Survey Highlights Surgeon Compensation, APPs, Diversity, and Other Issues

The Annual Board of Governors Survey was developed to collect demographics, patterns, opinions, and data across the spectrum of issues facing the practicing surgeon. Initiated almost a decade ago, this survey has provided ACS leaders’ perspectives on a variety of topics with the goal of translating the data into action across the College.

In 2022, the survey was expanded to include the Advisory Councils, Resident and Associate Society leaders, Young Fellows Association leaders, and various committee and workgroup leaders to better inform, and more importantly, reflect the changing demographics of ACS leadership.

Renamed the ACS Leadership Survey, the 2022 version of this assessment tool was distributed to 743 volunteer leaders and received a 63% response rate (470 responses); 70% of the respondents were male and primarily from the US (87%). The average age for an ACS leader respondent was 55.

While this response rate is considered high for most surveys, it was much lower than recent surveys sent exclusively to ACS Governors, which generally averaged a 94% to 96% response rate. While a 63% response rate falls short of the target, College leadership expects more robust participation in the survey in the future as its value continues to be promoted to membership.

The 2022 ACS Leadership Survey collected demographics and feedback on the following:

• Advanced practice providers (APPs)a
• Compensation
• Diversity, equity, and inclusion (DEI)
• Leadership communications
• Surgical volunteerism
• Wellness

Practice Setting

Trends seen in recent ACS Governors’ surveys also were reflected in the 2022 survey, such as the move from private practice into larger group practices. For example, more than 70% of respondents are in an employed practice model and most (64%) work in a university or academic medical center (see Figure 1). A total of 55% are employed in a surgical or private practice multispecialty group practice with five or more surgeons. Approximately two out of three respondents (65%) self-identify as white and are general surgeons. While these employment trends are reflective of recent studies, such as the 2022 Association of American Medical Colleges Physician Specialty Data Report, a more heterogenous sample may provide different perspectives on key issues facing the House of Surgery.

Leadership Communications Assessment

The survey inquired about the use of, and satisfaction with, communication efforts from the College. Respondents overwhelmingly chose email as the most used (95%) and preferred communication format (89%). Most respondents (53%) prefer weekly communication from the ACS. Information on clinical practice or consensus recommendations on surgery from the ACS were the most popular topic areas (69%).

Specific types of content also were more highly valued based on practice setting. For example, employed surgeons expressed more interest in receiving status reports on key ACS programs, services, or initiatives, while those in private practice ranked receiving updates on ACS political, legislative, or regulatory activities as more important.

Regarding which ACS programs, services, or communication vehicles were used or accessed by the respondents, the ACS website (78%), the Journal of the American College of Surgeons (JACS) (77%), and the ACS Bulletin (75%) were the top ranked. Satisfaction with  ACS resources was highest for the Surgical Education and Self-Assessment Program (SESAP^®) with 98% “extremely” or “somewhat satisfied.”

Although there were some slight differences in satisfaction scores among age groups, high satisfaction scores (more than 90%) were received for the following: Surgical Readings from SRGS podcast; the Optimal Resources for Quality and Safety also known as the (“Red Book”); ACS SurgeonsVoice; JACS; the ACS Bulletin; Optimal Resources for Surgical Education and Training; and topic-specific videos.

APPs

Because APPs are an important component of the global delivery of healthcare, and multiple programs have been developed to train and graduate APPs, the survey inquired about the use of, and attitudes toward APPs (see Figure 2).

Most respondents (78%) indicated they use APPs—primarily nurse practitioners and physician assistants—in their organizations/ practices, and almost all respondents (95%) were “extremely satisfied” or “somewhat satisfied” with the performance of APPs. APPs are primarily used in postoperative care (94%), preoperative care (86%), and patient and family communication (77%).

APPs allow for an increase in patient capacity (67%) and provide more time for surgeons to focus on acute patients (66%). 70% of private practice surgeons and 28% of employed surgeons use APPs as surgical assistants. Employed surgeons (70%) found more value in using APPs to allow residents to comply with duty hours than private practice surgeons (38%). All practice types observed that APPs provided improved communication and enhanced patient/family experience, increased access to patients, and improved work/life integration.

Among the 17% of respondents who do not use APPs, 26% indicated APPs take time away from residents. Other reasons for not using APPs included respondents deeming them unnecessary, lack of hospital support, and difficulty with the availability of APPs in certain geographic areas. Most of these respondents were in private practice.

Although 74% of respondents were “extremely satisfied” or “somewhat satisfied” with the competency of APP program graduates entering surgical practice, 69% believe APPs should be required to complete a clinical internship or training period following graduation and before clinical practice. 66% of respondents said they believe it is “extremely” or “very important” for the ACS to be involved in establishing requirements for APP training, and approximately 59% of respondents indicated it is “important” for the ACS to be involved in verifying APP training programs.

Surgical Volunteerism

Surgical volunteerism has become an increasingly popular experience for surgeons. More than half of the respondents have been involved in surgical volunteerism and 94% found it “satisfying.” Slightly more men (56%) than women (44%) have participated in surgical volunteerism.

83% reported an experience lasting 2 weeks or less. 69% of respondents who have not participated in volunteerism efforts ranked extended time away as the primary barrier. Locations in the US and Africa have been the most popular for surgical volunteerism, although opportunities in the Caribbean and Central and South America also were identified.

