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Professional Dissatisfaction: Are Orthopedic Surgeons Spoiled?
Several years ago, I was on the American Academy of Orthopaedic Surgeons leadership fellow committee, reviewing fellowship applications. The committee had been poised to very favorably rule on an application until a new member spoke up, stating that he had been in the applicant’s department and that points made in the recommending letter bore little resemblance to the person’s performance. Further study confirmed the dishonesty in the letter, and a more fit candidate was selected instead.
I was puzzled. Why would a leader in the field do such a thing? The question led me to a personal investigation into the monumental topic of professionalism and, more specifically, professionalism among orthopedic surgeons.
Physicians, Especially Orthopedists, Are Not Happy
Physicians, in general, are not a happy lot. According to a 2012 survey by the Physicians Foundation,1 77.4% of practicing physicians were pessimistic about the future of medicine, and 82% thought they had little ability to change the health care system. Sources of pessimism included “too much regulation/paperwork, loss of clinical autonomy, physicians not compensated for quality, erosion of physician/patient relationship, and money trumps patient care.” We are now in the age of “organizational physicians,” who, subject to institutional management, are experiencing a distressing loss of autonomy.
What sustains, or does not sustain, surgeons’ career satisfaction? Commonly stated positive factors include the ability to provide quality care, time with patients, income, and financial incentives2; reported negative factors include threat of malpractice, lack of autonomy, excessive administrative tasks, and high patient volume. Early-career physicians have the lowest career satisfaction, but physicians in mid-career have the highest rate of burnout and likelihood of leaving medical practice.3 Work–home conflict is most difficult in the early career, when families have young children, and the conflict generally goes unresolved. Burnout and low satisfaction with specialty choice are most common in mid-career.
Despite all the negative factors acting on medical practices, orthopedic surgeons have fared well financially, but not as well in career satisfaction. The Medscape Physician Compensation Report 20144 places orthopedics compensation first among 25 specialties listed, without a close second, but orthopedists rank 15th in thinking they are fairly compensated, and next to last in indicating they would choose medicine again as a career. A separate study of physician career satisfaction ranked orthopedics 32nd of 42 specialties studied.5
What is our problem, and what can we do about it? It’s hard to digest this information and not feel that orthopedists are, for lack of a better word, spoiled.
DeBotton6 wrote about status anxiety, which arises over and over again in daily life. Essentially, it is the envy or dissatisfaction one feels when a peer gets a better deal that does not seem just. A remarkable aspect of Medscape’s compensation report4 is that family medicine physicians, whose annual income was well under half that of orthopedic surgeons, were more likely to view themselves as fairly compensated. On this basis, we have to conclude that orthopedic surgeons have status anxiety. But why?
Humanism
Osler, the quintessential physician, counseled medical students: “Nothing will sustain you more potently in your humdrum routine … than the power to recognize the true poetry of life—the poetry of the commonplace, of the ordinary man, of the plain, toilworn woman, with their loves and their joys, their sorrows and their griefs.”7 In short, take the time to know your patients. In a study of physicians who were regarded as clinically excellent, several traits were noted: honest, nonjudgmental, genuinely caring, treating all patients equally, and constantly striving for excellence.8 A century after Osler, Stellato9 echoed the sentiment: “Listen to your patients, not just about their illness, but about their life.”
Humanism, then, is the trait underlying professionalism.10,11 Communication skills are essential to humanism.12 However, a study of specialty physicians in Spain “showed scarce empathic behaviours or behaviours that foster a shared decision making process.”13 In addition, a recent survey placed the communication skills of orthopedists last among 28 specialties.14 Assessment was based on how often a physician explains things, listens carefully, gives easy-to-understand instructions, shows respect, and spends enough time.
Could it be that orthopedists are not satisfied with their income because as a group they lack the communication skills and humanistic characteristics of lower-paid physicians?
Residency and the Academic Medical Center
The education of the orthopedic surgeon starts with the selection process. Simon15 noted that “the brightest, but not always the best” are selected largely because objective criteria are an excellent measure of cognitive achievement but not of character. Also noting that 10% of examinees pass part I of the board but fail part II, Simon opined that they “lack clinical judgment, communication skills, and, in some instances, ethics.” A 1999 team of authors found that 18% of research citations listed by orthopedic residency applicants were misrepresented, and a follow-up study by the same authors in 2007 noted a rate increase, to 20.6%.16 Both sets of authors wrote of a need for a better selection process and a better evaluative process during residency.
The residency process has been substantially altered by work-hour restrictions. The 20th-century residency, which emphasizes taking responsibility for the patient throughout a hospital stay, has now been dismissed as “nostalgic professionalism.” Residents are now advised to avoid such activities as checking laboratory results from home and coming to work when they are not feeling well.17 However, there has been considerable pushback against diminishing nostalgic professionalism, primarily from surgeons.18 “Teaching residents that they should go home to rest at the end of their shift without regard for the circumstances of their cases in progress is not an acceptable example for training.”19 Current promulgated restrictions on duty hours move concern for the “circumstances of their cases” to the back burner—the shift ends, the physician leaves. Residents are pulled one way by forces telling them to leave (Accreditation Council for Graduate Medical Education) and the other way by forces telling them to stay (their conscience).
How do residents develop their surgical identities and concepts of humanism and professionalism? There is a substantial body of evidence that the so-called hidden curriculum is the dominant factor: trainees emulate what their faculty say and do.20 As Gofton and Regehr21 noted, “It is vital for members of the surgical academic community to recognize [that] the attitudes, beliefs, and values implicit in every action, every word, every inaction, and every silence are not only shaping the attitudes, beliefs, and values of one’s protégés, but also are shaping the decisions of students who are considering the possibility of becoming one’s protégés.” It is not easy being a surgical role model given the conflicts affecting academic surgeons. For example, should a surgeon allot extra time so a trainee can do a case properly, or should the case be finished expeditiously in order to avoid canceling the next case, or to get to a committee meeting or a kid’s ballgame on time? Monetary pressures, along with the possibility of losing operative time because the schedule was not full, can influence the decision to operate or not.22 Trainees absorb what they hear and see.
In 2003, Inui23 published A Flag in the Wind: Educating for Professionalism in Medicine, in which he stated, “There can be little doubt that physicians in general as well as the leadership of the organization of medicine have been preoccupied with finances and the economics of medical care. … The topics and the language of academic leadership [have] shifted in the last twenty years. … Core functions of the academic medical center became ‘enterprises.’” He also noted, “The most difficult challenge of all may be the need to understand—and to be explicitly mindful of, and articulate about—medical education as a special form of personal and professional formation that is rooted in the daily activities of individuals and groups in academic medical communities.”23 In addition, the “institutional environment we create … [is] a reflection of the values we hold as a professional community.”23 In effect, the academic medical center is part of the hidden curriculum.
