222 K. Troppmann and C. Troppmann

were effectively taken.23 Similarly, in another national survey, half the surgeons felt that their work schedules did not allow enough time for their personal lives.18 In yet another recent national survey, 64% (of nearly 8,000 sampled surgeons) felt that their work schedules did not leave enough time for per- sonal and family life.19 Finally, several studies of surgeons in individual subspecialties have yielded similar results. In a ran- dom sample of members of the American Society of Plastic Surgeons, only half were satisfied with their time management between career and personal responsibilities.11 Similarly, a report from the American Pediatric Surgical Association Task Force on Family Issues noted that only 6% of practicing pedi- atric surgeons reported sufficient time for themselves, only 12% strongly disagreed with the statement “work has/had a detrimental effect on family life,” and only 11% strongly agreed that they were able to “balance my professional and family responsibilities.”17 These findings were further substan- tiated by the responses from their partners. Only 6% of the pediatric surgeons’ partners strongly agreed with the state- ment “we rarely experience(d) conflict between…professional and family duties.”17

Overall, the direct evidence for work–life imbalance among currently practicing surgeons is thus compelling and well documented in the peer-reviewed literature.

Indirect Evidence

There is also substantial indirect evidence (i.e., the observa- tion of the potential adverse consequences) for work–life imbalance in the lives of currently practicing surgeons.

Adverse Consequences of Work–Life

Imbalance: Personal Level

A failed relationship, with or without divorce, may reflect inadequate­ time with, or attention toward, a spouse or signifi- cant other. In a survey of academic surgeons, two-thirds of the

Chapter 14.  Work–Life Balance and Burnout 223

respondents reported that their demands at work “adversely affected their relationships with spouses.”24 Interestingly, in comparing medical specialties, divorce rates tended to be among the highest for surgeons,with a reported 30% incidence over a 30-year time span.25 Even after adjusting for other potentially confounding factors, being a surgeon conferred a relative risk of 1.7 for divorce, as compared with internists.25

Excessive alcohol use may also be traced back to work–life imbalance in at least some surgeons. In a survey of members of the Society of Surgical Oncology,nearly 7% of all respond- ing surgeons indicated that they had symptoms of alcohol dependence (could not fulfill their responsibilities because of drinking, were unable to stop drinking, were drinking in the morning, or were binge drinking).8 This surprisingly high inci- dence was corroborated in another study of a large number of surgical graduates. Of these, 7.3% had symptoms of alco- hol dependence.This alcohol dependence also contributed to practice attrition rate.6

Other serious mental health issues such as depression and suicide can also be causally linked to work–life imbalance in at least some of the affected surgeons. In a recent large national survey,30% of surgeons screened positive for depres- sion.19 Possibly as many as half of these surgeons would have qualified for a diagnosis of major depression if given a full psychiatric evaluation.19 It is thus not surprising that a recent study among surgeons found a 6.3% rate of suicidal ideations during the previous 12 months.21 Particularly for surgeons 45 years and older, this appeared to be a significant problem, as suicidal ideation was 1.5–3.0 times more common among surgeons than in the general population.21 For the actual sui- cide incidence, no specific data about surgeons is available. In the overall physician population, though, the estimated rela- tive risk for death from suicide (when compared with non- medical professionals) ranges between 1.5 and 3.8 for male physicians, and between 3.7 and 4.5 for female physicians.26, 27

Although not specifically studied for surgeons, chronic deterioration of physical health as manifested by hyperten- sion, cardiovascular disease (including coronary artery dis- ease), and sleep disorders, for instance, can also be indicators

224 K. Troppmann and C. Troppmann

of the chronic inability to master the challenges between a demanding professional life and the need to maintain good somatic and mental health and at least a basic physical fitness.

Adverse Consequences of Work–Life

Imbalance: Professional Level

Suboptimal patient care and adverse patient outcomes may serve as indirect proof of a problem with work–life imbal- ance. For instance, work–life imbalance has been causally associated with depression and burnout.The latter two condi- tions were shown to be independent predictors of the report- ing of a major medical error by surgeons.20, 21

Furthermore, whenever surgeons display disengagement, hostility, or disruptive behavior toward patients, colleagues, and coworkers there is a high likelihood that such behaviors are, at least in part, due to overwork and stress.

Many surgeons seek early retirement and may be moti- vated to do so because of difficulties with balancing work and personal life.22 The reported median retirement age for sur- geons is 57 years.28 This finding is particularly impressive since most surgeons have invested many years and consider- able financial means into their education, residency and fel- lowship training, and into the establishment of their surgical practice. Consistent with these findings, a surprisingly large proportion (approximately 40%) of surgeons would not rec- ommend their profession to their own children.19, 23, 29

Burnout

Overwhelming stress and work–life imbalance can also lead to burnout, which encompasses and affects both personal and professional domains. Burnout is characterized by emotional exhaustion, depersonalization (treating patients and col- leagues as objects rather than as human beings), and a decreased sense of personal accomplishment.30 Burnout tends to be more common in human service occupations such