Materials and Methods: We conducted a 59-item web-based survey questioning respondents institutional background, history of training, continuing education status/research activities, physical conditions, professional well-being, and job satisfaction level. Likert-type and open/ close ended questions were asked and scored. The participants were also asked to complete the Minnesota Satisfaction Questionnaire-Short Form.
Results: Of the 321 respondents, 75% were female, the median age was 41 years (range 28-71 years), experience as a pathologist ranged between 0.12 and 44 years (mean 11.4±9.16 years). Academic pathologists, senior pathologists with ≥20 years of experience, and pathologists working at large institutions and living in developed cities expressed better physical conditions, higher satisfaction with working conditions and, therefore, higher overall job satisfaction (p<0.05). 98% agreed that pathologists have a critical impact on patient management; however, the majority (>80%) thought that patients barely know what pathologists do and other physicians rarely understand the difficulty and limitations in pathology practice. 82% were happy to have chosen pathology but 45% reported to experience the feeling of being burnt out.
Conclusions: Our findings suggest that younger pathologists are less satisfied with their jobs and a surgical pathologists job satisfaction increases with the physical and technical quality of the pathology laboratory/institution, and years of experience. Pathologists seem to be aware of their important role in patient management although they think that pathology remains invisible to many physicians and patients.
Locke has described job satisfaction as a pleasurable or positive emotional state resulting from ones job experiences and claimed that it is determined by the discrepancy between what one wants and gets in a job [2]. While job satisfaction directly affects ones motivation and workplace performance, it would be unrealistic to consider that every individual has the same expectations in professional life since not every person is at the same level according to Maslows hierarchy of needs [3]. However, it is also true that a job must offer some basic qualities at least to fulfill certain needs of an individual.
To the best of our knowledge, there are only a few studies on the job satisfaction of surgical pathologists [4-6], some of which focus on the residency period [7,8]. In this study, we aimed to evaluate the job satisfaction levels of pathologists in Turkey and their perspective on pathology.
Sorting Data
Respondents were grouped based on their age, gender,
experience as a pathologist, the size and experience of their
laboratories, and the type of the hospital they worked/
trained at. Institutions with an actively working pathology
laboratory for >20 years were considered experienced.
The experience of the respondents was also grouped: 1)
0-2 years, 2) 3-10 years, 3) 11-19 years and 4) ≥ 20 years.
Institutions with a total biopsy number of >40.000 were
considered large (1-20.000 biopsies: small; 20.001-40.000:
medium-sized). The provincial development level, i.e.,
the level of socio-economic development in a residential
area/city, was grouped per the data provided by Ministry
of Development [14]. Mean scores were calculated for
Likert-type questions (including MSQ). A cut-off level of
3.5 points was determined as the mean dimension score
based on previous studies [15]. Likert-type questions
and the answer scores (between 1 and 5 points) were also
directly correlated with other variables while evaluating
job satisfaction and perception of pathology. The outcome
variables were converted into dichotomous variables for
statistical analyses. Similar answers for partial/complete
open-ended questions were grouped in the same category
for homogeneity.
Based on our initial findings, we divided the respondents into four groups to compare the variables: 1) non-academic junior, 2) academic junior, 3) non-academic senior, and 4) academic senior. 40 years of age was determined as the cut-off for seniority (≥40 years) [16]. Pathologists with an academic title were included in the academic groups. All parameters were also compared between the geographical regions of Turkey.
Statistical Analysis
Statistical analysis was performed using the SPSS version
20.0 (SPSS Inc. Chicago, IL) software. Mean and/or median
values were presented as mean±standard deviation (SD)
and/or median (interquartile range [IQR]). Frequencies
were compared via the chi-square test. Mean scores
were calculated for Likert-type questions and compared
using non-parametric tests based on the results of the
homogeneity analyses demonstrating that the data did
not show a normal distribution. Two independent groups
were compared using the Mann-Whitney U test, as the
Kruskal-Wallis test was used to compare >2 independent
groups. The Dunn test was performed as a post-hoc test to
further analyze the results of the Kruskal-Wallis test and to
better demonstrate the significant differences between the
subgroups. A value of p<0.05 (two-sided) was considered
statistically significant.