Curiously, academic institutions tend not to reward clinical excellence—a self-defeating measure for any institution that recognizes the importance of the hidden curriculum.24 A peer evaluation of hospitalists revealed that the most highly regarded were highly associated with humanism and a passion for clinical medicine.25 At a prominent institution, however, it was found that clinical educators were less likely than research faculty to hold a higher rank.26
Of the factors affecting physician dissatisfaction, workplace stress is predominant.27 In this age of organizational physicians, job satisfaction correlates with how a physician feels about his or her ability to function as a physician. In a study by Wai and colleagues,28 “surgical faculty reported low satisfaction with a number of questions about communication in their medical schools and their clinical practice locations.” The authors indicated that “medical school and department governance are critical determinants of faculty satisfaction within academic surgical centers.” Pololi and colleagues29 extensively studied the culture of academic medicine and summarized the sources of discontent: “competitive individualism, undervaluing of humanistic qualities, deprecation, and the erosion of trust.” In another study,30 they studied the incidence (~25%) of, and reasons for, considering to leave academic medicine. Reasons included feeling isolated in the department, lack of institutional support, poor communication with administrators, and a perceived difference between the stated culture of the institution and what was observed on a daily basis.30
What Can We Do?
The obvious starting point is the selection process—focusing more on finding the “best,” not necessarily the “brightest.”15 This is not easy. Recommendation letters are often based on limited contact and may or may not reflect applicants’ true character. Numerous websites advise resident applicants on what questions to expect and how to prepare and practice for them. I have found questions of current events very illuminating, as they can probe how applicants view the world. Given the high income of orthopedic surgeons, some applicants likely are attracted to that aspect of the specialty. These applicants are not the “best.”
Residents who exhibit questionable ethical reasoning or behavior must be identified and not be allowed to finish their program. It is the responsibility of the program, not the board, to ensure that those entering practice exhibit a high degree of professionalism. Faculty must seriously recognize, every day, that everything they do is part of the hidden curriculum.
As noted, the academic medical environment can be inimical. Faculty who experience dissonance must be able to effectively confront administrative leadership to express their concerns, and they need to feel their concerns are recognized. Leaders of academic medical centers must guide their institutions in such a way that the day-to-day functions are compatible with the stated mission and values.31
Chervenak and colleagues32 forcefully stated that “appropriate ethical values” are the core component that academic leadership needs in order to respond to the opposing forces of increasing pressures of patient satisfaction, compliance, liability, and other administrative demands on one hand and diminishing resources on the other hand. They listed 4 “professional virtues” that characterize responsible professional leadership: self-effacement, which obligates physician leaders to be unbiased; self-sacrifice, the willingness to risk individual and organizational self-interest, especially in the economic domain; compassion, or “What can I do to help?”; and integrity. The principles of effective leadership are not that complicated, but implementing them requires conviction and courage.33
Physicians increasingly are practicing in the organization setting. They need to increase their involvement in the organization in order to promulgate the needs of physicians. Organizational executive leadership is primarily driven by budgetary and capital planning processes; physician input is essential to ensure resources are directed toward better patient care. A feeling of loss of control over one’s practice is a primary cause of physician dissatisfaction. The schism between physicians and administrators traditionally has been characterized by a lack of trust; a more trusting relationship, reinforced by frequent constructive dialogue, will result in more physician control of the practice.34 This will be difficult, but it is necessary for improving professional satisfaction.
For practicing physicians, Wynia35 made the compelling case that professionalism demands self-regulation, which involves identifying and reporting impaired or incompetent physicians—another task that requires conviction and courage.
But the core issue is how an orthopedist regards the day-to-day aspects of his or her practice. Shanafelt and colleagues36 concluded that surgeons are not very good at assessing their own well-being and stress levels. Certainly high stress can affect well-being, which in turn can affect professionalism. West and Shanafelt37 uniquely described this relationship: “The effect of distress on professionalism in medicine has become clear in recent years. The well-documented decline of crucial elements of professionalism, including empathy and humanism, during medical training appears to be related in part to personal distress experienced during medical school and residency. Unfortunately, this decline continues as physicians move into practice, where distress also is associated with decreased compassion and empathy.” This description sounds completely synchronized with the current career dissatisfaction of orthopedic surgeons.
Improving orthopedists’ status requires ethical and involved leadership, both in academia and in our professional organizations, which too often seem mired in the (not so effective) status quo. Recognizing that the resident selection process is fallible is the first step in taking action—engaging in scrupulous role modeling and insisting that residents demonstrate professionalism and communication skills in their daily work. Becoming involved in organizational management is preferable to becoming angry and dissatisfied. Getting to know one’s patients is its own reward in terms of career satisfaction. Orthopedic surgeons have a well-earned macho image—that image can be enhanced with a dose of humanism. The result would be a true professional who enjoys his or her practice and has a satisfying career.
1. The Physicians Foundation. A Survey of America’s Physicians: Practice Patterns and Perspectives. An Examination of the Professional Morale, Practice Patterns, Career Plans, and Healthcare Perspectives of Today’s Physicians, Aggregated by Age, Gender, Primary Care/Specialists, and Practice Owners/Employees. http://www.physiciansfoundation.org/uploads/default/Physicians_Foundation_2012_Biennial_Survey.pdf. Published September 2012. Accessed September 26, 2015.
2. Deshpande SP, Deshpande SS. Career satisfaction of surgical specialties. Ann Surg. 2011;253(5):1011-1016.
3. Dyrbye LN, Varkey P, Boone SL, Satele DV, Sloan JA, Shanafelt TD. Physician satisfaction and burnout at different career stages. Mayo Clin Proc. 2013;88(12):1358-1367.
4. Medscape Physician Compensation Report 2014. New York, NY: Medscape; 2014.
5. Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Serv Res. 2009;9:166.
6. deBotton A. Status Anxiety. New York, NY: Vintage Books; 2004.
7. Golden RL. William Osler at 150: an overview of a life. JAMA. 1999;282(23):2252-2258.
8. Christmas C, Kravet SJ, Durso SC, Wright SM. Clinical excellence in academia: perspectives from masterful academic clinicians. Mayo Clin Proc. 2008;83(9):989-994.
9. Stellato TA. Humanism and the art of surgery. Surgery. 2007;142(4):433-438.
10. Gold A, Gold S. Humanism in medicine from the perspective of the Arnold Gold Foundation: challenges to maintaining the care in health care. J Child Neurol. 2006;21(6):546-549.
11. Cohen JJ. Viewpoint: linking professionalism to humanism: what it means, why it matters. Acad Med. 2007;82(11):1029-1032.
12. Holt GR. Bioethics and humanism in head and neck cancer. Arch Facial Plast Surg. 2010;12(2):85-86.
13. Ruiz-Moral R, Pérez Rodríguez E, Pérula de Torres LA, de la Torre J. Physician–patient communication: a study on the observed behaviours of specialty physicians and the ways their patients perceive them. Patient Educ Couns. 2006;64(1-3):242-248.
