Forum
Paul Klimo Jr., M.D.
Career Satisfaction and Burnout Among U.S. Neurosurgeons: A Feasibility and
Pilot Study
Paul Klimo Jr.1-3, Michael DeCuypere3, Brian T. Ragel4, Shirley McCartney4, William T. Couldwell5, Frederick A. Boop1-3
- OBJECTIVE: Neurosurgery is a challenging and stressful
field. Excessive stress and professional dissatisfaction can
lead to medical errors, negatively impact patient care, and
cause physician burnout. Our objective is to develop and
critically evaluate a survey measuring professional stress
and satisfaction and to obtain preliminary data on sources
and degree of stress and the prevalence of burnout among
American neurosurgeons.
- METHODS: A 107-item questionnaire was developed and
sent to 169 American neurosurgeons to evaluate career
satisfaction and stressors, quality of professional life, and
burnout. Participants were also asked about the survey
itself. Most variables were evaluated using the Likert-type
scale. Burnout was measured using the validated Maslach
Burnout Inventory.
- RESULTS: The 85 (50%) respondents were typically male,
full-time, board-certified neurosurgeons. Ninety-five
percent were satisfied as neurosurgeons (73% very satis-
fied). Most (88%) would choose neurosurgery again as
a career, but only 55% would recommend it to a child. Low
salary/income, low collections/billing, and uncertainty
Keywords
- Burnout
- Career
- Lifestyle
- Maslach Burnout Inventory
- Neurosurgery
- Satisfaction
- Stress
Abbreviations and Acronyms
ABNS: American Board of Neurological Surgeons
ACS: American College of Surgeons
CSNS: Council of State Neurosurgical Societies
DP: Depersonalization
EE: Emotional exhaustion
PA: Personal accomplishment
WORLD NEUROSURGERY 80 [5]: e59 e68, NOVEMBER 2013
Chief, Division of Pediatric Neurosurgery
Department of Neurosurgery
University of Tennessee Health Science Center
regarding future earnings/health care reform were reported
as stressful factors by the majority of participants. Compared
with published norms, the median scores were lower for
emotional exhaustion and depersonalization and higher for
personal accomplishment. The burnout rate was 27%.
- CONCLUSION: Our survey was well received and,
according to respondents, encompassed the major issues
associated with career stress, satisfaction, and burnout but
needs to be shortened. Respondents were generally satis-
fied with their career but identified several major stressors.
A larger study to identify predictors of career satisfaction/
dissatisfaction will help generate dialogue on improving
the quality of professional life for neurosurgeons.
INTRODUCTION
F
or a medical student, the decision to pursue a career in
neurosurgery is based, in part, on an interest in neuropa-
thology and a passion to use one’s hands and mind to treat
From the 1Semmes Murphey Neurologic & Spine Clinic, Memphis, Tennessee;
2
Le Bonheur Children’s Hospital, Memphis, Tennessee; 3Department of
Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee;
4
Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon;
and 5Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City,
Utah, USA
To whom correspondence should be addressed: Paul Klimo Jr., M.D., M.P.H.
[E mail: pklimo@semmes murphey.com]
Citation: World Neurosurg. (2013) 80, 5:e59 e68.
http://dx.doi.org/10.1016/j.wneu.2012.09.009
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878 8750/$ see front matter ª 2013 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org e59

