Faculty wellness in academic medicine: Addressing stressors in the workplace

Abstract

BACKGROUND:

Burnout is widely regarded as a syndrome resulting from chronic occupational stress. While physician burnout has been the subject of extensive research, physician wellness has been proposed as an alternative framework for understanding physician distress.

OBJECTIVE:

The purpose of this qualitative study was to understand the organizational context of faculty wellness within an academic health care system.

METHODS:

Semi-structured interviews were conducted with 24 chairs of clinical and non-clinical departments in a US university school of medicine.

RESULTS:

Chairs described several system-level factors perceived to interfere with faculty wellness such as a stricter regulatory environment, the loss of professional autonomy, the up or out promotion system, limitless hours, and the rise of shadow work. While all chairs articulated some degree of responsibility for the wellness of their faculty, some said they lacked the skills or knowledge of resources to fully engage in this role.

CONCLUSIONS:

Findings from this study are consistent with recent research on physician burnout, which has pivoted from describing burnout as an individual responsibility to including the professional, organizational, and societal factors which likely contribute to physician job satisfaction and well-being. As health care organizations, including academic medical centers, move toward systems-based solutions for physician occupational health, it will be incumbent upon organizational leaders to make administrative decisions favoring physician wellness.

Keywords

Physician burnout occupational stress organizational change culture of wellness

1 Introduction

The occupational health of physicians is in crisis. As rates of burnout, depression, substance use disorders, and suicide among physicians remain high [1 –5] health care systems are seeking ways to better predict and prevent physician distress. Changes in the next wave of health care reform will inevitably impact physicians and perhaps exacerbate the multiple factors related to physician distress [6]. Many health care providers are calling for a culture change in medicine [7]. Underscoring the importance of this issue, the National Academy of Medicine convened an Action Collaborative on Clinician Well-Being and Resilience and has called for targeted research on the organizational and health care system factors that inhibit the well-being of health care professionals [8, 9].

While there continues to be a substantial focus on physician burnout, physician wellness has been proposed as an alternative framework for understanding physician distress [10, 11]. Medical and professional organizations have proposed wellness models that emphasize balance among the multiple dimensions (i.e., physical, emotional, intellectual, social, occupational, financial, and spiritual) of human experience [12]. At present, there is no commonly accepted definition of the construct of wellness and no standardized measures of wellness for a physician population [13, 14].

Further, the emerging published literature on physician wellness is comprised of descriptions of wellness initiatives and programs in academic medicine for medical students and residents [15 –17] and to a lesser extent for faculty [18]. As with burnout, most wellness interventions have been focused on the individual. In more recent studies in both the physician burnout and wellness literatures, findings suggest that interventions should focus on both individual and organizational factors [19 –24].

The present study was originally conducted as part of a quality improvement activity on faculty wellness initiated by the dean of a school of medicine. This study on faculty wellness is from the point of view of department chairs. Department chairs set the academic priorities of their departments, manage department personnel, and liaise with the administration and senior leadership of the organization. As such, they are uniquely positioned to provide insight into the personal, professional, and organizational factors presumed to be associated with faculty wellness. An exploratory design was a useful first step for understanding the organizational context of faculty wellness within academic medicine. The following research questions guided this inquiry:

How do department chairs conceptualize faculty wellness? What responsibility, if any, do department chairs have for the wellness of their faculty?

What factors or conditions contribute to or interfere with the wellness of their faculty?

How do department chairs regard the quality and availability of existing resources for promoting faculty wellness? What resources are still needed?

The goal of this analysis is not to provide the final and conclusive answers to these research questions but to contribute to an emerging theory on faculty wellness that could form the basis for future investigations.

2 Methods

For this investigation of the phenomenon of faculty wellness, we employed a basic qualitative design [25]. An interpretivist approach [26] was adopted for this study to understand the meaning of faculty wellness from the perspective of those in the academic health care system. An inductive approach was also used by Schrijver et al. [27] and Van Den Berg et al. [28] in their investigations on the wellness of medical school faculty.

