This article is intended for surgeons and surgical trainees, but has broad applicability to anyone with an affiliation to health care, with particular relevance to those who train residents and/or hold leadership positions. After reading the article, surgeons will be able to:
“[The] dichotomy between work and life leads us down a self-destructive path filled with frustration and disappointment...In contrast, integration...creates a positive and constructive attitude towards both of these entities.”1 ~ Andreas Schwingshackl, MD, PhD
The notion of work-life balance was introduced into the American workforce in the 1980s. However, many argue the term creates an illusory goal that can never be achieved.2–4 Given the imbalance of hours surgeons spend at the hospital relative to waking hours at home, it is not surprising that many surgeons strive for work-life integration over work-life balance.5–7 (See Figure 1.) Efforts in work-life integration likely hold benefits for the health, wellbeing, and longevity of the surgical workforce. While Shanafelt et al. did not use the term “work-life integration,” they found that among surgeons who prioritized “incorporating a philosophy stressing work-life balance,” the prevalence of burnout was 40 percent less than among those who did not.8
Figure 1. Work-life balance vs integration. Adapted from the Berkeley Haas Department of Human Resources.9
Prior to the advent of integrated electronic medical records, the one way to “check” on a patient was to visit the patient’s bedside. At that time, notes were illegible acronyms scrawled onto a paper chart, and urgent laboratory and radiology results were seen by walking to those departments. Today, many tasks of monitoring can be accomplished remotely. Surgeons need only look to their smartphones to review real time vital signs, lab results, and the latest consultant’s updates. Notes can be entered in real time, or hours later. This technology may lead to patient monitoring and documentation duties being carried out while simultaneously doing “life” things, such as eating, exercising, laundry, and spending time with family and friends.
Technology also allows the accomplishment of “life” tasks while at work. With little more than a glance at a smartphone, one can check in with loved ones; catch up on friends’ vacations; and finish holiday shopping—all between cases, while walking to the elevator, or when a meeting isn’t holding one’s attention. Video calls allow clinicians to be in two places at once—enabling parents on night call to “tuck” their children in, or friends to join in singing happy birthday when missing a party. Even life tasks such as paying bills, scheduling babysitters, house cleaning, lawn care, and booking dinner reservations and haircuts can be readily accomplished at work while multitasking between cases.
It should be noted that these technologies are not without downsides. The administrative burden and reduced patient face time associated with EHRs has been linked to physician dissatisfaction and burnout.10 Fortunately, increased documentation support and shared documentation and order entry have been shown to increase time spent with patients and improve provider satisfaction.11 Unfortunately the negative impact of EHR and potential ameliorating interventions are beyond the scope of this article. Furthermore the use of social media has been linked to increased mental illness among young adults. While the mental health effects of professional social media use by adults has not been studied, the potential mental health impact of extensive engagement with social media should be considered.
While such integration of “work” and “life” is becoming increasingly possible, historical attitudes and unconscious bias related to discussion of “life” at “work” can prevent residents from feeling supported in establishing healthy integration. This excerpt from a 1998 article titled “Toward a Better Residency,” is illustrative:
“A culture within the program in which family life and recreation time are ridiculed or demeaned is inappropriate. Young surgeons should not be taught by their faculty and role models through innuendo and example to ignore their families.”12
Certainly the bar today is much higher than simply the absence of ridicule and disdain toward references to life outside of the hospital. Still, it is not unheard of for residents to be told to refrain from discussing their children at work or for residents in same-sex partnerships to be uncertain whether they are safe bringing their partner to departmental events. Further culture change towards a more inclusive work environment will facilitate work-life integration for surgeons of all backgrounds.
Perhaps nowhere is work-life integration more apparent than on social media. Twitter bios include clinical positions, research interests, family roles, hobbies, and sports team preferences. Photos of the #ILookLikeASurgeon social media movement highlight surgeons as “whole” people, capturing moments both inside and outside of the operating room. Photos tagged with #SelfCare acknowledge the demands of the profession and the need to reenergize and recoup. The #SurgParenting hashtag used for endearing photos and quotes about life as a surgeon parent exemplifies the fusion of dual identities. Started by surgery resident Luke Selby, MD, the hashtag is equally popular among men and women surgeons. Through the public nature of these images and conversations, work-life integration in surgery is normalized. (See Figure 2 for examples.)
