Reimagining Recruitment and Retention in Academic Plastic Surgery

Abstract

Background:

Recruitment and retention of academic surgeons is challenging. Decreased academic support and high clinical loads cause recruits to leave within 2 years. Here, we explore creative ways to manage top talent in academic practices.

Methods:

A scoping review of scholarly databases and business literature was performed, and the cumulative experience of the authors was incorporated.

Results:

New academic recruits feel the gap between their expectations and their actual experience. Despite known advantages of academics over private practice, including resident coverage, salary support, malpractice coverage, and professional advancement opportunities, the dwindling finances in academics have forced departments to use clinical revenues to fund their academic missions. Compensation plans are now more heavily linked to clinical productivity thresholds, often at the cost of academic goals. Additionally, institutions offer limited support for practice-building, and academic promotion criteria have not adapted to the clinical demands. Finally, these pressures have transformed academic practices into becoming fiercely competitive and noncollaborative. To prevent an exodus of new recruits from academic practices, retention strategies need to change. Individual goals must be respected and aligned with the success of all 3 groups: individual, the team, and the organization. Strong practice-building tools need to be developed for new recruits to create a collaborative culture. Fair compensation must include academic metrics, and a new, creative rewards plan that improves faculty experience is vital.

Conclusions:

Recruitment and retention are critical elements of academic plastic surgery, and redesigning strategies to keep and grow high-value faculty will ensure the growth and advancement of the field.

Takeaways

Question: Can creative ways to attract and retain top talent in academic plastic surgery drive new recruits toward private practice?

Findings: The wide gap between what new recruits seek and what they experience causes them to leave or decline the job. To elicit change, academic leaders must design strategies focused on respect and recognition for individuals and the team; provide practice-building tools early on; nurture a collaborative institutional culture; ensure fair compensation; and prove creative rewards to “delight” recruits.

Meaning: Recruitment and retention efforts need focus on redesigned strategies that meet and exceed the expectations of high-value faculty.

INTRODUCTION

The recruitment and retention of faculty is a critical part of building a strong academic plastic surgery practice. Traditionally, the perks of academic positions were inherently attractive: job security, guaranteed salaries, call coverage, paid time off, medicolegal coverage, funding for academic goals, and long-term faculty employment was the norm, not the exception. However, this trend has changed. Academic practices face financial cuts, relying more on clinical revenue to support their academic goals. In turn, faculty now face greater workloads, with additional clinical and administrative burdens and shrinking institutional support for their academic work.^1,2 The new order, where clinical productivity trumps academic output, causes academic surgeons to leave within 2 years due to burnout and disappointment.^3,4 They report the lowest rates of career satisfaction and the highest rates of work-home conflicts and depersonalization.^5,6 Many of them migrate to private practices, creating a vacancy that needs to be filled via a costly, time-consuming, and avoidable reentry into the recruitment process—a self-perpetuating cycle. Although this strategy meets clinical needs, the revolving door significantly weakens the mission of academic practices. Without retention of high-value, experienced faculty, academic practices simply cannot build gravitas in patient care, research, or even in the vital responsibility of educating future plastic surgeons (Fig. 1). Our work seeks potential solutions by identifying causes of academic disenchantment through an “expectation gap analysis”; examining how comparable nonmedical service sectors address similar problems; and exploring innovative ideas to attract and retain top professionals in academic centers.

Fig. 1.

Effects of the inability to retain top talent within an academic practice.

METHODS

A scoping review of scholarly databases was conducted to identify relevant resources for recruitment and retention of plastic surgeons into academic medicine. Additionally, the authors (at different career stages themselves) relied on their own cumulative experience in the field to generate this narrative, including material from business literature, behavioral science, marketing, and customer acquisition and retention, which provided comparative analysis from other nonmedical, high-skill service sectors.

