. Each question was analyzed separately. Some differences were noted in the number of respondents answering each question. When appropriate, X" testing and analysis of variance were performed on an IBM 3081 computer (IBM, Armonk, N.Y.) with SPSS software (SPSS, Chicago). A value of p < 0.05 was considered significant. Results
Personal data. The mean age of respondents was 58 ± 10.2 years (range 37 to 86 years). Three hundred and four (96.8%) were male, and 10 (3.2%) were female. Two hundred ninety-four (93 .9%) were married, 12 (3 .8%) were divorced or separated, and five (1.6%) had remained single. The spouse was gainfully employed in 23 .6% of the couples. Of those respondents who had ever married, all but one had one or more children (mean 3.06 ± 1.15, range 1 to 8). Professional data. Residency training had been completed in a university hospital by 79.9%, whereas 14.6% had trained in a community hospital and 5.5% in a military hospital. The mean year of residency completion was 1965 ± 9.9 years (range 1935 to 1984). All fellows of the South Atlantic Association are certified by the American Board of Obstetrics and Gynecology. The mean year of certification of the respondents was 1968 ± 9.2 years (range 1935 to 1987). Recertification had been achieved by 46.2%. The primary practice type was designated private practice by 210 (67.5%) respondents, teaching faculty by 69 (22.2%), and retired by 32 (10.3%). Excluding the
Horger 241
Volume 169, Number 2, Part 1 Am J Obstet Gynecol
Table I. Survey respondents' assessments of their practices, comparing private practice group with teaching faculty group (p < 0.001) Teaching faculty
Private practice Practice
No.
Obstetrics and gynecology Obstetrics Gynecology Endrocrinology-infertility Gynecologic oncology
110 2 86 5 7 210
TOTAL
1
%
No.
52.4 1.0 40.9 2.4 3.3 100.0
20 10 15 7 16 68
1
% 29.4 14.7 22.1 10.3 23.5 100.0
Table II. Survey respondents' assessments of time distribution (%) in their practices, comparing private practice group with teaching faculty group (p < 0.001) Activity
Patient care Research Education Administration
Private practice (n = 205) 92.1 0.4 3.3 4.2
:!: :!: :!: :!:
retired physicians, 130 of 278 respondents (46.8%) described their practice as both obstetrics and gynecology, 101 (36.3%) as primarily gynecology, 23 (8.3%) as gynecologic oncology, 12 (4.3%) as primarily obstetrics, and 12 (4.3%) as reproductive endocrinology or infertility. Exactly 50.0% noted that they continue at least some obstetrics practice. Group comparisons. With exclusion of those respondents who noted that they had retired, comparisons were made between the private practice group (n = 210) and the teaching faculty group (n = 69). Table I indicates that a higher percentage of teaching faculty than private practice fellows describe their practices as gynecologic oncology, primarily obstetrics, or reproductive endocrinology or infertility. This is thought to reflect the greater involvement in subspecialty certification among the teaching faculty (65.2% vs 17.3%, P < 0.001). Job setting of the private practice group was stated to be community hospital-based by 12.7%, full-time health maintenance organization by 0.5%, and simply private practice by the remaining 86.8%. In the teaching faculty group 85.1 % were university based and 14.9% were community hospital-based. The time distribution of the respondents is noted in Table II. Although patient care occupied the great majority of time for those in private practice, patient care also occupied more time than any of the other factors for the teaching faculty group. Factors influencing selection of practice type were explored through several points in the questionnaire. Fig. 1 illustrates those factors felt to be of most importance by the respondents in the two groups. In the
8.8 2.0 5.4 6.2
Teaching faculty (n 43.0 :!: 11.0 :!: 25.4:!: 20.6 :!:
=
65)
18.4 8.9 14.6 18.3
private practice group patient care involvement was the most important single factor for 86.0% and among the three most important factors for 96.6%. Interest in teaching was the most important single factor for 58.2% of the teaching faculty group and among the three most important factors for 97.0%. Interest in research was listed among the top three factors by 58.2% of this group, whereas 65.7% ranked patient care involvement this highly. Significantly more teaching faculty then private practitioners had done research work during residency training (81.2% vs 53.4%, P < 0.001). There were no significant differences noted in the number of private practice doctors and teaching faculty who had made presentations at medical meetings during residency (76.6% vs 73.1%) or who had published one or more articles from work performed during residency (68.6% vs 73.9%). Table III shows the number of papers published by the two groups of physicians during their professional .careers. Although the largest number of publications (245) was credited to a member of the private practice group, significantly more of the teaching faculty had one or more publications (97.1% vs 81.8%, P < 0.005) and ~ 10 publications (85.5% vs 13.9%, P < 0.001). Teaching faculty earned more continuing medical education credits than did private practice physicians. The teaching faculty group noted that 40.6% had earned ~ 100 continuing medical education credits in the past year, and 31.2% had earned ~ 150 credits. Corresponding figures for the private practice group are 16.1% and 4.5% (P < 0.001). Similarly, 73.4% of the teaching faculty group and 43.9% of the private
242
Horger
August 1993 Am J Obstet Gynecol
RESEARCH
f!:!I
PRIVATE
fZI
TEACHING
BUREAUCRACY
a
20
40
60
80
100
PERCENT Fig. 1. Factors influencing choice of practice type, comparing private practice group with teaching faculty group. Graph shows percentage of survey respondents in each group who selected each factor as one of three most important influences (p < 0.001).
