Journal of Clinical Anesthesia (2013) 25, 289–295

Original Contribution

Measuring determinants of career satisfaction ofanesthesiologists: validation of a survey instrument☆,☆☆

Anoushka M. Afonso MD (Clinical Instructor)a, James H. Diaz MD, DrPH (Professor)b,Corey S. Scher MD (Associate Professor)c,Robbie A. Beyl BS, MS (Doctoral Candidate in Biostatistics)d,Singh R. Nair MD (Director, Clinical Research Anesthesia)e,Alan David Kaye MD, PhD (Professor and Chairman)b,⁎

aDepartment of Anesthesiology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USAbDepartment of Anesthesiology, Louisiana Health Sciences University, New Orleans, New Orleans, LA 70112, USAcDepartment of Anesthesiology, New York University Langone Medical Center, New York, NY 10016, USAdSchool of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USAeDepartment of Anesthesiology, Montefiore Medical Center, Bronx, NY 10467, USA

Received 20 July 2012; revised 1 January 2013; accepted 17 January 2013

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Keywords:Anesthesiologists: aging;Burnout;Career satisfaction;Practice;Survey

AbstractStudy Objective: To measure the parameter of job satisfaction among anesthesiologists.Design: Survey instrument.Setting: Academic anesthesiology departments in the United States.Subjects: 320 anesthesiologists who attended the annual meeting of the ASA in 2009 (95% response rate).Measurements and Main Results: The anonymous 50-item survey collected information on 26independent demographic variables and 24 dependent ranked variables of career satisfaction amongpracticing anesthesiologists. Mean survey scores were calculated for each demographic variable and testedfor statistically significant differences by analysis of variance. Questions within each domain that wereinternally consistent with each other within domains were identified by Cronbach’s alpha≥ 0.7. P-values≤ 0.05 were considered statistically significant. Cronbach’s alpha analysis showed strong internalconsistency for 10 dependent outcome questions in the practice factor-related domain (α = 0.72), 6dependent outcome questions in the peer factor-related domain (α = 0.71), and 8 dependent outcomequestions in the personal factor-related domain (α = 0.81). Although age was not a variable, full-timestatus, early satisfaction within the first 5 years of practice, working with respected peers, and personalchoice factors were all significantly associated with anesthesiologist job satisfaction.Conclusions: Improvements in factors related to job satisfaction among anesthesiologists may lead tohigher early and current career satisfaction.© 2013 Elsevier Inc. All rights reserved.

☆ Supported by departmental funds only.☆☆ Presented in part at the annual meeting of the American Society of Anesthesiologists, San Diego, CA, Oct. 16-20, 2010.⁎ Correspondence: Alan David Kaye, MD, PhD, Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, Room

56, 1542 Tulane Ave., New Orleans, LA 70112, USA. Tel: +1 504 568-2319; fax: +1 504 568-2317.E-mail address: akaye@lsuhsc.edu (A.D. Kaye).

952-8180/$ – see front matter © 2013 Elsevier Inc. All rights reserved.ttp://dx.doi.org/10.1016/j.jclinane.2013.01.007

290 A.M. Afonso et al.

1. Introduction practice-related factors, 2) personnel and peer-related factors,

Anesthesiology has been recognized as a high-stressoccupation; job stress and burnout have been significantlycorrelated with job dissatisfaction among anesthesiologists,gastroenterologists, psychiatrists, primary care practitioners,and other specialists [1-4]. While certain independentpredictors of job dissatisfaction differ among the medicalspecialties, some remain constant across the specialties,including unexpected complications, increasing workloads,decreasing time off, reduced reimbursements, and malprac-tice suits [1-3]. Physicians who are satisfied with theircareers have been shown to provide better health care and tohave more satisfied patients [3]. Dissatisfaction amongphysicians leads to declining numbers of medical graduatesentering that specialty, increasing rates of medical errors, andexodus from the specialty or the medical profession [3].

Since prior investigations have not examined the impactof advancing age and other demographics on job satisfactionamong anesthesiologists, a cross-sectional survey study wasdesigned to investigate 1) the impact of advancing age on theselection of anesthesiology as a satisfying career early orlater in one’s career, and 2) the impact of several otherdemographic, practice, personnel, peer, financial, personal,and health-related factors on job satisfaction amongpracticing anesthesiologists over the span of their careers.