Table I: Demographic characteristics and institutional background of the respondents.
History of Training
Pathology was not the first specialty choice of 70% (n=225),
and 66% (n=213) did not have adequate information
about routine pathology practice when they graduated
from medical school. Most of the participants (73%;
n=235) had been trained at a university hospital; however,
barely more than half (52%; n=167) stated that they were
confident about their knowledge and skills on pathology
when they completed their residency period. Molecular
pathology, administration/management strategies, and
laboratory techniques seemed to be the weakest aspects of the residency programs (Supplement 1). Moreover, 21%
(n=67) reported a fear of responsibility/lack of confidence
to sign-out cases when they first started practicing, as 21%
(n=66) reported inexperience/lack of knowledge on several
topics of pathology, 20% (n=63) inexperience in laboratory
management, and 14% (n=46) lack of knowledge on
laboratory techniques. Remarkably, 11 of the 63 respondents
who reported inexperience in laboratory management had
to establish the laboratory themselves as they were assigned
to hospitals without a pathology laboratory while 6%
(n=18) complained about worse laboratory conditions than
they were used to.
The respondents that had been trained at a university hospital were more satisfied with their training (p<0.001). Interestingly, male participants were more satisfied with their training (p=0.031). Training satisfaction scores of academic and senior pathologists were significantly higher (p<0.001).
Workplace Physical Conditions (WPC)
While almost two thirds (65%; n=208) appeared to be
satisfied with their routine tissue processing and staining
procedures, barely half (49%; n=157) thought that the
technical and physical background of their laboratory
was satisfactory despite the presence of automated tissue
processing and/or staining systems and experienced
technical staff in many laboratories (Supplement 2). The
vast majority (88%; n=285) stated that turn-around times
for sign-out had been determined and written in the test
guidelines. Incomplete clinical information was considered
the most significant factor interfering with turnaround time,
followed by ancillary tests such as immunohistochemistry
etc. (Supplement 3). Unfortunately, 22% (n=70) reported a
verbal disagreement with a patient or patients next of kin,
and 2% (n=6) reported physical abuse mainly regarding
turn-around time, payments for the ancillary tests, or a
diagnosis of malignancy.
Academic pathologists and senior pathologists with ≥20 years of experience working at larger laboratories were significantly more satisfied with their WPC (p<0.001 and p=0.019). Respondents who worked at large or experienced institutions also had better technical background and physical condition satisfaction levels, and they stated to be working with more experienced staff/technicians (p<0.001). WPC satisfaction level, technical background scores, and the quality of the staff/technicians were also significantly associated with the level of provincial development of the city the respondents lived in (p<0.001).
Continuing Education Status/Research Activities
Getting a second opinion (consultation)
Of the 321 respondents, 65% (n=210) reported that they
did not subspecialize on certain fields. While the majority
(93%; n=298) consulted the cases intradepartmentally,
hematolymphoid pathology (33%, n=105) was the most
frequent subspecialty creating a need for a second opinion,
followed by dermatopathology including tumoral lesions
(16%, n=51) and soft tissue/bone pathology (13%, n=42).
Attendance at scientific meetings
Almost half (47%; n=151) stated that no clinicopathologic
meeting was being held at their institutions. Only 5% (n=15)
reported that they regularly attend monthly pathology
meetings/courses held by regional pathology societies,
while the majority (41%; n=130) reported this number
as once or twice a year. The number of respondents who
annually attended national and international pathology
meetings was low (28% (n=91) for the national pathology
meeting and 6% (n=18) for international pathology
meetings). The most important factors that determined
the decision to attend these meetings were the quality of
the scientific content (85%; n=273) and financial status/
support (76%; n=244).
Research activities and publication ethics
Almost two thirds had contributed to at least one original
research article and/or case report, also in cooperation with
other specialties (60%; n=193, 66%; n=212, respectively).
28% (n=90) claimed that their cases were included in
studies without their knowledge, or they were not listed as
a co-author (6%; n=18) although they fulfilled authorship
criteria by providing rare diagnoses, micro-photos,
performing further histopathological examination, etc.
