- Email: [email protected]
Practice patterns and job satisfaction in fellowship-trained endocrine surgeons
American Association of Endocrine Surgeons Practice patterns and job satisfaction in fellowship-trained endocrine surgeons Michael Tsinberg, MD, Quan-Yang Duh, MD, Robin M. Cisco, MD, Jessica E. Gosnell, MD, Anouk Scholten, MD, Orlo H. Clark, MD, and Wen T. Shen, MD, San Francisco, CA
Background. Debates about the difficult job market for young endocrine surgeons are ongoing. This study aimed to analyze the practice patterns and work-related satisfaction levels of recently trained endocrine surgeons. Methods. An anonymous survey was utilized. Participants were divided into 3 groups: ‘‘Young’’ (<3 years in practice), ‘‘middle’’ (3–5 years), and ‘‘older’’ (>5 years). Results. Fifty-six of 78 surgeons (72%) responded to the survey. Time in practice ranged from 1 to 9 years (mean, 3.9 ± 0.28). Forty-five (80%) described their practice as academic. Participants performed 244.1 ± 17.8 operations within the last year; 75.4 ± 3.3% were endocrine cases. More surgeons in the ‘‘young’’ group have academic practices (92%) and joined established endocrine surgery groups (54%) versus older surgeons (67% and 42%; P = .05). Of surgeons in the ‘‘young’’ group, 4% started their own practice versus 33% in the ‘‘older’’ group (P = .04). Level of satisfaction with financial compensation (3.2 on a 4-point scale versus 2.9) and lifestyle (3.6 vs 3.1) was also higher in the younger group (P = .009). Conclusion. Despite widespread speculation about scarcity of academic jobs after fellowship, recently trained endocrine surgeons are more likely to practice in academic settings and join established endocrine surgery practices when compared with older surgeons. Overall satisfaction level is higher among recently trained surgeons. (Surgery 2012;152:953-6.) From the Department of Surgery, University of California San Francisco, San Francisco, CA
ENDOCRINE SURGERY is a rapidly growing subspecialty of general surgery. The American Association of Endocrine Surgeons (AAES) was established in 1981 and continues to grow, with >400 members at this time. As the field of endocrine surgery evolves and matures, there is a growing need for advanced postgraduate training in this discipline. This need is also based on better outcomes after procedures done by fellowship-trained surgeons in high volume medical centers.1,2 Many general surgery residents want to proceed with an academic career and consider applying for fellowship training after residency completion. Practicing endocrine surgery has traditionally implied working in a large, academic medical Accepted for publication August 20, 2012. Reprint requests: Michael Tsinberg, MD, UCSF Department of Surgery, 1600 Divisadero Street, 3rd floor, C-347, San Francisco, CA 94115. E-mail: [email protected]. 0039-6060/$ - see front matter Ó 2012 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2012.08.032
center, and those hospitals usually have limited open positions for newly trained endocrine surgeons. Debates about the difficult job market for young endocrine surgeons take place every year at the AAES, American College of Surgeons, and other surgical meetings. We aimed to collect data regarding the job market for fellowship-trained endocrine surgeons. To do so, we performed a survey of fellowshiptrained endocrine surgeons from the past decade and analyzed their practice patterns and workrelated satisfaction levels. Based on the ongoing debates and discussions regarding bleak job prospects for young endocrine surgeons, we hypothesized that recently trained endocrine surgeons are less likely to practice in academic centers and are less satisfied with their work than their older fellowship-trained counterparts. MATERIALS AND METHODS Graduates of endocrine surgery fellowship programs were identified using the AAES website and through direct communication with fellowship SURGERY 953
954 Tsinberg et al
program directors and administrators. An anonymous survey was sent via email and responses were collected using the www.surveymonkey.com website. Our goal was to contact as many as possible fellowship graduates in each program. We were able to identify and contact endocrine surgeons who graduated from their fellowship in the time range from 1 to 9 years ago. The survey was focused on practice patterns of fellowship-trained endocrine surgeons and their satisfaction level. It included 8 questions regarding amount of endocrine versus general surgery cases performed per year, comfort level practicing endocrine surgery after fellowship training, satisfaction level with financial compensation, case mix, and lifestyle. An additional field for general comments was included in the survey as well. Here are our survey questions: 1. How many years have you been in practice since your fellowship? 2. How would you describe your current surgical practice---academic, private, or other (describe)? 3. How many cases have you done in the last year and how many of those were endocrine? 4. Have you joined an established endocrine surgery practice, general surgery group, or started your own practice? 5. How would you break down your number of cases for the last year: A. Thyroid B. Parathyroid C. Adrenals D. Pancreas E. General surgery 6. How would you grade your level of satisfaction (4 – completely satisfied, 3 – satisfied, 2 – could be better, 1 – not satisfied) with: A. Lifestyle B. Financial compensation C. Case mix 7. If you would be able to go back in time to your residency, would you pick another subspecialty? 8. General comments.