Table 1 Stratification of the domains tested

Domain Question (#)

Practice-related Boring work (14),Excessive work (15)Intellectual stimulation (23)Case variety (24)Case complexity (25)Less OR time (26)Call difficulty (29)Selling calls (30)Learning new skills (39)Malpractice threats (40)

Personnel/peer-related Case competition (18)Schedule control (19)Surgeon staff interaction (20)Anesthesiologist staff interaction (21)House staff interaction (22)Younger competitors (27)

Personal/health-related Medical health (31)Mental health (32)Physical health (33)Sexual health (34)Relationships (35)Parental role (36)Alcohol use (37)Controlled substance use (38)

OR=operating room.

2. Materials and methods

A focus group of practicing anesthesiologists wasconvened in the summer of 2009 at the Mt. Sinai MedicalCenter's Department of Anesthesiology in New York City,New York, in order to develop a survey on job satisfactionamong anesthesiologists attending the 2009 AmericanSociety of Anesthesiologists (ASA) Annual Meeting inNew Orleans, LA, October 16-19, 2009. Based on therecommendations of the focus group, job satisfaction wasdivided into 4 areas: practice-related, peer-related, personalhealth, and financially related.

The subsequent survey study was designed to test thefollowing null hypotheses: 1) that advancing age has noimpact on the assessment of anesthesiology as a satisfyingcareer early or later in one’s career as a practicinganesthesiologist; and that 2) demographics, practice-relatedfactors, personnel and peer-related factors, personal andhealth-related factors, and financial factors have no impacton job satisfaction among practicing anesthesiologists.

The 50-item survey was designed to collect informationon 26 demographic factors as independent variables and 24ranked variables of career satisfaction or not. The finalanalyzed survey consisted of 26 independent demographicvariables and 24 dependent outcome variables, which weredivided into the following three domains based on theprofessional recommendations of the focus group: 1)

and 3) personal and health-related factors [Table 1].To test the associations between advancing age and other

demographic factors on job satisfaction, a power analysis wasconducted to determine the number of study subjects needed tobe surveyed to achieve 90% statistical power to detect a truecorrelation of 0.3 at a 5% significance level [5]. The correlationcoefficient value of 0.3 was chosen because this value isgenerally accepted to represent a moderate degree ofassociation [5]. The sample size analysis indicated that 113study subjects would need to be surveyed to achieve 90%statistical power. Since a listing of registered ASA meetingattendees was not available to the investigators, a nonrando-mized convenience sample of meeting attendees was surveyedas randomized selection of survey subjects was not possible.

The job satisfaction surveys were specifically designedfor numerical coding to assure anonymity and confidentialitywhen administered to consenting anesthesiologists. Follow-ing Institutional Review Board (IRB) approval, the jobsatisfaction surveys were distributed to 320 ASA meetingattendees in the following 2 ways: 1) by practicinganesthesiologists, anesthesiology residents, and medicalstudents attending a survey booth area at the ASAconvention near the conference hall cafeteria; and 2) bypracticing anesthesiologists, anesthesiology residents, andmedical students directly handing out the surveys forcompletion by anesthesiologists from the conference hallcafeteria. To obtain a representative sample of the ASA

Table 2 Demographic characteristics of survey responders

Survey Responders Number (%) Satisfaction[mean (SD)]