Table III. Publications during professional career, comparing private practice group with teaching faculty group (p < 0.001) Private practice Publications
No.
0 1-9 10-19 20-29 30-39 40-49 50-59 2:60
38 142 7 9 4 0 1 8 209
I
practice group (p < 0.001) had earned ;;<: 150 continuing medical education credits in the past 3 years. The teaching faculty group recorded more hours worked in the office or in the hospital per average week. At least 60 hours per week were worked by 70.6% of thF. teaching faculty and 42.7% of the private practice group, whereas 13.3% of the teaching faculty and 7.4% of the private practitioners worked ;;<: 80 hours per week (p < 0.005). The private practice group listed more nights on call per average month. No call nights were recorded by 19.8% of the private practice group and 24.6% of the teaching faculty (not significant), whereas 62.4% of the private practitioners and only 8.7% of the teaching faculty (p < 0.001) recorded seven or more call nights per month. Of the teaching faculty group, 81.8% stated that they had no scheduled time off during the work week, whereas only 18.3% of the private practice group did
Teaching faculty %
No.
18.2 67.9 3.4 4.3 1.9
2 8 6 10 7 10 7 19 69
0.5 3.8
100.0
I
% 2.9 11.6 8.7 14.5 10.1 14.5 10.1 27.6
100.0
not have scheduled time off (p < 0.001). Similarly, 29.7% of the private practice group versus only 4.5% of the teaching faculty group had at least one full day off each week (p < 0.001). The teaching faculty group spent significantly more time at medical meetings than did the private practice group. Medical meeting attendance averaged :s; 10 days per year for 29.4% of the teaching faculty group versus 63.9% of the private practice group (p < 0.001). On the other hand, 63.2% of the teaching faculty versus 17.6% of the private practitioners attended medical meetings ;;<: 14 days per year (p < 0.001). Average vacation days per year did not differ significantly between the two groups. Eight to fourteen vacation days were used annually by 27.4% of the private practice group and 24.6% of the teaching faculty, 15 to 21 days by 30.9% of private practitioners and 37.7% of teaching faculty, and 22 to 28 days by 22.1 % and 26.1 %, respectively. More than 28 days' vacation were used by
Horger 243
Volume 169, Number 2, Part 1 Am J Obstet Gynecol
Table IV. Medical malpractice charges brought against physicians during professional career, comparing private practice group with teaching faculty group (not significant) Private practice Malpractice charges
No.
0 1 2
77 66 32 33 208
~3
I
Teaching faculty %
No.
37.0 31.7 15.4 15.9 100.0
28 16 15 8 67
I
% 41.8 23.9 22.4 11.9 100.0
Table V. Rating of satisfaction with professional career, comparing private practice group with teaching faculty group (not significant) Private practice Satisfaction rating
No.