PAUL KLIMO JR ET AL.
and care for patients with neurosurgical diseases. What cannot be
fully appreciated by a medical student or resident are the signifi-
cant challenges that come with having a career as a neurosurgeon
that can lead to professional and personal distress. When
professional distress escalates and remains unchecked by sources
of satisfaction, this imbalance can lead to burnout. Burnout is
a syndrome defined by the triad of high emotional exhaustion,
high depersonalization, and a low sense of personal accomplish-
ment (17). Burnout is specific to one’s relationship with work and
may lead to personal dysfunction and decreased productivity and
may affect patient care.
The issues of job satisfaction, quality of life, and burnout have
been extensively researched in many medical and surgical
specialties, such as otolaryngology (11, 13), family practice (16, 28),
internal medicine, (12) general surgery (5, 29), surgical (1, 2, 8)
and medical (19, 23) oncology, and orthopedics (24, 25). The
importance of stress and burnout among physicians was under-
scored in 2008 when the American College of Surgeons
commissioned a study through their Committee on Physician
Health and Competency (26). This survey had a sample size of
almost 8000 respondents from various surgical disciplines, ages,
practice types, and geographic settings. The authors found that
71% of surgeons overall were satisfied with their careers, but 40%
were burned out, 49% would not recommend their children
pursue a career as a surgeon, and only 36% felt their work
schedule left enough time for personal/family life.
To our knowledge, there has been no study of workplace
stresses and burnout conducted specifically for neurosurgeons by
neurosurgeons. We have created a survey that contains questions
regarding demographic information, practice characteristics,
career satisfaction, stress, and burnout. The purpose of this
feasibility and pilot study was twofold: (1) to determine whether
our survey is an adequate tool to measure the aforementioned
outcomes and to identify challenges of expanding this study to
a larger audience and (2) to obtain preliminary data.
METHODS
A questionnaire was developed by the authors (Table 1) and then
made accessible online (SurveyMonkey, Portland, Oregon, USA).
A group of practicing private and academic neurosurgeons was
asked to complete the survey electronically. Some of the potential
respondents were colleagues of the authors or worked in their
region. Along with a link to the survey was a cover letter stating
that the purposes of the study were to critically evaluate our survey
and elucidate factors that contribute to stress, satisfaction, and
burnout within the field of neurosurgery. Multiple reminder e-mail
correspondence was sent to surgeons requesting they complete
the online survey. Participation was completely voluntary, and the
data were deidentified by the survey administrator (S.M.) before
being analyzed and released to the other authors.
The survey consisted of 107 questions organized into seven
sections on demographics, professional stress and satisfaction,
quality of professional life, burnout, general questions, and survey
evaluation. The questions were derived from a well-established
scale (Maslach Burnout Inventory) and a previously published
article in the general surgery literature (29) or were developed by
the authors. Questions were primarily close-ended using the
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CAREER SATISFACTION AND BURNOUT AMONG NEUROSURGEONS
5-point ordinal-polytomous Likert-type scale (with a “not appli-
cable” option), but there were several open-ended questions,
including a space for general comments at the end. Burnout was
measured using the validated Maslach Burnout Inventory, which
contains 22 questions that assess the three burnout components:
emotional exhaustion (EE, 9 questions), depersonalization (DP, 5
questions), and personal accomplishment (PA, 8 questions). For
the questions on burnout, the respondents were asked to rate the
frequency of encountering the stated situation on a 7-point Likert-
type scale from “never” (0 points) to “daily” (6 points). A score
was then generated for each section of the Maslach Burnout
Inventory and results were then stratified into high, moderate, or
low levels of burnout based on published values (low EE
18,
high EE  27; low DP
5, high DP  10; high PA  40, low PA

33) (17). A surgeon was considered to be suffering burnout if he or
she had high emotional exhaustion and/or depersonalization
scores (26). A collective score was generated and compared with
group norms published for nurses and physicians (EE ¼ 22.19,
PA ¼ 36.53, DP ¼ 7.19) (17).
RESULTS
Survey Evaluation
The survey (Table 1) was sent to 169 surgeons, and 85 partial and
full responses (50%) were received. Eighty percent of study
participants agreed that the survey covered all major aspects of
career satisfaction, stress, and burnout. Fifty-five respondents
(69%) affirmed that the survey was not too long; the average time
to complete it was 23 minutes. In general, comments regarding
the study were positive and supportive.
Part 1: Demographics
Our study respondents were typically male, married, Caucasian,
full-time neurosurgeons with subspecialty training and American
Board of Neurological Surgeons (ABNS) certification (Table 2).
The age distribution of the survey respondents is shown in
Figure 1. Seventeen senior respondents had more than 25 years of
clinical practice.
Part 2: Professional Stressors
Responses to the 21 questions on professional stressors are shown
in Figure 2. One surgeon did not complete this section. Too much
call (question 1 [Q1]) was cited by 25 (30%) surgeons as affecting
their practice in a moderate to extreme amount, whereas 27 re-
ported it as a minor factor and 30 reported no effect (2 responded
“N/A”). Likewise, inadequate research time (Q2) and inadequate
administrative time (Q3) affected the practice from a moderate to
extreme amount for 35 (42%) and 22 (26%) neurosurgeons,
respectively, whereas few neurosurgeons reported it did not affect
their practice at all. Low salary/income (Q5) and low collections/
billing (Q6) affected the practice to some degree in 50 (60%) and
59 (70%) surgeons, respectively. Uncertainty regarding one’s
future earnings and/or health care reform (Q7) was a significant
factor in the practice of 67 (80%) neurosurgeons, including 33
(39%) who stated it was a moderate, large, or extreme influence.
Issues that are often cited as stressful, such as too many cases or
malpractice issues, were found to be a stressor by fewer than 20
respondents.
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PAUL KLIMO JR ET AL. CAREER SATISFACTION AND BURNOUT AMONG NEUROSURGEONS

Table 1. Neurosurgeon Career and Lifestyle Satisfaction Table 1. Continued

Survey
Part 1: Demographics
Part 1: Demographics
21. Over the last several years, please indicate the composition of your
1. What is your age (years)? <40, 41e45, 46e50, 51e55, 56e60, surgical cases (as a percentage out of 100) [numbers should add to
61e65, >65 100]: cranial, spinal