Board-certifiedyes 237 (77.70%) 5.57 (1.27)no 68 (22.30%) 5.63 (1.45)Age (yrs)20-30 31 (10.16%) 5.70 (1.32)31-40 69 (22.62%) 5.65 (1.32)41-50 74 (24.26%) 5.52 (1.30)51-60 90 (29.51%) 5.47 (1.35)N60 40 (13.11%) 5.80 (1.29)Gendermale 236 (77.38%) 5.61 (1.31)female 68 (22.30%) 5.53 (1.35)U.S. medical schoolyes 193 (63.28%) 5.50 (1.40)no 110 (36.07%) 5.74 (1.15)Practice Typeacademic 133 (45.24%) 5.58 (1.27)private 107 (36.39%) 5.69 (1.29)other 54 (18.37%) 5.39(1.46)Full-time or part-time statusfull-time 281 (93.36%) 5.56 (1.32)part-time 20 (6.64%) 5.80 (1.28)Region of practiceNew England 17 (6.51%) 5.65 (1.32)Mid-Atlantic 81 (31.03%) 5.36 (1.30)South Atlantic 42 (16.09%) 5.65 (1.37)East North Central 28 (10.73%) 5.75 (1.32)East South Central 19 (7.28%) 5.84 (1.17)West North Central 11 (4.21%) 5.73 (0.90)West South Central 35 (13.41%) 5.60 (1.31)Mountain 8 (3.07%) 5.13 (1.81)Pacific 20 (7.66%) 5.40 (1.39)Hours worked per weekb 40 22 (7.26%) 5.45 (1.77)40-50 66 (21.78%) 5.47 (1.32)50-60 119 (39.27%) 5.57 (1.25)60-70 78 (25.74%) 5.70 (1.27)N70 18 (5.94%) 5.72 (1.41)Years of experience0-5 82 (27.15%) 5.62 (1.35)5-10 46 (15.23%) 5.65 (1.16)10-20 60 (19.87%) 5.28 (1.38)20-30 79 (26.16%) 5.57 (1.35)30-40 28 (9.27%) 6.00 (1.31)40-50 6 (1.99%) 5.50 (0.55)N50 1 (0.33%) 7.00 (.)ASA memberYes 271 (89.14%) 5.55 (1.33)No 33 (10.86%) 5.88 (1.11)Incomeb$50,000 15 (5.30%) 6.07 (1.33)$50,00-$99,000 40 (14.13%) 5.45 (1.38)$100,00-$149,999 12 (4.24%) 5.83 (1.03)$150,00-$199,999 19 (6.71%) 5.47 (1.90)$200,00-$249,999 33 (11.66%) 5.30 (1.36)$250,00-$299,999 31 (10.95%) 5.58 (1.34)

Table 2 (continued)

Survey Responders Number (%) Satisfaction[mean (SD)]

$300,00-$399,999 72 (25.44%) 5.80 (1.05)$400,00-$499,999 43 (15.19%) 5.44 (1.28)N$500,000 18 (6.36%) 6.00 (0.97)

291Anesthesiologists' career satisfaction

active, nonresident membership, surveys were distributedonly to practicing board-certified and board-eligible anes-thesiologists. Study subjects were instructed to leave aquestion blank if they felt that none of the ranked responsechoices expressed how they felt or if the question did notapply to them or their practice pattern.

The demographic factors of all respondents were consid-ered as the independent or predictor indicators of jobsatisfaction versus dissatisfaction in a linear regressionmodel and included age, gender, U.S. versus internationalmedical school graduate, board certification, academic-private-government practice, region of practice, hours workedper week, years in practice, ASA membership, earlysatisfaction in the first 5 years of practice, and income levels.

For ease of administration, the independent demographicquestions and the ranked survey outcome questions werecombined into one 50-question instrument, but the indepen-dent and dependent variables were initially analyzedseparately and then combined in a linear regression model.Mean (standard deviation) survey scores were calculated foreach demographic predictor and satisfaction outcomevariable and tested for statistically significant differencesby analysis of variance (ANOVA).

Two other statistical methods were applied to the surveyresults: 1) Cronbach’s alpha calculations for survey outcomequestions per domain; and 2) linear regression of indepen-dent predictors of satisfaction on the dependent outcomes ofcareer satisfaction or not. Cronbach’s alpha coefficients,which measure the internal consistency of a set of responses,were computed for every nondemographic survey questionresponse and for the 4 domains of the survey: practice-related, peer-related, personal health, and financially related.Questions within each domain that correlated and wereinternally consistent with each other were identified by adomain Cronbach’s alpha of 0.7 or greater. All dependentvariables analyzed for internal consistency by Cronbach’salpha were scored dichotomously (yes/no) or ranked on anordinal, Likert scale.