1-2 3-4 5-6 7-8 9-10
1 10 23 71 102 207
I
15.2% of the private practice group and only 2.9% of the teaching faculty group, but this did not reach statistical significance. Given a variety of vacation choices, the respondents as a whole preferred beach vacations, followed in order by United States sightseeing, mountain trips, foreign travel, skiing, golf, and ocean cruises. No significant differences were noted in the frequency with which medical malpractice charges were brought against physicians in the two groups (Table IV). Similarly, there was no significant difference in the percentage of physicians in each of the two groups who had served as an expert witness in a malpractice suit (61.4% of private vs 73.9% of teaching). Career satisfaction. Each respondent was asked to rate degree of career satisfaction on the basis of 1 to 10, with 10 being highest. The mean rating of the combined groups was 8.17 ± 1.79. The ratings did not differ significantly between the two groups (Table V). However, when asked if they would choose again to enter the field of obstetrics and gynecology on completion of medical school today, significantly more of the teaching faculty group replied affirmatively (82.4% vs 55.3%, P < 0.001). If they were completing residency training in obstetrics and gynecology today, significantly more of the teaching faculty group would elect to take subspecialty fellowship training (95.6% vs 59.2%, P < 0.001). The questionnaire offered a situation in which medical school was completed today but training in obstetrics and gynecology was not permitted under any cir-
Teaching faculty %
No.
0.5 4.8
0 2 5 31 30 68
ILl
34.3 49.3 100.0
I
% 2.9 7.4 45.6 44.1 100.0
cumstances. Table VI shows the alternative specialties chosen by the respondents.
Comment Recent efforts to determine factors influencing the choice of private practice or academic careers have surveyed senior residents in pediatrics and internal medicine,5 pulmonary medicine fellows and practitioners,6 and radiologists in training and in practice.' No recent reports regarding the career choices of obstetricians and gynecologists are available, but one would assume that similar factors are operative. The likelihood of full-time private practice is based primarily on satisfaction achieved from patient care and the opportunity to help people. Additionally, a greater potential income level and a desire for autonomy, or a perceived freedom from bureaucracy and supervision, also appear to play significant roles in the choice of a private practice career. Preference for an academic career appears to be related to a perception of intellectual challenge and continued learning, interest in teaching, opportunity for research, influence of a faculty role model, participation in successful research during residency, personal publications during residency, and the opportunity to gain national recognition. 5 . ' It must be recognized that each of these papers was written by an academician and may be biased toward his or her particular viewpoint and goal. The current survey offered seven factors that may have influenced practice choice. Those factors of greatest influence to the private practitioners appear to have
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Horger
August 1993 Am J Obstet Gynecol
Table VI. Survey respondents' selection of alternative specialty if completing medical school today and training in obstetrics and gynecology were not permitted Specialty
No.
%
Surgical specialty Anesthesiology Radiology General surgery Orthopedics Family practice Ophthalmology Pathology Internal medicine Dermatology Urology Cardiology Psychiatry Pediatrics Neurology Other
68 26 24 21 19 18 18 18 12 9 9 7 5 1 0 15 270
25.2 9.6 8.9 7.8 7.0 6.7 6.7 6.7 4.4 3.3 3.3 2.6 1.8 0.4
been patient care involvement and income potential. Those who chose teaching careers stated that they were influenced by interest in teaching, patient care involvement, and interest in research. The choice of an academic career correlated significantly with performance of research work during residency. No correlation was noted between career choice and type of hospital in which residency occurred, publications during residency, or presentations during residency. The choice of academic career correlated significantly with postresidency fellowship training, but this may represent a post facto result of career choice rather than an influencing variable. The professional activities of the two practice groups differed in several respects. The private practice group recorded more call nights per month and more scheduled time off during the work week. The teaching faculty group showed significantly more subspecialization in obstetrics, endocrinology, or oncology; publications per physician; continuing medical education credits earned; hours worked per average week; and days spent at medical meetings each year. No significant differences were noted regarding vacation days per year, number of medical malpractice charges, or appearances as expert witnesses in malpractice suits. The essential question about our practice must relate to career satisfaction. Are our obstetricians and gynecologists happy in their work? The survey repondents rated their degree of satisfaction as 8.17 ± 1.79 out of a possible 10, and there were no differences in the ratings given by the two groups.
