Pre-clinical medical students' perception of surgical professions – too demanding and difficult to balance with private life?

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Hannes Becker, Hanna Gött, Jonas Tellermann, Patrick Haas, Constantin Roder, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6238373/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background: Surgical professions in Western Europe deal with serious challenges to inspire students to pursue a surgical career and counteract demographic change. Students’ interest in sub-specialization is influenced by socio-economic factors including work-life balance, flexible working hours and appreciation. However, robust data about the current perception of surgical professions in the early stage of medical education is lacking so far. Methods: We performed a voluntary online survey amongstudents who participated in an elective neurosurgical course during their preclinical stage of medical studies. The survey addressed perception of surgical professions, including personal requirements, profession impact on health and lifestyle and the topic of gender disparities and family planning. We also assessed viewpoints on support programs facilitating compatibility of surgical training and family life. Results: A total of 109 students participated in the voluntary survey (66.1% female; 33.0% male, 0.9% unknown). 55.5% of respondents had prior experiences with surgical professions and 33.9% planned to pursue a surgical career. Most respondents rated surgical professions as more demanding for the physical health and more harmful for the health of physicians than other specialties. However, mental implications were higher rated in other professions. Interestingly, female participants agreed to higher career chances for male residents as well as to difficulties to combine family planning and performing the surgical profession, whereas male participants remained more neutral to both statements. Overall, 89.0% of participants expressed interest in support programs increasing compatibility of professional and personal life. Furthermore, 65.1% of participants would be willing to accept an extension of their surgical resident time by a year. Conclusions: In summary, pre-clinical medical students rate surgical disciplines as highly demanding, competitive and difficult to balance with private life. Early awareness of structured support programs may positively influence may improve sustainable resident application numbers in surgical sub-specialties. Surgical career pre-clinical medical students medical education gender disparity work-life balance Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Health care systems in Western Europe have to deal with serious difficulties balancing between higher demand and a shortage of available specialists. Due to the demographic changes towards an ageing population, medical services, including both conservative and surgical procedures, are more often required while socio-economic predictions assume a rising demand during the following decades ( 1 , 2 ). However, available and talented future residents who will fill the gaps of an equally aging populations of practicing physicians in all medical subspecialties are rare and are highly sought after ( 3 , 4 ). Even more importantly, the current generation's expectations towards the medical profession have changed significantly over the last few years and strongly influences their choice of sub-specialization ( 5 , 6 ). Medical students’ socio-economic considerations include flexible working hours, personal appreciation, as well as a work-life balance including time and capabilities for family planning ( 7 ). Surgical training programs are distinguished by especially long working hours, hierarchical and socially challenging mentor relationships, and high personal commitment combined with unpredictable working schedules ( 3 , 7 ). Therefore, surgical subspecialties are becoming increasingly unattractive among medical students and surgical departments are facing difficulties acquiring motivated and talented residents to pursue a surgical career. Additionally, students’ perception of surgical disciplines are predominantly influenced by prejudicial attitudes and limited negative personal experiences during their medical training ( 8 ). Therefore, we aimed for assessing the student’s perception of surgery sub-specialties at an early stage of medical education to delineate potential barriers limiting their surgical interests and illuminate possible solutions for improving both the surgical role model perception and its implementation in surgical education. Materials and Methods A web-based survey was constructed using the online platform SurveyMonkey (SurveyMonkey Inc., San Mateo, California, USA). The contents of the survey were based on our experiences gained during a specific preclinical elective course for medical students. For many years we have offered an elective course where medical students shadow our neurosurgical on-call team for 12 hours and afterwards reflect on perceived surgical stereotypes, physician roles, interdisciplinary communication and their general interest in the surgical field (Supplementary Material 1). We were surprised by the negative stereotypes and preformed conceptions about the daily work in surgery and constructed our questions based on these expressions. The survey focuses on a structured evaluation of students’ interest in the field of surgery, their perception of requirements and challenges when pursuing a surgical career and their interest of entering a surgical training program. It was distributed to medical students who participated in the mentioned elective course between October 2023 and January 2025 (n = 130). Participation was completely voluntary and anonymous. No personal data was collected. We constructed 16 out of 18 questions using a five-tiered Likert scale for either expressing agreement or disagreement on different statement or interests. 