Introduction
Surgery is a highly satisfying but demanding career. The surgical workforce has been
changing recently, and the proportion of women increased.[1] Additionally, part-time work has become possible.[2] Although the European Working Time Directive limits surgeons' work week to 48 hours
and there are similar regulations in other countries, a surgeon's workload is still
high. A decreased quality of life and health-related problems for surgeons have been
recently addressed in the literature.[3]
[4]
[5] Residents are leaving training programs due to a suboptimal lifestyle or to choose
another specialty,[6] and a demand for part-time training has been documented.[7] Among medical students, the attractiveness of surgery has recently decreased.[8] All these effects have resulted in a shortage of surgeons, and head surgeons are
complaining about the decreased number of adequate applicants for surgery.[9]
Pediatric surgery is different from other surgical disciplines. Among surgical specialties,
pediatric surgeons reported the highest rate of work satisfaction, although they had
a higher workload than other specialties and a higher rate of work/home conflict.[10] Pediatric surgical residents have been shown to be highly motivated,[11] and the proportion of women is higher than other surgical disciplines. In 2013,
22% of the registered pediatric surgeons in Australasia were women,[12] in 2020, 27% of the pediatric surgery consultants in the Royal College of Surgeons
of England,[1] and in 2021, 32% of the ordinary active members of the Swiss Society of Pediatric
Surgery.[13]
The proportion of women in pediatric surgery in Germany was high, accounting for 40%
of the 738 fully trained pediatric surgeons in 2020.[14] The Act on part-time work has been in place since 2001, giving employees the right
to work less than full time. Despite the increasing number of pediatric surgeons,
the number of vacancies in pediatric surgery in Germany remains high.[15] Our study aimed to analyze this contradiction to determine the type of jobs that
are wanted by pediatric surgeons in Germany. The goal of our study was to address
the following question: “In which place of work, in which position, and with what
kind of working time do pediatric surgeons and trainees work now and want to work
in 5 years and in the long-term?” We approached this question with a survey among
the members of the German Society of Pediatric Surgery.
Materials and Methods
In Germany, pediatric surgery is performed in hospitals and private practice. Hospitals
can be divided into the following main four groups: university hospitals, community
hospitals, church hospitals, and private hospitals. Pediatric surgery training usually
takes place in a pediatric surgical department at a hospital. Trainees do not have
to work in general surgery to become pediatric surgeon.[16] In most German hospitals, there are, from lowest to highest, four positions that
a pediatric surgeon can occupy after finishing the training: Facharzt (fully trained
pediatric surgeon), Funktionsoberarzt (senior physician), Oberarzt (consultant), and
Chefarzt (department head). Usually, a department has one department head and several
surgeons in the other positions.
The number of fully trained pediatric surgeons is provided by the German Medical Association.[14] Among 738 pediatric surgeons who are working in Germany, approximately 70% are members
of the German Society of Pediatric Surgeons; the percentage of trainees is not known.
An anonymous online survey was sent to all the members of the German Society of Pediatric
Surgeons who were registered and working as a trainee or as a fully trained pediatric
surgeon, but not working in a leadership position, in private practice, or retired.
There were 512 questionnaires sent out as follows: 172 to trainees, 230 to pediatric
surgery consultants, and 110 to other fully trained pediatric surgeons. Answers were
obtained from October 2020 to January 2021. Anonymity was provided by ensuring that
the link to the questionnaire was not personalized and because the software did not
save any information except the answers to the questions.
The survey consisted of the following questions: What is your gender? How old are
you (presented in age groups of 10 years)? Actual situation: What is your actual work
schedule? What is your place of work? What is/was your last position in pediatric
surgery? What academic qualification do you have? Situation in 5 years: What working
schedule do you prefer? In which institution do you want to work? In which position
do you want to work? What is your desired academic qualification? Long-term situation:
What work schedule do you prefer? In which institution do you want to work? In which
position do you want to work? What is your desired academic qualification? In our
questionnaire, the work schedule was divided between full time and part time. Part
time was not defined, so it could be anything between 1 and 99% of the regular working
hours.
Data were analyzed using descriptive statistics. Results were evaluated separately
for men and women. This survey was performed anonymously, so Institutional Review
Board approval was not required, which was confirmed by the local ethical committee.
Results
Study Population
One hundred ninety-five of 512 (38%) respondents completed the questionnaire, among
whom 99 were women (51%), 94 were men (48%), 1 was diverse, and 1 did not provide
information about their gender. One hundred forty of 195 respondents (72%) were fully
trained pediatric surgeons, senior physicians, and consultants (69 females [49%] and
70 males [50%]). The group of consultants and senior physicians had a response rate
of 47%, while that of fully trained pediatric surgeons was 28% and trainees was 30%.