A linear regression model was used to correlate theindependent demographic predictor variables with theindividual domain scores of the practice-related, peer-related, and personal-related domains on the dependentoutcomes of satisfaction versus dissatisfaction. Regression(correlation) coefficients were then compared for statisticallysignificant differences in the impact of the predictor variableson the outcomes of satisfaction versus dissatisfaction. SASversion 9.2 (SAS, Inc., Cary, NC, USA) was used for all data

292 A.M. Afonso et al.

analysis. P-values less than or equal to 0.05 were consideredto be statistically significant.

3. Results

Of the 320 anesthesiologists surveyed, 304 surveysubjects returned completed surveys, for a survey responserate of 95%, providing the study with more than adequatestatistical power to detect associations of moderate strengthamong those completing the survey. Completed surveyswere returned either to the survey booth or to clearlyidentified survey workers. Demographic characteristics ofthe survey respondents are shown in Table 2.

The mean age of the study subjects (45.3 yrs) was similarto the mean age of the ASA membership (47.5 yrs) at thetime. Initial statistical tests showed that the only demo-graphic variable that affected the mean satisfaction scoreswas whether the anesthesiologist was practicing full-time orpart-time (F = 4.33, P = 0.039) [Table 3]. Of the 26satisfaction outcome questions, the only questions that had astatistically significant impact on the satisfaction scores wereQuestion 32, practice affected their mental health (F = 3.28,P = 0.023), and Question 36, practice affected their role as aparent (F = 2.78, P = 0.043) [Table 4].

Initial Cronbach’s alpha analyses prior to surveydistribution demonstrated strong (N 0.70) internal consisten-cy for 10 dependent outcome questions in the practice factor-related domain, 6 dependent outcome questions in the peerfactor-related domain, and 8 dependent outcome questions inthe personal factor-related domain for a total of 24 rankedsurvey outcome questions. Subsequently, the final Cron-bach’s alpha analyses, by demonstrating that those questionswere internally consistent among survey respondentsconfirmed that this part of the survey instrument wasreliable. The 24-item survey outcome questions demonstrat-ed strong internal consistency by domains on initial andsubsequent analyses by Cronbach’s alpha and validated the

Table 3 Analysis of variance of demographic data

Demographic question F-statistic P-value

Board-certified 0.31 0.5813Age 1.91 0.0941Gender 0.55 0.4588U.S. medical school 2.76 0.0984Practice type 1.55 0.2156Full-time or part-time status 4.33 0.0387 ⁎

Region of country 0.61 0.7664Hours per week 0.89 0.4737Years of experience 0.46 0.8354ASA member 0.17 0.6766Income 1.22 0.2870

⁎ P ≤ 0.05 (statistically significant difference).

findings from the focus group in measuring careersatisfaction by domains among practicing anesthesiologists.Overall, three questions in the practice factor domain thatwere not internally consistent were removed for the finalsurvey. Likewise, two questions in the initial personal factordomain that were not internally consistent were removedfrom the final survey.

The linear regression model used to predict the careersatisfaction scores, based on the independent demographicvariables as well as the three domains, was formed from the26 predictor questions. Advancing age and many otherpredictors had no impact on career satisfaction amongpracticing anesthesiologists [Table 5]. The only statisticallysignificant predictors of career satisfaction among anesthe-siologists included the following variables: 1) graduationfrom a U.S. medical school (P = 0.019); 2) full-time practiceof anesthesiology (P = 0.032); 3) early satisfaction with theprofession within the first 5 years of practice (P b 0.0001);and 4) working with respected peers (P = 0.03); andpersonal-health choice factors on career satisfaction (P =0.004) [Table 5].

The Cronbach's alpha coefficient for the personal-healthchoices domain was 0.81, reflecting high internal consisten-cy among the 8 survey questions in that domain. In themultivariate analysis of all responses to nondemographicsurvey questions, only the two questions that addressed theadverse effects of career choice on mental health (Q32) andon parenting (Q36) achieved statistically significant differ-ences from all other survey question responses. Therefore,questions addressing career impact on mental health andparenting contributed to the significant predictive capability(P = 0.004) of personal-health choice factors in theregression model to a greater extent than other domain-specific responses and should be included in job satisfactionsurveys for anesthesiologists [Table 4].