14. Quigley DD, Elliott MN, Farley DO, Burkhart Q, Skootsky SA, Hays RD. Specialties differ in which aspects of doctor communication predict overall physician ratings. J Gen Intern Med. 2014;29(3):447-454.
15. Simon MA. The education of future orthopaedists—dèjá vu. J Bone Joint Surg Am. 2001;83(9):1416-1423.
16. Konstantakos EK, Laughlin RT, Markert RJ, Crosby LA. Follow-up on misrepresentation of research activity by orthopaedic residency applicants: has anything changed? J Bone Joint Surg Am. 2007;89(9):2084-2088.
17. Arora VM, Farnan JM, Humphrey HJ. Professionalism in the era of duty hours: time for a shift change? JAMA. 2012;308(21):2195-2196.
18. Corlew S, Lineaweaver W. New professionalism, nostalgic professionalism, pejoratives, and evidence-based persuasion. Ann Plast Surg. 2014;72(3):263-264.
19. Rohrich RJ, Persing JA, Phillips L. Mandating shorter work hours and enhancing patient safety: a new challenge for resident education. Plast Reconstr Surg. 2003;111(1):395-397.
20. Jin CJ, Martimianakis MA, Kitto S, Moulton CA. Pressures to “measure up” in surgery: managing your image and managing your patient. Ann Surg. 2012;256(6):989-993.
21. Gofton W, Regehr G. Factors in optimizing the learning environment for surgical training. Clin Orthop Relat Res. 2006;(449):100-107.
22. Leung A, Luu S, Regehr G, Murnaghan ML, Gallinger S, Moulton CA. “First, do no harm”: balancing competing priorities in surgical practice. Acad Med. 2012;87(10):1368-1374.
23. Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003. http://www.bumc.bu.edu/mec/files/2010/06/AAMC_Inui_2003.pdf. Accessed September 26, 2015.
24. Durso SC, Christmas C, Kravet SJ, Parsons G, Wright SM. Implications of academic medicine’s failure to recognize clinical excellence. Clin Med Res. 2009;7(4):127-133.
25. Bhogal HK, Howe E, Torok H, Knight AM, Howell E, Wright S. Peer assessment of professional performance by hospitalist physicians. South Med J. 2012;105(5):254-258.
26. Thomas PA, Diener-West M, Canto MI, Martin DR, Post WS, Streiff MB. Results of an academic promotion and career path survey of faculty at the Johns Hopkins University School of Medicine. Acad Med. 2004;79(3):258-264.
27. Williams ES, Konrad TR, Scheckler WE, et al. Understanding physicians’ intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. 2001. Health Care Manage Rev. 2010;35(2):105-115.
28. Wai PY, Dandar V, Radosevich DM, Brubaker L, Kuo PC. Engagement, workplace satisfaction, and retention of surgical specialists in academic medicine in the United States. J Am Coll Surg. 2014;219(1):31-42.
29. Pololi LH, Kern DE, Carr P, Conrad P, Knight S. The culture of academic medicine: faculty perceptions of the lack of alignment between individual and institutional values. J Gen Intern Med. 2009;24(12):1289-1295.
30. Pololi LH, Krupat E, Civian JT, Ash AS, Brennan RT. Why are a quarter of faculty considering leaving academic medicine? A study of their perceptions of institutional culture and intentions to leave at 26 representiative U.S. medical schools. Acad Med. 2012;87(7):859-869.
31. Beckerle MC, Reed KL, Scott RP, et al. Medical faculty development: a modern-day Odyssey. Sci Transl Med. 2011;3(104):104cm31.
32. Chervenak FA, McCullough LB, Brent RL. The professional responsibility model of physician leadership. Am J Obstet Gynecol. 2013;208(2):97-101.
33. Gross RH. The coaching model for educational leadership principles. J Bone Joint Surg Am. 2004;86(9):2082-2084.
34. Mullins LA. Hospital–physician relationships: a synergy that must work. Front Health Serv Manage. 2003;20(2):37-41.
35. Wynia MK. The role of professionalism and self-regulation in detecting impaired or incompetent physicians. JAMA. 2010;304(2):210-212.
36. Shanafelt TD, Kaups KL, Nelson H, et al. An interactive individualized intervention to promote behavioral change to increase personal well-being in US surgeons. Ann Surg. 2014;259(1):82-88.
37. West CP, Shanafelt TD. Physician well-being and professionalism. Minn Med. 2007;90(8):44-46.
Several years ago, I was on the American Academy of Orthopaedic Surgeons leadership fellow committee, reviewing fellowship applications. The committee had been poised to very favorably rule on an application until a new member spoke up, stating that he had been in the applicant’s department and that points made in the recommending letter bore little resemblance to the person’s performance. Further study confirmed the dishonesty in the letter, and a more fit candidate was selected instead.
I was puzzled. Why would a leader in the field do such a thing? The question led me to a personal investigation into the monumental topic of professionalism and, more specifically, professionalism among orthopedic surgeons.
Physicians, Especially Orthopedists, Are Not Happy
Physicians, in general, are not a happy lot. According to a 2012 survey by the Physicians Foundation,1 77.4% of practicing physicians were pessimistic about the future of medicine, and 82% thought they had little ability to change the health care system. Sources of pessimism included “too much regulation/paperwork, loss of clinical autonomy, physicians not compensated for quality, erosion of physician/patient relationship, and money trumps patient care.” We are now in the age of “organizational physicians,” who, subject to institutional management, are experiencing a distressing loss of autonomy.
What sustains, or does not sustain, surgeons’ career satisfaction? Commonly stated positive factors include the ability to provide quality care, time with patients, income, and financial incentives2; reported negative factors include threat of malpractice, lack of autonomy, excessive administrative tasks, and high patient volume. Early-career physicians have the lowest career satisfaction, but physicians in mid-career have the highest rate of burnout and likelihood of leaving medical practice.3 Work–home conflict is most difficult in the early career, when families have young children, and the conflict generally goes unresolved. Burnout and low satisfaction with specialty choice are most common in mid-career.
Despite all the negative factors acting on medical practices, orthopedic surgeons have fared well financially, but not as well in career satisfaction. The Medscape Physician Compensation Report 20144 places orthopedics compensation first among 25 specialties listed, without a close second, but orthopedists rank 15th in thinking they are fairly compensated, and next to last in indicating they would choose medicine again as a career. A separate study of physician career satisfaction ranked orthopedics 32nd of 42 specialties studied.5
What is our problem, and what can we do about it? It’s hard to digest this information and not feel that orthopedists are, for lack of a better word, spoiled.