For trainees, 30 of 53 (57%) were women and 23 of 53 (43%) were men. Additionally,
4% of the whole study population were younger than 30 years, 44% were between 30 and
39 years, 34% were between 40 and 49 years, 15% were between 50 and 59 years, and
3% were older than 59 years.
Actual Working Situation
Among the 195 respondents, 27% worked as trainees, 16% as a fully trained pediatric
surgeon, 6% as a senior physician, 50% as a consultant, and 1% did not provide an
answer on their work position. The distribution between men and women is shown in
[Fig. 1]. Additionally, 66% worked full time, 25% worked part time, 8% did not work in pediatric
surgery at the time of the questionnaire, and 1% did not provide an answer about the
amount of work. Details about the distribution of work between men and women are provided
in [Fig. 2].
Fig. 1 Number of participants in a special position related to gender. n = 191.
Fig. 2 Distribution of age, gender, and workload. n = 192. “No” means not working at all or not working in pediatric surgery.
Among the participants, 40% were employed at a university hospital, 26% at a community
hospital, 19% at a church hospital, 11% at a private hospital, 4% in other settings,
1% was not employed, and 2% were working abroad. For 20% of the respondents, no further
academic qualification was acquired, while 70% had a doctorate, 8% had a postdoctoral
lecture qualification, and 4% had another academic qualification.
Details about the actual working situation and the desires for their future career
for both men and women are presented in [Table 1].
Table 1
Actual work situation and hopes for the future for women (n = 99) and men (n = 93)[a]
|
Now
|
In 5 y
|
Long term
|
|
Women
|
Men
|
Women
|
Men
|
Women
|
Men
|
|
Answers
|
99
|
|
91
|
|
99
|
|
93
|
|
99
|
|
93
|
|
|
Full time
|
47
|
47.5%
|
80
|
87.9%
|
37
|
37.4%
|
58
|
62.4%
|
35
|
35.4%
|
54
|
58.1%
|
|
Part time
|
41
|
41.4%
|
7
|
7.7%
|
60
|
60.6%
|
29
|
31.2%
|
60
|
60.6%
|
31
|
33.3%
|
|
Not working
|
|
|
|
|
1
|
1.0%
|
2
|
2.2%
|
1
|
1.0%
|
2
|
2.2%
|
|
Not working in pediatric surgery
|
11
|
11.1%
|
4
|
4.4%
|
1
|
1.0%
|
4
|
4.3%
|
3
|
3.0%
|
6
|
6.5%
|
|
Answers
|
99
|
|
91
|
|
97
|
|
87
|
|
94
|
|
85
|
|
|
Trainee
|
30
|
30.3%
|
22
|
24.2%
|
3
|
3.1%
|
1
|
1.1%
|
1
|
1.1%
|
0
|
0.0%
|
|
Fully trained pediatric surgeon
|
16
|
16.2%
|
15
|
16.5%
|
23
|
23.7%
|
13
|
14.9%
|
14
|
14.9%
|
2
|
2.4%
|
|
Senior physician
|
11
|
11.1%
|
1
|
1.1%
|
11
|
11.3%
|
9
|
10.3%
|
6
|
6.4%
|
2
|
2.4%
|
|
Consultant
|
42
|
42.4%
|
53
|
58.2%
|
72
|
74.2%
|
62
|
71.3%
|
70
|
74.5%
|
59
|
69.4%
|
|
Department head
|
|
|
|
|
15
|
15.5%
|
34
|
39.1%
|
21
|
22.3%
|
50
|
58.8%
|
|
Private practice
|
|
|
|
|
16
|
16.5%
|
10
|
11.5%
|
23
|
24.5%
|
18
|
21.2%
|
|
Other
|
|
|
|
|
3
|
3.1%
|
3
|
3.4%
|
4
|
4.3%
|
3
|
3.5%
|
|
Answers
|
99
|
|
93
|
|
96
|
|
87
|
|
95
|
|
85
|
|
|
University hospital
|
43
|
43.4%
|
33
|
35.5%
|
53
|
55.2%
|
41
|
47.1%
|
50
|
52.6%
|
37
|
43.5%
|
|
Community hospital
|
19
|
19.2%
|
30
|
32.3%
|
45
|
46.9%
|
47
|
54.0%
|
42
|
44.2%
|
43
|
50.6%
|
|
Church hospital
|
20
|
20.2%
|
15
|
16.1%
|
22
|
22.9%
|
15
|
17.2%
|
23
|
24.2%
|
15
|
17.6%
|
|
Private hospital
|
13
|
13.1%
|
9
|
9.7%
|
19
|
19.8%
|
13
|
14.9%
|
15
|
15.8%
|
11
|
12.9%
|
|
Other
|
3
|
3.0%
|
5
|
5.4%
|
4
|
4.2%
|
7
|
8.0%
|
4
|
4.2%
|
6
|
7.1%
|
|
Private practice
|
1
|
1.0%
|
4
|
4.3%
|
22
|
22.9%
|
16
|
18.4%
|
28
|
29.5%
|
17
|
20.0%
|
|
Work abroad
|
3
|
3.0%
|
|
|
15
|
15.6%
|
6
|
6.9%
|
13
|
13.7%
|
5
|
5.9%
|
|
Not working at the moment
|
1
|
1.0%
|
1
|
1.1%
|
|
|
|
|
|
|
|
|
|