Residency applicants are increasingly expressing an interest in surgical volunteerism as they choose surgery and specific training programs but only 24% indicated that formal electives are offered by organizations and/or practices. An opportunity exists for the ACS to further help incorporate surgical volunteerism into training programs and practices, especially if further data delineate its impact on increased resiliency and reduced burnout. Supporting time away for surgical volunteerism also could be a model for surgeons who may need to temporarily stop and/or start active practice, such as for health or family reasons.

Operation Giving Back (OGB) is a valuable and well-known member resource with only 27% of the respondents indicating they were unaware of the program. 40% of respondents who have not yet participated in OGB indicated they were interested in participating in the future. 

DEI

The ACS Leadership Survey included questions concerning DEI-related experiences of members and the respective organizations where they practice. Most respondents (81%) incorporate DEI programmatic information into regularly scheduled meetings, such as morbidity and mortality conferences, and these leaders also indicated that they recognize the value of social determinants of health in improving the care of surgical patients.

Although 60% of respondents have a designated DEI officer/ombudsman at their organization/ practice, this was not as prevalent in countries outside of the US. Similarly, 63% of US respondents worked at places with formal DEI training sessions compared with only 14% in other countries.

The availability of anonymous reporting systems for DEI concerns also was more prevalent in the US, with 51% able to anonymously report and only 8% in other countries. Of note, only 32% of surgeons underrepresented in medicine (URiM) reported the availability of anonymous reporting systems compared with 53% of White surgeons.

41% of respondents were required to complete DEI education when they began employment. Of these respondents, 82% were required to use online self-directed modules and 48% were required to engage in in-person training. (The survey did not include questions on the length, content, and structure of the in-person training.) 30% were provided or recommended DEI-related reading materials. Only 15% were required to participate in national training efforts.

Fewer respondents suggested that their organization/practice has demonstrated intentionality to promote URiM faculty to leadership positions (28%). Of these respondents, there was a significant difference between URiM surgeons (21%) and White surgeons (30%). Only 20% reported that their organization/practice has a transparent faculty salary reporting system, and the same number reported “a transparent model for achieving pay parity/equity.”

Wellness

Although 66% of respondents reported their organization/ practice offered programs for wellness, work-life balance, or resiliency, these programs were more prevalent in the US (72%) compared with other countries (25%) (see Figure 3). Similarly, while most (60%) had access to confidential resources for surgeons/staff experiencing stress or burnout, this access was higher in the US (66%) compared with other countries (23%). Family or parental leave was available for 53% of respondents, while only 8% reported the availability of elder care leave. Even fewer had access to daily childcare (12%) and emergency childcare (7%).

While 57% indicated they “somewhat” or “strongly” agreed that they have adequate time for rest, only 42% “somewhat” or “strongly” agreed they had adequate time to complete administrative work. More than half (54%) of surgeons in countries outside the US had adequate time for administrative work compared with only 39% in the US. Although surgeons indicated high levels of administrative burden, 76% indicated patient needs were still adequately covered when surgeons took time off. More women (42%) than men (24%) reported they had an insufficient amount of time off for rest.

Compensation

75% responded that some form of salary is a consideration included in compensation agreements (see Figure 4). 44% reported relative value unit (RVU)-based or other volume-based compensation is included in their compensation agreements, and 41% reported a productivity bonus. 41% indicated that administrative responsibilities are a consideration when negotiating compensation, and 31% also included contributions to the individual’s educational mission as a key driver.

Fewer respondents reported the inclusion of the following in compensation agreements: research grants (21%); patient experience measures (19%); quality/outcomes measures (14%); stipends or honoraria (14%); other administrative or contractual revenue (12%); profit-sharing or other practice investment earnings (8%); and DEI metrics (2%). Profit-sharing or other practice investment earning was higher ranked by private practice surgeons (83%) compared with employed surgeons (19%). More US surgeons (67%) ranked administrative responsibilities within institutions such as committee work and departmental leadership higher than surgeons in other countries (40%).

These data provide a basis for discussion and growth opportunities within the College, such as continued focus on work-life balance, improved compensation models, and increased surgical volunteerism opportunities to improve resiliency. Leaders working with DEI-related initiatives will be able to use these data to better address the gaps that members are encountering in their institutions.

As the College continues to enhance its day-to-day relevance to both members and surgical patients, it will continue to use data-driven approaches to communicate opportunities more effectively. Future ACS Leadership Surveys will focus on programs and efforts related to the College’s mission to safeguard standards of care in an optimal and ethical practice environment. 

Dr. Danielle Katz is an associate professor of orthopaedic surgery and associate dean of graduate medical education at the State University of New York Upstate Medical University in Syracuse. She also is Chair of the ACS Board of Governors Survey Workgroup.

Commentary

The 2022 ACS Leadership Survey: Encouraged and Disappointed

I hope you found this article insightful and informative. I did. Many of the points are key for informed action:

• Email remains the best way to communicate timely updates.
• Only 1 in 5 of us is not dependent on advanced practice providers to function.
• Barely 50% of us have the opportunity to report DEI problems anonymously.
• Compensation for the majority remains productivity based, regardless of the many additional responsibilities and tasks allocated.
• And perhaps, most strikingly, the lack of comprehensive family and parental leave and childcare policies, as well their enforcement continues to push the idea of work-life balance in the wrong direction.

The 2022 ACS Leadership Survey provides a great deal of raw data to inform and explain who we are and what we do as surgeons. As with any survey, it can only reflect those included, but our hope is that this sample becomes a more accurate representation of real practice.

The survey also enforces the importance and value of active participation in the ACS. As a leader, you are a representative of your chapter, specialty society, workgroup, or committee. As a member, you must demand from your leadership an active and accurate voice on the issues facing each one of us today.