University of Southern California Dissertations and Theses

The impact of the COVID-19 pandemic on physician burnout in LA County Hospital settings

(USC Thesis Other)

The impact of the COVID-19 pandemic on physician burnout in LA County Hospital settings

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content

The Impact of the COVID-19 Pandemic on Physician Burnout in LA County Hospital

Settings

by

Ramella Markarian

Rossier School of Education

University of Southern California

A dissertation submitted to the faculty

in partial fulfillment of the requirements for the degree of

Doctor of Education

May 2022

i.

© Copyright by Ramella Markarian 2022

All Rights Reserved

ii.
The Committee for Ramella Markarian certifies the approval of this Dissertation

Bryant Adibe Ph.D.

Jenifer Crawford Ph.D.

Emmy J. Min Ph.D., Committee Chair

Rossier School of Education

University of Southern California

2022

iii.
Abstract

Physicians are experiencing higher levels of burnout than any other profession. While this has
been true since research on professional burnout began decades ago, it is becoming increasingly
true during the COVID-19 pandemic. Physician burnout has a significant impact on physicians,
patients, physician and patient families, hospital administration and leadership, and the
communities that the hospitals and physicians serve. Physician burnout negatively impacts
physician mental and emotional wellbeing, physical health, career longevity, hospital revenue
and physician turnover, patient wellbeing, patient mortality, and even physician mortality.
Previous and current research and literature demonstrate that physician burnout
disproportionately affects female physicians more than male physicians. This was a mixed-
methods research study that includes a literature review, qualitative data through interviews, and
quantitative data through surveys. This study was conducted for physicians who worked during
the COVID-19 pandemic in a hospital setting within LA county. There was a total of 51
physicians who participated in the survey for this study and five physicians who participated in
the interviews for this study. The overarching focus of this study was to understand what
changes during the COVID-19 pandemic were implemented by hospital leadership that either
contributed to or helped alleviate physician burnout. The recommendations of this study are to
further research how physician identity impact physician burnout and in what ways hospital
leadership can contribute to alleviating physician burnout.

iv.
Acknowledgements

I would like to thank the following people, without whom I would not have been able to
complete this research, and without whom I would not have made it through my Doctoral
program!
My love and my heartfelt thanks to my two children who have been my biggest
accomplishment and achievement in life. Sione and Eric you both inspire me every day to be
a better version of myself. Your unconditional love and support during my most stressful
three years, helped me stay strong and push through; I hope I made you as proud as you make
me every single day. I love you both more than you’ll ever know and I am dedicating my
Doctoral Degree to both of you.
I’d like to thank my mom Mary and my aunt Helen who have been my rocks and my
angels– without them this difficult journey would not have been possible.
Finally, I’d like to extend my deepest gratitude to all the physicians who took the time
from their busy schedules and responded to the surveys and interviews. You are my heroes and I
dedicate this dissertation to all of you. I promise to continue my work and be an advocate to help
alleviate “Physician Burnout” as best as I can.

v.
Table of Contents

Abstract .................................................................................................................................................................... iv

Acknowledgements ................................................................................................................................................ v

Chapter One: Introduction ................................................................................................................................... 1

Related Literature on Physician Burnout and COVID-19 Pandemic ........................................ 2

Purpose of the Project and Questions ................................................................................................. 8

Conceptual Framework ........................................................................................................................... 9

Methodological Framework ................................................................................................................11

Definitions ................................................................................................................................................11

Organization of the Study ....................................................................................................................12

Chapter Two: Literature Review ..................................................................................................................... 13

Overview of Existing Physician Burnout ....................................................................................... 14

The Lack of Diversity and Inclusion in Healthcare Leadership .............................................. 22

The Pandemic ..........................................................................................................................................29

Bronfenbrenner’s Social-Ecological Systems Theory .................................................................34

Summary ...................................................................................................................................................38

Chapter Three: Methodology ........................................................................................................................... 39

Organizational Context and Mission .................................................................................................40

Organizational Performance Need ..................................................................................................... 41

Overview of Design ................................................................................................................................ 41

Research Methods ................................................................................................................................. 48

Chapter Four: Results and Findings ................................................................................................................ 53

Data Coding & Themes ........................................................................................................................59

vi.
Results and Findings .............................................................................................................................. 63

Summary of Findings ............................................................................................................................86

Chapter Five: Discussion, Conclusion, and Recommendations ............................................................ 87

Interpretation of the Findings ..............................................................................................................87

Physician Identity ...................................................................................................................................94

Limitation of the Study .........................................................................................................................95

Recommendations ..................................................................................................................................96

Implications for Positive Organizational Change ........................................................................100

Summary .................................................................................................................................................. 101

Conclusion ............................................................................................................................................... 103

References ............................................................................................................................................................ 105

Appendix A: Survey Questions ................................................................................................................... 118

Appendix B: Interview Questions ................................................................................................................ 121

vii.
1

Chapter One: Overview of the Study

This study aims to explore the extent to which the COVID-19 pandemic has impacted
existing physician burnout and the significance of leadership diversity and inclusion and
physician identity on the factors contributing to burnout and the level of burnout experienced.
Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and a
decreased sense of personal accomplishment (Shanafelt et al., 2012), all of which can
significantly impact physician performance at work as well as the emotional and mental
wellness of physicians (Patel et al., 2018). Increasing burnout rates among physicians in hospital
settings has been a significant problem as it leads to increased medical errors, lower quality of
care for patients, costly issues for hospitals, high physician turnover rates, and physician
depression and suicide (Patel et al., 2018). Burnout symptoms in the United States affect 30% to
68% of physicians overall, exceeding the levels of any other professional group (Shanafelt et al.,
2012). Diversity is defined as the differences and similarities that exist among people, and
inclusion refers to incorporating the ideas, perspectives, and contributions of everyone on the
diverse team (Kalina, 2019). Health care facilities can ensure their competitiveness and reduce
physician burnout by creating and maintaining a truly inclusive environment (Kalina, 2019).

The 2016 provider engagement survey by the Mayo Clinic indicates a 12% increase in
physicians reporting at least one symptom of burnout compared to the same survey conducted in
2011 (Shanafelt et al., 2016). While physician burnout in US hospital settings was already trending
upward, the COVID-19 pandemic’s impact is contributing to an acceleration of existing high levels
of physician burnout (Bendix, 2020). In addition to the stressors of demanding schedules, increasing
amounts of paperwork, frustrations with third-party funding sources, and
2

increasing regulations, policies, and procedures (Patel et al., 2018), physicians face further
challenges with caring for COVID-19 patients with limited resources while trying to stay healthy
themselves (Bendix, 2020). Pre-pandemic research demonstrated that burnout disproportionately
impacted female physicians, and now compounding burnout from the pandemic impacts female
physicians more so than their male counterparts (Michael, 2020). However, research does not yet
indicate a strong relationship between physician racial and ethnic identity and burnout (Cantor &
Mouzon, 2020). While this study is being conducted in the midst of the COVID-19 pandemic in
2020 and early 2021, and research on the topic is scarce, it is becoming evident that the pandemic’s
impact is increasing physician burnout (Bendix, 2020) and that physician identity may play a role in
the contributing factors and level of burnout experienced (Michael, 2020). Considering that before
the COVID-19 pandemic, increasing levels of physician burnout posed risks to the quality and
quantity of life for physicians and patients as well as the cultural and financial wellbeing of the
hospitals (Patel et al., 2018), exacerbating physician burnout may have dire consequences during and
after the pandemic.

Related Literature on Physician Burnout and COVID-19 Pandemic

Increasing levels of physician burnout pose risks to the quality and quantity of life for
physicians and patients and the cultural and financial well-being of Los Angeles county hospitals
(Patel et al., 2018). The extent of the impact of the COVID-19 pandemic on physician burnout is
yet unknown, and, if the impact exacerbates existing high levels of physician burnout, it could
create a greater risk of the adverse consequences of burnout, such as medical errors, absenteeism,
and costly physician turnover (Patel et al., 2018). Developing strategies to reduce burnout among
physicians within LA county hospitals could have a positive impact on overall physician
3

performance and wellbeing as well as patient safety and quality outcomes (Patel et al., 2018).
The need for strategies aimed at reducing physician burnout might be especially heightened
during and after the COVID-19 pandemic as the impact of the pandemic is likely to contribute
to physician burnout. Additionally, understanding the impact of the COVID-19 pandemic on
physician burnout may provide insights into how to prevent and treat physician burnout after the
pandemic (Hartzband & Groopman, 2020).

Contributors to Physician Burnout

Major contributors to physician burnout are identified as the implementation of electronic
health records and related policies and procedures (Bendix, 2020), lack of work-life balance
(Walden, 2016), and feelings of not being supported by hospital administration and leaders
(Patel et al., 2018).

Healthcare Leadership Diversity and Inclusion

Racial and ethnic diversity in hospital leadership. There may be a relationship
between some of the identified causes of physician burnout and a lack of diversity in healthcare
leadership. Research demonstrates that an organization’s long-term success is undermined when
leadership is made up of like-minded people as this undermines the ability to be innovative and
evolve through changing dynamics (Kalina, 2019). Research from the American Hospital
Association in 2019 demonstrates that 89% of all hospital CEOs were white (American College
of Healthcare Executives [ACHE], 2020). Given that the U.S. Census Bureau indicate that 60%
of the population is white (ACHE, 2020), it is apparent that the diversity of hospital leadership
is not reflective of the diversity of our society. Further, it is important to note that simply hiring
diverse physicians, staff, and leadership is not conducive to achieving the increased efficiency
4

and productivity that come from the inclusion of diversity perspectives and viewpoints,
each member must be valued, appreciated, and given the space to comfortably share
differing perspectives (Kalina, 2019).

An example of how increasing diversity and inclusion in healthcare leadership may
reduce burnout among physicians can be seen in physician’s identifying a lack of support from
hospital administration and leadership. Inclusion, beyond simply increasing numbers of diverse
members, have been shown to build trust and feelings of being supported within organizations
(Ely & Thomas, 2020). For examples, when diversity and inclusion truly exist in an
organization’s leadership, they will be more likely to explore new and creative approaches to
decreasing physician burnout. Additionally, an increased sense of belonging and support
within the organization may reduce physician burnout as a lack of trust and support was
identified as a leading contributor to physician burnout.

Gender diversity in hospital leadership. There may be a relationship between some of the
identified causes of physician burnout and the leadership gender gap in healthcare. A 2014 study
revealed that only 24% of senior executives and 18% of hospital CEOs were women (Hauser, 2014).
Considering that 76% of the healthcare workforce is comprised of women (Cheeseman &
Christnacht, 2019), it follows that the leadership gender gap is not representative of the healthcare
workforce. The need to narrow the gender gap in healthcare leadership becomes apparent as a 2017
study by the Center for Creative Leadership found that organizations with women in leadership roles
consistently ranked higher in job satisfaction, employees felt more supported, and employees
reported less job burnout (Clerkin, 2017). As research reveals that
5

women in leadership roles lead to higher job satisfaction and lower burnout rates, the high levels
of physician burnout may be related to the gender gap in healthcare leadership (Hauser, 2014).

An example of how narrowing the healthcare leadership gender gap may reduce burnout
among physicians can be seen within organizational expectations of work-life balance. The
gender gap in healthcare leadership may influence physician burnout rates as the existing
leadership cultures discourage work-life balance (Hughes et al., 2009). For example, physicians
identified negative behaviors observed in hospital leadership as contributing to burnout (Patel et
al., 2018). Examples of negative behaviors demonstrated by leadership include lack of work-life
balance, exclusivity, and lack of collaboration between departments (Patel et al., 2018). Research
also shows that the cultures of existing healthcare leadership demonstrate a disregard for work-
life balance (Hughes et al., 2009). Additional research demonstrates the significant influence that
many aspiring and established physicians attribute to observational learning, as in learning
expectations, processes, and procedures by observing the behaviors of organizational leadership
(Taylor et al., 2009). The literature demonstrates that by disregarding work-life balance, existing
leadership cultures create a professional environment that demands the same of their physicians
through observational learning. This is problematic as work-home interference is identified as a
contributor to physician burnout (Linzer et al., 2014).

