For Peer Review Abstract Introduction Physician wellness is important for physician engagement and reduction of medical errors 1–6, impacting patient care. A recent survey showed that academic otorhinolaryngologists reported low levels of professional fulfillment and high levels of burnout 7,8. This study explores wellness factors in facial plastic and reconstructive surgery (FPRS). Objective & Hypotheses To examine factors associated with fulfillment, burnout, and intent to leave within FPRS. Study Design Cross-sectional survey Methods AAFPRS members completed an anonymous and standardized survey to assess professional fulfillment and burnout. Chi-square testing was used for data analysis. Results Among 75 respondents (5% response rate), 34% lacked professional fulfillment and 18% experienced burnout, lower than reported rates in academic otorhinolaryngology7. Lack of decision-making power in recruitment/purchasing decisions and uncompensated otolaryngology call were driving factors. Conclusion Decreased autonomy and extra-subspecialty responsibilities drive burnout, lack of fulfillment, and intent to leave and should be considered in employment arrangements. Keywords: physician wellness, burnout, professional fulfillment, intent to leave Introduction Page 2 of 13 Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA Manuscript Submitted to Facial Plastic Surgery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Physician burnout has been shown to be related to loss of physician engagement, early retirement from practice and medical errors in multiple specialties 1–6,9. Efforts being made to reduce physician burnout and improve engagement have identified several driving factors, including finding meaning in work, control and flexibility, and improving workload/job demands 5. Recent data have shown academic otolaryngologists to have a high level of physician burnout and a low level of professional fulfillment when compared to many other medical and surgical specialties despite being a competitive, diverse, and sought-after specialty7. Otolaryngology is a complex field with subspecialties that differ greatly in terms of patient population, types of intervention performed, outcomes, and resultant physician lifestyle. Because of this, we sought to analyze physician burnout, fulfillment, and intent to leave within the subspecialty of facial plastics and reconstructive surgery (FPRS). Methods This study was approved through the Weill Cornell University Institutional review board (IRB 24- 04027290). An online, anonymous 43 question survey was distributed to all 1420 practicing members of AAFPRS. Current fellows and residents were excluded. Completion was voluntary without any incentive. A solicitation email was sent followed by one reminder email. The survey collected demographic information including years in practice, employment status, practice setting and type, geographic practice location, cosmetic or reconstructive focus of practice, average hours per week spent in surgery and office hours, intent to recruit another facial plastic surgeon, burden of call (for own practice, facial trauma, and general ENT), and intent to retire in the next 15 years. included in the survey were the questions contained in the Stanford Professional Fulfillment Index (SPFI), a validated instrument used to assess burnout and professional fulfillment8. Statistical analysis of the results was performed using chi square analysis in Microsoft Excel. Results Of the 1420 members solicited to complete this survey, there were 76 surveys completed in their entirety. The responses from one of these surveys were discarded as the survey was erroneously filled out by an FPRS fellow- in-training, with 75 remaining surveys included in the analysis (response rate of 5.3%). Page 3 of 13 Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA Manuscript Submitted to Facial Plastic Surgery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Demographics: Demographic information was collected for all respondents, which included geographic distribution, years out of training, practice setting, and specialty focus (table 1, figure 1). Respondents were fairly evenly distributed geographically. Respondents in private practice settings outnumbered those in academic settings by 2 to 1 and were relatively well-distributed in time practicing medicine (0-5 years through >25 years). The most common self-described practice focuses were “aging face/rhinoplasty/nonsurgical rejuvenation” (40%) and “50:50 cosmetic and reconstruction mix” (31%) (figure 