More Healing Hands Through More Harmonized Voices: The SCALPEL Study

Abstract

Introduction

Burnout and declining fulfillment are prevalent among facial plastic surgeons (FPS), yet the organizational drivers of these challenges remain underexplored. Ownership structure, workplace autonomy, and collective representation may influence surgeon well-being and workforce sustainability.

Objectives and Hypotheses

To assess how autonomy, ownership, and unionization relate to satisfaction and stress among FPS. We hypothesized that private practitioners would report greater autonomy and satisfaction, that academic and hospital-employed surgeons would experience more stress and diminished control, and that prior union exposure would correspond with more favorable views of collective representation.

Study Design

Cross-sectional observational survey (STROBE).

Methods

A 26-item anonymous survey was distributed to all 1,041 members of the American Academy of Facial Plastic and Reconstructive Surgery; 104 responded (10%). Variables included practice type, ownership, union history, autonomy, compensation satisfaction, stressors, and openness to unionization. Analyses employed chi-square tests and qualitative content analysis.

Results

Surgeons in private practice reported the highest autonomy and compensation satisfaction and the lowest rates of feeling rushed. Hospital-employed and academic surgeons were more likely to report diminished autonomy, administrative stress, and lack of influence over workplace decisions. Only 11% of respondents expressed interest in unionizing, though prior union members generally described positive experiences. Surgeons' beliefs about whether unionization affects patient care did not vary significantly by practice setting.

Conclusion

Structural factors, particularly the autonomy and ownership model, are strongly linked to satisfaction and stress among FPS. Organizational reforms that enhance autonomy and support collective voice may reduce burnout and improve workforce sustainability.

Keywords

organizational factors - unions - private equity - working conditions

Declaration of GenAI Use

This work was created entirely by the authors and in no way by artificial intelligence (AI). Please do not reprint, copy, or otherwise distribute this document without our express permission. Please do not input this piece into ChatGPT or any other AI service.

Contributors' Statement

All authors contributed sufficiently to this manuscript. K.A. conducted the following: conceptualization, data curation, formal analysis, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing (original and review). A.Y. conducted the following: formal analysis, investigation, methodology, software, validation, visualization, writing (original and review). C.H. conducted the following: formal analysis, investigation, methodology, software, validation, writing (original and review). D.S. conducted the following: formal analysis, investigation, methodology, software, validation, writing (original and review). J.F. conducted the following: conceptualization, data curation, investigation, methodology, supervision, validation, writing (original and review).

