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Work-Related Quality of Life of US General Surgery Residents: Is It Really so Bad?
2017 APDS SPRING MEETING
Work-Related Quality of Life of US General Surgery Residents: Is It Really so Bad? Muhammad H. Zubair, MD, Lala R. Hussain, MSc, MHA, Kristen N. Williams, MD and Kevin J. Grannan, MD Department of Surgery, Good Samaritan Hospital, Cincinnati, Ohio PURPOSE: The quality of working life of US surgical residents
has not been studied, and given the complexity of interaction between work and personal life there is a need to assess this interaction. We utilized a validated Work Related Quality of Life (WRQoL) questionnaire to evaluate the perceived workrelated quality of life of general surgery residents, using a large, nationally representative sample in the United States. METHODS: Between January 2016 and March 2016, all
US general surgery residents enrolled in an ACGME general surgery training program were invited to participate. The WRQoL scale measures perceived quality of life covering six domains: General Well-Being (GWB), Home-Work Interface (HWI), Job and Career Satisfaction (JCS), Control at Work (CAW), Working Conditions (WCS) and Stress at Work (SAW). RESULTS: After excluding for missing data, the final analysis
included 738 residents. The average age was 30 (±3) years, of whom 287 (38.9%) were female, 272 (36.9%) were from a community hospital, and 477 (64.6%) were juniors (postgraduate year ≤ 3). Demographically, the respondents matched expected percentages. When male and female residents were compared, males had statistically better HWI (po0.001), better GWB (p ¼ 0.03), more CAW (p ¼ 0.0003) and WCS (p ¼ 0.001). Junior residents had a lower JCS (p ¼ 0.002) and CAW (p ¼ 0.04) compared to seniors. There were no differences between university and community residents in any of the domains of WRQoL. Although residents were more stressed than other professions but the overall WRQoL was comparable. CONCLUSIONS: The nature of surgical residency and a
surgical career may in fact be more “stressful” than other
Presentation: This manuscript is accepted for podium presentation at 2017 APDS annual meeting, April 18-22, 2017, San Diego, CA. Correspondence: Inquiries to Muhammad H. Zubair, MD, Department of Surgery, Good Samaritan Hospital, 375 Dixmyth Avenue, Cincinnati, OH; fax: þ(513) 8527431; e-mail: [email protected]
professions, yet may not translate into a worsened Quality of Life. Our findings suggest further study is needed to elucidate why female residents have or experience a lower perceived WRQoL than their male colleagues. ( J Surg Ed C ]:]]]-]]]. J 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: work-related quality of life, residents, surgery, stress, well-being COMPETENCIES: Patient Care, Medical Knowledge, Practice
Based Learning and Improvement, Systems Based Practice, Professionalism, Interpersonal Skills and Communication
INTRODUCTION General surgery residents are perceived to have an underlying level of stress owing to long working hours and heavy workload that brings significant challenges to balance both personal and professional life. Although the quality of life, burnout, and career satisfaction among surgeons have been well studied, the quality of working life of US surgeons in training remains relatively unexplored and unexplained. Quality of working life is perceived to be associated with job motivation, job satisfaction, work involvement, life satisfaction, happiness, and self-rated anxiety.1 The term Quality of Work Life originated from an international labor relations conference in 1972 at Arden House, Columbia University, New York.2 There is no consensus upon definition of Quality of Work Life; it has been used as construct which relates to the well-being of the employees. Factors affecting the quality of working life of general surgery residents have important implications for their educational process, as well as patient care. The workrelated quality of life (WRQoL) questionnaire has been validated as a reliable assessment tool to measure perceived quality of life. Its use offers the opportunity to identify the
Journal of Surgical Education & 2017 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2017.09.018
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strengths and weaknesses of the environments in which residents work, and with this information, potentially plan targeted interventions to improve the quality of working lives of general surgery residents. The purpose of the study was to use this tool (WRQoL) to evaluate the perceived work-related quality of life of general surgery residents, using a large, nationally representative sample in the United States. We also want to compare the WRQoL of surgical residents in comparison to other professions that have been studied with this tool.
METHODS Between January 2016 and March 2016, all US general surgery residents enrolled in an Accreditation Council for Graduate Medical Education (ACGME) accredited general surgery training program were invited to participate in the study. Before sending the survey, approval was obtained from the Association of Program Directors in Surgery. An e-mail request was sent to all program directors or program coordinators to distribute the survey to their residents. The e-mail contained a cover letter that stated the purpose of the study along with a hyperlink to the survey. Participation in the study was voluntary, and all responses remained anonymous. Reminder e-mails were sent to encourage participation with no incentives. The study was approved by TriHealth Institutional Review Board, Cincinnati, Ohio.
The WRQoL scale was used to measure perceived quality of working life. The WRQoL is a validated 23-item psychometric questionnaire and is the most widely used instrument to assess employees’ capabilities at work, monitor employees’ workforce experience, and assess employees’ adaptabilities with regard to changes within the system/ organization (Table 1).3,4 It contains questions covering 6 domains: • • • • • •
Home-work interface (HWI)—3 items General well-being (GWB)—6 items Job and career satisfaction (JCS)—6 items Control at work (CAW)—3 items Working conditions (WCS)—3 items Stress at work (SAW)—2 items
Although the WRQoL scale contains 23 items, it is presented with 24 items. The 24th item serves as an indicator for validity and reliability of the scale and factors. Each item was scored on a 5-level Likert-scale (1 ¼ strongly disagree, 2 ¼ disagree, 3 ¼ neutral, 4 ¼ agree, and 5 ¼ strongly agree). The scores for the 3 negatively phrased items (questions 7, 9, and 19) were reversed. Each factor score was determined by finding the average of the items contributing to that factor, except for the 24th item, which was treated as a stand-alone item. Higher scores indicated greater perceived quality of life (Table 2).