Interestingly, another pathologist had been listed as a coauthor
instead of the person who initially provided the data
in 3 of these incidents.
Professional Well-being (PWB) and Overall Job
Satisfaction
More than half of the respondents were satisfied with the
city they lived in (64%; n=204), and the institution they
worked at (60%; n=194) (Figure 1). However, almost half
(45%; n=143) reported experiencing the feeling of burn out,
regardless of their seniority and academic status (p>0.05).
65% (n=209) reported having physical problems such as
back pain or neck pain and 59% (n=192) described fatigue
due to excessive working. In addition, 52% (n=167) thought
that case load/distribution in their department was not fair and 28% (n=89) stated that they experienced conflicts with
their colleagues (Supplement 4). The most common reasons
for the conflicts were personal disagreements (64/89), case
distribution (30/89), subspecialization (23/89), monthly
income (22/89), and differences in scientific/diagnostic
approach (20/89).
Figure 1: Answers to Likert-type questions on professional well-being and job satisfaction.
Respondents who worked at large or experienced institutions and academic pathologists expressed higher satisfaction with working conditions, and the PWB score was also significantly correlated with the level of provincial development of the city the respondents lived in (p<0.001). Pathologists from smaller institutions reported significantly less conflict with their colleagues (p=0.007). Female respondents were more satisfied with their working conditions and reported having better relationship with colleagues (p<0.05). Finally, the majority were not satisfied with their wage and salary supplements (76%; 80% per MSQ scores) (Figure 1, Supplement 5) and 64 respondents (20%) also described inadequate financial compensation as a discouraging factor.
Perception of pathology
Overall, 82% (n=263) of the participants were happy to have
chosen pathology (Figure 2), and interestingly happiness
was significantly associated with the level of provincial development of the city they lived in (p=0.024). The most
common factors that made the respondents happy were
flexible working hours/conditions (34%), to have a high
impact on patient management (18%), and to get and to
make the diagnosis (14%) (Supplement 6).
Figure 2: Answers to the questions about the perception of pathology.
Almost all (98.4%; n=316) agreed that pathologists have a critical impact on patient management, but 92% (n=295) thought that patients barely know about pathologists. The ratio of the respondents who agreed that other physicians understand the difficulty and limitations in pathology practice was only 16% (n=52) (Figure 2), and only 25% (n=85) were satisfied with the hospital administrations enthusiasm to improve the pathology laboratory (Figure 1). The perception of pathology of the respondents from large and experienced institutions was more favorable (p=0.021 and 0.015, respectively).
Minnesota Satisfaction Questionnaire
Academic pathologists and senior pathologists with ≥20
years of experience had significantly higher scores of MSQ
(p<0.001)(Supplement 5). The mean MSQ score was also
significantly associated with the mean training satisfaction
score (p=0.29), WPC satisfaction score (p=0.003), the
relationship between colleagues (p=0.037), and the
perception of pathology (p=0.001).
Comparison Between Subgroups and Geographic
Regions
Significant differences in satisfaction levels of workplace
conditions, professional well-being, job satisfaction,
and perception of pathology were observed between
nonacademic junior, academic junior, non-academic senior,
and academic senior pathologists (p<0.05) (Table II).
Respondents from the East and South East Regions tended to be younger (p<0.001) (Figure 3). The experience of the laboratory, the number of total biopsies and pathologists, and the satisfaction level with the technical and physical background were significantly higher in the Aegean and Marmara Regions (p<0.05).
Academic pathologists and senior pathologists with ≥20
years of experience are more satisfied with their jobs and
their working conditions
This is in fact consistent with findings of some other job
satisfaction surveys among non-pathology subspecialties
[18,19] and, more strikingly, academic pathologists have
been reported to express better job satisfaction in another
study by Jenkins et al. [4].
Age cannot be the only explanatory factor for the association between seniority and job satisfaction since age is not considered as a viable predictor of job satisfaction [20]. However, younger individuals motivation has been shown to increase as they are offered more career opportunities [21] and, in this study, many non-academic junior pathologists stated that the institution they worked at was not their preferred choice (partly due to compulsory service), suggesting that loss of motivation can indeed be a contributing factor to their dissatisfaction. This may also indicate that senior pathologists are more satisfied because they have reached their career goals or that they just got accustomed to the situation and gave up hoping for better. However, further investigation is required to fully explore this aspect.