Data were analyzed using JMP statistical software. Results are presented as mean values ± standard error of the mean. RESULTS The survey was sent to 78 fellowship-trained endocrine surgeons; 56 (72%) responded. There were 29 men (52%) and 27 women (48%) in the study.
Surgery December 2012
Time since graduation ranged from 1 to 9 years (mean, 3.9 ± 0.28). Forty-five surgeons (80%) described their practice as academic and 11 (20%) as private. Twenty-five (45%) surgeons began their careers by joining an established endocrine surgery group, 23 (41%) joined an established general surgery group, and 8 (14%) started their own surgical practice. The mean number of operations done in the last 12 months was 244.1 ± 17.8, of which 75.4 ± 3.3% were endocrine cases. Distribution of surgical procedures was as follows: 110.3 ± 9.9 thyroid operations, 56.6 ± 5.8 parathyroid, 12 ± 1.6 adrenalectomies, 2.8 ± 0.8 pancreatic resections, and 65 ± 11.4 general surgery cases. Forty-two surgeons (75%) rated their fellowship training as 5 on the scale from 1 to 5 and 14 (25%) considered it to be 4. Thirty-one respondents (55%) said that they are completely satisfied with their lifestyle, 23 (41%) were satisfied, and 2 (4%) answered ‘‘could be better.’’ Fourteen (25%) were completely satisfied with financial compensation, 38 (68%) were satisfied, and 4 (7%) answered ‘‘could be better.’’ Satisfaction with case mix included 25 (45%) completely satisfied, 26 (46%) satisfied, and 5 (9%) ‘‘could be better.’’ Fifty-one surgeons (91%) answered that in retrospect they would not choose another subspecialty in surgery, whereas 5 (9%) would possibly have chosen differently. Participants were divided in 3 groups based on time since fellowship graduation: 24 ‘‘young’’ (3 years in practice; 43%), 20 ‘‘middle’’ (5 years in practice; 36%), and 12 ‘‘older’’ (>5 years in practice; 21%). Subgroup analysis is presented in the Table. There was no correlation between job satisfaction levels and amount of general versus endocrine cases done per year. DISCUSSION The primary goal of this study was to analyze and better understand the current job market and job satisfaction levels for young endocrine surgeons. We hypothesized that recent fellowshiptrained endocrine surgeons would be less likely to find academic positions and would have lower job satisfaction when compared with older fellowshiptrained endocrine surgeons. The results of our survey provided evidence to the contrary. Solorzano et al, in their survey of young endocrine surgeons in 2009, showed that general surgery residents who train at academic programs with endocrine surgery fellowships seem more likely to enter the specialty, in part because of their exposure to mentors, enhanced opportunities to do research, and increased numbers of endocrine
Tsinberg et al 955
Surgery Volume 152, Number 6
Table. Analysis of 3 groups: ‘‘Young,’’ ‘‘middle,’’ and ‘‘older’’: Surgical practice patterns and satisfaction levels ‘‘Young’’ Type of practice, n (%) Academic Private Cases last 12 months (% endocrine) Thyroid cases Parathyroid cases Adrenalectomies Pancreatic cases General surgery cases Satisfaction level (1–4) Lifestyle Financial Case mix Would you pick another subspecialty? n (%) No Possibly
‘‘Middle’’
‘‘Older’’
15 (75) 5 (25) 307.7 ± 24.4 (75) 142.2 ± 17.1 62.7 ± 8 14.6 ± 2.6 4 ± 1.7 87.6 ± 24.3
8 (67) 4 (33) 320 ± 31.6 (80) 142.3 ± 18.7 97.1 ± 13.2 18 ± 4.7 2.4 ± 1.6 60.2 ± 17.2
3.6 3.2 3.1
3.7 3.4 3.6
3.1 2.6 3.4
21 (88) 3 (12)
19 (95) 1 (5)
11 (92) 1 (8)
P value .005
22 2 153.2 ± 67.9 ± 31.4 ± 6.7 ± 1.9 ± 48 ±
(92) (8) 22.3 (73) 11.5 5.9 1.6 0.7 14.8
.005 .0001 <.0001 .0005 <.0001 .005 .006 .05
.1