TABLE 1. The 23-Item WRQoL Scale Question Number
WRQoL Factor
WRQoL Question Text
JCS CAW JCS GWB HWI HWI SAW JCS GWB GWB JCS CAW WCS HWI GWB WCS GWB JCS SAW JCS GWB WCS CAW
I have a clear set of goals and aims to enable me to do my job. I feel able to voice opinions and influence changes in my area of work. I have the opportunity to use my abilities at work. I feel well at the moment. My employer provides adequate facilities and flexibility for me to fit work in around my family life. My current working hours/patterns suit my personal circumstances. I often feel under pressure at work.* When I have done a good job it is acknowledged by my line manager. Recently, I have been feeling unhappy and depressed.* I am satisfied with my life. I am encouraged to develop new skills. I am involved in decisions that affect me in my own area of work. My employer provides me with what I need to do my job effectively. My line manager actively promotes flexible working hours/patterns. In most ways, my life is close to ideal. I work in a safe environment. Generally, things work out well for me. I am satisfied with the career opportunities available for me here. I often feel excessive levels of stress at work.* I am satisfied with the training I receive in order to perform my present job. Recently, I have been feeling reasonably happy all things considered. The working conditions are satisfactory. I am involved in decisions that affect members of the public in my own area of work.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Reverse scored (*).
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TABLE 2. Subscale and Overall Reliability Scores for the WRQoL Scale Factor General well-being Home-work interface Job and career satisfaction Control at work Working conditions Stress at work Overall scale (23 items)
Cronbach’s α
Internal Consistency
0.911 0.808 0.851
Excellent Good Good
0.805 0.825 0.732 0.952
Good Good Acceptable Excellent
Standard descriptive summary statistics were used to characterize the general surgery resident population. The scores of the WRQoL questionnaire were calculated according to the manual.5 Likert-scale responses strongly agree/agree and strongly disagree/disagree were combined as agree and disagree. Differences in WRQoL scores for respondent’s characteristics, including age, sex, parental status (parent ¼ with at least 1 child), type of training program, type of educational setting, educational debt, and year of clinical training were explored using one-way analysis of variance (ANOVA). Residents were asked to describe themselves as married, “in a relationship,” or single. For statistical analysis, we combined “married” with “in a relationship” and labeled them together as “in a relationship” because of the similarity of the responses compared to those residents self-identified as “single.” Postgraduate year (PGY) level 1 to 2 (junior residents) were compared with PGY 3 to 45 (senior residents). P o0.05 was considered statistically significant.
RESULTS The survey was sent to 261 ACGME accredited surgery residency programs and was assumed to be available to 7834 residents from the 2015-2016 academic year. A total of 813 responses were received. After excluding responses with missing data, the final sample included 738 residents (Table 3). The overall reliability of the WRQoL scale was excellent, with Cronbach’s alpha value of 0.952.6 The average age was 30 (±3) years; 287 (38.9%) were females, 272 (36.9%) were from a community hospital, and 477 (64.6%) were juniors (postgraduate year ≤3). Table 3 provides a summary of the findings for the whole sample by WRQoL subscale.
support employees’ family and home life.5 Approximately 36% and 38% of the residents agreed that the current working hours/patterns suit their personal circumstances and the program supports flexible working hours, respectively. Fifty-two percent of the residents agreed or strongly agreed that adequate facilities and flexibility to fit work in and around family life is provided. However, when male and female residents were compared, the women residents perceived a poorer HWI that was significantly different. Being a senior, a categorical resident, or in a relationship increased HWI (Table 3 and Fig.). There was no statistically significant difference in perceived work-life balance between the university and community hospital trainees, or when compared by parental status. General Well-Being The GWB factor assesses a person’s contentment with their life in general. It measures the extent to which an individual feels good or content with their life as a whole, including the psychological well-being and general physical health aspects.5 Thirty-two percent of the surgical residents agreed that they have not experienced recent feelings of unhappiness or depression, and 41% of the residents agreed and 13% strongly agreed that they were “reasonably happy, all things considered.” The estimation of the timeline was on how recent the feeling was dependent on the participant; we did not specify for how long a person was feeling unhappy or depressed. Forty-three percent of the residents agreed while 18% strongly agreed that they felt “well at the moment,” and 43% agreed while 14% strongly agreed that they were satisfied with their life, although only 26% of the residents agreed that their life was “close to ideal.” Seventy percent agreed that “things work out well for me” (Fig.). Subgroups that have a higher sense of general well-being included male residents, residents that have children, and senior residents (Table 3 and Fig.). Job and Career Satisfaction