Job satisfaction of pathologists is correlated with physical
conditions of the pathology laboratory
This is somehow expected and also one of the main
reasons why academic pathologists, senior pathologists,
and pathologists working at larger laboratories expressed
higher job satisfaction since academic institutions and large
institutions usually have better physical background. On
the other hand, half of the respondents were not satisfied
with the technical and physical background of their
laboratory and described insufficient and poor physical
conditions in the grossing room and suboptimal conditions
for microscopic examination, and many also complained
about inexperienced and/or unknowing and reluctant staff/
technicians. Moreover, 11% of the respondents had to setup
the pathology laboratory when they were first assigned
to the hospitals they currently work at. Therefore, it is clear
that workplace conditions are significantly heterogeneous
in Turkey and the number of the pathologists who work at
non-teaching hospitals is too high to be ignored since 87%
of all the hospitals in Turkey are non-teaching hospitals
[17,22]. However, it may not be possible and/or rational
to reserve the same amount of funding for every laboratory
across the country. Thus, centralization of the pathology
services, i.e. adopting a centralized pathology laboratory
approach by determination of the need for a pathology
laboratory by the number of the hospital beds and/or type and number of the surgical procedures in a hospital
appear to be the best option to overcome the mentioned
obstacles [23,24], and to improve surgical pathologists job
satisfaction.
The city/area where the pathologist lives in affects job
satisfaction
Living in an advanced city or a developed area may offer
both better job opportunities and better sociocultural
activities, improving an individuals quality of life.
Although it is impossible to provide equal conditions for
every pathologist, centralization of the pathology services
may produce a solution for this problem as well.
Shortfalls in the training system and pathology service
design negatively affect junior pathologists motivation
Although we did not aim to assess training in pathology
in detail, respondents declared that administration/management
strategies, laboratory techniques, and molecular
pathology as the weakest aspects of their residency programs.
Working at laboratories with poor lab conditions
contribute to junior pathologists dissatisfaction and a
feeling of insecurity. Unfortunately, one fifth reported a
fear of responsibility/lack of confidence to sign-out cases
and another one fifth reported inexperience/lack of knowledge
on several topics of pathology when they first started
practicing. Hence, residency core curriculums must be standardized and updated to strengthen these aspects. Also,
reporting of the complex cases should be encouraged in the
residency period to overcome confidence problems. Training
on hematopathology, dermatopathology and soft tissue/
bone pathology should also be supported by special courses
and by online training, given that these are the top 3 topics
creating the need for a second opinion. Inter-institutional
rotations or training of the trainers have been suggested
as other solutions [24]. Additionally, constructing a new
training system focusing on subspecialty training may be
of help and encourage pathology residents to specialize in
areas that they are interested in. However, one should also
consider that this will also prolong the training period and
may cause a deterioration of the knowledge on surgical
pathology. A thorough targeted study comparing training
conditions and satisfaction in different institutions may
help to describe permanent solutions in detail.
It should be noted here that, albeit low, a number of pathologists (4%) expressed their discontent with the current inter-institutional consultation mechanism and pointed to a main shortfall: lack of an official feed-back loop to follow-up the results and/or discuss opinions. Usubutun et al. reported that suspecting the diagnosis, need for immunohistochemical studies, patient requests, and need for molecular studies are the most frequent reasons for consultation in Turkey [25]. The authors have also found that 59% of the consultant pathologists report the results to the first pathologist only if he/she asks for it [25]. Therefore, official/written protocols are needed to enable institutional feedback, or telepathology options with digital whole slide imaging can be encouraged as a good option for consultation [26], also allowing online discussion and feedback, thus enhancing self-confidence which may improve job satisfaction.
Interpersonal conflicts overshadow professionalism
Some respondents (mostly academic junior pathologists
and pathologists who work at large institutions) expressed
conflicts with their colleagues, mainly due to personal
disagreements, subspecialization and caseload distribution,
which may be attributable to the competition in larger settings
that decreases job satisfaction in return. Interpersonal
conflicts can be mediated by mutual compromise at a
personal level, by adopting the concept of team work,
or by administrative measures such as training [24].