2 of 18 questions were dichotomous, asking for agreement or disagreement. We provide the complete survey as a supplementary file (Supplementary Material 2). Overall, 109 students participated in the survey (response rate 83.8%). The anonymous and completely voluntary survey is in accordance with the Declaration of Helsinki. Ethical approval was not necessary since the survey was anonymous and completely voluntary (ethical committee Tuebingen/ 242/2024B02). Data processing was done with GraphPad Prism 10 (GraphPad Software, San Diego, CA, USA) and Microsoft® Excel (Version 16.93.1, Microsoft, Redmond, Washington, US). Figure 1 A was created using Biorender.com. Results Descriptive data of respondents and surgical interest Overall, 130 students in their preclinical stage of medical studies took part in the offered elective neurosurgical course between 2023 and 02/2025 (Fig. 1 A). 109 out of 130 (83.8%) students participated in the voluntary online survey (Fig. 1 B). All submitted surveys were completely filled out and could be included into post-hoc analysis. 72 participants were female (66.1%) and 36 were male, whereas one student did not specify its gender identity (Fig. 1 C). 56.0% of participants reported prior experience in the domain of surgery, whereas 33.9% expressed a future aspiration to pursue a career in surgery (Fig. 2 A). Interestingly, agreement towards pursuing a surgical career was pronounced in male participants (41.7% vs. 30.6%). General perception of surgical professions In the subsequent phase of the study, the students were confronted with a series of questions concerning their perceptions of manual requirements and their conjectures regarding surgical character traits (Fig. 2 B). 92 of 109 responders (84.4%) strongly agreed or agreed that a special manual talent is required for surgical training. On the other hand, 53.2% of participants agreed that necessary manual skills can be acquired by almost anyone during residency, whereas 22.0% disagreed. When asked to rate the agreement towards the statement “surgeons have limited contact with awake patients” 56.9% strongly disagreed or disagreed with the statement. However, 29.4% agreed to the respective statement. Even a higher percentage of students supported the assumption that surgeons favor emotional distances towards their patients (40.4%) outweighing 31.2% of responders who disagreed. Most of survey participants (58.7%) assumed strong competition among surgical residents with solemnly 11.0% disagreement. Interestingly, particularly female students strongly agreed to respective statement (22.2% vs. 9.7%), whereas 37.5% of male students remained neutral to the statement. Surgical profession impact on health and lifestyle When asked about the impact of entering surgical training on health and lifestyle, 70.7% correlate a surgical sub-specialization with longer working hours than other medical professions (Fig. 3 ). Focussing on the physical and mental demands of surgical profession, 68.8% of students rated surgical professions as more demanding for the physical health than other specialties. Of note, mental burden of daily work is rated superior in surgical professions to other medical professions in solemnly 26.6%, while 38 students (34.9%) remained neutral. Overall, 49.5% of respondents rated the surgical profession as more harmful to the health of practitioners than other medical fields. Here, we observed strong gender-dependent perception difference with 66.7% agreement and 8.3% disagreement among male students, while 29.2% of female participants disagreed to the respective statement. Gender disparities and family planning Next, the participants were queried about their perception of gender disparities and family planning in surgical professions (Fig. 4 ). The majority of respondents share the perspective that surgery is a domain occupied by males (53.2%), whereas 27.5% disagree. The response pattern to the statement “male residents have an advantage in pursuing a carrier in surgery” revealed a distinct gender dependency among the participant students. 59.7% of female responders agreed, whereas 22.2% of male students shared agreement and 44.4% remained neutral to the respective statement. We detected some pattern regarding combing surgical profession and family planning. Overall, 65.1% of students rated surgical profession and family planning as difficult to balance, while female students showed higher agreement with this statement (70.8%) than male students (25.0%). Lastly, we were interested in evaluating students’ willingness to utilize support programs that facilitate balancing of professional and familial obligations (Fig. 5 ). Overall, 89.0% of participants expressed interest in such programs enhancing the compatibility of professional and private life. Of note, 65.1% of participants would even be willing to accept an extension of their surgical resident time, while 33.3% would not accept an enlargement of their residency. Discussion The results of this survey reveal that only a third of the participating medical students would pursue a career in surgery. Especially for female medical students a surgical career pathway seems to be even more unattractive. Given the growing female majority among medical students and the increasing emphasis on work-life balance ( 9 ), it is especially important to pave the way for young talents to pursue a surgical career. Perception of the surgical stereotype and lifestyle Regarding the image of the surgical role most of the participating students agreed to an image of the competitive and manually skilled surgeon, who maintains an emotional distance or even evasive, approach towards their patients, spending minimal time with them while awake, and simultaneously dedicating themselves extensively to their career, burdened not only by extended working hours but also by demands on their physical and mental health (Fig. 2 – 3 ). This is in line with other study results evaluating students perception and persisting