DeBotton6 wrote about status anxiety, which arises over and over again in daily life. Essentially, it is the envy or dissatisfaction one feels when a peer gets a better deal that does not seem just. A remarkable aspect of Medscape’s compensation report4 is that family medicine physicians, whose annual income was well under half that of orthopedic surgeons, were more likely to view themselves as fairly compensated. On this basis, we have to conclude that orthopedic surgeons have status anxiety. But why?
Humanism
Osler, the quintessential physician, counseled medical students: “Nothing will sustain you more potently in your humdrum routine … than the power to recognize the true poetry of life—the poetry of the commonplace, of the ordinary man, of the plain, toilworn woman, with their loves and their joys, their sorrows and their griefs.”7 In short, take the time to know your patients. In a study of physicians who were regarded as clinically excellent, several traits were noted: honest, nonjudgmental, genuinely caring, treating all patients equally, and constantly striving for excellence.8 A century after Osler, Stellato9 echoed the sentiment: “Listen to your patients, not just about their illness, but about their life.”
Humanism, then, is the trait underlying professionalism.10,11 Communication skills are essential to humanism.12 However, a study of specialty physicians in Spain “showed scarce empathic behaviours or behaviours that foster a shared decision making process.”13 In addition, a recent survey placed the communication skills of orthopedists last among 28 specialties.14 Assessment was based on how often a physician explains things, listens carefully, gives easy-to-understand instructions, shows respect, and spends enough time.
Could it be that orthopedists are not satisfied with their income because as a group they lack the communication skills and humanistic characteristics of lower-paid physicians?
Residency and the Academic Medical Center
The education of the orthopedic surgeon starts with the selection process. Simon15 noted that “the brightest, but not always the best” are selected largely because objective criteria are an excellent measure of cognitive achievement but not of character. Also noting that 10% of examinees pass part I of the board but fail part II, Simon opined that they “lack clinical judgment, communication skills, and, in some instances, ethics.” A 1999 team of authors found that 18% of research citations listed by orthopedic residency applicants were misrepresented, and a follow-up study by the same authors in 2007 noted a rate increase, to 20.6%.16 Both sets of authors wrote of a need for a better selection process and a better evaluative process during residency.
The residency process has been substantially altered by work-hour restrictions. The 20th-century residency, which emphasizes taking responsibility for the patient throughout a hospital stay, has now been dismissed as “nostalgic professionalism.” Residents are now advised to avoid such activities as checking laboratory results from home and coming to work when they are not feeling well.17 However, there has been considerable pushback against diminishing nostalgic professionalism, primarily from surgeons.18 “Teaching residents that they should go home to rest at the end of their shift without regard for the circumstances of their cases in progress is not an acceptable example for training.”19 Current promulgated restrictions on duty hours move concern for the “circumstances of their cases” to the back burner—the shift ends, the physician leaves. Residents are pulled one way by forces telling them to leave (Accreditation Council for Graduate Medical Education) and the other way by forces telling them to stay (their conscience).
How do residents develop their surgical identities and concepts of humanism and professionalism? There is a substantial body of evidence that the so-called hidden curriculum is the dominant factor: trainees emulate what their faculty say and do.20 As Gofton and Regehr21 noted, “It is vital for members of the surgical academic community to recognize [that] the attitudes, beliefs, and values implicit in every action, every word, every inaction, and every silence are not only shaping the attitudes, beliefs, and values of one’s protégés, but also are shaping the decisions of students who are considering the possibility of becoming one’s protégés.” It is not easy being a surgical role model given the conflicts affecting academic surgeons. For example, should a surgeon allot extra time so a trainee can do a case properly, or should the case be finished expeditiously in order to avoid canceling the next case, or to get to a committee meeting or a kid’s ballgame on time? Monetary pressures, along with the possibility of losing operative time because the schedule was not full, can influence the decision to operate or not.22 Trainees absorb what they hear and see.
In 2003, Inui23 published A Flag in the Wind: Educating for Professionalism in Medicine, in which he stated, “There can be little doubt that physicians in general as well as the leadership of the organization of medicine have been preoccupied with finances and the economics of medical care. … The topics and the language of academic leadership [have] shifted in the last twenty years. … Core functions of the academic medical center became ‘enterprises.’” He also noted, “The most difficult challenge of all may be the need to understand—and to be explicitly mindful of, and articulate about—medical education as a special form of personal and professional formation that is rooted in the daily activities of individuals and groups in academic medical communities.”23 In addition, the “institutional environment we create … [is] a reflection of the values we hold as a professional community.”23 In effect, the academic medical center is part of the hidden curriculum.
Curiously, academic institutions tend not to reward clinical excellence—a self-defeating measure for any institution that recognizes the importance of the hidden curriculum.24 A peer evaluation of hospitalists revealed that the most highly regarded were highly associated with humanism and a passion for clinical medicine.25 At a prominent institution, however, it was found that clinical educators were less likely than research faculty to hold a higher rank.26
Of the factors affecting physician dissatisfaction, workplace stress is predominant.27 In this age of organizational physicians, job satisfaction correlates with how a physician feels about his or her ability to function as a physician. In a study by Wai and colleagues,28 “surgical faculty reported low satisfaction with a number of questions about communication in their medical schools and their clinical practice locations.” The authors indicated that “medical school and department governance are critical determinants of faculty satisfaction within academic surgical centers.” Pololi and colleagues29 extensively studied the culture of academic medicine and summarized the sources of discontent: “competitive individualism, undervaluing of humanistic qualities, deprecation, and the erosion of trust.” In another study,30 they studied the incidence (~25%) of, and reasons for, considering to leave academic medicine. Reasons included feeling isolated in the department, lack of institutional support, poor communication with administrators, and a perceived difference between the stated culture of the institution and what was observed on a daily basis.30
What Can We Do?
The obvious starting point is the selection process—focusing more on finding the “best,” not necessarily the “brightest.”15 This is not easy. Recommendation letters are often based on limited contact and may or may not reflect applicants’ true character. Numerous websites advise resident applicants on what questions to expect and how to prepare and practice for them. I have found questions of current events very illuminating, as they can probe how applicants view the world. Given the high income of orthopedic surgeons, some applicants likely are attracted to that aspect of the specialty. These applicants are not the “best.”
Residents who exhibit questionable ethical reasoning or behavior must be identified and not be allowed to finish their program. It is the responsibility of the program, not the board, to ensure that those entering practice exhibit a high degree of professionalism. Faculty must seriously recognize, every day, that everything they do is part of the hidden curriculum.