Does not matter
|
|
|
|
|
|
|
|
|
5
|
5.3%
|
10
|
11.8%
|
|
Do not know
|
|
|
|
|
11
|
11.5%
|
10
|
11.5%
|
9
|
9.5%
|
8
|
9.4%
|
|
Answers
|
99
|
|
93
|
|
97
|
|
85
|
|
94
|
|
83
|
|
|
Dissertation
|
68
|
68.7%
|
68
|
73.1%
|
60
|
61.9%
|
59
|
69.4%
|
52
|
55.3%
|
52
|
62.7%
|
|
Postdoctoral lecture qualification
|
7
|
7.1%
|
9
|
9.7%
|
25
|
25.8%
|
28
|
32.9%
|
30
|
31.9%
|
32
|
38.6%
|
|
Other
|
2
|
2.0%
|
5
|
5.4%
|
2
|
2.1%
|
4
|
4.7%
|
2
|
2.1%
|
5
|
6.0%
|
|
None
|
23
|
23.2%
|
15
|
16.1%
|
12
|
12.4%
|
4
|
4.7%
|
13
|
13.8%
|
4
|
4.8%
|
a For the plans for their work position, the place of work, and the academic titles,
more than one answers were possible, for example, the cumulative number of answers
in the detailed information exceeds the number of answers.
Where Do People Want to Work in the Future?
For their place of work in the future, participants could choose more than one options.
The most popular place to work in 5 years and in the long term were university hospitals,
and the least attractive place in Germany was private hospitals. About 10% could imagine
working abroad in the future ([Fig. 3]).
Fig. 3 Participants' workplace. n = 195. Cumulative numbers exceed 100% because more than one answers could be given.
A gender-specific analysis showed that women (55%, 5 years; 53%, long term) preferred
university hospitals more than men (46%, 5 years; 45%, long-term), while men (54%,
5 years; 52%, long term) preferred community hospitals more than women (47%, 5 years;
44%, long term).
Full Time or Part Time
At the time of the study, 129 participants (66%) worked full time, 49 participants
(25%) worked part time, and 15 participants (8%) did not work at all or did not work
in pediatric surgery. Two participants (1%) did not provide an answer to this question.
Ninety (46%) and 92 (47%) participants wanted to work part time in 5 years and in
the long term, respectively. Three participants did not want to work in the long term,
all of whom were older than 59 years. Nine participants (5%) did not want to work
in pediatric surgery in the long term, all of whom were between 30 and 59 years of
age. The detailed analysis of working time related to gender is presented in [Fig. 4].
Fig. 4 Flow chart of working time related to gender. n = 195. Working time (full time vs. part time) for men and women at the time of the
questionnaire (left), in 5 years (middle), and in the long term (right). f, female;
FT, full time; lt, long-term; m, male; noPS, not working/not working in pediatric
surgery; PT, part time; 5, in 5 years.
The age group that had the greatest desire to work part time in the future was the
50-to-59-year-old group, which had 57% of participants who wanted to work part time
in 5 years and 61% who wanted to work part time in the long term. This was followed
by the under 30 years age group, where 50% wanted to work part time in 5 years and
in the long term. The other results were 47% for 5 years and in the long term in the
30-to-39-year-old age group and 43 and 45%, respectively, in the 40-to-49-year-old
age group.
Among those who wanted to work part time in 5 years, 27% worked as a trainee and 48%
worked as a consultant. Additionally, 24% of trainees and 49% of consultants wanted
to work part time in the long term. Among those working at university hospitals at
the time of the questionnaire, 38% wanted to work part time in the long term, while
48% of those who worked at community hospitals, 57% of those who worked at church
hospitals, and 55% of those who worked at private hospitals wanted to work part time
in the long term.