The HWI factor assesses the work and life balance. It measures the degree to which the employer is perceived to
The JCS factor assess an individual’s job satisfaction based on opportunities provided by their workplace such as personal development, promotion, recognition, etc. The level to which the workplace provides a person with the best things at work, and the things that make employees feel accomplished and fulfilled are measured by JCS.5 Fifty-eight percent agreed and 28% strongly agreed that “I have a clear set of goals and aims to enable me to do my job,” and “have the opportunity to use my abilities at work.” Forty percent agreed that “When I have done a good job it is acknowledged by my program director.” Seventy-eight percent agreed that “I am encouraged to develop new skills.” Sixty-seven percent agreed to the question “I am satisfied with the career opportunities available for me here.” Sixty-
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Home-Work Interface
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TABLE 3. Potential Factors Related to WRQoL HWI Mean (SD)
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All (N ¼ 738) Sex Male (n ¼ 451) Female (n ¼ 287) Relationship status Not in a relationship (n ¼ 196) In a relationship (n ¼ 542) Parental status Not a parent (n ¼ 572) Parent (n ¼ 166) Type of resident Preliminary general surgery (n ¼ 101) Categorical general surgery (n ¼ 637) Type of training program (n ¼ 736) University based hospital (n ¼ 464) Community-based hospital (n ¼ 272) Educational debt o $200 K (n ¼ 364) ≥ $200 K (n ¼ 374) Year of clinical training (PGY) 1 to 2 (n ¼ 345) 3 to 45 (n ¼ 393) *
p o 05. p o 0.01. *** p o 0.001. **
GWB Mean (SD)
JCS Mean (SD)
CAW Mean (SD)
WCS Mean (SD)
SAW Mean (SD)
WRQoL Mean (SD)
3.13 (0.97)
3.33 (0.91)
3.77 (0.7)
3.24 (0.94)
3.79 (0.8)
2.39 (0.94)
3.3 (1.11)
3.24 (0.97)*** 2.97 (0.94)
3.38 (0.92)* 3.23 (0.88)
3.79 (0.72) 3.73 (0.67)
3.33 (0.96)** 3.11 (0.91)
3.87 (0.8) ** 3.67 (0.77)
2.41 (0.93) 2.37 (0.95)
3.36 (1.12) 3.22 (1.11)
2.99 (0.93)* 3.12 (0.98)
3.09 (0.92)*** 3.41 (0.88)
3.59 (0.71)*** 3.83 *(0.69)
3.03 (0.98)*** 3.32 (0.92)
3.60 (0.83)*** 3.86 (0.77)
2.27 (0.95)* 2.44 (0.93)
3.10 (1.15)** 3.38 (1.10)
3.11 (0.96) 3.22 (1.03)
3.27 (0.91)** 3.50 (0.88)
3.74 (0.7)* 3.88 (0.74)
3.21 (0.95) 3.35 (0.94)
3.78 (0.78) 3.84 (0.85)
2.38 (0.94) 2.46 (0.98)
3.27 (1.12) 3.43 (1.12)
2.75 (0.91)*** 3.19 (0.96)
2.91 (0.88)*** 3.39 (0.9)
3.33 (0.82)*** 3.84 (0.66)
2.75 (0.94)*** 3.32 (0.92)
3.45 (0.85)*** 3.85 (0.77)
2.28 (0.96) 2.41 (0.94)
2.82 (1.06)*** 3.38 (1.11)
3.09 (0.92) 3.20 (1.04)
3.36 (0.89) 3.27 (0.94)
3.79 (0.66) 3.74 (0.77)
3.21 (0.94) 3.29 (0.96)
3.79 (0.76) 3.78 (0.84)
2.42 (0.93) 2.35 (0.96)
3.32 (1.1) 3.28 (1.15)
3.13 (0.92) 3.14 (1.01)
3.34 (0.9) 3.31 (0.92)
3.77 (0.7) 3.76 (0.71)
3.25 (0.94) 3.24 (0.95)
3.83 (0.77) 3.76 (0.81)
2.45 (0.95) 2.34 (0.93)
3.28 (1.1) 3.33 (1.14)
3.00 (0.94)** 3.24 (0.98)
3.12 (0.92)*** 3.46 (0.88)
3.62 (0.74)*** 3.90 (0.64)
3.09 (0.95)*** 3.38 (0.92)
3.69 (0.8)** 3.88 (0.77)
2.33 (0.93) 2.45 (0.94)
3.12 (1.11)** 3.42 (1.12)
FIGURE 1. Distribution of responses to the items on WRQoL questionnaire presented as percentages.
nine percent agreed “I am satisfied with the training I receive in order to perform my present job.” Being in a relationship, a parent, a categorical surgery resident, and a senior were associated with a higher JCS. There was no significant difference in the means scores between university and community-based hospitals or male and female residents (Table 3 and Fig.). Control at Work
requirements that focus on workplace safety, security, and efficiency.5 A high proportion of residents agreed that their work environment is safe (82% agreed), working conditions are satisfactory (67% agreed), and appropriate work-related resources are provided (65% agreed). Once again, the difference between male and female residents under WCS was statistically significant. Being a senior, a categorical resident or in a relationship increased WCS. There was no significant difference in perceived working conditions between university and community hospital trainees (Table 3 and Fig.).
The CAW factor has 3 items that assess the involvement of an employee in decisions that affect their work. It echoes the level at which an employee feels they can exercise what they consider to be an appropriate level of control within their work environment.5 Fifty-two percent of the residents felt they were able to voice their opinions and influence change and 54% agreed they were involved in decisions that affected their area of work. Forty percent of the residents agreed that they were involved in decisions that affected their community. When compared with male residents, female residents perceived less control at work. Being a senior, a categorical resident, or in a relationship increased CAW (Table 3 and Fig.).
The SAW factor evaluates work-related stress and excessive pressure.5 A lower mean score indicates a poor perceived quality of life. Seventy-three percent of the residents agreed “feeling under pressure at work.” Forty-six percent agreed that they feel “excessive levels of stress at work.” Being a senior resident or being in a relationship both decreased SAW. There was no statistically significant difference in perceived stress at work between the university and community hospital trainees, male and female residents, and other subgroup comparisons (Table 3 and Fig.).