Although Güner et al. have claimed that Eastern cultures
rely on apprenticeship rather than standardized programs
in higher education [27], our professional organization(s)
can take a leadership role to help departments and training
programs define professionalism, ethical values, and codes of conduct for the practicing pathologist as suggested by
Domen [28] and the concept of professionalism may also
be implemented in standard training curriculums [29].
Alarm signal: Burn-out is not infrequent among
pathologists
Chronic fatigue due to excessive work load, sleep deprivation
or decreased personal time, perceived threats such as making
mistakes, loss of autonomy, inefficiencies in administrative
tasks, balancing needs (multitasking), chronic stress due to
workplace setting and personal factors have been suggested
as factors that may contribute to burn-out symptoms
among physicians [30]. In our study, 21% expressed feeling
pressured by the physicians for more rapid sign-out, which
is an important factor that causes job-related stress. Almost
half (45%) of the respondents reported to experience the
feeling of being burnt-out and 69% described fatigue due
to excessive working which is remarkably higher than the
series of Fritzsche et al, in which depression and burn-out
have been reported to affect 8% of pathologists [31]. On the
other hand, in a recent study on pathologists burn-out in
the United States, 71% of the respondents expressed having
felt burn-out at some time [32], and in another recent study
among pathology residents and fellows, the majority also
appraised their work-life balance as poor or fair [8]. A
previous study suggested that the main problem leading to
unbalanced workload in pathology laboratories in Turkey
to be the unequal institutional workload distribution
[33]. In other words, the workload in teaching hospitals is
remarkably higher than in smaller non-teaching hospitals,
and academic pathologists are expected to fulfill more
daily tasks (routine sign-out, teaching, research etc.) [33].
Ironically, the so-called flexible work hours seems to be
translated as excessive work hours in academic settings.
Moreover, the number of the pathologists in Turkey is also
clearly below the European average [17,34]. Therefore,
strategic personnel planning is required to improve the
quality and productivity, and increasing the number of
the staff and pathologists in teaching hospitals should
be considered. Adopting individual and/or institutional
system-wide solutions to cope with burn-out are
recommended [35].
Back pain and neck pain are the most common workrelated
physical symptoms
In total, 65% of the respondents complained about
musculoskeletal problems such as back and neck pain.
Musculoskeletal problems have mostly been reported in the
neck, shoulder and upper back areas, occasionally referred
to as pathologists hump [31]. Considering that these symptoms cause loss of manpower and fatigue, ergonomic
workplace optimization is recommended [31].
Pathologists are generally happy with their decision to
become a pathologist, but they feel invisible to the public
and other physicians
Despite the fact that pathology was not the first career choice
of the majority and they chose pathology without actually
knowing what pathologists do, more than 80% seem to be
content with their choice. We have recently shown that
flexible working conditions, scientific excitement, and
attributed importance of pathology were the main reasons
why pathology residents from different European countries
chose pathology as a profession [7], and the findings of this
study confirm that these are the most liked aspects of being
a pathologist as well.
However, almost every respondent agreed that other physicians and patients do not actually know what pathology is and what pathologists do. Most respondents expressed discontent about the lack of reputation in public and underestimation of pathology by other physicians. They acknowledged that many physicians do not know the limitations and difficulties of the pathologic examination and the patients consider pathology as a laboratory test performed on automated machines. While the invisibility of pathology is not country-specific [7], pathologists who work at large laboratories and academic centers seem to have a more favorable perception of pathology, probably due to the positive impact of long-term collaboration, and establishing a common language with clinicians increasing the feeling of being understood. As it is quite difficult to publicize pathology and to establish significant co-operation with physicians in small hospitals, we think that a national effort led by professional organization(s) would be the best way to introduce pathology to the public, and more joint meetings are required to develop cooperation with other physicians.