2.1 Setting and participants

This study was conducted in a US university school of medicine. Faculty in this school of medicine included MDs and PhDs serving in clinical, education, and/or research roles. Study participants were chairs of clinical and non-clinical departments in the school of medicine. All of the department chairs in this university (N = 30) were invited to participate in the study. Twenty-four department chairs consented to participate and were included in the final analysis of data.

2.2 Data collection

Semi-structured, individual interviews were conducted with participants over a four-month period in 2013. This method was useful to gain an understanding of reasons underlying people’s perceptions [25]. The general format of the interview protocol was lead questions asked uniformly to all participants followed by specific questions relevant to a particular person or topic. Since qualitative research is often an emergent process [29] the protocol evolved as new information was collected. Interviews were audiotaped and transcribed verbatim.

2.3 Data analysis

The technique of constant comparison was used to analyze the interview data [30, 31]. In the first phase of data analysis, a transcript was read several times in order to grasp the essence of the entire interview. Coding of the data proceeded with a line-by-line analysis of the responses to the interview questions. A descriptor was assigned to small units or chunks of data. In the second phase, patterns in the data were pursued and open-coded data were organized into categories. In the final phase, the researchers developed one or more themes that expressed the content of each of the groups. Half of the transcripts (n = 12) were coded in this way. Once the coding scheme was established, the remaining transcripts were analyzed allowing opportunity for new codes to emerge. Results were compared against the original research questions and inferences were made.

3 Results

3.1 Chairs’ Definitions for faculty wellness

Chairs had various definitions for faculty wellness. Many described the wellness of their faculty in terms of physical health such as adequate exercise, sleep, and nutrition. Fewer chairs described the wellness of their faculty in terms of mental health. Those who did recounted experiences with faculty suicide, drug and alcohol abuse, and depression. Several chairs focused on work-related wellness, which they described as maintaining a work-life balance or meeting professional expectations and obligations while sustaining job satisfaction. For at least one chair, wellness was indicated by the absence of burnout.

3.2 Factors related to faculty wellness

Chairs focused on the organizational factors perceived to interfere with faculty wellness. Chairs in this study headed either a clinical or non-clinical department, and organizational factors could be further refined by these settings though some factors were ubiquitous. For example, chairs of clinical departments cited an emphasis by the organization on metrics for clinical productivity and performance as well as limited control over staffing (i.e., numbers and schedules) as factors inhibiting faculty wellness. Chairs of non-clinical departments focused on the impact on their faculty of the reduction of federal funding for research, repeated grant rejections, and feeling as though their contributions were unacknowledged or unappreciated by the organization. Chairs of both clinical and non-clinical departments described a stricter regulatory environment, the loss of professional autonomy, the up or out promotion system, limitless hours, and the rise of shadow work (i.e., administrative burdens) as inhibitors of faculty wellness. While chairs acknowledged their faculty was straining to balance clinical service, research, and teaching, many attributed this to the price of success in academic medicine.

Chairs had less to say about the protective factors for promoting faculty wellness. A few chairs described how faculty mentoring fostered a supportive culture in their departments. These were largely informal efforts organized by senior faculty or the chairs themselves to help junior faculty navigate the academic environment. Natural peer support (as opposed to a structured peer support program) was mentioned by some chairs as a mechanism for promoting wellness. Overall, however, most chairs considered the multiple stressors faced by faculty as inevitable or unavoidable and found it difficult to conceptualize how a sense of wellness could be created in their current work environment.

A few chairs described a culture of cynicism regarding wellness in their departments and stated wellness initiatives had been met with some resistance. One chair described the pervasive culture of bravado and stoicism in medicine as a barrier to wellness initiatives. They speculated that this culture could discourage some faculty from seeking help. Other potential barriers to seeking help by troubled faculty were concerns over career blowback, the practicality of fitting therapy or other wellness-promoting activities into a crammed work schedule, and lack of knowledge of existing resources.