2. What is your gender? male, female 22. On average, how many hours per week do you spend in clinic? <5,
5e10, 11e15, 16e20, >20
3. Please indicate the race you identified on the 2010 U.S. Census form (or
equivalent) White, Black or African American, American Indian and 23. On average, how many hours per week do you spend teaching residents/
Alaska Native, Asian, native Hawaiian and other Pacific Islander, More than students? 0, <5, 5e10, 11e15, 16e20, >20, not applicable
one race
24. On average, how many hours per week do you spend on research (clinical
4. Please indicate ethnicity as identified on the 2010 U.S. Census form (or or basic science)? <5, 5e10, 11e15, 16e20, >20
equivalent) Not Hispanic or Latino, Hispanic or Latino
25. On average, how many hours per week do you spend on administrative
5. What is your marital status? single, stable partner, married, separated, tasks? <5, 5e10, 11e15, 16e20, >20
divorced, divorced/remarried
26. On average, how many weeks of vacation do you take per year? <1,
6. Do you have children? yes, no 1e2, 3e4, >4
7. Please indicate the state in which you practice written answer
27. Approximately how many minutes is your average daily commute to
8. Please indicate the setting of your practice large urban, smaller urban, work? <10, 10e20, 21e30, >30
suburban, rural
28. Over the last 5 years, how many times have you been named in
9. What is your practice type? solo, group, health maintenance organiza a malpractice lawsuit? none, 1e5, 6e10, >10
tion (HMO), university, private/academic, VA/U.S. Government hospital,
city/county hospital, other Part 2: Professional Stressors

10. I consider myself a full time clinical surgeon, part time clinical To what extent have the following factors affected you in your practice?
surgeon Answers:
11. If you practice in a university setting, what is your academic rank? not at all, small amount, moderate amount, large amount, extreme amount, not
instructor, assistant professor, associate professor, professor, emeritus, applicable (N/A)
not applicable, other 1. Too much call
12. If you practice in a university setting, what is your tenure status? non 2. Inadequate research time
tenure track, tenure track, tenured, not applicable, other
3. Inadequate administration time
13. How many years have you been in practice? <5, 5e10, 11e15,
4. Inadequate teaching time
16e20, 21e25, >25
5. Low salary/income
14. Have you received formal subspecialty training? yes, no
6. Low collections/billings
If yes, (please specify) written answer
7. Uncertainty of future earnings/health care reform
15. Have you voluntarily relinquished your cranial privileges to focus solely on
spinal surgery? yes, no 8. Chairman’s/senior partner’s demands
9. Hostile or difficult work environment
16. Have you received ABNS certification? yes, no
10. Loss of coworker/faculty
17. On average, how many hours do you work per week? <30, 30e40,
41e50, 51e60, 61e70, 71e80, >80 11. Sexual harassment
12. Malpractice issues
18. How many days of call do you take per month? <3, 3e5,
6e10, >10 13. Tenure/promotion dispute

19. On average, how many operative cases do you perform per year? <100, 14. Credentialing or certification dispute
100e150, 151e200, 201e250, 251e300, 301e350, 351e400, >401 15. Substance abuse
20. Over the last several years, please indicate the composition of your 16. Bioethics violation
surgical cases (as a percentage out of 100) [numbers should add to
100] adult, pediatric (<18 years of age)
VA, Veterans Affairs; ABNS, American Board of Neurological Surgeons.
*Sample of first 3 questions; the Maslach Burnout Inventory comprises 22 questions total.
Continues Continues

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PAUL KLIMO JR ET AL. CAREER SATISFACTION AND BURNOUT AMONG NEUROSURGEONS

Table 1. Continued Table 1. Continued

Part 2: Professional Stressors Part 4: Quality of Life

17. Not being appreciated by patients 5. My practice has an unfair call schedule
18. Too many cases 6. My practice should improve its reimbursement
19. Too few cases 7. My practice should work harder to diminish litigation
20. Too little vacation time 8. My practice should increase the number of staff neurosurgeons
21. Surgery related complications (morbidity and/or mortality) 9. My practice/program should increase the number of residents/physician
extenders
Part 3: Professional Satisfaction 10. My practice should decrease my administrative time

In relation to your practice, how satisfied are you with the factors listed 11. My practice should increase my allotted vacation time per year
below? 12. I would recommend neurosurgery to my child as a career
Answers:
very satisfied, somewhat satisfied, neutral, somewhat dissatisfied, very 13. At some point in my career, I have turned to substance abuse for stress
dissatisfied relief