5.6 100.0
There are differences in the professional activities of the private practice physicians and teaching faculty physicians among the fellows of the South Atlantic Association of Obstetricians and Gynecologists. These differences generally define the interests of the two groups and cause no great schism between the groups. Those who work in these two groups chose their careers because of very acceptable, self-satisfYing reasons. The great majority of our fellows have continued this satisfaction through their careers. REFERENCES
1. Margolis AJ, Greenwood S, Heilbron D. Survey of men and women residents entering United States obstetrics and gynecology programs in 1981. AM] OBSTET GYNECOL 1983; 146:541-6. 2. Metheny WP, Blount H, Holzman GB. Considering obstetrics and gynecology as a specialty: current attractors and detractors. Obstet Gynecol 1991;78:308-12. 3. Tudor C. Career plans and debt levels of graduating U.S. medical students, 1981-1986.] Med Educ 1988;63:271-5. 4. Association of American Medical Colleges graduating student survey reports. Washington, DC.: Association of American Medical Colleges, 1987 through 1992. 5. Benson MC, Linn L, Ward N, Wells KB, Brook RH, Leake B. Career orientations of medical and pediatric residents. Med Care 1985;23:1256-64. 6. Schraufnagel DE, Rezler AG. Factors in the choice of academic or practice careers in pulmonary medicine. Am Rev Respir Dis 1986;133:937-41. 7. Hillman B], F~ardo LL, Witzke DB, Cardenas D, Irion M, Fulginiti ]V. Influences affecting radiologists' choices of academic or private practice careers. Radiology 1990; 174: 561-4.
and Gynecology Founded in 1920
volume 169 number 2 part 1
AUGUST
1993
TRANSACTIONS OF THE FIFTY-FIFTH ANNUAL MEETING OF THE SOUTH ATLANTIC ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS Practice activities and career satisfaction among fellows of the South Atlantic Association of Obstetricians and Gynecologists Presidential address Edgar O. Horger III, MD
Columbia, South Carolina OBJECTIVE: The practice activities and career satisfaction of obstetricians and gynecologists in private practice were compared with those in a teaching faculty setting. STUDY DESIGN: The 475 fellOWS of the South Atlantic Association of Obstetricians and Gynecologists were surveyed; 314 responses (66.1 %) were received. Private practice and teaching faculty respondents were compared regarding practice description, factors influencing choice of practice type, practice activities, and career satisfaction. Data were examined by x2 testing and analysis of variance. RESULTS: Patient care involvement was the primary influence in practice choice by 86.0% of private practitioners; interest in teaching was the most important single factor for 58.2% of the teaching faculty. Significantly more teaching faculty than private practitioners had done research work during residency (81.2% vs 53.4%, P < 0.001). There were no differences regarding presentations at medical meetings during residency or publications from work performed during residency. The private practice group recorded more nights on call and more scheduled time off. The teaching faculty showed more publications, continuing medical education credits, hours worked per week, and medical meeting attendance. There were no differences in vacation days, malpractice charges, or expert witness appearances. The group showed no significant differences in their ratings of career satisfaction, but more of the teaching faculty group would elect again to enter obstetrics and gynecology if completing school today (82.4% vs 55.3%, P < 0.001). CONCLUSION: Professional activities of private practice physicians differ from those of teaching faculty physicians. The great majority of both groups are satisfied with their careers. (AM J OBSTET GVNECOL 1993;169:239-44.)