procedures performed during residency.3 Ellis et al, in their recent analysis concluded that surgical residents have completed more dedicated research years and were increasingly likely to seek fellowship training over time.4 Borman et al reviewed long-term data from the American Board of Surgery and reported that the percentage of general surgery residents choosing fellowships increased from 67 to 77% from 1993 to 2005.5 This trend of increasing numbers of residents seeking subspecialty training after completion of training is clearly present and may signify that more young surgeons would like to stay in academic settings to further pursue and practice their subspecialty field. Despite widespread speculation about the difficulty of finding an academic job after fellowship training, the results of this survey demonstrate that recently trained endocrine surgeons are more likely to practice in academic settings and join established endocrine surgery practices when compared with older fellowship-trained endocrine surgeons. This is most likely related to the increased number of academic fellowship programs as well as expanding demand for fellowship-trained surgeons in those programs. In the 30 years since its founding, the AAES has nearly quintupled its membership, and the number of fellowship programs has doubled in the last 5 years.6 This may help to explain the fact that more newly trained endocrine surgeons joined established endocrine surgery groups versus the higher proportion of surgeons from the ‘‘older’’ group who started practicing on their own.
Satisfaction level with financial compensation may be lower in the ‘‘older’’ group because reimbursements for operative procedures are declining. Satisfaction with the case mix may be lower in the ‘‘young’’ group because these more junior surgeons may have to do more general surgery cases in the beginning of their career as they establish their endocrine surgical practice. Satisfaction with lifestyle is has been considered a controversial topic in the surgical profession. Most surgeons are satisfied with their careers. Areas in need of improvement, particularly for non-university surgeons (more in ‘‘older’’ group), include reimbursement, work hours, and litigation.7-10 Despite our findings, we speculate that the field of endocrine surgery may likely experience further changes in job availability within the next decade as the job market hits its saturation point. Debates regarding the optimum number of fellowship programs and training positions will undoubtedly continue as the field grows and evolves. In conclusion, this survey of fellowship-trained endocrine surgeons from the past decade reveals that recent endocrine surgery graduates are highly likely to find positions in academic medical centers and are more satisfied with their jobs and compensation when compared with older, fellowshiptrained endocrine surgeons. We realize that our study is more like a snapshot in time and considering rapidly increasing number of fellowship graduates may not reflect current (this year and subsequent years) picture of the job market. That is why we think that close monitoring of the job market and the number of fellowship programs and
956 Tsinberg et al
positions by fellowship program directors and other leaders of the field will be required. REFERENCES 1. Sosa JA, Wang TS, Yeo HL, Mehta PJ, et al. The maturation of a specialty: workforce projections for endocrine surgery. Surgery 2007;142:876-83. 2. Mitchell J, Milas M, Barbosa G, Sutton J, et al. Avoidable reoperations for thyroid and parathyroid surgery: effect of hospital volume. Surgery 2008;144:899-906. 3. Solorzano C, Sosa JA, Lechner SZ, et al. Endocrine surgery: where are we today? A national survey of young endocrine surgeons Surgery 2010;147:536-41. 4. Ellis MC, Dhungel B, Weerasinghe R, et al. Trends in research time, fellowship training, and practice patterns among general surgery graduates. J Surg Educ 2011;68:309-12. 5. Borman KR, Vick LR, Biester TW, et al. Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery. J Am Coll Surg 2008;206:782-8. 6. Thompson NW. The founding of the American Association of Endocrine Surgeons: the time was right. Surgery 2011; 150:1303-7. 7. Balch CM, Shanafelt TD, Sloan JA, et al. Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Ann Surg 2011;254:558-68. 8. Troppmann KM, Palis BE, Goodnight JE, et al. Career and lifestyle satisfaction among surgeons: what really matters? The National Lifestyles in Surgery Today Survey. J Am Coll Surg 2009;209:160-9. 9. Campbell DA Jr. Physician wellness and patient safety. Ann Surg 2010;251:1001-2. 10. Kuerer HM, Eberlein TJ, Pollock RE, et al. Career satisfaction, practice patterns and burnout among surgical oncologists: report on the quality of life of members of the Society of Surgical Oncology. Ann Surg Oncol 14:3043-53.