Working Conditions
DISCUSSION
The concepts of WCS are similar to JCS and reflect the degree to which the organization meets an individual’s basic
This is the first study to investigate the perceived WRQoL of general surgery residents in the United States. Our study
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Stress at Work
TABLE 4. Comparison of WRQoL Scale Among Different Professions Study Our Study XiaoWen Zhao (nurses in China)8 Edwards (higher education staff)4 Easton (police in the UK)9 Mazloumi (train drivers in Iran)10 H. Kahyaoglu Sut (nurses without PMS Turkey)7 H. Kahyaoglu Sut (nurses with PMS Turkey)7 J.G. Opollo (Ugandan Nurses)12 Dai (nurses in Taiwan)11 *
Participants (n) JCS 738 733 2582 615 100 83 51 146 243
3.77 3.48 3.43 3.09 3.21 3.3 3 3.53 3.57
CAW
HWI GWB
SAW
WCS
3.24 3.29 3.39 2.98 3.04 3.4 2.9 Not clear 3.39
3.13 3.34 3.52 2.77 2 3.1 2.6 2.46 3.42
2.39 3.21 3.62 2.6 4.29 2.8 2.5 Not clear 3.46
3.79 3.33 3.62 2.81 1.37 2.9 2.4 Not clear 3.33
3.33 3.34 3.44 3.12 3.62 3.3 2.7 Not clear 3.25
PMS: Premenstrual syndrome
demonstrates several findings, some of which we believe are expected and anticipated, and others we believe are revealing. The highest mean ratings of work satisfaction were observed in the domains of JCS and WCS. This indicates that surgery residents were satisfied and motivated about their career choice. They were also satisfied with the fundamental resources and necessities provided to them by their organization to do their job safely and effectively. Our findings demonstrate that 72% of residents “often feel under pressure at work” (7-SAW, Fig.). Compared to other professions, surgical residents clearly perceived a high level of stress, at the same time, perceiving a high degree of job and career satisfactions as well as good working conditions (Table 4). When compared to other professions, general surgery residents’ WCS and JCS was better than all, and CAW, HWI, and GWB was better than most; on the contrary, SAW was high among surgery residents.7-12 It may be that the inherent nature of surgical training incorporates both high job satisfaction coupled with high stress. For surgical educators and program directors, the goal should be to eliminate unnecessary stress. This would include stresses such as system problems within a hospital that impair the efficient delivery of patient care. In several domains of the WRQoL scale, female residents appeared to have significantly lower scores. However, in the summary question “I am satisfied with the overall quality of my working life,” there was no significant difference. Female residents in our study was associated with a lower perceived support by the employer for maintaining a balance between home and work life; they were also more likely to have a decreased sense of well-being. This was in accordance with the findings by Elmore et al.14 and Dyrbe et al.13 Female residents had a decreased sense of control at work, as well as working conditions compared to their male colleagues. A recent systematic review by Khoushhal et al.15 identified females to have higher odds for attrition. Perhaps this is a consequence of the perceived lack of control at work or the “working conditions.” Senior general surgery residents had a higher job career satisfaction. This was in contrast to findings by Drolet
et al.16 who reported a decreased quality of life in senior general surgery residents. A possible explanation for the decrease may be due to the timing of the survey, which was distributed around the implementation of the new ACGME work-hour restrictions in 2011, and the residents were going through a transition. Our study clearly demonstrated an enhanced perception of work life of senior residents compared to junior residents. Stress is defined as a process by which certain environmental demands evoke an appraisal process in which perceived demand exceeds resources and results in undesirable physiological, psychological, or behavioral outcomes.17 Stress can enhance performance, but certain types and amount of stress can impair performance.17 Stressful crises impair communication and decision-making in residents.18 Patient care decisions require considerable thought and planning, often with incomplete information at hand. This can be a stressful experience, and compared to other jobs, surgery residents had the highest level of stress, even greater than the police in a large metropolitan city. Job career satisfaction and WCS were higher for surgical residents than any other profession previously measured using this tool. Paradoxically, surgical residents perceive a higher level of stress coupled with better working conditions, perhaps due to the nature of the “job,” i.e., the job (work) itself is inherently stressful yet fulfilling and rewarding. Pulcrano et al.19 suggested optimizing reimbursement, reevaluating training paradigms, examining departmental cultures, providing counseling and mentorship, and managing career expectations as some of the measures to improve resident quality of life. A recent survey by Lee et al.20 of surgery residents demonstrated that financial academic support and support for poor performers was associated with improved well-being and perceived clinical learning environment. General surgery residents and younger surgeons are at a risk of burnout compared to experienced surgeons, and surgical residents may be more prone to stress and burnout owing to a large number of work hours, stress to master both technical and theoretical knowledge, and to balance work-life and personal life.21-25 Compared to senior residents, junior residents and preliminary surgery residents
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perceived a decreased WRQoL in our study. This may be a factor explaining the significant attrition rate among surgical trainees, especially in the junior years of residency. Our findings are in agreement with a recent survey of nurses by Shukla et al.26 which showed that experience and seniority was associated with improved SAW, JCS, CAW, and HWI. There was no statistically significant difference in perceived WRQoL between residents training at university vs community hospitals, or among residents with high vs low educational debt. In resonance with Sullivan et al.,27 residents in a relationship reported better WRQOL in all domains. There is a correlation between QoL and job satisfaction, self-reported productivity, and performance. Attention to the psychosocial needs of staff can have benefits for both employees and employers.28,29 As such, this survey may not reflect the true status of QoL for general surgery residents.24,30-35 To date, there are 4 studies reporting the QoL for general surgery residents in the United States using the Short Form Health Survey (SF 12), Linear Analog Self-Assessment (LASA), and other survey instruments.36-38 These studies demonstrate considerable heterogeneity in defining quality of life for surgical residents, and this may confound efforts to define the quality of life.19 The WRQoL is an evidence-based measure of Quality of Working Life and provides an assessment of an employee’s contentment for use in planning interventions, monitoring workforce experience, and assessing the effect of organizational change. This study has limitations. As with all studies relying on self-reported data, there might be a response bias involved. Rates of depression increase and empathy decrease throughout the academic year.39,40 Although most of our survey responses were received between January 2016 and March 2016, this places our timings somewhere in the middle of the academic year. Our response rate from this survey represents only 10% of surgical residents in the United States, similar to Elmore et al. This alone may reflect a significant bias in the responders vs nonresponders. The responders appear to reflect the respective percentages of university vs community programs, male vs female residents, etc. Our sample was a representative of US general surgery resident population. Thirty-nine percent of our respondents were females compared to 43% from Elmore et al.14 and 45% by Stain et al.41 In other words, bias may be that responders are more/less content with their WRQoL, but the demographics are reflective of the national resident sample.
CONCLUSION
surgical career may, in fact, be more “stressful” than other professions, yet may not translate into a worsened Quality of Life. Our findings suggest that further study is needed to elucidate why female residents have or experience a lower WRQoL than their male colleagues.
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35. West CP, Huschka MM, Novotny PJ, et al. Associ-
Buddeberg C. Work stress and reduced health in young physicians: prospective evidence from Swiss residents. International Arch Occup Environ Health. 2008;82 (1):31-38.
ation of perceived medical errors with resident distress and empathy: a prospective longitudinal study. J Am Med Assoc. 2006;296(9):1071-1078.