1. Overall career as a surgeon Part 5: Maslach Burnout Inventory*

2. Balance between professional and personal life
How often do you experience the following?
3. Meeting your career expectations/goals Answers:
never, few times a year, monthly, few times a month, weekly, few times
4. Overall workload
a week, daily
5. Time for personal growth/development
1. I feel emotionally drained from my work
6. Your relationship with your patients
2. I feel used up at the end of the day
7. Intrinsic reward for helping patients
3. I feel fatigued when I get up in the morning to face another workday
8. Total hours worked per week
Part 6: General Questions
9. Unpredictability/irregularity of schedule
10. Technical aspects of my practice 1. If you were a 4th year medical student, would you still choose to pursue
neurosurgery as a career? yes, no
11. Intellectual challenge of work
2. How likely do you feel that your professional life will improve? likely,
12. Prestige of career/work somewhat likely, not sure, somewhat unlikely, unlikely
13. My neurosurgical colleagues 3. How likely do you feel that your professional life will worsen? likely,
14. The location of my practice somewhat likely, not sure, somewhat unlikely, unlikely

15. My salary/income 4. Please provide the most rewarding aspect of your

career? written answer

Part 4: Quality of Life
Please respond to the following statements using the answers below:
Answers:
strongly agree, agree, neutral, disagree, strongly disagree, not applicable (N/A)
1. My spouse/partner understands when I have to work extra hours
5. Please provide the most frustrating aspect of your
career? written answer
Part 7: Survey Evaluation
1. Has this survey addressed all the major aspects of career satisfaction,
stress and burnout among neurosurgeons? yes, no

2. My spouse/partner is willing to listen to work related problems If no, please tell us how we can make this survey better?

3. My spouse/partner encourages me to take advantage of professional 2. Was this survey too long? yes, no
opportunities
3. Please provide any other comments you would like to make. written
4. My practice should minimize emergency call answer

VA, Veterans Affairs; ABNS, American Board of Neurological Surgeons.

Continues *Sample of first 3 questions; the Maslach Burnout Inventory comprises 22 questions total.

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PAUL KLIMO JR ET AL.
Part 3: Professional Satisfaction
Figure 3 depicts the responses from 84 surgeons to the 15 ques-
tions on professional satisfaction. Sixty-one (73%) neurosurgeons
reported that they were very satisfied with their choice of career
(Q1). Factors that more than 50% of respondents reported being
very satisfied with were relationship with patients, intrinsic reward
for helping patients, intellectual challenge, prestige of career,
neurosurgical colleagues, location of practice, and salary/income.
The question that generated the most dissatisfied responses was
“time for personal growth/development” (Q5) (n ¼ 25, 30%).
Part 4: Quality of Professional Life
Responses to the 13 questions in this part of the survey are shown
in Figure 4 (n ¼ 82). There was strong spousal/partner support and
understanding as evidenced by the high rates of “strongly agree”
and “agree” responses for the first 3 questions: 74 (90%), 69
(84%), and 64 (78%), respectively. Most respondents did not feel
that they needed more partners (Q8) or more time for adminis-
trative duties or vacation (Q10, Q11). Conversely, 47 (57%) and 34
(41%) of surgeons felt that their practice should improve its
reimbursement (Q6) or increase the number of residents/physician
extenders (Q9), respectively. Forty-five (55%) respondents would
recommend neurosurgery to their child (Q12), whereas 19 had no
opinion and 18 would not. Only two surgeons admitted to
substance abuse as a means of relieving stress (Q13).
Part 5: Maslach Burnout Inventory
Characteristics of responding surgeons with respect to burnout are
summarized in Table 3 (n ¼ 81). The median scores for EE, DP,
and PA were 13, 4, and 39, respectively. Overall, 14% had high
emotional exhaustion, 27% had high depersonalization, and 27%
had a low sense of personal accomplishment. Twenty-two (27%)
neurosurgeons were considered burned out.
Part 6: General Questions
Seventy-one of 81 (88%) neurosurgeons would choose a career in
neurosurgery again. Forty-four of 81 neurosurgeons (54%) felt that
it was likely or somewhat likely that their career would improve
(Figure 5). Conversely, 21 (26%) felt that their career could worsen.
There were a considerable number of “not sure” responses for
both questions (16 and 19, respectively). Sixty-nine participants
provided comments to the question about the most rewarding and
frustrating aspects of their career, many of them giving more than
one answer. Helping patients/improving quality of life for
patients/saving lives was the most frequently cited rewarding
attribute of being a neurosurgeon (more than 40 responses). Other
rewarding aspects of one’s career included teaching (15
responses), research (13), intellectual/emotional/technical stimu-
lation (12), and working with children (7). Dealing with inefficient
hospital administration/bureaucracy (17 responses), unsupportive
senior colleagues or chairman (9), insufficient pay (8), too little
time (7), malpractice (7), and practicing defensive medicine (6)
were some of the more common negative responses. Other frus-
trations included government and insurance company interfer-
ence, administrative duties, patient dissatisfaction, lack of control,
and billing/collection.
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CAREER SATISFACTION AND BURNOUT AMONG NEUROSURGEONS
DISCUSSION
High levels of dissatisfaction and distress at work can negatively
affect not only the core function of a physician—to care for and
heal patients—but also other aspects of the job and personal life
(10, 21, 27). Several authors have found that physicians with
substantial personal distress and/or depression are more likely to
make medical errors, which can then lead to greater levels of
distress (9, 31), and physicians with substantial practice dissat-
isfaction, professional isolation, and workelife stress are less
likely to be involved with quality improvement activities (18).
Although stress does have some positive effects, Wetzel et al.
(32) showed that undue levels of stress impaired judgment,
decision making, and communication in the operating room.
Excessive stress can also lead to disruptive behavior, which can
negatively affect all members of the team involved in the care of
a patient (22).
Because of its potential to negatively impact the health of physi-
cians, their personal life relations, and patient care, it is important to
assess the degree and sources of satisfaction or dissatisfaction and
the prevalence of burnout. In fact, it has been argued that physician
wellness is so critical to the delivery of quality patient care and any
future health care reform that it should be routinely measured (6,
30). Career satisfaction and burnout have been intensely researched
in almost all areas of medicine; however, neurosurgery, arguably
one of the more stressful specialties, is one of the few exceptions.
Our study represents the first attempt to look at these issues
specifically for neurosurgeons.
Our Results
Despite the myriad of sources of stress in neurosurgery, the
majority of neurosurgeons (73%) were very satisfied being
neurosurgeons, with only 4 respondents having a neutral opinion
(N ¼ 2) or being somewhat dissatisfied (N ¼ 2), and 88% would
choose to be a neurosurgeon again. Just more than half felt that
their career would improve in the future. There are many reasons
why neurosurgeons find happiness in their profession, such as
intellectual and technical stimulation, prestige, working with
other neurosurgical colleagues, teaching, and research, but the
most common was the intrinsic reward of treating patients in the
hopes of improving their quality of life. Conversely, stress came
from administrative entanglements, negative patient interac-
tions, and insufficient time control. The participating neuro-
surgeons were most dissatisfied with the amount of time they
had for personal growth and development. In addition, anxiety
over future income and health care reform registered high
among the participants of this study (80%). Although 95% of
neurosurgeons reported being “satisfied” in their career, only
55% would recommend their profession to their offspring. An
explanation for discordance may be that there is a general
perception the present climate in neurosurgery is satisfactory,
but that in the future reimbursement will go down, time away
from work will be diminished, and government and health
system regulation will undoubtedly increase. Thus, although
neurosurgeons are generally happy at present, they fear that the
profession will be negatively impacted in the future. The overall
prevalence of burnout, as previously defined in the Methods
section, was 27%.
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PAUL KLIMO JR ET AL. CAREER SATISFACTION AND BURNOUT AMONG NEUROSURGEONS

