Advanced Training and Job Satisfaction Among Recent Canadian Plastic Surgery Graduates

Abstract

Background:

In order to increase one’s competitiveness in the current job market, Canadian plastic surgery graduates may complete additional degrees and multiple fellowships. The authors sought to determine the impact of this additional training on the practice profile of recent graduates and determine the current state of job satisfaction among this group.

Methods:

An anonymous cross-sectional online survey was created and sent to all 250 graduates of Canadian plastic surgery residencies from 2005 to 2015. Demographics were collected and questions grouped into clinical, teaching, research, and administrative components. Questions pertaining to job satisfaction were also included.

Results:

The response rate to the survey was 39%. Sixty-nine (71%) respondents had permanent attending positions at the time of survey completion, while the remaining 28 respondents did not. Among those with permanent positions, 59 (86%) completed at least one fellowship and 30 (43%) have an advanced degree. Of those who did fellowship training, 76% practice primarily in their area of subspecialty. Having an advanced degree showed a trend to a higher percentage of practice dedicated to research (5.6% vs 1.9%; P = .074) and more publications per year were seen among this group (1.31 vs 0.30; P = .028). Eighty-six percent of respondents are satisfied with their current attending position.

Conclusions:

The majority of recent Canadian plastic surgery graduates are undergoing fellowship training and are practicing primarily in their fields of subspecialty training. Having a postgraduate degree was associated with a higher number of publications per year as an attending surgeon. Job satisfaction is high among recent graduates.

Background

The field of plastic surgery is constantly evolving and each year a new group of graduates complete residency training and move on to the next stage of their career. It is important to examine each new generation of plastic surgeons to understand the current state of the workforce to prepare for the future. In 2007, Macadam et al¹ examined the current plastic surgery workforce in Canada. They concluded that there would be a future shortage of plastic surgeons in Canada based on retirement, emigration, and a growing population. However, given plastic surgery’s unique overlap with other specialties² and the constant evolution of the methods of delivering health care, predicting the future workforce needs is a complex task.^3-6 Additionally, in a publicly funded health-care system such as Canada’s, job availability is largely dependent on governmental funding and thus the current economy.^4,7

Recently, the Royal College of Physicians and Surgeons of Canada (RCPSC)⁴ has suggested that graduates from several surgical specialties are finding difficulty with employment in Canada, including plastic surgery. Given the current climate of employment, trainees may have the perception that additional training or education is required to improve the competitiveness of their employment application. Similar views have been found with other specialties in the Canadian medical school training system.⁸ Based on this perspective, we sought to investigate if recent Canadian plastic surgery graduates are pursuing postgraduate training in the form of multiple fellowships and advanced degrees given the current competitive job market.

Thus, the objectives of this study are twofold. The first objective characterizes the practice of recently graduated Canadian plastic surgeons (within the past 10 years) focusing on their job satisfaction and implementation and usefulness of advanced additional training in their practice. The second outcome surveyed current graduates who are yet to obtain permanent employment and the factors contributing to their difficulty in finding successful employment.

Methods

An anonymous cross-sectional electronic survey was created using Survey Monkey (copyright 1999-2016 SurveyMonkey, Inc, Palo Alto, California). The survey was available in both English and French. The survey was designed with input from 3 senior plastic surgeons at the University of Alberta. The plastic surgery residents at the University of Alberta were trialed as a beta group, with further survey modification from this group. A list of all surgeons who became a Fellow of the Royal College of Surgeons of Canada (FRCSC) in plastic surgery from 2005 to 2015 was obtained from the Canadian Society of Plastic Surgery. Inclusion criteria included completion of a plastic surgery residency in Canada and success on the Canadian fellowship examination which leads to obtainment of FRCSC designation that is generally necessary in Canada before independent practice. Surgeons who completed their residency outside of Canada were excluded from the study.

A link to the survey was e-mailed in January 2016 to all 250 plastic surgeons meeting inclusion criteria. Reminder e-mails were sent at 2 and 4 weeks and the survey closed 4 weeks later. Demographics were collected and questions were grouped into 4 categories: clinical, teaching, research, and administrative. Questions pertaining to job satisfaction were also included (see Online Appendix). Data collected from the survey responses was analyzed anonymously. Descriptive statistics were used and presented as mean ± standard deviation (SD). Statistical analysis was performed using the Mann-Whitney U test and P < .05 was deemed significant. To compare factors associated with employment, a logistic regression analysis was completed using gender, number of fellowships, and completion of an advanced degree as variables.