RESULTS

New recruits join academic practices with great enthusiasm and simply seek support for their clinical, research, and education goals.⁷ Historically, an academic position offered a certain modicum of “professional respect.” It encouraged new members to become innovators, researchers, and educators and develop cutting-edge technologies. The job security, guaranteed salaries, call coverage, paid time off, medicolegal coverage, and funding for academic goals made academic positions attractive. Retention was easier, and faculty stayed in departments for several years, helped by the high level of institutional support and easier access to grant funding. However, recent funding challenges have significantly transfigured academic environments. Financially strapped academic centers are now more heavily dependent on clinical revenues to fund academic work than ever. Most have implemented new compensation models that are weighted toward clinical productivity than academic output. Consequently, new faculty members felt overwhelming pressure to produce clinical revenue and were unable to pursue their own academic goals. Ironically, many private practitioners are themselves seeking employed positions, embittered by their unending battles with insurance companies, constant contract renegotiation, higher malpractice premiums, and the high costs of administrative and regulatory compliance practices. This article focuses only on how academic practices can become more attractive and does not address the trials and tribulations of private practice. Several systemic changes in academic practices and institutions accounted for the discrepancy between the new faculty expectations and their experienced reality of practicing in academic plastic surgery (Fig. 2). (See appendix, Supplemental Digital Content 1, which displays a table of previous survey-type studies that evaluated faculty perceptions of their positions, https://links.lww.com/PRSGO/E573.)

Fig. 2.

The gap between expectations of new recruits and the realities of academic practices they join.

The Expectation Gap

Mission

Most academic departments have defined their mission as a “tripartite mission” pursuing clinical, educational, and research excellence. However, only a few top-tier university programs have the requisite resources to accomplish all 3 goals. Most academic programs lack grants, are institutionally underfunded, or lack research infrastructure and consequently use their clinical revenue to cover educational costs. Their tripartite mission transmutes into a “monopartite mission” focusing solely on clinical output.^8,9

Productivity

Most academic centers now use relative value units to measure physician productivity and determine compensation.^10–12 This certainly boosts clinical productivity and revenue but also fosters unhealthy intradepartmental tension and competition, as more relative value units can increase salaries in an era of steadily decreasing physician compensation. This clearly comes at the expense of education, research, collaboration, and work-life balance (WLB). It negatively affects patient care, which becomes “volume-based,” often compromising quality for quantity.¹³

Financial Incentives

Compensation models based on productivity or salary alone can influence surgeons’ well-being, engagement, and patient care (Table 1). Surgeons with clinical productivity–based incentives reported a “perceived” preference for operative management, describing “quantity over quality.”¹⁴ Many described clinical productivity targets as a “hamster wheel” leading to burnout and financial anxiety. Because individual targets incentivize the performance of each surgeon, they acknowledged that the resultant unhealthy competition discouraged a shared practice model or multidisciplinary care. They advocated group targets to curtail these undesirable side effects. Salaried surgeons without additional productivity-based incentives reported that their operative decision-making was driven by “pure clinical judgment” and a self-imposed pressure to “do my part” to contribute to divisional goals. They reported more freedom to pursue other goals outside of direct patient care. Plastic surgery was the second-highest-paid specialty in 2024, despite a 13% reduction in pay from 2023. Even with the high pay, more than 40% were satisfied with their incomes. Alarmingly, the gender pay gap widened, with men earning 31% more than their female counterparts.¹⁵

Table 1.

How Compensation Models Affect Patient Care and Faculty Behavior

	Total Amount	Patient- Versus Physician-centered	Quality Versus Quantity	Individual Versus Team Care	Fosters Productivity Versus Laziness	Supports New Recruits Verus Cannibalizes Them
Fixed salary alone	Low	Likely patient-centered	Quality	Team	Potentially both	Supports
Salary + capped (fixed) bonus	Moderate	Patient-centered	Quality	Team	Potentially both	Supports
Salary + productivity bonus	Very high, no barriers	Physician-centered	Quantity	Individual	Productivity	Could potentially cannibalize
Incentive only	Sky is the limit	Physician-centered	Quantity	Individual	Productivity	Could potentially cannibalize

Work-Life Balance

Overall, 40% of 7905 responding surgeons (32% response rate) reported burnout, 30% screened positive for symptoms of depression, and 28% had a mental quality-of-life score more than one-half SD below the population norm.¹⁶ In a separate study surveying 4194 active Society of American Gastrointestinal and Endoscopic Surgeons members, 69% met burnout threshold, with high levels of emotional exhaustion and depersonalization and low levels of personal accomplishment. Eighty-one percent reported “being at the end of their rope,” 74% felt emotionally drained, and 65% felt used up daily.¹⁷ High productivity demands coupled with less support and shrinking operating room time availability increased dissatisfaction with WLB. Additional teaching, research, and administrative duties are time-consuming and without additional incentives.