Table 2. Demographic Information of Survey Respondents Table 2. Continued

(n ¼ 85)
6e10 33
Sex (M/F) 82/3 >10 16
Race (%) Number of cases per year
White 80 (94)
200 22
Asian 5 (6) 201e300 41
Marital status (%) 301e400 15
Married 71 (84) >401 7
Divorced 5 (6)
Y/N, yes/no; VA, Veterans Affairs; ABNS; American Board of Neurological Surgeons.
Divorced/Remarried 7 (8)
Other 2 (2)
Children (Y/N) 77/8
The only other study that has comparable data from neurosur-
Practice setting (%) gery (3) compiled the data from the neurosurgeons who responded
Large urban 53 (63) to the study sponsored by the ACS (26). Balch et al. (3) had 184
neurosurgical respondents, who were mostly private practitioners,
Smaller urban 24 (28)
whereas our study included mainly academicians. In that study,
Suburban 6 (7) compared with ours, a greater percentage of neurosurgeons would
Rural 2 (2) not choose the same career (28.3% vs. 12%), had a higher burnout
rate (38.5% vs. 27%), and would not recommend neurosurgery as
Practice type (%)
a career to their children (44.2% vs. 22%).
University 48 (56)
Group 16 (19) Our Survey, Study Limitations, and Future Directions
Private with academic affiliation 14 (17) Most of the participants in this pilot study felt that our survey
Solo 5 (6) covered the major aspects of job satisfaction, stress, and burnout
in neurosurgery (i.e., had face validity). Although 70% of
VA/U.S. government 1 (1) respondents indicated the survey was not overly long, we believe
Other 1 (1) that the average time to complete the survey—23 minutes—is too
Full time/part time clinical neurosurgeon 75/10 long and would be a major obstacle in maximizing our response
rate in future studies. Therefore, several modifications will be
Years in practice (%)
implemented in the next iteration, such as the removal of some
<5 14 (16.5) questions and simplification of others in an effort to shorten the
5e10 25 (29.4) time it takes to complete the questionnaire to less than 15
minutes. The next phase of this study is to expand it to a wider
11e15 13 (15.3)
audience to generate a much greater number of responses. A
16e20 8 (9.4) larger number of responses would allow us to evaluate demo-
21e25 8 (9.4) graphic (e.g., male/female, age, location of practice) and profes-
sional characteristics (e.g., years in practice, subspecialty, salaried
>25 17 (20)
Subspecialty training (Y/N) 58/27
ABNS certification (Y/N) 69/16
Hours worked per week

40 2
41e50 13
51e60 17
61e70 33
>71 20
Number of calls per month
<3 12
3e5 24

Continues Figure 1. Age distribution of 85 survey respondents.