Results

Response Rate and Demographics

Between 2005 and 2015, 250 graduates of Canadian plastic surgery programs obtained their FRCSC designation. One hundred fifty-six were male, 94 were female and 25 practice outside of Canada. Ninety-seven responses out of 250 plastic surgeons were obtained, yielding a response rate of 39%. There were 57 male and 40 female respondents, and the average age was 36.5 years. Seventy-one percent of respondents (N = 69) had permanent attending positions in hospitals at the time of survey completion. Demographic data is summarized in Table 1. Thirty-eight percent (N = 37) of respondents completed their residency training in Western Canada, 33% (N = 32) in Ontario, and 29% (N = 28) in Quebec or the Maritime provinces (Figure 1). Of those with permanent positions, 10% (N = 7) are currently practicing outside of Canada.

Table 1.

Demographics of Respondents.

Characteristics	N = 97	Percentage
Age (years)	36.5 (SD: 2.1)
Gender
Male	57	59%
Female	40	41%
Marital status
Divorced	1	1%
Married/common-law	72	74%
Single	22	23%
Other	2	2%
Children
Yes	50	52%
No	46	47%
Prefer not to disclose	1	1%
Current job situation
Permanent attending position	69	71%
Doing a locum	8	8%
In fellowship training	15	15%
Not working/job seeking	4	4%
Other	1	1%

Abbreviation: SD, standard deviation.

Figure 1.

Number of respondents by region of residency training.

Advanced Training

Among those with permanent attending positions, 86% (N = 59) completed at least one fellowship. The average number of fellowships completed among this group is 1.2 ± 0.71 (mean ± SD). Among respondents with permanent positions who were fellowship-trained, microsurgery (53%; N = 31) was the most common (Figure 2). Seventy-six percent (N = 45) of fellowship trained surgeons practice primarily in their area of subspecialty.

Figure 2.

Area of fellowship training among junior surgeons with permanent attending positions.

Forty-three percent (N = 30) of respondents with permanent positions have completed an advanced degree, 1 of which has a PhD (Doctor of philosophy). Among those with a Master’s degree, the majority completed a Master of Science (72%; N = 22), Master of Education (7%, N = 2), Master of Business Administration (7%, N = 2), or Master of Public Health (7%; N = 2). Having an advanced degree was not associated with a higher percentage of practice dedicated to research (5.6% vs 1.9%; P = .074). However, more papers were published per year among the group of respondents with advanced degrees (1.31 vs 0.30; P = .028). Among all respondents, 34% (N = 33) believe that having an advanced degree is necessary to obtain a desirable position compared to 45% (N = 44) who feel it is unnecessary, and 21% (N = 20) who remained neutral.

Practice Profile

Among those with permanent attending positions, the percentage of time dedicated to clinical duties was estimated at 83%. The remainder of time was divided between teaching (8%), research (4%), and administrative duties (6%). The most common breakdown of clinical duties for respondents was 5 to 8 operating room (OR) days per month (52% of respondents; N = 36), 5 to 8 full-day equivalents per month in clinic (42% of respondents; N = 30), and 5 to 8 days per month on call (54% of respondents; N = 37; Figure 3). Eighty-three percent (N = 57) of respondents felt that this was sufficient OR time to meet the needs of their practice.

Figure 3.

Practice profile of junior Canadian plastic surgeons: Number of days on-call, in the OR, and in clinic per month. OR indicates operating room.

Sixty-eight percent (N = 47) of respondents perform cosmetic plastic surgery as part of their practice. Among those who do, the majority (74% of respondents; N = 35) dedicate less than 25% of their practice to cosmetic procedures (Figure 4). The average survey respondent dedicates the majority of their practice to hand and wrist, general plastic surgery, and breast reconstruction (Figure 5). Eighty-one percent (N = 56) have a university affiliation and 84% (N = 58) spend time working with and teaching residents or medical students. Only 1 respondent (1.5%) stated that they have their own laboratory.

Figure 4.

Percentage of practice dedicated to cosmetic procedures.

Figure 5.

Areas of plastic surgery consuming the majority of junior plastic surgeons practices.