Practice Development

Most new recruits, especially in large academic institutions, are hired with enthusiasm, but are often left to fend for themselves once they join the faculty. As many can attest, navigating the clinical demands of complex medical centers, with their immense structural and functional barriers, interpersonal politics, and unique referral patterns, is neither intuitive nor taught. The onboarding experience is a gap made even more stressful for new recruits during their board collection periods.

Professional and Personal Growth

New academic plastic surgeons seek career development and leadership within and outside of their academic circles, requiring mentors and advocates both inside and outside of the institution. Most institutions lack these offerings, and when available, new recruits have difficulty accessing them. Heavy clinical loads distract from these goals due, in part, to their inherent opportunity cost—wherein the same time and effort could have generated clinical revenue.¹⁸

Promotion and Tenure

Institution-specific promotion and tenure (P&T) criteria vary, and although meant to reward the aspirant, they are too rigid, inflexible, and impractical¹⁹ and require one to excel in 1 of 4 tracks (clinical surgeon, clinical scholar, educator, or surgical scientist). Because most plastic surgeons take care of patients, operate, teach, and perform research, they feel that their contributions cannot be rigidly defined and find themselves “un-promotable.” Even the “traditional timeline” for promotion (every 5–7 y) seems unfounded. Because salary increases are linked to promotion, a negative P&T review creates disappointment.

Institutional Culture and Job Satisfaction

An unfavorable culture, unhelpful peers and leaders, or a change in institutional needs can break one’s enthusiasm for his or her work. Job satisfaction is related directly to shared departmental governance, collegiality, collaboration, psychological safety, and leadership.²⁰

Compensation in Comparable Sectors

Other industry counterparts in comparable nonmedical service sectors share similar problems with recruitment and retention. (See appendix, Supplemental Digital Content 2, which displays comparative analysis of recruitment and retention strategies in other nonmedical service sectors, https://links.lww.com/PRSGO/E574.) In response, they have created unique solutions that include a more holistic compensation model that values retention, WLB, and opportunities for personal and professional growth; bonus structures with a wider menu of incentive options designed to attract and retain top talent; and additional perks to maintain WLB and support for personal development. An analysis of these creative incentives reveals that successful retention strategies focus not only on monetary compensation but also align with the principles of creating value for the employee to facilitate his or her WLB and professional growth.

DISCUSSION

Too often, leaders of academic centers believe that they can attract top talent by simply increasing salaries. A deeper analysis clearly indicates that recruits drawn to academics crave much more than a competitive salary—WLB, appreciation, research, education, and support for their personal and professional growth.

Based on these findings, an effective recruitment and retention effort must include 3 basic steps. Step 1 is categorizing current faculty on clinical productivity, research, and risk of leaving, which can be mapped using productivity versus salary (Fig. 3). Step 2 is listening to the “internal customer.” Each faculty member should be seen as a valuable “internal customer” whose satisfaction is vital to a successful practice. Identifying specific needs and how they want to grow personally and professionally in academic practice allows a customized plan to meet those needs to be created. Behavioral studies show that both wants and needs vary based on career stage and personality (Table 2). Facets of practice that do and do not contribute to these goals can be identified. Step 3 is to incorporate their needs by focusing on respect, incentives that encourage individual success and organizational growth, a balance between clinical and academic service, and fair compensation. Faculty members who want to leave despite all retention efforts should be supported (Fig. 4).

Fig. 3.