What Is the Future Career Direction?
The participants could choose more than one options for what they wanted to achieve
in the future. [Table 2] shows their desired position in the long term. The most frequent response was consultant
(67%), followed by department head (37%) and private practice (22%).
Table 2
Desired long-term career position: combination of given options[a]
|
Number of responses
|
Percentage
|
Long-term career positions
|
|
Department head
|
Consultant
|
Senior physician
|
Fully trained pediatric surgeon
|
Trainee
|
Private practice
|
Other
|
|
28
|
14.4%
|
x
|
|
|
|
|
|
|
|
30
|
15.4%
|
x
|
x
|
|
|
|
|
|
|
9
|
4.6%
|
x
|
x
|
|
|
|
x
|
|
|
3
|
1.5%
|
x
|
|
|
|
|
x
|
|
|
2
|
1.0%
|
x
|
x
|
|
|
|
|
x
|
|
1
|
0.5%
|
x
|
x
|
|
x
|
|
x
|
|
|
64
|
32.8%
|
|
x
|
|
|
|
|
|
|
16
|
8.2%
|
|
x
|
|
|
|
x
|
|
|
3
|
1.5%
|
|
x
|
x
|
|
|
x
|
|
|
2
|
1.0%
|
|
x
|
|
|
|
|
x
|
|
1
|
0.5%
|
|
x
|
x
|
|
|
|
|
|
1
|
0.5%
|
|
x
|
x
|
x
|
|
|
|
|
1
|
0.5%
|
|
x
|
x
|
x
|
|
x
|
|
|
1
|
0.5%
|
|
x
|
|
x
|
|
|
|
|
2
|
1.0%
|
|
|
x
|
x
|
|
|
|
|
6
|
3.1%
|
|
|
|
x
|
|
|
|
|
3
|
1.5%
|
|
|
|
x
|
|
x
|
|
|
1
|
0.5%
|
|
|
|
x
|
x
|
x
|
|
|
5
|
2.6%
|
|
|
|
|
|
x
|
|
|
3
|
1.5%
|
|
|
|
|
|
|
x
|
|
13
|
6.7%
|
|
|
|
|
|
|
|
|
Number of responses
|
73
|
131
|
8
|
16
|
1
|
42
|
7
|
|
%
|
37.4%
|
67.2%
|
4.1%
|
8.2%
|
0.5%
|
21.5%
|
3.6%
|
a Each row describes the chosen career position alternatives and the number of participants
who chose the same combination.
Among the 37% of the respondents who wanted to become a department head, 62% had alternative
plans, while for 38%, this was the only option. This result was nearly equivalent
for 50 men (60% had alternative plans) and 21 women (67% had alternative plans). Additionally,
67% were consultants at the time of the questionnaire, 7% were senior physicians,
12% were fully trained pediatric surgeons, and 12% were trainees. Of those who wanted
to become a department head in the future, 67% had finished their doctoral thesis,
16% had their postdoctoral lecture qualification, and 14% had no academic degree.
Moreover, 47% worked at a university hospital at the time of the questionnaire, while
26% worked at a community hospital, 19% at a church hospital, 6% at a private hospital,
1% in another setting, and 1% worked abroad.
Thirty-three percent wanted to become a department head at a university hospital as
their only choice, and 15% wanted to work at a community hospital. Additionally, 14%
preferred to become a department head at any type of hospital, and 11% did not know.
Only 8%, not including those who had no preference, saw an option to practice at a
private hospital, and 12% saw an option at a church hospital. Only one person identified
a private hospital or a church hospital as their only choice.
Sixty-seven percent wanted to both work full time and be a department head, while
33% wanted to work part time.
The career goal of a consultant was an option for 75% of the women and 69% of the
men. Forty-eight percent already worked as a consultant, among whom 30% worked part
time. For the future, 53% wanted to work part time as a consultant.
Performing pediatric surgery outside of the hospital at a private practice was a goal
for 22% of the participants, among whom 53% were women. The age distribution was 12%
younger than 30 years, 38% between 30 and 39 years, 36% between 40 and 49 years, and
14% between 50 and 59 years. Additionally, 40% had no academic qualifications, and
only 2% had a postdoctoral lecture qualification.
Discussion
The situation for pediatric surgery in Germany is characterized by an increasing number
of pediatric surgical departments and pediatric surgeons.[17] This is different from other countries such as Canada, where the number of pediatric
surgeons has been consistent.[18] In Germany in 2021, pediatric surgery was performed in 134 hospitals, 35 (26%) of
which were university hospitals.[19] Forty percent of the respondents worked at university hospitals and wanted to work
at this type of hospital in the future. The attraction to community hospitals was
also high. Clerical and private hospitals did not have the same attraction for pediatric
surgeons.