1). Professional fulfillment and burnout: 34% of respondents reported a lack of professional fulfillment and 18% of respondents reported burnout. There was a strong association between lack of fulfillment and burnout, with respondents who reported lack of fulfilment also reporting higher levels of burnout (p=0.0004). Younger physicians (=< 15 years in practice) were less likely to feel professional fulfillment (p= 0.039) but did not have statistically higher rates of burnout (table 2). Practice setting (all subcategories) had an association with lack of professional fulfillment (p=0.006) (table 2). When this was analyzed again only within private practice setting (practice solo owner vs private practice partner vs private practice employee), a stronger association was correlated with being an employee and having lack of professional fulfillment (p=0.0008) (table 2). Lack of decision-making power in both purchasing and recruitment decisions was associated with lack of professional fulfillment (p=0.002, p=0.007), but there was no association with burnout (table 2). Lastly, taking general otolaryngology call was also associated with both burnout (p=0.011) and lack of professional fulfillment (p=0.029) (table 2). These associations did not reach statistical significance if the respondent was compensated for otolaryngology call responsibilities (table 3). Taking call for facial trauma or for one’s own practice was not associated with either lack of professional fulfillment or burnout (table 3). Intent to leave: Page 4 of 13 Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA Manuscript Submitted to Facial Plastic Surgery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review A similar analysis was performed to identify factors contributing to increased likelihood of leaving practice within either two or five years. Lack of professional fulfillment was associated with higher intent to leave within 2 years (p=0.007) and 5 years (p=0.014). Burnout was associated with intent to leave within two years (p=0.01), but it was not associated with intent to leave within 5 years (table 4). When analyzing members within a private practice subtype, it was found that there is an association with intent to leave within two and five years (p=0.026, p=0.01) with employees having a higher-than-expected intent to leave compared to partners or owners (table 4). This is also seen when analyzing decision-making power, where those without purchasing (p=0.04, at 5 years) or recruitment decision-making power (p=0.004 at 2 years, 0.017 at 5 years) are associated with a higher intent to leave (table 4). Taking otolaryngology call was associated with intent to leave within five years (p=0.005); this was not true if otolaryngology call was compensated, for trauma call, and for call for one’s own practice (tables 3, 4). Other factors: Table 3 shows the other factors analyzed in this study which were not associated with either lack of fulfillment, burnout, or intent to leave. Notably, practice focus, practice setting (academic vs private practice), and geographic regions were not found to have any association with the analyzed outcomes. Work conditions including hours worked, having support in the clinic or in the OR setting, or having nonclinical duties were not associated with intent to leave, burnout, or lack of professional fulfillment. As noted above, taking call for one’s own practice or taking call for facial trauma were not found to have any association. Discussion Physician burnout is of interest in the medical community given its association to physician retention, well- being, and ultimately, patient care. Otolaryngology, despite the perception that among surgical specialties, it is considered more of a “lifestyle friendly” specialty, has been shown to have high burnout and low fulfillment within academic medicine compared to other specialties7. Our study, the first to analyze these factors within the subspecialty of FPRS in both private practice and academic medicine, Page 5 of 13 Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA Manuscript Submitted to Facial Plastic Surgery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review found FPRS fares better than academic otolaryngology in both fulfillment (66% vs 38.5%) and burnout (18% vs 45.2%) 7. Our analysis revealed that low fulfillment and high burnout are linked to intent to leave. Notably, autonomy was a key overarching factor associated with these outcomes. Being required to take call outside one's subspecialty (general otolaryngology