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PAUL KLIMO JR ET AL. CAREER SATISFACTION AND BURNOUT AMONG NEUROSURGEONS

female surgeons (4, 5, 7, 15,

23), and private practitioners
(33) are at greater risk for
higher levels of stress and
burnout.
Selection bias is a major
potential limitation of our
study. Although the individ-
uals chosen to participate
in survey studies are often
randomly sampled, errors
caused by incomplete response
may still exist. People who
choose to respond on the
survey may be different from
those who do not respond,
thus biasing the estimates. In
other words, a selection bias
might result in a “happier”
group of respondents if
neurosurgeons who are burned
out or unhappy with their job
Figure 2. Responses by 84 respondents to questions regarding professional stressors (Table 1, Part 2).
are less inclined to participate
in the study. This could bias
the results away from true
or incentivized pay) as potential predictors of stress, career estimate of dissatisfaction and burnout among all neurosurgeons.
satisfaction, and burnout. For example, prior research has sug- In fact, our respondents did have lower median scores for
gested that younger and less-experienced physicians (11, 14, 19, emotional exhaustion (13.0 vs. 22.19) and depersonalization
20, 23), those working a greater number of hours per week (4, 11), (4.0 vs. 7.19) and higher personal accomplishment (39.0 vs.
36.53) compared with pub-
lished norms for health care
professionals (17). This
emphasizes the importance of
shortening the questionnaire
as much as possible to
encourage the highest
response rate possible.
The neurosurgeons asked to
participate in this study were
not randomly selected; some
were colleagues or friends of
the authors. Thus, we cannot
assume that our preliminary
results on stress/satisfaction/
burnout are a reflection of
neurosurgeons as a whole (i.e.,
potentially lacks external val-
idity), but they are likely repre-
sentative for the population
who did participate (i.e., inter-
nally valid). Although the
respondents who knew one or
more of the authors may have
felt more compelled to
complete the survey, this would
have had more of an effect on
Figure 3. Responses by 84 respondents to questions regarding professional satisfaction (Table 1, Part 3).
the response rate rather than
introducing bias to the results.

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Although we had
a response rate of 50%, this
was only achieved with
multiple reminders sent to
potential study participants.
There are two impediments
to achieving a higher
response rate with future
studies: time and interest.
Many, if not most, neurosur-
geons suffer from not having
enough time in the day for all
that they wish to do: clinical
duties, research, administra-
tive tasks, teaching, devoting
time with family, etc. We
tried to design a survey that
would capture the most
important aspects of the
questions we were interested
in while keeping it to a length
and time that most respon-
Figure 4. Responses by 82 respondents to questions regarding quality of professional life (Table 1, Part 4). dents would find agreeable.
As stated previously, we will
continue to make modifica-
Furthermore, as stated in the Methods, the authors were blinded to tions to the survey to shorten the time it takes to complete without
participants’ answers. sacrificing its key components/questions.
Finally, our group composition was fairly homogenous, including The bigger impediment is generating interest in our study.
mostly Caucasian, male, academic neurosurgeons. A larger study in Neurosurgeons are inundated with online surveys from orga-
which the survey is sent to a random population of active neuro- nized neurosurgery or industry almost on a daily basis. To
surgeons would hopefully minimize, although not eliminate, selec- expand this study, we would like to adopt the same model as the
tion bias and yield a more heterogenous population. ACS study. Our intention is to partner with the Council of State
Neurosurgical Societies (CSNS), which we hope would translate
Table 3. Burnout Indices Among 81 Neurosurgeons Who into interest in this project and thus a greater likelihood that
Responded to the Questions Regarding Burnout in the Pilot a neurosurgeon completes the survey. This is currently being
Study Survey actively pursued. Ultimately, we envision the data that would
come out of a larger study being used by academic or private
Burnout Indices Median Score Number (%) neurosurgeons at the national, state, local, and even at the
individual practice level as the force behind the development and
Emotional exhaustion 13.0
implementation of strategies that prevent or mitigate stress and
% low score (
18) 55 (68) burnout.
% moderate score 12 (18) Stress in neurosurgery will not diminish with time and is likely
to increase as neurosurgeons face an ever-increasing pressure to
% high score (27) 11 (14)
generate revenue for their hospitals or academic institutions, the
Depersonalization 4.0 uncertainty of future earnings, and the potentially negative
% low score (
5) 49 (61) consequences brought into their practice by health care reform. Sir
Winston Churchill stated that “Healthy citizens are the greatest
% moderate score 10 (12)
asset any country can have.” Having healthy and professionally
% high score (10) 22 (27) satisfied neurosurgeons is the single greatest asset in our
Personal accomplishment 39.0 profession as it will directly translate into improved patient care.
As such, the wellness of our colleagues needs to be measured and
% low score (
33) 22 (27)
carefully monitored if we are to continue to improve it.
% moderate score 19 (24)
% high score (40) 40 (49)
Burned out* 22 (27) CONCLUSIONS
Neurosurgery is a difficult, but highly rewarding, field. There are
*High score on emotional exhaustion and/or depersonalization subscales (see Methods).
many sources of frustration and stress, which, if left unbalanced