24. Shanafelt TD, Sloan JA, Habermann TM. The well-
being of physicians. Am J Med. 2003;114(6):513-519. 25. Troppmann KM, Palis BE, Goodnight JE, Ho HS,
Troppmann C. Career and lifestyle satisfaction among surgeons: what really matters? The National Lifestyles in Surgery Today Survey J Am Coll Surg. 2009;209 (2):160-169. 8
36. Antiel RM, Reed DA, Van Arendonk KJ, et al.
Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. JAMA Surg. 2013;148 (5):448-455. 37. Foley PJ, Roses RE, Kelz RR, et al. The state of general
surgery training: a different perspective. J Surg Educ. 2008;65(6):494-498. Journal of Surgical Education Volume ]/Number ] ] 2017
38. Lindeman BM, Sacks BC, Hirose K, Lipsett PA.
40. Rosen IM, Gimotty PA, Shea JA, Bellini LM. Evolu-
Multifaceted longitudinal study of surgical resident education, quality of life, and patient care before and after July 2011. J Surg Educ. 2013;70(6):769-776.
tion of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med. 2006;81(1):82-85.
39. Bellini LM, Baime M, Shea JA. Variation of mood and
41. Stain SC, Hiatt JR, Ata A, et al. Characteristics of
empathy during internship. J Am Med Assoc. 2002;287 (23):3143-3146.
highly ranked applicants to general surgery residency programs. JAMA Surg. 2013;148(5):413-417.
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Work-Related Quality of Life of US General Surgery Residents: Is It Really so Bad? Muhammad H. Zubair, MD, Lala R. Hussain, MSc, MHA, Kristen N. Williams, MD and Kevin J. Grannan, MD Department of Surgery, Good Samaritan Hospital, Cincinnati, Ohio PURPOSE: The quality of working life of US surgical residents
has not been studied, and given the complexity of interaction between work and personal life there is a need to assess this interaction. We utilized a validated Work Related Quality of Life (WRQoL) questionnaire to evaluate the perceived workrelated quality of life of general surgery residents, using a large, nationally representative sample in the United States. METHODS: Between January 2016 and March 2016, all
US general surgery residents enrolled in an ACGME general surgery training program were invited to participate. The WRQoL scale measures perceived quality of life covering six domains: General Well-Being (GWB), Home-Work Interface (HWI), Job and Career Satisfaction (JCS), Control at Work (CAW), Working Conditions (WCS) and Stress at Work (SAW). RESULTS: After excluding for missing data, the final analysis
included 738 residents. The average age was 30 (±3) years, of whom 287 (38.9%) were female, 272 (36.9%) were from a community hospital, and 477 (64.6%) were juniors (postgraduate year ≤ 3). Demographically, the respondents matched expected percentages. When male and female residents were compared, males had statistically better HWI (po0.001), better GWB (p ¼ 0.03), more CAW (p ¼ 0.0003) and WCS (p ¼ 0.001). Junior residents had a lower JCS (p ¼ 0.002) and CAW (p ¼ 0.04) compared to seniors. There were no differences between university and community residents in any of the domains of WRQoL. Although residents were more stressed than other professions but the overall WRQoL was comparable. CONCLUSIONS: The nature of surgical residency and a
surgical career may in fact be more “stressful” than other
Presentation: This manuscript is accepted for podium presentation at 2017 APDS annual meeting, April 18-22, 2017, San Diego, CA. Correspondence: Inquiries to Muhammad H. Zubair, MD, Department of Surgery, Good Samaritan Hospital, 375 Dixmyth Avenue, Cincinnati, OH; fax: þ(513) 8527431; e-mail: [email protected]
professions, yet may not translate into a worsened Quality of Life. Our findings suggest further study is needed to elucidate why female residents have or experience a lower perceived WRQoL than their male colleagues. ( J Surg Ed C ]:]]]-]]]. J 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: work-related quality of life, residents, surgery, stress, well-being COMPETENCIES: Patient Care, Medical Knowledge, Practice
Based Learning and Improvement, Systems Based Practice, Professionalism, Interpersonal Skills and Communication
INTRODUCTION General surgery residents are perceived to have an underlying level of stress owing to long working hours and heavy workload that brings significant challenges to balance both personal and professional life. Although the quality of life, burnout, and career satisfaction among surgeons have been well studied, the quality of working life of US surgeons in training remains relatively unexplored and unexplained. Quality of working life is perceived to be associated with job motivation, job satisfaction, work involvement, life satisfaction, happiness, and self-rated anxiety.1 The term Quality of Work Life originated from an international labor relations conference in 1972 at Arden House, Columbia University, New York.2 There is no consensus upon definition of Quality of Work Life; it has been used as construct which relates to the well-being of the employees. Factors affecting the quality of working life of general surgery residents have important implications for their educational process, as well as patient care. The workrelated quality of life (WRQoL) questionnaire has been validated as a reliable assessment tool to measure perceived quality of life. Its use offers the opportunity to identify the
Journal of Surgical Education & 2017 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2017.09.018
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strengths and weaknesses of the environments in which residents work, and with this information, potentially plan targeted interventions to improve the quality of working lives of general surgery residents. The purpose of the study was to use this tool (WRQoL) to evaluate the perceived work-related quality of life of general surgery residents, using a large, nationally representative sample in the United States. We also want to compare the WRQoL of surgical residents in comparison to other professions that have been studied with this tool.
METHODS Between January 2016 and March 2016, all US general surgery residents enrolled in an Accreditation Council for Graduate Medical Education (ACGME) accredited general surgery training program were invited to participate in the study. Before sending the survey, approval was obtained from the Association of Program Directors in Surgery. An e-mail request was sent to all program directors or program coordinators to distribute the survey to their residents. The e-mail contained a cover letter that stated the purpose of the study along with a hyperlink to the survey. Participation in the study was voluntary, and all responses remained anonymous. Reminder e-mails were sent to encourage participation with no incentives. The study was approved by TriHealth Institutional Review Board, Cincinnati, Ohio.
The WRQoL scale was used to measure perceived quality of working life. The WRQoL is a validated 23-item psychometric questionnaire and is the most widely used instrument to assess employees’ capabilities at work, monitor employees’ workforce experience, and assess employees’ adaptabilities with regard to changes within the system/ organization (Table 1).3,4 It contains questions covering 6 domains: • • • • • •
Home-work interface (HWI)—3 items General well-being (GWB)—6 items Job and career satisfaction (JCS)—6 items Control at work (CAW)—3 items Working conditions (WCS)—3 items Stress at work (SAW)—2 items
Although the WRQoL scale contains 23 items, it is presented with 24 items. The 24th item serves as an indicator for validity and reliability of the scale and factors. Each item was scored on a 5-level Likert-scale (1 ¼ strongly disagree, 2 ¼ disagree, 3 ¼ neutral, 4 ¼ agree, and 5 ¼ strongly agree). The scores for the 3 negatively phrased items (questions 7, 9, and 19) were reversed. Each factor score was determined by finding the average of the items contributing to that factor, except for the 24th item, which was treated as a stand-alone item. Higher scores indicated greater perceived quality of life (Table 2).