call) and limited decision-making power were significantly linked to burnout, low fulfillment, and intent to leave. Junior faculty in private practice were particularly vulnerable due to high otolaryngology call burdens and minimal autonomy. Some of these effects can be mitigated by appropriately compensating physicians for otolaryngology call. Our study confirmed this trend which was also reported in previous literature1–6. This lack of autonomy and desire for change is also seen on a more global level throughout medicine with increasing desire for physician unionization, which may continue increasing especially in the setting of increased private equity influences within medical practices10. A limitation to consider is that our study’s response rate was only 5%. While low, it should be noted that 75 completed surveys were analyzed. While a reminder email was sent to increase response rate, the recipients had no incentive to complete the survey. Even with the low response rate, this is the first survey to our knowledge to assess physician satisfaction and burnout specifically within FPRS, and so, the results hold value. As with all survey studies, a self-selection bias may have been introduced, as individuals who are highly dissatisfied with their jobs may be more likely to be motivated to voice their concerns and participate in a survey, while those who are satisfied may be less likely to take the time to complete it. This potential for selection bias suggests that the survey may be underreporting true physician satisfaction within FRPS. While this study has limitations, it offers valuable insights into factors affecting physician well-being and suggests strategies to mitigate burnout. Addressing autonomy concerns, such as call schedules and decision-making roles, may be crucial for improving physician satisfaction and retention within private and academic practices. Further research with improved response rates and potentially incorporating incentives for participation is warranted to better understand the factors influencing physician satisfaction Page 6 of 13 Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA Manuscript Submitted to Facial Plastic Surgery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review and burnout within FPRS. Further studies are also needed to analyze this trend within other subspecialties within otolaryngology as well as general otolaryngology practice. Acknowledgments: None Conflict of Interest: No conflict of interest to disclose Figure and Table Legends Figure 1: Specialty focus among the participants Table 1: Demographics of respondents Table 2: Factors associated with lack of professional fulfillment and burnout, NS: not significant Table 3: Factors not associated with lack of professional fulfillment, burnout, or intent to leave in two or five years Table 4: Tactors associated with intent to leave within two or five years, NS: not significant Page 7 of 13 Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA Manuscript Submitted to Facial Plastic Surgery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 1. Dawkins C, Burdess A. Burnout in surgeons: a ticking time bomb? Surgery (Oxford). 2020;38(10):659-663. doi:10.1016/j.mpsur.2020.07.011 2. Golub JS, Johns MM. From Burnout to Wellness: A Professional Imperative. Otolaryngol Head Neck Surg. 2018;158(6):967-969. doi:10.1177/0194599818764630 3. Haas JS, Cook EF, Puopolo AL, Burstin HR, Cleary PD, Brennan TA. Is the Professional Satisfaction of General Internists Associated with Patient Satisfaction? J Gen Intern Med. 2000;15(2):122- 128. doi:10.1046/j.1525-1497.2000.02219.x 4. Fred HL, Scheid MS. Physician Burnout: Causes, Consequences, and (?) Cures. Tex Heart Inst J. 2018;45(4):198-202. doi:10.14503/THIJ-18-6842 5. Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017;92(1):129-146. doi:10.1016/j.mayocp.2016.10.004 6. Satiani B, Way DP, Ellison EC. Understanding and Optimizing Physician Engagement. Journal of the American College of Surgeons. 2022;234(2):227. doi:10.1016/j.jamcollsurg.2021.09.013 7. Ligibel JA, Goularte N, Berliner JI, et al. Well-Being Parameters and Intention to Leave Current Institution Among Academic Physicians. JAMA Network Open. 2023;6(12):e2347894. doi:10.1001/jamanetworkopen.2023.47894 8. Vetter M, Vetter M, Cohn D, Yeager K, Fowler J. Utility of the Stanford Professional Fulfillment Index as a single survey instrument to assess holistic physician wellbeing. Gynecologic Oncology. 