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PAUL KLIMO JR ET AL. CAREER SATISFACTION AND BURNOUT AMONG NEUROSURGEONS

in an online survey that assessed personal and practice demo-

graphics, stress, satisfaction and dissatisfaction, and burnout.
Approximately three quarters of neurosurgeons were very satis-
fied with their career and about 27% were considered burned out.
Just over half would recommend neurosurgery as a career to their
children. We believe that our survey is a reasonable tool but
needs to be shortened. A number of challenges were identified
with this survey study, and strategies to overcome them are
currently under way. We hope to expand our study to a wider
audience and thus generate greater responses to identify risk
factors for stress and burnout. This information can then be used
at various levels to help improve the quality of professional life
for neurosurgeons.
Figure 5. Responses by 81 respondents to questions regarding the future
direction of career (Table 1, Part 6).

by either professional or personal sources of happiness, can lead ACKNOWLEDGMENTS

to burnout and can negatively affect personal relationships and the The authors thank Kristin Kraus, M.Sc., for her outstanding
quality of patient care. Eighty-five neurosurgeons participated editorial assistance in preparing this manuscript.

residents: prospective cohort study. BMJ 336: 18. Quinn MA, Wilcox A, Orav EJ, Bates DW,
REFERENCES 488-491, 2008. Simon SR: The relationship between perceived
practice quality and quality improvement activities
1. Balch CM, Copeland E: Stress and burnout among
10. Firth-Cozens J, Greenhalgh J: Doctors’ and physician practice dissatisfaction, profes-
surgical oncologists: a call for personal wellness
perceptions of the links between stress and sional isolation, and work-life stress. Med Care
and a supportive workplace environment. Ann
lowered clinical care. Soc Sci Med 44: 47:924-928, 2009.
Surg Oncol 14:3029-3032, 2007.
1017-1022, 1997.
19. Ramirez AJ, Graham J, Richards MA, Cull A,
2. Balch CM, Shanafelt TD, Sloan J, Satele DV,
11. Fletcher AM, Pagedar N, Smith RJ: Factors Gregory WM, Leaning MS, Snashall DC,
Kuerer HM: Burnout and career satisfaction
correlating with burnout in practicing otolaryn- Timothy AR: Burnout and psychiatric disorder
among surgical oncologists compared with other
gologists. Otolaryngol Head Neck Surg 146: among cancer clinicians. Br J Cancer 71:1263-1269,
surgical specialties. Ann Surg Oncol 18:16-25,
234-239, 2011. 1995.
2011.