Pathologists feel discouraged by inadequate financial
compensation
Only 20% of the respondents were satisfied with their
wage, a very low number compared to the United States,
where 63% of the pathologists feel satisfied with their
income [6]. As some of the respondents articulated, this
may be attributed to the underestimation of several timeconsuming
procedures in pathologic examinations (gross
examination, reporting of major resections etc.) and
relative ignorance of the public, other physicians, and
hospital administrations about the pathology workflow
which results in less payment compared to other specialties.
As might be expected, this leads to disappointment and frustration among pathologists and negatively affects their work motivation. At this point, the expectation from the professional organizations is simply to build awareness of the presence of many resentful and unhappy pathologists and to take steps to improve pathologists income.
Annual attendance to pathology congresses/meetings is
lower than desired and academic pathologists constitute
the core population
The number of respondents who annually attended the
national and international pathology meetings was very
low (28%), especially among non-academic seniors (12%
and 0%, respectively). The scientific content and financial
status/support appear as the main determinants of
attendance. Therefore, improvement of these factors may
encourage more pathologists to attend the meetings, and
increase professional excitement and job satisfaction.
Gender seems to affect job satisfaction
Although this finding is somehow biased due to the large
number of female respondents, female respondents were
more satisfied with their working conditions and expressed
better relationship with colleagues. Previously, it has been
controversially claimed that womens expectations are
lower than mens [36] and that women usually feel more
satisfied with their jobs even when they have worse job
options [36,37], which may also be true for pathologists.
We, interestingly, found that male participants were more
satisfied with their training, and felt more confident and
prepared to sign out cases when they first started practicing.
While self-esteem widely differs due to cultural differences
[38], similar results were observed among nursing students
as well [39]. Whether this could actually be the case for
pathologists needs further research.
The major limitations of our study were the relatively low response rate and the survey length. The survey was composed of 59 questions in addition to 20-item MSQ and this may have intimidated the potential respondents. However, the number of the respondents is within the 95%- 97% confidence interval and response to online surveys tends to be low in general. In addition, despite its length, it was completed by 321 respondents from all geographic regions and all but 8 cities of Turkey, providing quite a panorama about the job satisfaction throughout the country.
To summarize; our results show that the factors comprising job satisfaction varies in different groups of pathologists.
Non-academic junior pathologists are unhappy, feel more insecure as they more frequently work in smaller cities, and in less well-equipped laboratories. Academic juniors suffer from feeling burnt-out due to excessive and unbalanced workload, multitasking, and interpersonal conflicts. Non-academic seniors experience less conflict, are happy with working hours but are usually less satisfied with their monthly income and feel less motivated for participating in scientific meetings. Academic seniors, work in technically more advanced laboratories and express higher job satisfaction, but complain about the workload and multitasking.
In conclusion; despite all the discouraging conditions described in this study and their feeling of invisibility, most pathologists in Turkey are satisfied with their career choice, mainly because of their dedication to the importance of pathology for patient management. However serious improvements and innovation in the current system are necessary to overcome the feeling of burn-out and especially to foster junior pathologists hope and work motivation, and, therefore, to be able to offer a better future both to the pathologists and the patients.
CONFLICT of INTEREST
The authors declare they have no conflict of interest.
FUNDING
No funding was received.
ACKNOWLEDGEMENTS
The authors would like to thank Dr. Serpil Dizbay Sak, Dr.
Alp Usubutun, and the Federation of Turkish Pathology
Societies for their support for reaching the participants.
AUTHORSHIP CONTRIBUTIONS
Concept: BP, BD, Design: BP, BD, HH, Data collection or
processing: BP, GG, UA, BD, Analysis or Interpretation:
BP, HH, Literature search: BP, Writing: BP, BD, HH, GG,
UA, Approval: BP, BD, HH, GG, UA
1) Hopkins FG: Some aspects of biochemistry: The organising
capacities of specific catalysts (Second Purser Memorial Lecture).
Irish Journal of Medical Science. 1932;79:333-57.
2) Locke EA. The Nature and Causes of Job Satisfaction. In:
Dunnette, M D, Handbook of Industrial and Organizational
Psychology 1st ed. Chicago, IL: Rand McNally; 1976:1297-349.