Learning & Development for Leadership

Research demonstrates a relationship between leadership learning and organizational
culture (Waldman et al., 2009). Therefore, learning opportunities for healthcare leadership may
be a significant factor in creating gender-inclusive leadership and reducing physician burnout
(Clerkin, 2017). Developing learning opportunities for hospital leadership to recognize that a) a
6

lack of diversity and inclusion exists within healthcare leadership (Hauser, 2014), b) the lack of
diversity and inclusion in leadership may influence physician burnout rates (Clerkin, 2017), c)
physicians are learning from the behaviors that they see in leadership (Taylor et al., 2009), and d)
leadership is demonstrating a cultural expectation of an unhealthy work-life balance may be
critical to reducing physician burnout rates (Hughes et al., 2009). Initial leadership buy-in for
participating in such learning opportunities may be developed through research that reveals how
physicians, patients, and hospitals could be better served by reducing physician burnout (Patel et
al., 2018). By approaching the need for greater work-life balance through a learning perspective,
leadership may develop awareness and skills in demonstrating more positive behaviors and
thereby reducing burnout among physicians. Developing leadership buy-in may help reduce
physician burnout during and after the COVID-19 pandemic.

Importance of Organizational Innovation to Reduce Physician Burnout Rates

Developing educational programs for the health and wellness of physicians in US
hospital settings during and after the COVID-19 pandemic is essential to a LA County based
hospital organization’s ability to fulfill its mission and maintain successful operations. As these
are unprecedented experiences, innovation is paramount to success. Diversity and inclusion drive
innovation in organizations (Kalina, 2019). Traditionally, most learning and development
programs developed and implemented to decrease physician burnout focused on the physicians
and teaching them skills such as stress management (Kannampallil et al., 2020). These
approaches did not show a decrease in physician burnout rates, and in some cases, physician
burnout rates continued to increase (Kannampallil et al., 2020). The COVID-19 pandemic is an
opportunity to gain insight into the causes of physician burnout during normalcy and how the
7

increased demands of a pandemic can be prepared for future situations. Given that physician,
burnout contributes to medical errors, decreased quality of care, and physician depression and
illness (Patel et al., 2018), investing in preventing and treating physician burnout during and after
a pandemic can contribute to improved patient outcomes as well as a higher quality of care and
physician wellness.

Organizational Performance Goal

The goal for HealthFirst, Inc., a consulting agency, in working with hospitals is that 100%
of the physicians will receive training and coaching in regard to burnout causes, triggers,
symptoms, treatment, and innovative approaches. The entire training program will be for the
duration of six months and include instructor-led training, an eLearning component, and
professional coaching. The initial instructor-led training will be four hours a month, the
eLearning component will be a total of two hours a month, and the coach will meet regularly for
two hours with physicians and administration each month. The total time for the training
program pilot for the six months will be 48 hours per learner (approximately one workday each
month). After the initial six-month pilot training program, outcomes will be measured by a
review and evaluation of tracked data on patient outcomes, physician surveys, and patient and
patient family satisfaction surveys. After the initial six-month pilot program and subsequent
evaluation, the hospital learning and development department will assess either the need for a
new training program or the delivery and method of an ongoing training and supplemental
coaching program to ensure that physician burnout rates do not increase and therefore patient
outcomes, patient satisfaction, and physician wellness are consistently great.
8

The goal of the proposed educational program and strategies is to reduce physician
burnout in times of normalcy as well as during and after a pandemic. If physician burnout rates
are decreased in times of normalcy, the hospital may be more equipped to respond to a
pandemic and physicians may be better able to meet the demands of the pandemic without
sacrificing their physical and emotional wellbeing.

Stakeholder Group for the Study

The HealthFirst, Inc. stakeholders are the physicians and leadership, and, by extension,
the physicians’ patients and communities. However, for the purposes of this research study, the
focus will remain on physicians and administration as the stakeholders. The stakeholders’ goal
is to be able to provide quality healthcare, meet the community’s unmet healthcare needs, and
comply with third-party payor contracts as well as external regulations, policies, and procedures.
The physicians are on the front lines of achieving the organizational goals, and physician
performance, skills training, and behavior impact patient experience and satisfaction as well as
clinical outcomes and safety. The administration at hospitals are often heavily involved in the
creation of policies and procedures that significantly impact the situations identified by
physicians as triggering burnout. These also impact the organizations’ accreditations, federal
and state requirements and benchmarks, as well as contribution margins. It is, therefore,
necessary that this study focuses on the physicians and administrative leadership.

Purpose of the Project and Questions

The purpose of this study is to understand the extent to which the COVID-19 pandemic has
impacted existing high levels of physician burnout in US hospital settings and the role that
physician identity plays in the level of burnout that is experienced. Additionally, this study aims
9

to understand in what ways the COVID-19 pandemic has impacted physician burnout as well as
the insights that the impact of the pandemic may provide in regard to changes that can be
implemented during times of normalcy to prevent and treat high levels of physician burnout.
The following questions are addressed in this study:

1) What changes were implemented within the hospital because of the COVID-19
pandemic that either contributed to or helped alleviate physician burnout?

2) What factors, particularly physician gender, racial, or ethnic identity, during the
pandemic impacted the level of burnout physicians experienced?
Conceptual Framework

To address the impact of the COVID-19 pandemic on physician burnout, the researcher
will utilize Bronfenbrenner’s Ecological Systems Theory (Bronfenbrenner, 1994).
Bronfenbrenner’s Ecological Systems Theory proposes that inherent qualities of people and
the qualities of their environments interact and influence the growth and development of each
(Bronfenbrenner, 1994). The theory proposes a set of five systems: the microsystem,
mesosystem, ecosystem, macrosystem, and chronosystem that simultaneously influence each
other. Through this framework, human development is viewed through the way in which the
most immediate communities to the broader social and cultural environments all influence one
another. Ultimately, the theory places significance on the inherent qualities of individuals that
interact differently with environments (Bronfenbrenner, 1994). For instance, physicians with
very similar ecological systems still experience environments differently due to their
individual personality traits, temperaments, and other characteristics.
10

Bronfenbrenner’s theory enables the examination of the possible relationships between the
COVID-19 pandemic and physician burnout rates, which enables a deeper understanding of how the
pandemic may influence physicians differently based on physician identity, such as gender, race, or
ethnicity. It is important to understand physician well-being from the context of multiple
environmental factors by applying Bronfenbrenner’s Ecological Systems theory as a framework that
influences physician behavior and performance. The microsystem focuses on the relations between
the developing person and other people, structures, or processes in the immediate environment. In
this case, physicians’ immediate family, children, friends, immediate work environment, and all the
duties and expectations they experience. The mesosystem contains the interactions and connections
between their environments. The exosystem is the impact of the indirect environment in physicians’
development and contains the formal and informal social structures and cultural values that indirectly
affect physicians. The macrosystem consists of the beliefs, expectations, and lifestyles of the
physicians and their cultural setting. The chronosystem refers to time and the influence that changes
physicians’ development (Bronfenbrenner, 1994).

The Ecological Systems Theory might help explain how physicians react and cope with
the feelings associated with exhaustion and being overwhelmed, especially during a crisis such
as the pandemic. The Ecological Systems approach is a perspective and a framework that can be
applied across multiple contexts and in multiple settings to accurately represent the complex and
distinctive physicians’ environment that leads to burnout and how the pandemic impacts
existing burnout.
11

Methodological Framework

To address the research questions in this study and minimize the error margin, this study
is utilizing a mixed-methods approach, drawing quantitative data from surveys and qualitative
data from interviews. The first and second research questions are both mixed methods
questions that seeks to collect and review both qualitative and quantitative data.

Definitions

Burnout

A syndrome characterized by emotional exhaustion, depersonalization, and a decreased
sense of personal accomplishment (Shanafelt et al., 2012), all of which can significantly impact
physician performance at work as well as the emotional and mental wellness of physicians
(Patel et al., 2018).

Diversity

The differences and similarities that exist among people (Kalina, 2019).

Hospital

A hospital is an institution that provides medical treatment and nursing care for patients.

Inclusion

Incorporating the ideas, perspectives, and contributions of everyone on the diverse
team (Kalina, 2019).
Intensive Care Unit (ICU)

This is the department within a hospital in which patients who have critical complications
are kept under constant observation.
Physician
12

A person licensed to practice medicine. For the purposes of this study, the term
physician is used to refer to licensed professional medical practitioners who work with a US
hospital setting on a full-time basis.

Specialists

A specialist physician is a doctor trained and practicing in a specific field of medicine.

Organization of the Study

This study has been organized into five chapters. This chapter is the first and provides the
reader with an introduction to the problem of practice being researched and the stakeholders as
well as the organizational context, mission, and performance goals. Chapter two provides
information on the existing research on physician burnout and the extent to which the COVID-
19 pandemic has impacted physician burnout, as well as outlines of areas that may benefit from
further research. Chapter three discusses the participating stakeholders and the methodologies
employed in the research for this study. Chapter four describes the results and findings of this
study. Chapter five identifies and describes proposed solutions, implementation, and evaluation
for the problem of practice.
13

Chapter Two: Review of the Literature

The purpose of this literature review is to provide the reader with an overview of existing
physician burnout within LA County hospital settings, the extent to which the COVID-19
pandemic has impacted existing physician burnout, and the role that physician identity,
specifically gender, race, and ethnicity, plays in physician burnout both prior to and during the
pandemic. While the review is being written during the COVID-19 pandemic literature is still
developing on the pandemic’s impact on physician burnout, recent literature suggests a
relationship between the pandemic and physician burnout as well as the significance of physician
identity on the extent of the impact of the pandemic. Literature published prior to the pandemic
confirms a relationship between physician gender and levels of burnout while research on
physician race or ethnicity and burnout is still needed, and new research suggests a relationship
between the impact of the COVID-19 pandemic on physician burnout and physician identity.

The first part of this chapter gives a brief overview of existing physician burnout and its
relationship with physician identity. Next, the history and nature of pandemics and details about
the COVID-19 pandemic are discussed. Afterward, the extent of impact the COVID-19
pandemic has had on existing physician burnout and the relationship between the impact of the
COVID-19 pandemic and physician identity. The chapter then provides an overview of the
ways in which the COVID-19 pandemic has helped to alleviate some of the existing physician
burnout. Finally, this chapter introduces Bronfenbrenner’s social ecological systems theory as a
lens through which to view the relationships between physician burnout, identity, and the
COVID-19 pandemic.
14

Overview of Existing Physician Burnout

Burnout was first studied in 1974, and studies focusing specifically on physician burnout
did not take place until 2011(Shanafelt et al., 2017). The study demonstrated that burnout was
more common among physicians than any other professional group (Shanafelt et al., 2017).
Research conducted prior to the COVID-19 pandemic, demonstrates that burnout is experienced
by more than 50% of physicians and impacts patients, physicians, their families, coworkers,
friends, and healthcare organizations (Rothenberger, 2017). Physician burnout is a syndrome
described as extreme exhaustion, cynicism, and decreased effectiveness at work (Shanafelt et al.,
2017). Burnout builds over time, and behaviors associated with physician burnout include
substance abuse, withdrawal, depression, interpersonal conflicts, suicidal ideation, and even
suicide (Rothenberger, 2017). According to Rothenberger, physicians experiencing burnout
have demonstrated irrational and unprofessional behavior, including verbal abuse against
colleagues. Physician burnout has also been linked to medical errors, physician turnover, and
higher mortality rates in hospitalized patients (Shanafel et al., 2017). As burnout continues to
build upon itself, its impact worsens and significantly influences the quality-of-care patients
receive and the level of patient satisfaction (Rothenberger, 2017).

Training and professional development opportunities have been employed by many
hospitals to prevent or reduce physician burnout (Rothenberger, 2017). However, individual and
organizational strategies have only been partially successful in mitigating burnout or enhancing
physician well-being (Rothenberger, 2017). It is generally agreed upon that further research is
needed to establish training or professional development that provides effective solutions to
physician burnout at both the individual and organizational level (West, 2016). Many training or
15

professional development efforts employed include building physician resiliency, which has
not proven fully successful except that resilience is identified as the cornerstone of well-being
(Parks-Savage et al., 2018). It follows then that a closer look at the contributors to physician
burnout may be necessary in identifying solutions beyond developing physician resilience.