As noted, the academic medical environment can be inimical. Faculty who experience dissonance must be able to effectively confront administrative leadership to express their concerns, and they need to feel their concerns are recognized. Leaders of academic medical centers must guide their institutions in such a way that the day-to-day functions are compatible with the stated mission and values.31
Chervenak and colleagues32 forcefully stated that “appropriate ethical values” are the core component that academic leadership needs in order to respond to the opposing forces of increasing pressures of patient satisfaction, compliance, liability, and other administrative demands on one hand and diminishing resources on the other hand. They listed 4 “professional virtues” that characterize responsible professional leadership: self-effacement, which obligates physician leaders to be unbiased; self-sacrifice, the willingness to risk individual and organizational self-interest, especially in the economic domain; compassion, or “What can I do to help?”; and integrity. The principles of effective leadership are not that complicated, but implementing them requires conviction and courage.33
Physicians increasingly are practicing in the organization setting. They need to increase their involvement in the organization in order to promulgate the needs of physicians. Organizational executive leadership is primarily driven by budgetary and capital planning processes; physician input is essential to ensure resources are directed toward better patient care. A feeling of loss of control over one’s practice is a primary cause of physician dissatisfaction. The schism between physicians and administrators traditionally has been characterized by a lack of trust; a more trusting relationship, reinforced by frequent constructive dialogue, will result in more physician control of the practice.34 This will be difficult, but it is necessary for improving professional satisfaction.
For practicing physicians, Wynia35 made the compelling case that professionalism demands self-regulation, which involves identifying and reporting impaired or incompetent physicians—another task that requires conviction and courage.
But the core issue is how an orthopedist regards the day-to-day aspects of his or her practice. Shanafelt and colleagues36 concluded that surgeons are not very good at assessing their own well-being and stress levels. Certainly high stress can affect well-being, which in turn can affect professionalism. West and Shanafelt37 uniquely described this relationship: “The effect of distress on professionalism in medicine has become clear in recent years. The well-documented decline of crucial elements of professionalism, including empathy and humanism, during medical training appears to be related in part to personal distress experienced during medical school and residency. Unfortunately, this decline continues as physicians move into practice, where distress also is associated with decreased compassion and empathy.” This description sounds completely synchronized with the current career dissatisfaction of orthopedic surgeons.
Improving orthopedists’ status requires ethical and involved leadership, both in academia and in our professional organizations, which too often seem mired in the (not so effective) status quo. Recognizing that the resident selection process is fallible is the first step in taking action—engaging in scrupulous role modeling and insisting that residents demonstrate professionalism and communication skills in their daily work. Becoming involved in organizational management is preferable to becoming angry and dissatisfied. Getting to know one’s patients is its own reward in terms of career satisfaction. Orthopedic surgeons have a well-earned macho image—that image can be enhanced with a dose of humanism. The result would be a true professional who enjoys his or her practice and has a satisfying career.
Several years ago, I was on the American Academy of Orthopaedic Surgeons leadership fellow committee, reviewing fellowship applications. The committee had been poised to very favorably rule on an application until a new member spoke up, stating that he had been in the applicant’s department and that points made in the recommending letter bore little resemblance to the person’s performance. Further study confirmed the dishonesty in the letter, and a more fit candidate was selected instead.
I was puzzled. Why would a leader in the field do such a thing? The question led me to a personal investigation into the monumental topic of professionalism and, more specifically, professionalism among orthopedic surgeons.
Physicians, Especially Orthopedists, Are Not Happy
Physicians, in general, are not a happy lot. According to a 2012 survey by the Physicians Foundation,1 77.4% of practicing physicians were pessimistic about the future of medicine, and 82% thought they had little ability to change the health care system. Sources of pessimism included “too much regulation/paperwork, loss of clinical autonomy, physicians not compensated for quality, erosion of physician/patient relationship, and money trumps patient care.” We are now in the age of “organizational physicians,” who, subject to institutional management, are experiencing a distressing loss of autonomy.
What sustains, or does not sustain, surgeons’ career satisfaction? Commonly stated positive factors include the ability to provide quality care, time with patients, income, and financial incentives2; reported negative factors include threat of malpractice, lack of autonomy, excessive administrative tasks, and high patient volume. Early-career physicians have the lowest career satisfaction, but physicians in mid-career have the highest rate of burnout and likelihood of leaving medical practice.3 Work–home conflict is most difficult in the early career, when families have young children, and the conflict generally goes unresolved. Burnout and low satisfaction with specialty choice are most common in mid-career.
Despite all the negative factors acting on medical practices, orthopedic surgeons have fared well financially, but not as well in career satisfaction. The Medscape Physician Compensation Report 20144 places orthopedics compensation first among 25 specialties listed, without a close second, but orthopedists rank 15th in thinking they are fairly compensated, and next to last in indicating they would choose medicine again as a career. A separate study of physician career satisfaction ranked orthopedics 32nd of 42 specialties studied.5
What is our problem, and what can we do about it? It’s hard to digest this information and not feel that orthopedists are, for lack of a better word, spoiled.
DeBotton6 wrote about status anxiety, which arises over and over again in daily life. Essentially, it is the envy or dissatisfaction one feels when a peer gets a better deal that does not seem just. A remarkable aspect of Medscape’s compensation report4 is that family medicine physicians, whose annual income was well under half that of orthopedic surgeons, were more likely to view themselves as fairly compensated. On this basis, we have to conclude that orthopedic surgeons have status anxiety. But why?
Humanism
Osler, the quintessential physician, counseled medical students: “Nothing will sustain you more potently in your humdrum routine … than the power to recognize the true poetry of life—the poetry of the commonplace, of the ordinary man, of the plain, toilworn woman, with their loves and their joys, their sorrows and their griefs.”7 In short, take the time to know your patients. In a study of physicians who were regarded as clinically excellent, several traits were noted: honest, nonjudgmental, genuinely caring, treating all patients equally, and constantly striving for excellence.8 A century after Osler, Stellato9 echoed the sentiment: “Listen to your patients, not just about their illness, but about their life.”
Humanism, then, is the trait underlying professionalism.10,11 Communication skills are essential to humanism.12 However, a study of specialty physicians in Spain “showed scarce empathic behaviours or behaviours that foster a shared decision making process.”13 In addition, a recent survey placed the communication skills of orthopedists last among 28 specialties.14 Assessment was based on how often a physician explains things, listens carefully, gives easy-to-understand instructions, shows respect, and spends enough time.
Could it be that orthopedists are not satisfied with their income because as a group they lack the communication skills and humanistic characteristics of lower-paid physicians?
Residency and the Academic Medical Center
The education of the orthopedic surgeon starts with the selection process. Simon15 noted that “the brightest, but not always the best” are selected largely because objective criteria are an excellent measure of cognitive achievement but not of character. Also noting that 10% of examinees pass part I of the board but fail part II, Simon opined that they “lack clinical judgment, communication skills, and, in some instances, ethics.” A 1999 team of authors found that 18% of research citations listed by orthopedic residency applicants were misrepresented, and a follow-up study by the same authors in 2007 noted a rate increase, to 20.6%.16 Both sets of authors wrote of a need for a better selection process and a better evaluative process during residency.