stereotypes associated with surgical sub-specialties ( 10 ). There is evidence, that indeed working hours in surgical sub-specialties exceed the average for other medical subspecialities ( 11 – 13 ). This has a substantial impact on the physical and mental well-being and higher rates of burnout in surgical residents compared to their medical counterparts ( 14 , 15 ). The prevailing data supports the hypothesis that the image of surgeons held by medical students is often a result of preconceived ideas and stereotypes, often cultivated by media, rather than an accurate reflection of the reality of the profession ( 8 ). This image often resolves once students have gained more insight into the clinical practice of surgery. Nevertheless, offered possibilities for students in early stages of their medical education are often lacking, leading to a delayed perception of the actual surgical working environment and increases possible misperception and prejudices( 10 , 16 ). Gender disparities in surgery The surgical role perceived by medical students has several traits that reflect masculine gender normative stereotypes ( 17 – 19 ). Although the number of female residents in surgery increases, female surgeons are less likely to be promoted or even account for leadership positions ( 20 – 22 ).Furthermore, even female leaders who have succeeded have reported a lack of female role models or mentors. Additionally, female residents face higher stress levels, are at higher risk for burnout and often experience gender associated microaggression and discrimination by their co-workers and patients ( 23 – 25 ). Consequently, it is a legit and accurate perception among medical students, that surgery is a male-dominated field. Moreover, the gender disparity in our collective´s perception of the impact of the burden on mental health is consistent with existing data. Almost two thirds of the participants of this survey agreed, that a surgical career is difficult to balance with family planning. Female medical students agreed to this even more frequently. Recent surveys conducted by neuro-oncological, German and European societies of neurosurgery and interdisciplinary neurooncology have supported the relevance of this issue, particularly among female clinicians ( 20 , 26 , 27 ). As self-fulfillment and a focus on work-life balance is rated more relevant in the current generation of medical students, the availability of childcare programs and opportunities for maternity or paternity leave have an increasing impact on career choices of generation Y medical students ( 7 ). Need for support programs and role models In our cohort, 89.0% of participants expressed interest in potential support programs for balancing a surgical career with family life. Furthermore, 65% of the participants would even accept an extension of their surgical residency training by one year. This might implicate that the obstacle to pursue a career in surgery might be less likely based on the lack of interest and motivation, but more a consideration of eligible concerns. The willingness of the participating medical students to extend their residency reflects a demand for support to face the aforementioned issues. This is in line with students in their last year expressing the need for structured teaching leadership, communication and career management skills ( 28 ). The generation, currently entering the medical field faces a lack of representation and role models, which can only be compensated by structured mentoring and support programs ( 26 , 29 ). Experience from recently generated structured mentoring programs, especially for young female clinicians show, that there is a great acceptance and need for support ( 27 ). Of note, the literature has emphasized the necessity for change and the implementation of sustainable resident programs, incorporating sufficient time for personal development and private life ( 30 ). Legislative changes, such as working hour restrictions have been shown to have not only a positive impact on physicians’ health but also on increasing patients’ safety ( 31 ). However, a negative effect on surgical training is also evident due to decreased surgical exposure during training ( 32 ).Taken together, it will remain an ongoing challenge to provide a surgical residency program that integrates a structured, high-quality training curriculum with sustainable work-life balance and fair career opportunities. While support programs are an important prerequisite especially for female future surgeons, early promotion of such structural improvements among medical students are necessary to attract the best talents. Conclusion Overall, survey participants in their early stage of medical education rate surgical disciplines as highly demanding, competitive and difficult to balance with private life. This finding is indicative of a general negative perception of the surgical profession. The results of the study advocate for the implementation of programs that support the reconciliation of professional and family life. Such programs may contribute to an enhancement in sustainable resident application numbers in surgical subspecialties and might improve the physical and mental health of surgical residents. Declarations Ethics approval and consent to participate not applicable After careful considerations of the local ethical committee Tuebingen, the need for consent to participate was waived by the Institutional Review Board (local ethical committee Tuebingen). Ethical approval was not necessary since the survey was anonymous and completely voluntary (ethical committee Tuebingen/ 242/2024B02). Consent for publication: not applicable Competing interests: the authors declare that they have no competing interests Data availability: All data analyzed during this study are included in this published article and its supplementary information files. Author contributions Conception: FB, Data curation and analysis: HB, HG, JT, PH, CR, MT, FB, Writing of first manuscript draft: HB, HG and FB, Figure curation: HB. All authors read and approved the final manuscript. Acknowledgements We acknowledge support by the Open Access Publishing Fund of the University of Tübingen Supplementary Supplementary Material 1: Reflection Questions Supplementary Material 2: Survey on the role perception of surgeons Funding None. Open Access funding enabled and organized by Projekt DEAL. References Etzioni DA, Liu JH, Maggard MA, Ko CY. The aging population and its impact on the surgery workforce. Ann Surg. 2003;238(2):170-7. Perera SK, Jacob S, Wilson BE, Ferlay J, Bray F, Sullivan R, et al. 