Contributors to Physician Burnout

There are many factors credited with contributing to physician burnout, which is
understood as the effect of cumulative stress from significant changes in society, the medical
profession and the healthcare system (Rothenberger, 2017). Stress is described as a general
reaction that occurs in response to different stimuli (Bieliauskas, 2020). The stimuli that create
stress within an organism are known as stressors (Bieliauskas, 2020). Research has found that
physicians with higher stress levels, or more exposure to stressors, demonstrate more symptoms
of burnout (Lee, 2008). In fact, American psychologist, Herbert Freudenberger, coined the term
“burnout” to describe what people in the healing professions were experiencing as the
consequences of severe or chronic stress and anxiety (Rothenberger, 2017). Essentially, burnout
is considered to be stress-induced (Rothenberger, 2017). Therefore, the issues or experiences
that are identified as contributing to burnout among physicians can be viewed as stressors.

It is also thought that physician identity in terms of gender, race, and ethnicity may
have a relationship with physician burnout. While this study is interested in understanding the
relationship between physician identity and physician burnout, existing research demonstrates
that physicians with marginalized racial or ethnic identities experience lower rates of physician
burnout (Garcia et al., 2020). However, there is not enough research for this relationship to be
considered conclusive and it is unclear whether physicians with marginalized racial and ethnic
16

identities experience lower rates of burnout or are less likely to report burnout (Cantor &
Mouzon, 2020). Additionally, higher rates of burnout are found among female physicians (Lee,
2008). In addition to decreased physician autonomy, increased workload, the implementation of
electronic health records (EHRs), and a lack of support from hospital administration (Shanafelt et
al., 2017) noted by physicians in general as causing burnout, female physicians experience
additional stressors. For instance, the healthcare leadership gender gap (Hauser, 2014), lack of
work-life balance (Walden, 2016), and challenges of motherhood uniquely impact female
physicians (Michael, 2020). It is important to consider that physicians with marginalized
identities may experience greater stressors due to intersectionality, which is described as the
intersecting effects of race, class, gender, and other marginalizing characteristics that affect
health (Seng et al., 2012). It follows then that physician identity is a contributor to physician
burnout, though the extent of which is unknown.

This study is also interested in the extent to which the COVID-19 pandemic has created
additional stressors for physicians and to what extent this has impacted existing levels of
physician burnout. While reviewing pre-pandemic literature on physician burnout and
contributing factors, it is important to keep in mind that many of these contributing stressors are
exacerbated by the COVID-19 pandemic and are accompanied by additional stressors (Gibson,
2021). Literature published in the beginning of the pandemic demonstrated that physician
burnout rates may have decreased, although by the end of 2021 research demonstrates that the
pandemic is causing increased exposure to stressors for physicians and therefore higher rates of
burnout (Gibson, 2021).
17

Decreased Autonomy

Research demonstrates a relationship between a sense of decreased autonomy among
physicians and physician burnout (Shanafelt et al., 2017). Autonomy is often identified as the
most important aspect of providing service as a professional physician (Matthews, 2008). The
ability to manage one’s clinical work allows physicians to utilize the skills that enabled them to
excel in school and as medical students (Shanafelt et al., 2017). It follows then that decreased
autonomy in the healthcare industry does not allow physicians to utilize their strengths, which
is linked to a decreased sense of job satisfaction (Matthews, 2008). There are many causes of
the current state of decreased physician autonomy in the healthcare industry, including
advancements in medical science that require collaboration between various specialists and
medical offices for the treatment of one patient (Matthews, 2008). Further, physicians are now
being monitored by hospital administration or employers, insurance companies or third-party
payors, patients, and regulatory agencies (Matthews, 2008). Physicians have expressed feelings
of inability to diagnose and treat patients according to their knowledge and experience unless it
meets the specified criteria that satisfy all regulatory agencies (Matthews, 2008).

Since the early 2000s, the narrowing of insurance networks and the employment of
physicians have both contributed to exceptionally high levels of physician burnout (Shanafelt et
al., 2017). Physicians who have been accepted into medical school and succeeded in completing
medical school and their residencies are identified as generally having done so based on their
intellectual abilities and skills in evaluating circumstances and offering appropriate solutions
(Shanafelt et al., 2017). Once medical students become professional physicians and must work
within the confines of insurance companies and hospital guidelines, they may feel denied the
18

opportunity to fully utilize these same skills. A hospital environment that hinders their ability to
now practice their specialty based on these very attributes serves as a major stressor and
contributor to burnout (Shanafelt et al., 2017). Physician autonomy is defined as the freedom to
determine the conditions of practice and the care delivered in pursuing the goal of patient well-
being (Emanuel et al., 2012). As physician autonomy, defined as the perceived degree of control
over one’s work (Vilendrer et al., 2020), is a leading cause of physician burnout, research
indicates that hospital leadership needs to specifically address the problem of autonomy through
their management style. For instance, when leading physicians, research has found it most
effective to ask physicians for their input and ideas and recognize individual achievements to
help build a greater sense of autonomy among physicians (Shanafelt et al., 2017).

Increased Workload

The increased workload placed on physicians is greatly contributing to high levels of
physician burnout (Shanafelt et al., 2017). In fact, research has found a strong relationship
between physicians working long hours and experiencing depression and occupational stress
(Tomioka et al., 2011). The reasons for this are several, including the treatment of an aging
population that places a higher demand on hospital resources and compounding pressure for
hospitals to cut operating costs (Powell, 2012). Additionally, as physicians in many hospitals
are paid for work performed, they may take on higher numbers of patients to help offset the
costs of medical school and student loans (Vilendrer, 2020).

The existing literature on physician workload demonstrates a relationship between
physician workload and mortality rates. As workload increases, procedures tend to be rushed at the
expense of patient safety (Powell, 2012). Additionally, in hospital settings, when physicians
19

are busy with a high volume of patients, they may choose to discharge lower severity patients
early, which can affect patient outcomes and even mortality rates (Powell et al., 2012). The high
volume of patients then creates a feedback loop where conditions causing burnout affect patient
safety, and higher mortality rates affect physician burnout rates (Shanafelt et al., 2017).
Research demonstrates that hospitals can increase profits and mitigate physician burnout by
taking a multifaceted approach to operations changes that do not increase physician workload
without providing clinical autonomy along with quality management training of clinical and
non-clinical staff (Powell, 2012). Research then supports the need for increased physician
autonomy and management of workload as well as the value of learning and development in
decreasing physician burnout.

Electronic Health Records

Electronic health records (EHRs) are also noted as a leading cause of physician burnout,
which is interesting since technology seems to have decreased the workload for many other
professionals (Shanafelt et al., 2017). Research has found that 84.5% of physicians use EHRs
and are at increased risk for burnout (Collier, 2017). The use of EHRs is reported as contributing
to physician burnout by causing frustration and stress, increasing workload, decreasing
physician ability to connect with patients, and reducing clinical work to data entry (Collier,
2017). Researchers observed 57 physicians for 430 hours and found that over 80% of their work
hours were spent performing clerical work and interfacing with the EHR (Shanafelt et al., 2017).
The amount of time physicians spend on EHRs is particularly alarming when considering that
physician satisfaction is found to derive primarily from patient relationships (Rothenberger,
2017). As physician burnout is shown to include a lack of work satisfaction and a sense of
20

fulfillment (Shanafelt et al., 2017), it follows that increased physician satisfaction may contribute
to decreased levels of physician burnout.

Research has specifically revealed a relationship between the amount of time spent
interfacing with the EHR and levels of emotional exhaustion in physicians (Adler-Milstein et al.,
2020). The promise of EHRs in enabling access to patient medical records in real-time whether
in a hospital or different clinical offices, is exciting. The last decade has seen a major shift in the
health care industry moving toward the widespread implementation and use of EHRs (Adler-
Milstein et al., 2020). The solutions for reducing physician burnout caused by EHRs must,
therefore, focus on learning and development.

Physician Identity

In addition to decreased physician autonomy, increased workload, and the
implementation and use of EHRs, physician identity is also identified as a factor in stress and
burnout among physicians. While this study refers to physician identity as gender, race, and
ethnicity, this section of the literature review will focus on physician gender because research
on physician race/ethnicity and physician burnout is still inconclusive.

In regard to gender, however, female physicians are found to experience greater stress and
demonstrate a higher risk for burnout (Lee, 2008). This is due to several different factors and
relationships. For instance, patients have different expectations of female versus male physicians
(Gazele, 2015). Female patients are also noted as being more empathetic listeners, which may
explain why female physicians tend to have longer visits compared to male physicians (Gazele,
2015). Longer visits are challenging because female physicians are not provided longer visit time
21

and are documented as generally having more patients than male physicians. Studies also
indicate that female physicians have more patients with psychosocial issues (Gazele, 2015).

Various studies show that gender differences and gender expectations are major
contributors to female physician burnout (Gazele, 2015). Researchers (Shanafelt, 2009)
surveyed 1,043 female and 6,815 male physicians and found generally equal work hours
between men and women. However, women are more likely to experience burnout and
depression compared to their male counterparts (Shanafelt, 2009). The study found that 43.3%
of women surgeons met the criteria for burnout compared to 39% of men (Shanafelt, 2009). The
problem of female physician burnout is important to address because rapidly increasing burnout
rates in female physicians have many adverse consequences, including medical errors, suicide,
depression, and absenteeism (Shanafelt, 2009).

Hospital Leadership

As feelings of not being supported by hospital administration and leaders is noted as
contributing to physician burnout (Patel et al., 2018), to reduce physician burnout rates in LA
County hospitals, there must be organizational change that starts with the hospital leadership and
administration. Research demonstrates that organizations that have greater work-life balance,
positive leadership behaviors, and a collaborative environment, report lower rates of physician
burnout (Patel et al., 2018). Adversely, hospital leadership can negatively impact physician
burnout rates through organizational issues that lead to excessively long workdays for physicians
and a lack of communication with physicians on the expectations of their role or duties
(Kurapati, 2020). Furthermore, diversity and inclusion have been shown to build feelings of
22

being supported within organizations (Ely & Thomas, 2020). It follows then that diversifying
hospital leadership and administration may reduce physician burnout rates.
The Lack of Diversity and Inclusion in Healthcare Leadership

While research demonstrates the benefits of diversity and inclusion within organizational
leadership, racial and ethnic diversity among hospital leadership has made little progress
(Livingston, 2018). Minority percentage representation among hospital executive leadership
actually decreased between 2011 and 2015 from 12% to 11% and minority representation
among CEOs has stayed at 9% from 2011 through 2015 (Livingston, 2018). In order to create
greater diversity among hospital leadership and administration, there must be organizational and
systemic change. The path to hospital leadership generally begins in medical school or similar
programs (Livingston, 2018), however, students with marginalized racial or ethnic identities are
still a minority of the applicants to such programs (Olds, 2019). Studies show that only 13% of
primary care physicians are black, Latinx, or Native American (Olds, 2019). The healthcare
profession has historically been white and male, and progress toward diversity and inclusion
remains slow (St. George’s University, 2018).

Similarly, the healthcare leadership gender gap has been an issue since the inception of the
healthcare industry (Starr, 1982) and has not shown significant improvement since (Hauser, 2014).
In fact, healthcare is repeatedly identified as amongst the top three industries with the greatest
leadership gender gap. Hauser’s 2014 study that found that only 24% of senior executives and 18%
of hospital CEOs were women. These numbers are particularly alarming when we consider that 76%
of the healthcare workforce is comprised of women (Cheeseman & Christnacht, 2019). An early
argument in defense of the gender gap was that there simply are not
23

women qualified or interested in such leadership roles, though evidence suggests the opposite is
true. The percentage of women in the workforce and the fact that women in the full-time
workforce are more likely than men to have a degree in higher education (Cheeseman, 2019)
suggests that there are more than a few qualified candidates for organizations to choose from
whether hiring externally or promoting internally. Further, most women who have attained a
degree in higher education and are in the full-time workforce want to be in leadership roles
(Clerkin, 2017).