Job Satisfaction

Seventy-one percent (N = 49) of respondents got their first choice of location for attending position and 86% (N = 59) of them remain satisfied with their current position. Only 9 (13%) respondents were dissatisfied and 1 remained neutral. Among those dissatisfied, the main source of dissatisfaction came from lack of access to hospital resources (33%; N = 3). Seventeen percent (N = 12) have switched jobs at least once since starting practice and 5.8% (N = 4) are currently looking for a new position. Practicing primarily in one’s area of subspecialty training did not show a correlation with job satisfaction (P = .063). The main factor influencing job satisfaction was work–life balance, followed by collegiality within the plastic surgery program, and location (Figure 6). When respondents were asked to rank the same list of factors in relation to their satisfaction with their current position, the highest ranking was access to OR time, followed by location and opportunity to teach (Figure 7).

Figure 6.

Factors influencing job satisfaction among junior plastic surgeons.

Figure 7.

Satisfaction in current practice among junior plastic surgeons.

Unemployed Graduates

Among the 28 respondents who do not yet have a permanent position, the average number of years since completion of residency was 1.5 ± 1.28 years (mean ± SD). Most respondents from this group had either completed one fellowship (29%; N = 8) or were in the process of completing their first fellowship (46%; N = 13; Figure 8). Among those who have obtained fellowship training or are in the process of doing so, the majority obtained (or are obtaining) fellowship training in microsurgery (50%; N = 13), hand and wrist (46%; N = 12), breast reconstruction (27%; N = 7), and craniofacial surgery (27%; N = 7; Figure 9). Twenty-nine percent (N = 8) of those in this group have completed an advanced degree. Among this group of recent trainees who were obtaining or just completed subspeciality fellowships, 20 respondents (71%) stated that they still did not have a permanent attending position arranged at the time of the survey.

Figure 8.

Highest level of training completed among plastic surgery graduates who do not yet have a permanent position.

Figure 9.

Area of fellowship training among plastic surgery graduates who do not yet have a permanent position.

When this group was asked about anxiety toward future job prospects, 57% (N = 16) were either somewhat or very pessimistic. Forty-three percent (N = 12) of those trainees in this group had done a locum tenens or temporary plastic surgery position at some point and 21% (N = 6) have spent greater than 12 months in similar temporary employment positions. Respondents with permanent attending positions were compared to those without a permanent position (Table 2). Having a greater number of fellowships was found to have a significant positive correlation with having a permanent attending position (odds ratio = 3.3; P = .029). No significant association was found for gender or having an advanced degree.

Table 2.

Logistic Regression of Variables Comparing Junior Plastic Surgeons With Permanent Attending Positions Versus Those Without.

Variable	OR (95% CI)	P
Number of fellowships	3.3 (1.13-9.39)	.029a
Gender	3.4 (0.90-12.8)	.072
Advanced degree	1.15 (0.33-3.98)	.83

Abbreviations: CI, confidence interval; OR, odds ratio.

^aStatistically significant.

Discussion

The response rate of 39% was similar to previous surveys looking at the plastic surgery workforce.^1,6 Although there is potential for non-responder bias, the responder group had a similar male to female gender ratio (58.8% male; 41.2% female) as the non-responder group (64.7% male; 35.3% female; P = .35). Furthermore, there were equal percentages of respondents who obtained certification between 2005 and 2010 (45 of 116; 39%) as there were from those obtaining certification between 2011 and 2015 (52 of 134; 39%). Given these similarities, it is felt that the survey is likely representative of various demographic features of the group of surgeons surveyed.

When looking at advanced training, 86% of recent Canadian plastic surgery graduates with permanent positions pursued fellowship training, a slight increase from 80% of graduates from 1996 to 2006.⁹ This is a substantial increase from 54% of the Canadian plastic surgery community as a whole having fellowship training in 2005.¹ In our study, the average number of fellowships completed by respondents was 1.2; an increase from an average of 0.66 fellowships reported in 2005.¹ This suggests that almost twice as many fellowships are being undertaken by recent graduates, compared to previous reports. Although this number of 0.66 was in relation to the Canadian plastic surgery community as a whole, it illustrates a trend away from the generalist plastic surgeon toward increased subspecialty training. Thus, our study suggests that an increasing number of Canadian plastic surgery graduates are pursuing at least one or more than one fellowship position. This trend may be due to graduates completing additional fellowships while awaiting a job opening, increased demands for subspecialty training within the field or simply because of personal interest to pursue additional training. This increased number of fellowships likely represents a combination of each of these factors.