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Supplementary Files SupplementaryMaterial1.docx Supplementary Material 1: Reflection Questions SupplementaryMaterial2.docx Supplementary Material 2: Survey on the role perception of surgeons Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 21 May, 2025 Reviewers invited by journal 21 May, 2025 Editor invited by journal 30 Apr, 2025 Editor assigned by journal 09 Apr, 2025 Submission checks completed at journal 05 Apr, 2025 First submitted to journal 05 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6238373","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":440809794,"identity":"baea3130-aa6e-47ed-b02a-66772a319919","order_by":0,"name":"Hannes Becker","email":"data:image/png;base64,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","orcid":"","institution":"University Hospital Tuebingen, Eberhard Karl University Tuebingen","correspondingAuthor":true,"prefix":"","firstName":"Hannes","middleName":"","lastName":"Becker","suffix":""},{"id":440809795,"identity":"21645b97-8fb2-43da-b7d6-3ee563292732","order_by":1,"name":"Hanna Gött","email":"","orcid":"","institution":"University Hospital Tuebingen, Eberhard Karl University Tuebingen","correspondingAuthor":false,"prefix":"","firstName":"Hanna","middleName":"","lastName":"Gött","suffix":""},{"id":440809796,"identity":"6ac847ef-4f1e-470f-bc0a-8d09c017dcfd","order_by":2,"name":"Jonas Tellermann","email":"","orcid":"","institution":"University Hospital Tuebingen, Eberhard Karl University Tuebingen","correspondingAuthor":false,"prefix":"","firstName":"Jonas","middleName":"","lastName":"Tellermann","suffix":""},{"id":440809797,"identity":"9fa33142-2969-4236-9083-95647a2a85a4","order_by":3,"name":"Patrick Haas","email":"","orcid":"","institution":"University Hospital Tuebingen, Eberhard Karl University Tuebingen","correspondingAuthor":false,"prefix":"","firstName":"Patrick","middleName":"","lastName":"Haas","suffix":""},{"id":440809799,"identity":"74dbe481-a84b-4d10-842a-e16a13405b71","order_by":4,"name":"Constantin Roder","email":"","orcid":"","institution":"University Hospital Tuebingen, Eberhard Karl University Tuebingen","correspondingAuthor":false,"prefix":"","firstName":"Constantin","middleName":"","lastName":"Roder","suffix":""},{"id":440809801,"identity":"31d5db4b-ebe2-43f5-8044-758194ad6507","order_by":5,"name":"Marcos Tatagiba","email":"","orcid":"","institution":"University Hospital Tuebingen, Eberhard Karl University Tuebingen","correspondingAuthor":false,"prefix":"","firstName":"Marcos","middleName":"","lastName":"Tatagiba","suffix":""},{"id":440809803,"identity":"1bd1ac65-b2cc-44ee-a411-f0b078020372","order_by":6,"name":"Felix Behling","email":"","orcid":"","institution":"University Hospital Tuebingen, Eberhard Karl University Tuebingen","correspondingAuthor":false,"prefix":"","firstName":"Felix","middleName":"","lastName":"Behling","suffix":""}],"badges":[],"createdAt":"2025-03-16 15:23:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6238373/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6238373/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81201841,"identity":"f34b21ba-0365-4e56-84ad-063e06e694a4","added_by":"auto","created_at":"2025-04-23 11:23:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":190049,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Flow chart depicting conceived study design with (B) overall participation in online survey and (C) gender distribution of participants.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6238373/v1/a9522f8c726ae8a24c422bcd.png"},{"id":81200948,"identity":"981acf1f-4a7a-408f-a0b5-cd0710c9c68d","added_by":"auto","created_at":"2025-04-23 11:15:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":7702624,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Feedback on participants interest as well as experience in surgical field. (B) distribution of answers regarding perception of surgical professions.\u003c/p\u003e","description":"","filename":"Figure2tif.png","url":"https://assets-eu.researchsquare.com/files/rs-6238373/v1/a61b0481242d7e127b8f3571.png"},{"id":81199852,"identity":"2f60e52d-5e5c-454e-a170-f57b8cc8f39e","added_by":"auto","created_at":"2025-04-23 11:07:58","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":4823123,"visible":true,"origin":"","legend":"\u003cp\u003ePerceived impact of surgical specialty on the individual’s health and lifestyle as well as the gender-based answer comparison of its harmfulness compared to non-surgical disciplines\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-6238373/v1/43df4cfc95399cd1c7e1ef91.png"},{"id":81199855,"identity":"053a974d-8705-4785-a427-b933a70e7293","added_by":"auto","created_at":"2025-04-23 11:07:58","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":3722091,"visible":true,"origin":"","legend":"\u003cp\u003eGeneral agreement of answers based in gender disparities within the surgical field.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-6238373/v1/dd771961d594d9c4d3120683.png"},{"id":81200953,"identity":"39c8da61-c304-435e-8947-f882ef373293","added_by":"auto","created_at":"2025-04-23 11:15:59","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":173712,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Distribution of answers respecting the participants willingness to accept support programs aiming to improve work-life-balance (B) in exchange for an extended training period.