Race & Gender Pay Gap

Women are an increasingly greater part of the healthcare workforce and hospital
physicians, while also having greater patient outcomes than male physicians, the healthcare
gender pay gap continues to be an issue (Sheridan et al., 2020). In fact, several studies have
found that female physicians earn anywhere from 8 to 29% less than their male counterparts
(Sheridan et al., 2020). The healthcare gender pay disparity was traditionally attributed to
female physicians working less hours than male physicians (Sheridan et al., 2020), research now
demonstrates that female physicians generally see more patients than their male counterparts
(Gazele, 2015).

It is important to note that the racial and ethnic pay gap exists for both men and women,
though research on equity has focused heavily on gender and has generally ignored race and
ethnicity as a factor (Treadwell, 2019). Racial and ethnic minorities are underrepresented in
hospital leadership (Livingston, 2018) and the small percentage of professionals who are hired in
executive or leadership roles are not paid equally to their White counterparts (Treadwell, 2019).
24

Research continues to demonstrate that pay rates and bonuses are determined through
formal and informal attributes ascribed to physicians and that women are evaluated differently
than their male counterparts due to implicit biases and stereotypes (Roth, 2015). This may be
true for people with marginalized racial or ethnic identities as well. This seems to be
indicative that a change in leadership would also enable a change in the pay gap.

Need for Leadership Change

One of the common perceptions among existing healthcare leadership is that the gender
gap is due to women not negotiating for a title and pay during the hiring and promoting
processes (Barkholz, 2017). Even programs aimed at developing gender equity in healthcare
leadership are designed in a way that may reinforce the notion that women are at the core of the
problem (Freund, 2020). Research, however, identifies that the male-dominated cultures of
existing healthcare leadership and a disregard for work-life balance are significant barriers to
gender equity in healthcare leadership (Hughes et al., 2009). Even medical society leadership has
a long-standing gender gap that significantly impacts career and leadership opportunities and for
women physicians (Silver et al., 2019).

Current healthcare leaders need to be able to lead the systemic transformation toward
thriving and sustainable organizations. Population health initiatives, new government mandates,
revenue challenges, budget pressures, as well as demands for improved quality and access to
care, are driving fundamental changes in the healthcare industry (Elton, 2016). Models of
healthcare that were successful until recently were disease and episodic care focused, and these
are moving toward a focus on wellness, prevention, primary care, and increased patient
involvement in decision-making (Elton, 2016). Population health initiatives are creating industry
25

change by focusing on a holistic approach to health that includes diet, nutrition, and exercise
(Mansour, 2015). This significant shift places more accountability on the provider to develop
innovative modalities of care with higher quality and at lower costs. This calls for a more
integrated model of care, which requires a more collaborative and transformational leadership
style. For instance, Hospital Medicine programs are a new field that has emerged over the
past 20 years in response to this changing landscape (Freund, 2020). Research reveals that the
leadership styles generally employed by women are particularly well suited for contemporary
organizations (Hoyt & Murphy, 2015).

An analysis of research conducted by the Harvard Mental Health Letter (2004) found
that women are more likely than men to employ a “Transformational” style of leadership, which
inspires and motivates subordinates while empowering them to take initiative and make
decisions. These benefits of diverse leadership directly correspond with the stressors of
decreased physician autonomy identified as contributing to physician burnout (Shanafelt et al.,
2017). Additionally, the Center for Creative Leadership found that organizations with women in
leadership roles consistently ranked higher in job satisfaction, employees felt more supported,
and employees reported less job burn-out (Clerkin, 2017). These benefits could specifically help
healthcare organizations develop more collaborative approaches to finding solutions and
otherwise benefit from the inclusion of diverse perspectives. The potential benefits of female
leadership are incredible, and include lower neonatal mortality rates (Downs et al., 2014). The
growing body of literature on the positive impact of inclusive leadership demonstrates the
necessity of developing diverse healthcare leadership.
26

Stereotypes

Stereotypes, specific characteristics assigned to a targeted group, significantly impact
opportunities in healthcare leadership (Duehr & Bono, 2006). Research demonstrates that
physicians with marginalized racial and ethnic identities experience significant racism while
providing healthcare in hospital settings and generally feel unsupported by their organizations
when racist incidents occur (Serafini et al., 2020). Research also demonstrates a lack of racial
and ethnic diversity among physicians and hospital leadership (Livingston, 2018). While more
research is needed, it is likely that there is a relationship between racial stereotypes and a lack
of diversity in hospital leadership.

The American College of Healthcare Executives (ACHE, 2018) conducted a series of
research surveys on gender and careers in healthcare management and found that more women
than men are in management roles in specialized areas such as nursing, quality assurance, and
the continuum of care. However, they found a higher proportion of men than women were found
in general management and executive positions. It seems that there is greater gender equity in
hiring and promoting practices for areas thought of as fitting of qualities that are stereotypical of
women. The research by the American College of Healthcare Executives (ACHE, 2018)
parallels research that shows women faculty in medical schools are found in higher numbers
when the research is centered around grants, mentorship programs, and community-based public
service (Schor, 2019). This research suggests that women are still forging their careers in male-
dominated systems and against stereotypes that do not support the advancement of women’s
careers (Harvard Mental Health Letter, 2004).
27

The potential advantages of female leadership are hindered by negative stereotypes of
women in the workplace (Hoyt & Murphy, 2016). An examination of gender and leadership
stereotypes of male and female leaders revealed that male leaders rate women as more leader-
like than they did 15-30 years ago (Duehr & Bono, 2006). However, male leaders still hold
gender stereotypes considering women to possess fewer traits of a successful leader, such as
being modest, quiet, and nurturing (Duehr & Bono, 2006). Further, many leaders associate
stereotypical masculine characteristics with success and achievement, such as assertiveness,
aggressiveness, and task-oriented leadership abilities (Barnet-Verzat, 2008). People have
preconceived notions of what it means to be a woman and another set of preconceived notions of
what it means to be a leader (Hoyt & Murphy, 2016). Stereotype-based expectations are
burdensome to women in the workplace because the preconceived notions of being a woman and
of being a leader generally conflict (Hoyt & Murphy, 2016).

Women lack the resources to prepare for leadership roles early on and throughout their
careers. For the purposes of this paper, the term “resources” is in reference to the time and
professional mentorships needed for one to prepare for and advance to a leadership role. The KPMG
Women’s Leadership Study in 2015 surveyed 3,014 professional working women, between the ages
of 18 and 64 and found that 86% recalled being taught to be nice to others while growing up with
their families, and less than 44% were encouraged to be good leaders (KPMG, 2015). The benefits
of mentoring in advancing one’s career and influence have been well documented, as has the lack of
access to such mentorships for women (Bower, 2008). It seems that if encouraged and guided at an
early age, more women would be prepared to display the characteristics that are deemed necessary
in leadership earlier in their careers (Bower, 2008).
28

Role Models & Mentors

Finally, an important resource that is not as readily available to women wanting to join
healthcare leadership is mentorships and role models (Bower, 2008). With the lack of racial and
ethnic diversity in hospital leadership, this is also likely true of physicians of marginalized racial
or ethnic identities. While both genders are equally represented among medical students (World
Health Organization, 2012), the faculty and staff of medical schools do not reflect this. For
instance, qualified leaders often come from either a clinical or business administration
background (Schor, 2019). Yet biomedical research, in general, is dominated by men, and the
higher up the academic ladder we look, the fewer women there are (Schor, 2019). Additionally,
less than 20% of full-time professors in American business schools are women (Schor, 2019).
African Americans make up approximately 13% of the US population and only 3% of
physicians (Knight, 2020). It seems likely that the race and gender gap is influenced by the lack
of role models in leadership positions as early as the educational level (Schor, 2019). Despite the
growing body of research on the gender gap in healthcare leadership, the lack of improvement
suggests there exists a lack of actions such as succession planning and career development to
advance women in healthcare leadership roles (Bower, 2008).

The race and gender gap in healthcare leadership is rooted in a white male-dominated culture
that has been in existence since the inception of the healthcare industry. The vast majority of the
healthcare workforce are women (Hauser, 2014) and there is an increased need for new leadership
within healthcare (Freund, 2020). It follows then that greater equity in leadership is necessary for
decreasing physician burnout by benefiting the employees, staff, patients (Freund, 2020). Further,
burnout is seen in female physicians, more so than in male physicians (Gazele,
29

2015). Studies have also found that female physicians generally see more patients than their male
counterparts do (West, et al., 2014). It follows then that addressing the problem of female
physician burnout may have a positive impact on overall physician performance and well-being
as well as patient well-being.

The Pandemic

While pandemics are not new to human history, as we know from the Plague, the 1918
Influenza, Cholera, Malaria, Tuberculosis, and HIV/AIDS, the definition of a pandemic is
relatively new (McMillen, 2016). After the 2009 H1N1 influenza pandemic, controversy
emerged over the definition of pandemics used by the World Health Organization (WHO) and
other agencies (McMillen, 2016). In response, specialists at the National Institute of Allergy and
Infectious Diseases at the National Institutes of Health (NIH) came up with a broad framework
that can work to help define what a pandemic is (McMillen, 2016). A pandemic must meet eight
criteria: 1) wide geographic extension, 2) disease movement, 3) high attack rates and
explosiveness, 4) minimal population immunity, 5) novelty, 6) infectiousness, 7) contagiousness,
and 8) severity.

COVID-19, the viral pandemic that emerged in the world in late 2019, was declared a
pandemic in March 2020 by the World Health Organization (WHO). Differing from other
pandemics, “the COVID-19 pandemic has managed to overwhelm the global healthcare
infrastructure in a matter of months” (Gannotta, 2020). As pandemics are recognized as being
characterized by extreme fear and dread within societies around the world (McMillen, 2016), this
has been the true of the COVID-19 pandemic as well.
30

This study is being conducted in the fall of 2020, in the midst of the COVID-19
pandemic, and very little research has been conducted on this pandemic at this time.
Additionally, most historical work on previous pandemics focuses on what happened during the
pandemic and not on what came after (McMillen, 2016). The outcomes and the pandemic’s
impact on physician burnout must be surmised from the existing literature physician burnout and
on the effects of the pandemic on physician burnout.

Physician Burnout and the COVID-19 Pandemic

It is widely accepted that before the COVID-19 pandemic, high rates of physician
burnout in US hospital settings had adverse effects on the quality and quantity of life for
physicians, patients, and hospitals (Patel et al., 2018). In addition to the existing stressors
contributing to physician burnout, physicians are now faced with new challenges in regard to
caring for COVID-19 patients while attempting to prevent the contraction and spread of the virus
(Bendix, 2020). This study suggests that research on the extent of the impact of the COVID-19
pandemic on physician burnout and whether the impact exacerbates existing high levels of
physician burnout is needed. The COVID-19 pandemic could create a greater risk of the existing
adverse consequences of burnout, such as medical errors, absenteeism, and costly physician
turnover (Patel et al., 2018).

The COVID-19 pandemic has impacted the amount of work physicians have in different
ways (Saleh, 2020). Some physicians, such as family or general practitioners, have experienced a
decrease in patient volume as many patients avoid going into physician offices during a
pandemic (Saleh, 2020). Other physicians, such as those in Intensive Care Units (ICUs),
Emergency Rooms (ERs), and pulmonologists, are experiencing a massive increase in patient
31

volume (Saleh, 2020). The increase in the volume of patients increases the risk of physician
burnout (Powell, 2012). This is particularly concerning when considering that physicians
were already experiencing stress and burnout due to their workload prior to the pandemic
(Powell, 2012). The pandemic has only exacerbated the situation for many physicians as there
is an increased need for care.