Publikationsverlauf

Eingereicht: 24. September 2025

Angenommen: 30. September 2025

Accepted Manuscript online:
01. Oktober 2025

Artikel online veröffentlicht:
14. Oktober 2025

• References

• 1 Ligibel JA, Goularte N, Berliner JI. et al. Well-being parameters and intention to leave current institution among academic physicians. JAMA Netw Open 2023; 6 (12) e2347894-e2347894
• 2 Morrissette M, Michalowski A, Sclafani AP. Factors contributing to burnout and professional fulfillment among AAFPRS members. Facial Plast Surg 2025;
• 3 U.S. Department of the Treasury, Office of Economic Policy. Labor Unions and the Middle Class. Washington, DC: U.S. Department of the Treasury; 2023 https://home.treasury.gov/system/files/136/Labor-Unions-And-The-Middle-Class.pdf
• 4 Abraham-Aggarwal K, Spertus D, Avgar A. et al. The impact of unions on US direct care workers in long-term care settings: a systematic review. J Am Med Dir Assoc 2024; 25 (12) 105236
• 5 Bowling III D, Richman BD, Schulman KA. The rise and potential of physician unions. JAMA 2022; 328 (07) 617-618
• 6 Bowling III DS, Richman BD, Schulman KA. Collective bargaining: physician unions and their implications for health care. Health Serv Res 2022; 57 (06) 1214-1217
• 7 Ahmed AM, Kadakia K, Ahmed A, Shultz B, Li X. Trends in labor unionization among US health care workers, 2009-2021. JAMA 2022; 328 (24) 2404-2411
• 8 Hendrix JM, Burgart AM, Baker EB, Wolman RL, Kras JF. Physician unionization: opportunities and challenges for anesthesiologists in the United States. Anesth Analg 2024; 139 (02) 432-438
• 9 Zeitouni F, Attaluri PK, Wirth PJ, Shaffrey EC, Rao V. State of physician unionization. J Surg Educ 2024; 81 (07) 929-937
• 10 Lutsky J. Is your physician becoming a teamster: the rising trend of physicians joining labor unions in the late 1990s. DePaul J Health Care Law 1997; 2: 55
• 11 AMA analysis shows most physicians work outside private practice. American Medical Association; 2024. Accessed October 4, 2025 at: https://www.ama-assn.org/press-center/press-releases/ama-analysis-shows-most-physicians-work-outside-private-practice
• 12 Institute PA. Chicago NatUo. The Impact of Practice Acquisitions and Employment on Physician Experience and Care Delivery. 2023. Accessed October 4, 2025 at: https://www.physiciansadvocacyinstitute.org/PAI-Research/Employed-Physician-Survey
• 13 Rotenstein LS, Brown R, Sinsky C, Linzer M. The association of work overload with burnout and intent to leave the job across the healthcare workforce during COVID-19. J Gen Intern Med 2023; 38 (08) 1920-1927
• 14 Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005; 15 (09) 1277-1288
• 15 Rao SK, Kimball AB, Lehrhoff SR. et al. The impact of administrative burden on academic physicians: results of a hospital-wide physician survey. Acad Med 2017; 92 (02) 237-243
• 16 Berg S. Surgeon general: Why fighting burnout is our “moral obligation”. 2022. Accessed October 4, 2025 at: https://www.ama-assn.org/practice-management/physician-health/surgeon-general-why-fighting-burnout-our-moral-obligation
• 17 Sinsky CA, Brown RL, Rotenstein L, Carlasare LE, Shah P, Shanafelt TD. Association of work control with burnout and career intentions among U.S. physicians: a multi-institution study. Ann Intern Med 2025; 178 (01) 20-28
• 18 McAbee JH, Ragel BT, McCartney S. et al. Factors associated with career satisfaction and burnout among US neurosurgeons: results of a nationwide survey. J Neurosurg 2015; 123 (01) 161-173
• 19 Ames SE, Cowan JB, Kenter K, Emery S, Halsey D. Burnout in orthopaedic surgeons: a challenge for leaders, learners, and colleagues: AOA critical issues. J Bone Joint Surg Am 2017; 99 (14) e78
• 20 Celik SU, Aslan A, Coskun E. et al. Prevalence and associated factors for burnout among attending general surgeons: a national cross-sectional survey. BMC Health Serv Res 2021; 21 (01) 39
• 21 Barger LK, Weaver MD, Landrigan CP. et al. Resident physician intentions regarding unionization. JAMA Netw Open 2025; 8 (04) e253106-e253106
• 22 Carlson R. Is there a physician union in your future?. Fam Pract Manag 1999; 6 (01) 21-25
• 23 Felton JS. How the occupational physician works with the unions. Occup Med (Lond) 1997; 47 (02) 117-119
• 24 Hoff TJ. Physician unionization in the United States: fad or phenomenon?. J Health Hum Serv Adm 2000; 23 (01) 5-23
• 25 McGraw SE, Rodriguez TA. Is there a physician union in your future?. Physician Exec 1997; 23 (08) 25-29
• 26 Sobal LV, Hepner JO. Physician unions: any doctor can join, but who can bargain collectively?. Hosp Health Serv Adm 1990; 35 (03) 327-340
• 27 Association AM. ARC issue brief: collective bargaining for physicians and physicians-in-training. 2023. https://www.ama-assn.org/system/files/advocacy-issue-brief-physician-unions.pdf
• 28 Mathewes F. 5 Physician Unions in 2024. 2024. Accessed October 4, 2025 at: https://www.beckersphysicianleadership.com/news/5-physician-unions-in-2024/
• 29 Brajcich BC, Chung JW, Wood DE. et al. National evaluation of the association between resident labor union participation and surgical resident well-being. JAMA Netw Open 2021; 4 (09) e2123412-e2123412
• 30 Sklar D, Chang B, Hoffman BD. Commentary: experience with resident unions at one institution and implications for the future of practicing physicians. Acad Med 2011; 86 (05) 552-554
• 31 Appelbaum E, Batt R. Private equity buyouts in healthcare: Who wins, who loses?. Vol 118. 2020
• 32 Appelbaum E, Batt R. Preying on the Dying: Private Equity Gets Rich in. 2023; Center for Economic and Policy Research. https://cepr.net/publications/preying-on-the-dying-private-equity-gets-rich-in-hospice-care/
• 33 Appelbaum E, Batt R, Curchin E. Profiting at the expense of seniors: the financialization of home health care. Center for Economic and Policy Research 2023; (September): 26A https://www.cepr.net/wp-content/uploads/2023/09/2023-09-Profiting-at-the-Expense-of-Seniors-Appelbaum-Batt-Curchin.pdf
• 34 Batt R. Financialization in Health Care: The Transformation of US Hospital Systems. 2021. Center for Economic and Policy Research. https://cepr.net/wp-content/uploads/2021/10/AB-Financialization-In-Healthcare-Spitzer-Rept-09-09-21.pdf
• 35 Braun RT, Yun H, Casalino LP. et al. Comparative performance of private equity–owned US nursing homes during the COVID-19 pandemic. JAMA Netw Open 2020; 3 (10) e2026702-e2026702