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-6238373/v1/042c0ac0489074ec8344edb5.png"},{"id":81202486,"identity":"8b8d06fe-e221-4b85-bdd8-28f788934c84","added_by":"auto","created_at":"2025-04-23 11:32:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":15258047,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6238373/v1/144d81cd-c0b1-4020-b120-816ebd972121.pdf"},{"id":81199845,"identity":"7c03f11f-1189-44bf-9ec8-825427c97792","added_by":"auto","created_at":"2025-04-23 11:07:58","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15811,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Material 1: Reflection Questions\u003c/p\u003e","description":"","filename":"SupplementaryMaterial1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6238373/v1/3a1fd9189e72bd48733b3b40.docx"},{"id":81199844,"identity":"6670c72d-dc22-49a3-b6b8-3b0d11622ee9","added_by":"auto","created_at":"2025-04-23 11:07:58","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":22983,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Material 2: Survey on the role perception of surgeons\u003c/p\u003e","description":"","filename":"SupplementaryMaterial2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6238373/v1/59f89e08e9029e929915049d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pre-clinical medical students' perception of surgical professions – too demanding and difficult to balance with private life?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHealth care systems in Western Europe have to deal with serious difficulties balancing between higher demand and a shortage of available specialists. Due to the demographic changes towards an ageing population, medical services, including both conservative and surgical procedures, are more often required while socio-economic predictions assume a rising demand during the following decades (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, available and talented future residents who will fill the gaps of an equally aging populations of practicing physicians in all medical subspecialties are rare and are highly sought after (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Even more importantly, the current generation's expectations towards the medical profession have changed significantly over the last few years and strongly influences their choice of sub-specialization (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Medical students\u0026rsquo; socio-economic considerations include flexible working hours, personal appreciation, as well as a work-life balance including time and capabilities for family planning (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Surgical training programs are distinguished by especially long working hours, hierarchical and socially challenging mentor relationships, and high personal commitment combined with unpredictable working schedules (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Therefore, surgical subspecialties are becoming increasingly unattractive among medical students and surgical departments are facing difficulties acquiring motivated and talented residents to pursue a surgical career. Additionally, students\u0026rsquo; perception of surgical disciplines are predominantly influenced by prejudicial attitudes and limited negative personal experiences during their medical training (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Therefore, we aimed for assessing the student\u0026rsquo;s perception of surgery sub-specialties at an early stage of medical education to delineate potential barriers limiting their surgical interests and illuminate possible solutions for improving both the surgical role model perception and its implementation in surgical education.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eA web-based survey was constructed using the online platform SurveyMonkey (SurveyMonkey Inc., San Mateo, California, USA). The contents of the survey were based on our experiences gained during a specific preclinical elective course for medical students. For many years we have offered an elective course where medical students shadow our neurosurgical on-call team for 12 hours and afterwards reflect on perceived surgical stereotypes, physician roles, interdisciplinary communication and their general interest in the surgical field (Supplementary Material 1). We were surprised by the negative stereotypes and preformed conceptions about the daily work in surgery and constructed our questions based on these expressions. The survey focuses on a structured evaluation of students\u0026rsquo; interest in the field of surgery, their perception of requirements and challenges when pursuing a surgical career and their interest of entering a surgical training program. It was distributed to medical students who participated in the mentioned elective course between October 2023 and January 2025 (n\u0026thinsp;=\u0026thinsp;130). Participation was completely voluntary and anonymous. No personal data was collected. We constructed 16 out of 18 questions using a five-tiered Likert scale for either expressing agreement or disagreement on different statement or interests. 2 of 18 questions were dichotomous, asking for agreement or disagreement. We provide the complete survey as a supplementary file (Supplementary Material 2). Overall, 109 students participated in the survey (response rate 83.8%).\u003c/p\u003e \u003cp\u003e The anonymous and completely voluntary survey is in accordance with the Declaration of Helsinki. Ethical approval was not necessary since the survey was anonymous and completely voluntary (ethical committee Tuebingen/ 242/2024B02).\u003c/p\u003e \u003cp\u003eData processing was done with GraphPad Prism 10 (GraphPad Software, San Diego, CA, USA) and Microsoft\u0026reg; Excel (Version 16.93.1, Microsoft, Redmond, Washington, US). Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA was created using Biorender.com.