Given that 76% of respondents practice primarily in their area of fellowship training, it appears that fellowship training is an important component of the recent graduate’s practice. Interestingly, only 41% of American Plastic Surgery graduates from 2005 to 2010 completed fellowship training¹⁰ and 24% to 49% of senior plastic surgery residents in the United States plan to do subspecialty fellowship training.^6,11 The difference between American and Canadian plastic surgeons may be due to job availability as a by-product of the difference in the amount of private for-profit health care provided as compared to a nationalized public health-care system.

A large portion (43%) of recent Canadian graduates have obtained advanced degrees whereas, by comparison, only 6% of American plastic surgery graduates from 2005 to 2010 had advanced degrees.¹⁰ Despite 43% of respondents having advanced degrees, the overall group spends 4% of their time on research and only one respondent had their own laboratory. The discordance in the number of plastic surgeons that have advanced degrees and the use of those degrees for plastic surgery research may be a by-product of job market competitiveness. Residents may complete an advanced degree to make themselves more competitive in the job market. An additional explanation may be the lack of dedicated research time for new graduates entering clinical practices. Due to the design of our survey, we are unable to differentiate the surgeons who completed advanced degrees during or after their residency from surgeons who received degrees prior to plastic surgery training. Often degrees received prior to entering residency training may be less directly related to academic plastic surgery. As a result, these surgeons may spend less time conducting research upon entering practice than those who obtained their research training during residency or fellowship.

The majority of respondents perform cosmetic plastic surgery as part of their practice but dedicate less than 25% of their practice to it. However, whether these surgeons were satisfied with the amount of their practice dedicated to cosmetic procedures, and which types of procedures they perform was not elucidated. Future studies could evaluate this and compare to graduating residents perceived level of competence with a variety of cosmetic procedures at the time of residency completion.¹²

Overall, job satisfaction is high with 86% of respondents satisfied with their current position. In addition, despite a more competitive job market, 71% of respondents are working at their first choice of location. When looking at factors that influence job satisfaction, lifestyle factors were highly valued, consistent with previous studies looking at the younger generation of plastic surgeons.^13,14 The 10% emigration rate per year shown in plastic surgeons graduating between 2005 and 2015 was substantially less than the rate of 21% for surgeons graduating between 1995 and 2005.¹ This supports the idea put forth by the RCPSC⁴ that the newer generation physicians and surgeons are more likely to want to practice closer to home. This is valuable information for those involved in hiring new surgeons as well as committees involved in future workforce planning.

When looking at the group of 28 graduates who did not yet have a permanent position at the time of survey, it is important to note that 14 (50%) of these respondents were currently doing fellowship training. Therefore, the numbers shown are falsely elevated given that half of this unemployed group is still pursuing further training. This still leaves 14 graduates without a permanent position. Given that there were on average 28 graduates per year from 2013 to 2015, this number is not insignificant. However, 12 (43%) respondents among this group have done or are currently doing a locum, which can provide temporary employment and can sometimes result in a permanent position. Having a greater number of fellowships was found to be positively associated (odds ratio = 3.3; P = .029) with having a permanent attending position (Table 2). This could mean that having more fellowships makes a surgeon more employable. However, it may also be the result of surgeons doing additional fellowships in the interim, while awaiting a job opening for a desirable permanent position.

Although the 2007 workforce study¹ predicted that there would be a future shortage of plastic surgeons in Canada, this did not come to fruition. A significant contributing factor was likely the 2008 financial crisis, which forced surgeons on the verge of retirement to continue working for several more years.⁴ A steady increase in plastic surgery residency positions likely also contributed to a surplus of graduating residents at a time when surgeons were delaying retirement. Although nobody could have predicted that the 2008 financial crisis would occur, this further highlights the complexity of predicting the future workforce needs within the plastic surgery community. Current workforce planning within the Canadian plastic surgery community has limited residency positions to attempt to avoid a surplus of graduating plastic surgeons. However, more emphasis could be placed on making information available to current residents as to the number of upcoming positions, their geographic location, academic versus community practice, and which type of fellowship training will be sought. This could help facilitate career planning among current plastic surgery residents.

The results of the survey provide valuable information about the current employment status of recent Canadian plastic surgery graduates. This includes demographics, practice profile, job satisfaction, and implementation of advanced training into practice. In addition, information was gained on recent graduates who do not yet have a permanent attending position. To conclude, the majority of recent plastic surgery graduates are undergoing fellowship training and almost half have advanced degrees. Most of these graduates are practicing primarily in their field of subspecialty fellowship training. Among this group, having a postgraduate degree was associated with more publications as an attending surgeon. Job satisfaction is high among surgeons once they have obtained a permanent attending position.