Key words: Survey, practice activities, career satisfaction From the Department of Obstetrics and Gynecology, University of South Carolina School of Medicine. Presented at the Fifth-fifth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Hot Springs, Virginia, January 31-February 3, 1993. Reprint requests: Edgar O. Horger III, MD, Department of Obstetrics and Gynecology, Two Richland Medical Park #208, Columbia, SC 29203. Copyright © 1993 by Mosby-Year Book, Inc. 0002-9378/93 $1.00 + .20 6/6/47755
Delivery of this presidential address is accompanied by a barrage of emotions. Excitement is certainly understandable, but I also have feelings of trepidation from standing before this august body, humility engendered by the addition of my name to your distinguished list of past presidents, and satisfaction gained from the experiences of my entire professional career. Your president completed his residency in obstetrics and
239
240 Horger
gynecology more than 25 years ago and embarked on an academic career involving teaching, research, and patient care. The satisfaction I have had with my career prompted me to look at the career choices made by others in obstetrics and gynecology. I wondered about practice activities, career satisfaction, and just why you chose to do what you do. Why did any of you choose obstetrics and gynecology? The thrill of the birth process, opportunity to perform surgical procedures, primary care of young, generally healthy people, active lifestyle, and financial considerations all are stated to be common factors in the selection of obstetrics and gynecology residency by graduating medical students. I. 2 The choice of obstetrics and gynecology training by graduating students has shown a fairly steady rise during the past decade, from 6.3% in 1981 to 7.1% in 1987 and 8.4% in 1992.3 . 4 On the other hand, many medical students point to the life-style, malpractice risks, and insurance premiums as primary reasons for their rejecting obstetrics and gynecology! Interest in academic careers appears to be increasing among graduating medical students. The graduation questionnaire administered yearly to all graduating seniors at United States medical schools shows academic careers to be about 33% more popular in 1992 than in 1981. This interest has shown a steady rise, from 22.5% in 1981 to 27.7% in 1986 and 30.0% in 1992. Interest in private practice has shown a modest decrease in this period, from 63.5% in 1981 to 54.1 % in 1992 ." 4 Although multiple factors must be operative in one's choice of practice type, interest in research and teaching and satisfaction achieved from patient care are stated most commonly. The South Atlantic Association of Obstetricians and Gynecologists has an excellent mix of private practitioners and academic faculty physicians. The two groups show excellent interaction and cooperation in management of the affairs of the association and in production of the scientific programs. Perhaps this cohesion is the reason I have had such pleasure and stimulation from the meetings of the association over the last 30 years. As a point of reference, I attended my first South Atlantic meeting as a first-year resident in 1964, and I have attended 22 of 30 meetings since that time, including the last 13 meetings in a row. I have appeared on your scientific program 10 times, and I have served on your Executive Board for the past 11 years. The mixture of private practitioners and academic faculty was discussed in 1983 at the first Executive Board meeting that I attended. There was some concern regarding a bylaws limitation of 250 active fellows and a long waiting list for membership. An ad hoc committee proposed a group of distinguished service fellows (primarily the professors) to be split off from the
August 1993 Am J Obstet Gynecol
role of active fellows, thereby allowing room for new initiates. I was pleased when our mixture of private practice and teaching faculty was allowed to remain intact by a simple bylaws amendment raising the number of active fellows to 300. Since that time I have wondered frequently about the differences between private practice doctors and teaching faculty within the South Atlantic Association of Obstetricians and Gynecologists. My questions and concerns prompted a survey of the association's members. Although the stated purposes of the survey were to assess the practice activities and career satisfaction of the fellows, I also wished to compare the private practice group with the teaching faculty group. Material and methods
A 58-point questionnaire was formulated to determine demographic characteristics, residency training, practice description, factors influencing choice of practice type, practice activities, and career satisfaction. The survey was mailed to all active fellows and senior fellows of the association on March 30, 1992. Of 475 surveys mailed, 314 responses (66.1 %) were received. Each question was analyzed separately. Some differences were noted in the number of respondents answering each question. When appropriate, X" testing and analysis of variance were performed on an IBM 3081 computer (IBM, Armonk, N.Y.) with SPSS software (SPSS, Chicago). A value of p < 0.05 was considered significant. Results
Personal data. The mean age of respondents was 58 ± 10.2 years (range 37 to 86 years). Three hundred and four (96.8%) were male, and 10 (3.2%) were female. Two hundred ninety-four (93 .9%) were married, 12 (3 .8%) were divorced or separated, and five (1.6%) had remained single. The spouse was gainfully employed in 23 .6% of the couples. Of those respondents who had ever married, all but one had one or more children (mean 3.06 ± 1.15, range 1 to 8). Professional data. Residency training had been completed in a university hospital by 79.9%, whereas 14.6% had trained in a community hospital and 5.5% in a military hospital. The mean year of residency completion was 1965 ± 9.9 years (range 1935 to 1984). All fellows of the South Atlantic Association are certified by the American Board of Obstetrics and Gynecology. The mean year of certification of the respondents was 1968 ± 9.2 years (range 1935 to 1987). Recertification had been achieved by 46.2%. The primary practice type was designated private practice by 210 (67.5%) respondents, teaching faculty by 69 (22.2%), and retired by 32 (10.3%). Excluding the
Horger 241
Volume 169, Number 2, Part 1 Am J Obstet Gynecol
Table I. Survey respondents' assessments of their practices, comparing private practice group with teaching faculty group (p < 0.001) Teaching faculty
Private practice Practice
No.