DISCUSSION Dr John B. Hanks (Charlottesville, VA): The American Board of Surgery has looked into the proliferation of fellowships with regard to fellowships across the board. And one of the reasons that a lot of the finishing general surgery residents are going into fellowships is looking for some independence, and the thought that they are trying to develop confidence in doing their cases. In your study, or with your data, do you have any feeling for satisfaction being correlated with confidence and independence of doing cases? Because I think that would have a lot to do with going into academics or into privates. Dr Michael Tsinberg (San Francisco, CA): There was a question on the survey about how comfortable do you feel after your fellowship training. There was a scale from 1 through 5. So it was about, I think, 10% of people responded 4, so not completely confident. But I didn’t see any correlation between that and training and confidence level in that particular study. Dr Sally E. Carty (Pittsburgh, PA): How old was your oldest respondent? One of the oldest methods for training in endocrine surgery is the apprenticeship. And one of the second oldest was going to NIH as a clinical associate in surgical oncology and training with Jeff Norton
Surgery December 2012
or Dr Brennan, or whoever was the dominant endocrine surgeon at the time. How old or young were your respondents? Dr Michael Tsinberg: Well, we didn’t survey by age, per se; just the time since fellowship. So I can’t really answer about that. I know that it was 9 years after completion of fellowship was kind of the oldest participant, but I’m not sure about the age. Dr Michael Yeh (Los Angeles, CA): I know you raised the issue of saturation. I think we are far from saturated. Paul Gauger has a nice paper showing that only one fourth of endocrine cases nationally are performed by someone with any interest in the field. We validated that finding a couple of years ago with an outcomes study. So I think there are a lot of cases still to be done by endocrine surgeons. And I think the limiting factor, in terms of finding jobs, is convincing hospital CEOs, deans, and chairs that they do need an endocrine surgeon. Dr Michael Tsinberg: I totally agree. Dr Jennifer Rosen (Boston, MA): And I think I fall comfortably into the middle-aged surgeon, maybe old. I’m not sure. I have 2 comments and a question. The comments really are to consider looking at gender, if you are able to collect enough data, to do a logistic regression in the future, because gender might have a strong influence on that. And you might find that there are differences in how many in each gender and the different age groups. And we know that gender is a factor in job satisfaction. So the second is, you also might consider asking a next-level question about the reason for satisfaction or dissatisfaction if they went into an endocrine academic job with the idea that they would be doing primarily endocrine surgery. And then the question for you is, how does this compare with, say, SSO fellowship-trained surgeons? Dr Michael Tsinberg: I can’t make comment on that because I am just not familiar with the data of SSO fellowship. Dr Samuel Snyder (Temple, TX): I’m pleased to see the high satisfaction results with the recent graduates of fellowships. I have 1 question. Were you able to take into account crossover between private practice and academic practice? Or did all of them start out in private practice and stay that way or start out in academic and none of them switched to private practice? Did your study account for that? Dr Michael Tsinberg: There wasn’t a specific question about this and we didn’t survey that part, if they crossed over or not. We just asked if they started in private or academic practice. And the presumption was that they stayed in the same practice. Dr Corry Weber (White Plains, NY): I think you bring up some important points for new fellowship graduates. As probably one of the older in your study, I’m one who actually shifted from an academic center to a more hospitalbased practice in a community. And I would just encourage you and your fellows to understand that there’s a very broad and rewarding profession out there beyond the academic centers. And, certainly, I do believe that the market is not saturated as well, and that you can find jobs.