TABLE 1. The 23-Item WRQoL Scale Question Number
WRQoL Factor
WRQoL Question Text
JCS CAW JCS GWB HWI HWI SAW JCS GWB GWB JCS CAW WCS HWI GWB WCS GWB JCS SAW JCS GWB WCS CAW
I have a clear set of goals and aims to enable me to do my job. I feel able to voice opinions and influence changes in my area of work. I have the opportunity to use my abilities at work. I feel well at the moment. My employer provides adequate facilities and flexibility for me to fit work in around my family life. My current working hours/patterns suit my personal circumstances. I often feel under pressure at work.* When I have done a good job it is acknowledged by my line manager. Recently, I have been feeling unhappy and depressed.* I am satisfied with my life. I am encouraged to develop new skills. I am involved in decisions that affect me in my own area of work. My employer provides me with what I need to do my job effectively. My line manager actively promotes flexible working hours/patterns. In most ways, my life is close to ideal. I work in a safe environment. Generally, things work out well for me. I am satisfied with the career opportunities available for me here. I often feel excessive levels of stress at work.* I am satisfied with the training I receive in order to perform my present job. Recently, I have been feeling reasonably happy all things considered. The working conditions are satisfactory. I am involved in decisions that affect members of the public in my own area of work.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Reverse scored (*).
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TABLE 2. Subscale and Overall Reliability Scores for the WRQoL Scale Factor General well-being Home-work interface Job and career satisfaction Control at work Working conditions Stress at work Overall scale (23 items)
Cronbach’s α
Internal Consistency
0.911 0.808 0.851
Excellent Good Good
0.805 0.825 0.732 0.952
Good Good Acceptable Excellent
Standard descriptive summary statistics were used to characterize the general surgery resident population. The scores of the WRQoL questionnaire were calculated according to the manual.5 Likert-scale responses strongly agree/agree and strongly disagree/disagree were combined as agree and disagree. Differences in WRQoL scores for respondent’s characteristics, including age, sex, parental status (parent ¼ with at least 1 child), type of training program, type of educational setting, educational debt, and year of clinical training were explored using one-way analysis of variance (ANOVA). Residents were asked to describe themselves as married, “in a relationship,” or single. For statistical analysis, we combined “married” with “in a relationship” and labeled them together as “in a relationship” because of the similarity of the responses compared to those residents self-identified as “single.” Postgraduate year (PGY) level 1 to 2 (junior residents) were compared with PGY 3 to 45 (senior residents). P o0.05 was considered statistically significant.
RESULTS The survey was sent to 261 ACGME accredited surgery residency programs and was assumed to be available to 7834 residents from the 2015-2016 academic year. A total of 813 responses were received. After excluding responses with missing data, the final sample included 738 residents (Table 3). The overall reliability of the WRQoL scale was excellent, with Cronbach’s alpha value of 0.952.6 The average age was 30 (±3) years; 287 (38.9%) were females, 272 (36.9%) were from a community hospital, and 477 (64.6%) were juniors (postgraduate year ≤3). Table 3 provides a summary of the findings for the whole sample by WRQoL subscale.
support employees’ family and home life.5 Approximately 36% and 38% of the residents agreed that the current working hours/patterns suit their personal circumstances and the program supports flexible working hours, respectively. Fifty-two percent of the residents agreed or strongly agreed that adequate facilities and flexibility to fit work in and around family life is provided. However, when male and female residents were compared, the women residents perceived a poorer HWI that was significantly different. Being a senior, a categorical resident, or in a relationship increased HWI (Table 3 and Fig.). There was no statistically significant difference in perceived work-life balance between the university and community hospital trainees, or when compared by parental status. General Well-Being The GWB factor assesses a person’s contentment with their life in general. It measures the extent to which an individual feels good or content with their life as a whole, including the psychological well-being and general physical health aspects.5 Thirty-two percent of the surgical residents agreed that they have not experienced recent feelings of unhappiness or depression, and 41% of the residents agreed and 13% strongly agreed that they were “reasonably happy, all things considered.” The estimation of the timeline was on how recent the feeling was dependent on the participant; we did not specify for how long a person was feeling unhappy or depressed. Forty-three percent of the residents agreed while 18% strongly agreed that they felt “well at the moment,” and 43% agreed while 14% strongly agreed that they were satisfied with their life, although only 26% of the residents agreed that their life was “close to ideal.” Seventy percent agreed that “things work out well for me” (Fig.). Subgroups that have a higher sense of general well-being included male residents, residents that have children, and senior residents (Table 3 and Fig.). Job and Career Satisfaction