3.3 Chairs’ Roles in faculty wellness

All chairs articulated some degree of responsibility for the wellness of their faculty. Chairs described approaches like having an open-door policy to encourage faculty to talk when needed. Several said it was their responsibility to lead by example and model desired behavior either by setting the psychological tone of the department or by maintaining their own physical health. Some stated their positions required them to have the capacity to respond to issues or crises as they developed. A few chairs took a more direct approach. They described taking actions to encourage individual or departmental success. One chair focused on fostering faculty autonomy, which he said was eroding due to the excessive bureaucratization of academic medicine. A few chairs described hiring practices to promote equity while others terminated faculty perceived as barriers to the greater good of their departments.

Some chairs said they had a limited role in the wellness of their faculty and lacked the skill or knowledge of resources to fully engage in this role. They expressed uncertainty on how to inquire about a faculty’s wellness and were unclear what, if any, laws or policies protected a faculty member’s right to privacy in the workplace. As a result, many did not feel empowered to act until there were obvious problems such as interpersonal conflicts, unprofessional behavior, or inadequate performance of duties. Chairs confronted with these personnel issues consulted administrative resources, such as the dean’s office or the state physician health program, for guidance. At least one chair acknowledged an inherent conflict in faculty disclosing issues of wellness to the chairs because of their role in deciding faculty promotion and tenure. Many chairs said it was incumbent on the dean’s office to endorse faculty wellness where much of the power to make systems-level change resided.

3.4 Chairs’ Perceptions of their own wellness

Some chairs were forthcoming with their own experiences of work-related wellness. It was clear chairs were not immune from the personal, professional, and organizational factors that were, from their perspectives, affecting the wellness of their faculty. Chairs said their administrative workloads had increased causing interpersonal relationships with their faculty to suffer. Chairs also described juggling multiple, competing priorities and operating from a position of high responsibility but low authority. Chairs were aware of the potential adverse effects of physician distress in the workplace (e.g., medical errors and patient dissatisfaction) and were concerned how these consequences if not managed might reflect on their departments or on the school of medicine. At least one chair questioned whether new graduates should even consider academic medicine as a career path. In essence, these chairs described feeling “lonely at the top”—isolated from their faculty both personally and professionally—and were questioning their capacity to support distressed faculty when they themselves were taxed and stressed.

3.5 Resources for faculty wellness

Beyond the dean’s office and the state physician health programs, chairs’ knowledge of existing resources to promote faculty wellness was limited, and none were aware of a complete set of resources. A few had referred faculty to the employee assistance program and the human resources department. Some described homegrown solutions for wellness such as a champion of wellness in their department or service chiefs who were particularly attuned to the needs of staff. Almost all said it would be useful for the school of medicine to maintain a comprehensive and centralized list of resources for faculty wellness.

In terms of desired resources for faculty wellness, chairs of both clinical and non-clinical departments wanted direction from the organization on how to talk with faculty about wellness without compromising their privacy. Many chairs said a mid-level detection and support system was needed to deescalate situations before complaints reached the ombuds. Chairs of non-clinical departments wanted the school to offer seminars on work-life balance and how to get off the ground in research. Those conceptualizing wellness in terms of physical health wanted investments in infrastructure such as shower facilities, lockers, and exercise equipment and healthier after-hours ala carte options in the cafeteria.

4 Discussion

We conducted individualized, semi-structured interviews with department chairs in a school of medicine to understand the state of faculty wellness. We found chairs in this study had various understandings of wellness. This finding provides further support for wellness as a multidimensional construct and alludes to a conceptual definition that is not merely the absence of burnout. As research on physician wellness moves forward, it is important to provide conceptual clarity for a wellness construct since the approaches for enhancing wellness may be distinct from those for preventing burnout [11 , 14].