Background. Debates about the difficult job market for young endocrine surgeons are ongoing. This study aimed to analyze the practice patterns and work-related satisfaction levels of recently trained endocrine surgeons. Methods. An anonymous survey was utilized. Participants were divided into 3 groups: ‘‘Young’’ (<3 years in practice), ‘‘middle’’ (3–5 years), and ‘‘older’’ (>5 years). Results. Fifty-six of 78 surgeons (72%) responded to the survey. Time in practice ranged from 1 to 9 years (mean, 3.9 ± 0.28). Forty-five (80%) described their practice as academic. Participants performed 244.1 ± 17.8 operations within the last year; 75.4 ± 3.3% were endocrine cases. More surgeons in the ‘‘young’’ group have academic practices (92%) and joined established endocrine surgery groups (54%) versus older surgeons (67% and 42%; P = .05). Of surgeons in the ‘‘young’’ group, 4% started their own practice versus 33% in the ‘‘older’’ group (P = .04). Level of satisfaction with financial compensation (3.2 on a 4-point scale versus 2.9) and lifestyle (3.6 vs 3.1) was also higher in the younger group (P = .009). Conclusion. Despite widespread speculation about scarcity of academic jobs after fellowship, recently trained endocrine surgeons are more likely to practice in academic settings and join established endocrine surgery practices when compared with older surgeons. Overall satisfaction level is higher among recently trained surgeons. (Surgery 2012;152:953-6.) From the Department of Surgery, University of California San Francisco, San Francisco, CA
ENDOCRINE SURGERY is a rapidly growing subspecialty of general surgery. The American Association of Endocrine Surgeons (AAES) was established in 1981 and continues to grow, with >400 members at this time. As the field of endocrine surgery evolves and matures, there is a growing need for advanced postgraduate training in this discipline. This need is also based on better outcomes after procedures done by fellowship-trained surgeons in high volume medical centers.1,2 Many general surgery residents want to proceed with an academic career and consider applying for fellowship training after residency completion. Practicing endocrine surgery has traditionally implied working in a large, academic medical Accepted for publication August 20, 2012. Reprint requests: Michael Tsinberg, MD, UCSF Department of Surgery, 1600 Divisadero Street, 3rd floor, C-347, San Francisco, CA 94115. E-mail: [email protected]. 0039-6060/$ - see front matter Ó 2012 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2012.08.032
center, and those hospitals usually have limited open positions for newly trained endocrine surgeons. Debates about the difficult job market for young endocrine surgeons take place every year at the AAES, American College of Surgeons, and other surgical meetings. We aimed to collect data regarding the job market for fellowship-trained endocrine surgeons. To do so, we performed a survey of fellowshiptrained endocrine surgeons from the past decade and analyzed their practice patterns and workrelated satisfaction levels. Based on the ongoing debates and discussions regarding bleak job prospects for young endocrine surgeons, we hypothesized that recently trained endocrine surgeons are less likely to practice in academic centers and are less satisfied with their work than their older fellowship-trained counterparts. MATERIALS AND METHODS Graduates of endocrine surgery fellowship programs were identified using the AAES website and through direct communication with fellowship SURGERY 953
954 Tsinberg et al
program directors and administrators. An anonymous survey was sent via email and responses were collected using the www.surveymonkey.com website. Our goal was to contact as many as possible fellowship graduates in each program. We were able to identify and contact endocrine surgeons who graduated from their fellowship in the time range from 1 to 9 years ago. The survey was focused on practice patterns of fellowship-trained endocrine surgeons and their satisfaction level. It included 8 questions regarding amount of endocrine versus general surgery cases performed per year, comfort level practicing endocrine surgery after fellowship training, satisfaction level with financial compensation, case mix, and lifestyle. An additional field for general comments was included in the survey as well. Here are our survey questions: 1. How many years have you been in practice since your fellowship? 2. How would you describe your current surgical practice---academic, private, or other (describe)? 3. How many cases have you done in the last year and how many of those were endocrine? 4. Have you joined an established endocrine surgery practice, general surgery group, or started your own practice? 5. How would you break down your number of cases for the last year: A. Thyroid B. Parathyroid C. Adrenals D. Pancreas E. General surgery 6. How would you grade your level of satisfaction (4 – completely satisfied, 3 – satisfied, 2 – could be better, 1 – not satisfied) with: A. Lifestyle B. Financial compensation C. Case mix 7. If you would be able to go back in time to your residency, would you pick another subspecialty? 8. General comments.