Obstetrics and gynecology Obstetrics Gynecology Endrocrinology-infertility Gynecologic oncology
110 2 86 5 7 210
TOTAL
1
%
No.
52.4 1.0 40.9 2.4 3.3 100.0
20 10 15 7 16 68
1
% 29.4 14.7 22.1 10.3 23.5 100.0
Table II. Survey respondents' assessments of time distribution (%) in their practices, comparing private practice group with teaching faculty group (p < 0.001) Activity
Patient care Research Education Administration
Private practice (n = 205) 92.1 0.4 3.3 4.2
:!: :!: :!: :!:
retired physicians, 130 of 278 respondents (46.8%) described their practice as both obstetrics and gynecology, 101 (36.3%) as primarily gynecology, 23 (8.3%) as gynecologic oncology, 12 (4.3%) as primarily obstetrics, and 12 (4.3%) as reproductive endocrinology or infertility. Exactly 50.0% noted that they continue at least some obstetrics practice. Group comparisons. With exclusion of those respondents who noted that they had retired, comparisons were made between the private practice group (n = 210) and the teaching faculty group (n = 69). Table I indicates that a higher percentage of teaching faculty than private practice fellows describe their practices as gynecologic oncology, primarily obstetrics, or reproductive endocrinology or infertility. This is thought to reflect the greater involvement in subspecialty certification among the teaching faculty (65.2% vs 17.3%, P < 0.001). Job setting of the private practice group was stated to be community hospital-based by 12.7%, full-time health maintenance organization by 0.5%, and simply private practice by the remaining 86.8%. In the teaching faculty group 85.1 % were university based and 14.9% were community hospital-based. The time distribution of the respondents is noted in Table II. Although patient care occupied the great majority of time for those in private practice, patient care also occupied more time than any of the other factors for the teaching faculty group. Factors influencing selection of practice type were explored through several points in the questionnaire. Fig. 1 illustrates those factors felt to be of most importance by the respondents in the two groups. In the
8.8 2.0 5.4 6.2
Teaching faculty (n 43.0 :!: 11.0 :!: 25.4:!: 20.6 :!:
=
65)
18.4 8.9 14.6 18.3
private practice group patient care involvement was the most important single factor for 86.0% and among the three most important factors for 96.6%. Interest in teaching was the most important single factor for 58.2% of the teaching faculty group and among the three most important factors for 97.0%. Interest in research was listed among the top three factors by 58.2% of this group, whereas 65.7% ranked patient care involvement this highly. Significantly more teaching faculty then private practitioners had done research work during residency training (81.2% vs 53.4%, P < 0.001). There were no significant differences noted in the number of private practice doctors and teaching faculty who had made presentations at medical meetings during residency (76.6% vs 73.1%) or who had published one or more articles from work performed during residency (68.6% vs 73.9%). Table III shows the number of papers published by the two groups of physicians during their professional .careers. Although the largest number of publications (245) was credited to a member of the private practice group, significantly more of the teaching faculty had one or more publications (97.1% vs 81.8%, P < 0.005) and ~ 10 publications (85.5% vs 13.9%, P < 0.001). Teaching faculty earned more continuing medical education credits than did private practice physicians. The teaching faculty group noted that 40.6% had earned ~ 100 continuing medical education credits in the past year, and 31.2% had earned ~ 150 credits. Corresponding figures for the private practice group are 16.1% and 4.5% (P < 0.001). Similarly, 73.4% of the teaching faculty group and 43.9% of the private
242
Horger
August 1993 Am J Obstet Gynecol
RESEARCH
f!:!I
PRIVATE
fZI
TEACHING
BUREAUCRACY
a
20
40
60
80
100
PERCENT Fig. 1. Factors influencing choice of practice type, comparing private practice group with teaching faculty group. Graph shows percentage of survey respondents in each group who selected each factor as one of three most important influences (p < 0.001).
Table III. Publications during professional career, comparing private practice group with teaching faculty group (p < 0.001) Private practice Publications
No.