Faculty distribution based on salary (x axis) vs their clinical productivity (y axis). The same method can measure productivity in clinical, research, and education areas (interchangeably plotted on the y axis) and compare them with their salaries as well. AAMC, Association of American Medical Colleges.

Table 2.

Needs Assessment

	Examples	Feasible Yes/No
Stated needs	Compensation, bonus, work details, support	Yes
Real needs	Simpler cases, little/no work friction	Yes
Delight needs	Surprise raise, rewards, game tickets, dinner reservations and play tickets, club membership, golf invitations, fund-raising gala invitations	Yes
Secret needs	Reluctant to admit; desires national recognition for status, association membership, speaking invitations yet unwilling to admit	Yes

Fig. 4.

Essential steps for recruitment and retention.

Creative ways to design a holistic compensation model to reward clinical, academic, research, and mentoring responsibilities include:

• The entire faculty must acknowledge that if clinical strength and innovative research performance are sought, then income-sharing is necessary.²¹

A “retention fund” should be established, which is available at the discretion of the chair and an institutional designee, to support faculty goals and retention. Critics might argue that this is impossible, and no institutional leadership will agree to budget for this purpose. Here, we present a strong financial argument to convince leaders about the monetary benefit, thereby ensuring their buy-in. (See appendix, Supplemental Digital Content 3, which displays financial cost-analysis that supports the creation of a retention fund, https://links.lww.com/PRSGO/E575.)

• First, calculate the total value of retaining a high-value faculty (V_ret) versus the cost of hiring and recruitment (V_rec). Specifically, V_ret is the difference between the revenues brought in by the retained faculty and the costs of their retention and salary. Similarly, V_rec alludes to the recruitment costs, the ramp-up time wherein revenue goals are not fully achieved, and their salary support. The difference between the 2 is expressed in the equation:

$${\displaystyle \begin{array}{l}{\displaystyle \begin{array}{l}{\displaystyle \mathrm{I}\mathrm{n}\mathrm{s}\mathrm{t}\mathrm{i}\mathrm{t}\mathrm{u}\mathrm{t}\mathrm{i}\mathrm{o}\mathrm{n}\mathrm{a}\mathrm{l}\mathrm{c}\mathrm{o}\mathrm{s}\mathrm{t}(\mathrm{I}\mathrm{C})}\\ =(\mathrm{r}\mathrm{e}\mathrm{t}\mathrm{a}\mathrm{i}\mathrm{n}\mathrm{e}\mathrm{d}\mathrm{f}\mathrm{a}\mathrm{c}\mathrm{u}\mathrm{l}\mathrm{t}\mathrm{y}\mathrm{r}\mathrm{e}\mathrm{v}\mathrm{e}\mathrm{n}\mathrm{u}\mathrm{e}(\mathrm{r}\mathrm{e}\mathrm{t}\mathrm{e}\mathrm{n}\mathrm{t}\mathrm{i}\mathrm{o}\mathrm{n}\mathrm{c}\mathrm{o}\mathrm{s}\mathrm{t}\mathrm{s}+\mathrm{s}\mathrm{a}\mathrm{l}\mathrm{a}\mathrm{r}\mathrm{y}))\\ {\displaystyle -(\mathrm{h}\mathrm{i}\mathrm{r}\mathrm{i}\mathrm{n}\mathrm{g}\mathrm{c}\mathrm{o}\mathrm{s}\mathrm{t}\mathrm{s}+\mathrm{n}\mathrm{e}\mathrm{w}\mathrm{r}\mathrm{e}\mathrm{c}\mathrm{r}\mathrm{u}\mathrm{i}\mathrm{t}\mathrm{s}\mathrm{a}\mathrm{l}\mathrm{a}\mathrm{r}\mathrm{y}}\\ +\mathrm{r}\mathrm{a}\mathrm{m}\mathrm{p}\text{-}\mathrm{u}\mathrm{p}\mathrm{c}\mathrm{o}\mathrm{s}\mathrm{t}\mathrm{s}\mathrm{l}\mathrm{o}\mathrm{s}\mathrm{t}\mathrm{r}\mathrm{e}\mathrm{v}\mathrm{e}\mathrm{n}\mathrm{u}\mathrm{e}\mathrm{s})\end{array}}\end{array}}$$