Data were analyzed using JMP statistical software. Results are presented as mean values ± standard error of the mean. RESULTS The survey was sent to 78 fellowship-trained endocrine surgeons; 56 (72%) responded. There were 29 men (52%) and 27 women (48%) in the study.
Surgery December 2012
Time since graduation ranged from 1 to 9 years (mean, 3.9 ± 0.28). Forty-five surgeons (80%) described their practice as academic and 11 (20%) as private. Twenty-five (45%) surgeons began their careers by joining an established endocrine surgery group, 23 (41%) joined an established general surgery group, and 8 (14%) started their own surgical practice. The mean number of operations done in the last 12 months was 244.1 ± 17.8, of which 75.4 ± 3.3% were endocrine cases. Distribution of surgical procedures was as follows: 110.3 ± 9.9 thyroid operations, 56.6 ± 5.8 parathyroid, 12 ± 1.6 adrenalectomies, 2.8 ± 0.8 pancreatic resections, and 65 ± 11.4 general surgery cases. Forty-two surgeons (75%) rated their fellowship training as 5 on the scale from 1 to 5 and 14 (25%) considered it to be 4. Thirty-one respondents (55%) said that they are completely satisfied with their lifestyle, 23 (41%) were satisfied, and 2 (4%) answered ‘‘could be better.’’ Fourteen (25%) were completely satisfied with financial compensation, 38 (68%) were satisfied, and 4 (7%) answered ‘‘could be better.’’ Satisfaction with case mix included 25 (45%) completely satisfied, 26 (46%) satisfied, and 5 (9%) ‘‘could be better.’’ Fifty-one surgeons (91%) answered that in retrospect they would not choose another subspecialty in surgery, whereas 5 (9%) would possibly have chosen differently. Participants were divided in 3 groups based on time since fellowship graduation: 24 ‘‘young’’ (3 years in practice; 43%), 20 ‘‘middle’’ (5 years in practice; 36%), and 12 ‘‘older’’ (>5 years in practice; 21%). Subgroup analysis is presented in the Table. There was no correlation between job satisfaction levels and amount of general versus endocrine cases done per year. DISCUSSION The primary goal of this study was to analyze and better understand the current job market and job satisfaction levels for young endocrine surgeons. We hypothesized that recent fellowshiptrained endocrine surgeons would be less likely to find academic positions and would have lower job satisfaction when compared with older fellowshiptrained endocrine surgeons. The results of our survey provided evidence to the contrary. Solorzano et al, in their survey of young endocrine surgeons in 2009, showed that general surgery residents who train at academic programs with endocrine surgery fellowships seem more likely to enter the specialty, in part because of their exposure to mentors, enhanced opportunities to do research, and increased numbers of endocrine
Tsinberg et al 955
Surgery Volume 152, Number 6
Table. Analysis of 3 groups: ‘‘Young,’’ ‘‘middle,’’ and ‘‘older’’: Surgical practice patterns and satisfaction levels ‘‘Young’’ Type of practice, n (%) Academic Private Cases last 12 months (% endocrine) Thyroid cases Parathyroid cases Adrenalectomies Pancreatic cases General surgery cases Satisfaction level (1–4) Lifestyle Financial Case mix Would you pick another subspecialty? n (%) No Possibly
‘‘Middle’’
‘‘Older’’
15 (75) 5 (25) 307.7 ± 24.4 (75) 142.2 ± 17.1 62.7 ± 8 14.6 ± 2.6 4 ± 1.7 87.6 ± 24.3
8 (67) 4 (33) 320 ± 31.6 (80) 142.3 ± 18.7 97.1 ± 13.2 18 ± 4.7 2.4 ± 1.6 60.2 ± 17.2
3.6 3.2 3.1
3.7 3.4 3.6
3.1 2.6 3.4
21 (88) 3 (12)
19 (95) 1 (5)
11 (92) 1 (8)
P value .005
22 2 153.2 ± 67.9 ± 31.4 ± 6.7 ± 1.9 ± 48 ±
(92) (8) 22.3 (73) 11.5 5.9 1.6 0.7 14.8
.005 .0001 <.0001 .0005 <.0001 .005 .006 .05
.1