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive data of respondents and surgical interest\u003c/h2\u003e \u003cp\u003eOverall, 130 students in their preclinical stage of medical studies took part in the offered elective neurosurgical course between 2023 and 02/2025 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). 109 out of 130 (83.8%) students participated in the voluntary online survey (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). All submitted surveys were completely filled out and could be included into post-hoc analysis. 72 participants were female (66.1%) and 36 were male, whereas one student did not specify its gender identity (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). 56.0% of participants reported prior experience in the domain of surgery, whereas 33.9% expressed a future aspiration to pursue a career in surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Interestingly, agreement towards pursuing a surgical career was pronounced in male participants (41.7% vs. 30.6%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eGeneral perception of surgical professions\u003c/h3\u003e\n\u003cp\u003eIn the subsequent phase of the study, the students were confronted with a series of questions concerning their perceptions of manual requirements and their conjectures regarding surgical character traits (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). 92 of 109 responders (84.4%) strongly agreed or agreed that a special manual talent is required for surgical training. On the other hand, 53.2% of participants agreed that necessary manual skills can be acquired by almost anyone during residency, whereas 22.0% disagreed. When asked to rate the agreement towards the statement \u0026ldquo;surgeons have limited contact with awake patients\u0026rdquo; 56.9% strongly disagreed or disagreed with the statement. However, 29.4% agreed to the respective statement. Even a higher percentage of students supported the assumption that surgeons favor emotional distances towards their patients (40.4%) outweighing 31.2% of responders who disagreed. Most of survey participants (58.7%) assumed strong competition among surgical residents with solemnly 11.0% disagreement. Interestingly, particularly female students strongly agreed to respective statement (22.2% vs. 9.7%), whereas 37.5% of male students remained neutral to the statement.\u003c/p\u003e\n\u003ch3\u003eSurgical profession impact on health and lifestyle\u003c/h3\u003e\n\u003cp\u003eWhen asked about the impact of entering surgical training on health and lifestyle, 70.7% correlate a surgical sub-specialization with longer working hours than other medical professions (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Focussing on the physical and mental demands of surgical profession, 68.8% of students rated surgical professions as more demanding for the physical health than other specialties. Of note, mental burden of daily work is rated superior in surgical professions to other medical professions in solemnly 26.6%, while 38 students (34.9%) remained neutral. Overall, 49.5% of respondents rated the surgical profession as more harmful to the health of practitioners than other medical fields. Here, we observed strong gender-dependent perception difference with 66.7% agreement and 8.3% disagreement among male students, while 29.2% of female participants disagreed to the respective statement.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eGender disparities and family planning\u003c/h3\u003e\n\u003cp\u003eNext, the participants were queried about their perception of gender disparities and family planning in surgical professions (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The majority of respondents share the perspective that surgery is a domain occupied by males (53.2%), whereas 27.5% disagree. The response pattern to the statement \u0026ldquo;male residents have an advantage in pursuing a carrier in surgery\u0026rdquo; revealed a distinct gender dependency among the participant students. 59.7% of female responders agreed, whereas 22.2% of male students shared agreement and 44.4% remained neutral to the respective statement. We detected some pattern regarding combing surgical profession and family planning. Overall, 65.1% of students rated surgical profession and family planning as difficult to balance, while female students showed higher agreement with this statement (70.8%) than male students (25.0%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eLastly, we were interested in evaluating students\u0026rsquo; willingness to utilize support programs that facilitate balancing of professional and familial obligations (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Overall, 89.0% of participants expressed interest in such programs enhancing the compatibility of professional and private life. Of note, 65.1% of participants would even be willing to accept an extension of their surgical resident time, while 33.3% would not accept an enlargement of their residency.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this survey reveal that only a third of the participating medical students would pursue a career in surgery. Especially for female medical students a surgical career pathway seems to be even more unattractive. Given the growing female majority among medical students and the increasing emphasis on work-life balance (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), it is especially important to pave the way for young talents to pursue a surgical career.