Full Time or Part Time
The workload for pediatric surgeons has been reported to be higher than in other surgical
specialties[10] or higher than what the pediatric surgeons wished it to be.[20] There is a danger of burn out, even in pediatric surgery.[21] The European Working Time Directive allows an average of 48 hours of working time
per week. In Germany, full-time regular working hours are 38.5 to 42 hours per week,
and overtime is common.[22] On-call duties are usually added to these hours. At the time of the questionnaire,
41% of the women and 9% of the men worked part time. In the future, 61% of the women
and 34% of the men wanted to work part time, and most of them wanted a permanent reduction
in their work hours. We did not ask for the reasons why they wanted reduced working
time. In the literature, part-time work or reduced working time in surgery is often
related to children, especially for female surgeons.[2]
[20]
[23] However, in our study group, a high number of men wanted to work part time in the
future, and the highest percentage of respondents who wanted to reduce their working
time was seen in the age group between 50 and 59 years. There are no equivalent findings
in the literature, so this should be analyzed further in follow-up studies.
Career
Internationally, career satisfaction in pediatric surgery has been reported to be
high.[24]
[25]
[26]
[27] In our study, we did not directly ask about career satisfaction, but the desire
to stop practicing pediatric surgery was low (5%). Career planning differed for men
and women in our study. For 25% of the women and 21% of the men, working in a private
practice was an option for a long-term perspective. Most respondents wanted to continue
their career in the hospital setting. The option to remain in a lower position as
a fully trained pediatric surgeon was a perspective for 15% of the women but only
2% of the men. Eleven percent of the women and 1% of the men had the position of a
senior physician at the time of the study. Often, senior physicians and consultants
perform the same kind of work, but they are paid differently, with the consultant
earning more money.[28] This explains why the position was not attractive to both genders for the future.
Seventy-five percent of the women and 69% of the men wanted to become a consultant.
However, 22% of the women and 59% of the men wanted to become a department head.
In our study, men showed greater ambition to strive for a higher position than women.
The differences in career development between men and women have been discussed for
many years in the literature,[25] and it has been called the glass ceiling phenomenon for women.[29]
[30] In an older study from 2004, major barriers to career success included “excessive
clinical load, on-call responsibilities, lack of appropriate mentorship, and lack
of support from the division director or departmental chairperson.”[31] The lack of role models was seen as another barrier,[32] which is supported by the fact that only 16% of department heads in pediatric surgery
in Germany were women in 2021.[19] The desire for a reduced workload, which was higher in women, could also be an explanation
for the different career plans. Conversely, one-third of the participants who wanted
to become a department head also wanted to work part time. The option for a department
head to work part time has now been observed in Germany.[33]
[34] As we did not ask for reasons, we do not have any support for these explanations,
and this area requires further research.
For the first time in Germany, there were more female trainees than male trainees
in pediatric surgery in 2014 (male-to-female ratio, 49:51%), and this ratio has been
increasing ever since, with a male-to-female trainee ratio of 42:58% in 2017.[35] In 2020, almost two-thirds of the medical students were women, so this trend is
expected to continue. Actual career ambitions for pediatric surgeons in Germany are
different from those of traditional career models. This fact and the great number
of vacancies will probably lead to different job models for the future. Part-time
work will be more common, which is supported by a legal right in Germany. Further
studies should highlight the effect of this change on the quality of patient care
and determine the best practice models, which can be templates for other countries
where these changes in gender and working time might occur in the future.
Limitations
There are some limitations to our study. There might be a bias in enrollment because
our study only included members of the German Society of Pediatric Surgeons. The response
rate in our study was 38%, which is close to 40% recommended rate for surveys in research.[36] There is also the possibility of responder bias. The percentage of fully trained
female pediatric surgeon respondents was higher (49%) compared with the official numbers
(40%). This could lead to a bias within our study, and therefore, in our analyses
that differentiated between men and women. Respondents who wanted to change their
job in the near future may have been more likely to respond to the survey, and thus,
they may be overrepresented in the sample. This may be supported by the fact that
the group of pediatric surgeons older than 50 years was underrepresented.
In our survey, we excluded members of the German Society of Pediatric Surgery who
were already working as a department head or who had a private practice because they
normally do not change their working conditions except when they retire. As the job
market changes rapidly, we will include these people in our next survey.