0 1-9 10-19 20-29 30-39 40-49 50-59 2:60
38 142 7 9 4 0 1 8 209
I
practice group (p < 0.001) had earned ;;<: 150 continuing medical education credits in the past 3 years. The teaching faculty group recorded more hours worked in the office or in the hospital per average week. At least 60 hours per week were worked by 70.6% of thF. teaching faculty and 42.7% of the private practice group, whereas 13.3% of the teaching faculty and 7.4% of the private practitioners worked ;;<: 80 hours per week (p < 0.005). The private practice group listed more nights on call per average month. No call nights were recorded by 19.8% of the private practice group and 24.6% of the teaching faculty (not significant), whereas 62.4% of the private practitioners and only 8.7% of the teaching faculty (p < 0.001) recorded seven or more call nights per month. Of the teaching faculty group, 81.8% stated that they had no scheduled time off during the work week, whereas only 18.3% of the private practice group did
Teaching faculty %
No.
18.2 67.9 3.4 4.3 1.9
2 8 6 10 7 10 7 19 69
0.5 3.8
100.0
I
% 2.9 11.6 8.7 14.5 10.1 14.5 10.1 27.6
100.0
not have scheduled time off (p < 0.001). Similarly, 29.7% of the private practice group versus only 4.5% of the teaching faculty group had at least one full day off each week (p < 0.001). The teaching faculty group spent significantly more time at medical meetings than did the private practice group. Medical meeting attendance averaged :s; 10 days per year for 29.4% of the teaching faculty group versus 63.9% of the private practice group (p < 0.001). On the other hand, 63.2% of the teaching faculty versus 17.6% of the private practitioners attended medical meetings ;;<: 14 days per year (p < 0.001). Average vacation days per year did not differ significantly between the two groups. Eight to fourteen vacation days were used annually by 27.4% of the private practice group and 24.6% of the teaching faculty, 15 to 21 days by 30.9% of private practitioners and 37.7% of teaching faculty, and 22 to 28 days by 22.1 % and 26.1 %, respectively. More than 28 days' vacation were used by
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Volume 169, Number 2, Part 1 Am J Obstet Gynecol
Table IV. Medical malpractice charges brought against physicians during professional career, comparing private practice group with teaching faculty group (not significant) Private practice Malpractice charges
No.
0 1 2
77 66 32 33 208
~3
I
Teaching faculty %
No.
37.0 31.7 15.4 15.9 100.0
28 16 15 8 67
I
% 41.8 23.9 22.4 11.9 100.0
Table V. Rating of satisfaction with professional career, comparing private practice group with teaching faculty group (not significant) Private practice Satisfaction rating
No.
1-2 3-4 5-6 7-8 9-10
1 10 23 71 102 207
I
15.2% of the private practice group and only 2.9% of the teaching faculty group, but this did not reach statistical significance. Given a variety of vacation choices, the respondents as a whole preferred beach vacations, followed in order by United States sightseeing, mountain trips, foreign travel, skiing, golf, and ocean cruises. No significant differences were noted in the frequency with which medical malpractice charges were brought against physicians in the two groups (Table IV). Similarly, there was no significant difference in the percentage of physicians in each of the two groups who had served as an expert witness in a malpractice suit (61.4% of private vs 73.9% of teaching). Career satisfaction. Each respondent was asked to rate degree of career satisfaction on the basis of 1 to 10, with 10 being highest. The mean rating of the combined groups was 8.17 ± 1.79. The ratings did not differ significantly between the two groups (Table V). However, when asked if they would choose again to enter the field of obstetrics and gynecology on completion of medical school today, significantly more of the teaching faculty group replied affirmatively (82.4% vs 55.3%, P < 0.001). If they were completing residency training in obstetrics and gynecology today, significantly more of the teaching faculty group would elect to take subspecialty fellowship training (95.6% vs 59.2%, P < 0.001). The questionnaire offered a situation in which medical school was completed today but training in obstetrics and gynecology was not permitted under any cir-
Teaching faculty %
No.
0.5 4.8
0 2 5 31 30 68
ILl
34.3 49.3 100.0
I
% 2.9 7.4 45.6 44.1 100.0
cumstances. Table VI shows the alternative specialties chosen by the respondents.