The residency process has been substantially altered by work-hour restrictions. The 20th-century residency, which emphasizes taking responsibility for the patient throughout a hospital stay, has now been dismissed as “nostalgic professionalism.” Residents are now advised to avoid such activities as checking laboratory results from home and coming to work when they are not feeling well.17 However, there has been considerable pushback against diminishing nostalgic professionalism, primarily from surgeons.18 “Teaching residents that they should go home to rest at the end of their shift without regard for the circumstances of their cases in progress is not an acceptable example for training.”19 Current promulgated restrictions on duty hours move concern for the “circumstances of their cases” to the back burner—the shift ends, the physician leaves. Residents are pulled one way by forces telling them to leave (Accreditation Council for Graduate Medical Education) and the other way by forces telling them to stay (their conscience).
How do residents develop their surgical identities and concepts of humanism and professionalism? There is a substantial body of evidence that the so-called hidden curriculum is the dominant factor: trainees emulate what their faculty say and do.20 As Gofton and Regehr21 noted, “It is vital for members of the surgical academic community to recognize [that] the attitudes, beliefs, and values implicit in every action, every word, every inaction, and every silence are not only shaping the attitudes, beliefs, and values of one’s protégés, but also are shaping the decisions of students who are considering the possibility of becoming one’s protégés.” It is not easy being a surgical role model given the conflicts affecting academic surgeons. For example, should a surgeon allot extra time so a trainee can do a case properly, or should the case be finished expeditiously in order to avoid canceling the next case, or to get to a committee meeting or a kid’s ballgame on time? Monetary pressures, along with the possibility of losing operative time because the schedule was not full, can influence the decision to operate or not.22 Trainees absorb what they hear and see.
In 2003, Inui23 published A Flag in the Wind: Educating for Professionalism in Medicine, in which he stated, “There can be little doubt that physicians in general as well as the leadership of the organization of medicine have been preoccupied with finances and the economics of medical care. … The topics and the language of academic leadership [have] shifted in the last twenty years. … Core functions of the academic medical center became ‘enterprises.’” He also noted, “The most difficult challenge of all may be the need to understand—and to be explicitly mindful of, and articulate about—medical education as a special form of personal and professional formation that is rooted in the daily activities of individuals and groups in academic medical communities.”23 In addition, the “institutional environment we create … [is] a reflection of the values we hold as a professional community.”23 In effect, the academic medical center is part of the hidden curriculum.
Curiously, academic institutions tend not to reward clinical excellence—a self-defeating measure for any institution that recognizes the importance of the hidden curriculum.24 A peer evaluation of hospitalists revealed that the most highly regarded were highly associated with humanism and a passion for clinical medicine.25 At a prominent institution, however, it was found that clinical educators were less likely than research faculty to hold a higher rank.26
Of the factors affecting physician dissatisfaction, workplace stress is predominant.27 In this age of organizational physicians, job satisfaction correlates with how a physician feels about his or her ability to function as a physician. In a study by Wai and colleagues,28 “surgical faculty reported low satisfaction with a number of questions about communication in their medical schools and their clinical practice locations.” The authors indicated that “medical school and department governance are critical determinants of faculty satisfaction within academic surgical centers.” Pololi and colleagues29 extensively studied the culture of academic medicine and summarized the sources of discontent: “competitive individualism, undervaluing of humanistic qualities, deprecation, and the erosion of trust.” In another study,30 they studied the incidence (~25%) of, and reasons for, considering to leave academic medicine. Reasons included feeling isolated in the department, lack of institutional support, poor communication with administrators, and a perceived difference between the stated culture of the institution and what was observed on a daily basis.30
What Can We Do?
The obvious starting point is the selection process—focusing more on finding the “best,” not necessarily the “brightest.”15 This is not easy. Recommendation letters are often based on limited contact and may or may not reflect applicants’ true character. Numerous websites advise resident applicants on what questions to expect and how to prepare and practice for them. I have found questions of current events very illuminating, as they can probe how applicants view the world. Given the high income of orthopedic surgeons, some applicants likely are attracted to that aspect of the specialty. These applicants are not the “best.”
Residents who exhibit questionable ethical reasoning or behavior must be identified and not be allowed to finish their program. It is the responsibility of the program, not the board, to ensure that those entering practice exhibit a high degree of professionalism. Faculty must seriously recognize, every day, that everything they do is part of the hidden curriculum.
As noted, the academic medical environment can be inimical. Faculty who experience dissonance must be able to effectively confront administrative leadership to express their concerns, and they need to feel their concerns are recognized. Leaders of academic medical centers must guide their institutions in such a way that the day-to-day functions are compatible with the stated mission and values.31
Chervenak and colleagues32 forcefully stated that “appropriate ethical values” are the core component that academic leadership needs in order to respond to the opposing forces of increasing pressures of patient satisfaction, compliance, liability, and other administrative demands on one hand and diminishing resources on the other hand. They listed 4 “professional virtues” that characterize responsible professional leadership: self-effacement, which obligates physician leaders to be unbiased; self-sacrifice, the willingness to risk individual and organizational self-interest, especially in the economic domain; compassion, or “What can I do to help?”; and integrity. The principles of effective leadership are not that complicated, but implementing them requires conviction and courage.33
Physicians increasingly are practicing in the organization setting. They need to increase their involvement in the organization in order to promulgate the needs of physicians. Organizational executive leadership is primarily driven by budgetary and capital planning processes; physician input is essential to ensure resources are directed toward better patient care. A feeling of loss of control over one’s practice is a primary cause of physician dissatisfaction. The schism between physicians and administrators traditionally has been characterized by a lack of trust; a more trusting relationship, reinforced by frequent constructive dialogue, will result in more physician control of the practice.34 This will be difficult, but it is necessary for improving professional satisfaction.
For practicing physicians, Wynia35 made the compelling case that professionalism demands self-regulation, which involves identifying and reporting impaired or incompetent physicians—another task that requires conviction and courage.
But the core issue is how an orthopedist regards the day-to-day aspects of his or her practice. Shanafelt and colleagues36 concluded that surgeons are not very good at assessing their own well-being and stress levels. Certainly high stress can affect well-being, which in turn can affect professionalism. West and Shanafelt37 uniquely described this relationship: “The effect of distress on professionalism in medicine has become clear in recent years. The well-documented decline of crucial elements of professionalism, including empathy and humanism, during medical training appears to be related in part to personal distress experienced during medical school and residency. Unfortunately, this decline continues as physicians move into practice, where distress also is associated with decreased compassion and empathy.” This description sounds completely synchronized with the current career dissatisfaction of orthopedic surgeons.