Physicians are also taking on even more patients as other physicians are becoming ill,
needing to quarantine, and even passing away (Saleh, 2020). Continuing to work on the
frontlines of the pandemic while losing colleagues to infection, quarantine, and even death
further adds to physicians’ stress and burnout as they fear for the well-being of their coworkers,
families, and their own health (Bendix, 2020). Many physicians fear contracting the virus and
exposing family members to infection. To mitigate this risk, physicians isolate outside of the
workplace (Saleh, 2020). This creates more burnout as stressed physicians are then deprived of
the close relationships that often counter their feelings that lead to burnout (Saleh, 2020).
Research in China and Italy have demonstrated that the pandemic has already caused significant
strain on the mental health of healthcare workers (Saleh, 2020).

While many people around the world are experiencing depression and anxiety due to the
pandemic as well as the subsequent stay-at-home orders and economic crisis, frontline
physicians have these same concerns and additionally must face the stressors of caring for others
under rapidly evolving conditions, a nationwide shortage of personal protective equipment, a
lack of research and content, and fear of contracting the virus (Romanelli et al., 2020).
32

Physician Identity & Pandemic Burnout

As burnout disproportionately impacted female physicians prior to the COVID-19
pandemic, it is not surprising that compounding burnout from the pandemic also impacts female
physicians more so than their male counterparts (Michael, 2020). While research does not yet
exist on how female physicians' societal expectations differ during a pandemic, recent research
developed by responses to surveys demonstrates stressors that either leads to or exacerbate
burnout, particularly for female physicians during a pandemic (Michael, 2020). A study in
Canada demonstrates that female and ethnic minority physicians are more likely to report
components of burnout during the COVID-19 pandemic, but more research is needed for
conclusive findings (Khan et al., 2021).

One reason for the COVID-19 pandemic producing a more significant impact of stress on
female physicians is motherhood. Physicians who are mothers have been shown to have a greater
dissatisfaction with their work-life balance during the pandemic (Michael, 2020). In addition to
the stressors of the pandemic as a citizen and as a physician, these physicians are also faced with
daily responsibilities of taking on the majority of household and familial responsibilities,
including childcare (Michael, 2020). In addition, to have greater pressures and responsibilities in
both professional and domestic aspects of life (Saleh, 2020), physicians who are mothers are also
needing to navigate uncharted territory with sudden homeschool, changing schedules, or lack of
childcare. Research also demonstrated that at least half of mothers reported their biggest concern
as exposing their children to COVID-19 (Michael, 2020).

Female physicians also experience the stressors that lead to burnout during a pandemic
differently because of the differences in their perceptions and self-accountability. Female
33

physicians are found to be more empathetic toward patients and colleagues (Gazele, 2015), and
these traits seem to hold true during the pandemic as well. Physicians who are mothers were
found to have greater concern for the well-being of their coworkers and staff during the
pandemic (Michael, 2020). While navigating the personal stress of a pandemic, the stress or
increased workload and more critically ill patients due to the pandemic, along with increased
concern for the well-being of their families, colleagues, and patients, is likely contributing to
increased burnout for female physicians more so than their male counterparts.

Insights Gained from the Pandemic that can Reduce Physician Burnout

Understanding the impact of the COVID-19 pandemic on physician burnout may provide
insights into how to prevent and treat physician burnout after the pandemic (Hartzband &
Groopman, 2020). In some ways, the COVID-19 pandemic has decreased general physician
burnout. This may be because the current healthcare needs that have suddenly emerged during
the pandemic have returned the system to the focus of disease and episodic care (Elton, 2016). In
this way, some physicians are experiencing an increase in autonomy, the decrease of which had
previously been noted as a major contributor to physician burnout (Shanafelt et al., 2017).

Paradoxically, other physicians or surgeons are experiencing slowdowns or complete
shutdowns or are being redirected to other clinical areas (Romanelli et al., 2020). This creates
uncertainty and stress and perhaps even a feeling of decreased autonomy. Yet research suggests
that physicians in these situations are still reporting a decrease in symptoms of burnout. One
significant contributor to a renewed sense of professional fulfillment and decreased burnout
during the pandemic has been a sense of comradery and unified purpose with other healthcare
workers as well as an understanding of the importance of their work in the immediate (Romanelli
34

et al., 2020). This collaboration between medical specialists can be a valuable area in which
to understand the causes of not feeling this way prior to the pandemic and how to continue to
develop such sentiments for physicians after the pandemic.

Recent studies (Hartzband & Groopman, 2020) have revealed that during the pandemic
physicians are experiencing a decrease in the triggers that normally contribute to burnout. As
leadership has not changed and the work-life balance for physicians has generally worsened as
many physicians are being asked to work more days and longer hours (Hartzband & Groopman,
2020).

Bronfenbrenner’s Social-Ecological Systems Theory

It is important to understand physicians’ well-being, and more particularly in times of
normalcy and during the pandemic from the context of multiple environmental factors and their
relationships. We are able to do this by applying Bronfenbrenner’s social-ecological systems
theory as a framework through which to view the situations and relevant research. The social-
ecological systems theory approaches an issue, such as physician burnout, with the
understanding that its causes and effects extend far beyond the immediate situation
(Bronfenbrenner, 1996). American psychologist, Urie Bronfenbrenner, developed the
ecological systems theory in the late 1970s as a framework for psychologists to use in
examining an individual’s relationships within communities and wider societies.

The ecological systems are composed of five systems: the microsystem, mesosystem,
exosystem, macrosystem, and chronosystem (Bronfenbrenner, 1994). The microsystem is the
relationship between the people or objects someone interacts with firsthand and the forces that
shape them and indirectly influence the development of the individual (Bronfenbrenner, 1997).
35

The microsystem places equal value on the setting of the individual and the links between the
setting that the person directly interacts with and those that impact the people or objects the
individual interacts with (Bronfenbrenner, 1997). For example, the relationship of a child and
his mother, and the relationship of the mother and her supervisor at work. The microsystem
focuses on the relations between the developing person and other people, structures, or
processes in their immediate environment. In this case, female physicians’ children, friends, and
immediate work environment and all the duties and expectations.

The mesosystem is the set of relationships between two or more settings that the
individual directly interacts with (Bronfenbrenner, 1997). The mesosystem is further broken
down into four different types of interconnections between settings: multisetting participation,
indirect linkage, intersetting communications, and intersetting knowledge (Bronfenbrenner,
1997). An example of the relationships between settings in the mesosystem are that of an
individual entering the workplace alone and without knowing anyone who also works there,
which creates a solitary link between the two settings. Otherwise, an individual may be hired into
a family business in which case there exists a multisetting link between family and the workplace
(Bronfenbrenner, 1997). The mesosystem contains the interactions and connections between
their environments. In the case of physicians during the pandemic, an example of the
mesosystem can be the interaction between the physician’s work environment and her children,
such as the fear of exposing her children to the virus because of her work environment.

The exosystem is defined as the setting(s) that the individual does not interact with
directly but that equally influence the individual’s socialization and development
(Bronfenbrenner, 1997). The exosystem is the impact of their indirect environment on their
36

development and contains the formal and informal social structures and cultural values that
indirectly affect them. For example, the exosystem may be state regulations that impact the
individual’s school which then influence the individual’s development although the individual
does not interact with state policymakers or those who implement them. In reference to this
paper, an example of the exosystem is societal expectations, such as female physicians who
take on the role of caregivers for their families, patients, and coworkers.

The macrosystem consists of the beliefs, expectations, and lifestyle of the physicians
and their cultural setting. The macrosystem is the consistency between the individual’s culture
or subculture and all of the other systems identified within the social-ecological systems theory
(Bronfenbrenner, 1997). For example, according to the macrosystem, an individual’s childhood
relationship with his father can decades later impact the individual’s leadership style within the
workplace. The macrosystem in this example includes stereotypes and certain prejudice against
female physicians by their peers and patients, lack of promotion of female physicians into
leadership roles, such as department chairs, directors, and mentors, and the pay inequality
between female and male physicians.

The ecological systems theory might help explain how male and female physicians react
and cope with the feelings associated with exhaustion and being overwhelmed both during the
pandemic and prior to it. This approach can be applied across multiple contexts and in multiple
settings to accurately represent the complex and distinctive environments of physicians and
particularly female physicians. For instance, this theory helps frame the understanding of
stereotyping and how it impacts physician performance and creates dissatisfaction leading to
burnout. Social expectations, which differ for men and women, similarly impact female
37

physicians’ workload and ultimately lead to burnout. Even the hospital settings, such as the lack
of work-life balance (Hughes et al., 2009), are structured in such a way that impact female
physicians differently than they do male physicians. The issue of female physician burnout is
particularly important to recognize in this context since, according to Bronfenbrenner, the
actions of others are the most powerful influence on one’s development (Bronfenbrenner, 1994).

Core Concepts

Through this framework, human development is viewed through the way in which the most
immediate communities to the broader social and cultural environments all influence one another.
Ultimately, the theory places significance on the inherent qualities of individuals that interact
differently with environments (Bronfenbrenner, 1994). For instance, physicians with very similar
ecological systems still experience environments differently due to their individual personality
traits, temperaments, and other characteristics. This framework is invaluable to this research that
focuses essentially on diversity as it provides insight into physician identity,

38

behavior, and performance in relation to hospital systems, social expectations, and
cultural stereotypes.
Summary

This literature review provided the reader with an overview of existing physician
burnout within US hospital settings, the extent to which the COVID-19 pandemic has impacted
existing physician burnout, and the role that physician identity plays in physician burnout both
prior to and during the pandemic. This review includes extensive literature on the causes of
inequity within healthcare leadership, its effects, and the potential advantages of increased
diverse leadership in the industry. This research is important as later chapters explore how
physician identity may influence the impact of the COVID-19 pandemic on physician burnout.

Further, the need for strategies aimed at reducing physician burnout might be especially
heightened during and after the COVID-19 pandemic as the impact of the pandemic is likely to
contribute to physician burnout. While further research is needed on the impact of the pandemic
on physician burnout, recent literature does suggest that the COVID-19 pandemic has impacted
existing physician burnout, and that gender plays a role in the effects and extent of the impact.

Bronfenbrenner’s ecological systems theory provides a framework through which to view the
relationships between existing physician burnout, the role of gender in regard to physician
burnout, and the impact of the COVID-19 pandemic on existing levels of physician burnout.
39

Chapter Three: Methodology

Physician burnout is a critical factor in patient outcomes, physician wellness,
organizational culture, and overall hospital success (Patel et al., 2018). While all physicians are
susceptible to burnout and subsequent negative consequences, female physicians are generally
impacted at higher rates (Lee, 2008). During the COVID-19 pandemic, physician burnout has
become even more prevalent in some cases, and the discrepancy in level of impact based on
physician gender has also been impacted. Existing research cannot yet explain a relationship
between physician race and/or ethnicity and physician burnout (Garcia et al., 2020). The
literature review outlined in chapter two suggests that an analysis of physician burnout during the
COVID-19 pandemic can provide information on the causes, effects, and possible solutions to
physician burnout in general. The purpose of this research is to understand what factors
contribute to both increasing and decreasing burnout rates among physicians during the
pandemic and what role physician identity plays in the impact of the pandemic on burnout levels.
This chapter provides an overview of this study’s design and how it relates to the research
questions, and reviews the methodology, validity and reliability, ethics, and limitations and
delimitations. While the research questions were provided in Chapter One, they are included here
for reference: 1) What changes were implemented within the hospital because of the COVID-19
pandemic that either contributed to or helped alleviate physician burnout?, and 2)What factors,
particularly physician gender, racial, or ethnic identity, during the pandemic impacted the level
of burnout physicians experienced?
40

Organizational Context and Mission

HealthFirst, Inc. is a performance development agency working with physicians and
health organizations around the world on the professional development and overall wellbeing of
physicians. This work also entails recruiting physicians and helping organizations with
retention rates. HealthFirst, Inc. is a member of numerous national and international networks
and organizations for physicians and hospitals. The mission of the HealthFirst, Inc. organization
is “to promote and improve the health and wellbeing of our communities by empowering
physicians and healthcare organizations to be engaged and aligned with local needs and
community organizations in promoting and implementing wellbeing strategies.” The goal of the
organization is to identify obstacles that physicians face in delivering safe and high-quality
health care to their communities, and to provide solutions to overcome them.