A major theme that emerged was the perceived locus of responsibility for wellness (i.e., internal vs. external). Chairs had differing views on whether the individual or the organization was ultimately responsible (or to blame) for faculty wellness. Nonetheless, most chairs focused on the organizational and professional factors rather than the personal factors they perceived as inhibiting faculty wellness. In other words, from their perspective it was not the episodic life events that largely inhibited a faculty member’s overall wellness but the loss of professional autonomy, the fixation on hospital performance metrics by administrators, and the uncertain business of academic medicine. This finding is consistent with recent studies pointing to system-level drivers of physician burnout [20 , 33] and extrinsic factors as barriers to work-related wellness for academic physicians [28].

We found that most chairs described their primary role as administrators of the operations of the department of which tending to the wellness of their faculty was an ancillary concern. Yet, given the various approaches to managing faculty wellness described by chairs in this study, it seems department chairs could play a more significant role in faculty wellness. For example, Shanafelt et al. [34] found a significant relationship between the leadership qualities of physician supervisors and the professional satisfaction and burnout of individual physicians. This finding underscores the importance of good leadership to the immediate satisfaction and well-being of health care providers and the general success of the health care organization. Thus, to raise the chair’s profile on wellness, organizational leadership must first make faculty wellness a priority, much as professionalism, ethics, quality of care, and patient safety have become high priorities in medical practice, and then formalize wellness into the role of the department chair.

Chairs naturally have different dispositions, skill sets, and leadership styles and, consequently, each will take a different approach to wellness management in their departments. Few chairs in this study asked faculty directly about their wellness either for fear of intruding on their privacy or for lack of adequate skills in this area. Fear of not having anything to offer faculty might also impede questions about a faculty’s wellness. As a result, a faculty’s experience of generalized distress, depression, or low-level burnout could go unnoticed by a department chair. We found it was not until a behavior hit the threshold of overtly unprofessional or dangerous that intervention was sought by chairs and in most cases, chairs knew how to access organizational resources for faculty in crisis.

If department chairs are to have a more pronounced role in faculty wellness, it will be incumbent on a school of medicine to support chairs in this role with training and resources. For example, chairs could benefit from training on recognizing the physical and mental signs of emotional distress and on interacting with distressed faculty. Additionally, clear directives for discussing the personal health and well-being of faculty members are needed. This would include an employer’s legal obligations with respect to maintaining the privacy of employee information and what constitutes invasion of privacy in the workplace. This approach might empower chairs to act before an issue exacerbates and results in disruptive or dangerous faculty behavior. Chairs also should have access to a comprehensive and centralized list of resources for faculty wellness as well as instruction on the referral process. This complete set of training and resources should be offered as part of the onboarding protocol for newly hired department chairs and as needed to existing chairs.

Still, chairs in this study described with remarkable consistency systemic inhibitors to faculty wellness in academic medicine, which cannot be resolved by merely bolstering the department chair with training and resources. There was some sense that in establishing faculty wellness as an organizational priority the dean of the school of medicine and executive leadership could, by their actions, improve the state of faculty wellness. Others have reached this same conclusion [27 , 35–37].

There are several potential limitations to this study. This study was conducted at one academic health care organization. As such, these findings may not generalize to other academic health care organizations or health care settings. Also, the focus of this study was department chairs’ perceptions of their faculty’s wellness. Chairs’ insights to the factors contributing to or interfering with the wellness of their faculty may be different from faculty members’ experiences and perceptions of these factors. A next step would be to conduct focus groups with faculty in these departments to triangulate the findings on this phenomenon. Results of this qualitative phase could shape the collection of data in a second quantitative phase by developing a survey that would be distributed to a representative sample of faculty in academic health care organizations.

5 Conclusion

In this exploratory study on faculty wellness in an academic health care system, we found preliminary evidence indicating system-level factors may inhibit faculty wellness. Additionally, for department chairs to play a more significant role in the management of their faculty’s wellness the organization must make wellness a priority and support the department chair in this role. Findings from this study are consistent with recent research on physician burnout, which has pivoted from describing burnout as an individual responsibility to including the professional, organizational, and societal factors, which likely contribute to physician job satisfaction and well-being.

Conflict of interest

None to report.

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