OR

$${\displaystyle \begin{array}{l}{\displaystyle \mathrm{I}\mathrm{C}=(\mathrm{V}\mathrm{a}\mathrm{l}\mathrm{u}\mathrm{e}\mathrm{o}\mathrm{f}\mathrm{r}\mathrm{e}\mathrm{t}\mathrm{e}\mathrm{n}\mathrm{t}\mathrm{i}\mathrm{o}\mathrm{n})V_{\mathrm{r}\mathrm{e}\mathrm{t}}-(\mathrm{v}\mathrm{a}\mathrm{l}\mathrm{u}\mathrm{e}\mathrm{o}\mathrm{f}\mathrm{r}\mathrm{e}\mathrm{c}\mathrm{r}\mathrm{u}\mathrm{i}\mathrm{t}\mathrm{m}\mathrm{e}\mathrm{n}\mathrm{t})V_{\mathrm{r}\mathrm{e}\mathrm{c}}.}\end{array}}$$

Typically, hiring costs range from 0.5 to 1 times the annual salary per position. For example, if 2 faculty members leave the practice every 18 months, retention will save the medical center at least $500K in recruitment costs. This money can instead be invested in a “retention fund” used for rewarding nonclinical work.²²

This approach allows the academic leaders to quantify whether one choice is better than the other. If retention is indeed more profitable than recruitment, the money that would have otherwise been wasted could be set aside as a “retention fund.”

• Another way to source the retention fund could be setting aside a set percentage of departmental profits every year or the occasional windfall profits from a bumper year.

• Finally, a practice could petition for philanthropic support to retain high-value academicians who are pursuing cutting-edge research.

  • -Clinical productivity benchmarks need to be reliable and transparent, preventing administrators from arbitrarily inflating expectations and making bonuses harder to earn.²³
  • -For the same reason, academic leaders must make salary standards transparent and easily available to all. Specifically, the Association of American Medical Colleges generates a salary compensation report annually. The current cost to buy these documents for nonmembers is $1500.²⁴

Because career satisfaction is linked to autonomy and resilience, a shared governance model that involves faculty in important decision-making is vital.²⁵ Additionally, a focus on career advancement significantly helps retention and could include the provision of conference support; research infrastructure; start-up funding; in-job training opportunities in coding or board preparation; and, when feasible, a sabbatical.²⁶

Alarmingly, our findings indicate that women faculty face far more difficulty in balancing career and family needs, including choices on the timing of pregnancy and delivery and whether they will have adequate support after childbirth. In fact, many avoid academic jobs because they do not support starting a family.²⁷ This is clearly discriminatory and must be addressed openly. Departments must proactively foster a family-supportive workplace by providing convenient on-site child-care facilities that are open early enough for clinical surgeons to use during early work hours, as well as offering paternal and maternal leave, help with reproductive medicine, and assistance with care for sick family members.

Helping new recruits navigate the complex hospital biosphere benefits both the recruit and the institution. It starts with identifying the service needs in which new recruits are interested, followed by the provision of start-up funds, a campaign of institutional recognition, and marketing to build these programs. Active mentorship from mid- and later-career faculty to guide younger colleagues could foster a collegial, supportive, and trusting departmental environment.²⁸ Practice-building instills a unique pride in this young faculty—a feeling of ownership that can then be shared, presented, and published.^29,30

Obtaining research support is difficult for most recruits and their academic departments. Institutional and intramural funds are essential for young surgeons to develop preliminary data for exploratory grants. These are shrinking rapidly—barely 35% of academic programs provide initial research seed funding, and only 39% allow protected time,³¹ making competitive grant writing impossible alongside heavy clinical demands. Senior mentors who have themselves won these awards could guide young faculty in obtaining early-career K-grants or T-awards (institutional training grants) and Plastic Surgery Foundation, Association of Academic Plastic Surgeons, and Plastic Surgery Research Council, or industry grants. Collectively, these efforts also boost the academic and professional profile of young faculty, creating a stronger bond—a “stickiness” to academic practice.