HealthFirst, Inc.’s executive leadership is the researcher of this study and clients are
individual physicians and healthcare organizations around the world. The physicians include
specialists, generalists, and emergency-care physicians. The focus of this research will be on
the physicians who working during the COVID-19 pandemic regardless of specialty, although a
closer look will be made of physicians in the Intensive Care Unit (ICU) and pulmonologists as
they work more directly with COVID-19 patients.

The mission of the physicians is to provide safe, efficient, and quality health care to all
patients while maintaining compliance with policies and procedures set by their hospital, third-
party funding sources, and state and federal regulatory agencies. Physicians at Los Angeles
County hospitals are generally impacted by changes to policies and procedures made by
executive leadership, administration, and funding sources as well as state and federal regulations.
41

As frontline physicians during the COVID-19 pandemic, hospital physicians are experiencing the
stress and uncertainty within society as well as the additional stressors that are specific to the
nature of their work. The specific stressors physicians face include increased risk of exposure,
community stigma as healthcare workers with exposure, feelings of responsibility to protect their
families from potential exposure, and isolation from family in attempts to prevent spreading
potential infection. It is likely that the increased exposure to patient morbidity and patient
development of critical complications also impacts physician stress levels. This study sought to
understand the extent to which the COVID-19 pandemic impacted existing levels of physician
burnout and the role that physician identity played in the level of burnout experienced.

Organizational Performance Need

For HealthFirst, Inc. to fulfill its mission, the organization strives to increase physician
satisfaction and engagement during and after the COVID-19 pandemic by reducing physician
burnout through learning and development. It is evident that if physicians are not maintaining
their own wellness, then hospitals are not achieving their goal of providing safe and high-quality
care to their respective communities. Further, increased rates of physician burnout could
contribute to increased medical errors and malpractice lawsuits as well as higher rates of patient
morbidity. It is, therefore, of utmost importance that performance development and evaluation
are implemented to decrease physician burnout. While many hospitals have implemented
physician training on stress release and management, such efforts have not been shown effective
in general studies (Hartzband & Groopman, 2020). It is imperative that hospitals implement
learning and development opportunities for physicians and administration responsible for
policies and procedures that impact physicians. This may help combat factors contributing to
42

high levels of burnout that are now being exacerbated by the COVID-19
pandemic (Kannampallil et al., 2020).
Overview of Design

This study utilized a mixed methods approach, drawing quantitative data from surveys and
qualitative data from interviews. As this is a mixed methods study, the first research question and the
second research question are both mixed methods questioned (Creswell, 2020). Surveys and
interviews both sought to evaluate the impact of the COVID-19 pandemic on existing physician
burnout, factors contributing to the increase or decrease of physician burnout during the first and
second waves of the pandemic, and the role of leadership diversity on the level of burnout
experienced. Specifically, however, the surveys provide quantitative data for this study while
interviews provide qualitative data (Creswell, 2020). Additionally, the survey utilizes two questions
from the 22 Maslach Burnout Inventory (MBI) questions. MBI is the leading tool around the world
in measuring burnout. Published in 1981, the MBI survey is designed to understand what the burnout
experience is, why it is a problem, and what causes it (Maslach & Leiter, 2021). However, because
of the length of the MBI and the time it takes to complete, it is not frequently used in survey research
(West et al., 2012). This research study utilized two of the 22 questions that research shows as
providing results that are comparative to those from the full MBI (West et al., 2012). Studies have
found that the two single questions from the MBI that are used in this research study accurately
assess emotional exhaustion and depersonalization, which are prerequisites to a diagnosis of burnout
(Hansen et al., 2016). The single questions from the MBI were a great addition as this study also
collected qualitative data. Understanding the research questions through an analysis of both the
qualitative and quantitative data assisted in
43

resolving the mixed-methods question (Creswell, 2020). Through this approach, qualitative and
quantitative findings were analyzed together. With method one being survey and method two
being interviews that collected data in the form of the interviewer’s notes of the interview, a
mixed methods approach in this study supported a greater understanding of how the pandemic
impacts burnout levels in physicians due to different factors. Triangulating data sources is
described by Creswell as a method of seeking convergence across qualitative and quantitative
methods. In regard to this study, this meant collecting and compiling qualitative and
quantitative data that supported one another’s findings.
Research Setting

The survey utilized 16 close-ended questions, each with five Likert-scale responses to
choose from that vary between “strongly agree” to “strongly disagree.” The survey also included
two questions pulled directly from the MBI questions to assist in surveying burnout. Five additional
close-ended questions asked participants to identify whether they were employed by a hospital or
not, their gender identity, ethnic and/or racial identity, age range, and years of professional
experience as a healthcare provider. The survey was sent via email invitation to nearly one hundred
physicians affiliated with numerous professional organizations and social media groups, including
the Los Angeles County Medical Association, the California Medical Association, the Armenian
American Medical Society, and the American Medical Women’s Society. Survey invitations were
sent to all physicians whose email addresses were available to the researcher through affiliation with
these organizations as well as physicians who were otherwise a part of the researcher’s professional
network. In the email invitation, the researcher stated that criteria for participation was working as a
physician during the COVID-19 pandemic.
44

The surveys were sent to participants as a link through Qualtrics, and participants chose whether
or not to participate, and information on participants was not documented in the research and will
not be shared with other parties.

The interviews utilized nine questions that differ from those asked in the survey and
focused on the impact of the pandemic on physicians’ personal and professional lives as well
as their burnout levels and emotional wellbeing. The interview questions were asked of
physicians who were on the front lines of providing care during the pandemic, namely
Emergency Room physicians and physicians serving in Intensive Care Units as physicians in
these specialties as these are the most patient-facing during pandemic and thus have the
greatest risk of exposure (Cook & Lennane, 2021). Physicians who were interviewed were
those who noted interest in being interviewed when completing the survey and were asked to
participant solely on a voluntary basis. Interviews were to conducted either through Zoom
online conferencing or by phone. Each interview took place from 30 minutes to one hour.
Interviews were recorded when approved by participants. Otherwise, interviews were not
recorded, and the interviewer took notes while participants responded to interview questions.

The Researcher

The researcher’s positionality as founder of a physician performance development and
consulting agency has a bearing on access to professional organizations and associations so that the
researcher can send surveys to dozens of LA County physicians. Researcher positionality, however,
should not be a significant factor in whether or not physicians choose to participate in the survey.
Therefore, invitees do not have an incentive to participate if they do not want to.
45

The interviews were conducted with physicians who completed the survey and were
interested in participating in an interview. The researcher communicated that participation is
entirely voluntary and does not make any difference in their professional relationship. In the
interviews, however, the researcher’s identity as a female within the healthcare industry may
cause implicit bias in interviewees' perceptions or observations and their responses to interview
cases, something research has shown to take place in peer reviewers of female health researchers
(States News Service, 2018). This is a further reason for choosing a mixed-method approach to
data collection for this study.
Data Sources

With IRB approval, the survey was administered to physicians, in the Los Angeles County
area. Interviews were distributed to potential participants with a one-week turnaround time requested.
Data was collected through Qualtrics immediately as participants completed and submitted surveys.
Interview observations and findings were based on notes taken during interviews and evaluated
when all interviews were complete. This study expected to conduct and evaluate ten interviews over
two weeks and was able to conduct a total of five due to participant interest. Analyses of both
quantitative and qualitative data was then compared and evaluated.

Surveys

Surveys were 20 questions total and distributed to dozens of potential participants via
email. Participants of the surveys are all physicians who belong to various professional
organizations and associations.
46

Interviews

Interviews were nine questions in length and targeted physicians who were working on
the front lines of the pandemic, such as Emergency Room physicians and Intensive Care Unit
physicians in the Los Angeles County area. Interviews were approximately 30 minutes to one
hour in length each.

Participants

Purposive sampling is described as deliberately selecting locations or persons for a study
that are relevant to answering the research questions of a study (Maxwell, 2013). Participants of
both the surveys and interviews will be physicians who work or have worked during the
COVID-19 pandemic in a hospital setting in the Los Angeles County area. These physicians
were specifically chosen to participate in this study so that post-survey and post-interview data
analysis may demonstrate relationships between physician burnout and wellbeing during the
COVID-19 pandemic. Since the experiences of the pandemic differ between counties and
regions, it is important that the sampling is limited to LA County only. Interview participants
were generally between the ages of 30 and 65, both male and female, either single, married, or in
a relationship, both with and without children, and various medical specialties. The physicians
who participated in the interviews were working as physicians during the pandemic.

Instrumentation

The problems that this study seeks to understand are complex, like those of all social and
health science research, which is why a mixed-methods approach is best (Creswell, 2014). One
method of quantitative data collection, a survey, was used in this study. The survey was used to
provide the researcher with an understanding of the impact of the COVID-19 pandemic on
47

physician burnout. Additionally, the survey sought to understand whether physician identity
played a significant role in the extent to which the pandemic impacted physician burnout. In
addition to the quantitative survey data collection method, one qualitative data collection
method, interviews, were used. The interviews sought to provide the researcher a more in-depth
understanding of the impact of the COVID-19 pandemic on physician burnout and the degree
to which physician identity influenced the extent of the impact. The two data collection
methods are necessary together as the interviews allow the researcher observational analysis. In
contrast, the surveys allow for data without the researcher’s implicit biases as a woman in the
healthcare industry potentially influencing the findings (States News Service, 2018). Both the
survey and the interview asked various open and closed-ended questions so that specific data
can be collected on every participant while also allowing for potentially new information that
may impact findings.

Data Collection Procedures

Qualitative and quantitative data was collected concurrently with equal weight given to
both (Creswell, 2014). The survey was distributed to participants and was estimated to take no
more than 5 minutes for each participant to complete the survey. Interviews were 30 to 60
minutes each and were conducted either by phone or a video conferencing program, such as
Zoom. Survey data was captured online by the survey processing third-party program Qualtrics.
Interview data was conducted by the researcher using field notes. Participants declined being
recorded during the interviews. Data saturation is described as the point at which researchers
stop collecting data as it no longer provides new information (Maxwell, 2013). This research
study ceased to collect data prior to data saturation.
48

Data Analysis

Quantitative and qualitative data was gathered concurrently though analyzed sequentially
with quantitative data reviewed first as this is better suited to interpreting relationships between
physician burnout, the pandemic, and physician identity (Creswell, 2014).

Research Methods

To address these questions the researcher developed a survey that utilized 16 close-
ended questions, each with five Likert-scale responses to choose from that vary between
“strongly agree” to “strongly disagree.” The survey also included two questions pulled directly
from the MBI questions to assist in surveying burnout. Five additional close-ended questions
asked participants to identify whether they are employed by a hospital or not, their gender
identity, ethnic and/or racial identity, age range, and years of professional experience as a
healthcare provider. The survey was sent to dozens of physicians within the researcher’s
professional network. The survey took about five minutes to complete for each participant. A
total of 51 surveys were completed.

The researcher also developed an interview that utilized nine questions that differed from
those asked in the survey and focused on the impact of the pandemic on physicians’ personal
and professional lives as well as their burnout levels and emotional wellbeing. The interview
questions were asked of five physicians who are on the front lines of providing care during the
pandemic, namely Emergency Room physicians, physicians serving in Intensive Care Units, and
infectious disease specialists as physicians in these specialties are the most patient facing during
pandemic and thus have the greatest risk of exposure. Physicians who were interviewed were
49

from within the researcher’s professional network. Each interview was about 45 minutes
in length. A total of five interviews were conducted.
Method 1: Surveys

Survey responses to the closed-ended questions were evaluated in the form of data charts
and graphics populated through the third-party survey data program, Qualtrics. This data was
reviewed for relationships between physician identified burnout and stress triggers during the
pandemic and physician identity. Survey responses to the open-ended questions were reviewed
by the researcher and evaluated as qualitative data, although this data may be quantified
(Creswell, 2014).

Method 2: Interviews

Interview data will be collected in the form of field notes written by the researcher. Field
notes include descriptions of how the researcher perceives the interviewee. For instance,
stressed tone, non-verbal communication, the appearance of exhaustion, and so forth. This data
will be quantified by creating factors or themes that can be compared to the quantitative data
collected through the surveys (Creswell, 2014). Data from the interviews may also assist in
analyzing outliers from the quantitative data collected from the surveys (Creswell, 2014).