procedures performed during residency.3 Ellis et al, in their recent analysis concluded that surgical residents have completed more dedicated research years and were increasingly likely to seek fellowship training over time.4 Borman et al reviewed long-term data from the American Board of Surgery and reported that the percentage of general surgery residents choosing fellowships increased from 67 to 77% from 1993 to 2005.5 This trend of increasing numbers of residents seeking subspecialty training after completion of training is clearly present and may signify that more young surgeons would like to stay in academic settings to further pursue and practice their subspecialty field. Despite widespread speculation about the difficulty of finding an academic job after fellowship training, the results of this survey demonstrate that recently trained endocrine surgeons are more likely to practice in academic settings and join established endocrine surgery practices when compared with older fellowship-trained endocrine surgeons. This is most likely related to the increased number of academic fellowship programs as well as expanding demand for fellowship-trained surgeons in those programs. In the 30 years since its founding, the AAES has nearly quintupled its membership, and the number of fellowship programs has doubled in the last 5 years.6 This may help to explain the fact that more newly trained endocrine surgeons joined established endocrine surgery groups versus the higher proportion of surgeons from the ‘‘older’’ group who started practicing on their own.
Satisfaction level with financial compensation may be lower in the ‘‘older’’ group because reimbursements for operative procedures are declining. Satisfaction with the case mix may be lower in the ‘‘young’’ group because these more junior surgeons may have to do more general surgery cases in the beginning of their career as they establish their endocrine surgical practice. Satisfaction with lifestyle is has been considered a controversial topic in the surgical profession. Most surgeons are satisfied with their careers. Areas in need of improvement, particularly for non-university surgeons (more in ‘‘older’’ group), include reimbursement, work hours, and litigation.7-10 Despite our findings, we speculate that the field of endocrine surgery may likely experience further changes in job availability within the next decade as the job market hits its saturation point. Debates regarding the optimum number of fellowship programs and training positions will undoubtedly continue as the field grows and evolves. In conclusion, this survey of fellowship-trained endocrine surgeons from the past decade reveals that recent endocrine surgery graduates are highly likely to find positions in academic medical centers and are more satisfied with their jobs and compensation when compared with older, fellowshiptrained endocrine surgeons. We realize that our study is more like a snapshot in time and considering rapidly increasing number of fellowship graduates may not reflect current (this year and subsequent years) picture of the job market. That is why we think that close monitoring of the job market and the number of fellowship programs and
956 Tsinberg et al
positions by fellowship program directors and other leaders of the field will be required. REFERENCES 1. Sosa JA, Wang TS, Yeo HL, Mehta PJ, et al. The maturation of a specialty: workforce projections for endocrine surgery. Surgery 2007;142:876-83. 2. Mitchell J, Milas M, Barbosa G, Sutton J, et al. Avoidable reoperations for thyroid and parathyroid surgery: effect of hospital volume. Surgery 2008;144:899-906. 3. Solorzano C, Sosa JA, Lechner SZ, et al. Endocrine surgery: where are we today? A national survey of young endocrine surgeons Surgery 2010;147:536-41. 4. Ellis MC, Dhungel B, Weerasinghe R, et al. Trends in research time, fellowship training, and practice patterns among general surgery graduates. J Surg Educ 2011;68:309-12. 5. Borman KR, Vick LR, Biester TW, et al. Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery. J Am Coll Surg 2008;206:782-8. 6. Thompson NW. The founding of the American Association of Endocrine Surgeons: the time was right. Surgery 2011; 150:1303-7. 7. Balch CM, Shanafelt TD, Sloan JA, et al. Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Ann Surg 2011;254:558-68. 8. Troppmann KM, Palis BE, Goodnight JE, et al. Career and lifestyle satisfaction among surgeons: what really matters? The National Lifestyles in Surgery Today Survey. J Am Coll Surg 2009;209:160-9. 9. Campbell DA Jr. Physician wellness and patient safety. Ann Surg 2010;251:1001-2. 10. Kuerer HM, Eberlein TJ, Pollock RE, et al. Career satisfaction, practice patterns and burnout among surgical oncologists: report on the quality of life of members of the Society of Surgical Oncology. Ann Surg Oncol 14:3043-53.