Comment Recent efforts to determine factors influencing the choice of private practice or academic careers have surveyed senior residents in pediatrics and internal medicine,5 pulmonary medicine fellows and practitioners,6 and radiologists in training and in practice.' No recent reports regarding the career choices of obstetricians and gynecologists are available, but one would assume that similar factors are operative. The likelihood of full-time private practice is based primarily on satisfaction achieved from patient care and the opportunity to help people. Additionally, a greater potential income level and a desire for autonomy, or a perceived freedom from bureaucracy and supervision, also appear to play significant roles in the choice of a private practice career. Preference for an academic career appears to be related to a perception of intellectual challenge and continued learning, interest in teaching, opportunity for research, influence of a faculty role model, participation in successful research during residency, personal publications during residency, and the opportunity to gain national recognition. 5 . ' It must be recognized that each of these papers was written by an academician and may be biased toward his or her particular viewpoint and goal. The current survey offered seven factors that may have influenced practice choice. Those factors of greatest influence to the private practitioners appear to have
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August 1993 Am J Obstet Gynecol
Table VI. Survey respondents' selection of alternative specialty if completing medical school today and training in obstetrics and gynecology were not permitted Specialty
No.
%
Surgical specialty Anesthesiology Radiology General surgery Orthopedics Family practice Ophthalmology Pathology Internal medicine Dermatology Urology Cardiology Psychiatry Pediatrics Neurology Other
68 26 24 21 19 18 18 18 12 9 9 7 5 1 0 15 270
25.2 9.6 8.9 7.8 7.0 6.7 6.7 6.7 4.4 3.3 3.3 2.6 1.8 0.4
been patient care involvement and income potential. Those who chose teaching careers stated that they were influenced by interest in teaching, patient care involvement, and interest in research. The choice of an academic career correlated significantly with performance of research work during residency. No correlation was noted between career choice and type of hospital in which residency occurred, publications during residency, or presentations during residency. The choice of academic career correlated significantly with postresidency fellowship training, but this may represent a post facto result of career choice rather than an influencing variable. The professional activities of the two practice groups differed in several respects. The private practice group recorded more call nights per month and more scheduled time off during the work week. The teaching faculty group showed significantly more subspecialization in obstetrics, endocrinology, or oncology; publications per physician; continuing medical education credits earned; hours worked per average week; and days spent at medical meetings each year. No significant differences were noted regarding vacation days per year, number of medical malpractice charges, or appearances as expert witnesses in malpractice suits. The essential question about our practice must relate to career satisfaction. Are our obstetricians and gynecologists happy in their work? The survey repondents rated their degree of satisfaction as 8.17 ± 1.79 out of a possible 10, and there were no differences in the ratings given by the two groups.
5.6 100.0
There are differences in the professional activities of the private practice physicians and teaching faculty physicians among the fellows of the South Atlantic Association of Obstetricians and Gynecologists. These differences generally define the interests of the two groups and cause no great schism between the groups. Those who work in these two groups chose their careers because of very acceptable, self-satisfYing reasons. The great majority of our fellows have continued this satisfaction through their careers. REFERENCES
1. Margolis AJ, Greenwood S, Heilbron D. Survey of men and women residents entering United States obstetrics and gynecology programs in 1981. AM] OBSTET GYNECOL 1983; 146:541-6. 2. Metheny WP, Blount H, Holzman GB. Considering obstetrics and gynecology as a specialty: current attractors and detractors. Obstet Gynecol 1991;78:308-12. 3. Tudor C. Career plans and debt levels of graduating U.S. medical students, 1981-1986.] Med Educ 1988;63:271-5. 4. Association of American Medical Colleges graduating student survey reports. Washington, DC.: Association of American Medical Colleges, 1987 through 1992. 5. Benson MC, Linn L, Ward N, Wells KB, Brook RH, Leake B. Career orientations of medical and pediatric residents. Med Care 1985;23:1256-64. 6. Schraufnagel DE, Rezler AG. Factors in the choice of academic or practice careers in pulmonary medicine. Am Rev Respir Dis 1986;133:937-41. 7. Hillman B], F~ardo LL, Witzke DB, Cardenas D, Irion M, Fulginiti ]V. Influences affecting radiologists' choices of academic or private practice careers. Radiology 1990; 174: 561-4.