3) Maslow AH. A theory of human motivation. Psychological
Review. 1943;50:370-96.
4) Jenkins D, Philips Z, Grisaffii K, Whynes DK. The boundaries
of cellular pathology: How pathologists see their clinical role. J
Pathol. 2002;196:356-63.
5) Howell LP, Lyons ML, Thor A, Dandar V. Sex differences in
workplace satisfaction and engagement of academic pathologists:
Opportunities to enhance faculty diversity. Arch Pathol Lab Med.
2015;139:936-42.
6) Xu H, Remick DG. Pathology: A satisfying medical profession.
Acad Pathol. 2016;3:1-4.
7) Pehlivanoglu B, Hassoy H, Calle C, Dendooven A, Nalbantoglu
I, Reshchikova L, Gul G, Doganavsargil B. How does it feel to be
a pathology resident? Results of a survey on experiences and job
satisfaction during pathology residency. Virchows Arch. 2017;
471:413-22.
8) Kelly M, Soles R, Garcia E, Kundu I. Job stress, burnout, worklife
balance, well-being, and job satisfaction among pathology
residents and fellows. Am J Clin Pathol. 2020;153:449-69.
9) National Academies of Sciences, Engineering, and Medicine;
National Academy of Medicine; Committee on Systems
Approaches to Improve Patient Care by Supporting Clinician
Well-Being. Taking action against clinician burnout: A systems
approach to professional well-being. Washington, DC: The
National Academies Press, 2019.
10) Doble SE, Santha JC. Occupational well-being: Rethinking
occupational therapy outcomes. Can J Occup Ther. 2008;
75(3):184-90.
11) Yeo H, Viola K, Berg D, Lin Z, Nunez-Smith M, Cammann C,
Bell RH Jr, Sosa JA, Krumholz HM, Curry LA. Attitudes, training
experiences, and professional expectations of US general surgery
residents: A national survey. Jama. 2009;302:1301-8.
12) Ford JC. If not, why not? Reasons why Canadian postgraduate
trainees chose-or did not choose-to become pathologists. Hum
Pathol. 2010;41:566-73.
13) Minnesota Satisfaction Questionnaire-Short Form. available
at http://vpr.psych.umn.edu/sites/vpr.dl.umn.edu/files/msq_
booklet_short-form_1977.pdf. 1977.
14) İllerin ve bölgelerin sosyo-ekonomik gelişmişlik sıralaması
araştırması: SEGE-2017. Accessed on June 6, 2020. Available from:
https://www.bakkakutuphane.org/upload/dokumandosya/l_
sege-2017.pdf.
15) Martha C, Griffet J. Brief report: How do adolescents perceive the
risks related to cell-phone use? J Adolesc. 2007;30:513-21.
16) The Age Discrimination in Employment Act of 1967. Available at:
https://www.eeoc.gov/statutes/age-discrimination-employmentact-
1967. Accessed on May 31, 2020.
17) Türkiyede Sağlık Eğitimi ve Sağlık İnsan Gücü Durum Raporu,
2014. Available at: https://sbu.saglik.gov.tr/Ekutuphane/Yayin/
467 (Accessed on 24.03.2020).
18) Yu J, Gao J, Chen J, Sun Y. Academic versus non-academic
neurosurgeons in China: A national cross-sectional study
on workload, burnout and engagement. BMJ Open. 2019;
9(10):e028309.
19) Busis NA, Shanafelt TD, Keran CM, Levin KH, Schwarz HB,
Molano JR, Vidic TR, Kass JS, Miyasaki JM, Sloan JA, Cascino
TL. Burnout, career satisfaction, and well-being among US
neurologists in 2016. Neurology. 2017;88:797-808.
20) Bernal D, Snyder D, McDaniel M. The age and job satisfaction
relationship: Does its shape and strength still evade us? J Gerontol
B Psychol Sci Soc Sci. 1998;53:P287-93.
21) Boumans NP, de Jong AH, Janssen SM. Age-differences in
work motivation and job satisfaction. The influence of age on
the relationships between work characteristics and workers
outcomes. Int J Aging Hum Dev. 2011;73:331-50.
22) Health Statistics Yearbook, Ministry of Health of Turkey, 2018.