DISCUSSION Dr John B. Hanks (Charlottesville, VA): The American Board of Surgery has looked into the proliferation of fellowships with regard to fellowships across the board. And one of the reasons that a lot of the finishing general surgery residents are going into fellowships is looking for some independence, and the thought that they are trying to develop confidence in doing their cases. In your study, or with your data, do you have any feeling for satisfaction being correlated with confidence and independence of doing cases? Because I think that would have a lot to do with going into academics or into privates. Dr Michael Tsinberg (San Francisco, CA): There was a question on the survey about how comfortable do you feel after your fellowship training. There was a scale from 1 through 5. So it was about, I think, 10% of people responded 4, so not completely confident. But I didn’t see any correlation between that and training and confidence level in that particular study. Dr Sally E. Carty (Pittsburgh, PA): How old was your oldest respondent? One of the oldest methods for training in endocrine surgery is the apprenticeship. And one of the second oldest was going to NIH as a clinical associate in surgical oncology and training with Jeff Norton
Surgery December 2012
or Dr Brennan, or whoever was the dominant endocrine surgeon at the time. How old or young were your respondents? Dr Michael Tsinberg: Well, we didn’t survey by age, per se; just the time since fellowship. So I can’t really answer about that. I know that it was 9 years after completion of fellowship was kind of the oldest participant, but I’m not sure about the age. Dr Michael Yeh (Los Angeles, CA): I know you raised the issue of saturation. I think we are far from saturated. Paul Gauger has a nice paper showing that only one fourth of endocrine cases nationally are performed by someone with any interest in the field. We validated that finding a couple of years ago with an outcomes study. So I think there are a lot of cases still to be done by endocrine surgeons. And I think the limiting factor, in terms of finding jobs, is convincing hospital CEOs, deans, and chairs that they do need an endocrine surgeon. Dr Michael Tsinberg: I totally agree. Dr Jennifer Rosen (Boston, MA): And I think I fall comfortably into the middle-aged surgeon, maybe old. I’m not sure. I have 2 comments and a question. The comments really are to consider looking at gender, if you are able to collect enough data, to do a logistic regression in the future, because gender might have a strong influence on that. And you might find that there are differences in how many in each gender and the different age groups. And we know that gender is a factor in job satisfaction. So the second is, you also might consider asking a next-level question about the reason for satisfaction or dissatisfaction if they went into an endocrine academic job with the idea that they would be doing primarily endocrine surgery. And then the question for you is, how does this compare with, say, SSO fellowship-trained surgeons? Dr Michael Tsinberg: I can’t make comment on that because I am just not familiar with the data of SSO fellowship. Dr Samuel Snyder (Temple, TX): I’m pleased to see the high satisfaction results with the recent graduates of fellowships. I have 1 question. Were you able to take into account crossover between private practice and academic practice? Or did all of them start out in private practice and stay that way or start out in academic and none of them switched to private practice? Did your study account for that? Dr Michael Tsinberg: There wasn’t a specific question about this and we didn’t survey that part, if they crossed over or not. We just asked if they started in private or academic practice. And the presumption was that they stayed in the same practice. Dr Corry Weber (White Plains, NY): I think you bring up some important points for new fellowship graduates. As probably one of the older in your study, I’m one who actually shifted from an academic center to a more hospitalbased practice in a community. And I would just encourage you and your fellows to understand that there’s a very broad and rewarding profession out there beyond the academic centers. And, certainly, I do believe that the market is not saturated as well, and that you can find jobs.