2021;162:S327-S328. doi:10.1016/S0090-8258(21)01272-5 9. Scott G, Hogden A, Taylor R, Mauldon E. Exploring the impact of employee engagement and patient safety. Int J Qual Health Care. 2022;34(3):mzac059. doi:10.1093/intqhc/mzac059 10. Rooke-Ley H, Richman B, Bowling DS, Nikolov M, Schulman K. Unionization Efforts by Physicians Between 2000 and 2024. JAMA. Published online December 18, 2024. doi:10.1001/jama.2024.23721 Page 8 of 13 Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA Manuscript Submitted to Facial Plastic Surgery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Factors Contributing to Burnout and Professional Fulfillment among AAFPRS Members Margareta Morrissette, MD1, Alexandra Michalowski, MD1, Anthony P Sclafani, MD, MBA, FACS1 1Department of Otolaryngology-Head & Neck Surgery, Weill Cornell Medical College, New York, NY USA No financial disclosures. Conflict of Interest: None Correspondence: Anthony P Sclafani, MD, MBA, FACS Department of Otolaryngology-Head & Neck Surgery Weill Cornell Medical Center 1305 York Avenue, Y-511 NY, NY 10021 Telephone: 646-962-2285 Fax: 646-962-0100 Email: ans9243@med.cornell.edu Page 9 of 13 Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA Manuscript Submitted to Facial Plastic Surgery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 mailto:ans9243@med.cornell.edu For Peer Review 305x176mm (96 x 96 DPI) Page 10 of 13 Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA Manuscript Submitted to Facial Plastic Surgery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Characteristic Category/Subgroup Percentage of Respondents Geographic Region Northeast (ME, NH, VT, MA, RI, CT, NY, PR, USVI) 20% Mid-Atlantic (PA, NJ, DE, MD, WV, VA, DC) 8% Southeast (KY, TN, NC, SC, GA, FL, AL, MS) 22% Southwest (AR, LA, OK, TX, NM) 11% Mountain-Plains (MT, WY, UT, CO, KS, MO) 8% West (AK, HI, AZ, CA, NV, ID, OR, WA) 20% Midwest (ND, SD, NE, MN, IA, WI, IL, MI, IN, OH) 12% Type of area of practice Urban 47% Suburban 48% Rural 5% Years in practice <5 years 20% 5-15 years 32% 16-25 years 21% 25+ years 27% Primary practice setting Academic practice (associate professor or higher rank) 23% Academic practice (Asst professor level) 11% Private (co-) owner/partner 11% Private practice- employed 20% Private practice sole owner 36% Table 1: Demographics of respondents Page 11 of 13 Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA Manuscript Submitted to Facial Plastic Surgery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Factor Association with Lack of Professional Fulfillment Burnout P value Practice Setting and Type Setting: Any 0.006 NS Private practice subtypes 0.0008 NS Years after fellowship (<=15 years) 0.039 NS Work Conditions Lack of Purchasing Decision-Making 0.002 NS Lack of Recruiting Decision-Making 0.007 NS Call responsibilities Otolaryngology call 0.029 0.011 Table 2: Factors associated with lack of professional fulfillment or burnout, NS: not significant Page 12 of 13 Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA Manuscript Submitted to Facial Plastic Surgery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Factors Not Associated with Lack of Professional Fulfillment, Burnout or Intent to Leave in 2/5 Years Practice Setting and Type Practice type (cosmetic vs reconstructive vs mixed) Setting: Academic (by levels), Setting: Academic vs Private Practice Geographic Region Urban, Suburban or Rural Work Conditions Hours worked/week NP/PA support in office Resident/fellow support in OR Non-Clinical Duties for Revenue Call Responsibilities Own Practice call Otolaryngology call with compensation Facial Trauma call Facial Trauma call with compensation Table 3: Factors not associated with lack of professional fulfillment, burnout, or intent to leave in two or five years Page 13 of 13 Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA Manuscript Submitted to Facial Plastic Surgery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Factor Association with Intent to Leave within 2 years Intent to Leave within 5 years P value Lack of Professional Fulfillment 0.007 0.014 Burnout 0.01 NS Practice Setting and Type Private practice subtypes 0.026 0.01 Years after fellowship NS 0.0045 Work Conditions Lack of Purchasing Decision-Making NS 0.041 Lack of Recruiting Decision-Making 0.004 0.017 Call Responsibilities Otolaryngology call NS 0.005 Table 4: Factors associated with intent to leave within two or five years, NS: not significant Page 14 of 13 Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA Manuscript Submitted to Facial Plastic Surgery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60