Improving orthopedists’ status requires ethical and involved leadership, both in academia and in our professional organizations, which too often seem mired in the (not so effective) status quo. Recognizing that the resident selection process is fallible is the first step in taking action—engaging in scrupulous role modeling and insisting that residents demonstrate professionalism and communication skills in their daily work. Becoming involved in organizational management is preferable to becoming angry and dissatisfied. Getting to know one’s patients is its own reward in terms of career satisfaction. Orthopedic surgeons have a well-earned macho image—that image can be enhanced with a dose of humanism. The result would be a true professional who enjoys his or her practice and has a satisfying career.
1. The Physicians Foundation. A Survey of America’s Physicians: Practice Patterns and Perspectives. An Examination of the Professional Morale, Practice Patterns, Career Plans, and Healthcare Perspectives of Today’s Physicians, Aggregated by Age, Gender, Primary Care/Specialists, and Practice Owners/Employees. http://www.physiciansfoundation.org/uploads/default/Physicians_Foundation_2012_Biennial_Survey.pdf. Published September 2012. Accessed September 26, 2015.
2. Deshpande SP, Deshpande SS. Career satisfaction of surgical specialties. Ann Surg. 2011;253(5):1011-1016.
3. Dyrbye LN, Varkey P, Boone SL, Satele DV, Sloan JA, Shanafelt TD. Physician satisfaction and burnout at different career stages. Mayo Clin Proc. 2013;88(12):1358-1367.
4. Medscape Physician Compensation Report 2014. New York, NY: Medscape; 2014.
5. Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Serv Res. 2009;9:166.
6. deBotton A. Status Anxiety. New York, NY: Vintage Books; 2004.
7. Golden RL. William Osler at 150: an overview of a life. JAMA. 1999;282(23):2252-2258.
8. Christmas C, Kravet SJ, Durso SC, Wright SM. Clinical excellence in academia: perspectives from masterful academic clinicians. Mayo Clin Proc. 2008;83(9):989-994.
9. Stellato TA. Humanism and the art of surgery. Surgery. 2007;142(4):433-438.
10. Gold A, Gold S. Humanism in medicine from the perspective of the Arnold Gold Foundation: challenges to maintaining the care in health care. J Child Neurol. 2006;21(6):546-549.
11. Cohen JJ. Viewpoint: linking professionalism to humanism: what it means, why it matters. Acad Med. 2007;82(11):1029-1032.
12. Holt GR. Bioethics and humanism in head and neck cancer. Arch Facial Plast Surg. 2010;12(2):85-86.
13. Ruiz-Moral R, Pérez Rodríguez E, Pérula de Torres LA, de la Torre J. Physician–patient communication: a study on the observed behaviours of specialty physicians and the ways their patients perceive them. Patient Educ Couns. 2006;64(1-3):242-248.
14. Quigley DD, Elliott MN, Farley DO, Burkhart Q, Skootsky SA, Hays RD. Specialties differ in which aspects of doctor communication predict overall physician ratings. J Gen Intern Med. 2014;29(3):447-454.
15. Simon MA. The education of future orthopaedists—dèjá vu. J Bone Joint Surg Am. 2001;83(9):1416-1423.
16. Konstantakos EK, Laughlin RT, Markert RJ, Crosby LA. Follow-up on misrepresentation of research activity by orthopaedic residency applicants: has anything changed? J Bone Joint Surg Am. 2007;89(9):2084-2088.
17. Arora VM, Farnan JM, Humphrey HJ. Professionalism in the era of duty hours: time for a shift change? JAMA. 2012;308(21):2195-2196.
18. Corlew S, Lineaweaver W. New professionalism, nostalgic professionalism, pejoratives, and evidence-based persuasion. Ann Plast Surg. 2014;72(3):263-264.
19. Rohrich RJ, Persing JA, Phillips L. Mandating shorter work hours and enhancing patient safety: a new challenge for resident education. Plast Reconstr Surg. 2003;111(1):395-397.
20. Jin CJ, Martimianakis MA, Kitto S, Moulton CA. Pressures to “measure up” in surgery: managing your image and managing your patient. Ann Surg. 2012;256(6):989-993.
21. Gofton W, Regehr G. Factors in optimizing the learning environment for surgical training. Clin Orthop Relat Res. 2006;(449):100-107.
22. Leung A, Luu S, Regehr G, Murnaghan ML, Gallinger S, Moulton CA. “First, do no harm”: balancing competing priorities in surgical practice. Acad Med. 2012;87(10):1368-1374.
23. Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003. http://www.bumc.bu.edu/mec/files/2010/06/AAMC_Inui_2003.pdf. Accessed September 26, 2015.
24. Durso SC, Christmas C, Kravet SJ, Parsons G, Wright SM. Implications of academic medicine’s failure to recognize clinical excellence. Clin Med Res. 2009;7(4):127-133.
25. Bhogal HK, Howe E, Torok H, Knight AM, Howell E, Wright S. Peer assessment of professional performance by hospitalist physicians. South Med J. 2012;105(5):254-258.
26. Thomas PA, Diener-West M, Canto MI, Martin DR, Post WS, Streiff MB. Results of an academic promotion and career path survey of faculty at the Johns Hopkins University School of Medicine. Acad Med. 2004;79(3):258-264.
27. Williams ES, Konrad TR, Scheckler WE, et al. Understanding physicians’ intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. 2001. Health Care Manage Rev. 2010;35(2):105-115.
28. Wai PY, Dandar V, Radosevich DM, Brubaker L, Kuo PC. Engagement, workplace satisfaction, and retention of surgical specialists in academic medicine in the United States. J Am Coll Surg. 2014;219(1):31-42.
29. Pololi LH, Kern DE, Carr P, Conrad P, Knight S. The culture of academic medicine: faculty perceptions of the lack of alignment between individual and institutional values. J Gen Intern Med. 2009;24(12):1289-1295.
30. Pololi LH, Krupat E, Civian JT, Ash AS, Brennan RT. Why are a quarter of faculty considering leaving academic medicine? A study of their perceptions of institutional culture and intentions to leave at 26 representiative U.S. medical schools. Acad Med. 2012;87(7):859-869.
31. Beckerle MC, Reed KL, Scott RP, et al. Medical faculty development: a modern-day Odyssey. Sci Transl Med. 2011;3(104):104cm31.
32. Chervenak FA, McCullough LB, Brent RL. The professional responsibility model of physician leadership. Am J Obstet Gynecol. 2013;208(2):97-101.
33. Gross RH. The coaching model for educational leadership principles. J Bone Joint Surg Am. 2004;86(9):2082-2084.
34. Mullins LA. Hospital–physician relationships: a synergy that must work. Front Health Serv Manage. 2003;20(2):37-41.
35. Wynia MK. The role of professionalism and self-regulation in detecting impaired or incompetent physicians. JAMA. 2010;304(2):210-212.