Validity and Reliability

As explained by Merriam and Tisdell, quantitative data must demonstrate to the reader that
appropriate measures have been taken in choosing the participants and collecting and analyzing
data. Further, the qualitative data must demonstrate to the reader that the researcher’s findings and
observations are reasonable (Merriam & Tisdell, 2015). Therefore, this study has been conducted
with surveys that physicians during the COVID-19 pandemic will be asked to
50

complete. The data from their voluntary survey will then be quantified by a third-party data
collection program. This researcher is also collecting qualitative data in interviews and
observations and will then describe findings with examples pulled directly from the data
collection process. As the research questions for this study seek to understand the relationships
between physician burnout, the pandemic, and physician identity, this research will provide
insight into these relationships by pulling from a pool of physicians varying in age, gender, race,
ethnicity, sexual orientation, specialty, and level of experience.

The validity and reliability of this study are based on internal validity. In contrast, the
researcher expresses her position to the reader that there is a lack of objectivity in the data
collection as the researcher is a woman working within the healthcare industry and believes that
the existing literature on the topic is accurate when it depicts that physician burnout is a problem
and that the extent to which physicians experience burnout is influenced by physician identity.
As this is the underlying premise of the study, the researcher sought to understand the
relationship between physician burnout, identity, and the pandemic. The interviews, for instance,
asked questions similar to those asked in the survey but focused on physician specialty and
identity. This supported data on whether physician identity is the most significant factor or if
physician specialty is equally influential or more so than physician identity factors. The
researcher worked with the interviewees personally, and explained her positionality and
opinions about the existing research.

In regard to the survey and reliability, the researcher believes that if the survey was
distributed to another set of physicians, it would yield similar data. The questions were created to
understand the relationship between physician burnout, physician identity, and the COVID-19
51

pandemic. The data was collected and analyzed through a third-party program quantifying
data using charts and graphs, which are shared with the reader in the following chapter. To
increase reliability, the surveys included uniform instructions and asked participants to have
minimal distractions when taking them.

Ethics

This study used a mixed-method approach to collect data on human subjects with specific
background criteria. This research was prepared in a way to maximize benefit to physicians,
organizations, and their communities. The benefit of this research is to assist hospital
administration and physicians in understanding the triggers of and solutions to physician burnout.
The risk to participants was limited low-level psychological stress during the survey or interview
process.

In an effort to protect human subjects during data collection, the survey and interview
were by invitation, which stated that participation was entirely voluntary and would not impact
personal or professional relationships in any way. The survey was not completely anonymous
as the Qualtrics application records IP addresses of survey participants, though the researcher
will not use this as identifying information and the results of the survey will be anonymously
used in the research. The interviews are not anonymous as the researcher was present and
taking notes. However, the interview results are included in the research without any
identifying information in regard to the interview participants. The interview included an
explanation that any question may be skipped at the discretion of the interviewee.
52

Limitations and Delimitations

As limitations and delimitations are the influences on a study, it is essential to understand
what factors that are out of the researcher’s control may impact the data collection process or
findings and what choices the researcher made that influence the study. As a portion of this study is
qualitative, there were limitations, such as the truthfulness of human subject responses, the
participation of human subjects, and, during observation and interviewing the researcher's conscious
or unconscious bias. The researcher's professional experience and personal opinions, which have
been acquired through years in leading physician performance and development, frame the study and
are delimitations. This study is also limited in participants' breadth as the researcher reached out to
professionals within her network of southern California physicians. While this study's findings may
provide general overview, the process does not allow the participants to serve as a sampling of the
general physician population in US hospital settings.
53

Chapter Four: Results and Findings

The purpose of this mixed methods study was to explore the extent to which the COVID-
19 pandemic has impacted existing physician burnout and the significance of leadership
diversity and inclusion and physician identity on the factors contributing to burnout and the level
of burnout experienced. This study utilized a mixed methods approach, drawing quantitative
data from 51 surveys and qualitative data from five interviews. This chapter reviews stakeholder
participants in the study and then draws upon Bronfenbrenner’s social ecological systems theory
to synthesize the findings and results from the physician survey and interviews in regard to the
two research questions identified earlier.

The stakeholders for this study were identified as physicians, patients, hospital
administration, and the communities within LA County. However, the stakeholder group of
focus for this study are the physicians working during the COVID-19 pandemic within LA
County hospitals. This study sought to develop a sample of physicians who reflect the age,
gender, racial and/or ethnic diversity of the LA County physician population. This study,
conducted in the summer and fall of 2021, quantitatively and qualitatively explored the research
questions with physicians within the researcher’s professional network who identified as
working during the COVID-19 pandemic. This section reviews the physicians who participated
in the survey and those who participated in the interview.

Method 1: Quantitative

Quantitative data analysis was conducted on the results of the survey on physician burnout.
The survey was sent to nearly 100 physicians practicing in Los Angeles County, out of the
stakeholders who were reached, 51% responded. These physicians were specifically chosen
54

to participate in this study so that post-survey and post-interview data analysis may provide
insight into physician burnout and wellbeing during the COVID-19 pandemic. Survey
participants responded to the closed-ended questions and data was evaluated in the form of
data charts and graphics populated through the third-party survey data program, Qualtrics.

The quantitative survey was sent by email to dozens of physicians within the researcher’s
professional network. The email asked that physicians who worked in LA County hospitals
during the COVID-19 pandemic participate in the short, voluntary survey regarding their
experience, concerns, and the impact of the pandemic on their work and wellbeing. The survey
was sent to nearly hundred physicians within the researcher’s professional network by email
invitation. In the email invitation, the researcher stated criteria for participation was working as a
physician during the COVID-19 pandemic. The surveys were sent to participants as a link
through Qualtrics, and participants chose whether or not to participate.

Figure 2 shows the data on the participant responses to question #17 of the survey which
asked participants for their gender identity. 27 of the 51 participants identified as female, 22 of
the participants identified as male, and 2 preferred not to select an answer. Figure 2 shows the
data on the participant responses to question #33 of the survey which asked participants for their
race and/or ethnic identity. 29 of the 51 participants identified as caucasian, 10 identified as
multiethnic, 5 identified as Asian, 2 identified as African American, 2 identified as multiracial,
and 2 prefered not to select an answer.
55

Figure 2

Participant responses to #17 regarding gender identity

Figure 3

Participant responses to #33 regarding racial and ethnic identity

56

The study sought to develop a sample that was representative of the diversity in gender
identity, and racial and/or ethnic identity among physicians working during the COVID-19
pandemic within LA county hospitals. The researcher recognizes that the sample population is
not representative of the racial and ethnic diversity among the entire population of LA county
physicians during COVID-19 pandemic.

For research questions number one and two, the survey results provide sufficient data
for analysis. Research question number one, “what changes were implemented within the
hospital because of the COVID-19 pandemic that either contributed to or helped alleviate
physician burnout?” is explored through the qualitative data.

Method 2: Qualitative

Qualitative data analysis was conducted by the interpretation of the interviews on
physician burnout. 25 physicians were sent a letter inviting them to participate in an interview,
and those who participated in the survey were offered the link to participate in the interview. Of
all who were invited to participate, five responded and participated in the interview with the
researcher. Interview data was collected in the form of field notes written by the researcher.
Field notes included descriptions of how the researcher perceived the interviewee. For instance,
stressed tone, non-verbal communication, the appearance of exhaustion, and so forth. Interview
responses were analyzed for key words and concepts to assess the interview group’s response for
each question.

As described in Chapter Three, a total of five physicians participated in the interviews.
The researcher reached out to physicians within her professional network as potential interview
participants. Two physicians reached out to the researcher to participate in the interview after
57

completing the survey and being notified of the voluntary interview. The interviews sought to
gather data specifically from physicians who were working on the front lines of the COVID-19
pandemic, which was identified as ER physicians, ICU physicians, and infectious disease
physicians. Of the physicians interviewed, all of the female physicians were mothers with
children ranging in age from 3 years old to late twenties. The male ER physician was the only
one interviewed who did not have children. It was clear to this researcher from the responses
provided that the physicians were invested in their work, patients, and teams. They also seemed
tired and stressed, and each became emotional at least once during the interview.

Figure 4 below demonstrates the data on interview participants’ gender identity with 60%
identifying as female and 40% identifying as male. Figure 5demonstrates the data on interview
participants’ specialty with 40% identifying as ER physicians, 40% identifying as ICU
physicians, and 20% identifying as infectious disease physicians. Figure 6 below demonstrates
the data on interview participants’ ethnic and racial identity, with two identifying as Southwest
Asian North African (Middle Eastern), two identifying as Caucasian, and one identifying as
Latinx.
58

Figure 4

Interview participating physician’s gender identity

Figure 5

Interview participating physician’s medical specialty

59

Figure 6

Interview participating physician’s racial/ethnic identity

Qualitative data analysis was conducted on the results of the interviews on physician
burnout. During the interviews, which were conducted via Zoom, the interviewer took notes on
her computer. Since interviewees did not agree to recording the interviews, interviews could not
be transcribed and only the notes taken by the researcher serve as documentation of the interview
findings.

Data Coding & Themes

Qualitative analysis of the interview data was conducted by coding. Coding is the process
of data organization that takes place as the researcher selects a word to represent a concept,
phrase, or explanation provided by the interviewee during the interview (Creswell, 2020). In this
study, the researcher used In Vivo coding as the codes are drawn from the actual language used
by the interviewee (Creswell, 2020). The codes developed by the researcher are “expected
60

codes” as they are not surprising or unexpected given the existing research and literature on
physician burnout and wellbeing (Creswell, 2020). It is important to note that while the
researcher has attempted to be objective in coding the interview descriptions or themes, the
researcher’s proximity to physicians in both professional and personal relationships likely
impacted the interpretation of interview data.

The researcher reviewed the interview fieldnotes for all five participants and created
codes for the responses to what contributed to physician burnout during the pandemic and then
reviewed the fieldnotes and created codes for what helped to alleviated feelings of physician
burnout during the pandemic. According to Saldana, coding is the process of identifying a term
or phrase that summarizes that essence of a particular set of data. For the purposes of this study,
the researcher used her observations during the interview and the notes taken to code the overall
takeaway of the interviewee’s responses to the interview questions (Saldana, 2015). The
following sections of this study are based on codes the researcher created from the interview
notes using the process of In Vivo coding. In Vivo coding refers to assigning words to describe
statements made by the interviewees (Saldana, 2015). In Vivo coding is a first cycle method for
the beginning stages data analysis (Saldana, 2015). After reading through the codes, the
researcher created word clouds of words that were used for more than one interview. Second
cycle coding is the process of prioritizing the codes, and usually using the codes pulled during
first cycle coding (Saldana, 2015). The word clouds, which are explained and displayed below,
are demonstrations as both first and second cycle coding. First cycle coding determined the
codes to describe the factors contributing to as well as the factors alleviating burnout among the
physicians interviewed. The word clouds also prioritize the codes by the frequency of their use.
61

Word Cloud of Contributing Factors’ Codes

The first word cloud consists of the codes created in regard to the description of factors
that contributed to burnout for the physicians interviewed during the COVID-19 pandemic. The
codes that were drawn from the five interviews are: death (as in many patient deaths and that
being a major source of anxiety and sorrow), disorder (as in the chaos and disorder in the
hospitals and departments due to staff shortages, volume of patient infected with the COVID
virus, fear of contraction, lack of ability to support), anxiety (as in the stress of losing patients,
the anxiety caused by the risk of contracting and/or infecting others with the COVID virus),
isolation (as in physically isolating from family and friends to minimize risk of exposing others
to the virus as well as isolating from friends and family due to the fear and anxiety caused by the
death and disorder in the workplace), fear (as in the fear of contracting the virus, the fear of not
being able to help patients, the fear of exposing loved ones to the virus), and supported (as in
support provided by hospital admin, leadership, and/or colleagues in regard to physical safety
and wellbeing). Figure 7 is the word cloud generated in regard to the factors contributing to
burnout while working as a physician in an LA County hospital during the COVID-19 pandemic.
Death and isolation were used five times. Anxiety, disorder, and fear were used four times, and
supported was used twice.
62