4. Discussion

This survey study was designed to examine the impact ofadvancing age and other factors related to job satisfactionamong practicing anesthesiologists attending the 2009Annual Meeting of the American Society of Anesthesiolo-gists. The study was conducted and analyzed in accordancewith the recommendations for reporting survey results [6].The demographic characteristics of the 304 survey re-sponders mirrored the demographic characteristics of theASA membership when compared with the ASA member-ship at that time with a mean age of the study subjects (45.3yrs) similar to the mean age of the ASA membership (47.5yrs). In addition, the sample gender representation in thestudy population (77.4% men) nearly matched that of theASA membership (77.6% men).

The external validity of this study was supported by thehigh survey response rate to a focus group pretested survey

Table 4 Analysis of variance of survey outcome data

Question (#) F-statistic P-value

Working as an anesthesiologist is boring (14) 1.79 0.1522Work hours (15) 0.54 0.6580Impediments to promotion (16) 0.87 0.4592Inadequate compensation (17) 0.35 0.7884Sense of competition with youngeranesthesiologists (18)

1.67 0.1749

Lack control over my schedule (19) 1.66 0.1779Professional interactions with surgeons (20) 0.95 0.4169Professional interactions with other attendinganesthesiologists (21)

1.96 0.1227

Professional interactions with house staff (22) 0.57 0.6365Adequate intellectual stimulation at work (23) 0.52 0.6679Clinical cases lack variety (24) 0.24 0.8675Being “phased out” and assigned less complexcases (25)

0.64 0.5913

Being “phased out” and assigned less operatingroom time (26)

0.52 0.6678

Feel threatened when new, young attendings jointhe service (27)

1.45 0.2299

Gained prestige over course of my career (28) 0.54 0.6551Taking call is more difficult now (29) 0.12 0.9510Have been selling calls (30) 0.56 0.4566Affected my medical health (31) 0.45 0.7144Affected my mental health (32) 3.28 0.0226 ⁎

Affected my physical health (33) 0.96 0.4121Affected having a faithful relationship (34) 2.15 0.0957Affected a relationship with a significant other (35) 1.57 0.1983Affected my role as a parent (36) 2.78 0.0427 ⁎

Excessive alcohol consumption (37) 0.48 0.6998Use of controlled substances (38) 1.17 0.3221Difficult to learn new skills or to learn to use newtechnology (39)

1.64 0.1834

Concerned with threatening malpractice arena (40) 0.66 0.5792

⁎ P ≤ 0.05 (statistically significant difference).

293Anesthesiologists' career satisfaction

(95%); the demographic consistency of the study subjectswith the general membership of the ASA; the similarity ofindependent survey responses when stratified by demo-graphics, and by the selection of the same validated practice,personnel/peer, personal/health, and financial domains asused in other survey investigations of job satisfaction amongpracticing physicians in other specialties [1-4]. Therefore,the completed and returned surveys comprised a represen-tative sample of responses from the ASA membership targetpopulation and were assumed to reflect the opinions ofpracticing anesthesiologists at large.

Advancing age and many other independent predictorshad no statistically significant impact on career satisfactionamong practicing anesthesiologists [Table 5]. The onlystatistically significant predictors of career satisfactionamong anesthesiologists included the following variables:1) graduation from a U.S. medical school (P = 0.019); 2) full-time practice of anesthesiology (P = 0.032); 3) earlysatisfaction with the profession within the first 5 years of

practice (P b 0.0001); 4) working with respected peers (P =0.03); and personal-choice factors (P = 0.004) [Table 5]. In2011, Koshy and co-investigators reported the results of asurvey study of job satisfaction and stress among Indiananesthesiologists and identified good interactions withsurgical colleagues as stress preventers; our results supportedtheir findings [7].

The results of this investigation have demonstrated thatadvancing age, gender, board certification, academic-private-government practice, region of practice, hoursworked per week, years in practice, ASA membership,and income levels had no statistically significant effect oncareer satisfaction among practicing anesthesiologistscompared to full-time practice by U.S. graduates express-ing satisfaction with their career choice in the first 5 yearsof practice. Gender and location of practice have beenshown previously not to influence job satisfaction amongpracticing anesthesiologists, and this study confirmed thosefindings [8,9].