36. Shanafelt TD, Kaups KL, Nelson H, et al. An interactive individualized intervention to promote behavioral change to increase personal well-being in US surgeons. Ann Surg. 2014;259(1):82-88.
37. West CP, Shanafelt TD. Physician well-being and professionalism. Minn Med. 2007;90(8):44-46.
1. The Physicians Foundation. A Survey of America’s Physicians: Practice Patterns and Perspectives. An Examination of the Professional Morale, Practice Patterns, Career Plans, and Healthcare Perspectives of Today’s Physicians, Aggregated by Age, Gender, Primary Care/Specialists, and Practice Owners/Employees. http://www.physiciansfoundation.org/uploads/default/Physicians_Foundation_2012_Biennial_Survey.pdf. Published September 2012. Accessed September 26, 2015.
2. Deshpande SP, Deshpande SS. Career satisfaction of surgical specialties. Ann Surg. 2011;253(5):1011-1016.
3. Dyrbye LN, Varkey P, Boone SL, Satele DV, Sloan JA, Shanafelt TD. Physician satisfaction and burnout at different career stages. Mayo Clin Proc. 2013;88(12):1358-1367.
4. Medscape Physician Compensation Report 2014. New York, NY: Medscape; 2014.
5. Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Serv Res. 2009;9:166.
6. deBotton A. Status Anxiety. New York, NY: Vintage Books; 2004.
7. Golden RL. William Osler at 150: an overview of a life. JAMA. 1999;282(23):2252-2258.
8. Christmas C, Kravet SJ, Durso SC, Wright SM. Clinical excellence in academia: perspectives from masterful academic clinicians. Mayo Clin Proc. 2008;83(9):989-994.
9. Stellato TA. Humanism and the art of surgery. Surgery. 2007;142(4):433-438.
10. Gold A, Gold S. Humanism in medicine from the perspective of the Arnold Gold Foundation: challenges to maintaining the care in health care. J Child Neurol. 2006;21(6):546-549.
11. Cohen JJ. Viewpoint: linking professionalism to humanism: what it means, why it matters. Acad Med. 2007;82(11):1029-1032.
12. Holt GR. Bioethics and humanism in head and neck cancer. Arch Facial Plast Surg. 2010;12(2):85-86.
13. Ruiz-Moral R, Pérez Rodríguez E, Pérula de Torres LA, de la Torre J. Physician–patient communication: a study on the observed behaviours of specialty physicians and the ways their patients perceive them. Patient Educ Couns. 2006;64(1-3):242-248.
14. Quigley DD, Elliott MN, Farley DO, Burkhart Q, Skootsky SA, Hays RD. Specialties differ in which aspects of doctor communication predict overall physician ratings. J Gen Intern Med. 2014;29(3):447-454.
15. Simon MA. The education of future orthopaedists—dèjá vu. J Bone Joint Surg Am. 2001;83(9):1416-1423.
16. Konstantakos EK, Laughlin RT, Markert RJ, Crosby LA. Follow-up on misrepresentation of research activity by orthopaedic residency applicants: has anything changed? J Bone Joint Surg Am. 2007;89(9):2084-2088.
17. Arora VM, Farnan JM, Humphrey HJ. Professionalism in the era of duty hours: time for a shift change? JAMA. 2012;308(21):2195-2196.
18. Corlew S, Lineaweaver W. New professionalism, nostalgic professionalism, pejoratives, and evidence-based persuasion. Ann Plast Surg. 2014;72(3):263-264.
19. Rohrich RJ, Persing JA, Phillips L. Mandating shorter work hours and enhancing patient safety: a new challenge for resident education. Plast Reconstr Surg. 2003;111(1):395-397.
20. Jin CJ, Martimianakis MA, Kitto S, Moulton CA. Pressures to “measure up” in surgery: managing your image and managing your patient. Ann Surg. 2012;256(6):989-993.
21. Gofton W, Regehr G. Factors in optimizing the learning environment for surgical training. Clin Orthop Relat Res. 2006;(449):100-107.
22. Leung A, Luu S, Regehr G, Murnaghan ML, Gallinger S, Moulton CA. “First, do no harm”: balancing competing priorities in surgical practice. Acad Med. 2012;87(10):1368-1374.
23. Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003. http://www.bumc.bu.edu/mec/files/2010/06/AAMC_Inui_2003.pdf. Accessed September 26, 2015.
24. Durso SC, Christmas C, Kravet SJ, Parsons G, Wright SM. Implications of academic medicine’s failure to recognize clinical excellence. Clin Med Res. 2009;7(4):127-133.
25. Bhogal HK, Howe E, Torok H, Knight AM, Howell E, Wright S. Peer assessment of professional performance by hospitalist physicians. South Med J. 2012;105(5):254-258.
26. Thomas PA, Diener-West M, Canto MI, Martin DR, Post WS, Streiff MB. Results of an academic promotion and career path survey of faculty at the Johns Hopkins University School of Medicine. Acad Med. 2004;79(3):258-264.
27. Williams ES, Konrad TR, Scheckler WE, et al. Understanding physicians’ intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. 2001. Health Care Manage Rev. 2010;35(2):105-115.
28. Wai PY, Dandar V, Radosevich DM, Brubaker L, Kuo PC. Engagement, workplace satisfaction, and retention of surgical specialists in academic medicine in the United States. J Am Coll Surg. 2014;219(1):31-42.
29. Pololi LH, Kern DE, Carr P, Conrad P, Knight S. The culture of academic medicine: faculty perceptions of the lack of alignment between individual and institutional values. J Gen Intern Med. 2009;24(12):1289-1295.
30. Pololi LH, Krupat E, Civian JT, Ash AS, Brennan RT. Why are a quarter of faculty considering leaving academic medicine? A study of their perceptions of institutional culture and intentions to leave at 26 representiative U.S. medical schools. Acad Med. 2012;87(7):859-869.
31. Beckerle MC, Reed KL, Scott RP, et al. Medical faculty development: a modern-day Odyssey. Sci Transl Med. 2011;3(104):104cm31.
32. Chervenak FA, McCullough LB, Brent RL. The professional responsibility model of physician leadership. Am J Obstet Gynecol. 2013;208(2):97-101.
33. Gross RH. The coaching model for educational leadership principles. J Bone Joint Surg Am. 2004;86(9):2082-2084.
34. Mullins LA. Hospital–physician relationships: a synergy that must work. Front Health Serv Manage. 2003;20(2):37-41.
35. Wynia MK. The role of professionalism and self-regulation in detecting impaired or incompetent physicians. JAMA. 2010;304(2):210-212.
36. Shanafelt TD, Kaups KL, Nelson H, et al. An interactive individualized intervention to promote behavioral change to increase personal well-being in US surgeons. Ann Surg. 2014;259(1):82-88.
37. West CP, Shanafelt TD. Physician well-being and professionalism. Minn Med. 2007;90(8):44-46.