3. Balch CM, Shanafelt TD, Sloan JA, Satele DV,
Freischlag JA: Distress and career satisfaction
among 14 surgical specialties, comparing
academic and private practice settings. Ann Surg
254:558-568, 2011.
4. Ballenger-Browning KK, Schmitz KJ,
Rothacker JA, Hammer PS, Webb-Murphy JA,
Johnson DC: Predictors of burnout among mili-
tary mental health providers. Mil Med 176:
253-260, 2011.
5. Campbell DA Jr, Sonnad SS, Eckhauser FE,
Campbell KK, Greenfield LJ: Burnout among
American surgeons. Surgery 130:696-702, 2001;
discussion 702-705.
6. Dyrbye LN, Shanafelt TD: Physician burnout:
a potential threat to successful health care reform.
JAMA 305:2009-2010, 2011.
7. Dyrbye LN, Shanafelt TD, Balch CM, Satele D,
Sloan J, Freischlag J: Relationship between work-
home conflicts and burnout among American
surgeons: a comparison by sex. Arch Surg 146:
211-217, 2011.
8. Elit L, Trim K, Mand-Bains IH, Sussman J,
Grunfeld E: Job satisfaction, stress, and burnout
among Canadian gynecologic oncologists. Gyne-
col Oncol 94:134-139, 2004.
9. Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ,
Lewin D, Chiang VW, Edwards S,
Wiedermann BL, Landrigan CP: Rates of medi-
cation errors among depressed and burnt out
12. Glasheen JJ, Misky GJ, Reid MB, Harrison RA,
Sharpe B, Auerbach A: Career satisfaction and
burnout in academic hospital medicine. Arch
Intern Med 171:782-785, 2011.
13. Johnson JT, Wagner RL, Rueger RM, Goepfert H:
Professional burnout among head and neck
surgeons: results of a survey. Head Neck 15:
557-560, 1993.
14. Keswani RN, Taft TH, Cote GA, Keefer L:
Increased levels of stress and burnout are
related to decreased physician experience and
to interventional gastroenterology career
choice: findings from a US survey of endo-
scopists. Am J Gastroenterol 106:1734-1740,
2011.
15. Kuerer HM, Eberlein TJ, Pollock RE,
Huschka M, Baile WF, Morrow M, Michelassi F,
Singletary SE, Novotny P, Sloan J, Shanafelt TD:
Career satisfaction, practice patterns and
burnout among surgical oncologists: report on
the quality of life of members of the Society of
Surgical Oncology. Ann Surg Oncol 14:
3043-3053, 2007.
16. Lee FJ, Stewart M, Brown JB: Stress, burnout, and
strategies for reducing them: what’s the situation
among Canadian family physicians? Can Fam
Physician 54:234-235, 2008.
17. Maslach C, Jackson S, Leiter M: Maslach Burnout
Inventory manual. 3rd ed. Palo Alto, CA: Consul-
ting Psychologists Press; 1996.
20. Ramondetta LM, Urbauer D, Brown AJ,
Richardson G, Thaker PH, Koenig HG,
Levenback C, Sun C: Work related stress among
gynecologic oncologists. Gynecol Oncol 123:
365-369, 2011.
21. Rosenstein AH, Mudge-Riley M: The impact of
stress and burnout on physician satisfaction
and behaviors. Physician Exec 36:16-18, 2010:20,
22-13.
22. Rosenstein AH, O’Daniel M: Impact and impli-
cations of disruptive behavior in the perioperative
arena. J Am Coll Surg 203:96-105, 2006.
23. Roth M, Morrone K, Moody K, Kim M, Wang D,
Moadel A, Levy A: Career burnout among pedi-
atric oncologists. Pediatr Blood Cancer 57:
1168-1173, 2011.
24. Saleh KJ, Quick JC, Sime WE, Novicoff WM,
Einhorn TA: Recognizing and preventing burnout
among orthopaedic leaders. Clin Orthop Relat
Res 467:558-565, 2009.
25. Sargent MC, Sotile W, Sotile MO, Rubash H,
Vezeridis PS, Harmon L, Barrack RL: Managing
stress in the orthopaedic family: avoiding
burnout, achieving resilience. J Bone Joint Surg
Am 93:e40, 2011.
26. Shanafelt TD, Balch CM, Bechamps GJ, Russell T,
Dyrbye L, Satele D, Collicott P, Novotny PJ,
Sloan J, Freischlag JA: Burnout and career satis-
faction among American surgeons. Ann Surg 250:
463-471, 2009.

WORLD NEUROSURGERY 80 [5]: e59 e68, NOVEMBER 2013 www.WORLDNEUROSURGERY.org e67

 FORUM
PAUL KLIMO JR ET AL. CAREER SATISFACTION AND BURNOUT AMONG NEUROSURGEONS

27. Shanafelt TD, West C, Zhao X, Novotny P,
Kolars J, Habermann T, Sloan J: Relationship
between increased personal well-being
and enhanced empathy among internal medi-
cine residents. J Gen Intern Med 20:559-564,
2005.
28. Soler JK, Yaman H, Esteva M, Dobbs F,
Asenova RS, Katic M, Ozvacic Z, Desgranges JP,
Moreau A, Lionis C, Kotanyi P, Carelli F,
Nowak PR, de Aguiar Sa Azeredo Z, Marklund E,
Churchill D, Ungan M: Burnout in European
family doctors: the EGPRN study. Fam Pract 25:
245-265, 2008.
29. Troppmann KM, Palis BE, Goodnight JE, Ho HS,
Troppmann C: Career and lifestyle satisfaction
among surgeons: what really matters? The
National Lifestyles in Surgery Today Survey. J Am
Coll Surg 209:160-169, 2009.
30. Wallace JE, Lemaire JB, Ghali WA: Physician
wellness: a missing quality indicator. Lancet 374:
1714-1721, 2009.
31. West CP, Huschka MM, Novotny PJ, Sloan JA,
Kolars JC, Habermann TM, Shanafelt TD: Asso-
ciation of perceived medical errors with resident
distress and empathy: a prospective longitudinal
study. JAMA 296:1071-1078, 2006.
32. Wetzel CM, Kneebone RL, Woloshynowych M,
Nestel D, Moorthy K, Kidd J, Darzi A: The effects
of stress on surgical performance. Am J Surg 191:
5-10, 2006.
33. Whippen DA, Canellos GP: Burnout syndrome in
the practice of oncology: results of a random
survey of 1,000 oncologists. J Clin Oncol 9:
1916-1920, 1991.
Citation: World Neurosurg. (2013) 80, 5:e59 e68.
http://dx.doi.org/10.1016/j.wneu.2012.09.009
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
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