The HWI factor assesses the work and life balance. It measures the degree to which the employer is perceived to
The JCS factor assess an individual’s job satisfaction based on opportunities provided by their workplace such as personal development, promotion, recognition, etc. The level to which the workplace provides a person with the best things at work, and the things that make employees feel accomplished and fulfilled are measured by JCS.5 Fifty-eight percent agreed and 28% strongly agreed that “I have a clear set of goals and aims to enable me to do my job,” and “have the opportunity to use my abilities at work.” Forty percent agreed that “When I have done a good job it is acknowledged by my program director.” Seventy-eight percent agreed that “I am encouraged to develop new skills.” Sixty-seven percent agreed to the question “I am satisfied with the career opportunities available for me here.” Sixty-
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Home-Work Interface
4
TABLE 3. Potential Factors Related to WRQoL HWI Mean (SD)
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All (N ¼ 738) Sex Male (n ¼ 451) Female (n ¼ 287) Relationship status Not in a relationship (n ¼ 196) In a relationship (n ¼ 542) Parental status Not a parent (n ¼ 572) Parent (n ¼ 166) Type of resident Preliminary general surgery (n ¼ 101) Categorical general surgery (n ¼ 637) Type of training program (n ¼ 736) University based hospital (n ¼ 464) Community-based hospital (n ¼ 272) Educational debt o $200 K (n ¼ 364) ≥ $200 K (n ¼ 374) Year of clinical training (PGY) 1 to 2 (n ¼ 345) 3 to 45 (n ¼ 393) *
p o 05. p o 0.01. *** p o 0.001. **
GWB Mean (SD)
JCS Mean (SD)
CAW Mean (SD)
WCS Mean (SD)
SAW Mean (SD)
WRQoL Mean (SD)
3.13 (0.97)
3.33 (0.91)
3.77 (0.7)
3.24 (0.94)
3.79 (0.8)
2.39 (0.94)
3.3 (1.11)
3.24 (0.97)*** 2.97 (0.94)
3.38 (0.92)* 3.23 (0.88)
3.79 (0.72) 3.73 (0.67)
3.33 (0.96)** 3.11 (0.91)
3.87 (0.8) ** 3.67 (0.77)
2.41 (0.93) 2.37 (0.95)
3.36 (1.12) 3.22 (1.11)
2.99 (0.93)* 3.12 (0.98)
3.09 (0.92)*** 3.41 (0.88)
3.59 (0.71)*** 3.83 *(0.69)
3.03 (0.98)*** 3.32 (0.92)
3.60 (0.83)*** 3.86 (0.77)
2.27 (0.95)* 2.44 (0.93)
3.10 (1.15)** 3.38 (1.10)
3.11 (0.96) 3.22 (1.03)
3.27 (0.91)** 3.50 (0.88)
3.74 (0.7)* 3.88 (0.74)
3.21 (0.95) 3.35 (0.94)
3.78 (0.78) 3.84 (0.85)
2.38 (0.94) 2.46 (0.98)
3.27 (1.12) 3.43 (1.12)
2.75 (0.91)*** 3.19 (0.96)
2.91 (0.88)*** 3.39 (0.9)
3.33 (0.82)*** 3.84 (0.66)
2.75 (0.94)*** 3.32 (0.92)
3.45 (0.85)*** 3.85 (0.77)
2.28 (0.96) 2.41 (0.94)
2.82 (1.06)*** 3.38 (1.11)
3.09 (0.92) 3.20 (1.04)
3.36 (0.89) 3.27 (0.94)
3.79 (0.66) 3.74 (0.77)
3.21 (0.94) 3.29 (0.96)
3.79 (0.76) 3.78 (0.84)
2.42 (0.93) 2.35 (0.96)
3.32 (1.1) 3.28 (1.15)
3.13 (0.92) 3.14 (1.01)
3.34 (0.9) 3.31 (0.92)
3.77 (0.7) 3.76 (0.71)
3.25 (0.94) 3.24 (0.95)
3.83 (0.77) 3.76 (0.81)
2.45 (0.95) 2.34 (0.93)
3.28 (1.1) 3.33 (1.14)
3.00 (0.94)** 3.24 (0.98)
3.12 (0.92)*** 3.46 (0.88)
3.62 (0.74)*** 3.90 (0.64)
3.09 (0.95)*** 3.38 (0.92)
3.69 (0.8)** 3.88 (0.77)
2.33 (0.93) 2.45 (0.94)
3.12 (1.11)** 3.42 (1.12)
FIGURE 1. Distribution of responses to the items on WRQoL questionnaire presented as percentages.
nine percent agreed “I am satisfied with the training I receive in order to perform my present job.” Being in a relationship, a parent, a categorical surgery resident, and a senior were associated with a higher JCS. There was no significant difference in the means scores between university and community-based hospitals or male and female residents (Table 3 and Fig.). Control at Work
requirements that focus on workplace safety, security, and efficiency.5 A high proportion of residents agreed that their work environment is safe (82% agreed), working conditions are satisfactory (67% agreed), and appropriate work-related resources are provided (65% agreed). Once again, the difference between male and female residents under WCS was statistically significant. Being a senior, a categorical resident or in a relationship increased WCS. There was no significant difference in perceived working conditions between university and community hospital trainees (Table 3 and Fig.).
The CAW factor has 3 items that assess the involvement of an employee in decisions that affect their work. It echoes the level at which an employee feels they can exercise what they consider to be an appropriate level of control within their work environment.5 Fifty-two percent of the residents felt they were able to voice their opinions and influence change and 54% agreed they were involved in decisions that affected their area of work. Forty percent of the residents agreed that they were involved in decisions that affected their community. When compared with male residents, female residents perceived less control at work. Being a senior, a categorical resident, or in a relationship increased CAW (Table 3 and Fig.).
The SAW factor evaluates work-related stress and excessive pressure.5 A lower mean score indicates a poor perceived quality of life. Seventy-three percent of the residents agreed “feeling under pressure at work.” Forty-six percent agreed that they feel “excessive levels of stress at work.” Being a senior resident or being in a relationship both decreased SAW. There was no statistically significant difference in perceived stress at work between the university and community hospital trainees, male and female residents, and other subgroup comparisons (Table 3 and Fig.).