To reduce the anxiety new recruits have about their candidacy for promotion and tenure, several steps need to be taken. Department P&T criteria need to be transparent, unambiguous, and closely match the daily activities of faculty members. A semiannual review of each faculty member’s progress toward meeting P&T criteria could help juniors advance in a targeted manner. Nominating juniors for national and international presentations; membership; and, eventually, leadership of professional bodies supports their career advancement.

The role of the practice leaders in recruitment and retention is just as important. They need to invite faculty members to help shape institutional priorities and goals. Pathways should be built for junior academic surgeons to obtain referrals, grow their practices, foster clinical and research collaboration both inside and outside the institution, and identify opportunities so they can access shared data for multidisciplinary research.^32,33

Equally important is the provision of rewards that exceed expectations. Borrowed from customer marketing literature, this concept leverages the difference between simply meeting “customers’ satisfaction” and delivering a service that wins their “delight” (Table 3). This methodology (Fig. 5) can be adapted to improve faculty retention as well by giving faculty something they want, but did not expect; making the target to bonus; and leveraging the “surprise and exclusivity” of a memorable experience at work. This retention strategy is unique and could attract newer entrants, thus making recruitment easier. It focuses less on the fleeting allure of salary increases alone and much more on establishing long-lasting relationships.

Table 3.

Customer Satisfaction Versus Delight

	Customer Satisfaction	Customer Delight
Expectations	Met	Beyond expected, creates surprise, an emotional response
Loyalty	Met	Stronger connection, brand advocacy, encourages others to join, long-term success
Experience	Comparable to other sites	Exceeds previous experience
Grades	Good	Excellent
Recommend others	Likely	Definitely
Productivity and response	Average to good	Enhanced, will go the extra mile

Fig. 5.

Creative incentives that make the practice an attractive place of work.

Study Limitations

First, we emphasize that this is a scoping review and presented as a narrative. This format is important to interpret in the specific context of each academic environment, which can vary significantly. It is not a one-size-fits-all solution. This work does not account for changing external factors, both economic and social, that could affect employment trends. A recession could sway recruits toward academics, or decreased insurance reimbursements could decrease an academic center’s ability to recruit.

Recruitment Fund

Our suggestion of seeking institutional investment of recruitment dollars into the creation of a retention fund may not be sanctioned by institutional leaders, who may discard this approach as “experimental.” In Supplemental Digital Content 3 (https://links.lww.com/PRSGO/E575), we explain how the retention fund can be designed and funded. This document also explains the financial basis to convince institutional leaders using their terminologies to support the creation of the fund using a financial cost-benefit analysis. Further, we also have a detailed manuscript (submitted, presently under review) that focuses solely on the financial costs of decisions to retain and recruit and on how a retention fund can be created.

Critics may argue that recommendations that focus on customer delight seem inapplicable in clinical settings. Although these are adaptations of marketing strategy, they would not deter retention, nor would they harm one’s reputation. If executed with an individualized touch—with a genuine, heartfelt, and honest aim to engage faculty, these spontaneous measures are much more memorable than many measures currently used. To be complete, we do recognize that some retention measures can backfire and have listed them separately (Fig. 6). Finally, despite all the strategies used in nonmedical sectors included in this study, the problem of recruitment and retention is ubiquitous, and no magic solution fits all needs.

Fig. 6.

Harmful incentives that could backfire.

CONCLUSIONS

Recruitment and retention, the lifeblood of academic plastic surgery, need to be redesigned to keep and grow high-value faculty. These efforts build high-quality departments, clinical and research centers of excellence, and a better-trained next generation of plastic surgeons, yielding rich dividends overall.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

Supplementary Material

gox-14-e7392-s001.pdf ^{(170.8KB, pdf)}

gox-14-e7392-s002.pdf ^{(134.9KB, pdf)}

gox-14-e7392-s003.pdf ^{(141.8KB, pdf)}