Table 5 Linear regression model: predictors of careersatisfaction among anesthesiologists

P-value

VariableBoard-certified 0.9712Age 0.0859Gender 0.4893U.S. medical school 0.0193 ⁎

Practice type 0.4516Full-time or part-time 0.0319 ⁎

Region of the country 0.8542Hours per week 0.2500Years of experience 0.6321ASA member 0.7027Satisfaction with profession in firstfew yrs of practice

b 0.0001 ⁎

DomainIncome 0.6092Practice factor 0.5525Peer factor 0.0300 ⁎

Personal factor 0.0036 ⁎

⁎ P ≤ 0.05 (statistically significant).

294 A.M. Afonso et al.

In 2006, Fernandez Torres and co-investigators measuredpredictors for burnout among Spanish anesthesiologistsusing the Maslach Burnout Inventory, and reported nosignificant differences in burnout scores in relation to genderor region and type of practice [8]. Andrade and co-investigators also demonstrated that gender had no signifi-cant effects on the measurement of burnout and stress levelsas surrogates for job satisfaction among practicing anesthe-siologists using previously validated survey instruments [9].This study confirmed the findings of the prior investigationsthat both gender and regional location of practice had nostatistically significant impact on career satisfaction amongpracticing anesthesiologists using a survey instrumentdesigned to assess job satisfaction specifically amongpracticing anesthesiologists.

There was no intention to leave or change specialtycareers detected in this study. However, to date only oneother study has addressed early career changes amonganesthesiologists compared with other medical specialists. In1982, Seltzer and Veloski reported changes in specialtychoices among 1,151 graduates of the same medical schoolover the period 1968 - 1976 [10]. Of 31 graduates choosinganesthesiology as a career, 26 (84%) remained in anesthe-siology, and 9 changed to other medical specialties [10]. Theauthors concluded that the ability of anesthesiology to retainphysicians who originally planned to specialize in anesthe-siology, or to gain physicians who switched to anesthesiol-ogy from other specialties, was no different from that foundin the other specialties studied [10]. This survey studyconfirmed the earlier findings reported by Seltzer andVeloski [1]. Although this survey study was not designedto address specialty retention or reasons for retirement, itidentified the interactions of career and personal health-

related issues and career and parental roles as significantcontributors to career satisfaction that, if further addressed,may improve career recruitment, retention, and decisionsregarding early retirement [3-13].

The design limitations of this study, which should beaddressed in future investigations, included: 1) using a cross-sectional survey design with convenience sampling thatrelied only on self-reported data, thereby introducing thepossibility of recall bias for some survey items; 2) not using apreviously validated survey instrument of job satisfaction,such as the Maslach Burnout Inventory or the Social Supportand Personal Coping Survey; and 3) not readministering thesurvey to another different group of anesthesiologist toconfirm test-retest reliability [10-12].

In conclusion, this survey study confirmed severalfindings of previous studies of job satisfaction amonganesthesiologists using previously validated survey instru-ments [7-13]. As in a 2009 study with surveys mailed to1,208 active and retired ASA members in Northern NewEngland, this survey study found that chronological age isnot a strong correlate of an individual’s practice pattern,behavior, or performance [13]. Designed specifically foranesthesiologists, the newly designed survey tool validatedin this study also identified several other factors associatedwith career satisfaction among anesthesiologists. Full-timestatus, early satisfaction within the first 5 years of practice,working with respected peers and personal-health choicefactors were all significantly associated with anesthesiolo-gists’ job satisfaction. Job satisfaction among anesthesiolo-gists was significantly influenced by a set of factors thatcould be targeted for improvement in order to increase careersatisfaction among anesthesiologists. Further investigationsthat measure and confirm the significant predictors of jobsatisfaction among anesthesiologists using a validated surveyinstrument may increase career retention and career specialtychoice of anesthesiology by medical graduates.

Acknowledgments

The authors would like to thank Amit P. Prabhakar, BS,MS, Senior Medical Student and Research Associate,Department of Anesthesiology, Louisiana State UniversitySchool ofMedicine, NewOrleans, LA; and Patrick Torres, BS,Medical Student and Research Associate, Department ofAnesthesiology, Louisiana State University School of Medi-cine, New Orleans, for help with manuscript preparation.

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