Available at: https://dosyasb.saglik.gov.tr/Eklenti/36164, siy-
2018en2pdf.pdf?0 (Accessed on May 10th, 2020). 2018.
23) Patoloji Dernekleri Federasyonu. Türkiyede patolojinin durumu
ve öneriler (Strateji raporu), 21 Mayıs 2010. 2010.
24) Patoloji Dernekleri Federasyonu. Türkiyede patolojinin sorunları
ve çözüm önerileri: Bir durum saptaması, 2017. Available at:
http://www.turkpath.org.tr/upload/content/files/Turkiyede_
Patolojinin_Sorunlari_ve_cozum_onerileri_bir_durum_
saptamasi_2017.pdf (Accessed on: 10 May 2020). 2017.
25) Usubutun A, Balci S, Yorukoglu K. The situation of consultation
practice in pathology in Turkey. Turk Patoloji Derg. 2012; 28:195-203.
26) Mukhopadhyay S, Feldman MD, Abels E, Ashfaq R, Beltaifa S,
Cacciabeve NG, Cathro HP, Cheng L, Cooper K, Dickey GE,
Gill RM, Heaton RP, Jr., Kerstens R, Lindberg GM, Malhotra
RK, Mandell JW, Manlucu ED, Mills AM, Mills SE, Moskaluk
CA, Nelis M, Patil DT, Przybycin CG, Reynolds JP, Rubin BP,
Saboorian MH, Salicru M, Samols MA, Sturgis CD, Turner KO,
Wick MR, Yoon JY, Zhao P, Taylor CR. Whole slide imaging
versus microscopy for primary diagnosis in surgical pathology:
A multicenter blinded randomized noninferiority study of 1992
cases (pivotal study). Am J Surg Pathol. 2018;42:39-52.
27) Guner G, Muderrisoglu C, Kosemehmetoglu K, Soylemezoglu
F. Professionalism in pathology: The turkish experience. Arch
Pathol Lab Med. 2018;142:433.
28) Domen RE. Ethical and professional issues in pathology: A
survey of current issues and educational efforts. Hum Pathol.
2002;33:779-82.
29) Domen RE, Johnson K, Conran RM, Hoffman RD, Post MD,
Steinberg JJ, Brissette MD, Gratzinger DA, McCloskey CB, Raciti
PM, Roberts CA, Rojiani AM, Powell SZ. Professionalism in
pathology: A case-based approach as a potential educational tool.
Arch Pathol Lab Med. 2017;141:215-9.
30) Schrijver I. Pathology in the medical profession? Taking the pulse
of physician wellness and burnout. Arch Pathol Lab Med. 2016;
140:976-82.
31) Fritzsche FR, Ramach C, Soldini D, Caduff R, Tinguely M, Cassoly
E, Moch H, Stewart A. Occupational health risks of pathologists-
-results from a nationwide online questionnaire in Switzerland.
BMC Public Health. 2012;12:1054.
32) Garcia E, Kundu I, Kelly M, Soles R, Mulder L, Talmon GA. The
American Society for Clinical Pathologys Job Satisfaction, Well-
Being, and Burnout Survey of Pathologists. Am J Clin Pathol.
2020;153:435-48.
33) Usubutun A, Uner S, Harorlu F, Ozer E, Tuzlali S, Ruacan A, Koc
O, Yorukoglu K. Pathology laboratories staff workload evaluation
in Turkey: A survey study. Turk Patoloji Derg. 2011;27:98-105.
34) Ruiter DJ, Roald B, Underwood J, Prat J. Histopathology training
in Europe: A lesson for other specialties? Virchows Arch. 2004;
444:278-82.
35) Hernandez JS, Wu RI. Burnout in pathology: Suggestions for
individual and systemwide solutions. J Am Soc Cytopathol. 2018;
7:166-8.
36) Clark AE. Job satisfaction and gender: Why are women so happy
at work? Labour Economics. 1997;4:341-72.
37) Grönlund A, Öun I. The gender-job satisfaction paradox and
the dual-earner society: Are women (still) making work-family
trade-offs? Work. 2018;59:535-45.
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