While surgeons have a duty to monitor their digital footprint and social media presence, this professional duty should not be interpreted as needing to post personal content on social media.13 Individuals have varying comfort levels with sharing personal and family photos and posts. Furthermore, while available data suggest the risks of such posts are low, safety is not guaranteed.14
Figure 2. Examples of tweets modeling work-life integration.
After a long week in the OR getting outside reinvigorates me! #ILookLikeASurgeon #SelfCare pic.twitter.com/FtWHKrTr5b
The best day of my life!! Welcome Olivia Elmira Pedraza!! #ILookLikeASurgeon #ILookLikeADadToo pic.twitter.com/eWgIR8MIxE
Department chairs, program directors, and faculty are role models whose actions and inactions set the culture. Indeed, leadership qualities of department chairs have been shown to correlate with faculty burnout.15 There are myriad ways for faculty to acknowledge the existence of a personal life that supports their life’s work. For example, at surgical conferences, presenters may close their presentations with a photo of their children, beloved pet, or image of themselves engaged in a favorite pastime. Attending surgeons overheard discussing hobbies, self-care, challenges with family, or recent accomplishments outside of surgery promote a culture of acceptance of work-life integration. National leaders in surgery also play a role in influencing the surgical culture by presenting at conferences, setting societal priorities, and posting on social media.
Conversations on work-life integration have traditionally emphasized challenges faced by women surgeons presumed to be mothers. This notion is outdated on many levels. The reality is that only 59 percent of female surgeons have children, while 92 percent of their male colleagues are dads.16 Furthermore, “family” means something different to every individual: a married, heterosexual nuclear family should never be assumed. Couples of all sexual orientations may be married or cohabiting. Surgeons may become parents with or without a partner. Single and childfree surgeons may use “family” to refer to their family of origin or the created kinship of a “chosen family.” Surgeon households may include roommates, pets, extended family, and aging parents. Acknowledging the diversity of family structures validates the importance of family for all surgeons.
While technology and professional expectations of surgeons have negated the physical separation of “work” and “life,” work-life integration does not preclude healthy boundaries or spending time fully engaged in work duties and other life activities. Certainly, complete focus is absolutely necessary when operating, seeing patients in clinic, consulting for other services, and leading family meetings. Similarly, there are moments of personal and family life that require exclusive attention. The amount of “work-free” time needed for self-care and family commitments varies by individual. Being mindful of the stresses of attending to work duties when not at the hospital can be useful in determining individual needs for “work-free” time.
Additionally, work-life integration should not be interpreted to mean surgeons should always be working. Indeed the authors hope advances in team-based care and improved patient handoffs will serve to increase surgeons’ comfort with signing off from patient care duties upon leaving the hospital or embarking on a vacation. Ideally, all work activities conducted at home are performed out of surgeon’s preference and expected benefit rather than fears for patient safety or stress-related anxiety.
The high prevalence of burnout and attrition in surgery combined with the logistical and emotional challenges unique to training make a compelling case that acquisition of skills and strategies for work-life integration must begin in residency.17–19 Putting life on hold is not an effective strategy. The reasons to support work-life integration are manifold. First, it is an investment in patient safety; burnout and depression have been linked to medical errors among surgeons and provision of suboptimal care by residents.20,21 Second, students’ perception of the feasibility of work-life integration likely impact their choice of specialty; in order to recruit a diverse surgical workforce and avoid losing candidates to other specialties, work-life integration must be viewed as a reasonable goal for surgeons. For these reasons, promotion of work-life integration affects not only the experience of surgeons today; it also impacts the surgeons of tomorrow.
The concept of work-life integration acknowledges there is no perfect balance to be achieved between “work” and “life.” In order to be successful most surgeons find themselves accomplishing some work tasks at home and tending to some life responsibilities while at work (i.e., work-life integration). Technologies such as EMR and smart phones facilitate much of this integration. Images shared through social media, role modeling by surgeon leaders, and inclusive definitions of family all serve to foster healthy work-life integration.
The benefits of work-life integration over work-life balance are manifold. Rather than filtering essential parts of one’s “life” identity when at “work,” work-life integration allow us to come to work whole.