\u003c/p\u003e\n\u003ch3\u003ePerception of the surgical stereotype and lifestyle\u003c/h3\u003e\n\u003cp\u003e Regarding the image of the surgical role most of the participating students agreed to an image of the competitive and manually skilled surgeon, who maintains an emotional distance or even evasive, approach towards their patients, spending minimal time with them while awake, and simultaneously dedicating themselves extensively to their career, burdened not only by extended working hours but also by demands on their physical and mental health (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). This is in line with other study results evaluating students perception and persisting stereotypes associated with surgical sub-specialties (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is evidence, that indeed working hours in surgical sub-specialties exceed the average for other medical subspecialities (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This has a substantial impact on the physical and mental well-being and higher rates of burnout in surgical residents compared to their medical counterparts (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The prevailing data supports the hypothesis that the image of surgeons held by medical students is often a result of preconceived ideas and stereotypes, often cultivated by media, rather than an accurate reflection of the reality of the profession (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This image often resolves once students have gained more insight into the clinical practice of surgery. Nevertheless, offered possibilities for students in early stages of their medical education are often lacking, leading to a delayed perception of the actual surgical working environment and increases possible misperception and prejudices(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eGender disparities in surgery\u003c/h3\u003e\n\u003cp\u003eThe surgical role perceived by medical students has several traits that reflect masculine gender normative stereotypes (\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Although the number of female residents in surgery increases, female surgeons are less likely to be promoted or even account for leadership positions (\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).Furthermore, even female leaders who have succeeded have reported a lack of female role models or mentors. Additionally, female residents face higher stress levels, are at higher risk for burnout and often experience gender associated microaggression and discrimination by their co-workers and patients (\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Consequently, it is a legit and accurate perception among medical students, that surgery is a male-dominated field. Moreover, the gender disparity in our collective\u0026acute;s perception of the impact of the burden on mental health is consistent with existing data.\u003c/p\u003e \u003cp\u003eAlmost two thirds of the participants of this survey agreed, that a surgical career is difficult to balance with family planning. Female medical students agreed to this even more frequently. Recent surveys conducted by neuro-oncological, German and European societies of neurosurgery and interdisciplinary neurooncology have supported the relevance of this issue, particularly among female clinicians (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs self-fulfillment and a focus on work-life balance is rated more relevant in the current generation of medical students, the availability of childcare programs and opportunities for maternity or paternity leave have an increasing impact on career choices of generation Y medical students (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eNeed for support programs and role models\u003c/h2\u003e \u003cp\u003eIn our cohort, 89.0% of participants expressed interest in potential support programs for balancing a surgical career with family life. Furthermore, 65% of the participants would even accept an extension of their surgical residency training by one year. This might implicate that the obstacle to pursue a career in surgery might be less likely based on the lack of interest and motivation, but more a consideration of eligible concerns. The willingness of the participating medical students to extend their residency reflects a demand for support to face the aforementioned issues. This is in line with students in their last year expressing the need for structured teaching leadership, communication and career management skills (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The generation, currently entering the medical field faces a lack of representation and role models, which can only be compensated by structured mentoring and support programs (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eExperience from recently generated structured mentoring programs, especially for young female clinicians show, that there is a great acceptance and need for support (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Of note, the literature has emphasized the necessity for change and the implementation of sustainable resident programs, incorporating sufficient time for personal development and private life (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Legislative changes, such as working hour restrictions have been shown to have not only a positive impact on physicians\u0026rsquo; health but also on increasing patients\u0026rsquo; safety (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). However, a negative effect on surgical training is also evident due to decreased surgical exposure during training (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).Taken together, it will remain an ongoing challenge to provide a surgical residency program that integrates a structured, high-quality training curriculum with sustainable work-life balance and fair career opportunities. While support programs are an important prerequisite especially for female future surgeons, early promotion of such structural improvements among medical students are necessary to attract the best talents.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOverall, survey participants in their early stage of medical education rate surgical disciplines as highly demanding, competitive and difficult to balance with private life. This finding is indicative of a general negative perception of the surgical profession. The results of the study advocate for the implementation of programs that support the reconciliation of professional and family life. Such programs may contribute to an enhancement in sustainable resident application numbers in surgical subspecialties and might improve the physical and mental health of surgical residents.