Working Conditions
DISCUSSION
The concepts of WCS are similar to JCS and reflect the degree to which the organization meets an individual’s basic
This is the first study to investigate the perceived WRQoL of general surgery residents in the United States. Our study
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Stress at Work
TABLE 4. Comparison of WRQoL Scale Among Different Professions Study Our Study XiaoWen Zhao (nurses in China)8 Edwards (higher education staff)4 Easton (police in the UK)9 Mazloumi (train drivers in Iran)10 H. Kahyaoglu Sut (nurses without PMS Turkey)7 H. Kahyaoglu Sut (nurses with PMS Turkey)7 J.G. Opollo (Ugandan Nurses)12 Dai (nurses in Taiwan)11 *
Participants (n) JCS 738 733 2582 615 100 83 51 146 243
3.77 3.48 3.43 3.09 3.21 3.3 3 3.53 3.57
CAW
HWI GWB
SAW
WCS
3.24 3.29 3.39 2.98 3.04 3.4 2.9 Not clear 3.39
3.13 3.34 3.52 2.77 2 3.1 2.6 2.46 3.42
2.39 3.21 3.62 2.6 4.29 2.8 2.5 Not clear 3.46
3.79 3.33 3.62 2.81 1.37 2.9 2.4 Not clear 3.33
3.33 3.34 3.44 3.12 3.62 3.3 2.7 Not clear 3.25
PMS: Premenstrual syndrome
demonstrates several findings, some of which we believe are expected and anticipated, and others we believe are revealing. The highest mean ratings of work satisfaction were observed in the domains of JCS and WCS. This indicates that surgery residents were satisfied and motivated about their career choice. They were also satisfied with the fundamental resources and necessities provided to them by their organization to do their job safely and effectively. Our findings demonstrate that 72% of residents “often feel under pressure at work” (7-SAW, Fig.). Compared to other professions, surgical residents clearly perceived a high level of stress, at the same time, perceiving a high degree of job and career satisfactions as well as good working conditions (Table 4). When compared to other professions, general surgery residents’ WCS and JCS was better than all, and CAW, HWI, and GWB was better than most; on the contrary, SAW was high among surgery residents.7-12 It may be that the inherent nature of surgical training incorporates both high job satisfaction coupled with high stress. For surgical educators and program directors, the goal should be to eliminate unnecessary stress. This would include stresses such as system problems within a hospital that impair the efficient delivery of patient care. In several domains of the WRQoL scale, female residents appeared to have significantly lower scores. However, in the summary question “I am satisfied with the overall quality of my working life,” there was no significant difference. Female residents in our study was associated with a lower perceived support by the employer for maintaining a balance between home and work life; they were also more likely to have a decreased sense of well-being. This was in accordance with the findings by Elmore et al.14 and Dyrbe et al.13 Female residents had a decreased sense of control at work, as well as working conditions compared to their male colleagues. A recent systematic review by Khoushhal et al.15 identified females to have higher odds for attrition. Perhaps this is a consequence of the perceived lack of control at work or the “working conditions.” Senior general surgery residents had a higher job career satisfaction. This was in contrast to findings by Drolet
et al.16 who reported a decreased quality of life in senior general surgery residents. A possible explanation for the decrease may be due to the timing of the survey, which was distributed around the implementation of the new ACGME work-hour restrictions in 2011, and the residents were going through a transition. Our study clearly demonstrated an enhanced perception of work life of senior residents compared to junior residents. Stress is defined as a process by which certain environmental demands evoke an appraisal process in which perceived demand exceeds resources and results in undesirable physiological, psychological, or behavioral outcomes.17 Stress can enhance performance, but certain types and amount of stress can impair performance.17 Stressful crises impair communication and decision-making in residents.18 Patient care decisions require considerable thought and planning, often with incomplete information at hand. This can be a stressful experience, and compared to other jobs, surgery residents had the highest level of stress, even greater than the police in a large metropolitan city. Job career satisfaction and WCS were higher for surgical residents than any other profession previously measured using this tool. Paradoxically, surgical residents perceive a higher level of stress coupled with better working conditions, perhaps due to the nature of the “job,” i.e., the job (work) itself is inherently stressful yet fulfilling and rewarding. Pulcrano et al.19 suggested optimizing reimbursement, reevaluating training paradigms, examining departmental cultures, providing counseling and mentorship, and managing career expectations as some of the measures to improve resident quality of life. A recent survey by Lee et al.20 of surgery residents demonstrated that financial academic support and support for poor performers was associated with improved well-being and perceived clinical learning environment. General surgery residents and younger surgeons are at a risk of burnout compared to experienced surgeons, and surgical residents may be more prone to stress and burnout owing to a large number of work hours, stress to master both technical and theoretical knowledge, and to balance work-life and personal life.21-25 Compared to senior residents, junior residents and preliminary surgery residents
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perceived a decreased WRQoL in our study. This may be a factor explaining the significant attrition rate among surgical trainees, especially in the junior years of residency. Our findings are in agreement with a recent survey of nurses by Shukla et al.26 which showed that experience and seniority was associated with improved SAW, JCS, CAW, and HWI. There was no statistically significant difference in perceived WRQoL between residents training at university vs community hospitals, or among residents with high vs low educational debt. In resonance with Sullivan et al.,27 residents in a relationship reported better WRQOL in all domains. There is a correlation between QoL and job satisfaction, self-reported productivity, and performance. Attention to the psychosocial needs of staff can have benefits for both employees and employers.28,29 As such, this survey may not reflect the true status of QoL for general surgery residents.24,30-35 To date, there are 4 studies reporting the QoL for general surgery residents in the United States using the Short Form Health Survey (SF 12), Linear Analog Self-Assessment (LASA), and other survey instruments.36-38 These studies demonstrate considerable heterogeneity in defining quality of life for surgical residents, and this may confound efforts to define the quality of life.19 The WRQoL is an evidence-based measure of Quality of Working Life and provides an assessment of an employee’s contentment for use in planning interventions, monitoring workforce experience, and assessing the effect of organizational change. This study has limitations. As with all studies relying on self-reported data, there might be a response bias involved. Rates of depression increase and empathy decrease throughout the academic year.39,40 Although most of our survey responses were received between January 2016 and March 2016, this places our timings somewhere in the middle of the academic year. Our response rate from this survey represents only 10% of surgical residents in the United States, similar to Elmore et al. This alone may reflect a significant bias in the responders vs nonresponders. The responders appear to reflect the respective percentages of university vs community programs, male vs female residents, etc. Our sample was a representative of US general surgery resident population. Thirty-nine percent of our respondents were females compared to 43% from Elmore et al.14 and 45% by Stain et al.41 In other words, bias may be that responders are more/less content with their WRQoL, but the demographics are reflective of the national resident sample.
CONCLUSION
surgical career may, in fact, be more “stressful” than other professions, yet may not translate into a worsened Quality of Life. Our findings suggest that further study is needed to elucidate why female residents have or experience a lower WRQoL than their male colleagues.
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