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e\u0026nbsp; not applicable\u003cbr\u003e\u0026nbsp;After careful considerations of the local ethical committee Tuebingen, the need for consent to participate was waived by the Institutional Review Board (local ethical committee Tuebingen). Ethical approval was not necessary since the survey was anonymous and completely voluntary (ethical committee Tuebingen/ 242/2024B02).\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eConsent for publication:\u003c/u\u003e not applicable\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eCompeting interests:\u003c/u\u003e the authors declare that they have no competing interests\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eData availability:\u0026nbsp;\u003c/u\u003eAll data analyzed during this study are included in this published article and its supplementary information files.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eConception: FB, Data curation and analysis: HB, HG, JT, PH, CR, MT, FB, Writing of first manuscript draft: HB, HG and FB, Figure curation: HB. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge support by the Open Access Publishing Fund of the University of T\u0026uuml;bingen\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eSupplementary\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupplementary Material 1: \u0026nbsp; \u0026nbsp; Reflection Questions \u0026nbsp;\u0026nbsp;\u003cbr\u003eSupplementary Material 2: \u0026nbsp; \u0026nbsp; Survey on the role perception of surgeons\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003cbr\u003e\u003c/strong\u003eNone.\u003c/p\u003e\n\u003cp\u003eOpen Access funding enabled and organized by Projekt DEAL.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEtzioni DA, Liu JH, Maggard MA, Ko CY. The aging population and its impact on the surgery workforce. 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Acta Neurochir (Wien). 2019;161(5):843-53.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Surgical career, pre-clinical medical students, medical education, gender disparity, work-life balance","lastPublishedDoi":"10.21203/rs.3.rs-6238373/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6238373/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Surgical professions in Western Europe deal with serious challenges to inspire students to pursue a surgical career and counteract demographic change. Students’ interest in sub-specialization is influenced by socio-economic factors including work-life balance, flexible working hours and appreciation. However, robust data about the current perception of surgical professions in the early stage of medical education is lacking so far.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We performed a voluntary online survey amongstudents who participated in an elective neurosurgical course during their preclinical stage of medical studies. The survey addressed perception of surgical professions, including personal requirements, profession impact on health and lifestyle and the topic of gender disparities and family planning. We also assessed viewpoints on support programs facilitating compatibility of surgical training and family life.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 109 students participated in the voluntary survey (66.1% female; 33.0% male, 0.9% unknown). 55.5% of respondents had prior experiences with surgical professions and 33.9% planned to pursue a surgical career. Most respondents rated surgical professions as more demanding for the physical health and more harmful for the health of physicians than other specialties. However, mental implications were higher rated in other professions. Interestingly, female participants agreed to higher career chances for male residents as well as to difficulties to combine family planning and performing the surgical profession, whereas male participants remained more neutral to both statements.\u003c/p\u003e\n\u003cp\u003eOverall, 89.0% of participants expressed interest in support programs increasing compatibility of professional and personal life. Furthermore, 65.1% of participants would be willing to accept an extension of their surgical resident time by a year.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eIn summary, pre-clinical medical students rate surgical disciplines as highly demanding, competitive and difficult to balance with private life. Early awareness of structured support programs may positively influence may improve sustainable resident application numbers in surgical sub-specialties.\u003c/p\u003e","manuscriptTitle":"Pre-clinical medical students' perception of surgical professions – too demanding and difficult to balance with private life?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-23 11:07:53","doi":"10.21203/rs.3.rs-6238373/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"3815729860838547075398257744024513545","date":"2025-05-21T12:49:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-21T12:39:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-30T08:31:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-09T07:46:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-05T12:09:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-04-05T12:08:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3665c4e4-e5de-4b03-9462-c6e6e2e0d0df","owner":[],"postedDate":"April 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-05-21T12:53:24+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-23 11:07:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6238373","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6238373","identity":"rs-6238373","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}