Figure 7

Word cloud of codes describing factors contributing to physician burnout during the pandemic

Word Cloud of Alleviating Factors’ Codes

The second word cloud consists of the codes created in regard to the description of
factors that alleviating feelings of burnout for the physicians interviewed during the COVID-19
pandemic. The codes that were drawn from the five interviews are: outdoors (as in engaging in
outdoor activities or spending time outdoors), family (as in being able to spend time with family),
collaboration (as in collaborating with colleagues and hospital staff on common goals,
developing comradery and shared experience), exercise (physical exercise or activity aside from
work), nutrition (as in eating healthy and nutritious meals and snacks). Figure 8 is the word cloud
generated in regard to the factors contributing to alleviating feelings of burnout while working as
a physician in an LA County hospital during the COVID-19 pandemic. Exercise, outdoors, and
collaboration were used three times. Nutrition and family were used once.
63

Figure 8

Word cloud of codes describing factors contributing to alleviating feelings of physician
burnout during the pandemic

Results and Findings

This section reviews the quantitative data results of the survey and the qualitative
findings of the interviews. The results and findings are viewed through the factors and data
identified in the first three chapters as likely being significant in the extent to which physician
burnout is impacted by the COVID-19 pandemic. Research questions numbers two and three,
and Bronfenbrenner’s theoretical framework were used to formulate the survey and the interview
questions. The results and findings in this chapter are organized by the layers of
Bronfenbrenner’s social ecological systems theory: microsystem, mesosystem, exosystem,
macrosystem, and the chronosystem. The following paragraphs in this section are the codes as
they pertain to Bronfenbrenner’s ecological systems and the subheadings established by the
word cloud.
64

Physician Identity

The first of Bronfenbrenner’s five ecological systems is the microsystem. The
microsystem focuses on the relations between the developing person and other people, structures,
or processes in the immediate environment (Bronfenbrenner, 1994). In this case, physicians’
immediate family, immediate work environment, and all the duties and expectations they
experience on a day-to-day basis.

In understanding the extent of impact the COVID-19 pandemic had on physician burnout
and if physician identity in regard to gender, race, and ethnicity, the researcher reviewed the
survey responses for all participants, reviewed the results separately filtered by gender identity,
and reviewed the results separately filtered by racial and/or ethnic identity. The responses to this
question on the survey may be telling of the extent of burnout physicians experienced as this is
one of the two questions pulled directly from the MBI. The data from question number 30 of the
survey, “I feel burned out” demonstrates that 17.65% experience burnout daily, 17.65%
experience burnout a few times a week, and 27.45% experience burnout a few times a month,
and another 13.73% experience burnout once a month. More than 75% of surveyed physicians
experience burnout during the pandemic at least once a month. In comparison to pre-pandemic
literature that states burnout symptoms in the United States affect 30% to 68% of physicians
overall (Shanafelt et al., 2012), the quantitative data from this study demonstrates that during the
COVID-19 pandemic and the sample population of participants had a higher percentage
identifying with burnout than the sample populations that were surveyed for physician burnout
pre-COVID in the existing literature mentioned above and in Chapter Two of this study.
65

The data demonstrates that physicians who did not identify as Caucasian had a greater
percentage of indication that they experienced burnout experienced in comparison to the survey
data percentages demonstrated by physicians who identified as Caucasian. Figure 9 is a graph of
the survey results to the question of burnout by physicians who identified as Caucasian. Figure
10 is a graph of the survey results to the question of burnout by physicians who identified as
either African American, Asian, Multiracial, Multiethnic, or prefer not to say. Survey
participants who identified as Caucasian were more likely to select “Never” or “A few times a
year or less” while survey participants who identified with a racial or ethnic identity other than
Caucasian were more likely to select “Everyday,” “A few times a week,” or “A few times a
month”

Figure 9

Survey results to the question of burnout by physicians who identify as Caucasian.

66

Figure 10

Survey results to the question of burnout by physicians who identify not as Caucasian.

A male physician working in a LA County hospital in the Intensive Care Unit and
who identified as Caucasian, stated in the interview:

I was in charge of ICU and had to make sure we had all shifts covered. My biggest worry
was staffing shortages, working with admin to make sure we had supplies and needed
equipment. I occasionally covered extra shifts because of shortages. Most ICU physicians
worked extra shifts and longer hours. I didn’t deal much with family members.

In this passage from the interview, the physician describes his experiences managing an Intensive
Care Unit during the Covid-19 pandemic. He doesn’t describe how these experiences impacted him
emotionally but focuses on the immediate needs of the team and the patients as the most
67

stressful aspects of his work. He also doesn’t describe being away from family as stressful. It
may even be that “didn’t deal much with family members” can be interpreted as a relief to
not engage with family perhaps as much as he did prior to the pandemic.

A male physician working in a LA County hospital in the Intensive Care Unit and who
did not identify as Caucasian, stated in the interview: “I was being asked by my leader to take
extra shifts and of course I couldn’t say no. Some days I worked 16 hours.” In this interview it
seemed that physician felt a responsibility to his supervisor to work as much as possible. It may
also be that in saying “of course I couldn’t say no” he is referring to the volume of patients and
not wanting to turn down shifts if it meant the ICU would be understaffed.

Figure 11 is a graph of the survey results to the question of burnout by physicians who
identified as female (27 participants total). Figure 12 is a graph of the survey results to the
question of burnout by physicians who identified as male (22 participants total). Two
participants of the total participating physicians chose not to identify as male, female, or
nonbinary and are not represented in the figures.
68

Figure 11

Survey responses to question of burnout by physicians identifying as female

Figure 12

Survey responses to question of burnout by physicians identifying as male

69

In understanding the extent of impact the COVID-19 pandemic had on physician burnout
and if physician identity in regard to gender, race, and ethnicity, the researcher reviewed the
survey responses for all participants, reviewed the results separately filtered by gender identity,
and reviewed the results separately filtered by racial and/or ethnic identity. The data from
question number 31 of the survey, which is the second question of the two pulled directly from
the MBI, “I have become more callous towards people since I took this job” demonstrates that
1.96% experience being more callous towards people daily, 11.76% experience being more
callous towards people a few times a week, and 37.25% experience being more callous towards
people a few times a month, and another 5.88% experience being more callous towards people
once a month. About 56.86% of surveyed physicians experience being more callous towards
people at least once a month. Figure 13 is a graph that demonstrates the general survey
responses to question #31 regarding being more callous toward people since taking the job.

Figure 13

General survey responses to question #31

70

The data demonstrates that physicians who did not identify as Caucasian had a greater
percentage of participants select responses that demonstrates having the experience of becoming
more callous toward people since taking the job. Figure 14 is a graph of the survey results to the
question of becoming more callous toward people by physicians who identified as Caucasian.
Figure 15 is a graph of the survey results to the question of becoming more callous toward
people by physicians who identified as either African American, Asian, Multiracial, Multiethnic,
or prefer not to say. Survey participants who identified as Caucasian were more likely to select
“Never” or “A few times a year or less” while survey participants who identified with a racial
and/or ethnic identity other than Caucasian were more likely to select “A few times a week,” or
“A few times a month.” Few physicians who identified as Caucasian selected “Everyday” in
response to becoming more callous toward people while none of the physicians who identified
with a racial and/or ethnic identity other than Caucasian selected “Everyday.”

Figure 14

Survey responses to question #31 by physicians who identify as Caucasian

71

Figure 15

Survey responses to question #31 by physicians who do not identify as Caucasian

The survey data does not demonstrate a significant difference in the percentage of
participants who identified as male or the participants who identified as female in regard to the
question of whether or not they have experienced becoming more callous toward people since
taking the job. Figure 16 is a graph of the survey results to the question of becoming more
callous toward people by physicians who identified as female (27 participants total). Figure 17 is
a graph of the survey results to the question of becoming more callous toward people by
physicians who identified as male (22 participants total). Participating physicians who identified
as female were more likely to select “Everyday,” “A few times a week,” or “A few times a
72

month.” Participating physicians who identified as male were more likely to select “Never” or “A
few times a year or less.” None of the physicians who identified as male selected “Everyday.”

Figure 16

Survey responses to question #31 by physicians who identified as female

Figure 17

Survey responses to question #31 by physicians who identified as male

73

While the researcher does not have comparative data on pre-pandemic experiences of
being more callous toward people since taking the job for these physicians, the difference
between the percentages of physicians identifying with the experience mentioned in question
#31 and those identifying with the feelings of burn out mentioned in question #30 seems to
suggest that interpersonal interactions are not a significant factor in increased physician burnout
during the COVID-19 pandemic.

Isolation

In this study, family is described as significant other, children, and parents. While only
20% of the interviews were coded with family as a contributor to alleviating feelings of burnout,
100% of the interviews were coded with isolation from family and friends as contributing to
feelings of burnout. Similarly, more than 88% of survey participants selected that they strongly
agree that they were concerned with transmitting COVID-19 to their families. More than 82% of
survey participants selected that they either strongly agreed or somewhat agreed with the
statement of having to isolate from family. Figure 18 is a graph demonstrating survey responses
to the question, “I was concerned with transmitting COVID-19 to my family” and figure 19 is a
graph demonstrating survey responses to the question, “I had to isolate myself from my family.”
While there isn’t significant data to suggest that spending time with family would alleviate
symptoms of burnout, the data does suggest that being concerned with the safety of their families
during the pandemic along with having to isolate from family were factors contributing to
burnout.
74

Figure 18

Survey response to question of concern with transmitting virus to family

Figure 19

Survey responses to question of having to isolate from family

75

In addition to the survey data, interview participants spoke about the need to isolate from
family. One of the interview participants, a woman working as an Infectious Disease Specialist
in a hospital based in LA County, stated: “I have few older children and they understand that I
had this big commitment to my patients my husband took over most of the duties, I isolated
myself and I believe I worked over 18 hours daily.” While the physician explains that this was a
stressful situation of working long hours and isolating from family, she also describes the
situation as not as stressful as it may have been had her children been younger and in greater
need of her care or support, or if her husband would not have been able to take on more
responsibilities in running the household.

A male physician working in the Intensive Care Unit stated: “I had to isolate myself from
my family, I stayed at a friend’s vacant backhouse for weeks. I limited time with my family, I
was infected with the virus and had to quarantine myself for two weeks and then go back to
work.” In this interview, the physician also describes the need to isolate and quarantine as more
matter of fact. It may be important to note that this physician and the infectious disease specialist
quoted above are both in their late 50s. A female ICU physician in her late 30s stated:

As a mother of two I was extremely stressed with my position as a mother I had
responsibilities towards my kids, schooling etc. and as a physician, I felt responsible to
my family and also to my patients and I was having a hard time balancing my life. I was
fearful to transmit virus to my family so I had to limit my time and isolate often.

In this interview it seems that the physician may be overwhelmed by feeling responsible
for her personal family as well as her patients. It may be helpful for future research to collect
76

data on physician age and the age of physician children in regard to the impact of isolation
during a pandemic.

In an interview, a male physician working in the Emergency Room during the pandemic

stated:

I had to isolate myself for weeks in a small room next to our garage, had limited my time
with family and especially my parents. I felt responsible for them, I was not able to be
around my kids so I was lacking that emotional support from family.

It seems likely that isolation contributed to burnout for physicians because of the lack of
family support that would normally be present, the increased stress in the workplace that may
have created a greater need for that family support, as well as the feelings of fear and
responsibility for family that fueled the need for isolation.

Lack of Hospital Support

Within the immediate work environment for physicians, and therefore within the
microsystem, this study includes disorder and hospital support. 80% of the interviews were
coded with disorder in the immediate work environment as a contributor to feelings of burnout.
Similarly, only 40% of interviews were coded as feeling supported by the hospital leadership or
administration being present and as helping to alleviate feelings of burnout. Interviewees
described the disorder or lack of support as reduced staff and help due to illness, isolation, or
death, lack of resources to help volume of patients, working long shifts with little breaks or time
off, disorganization and lack of strategy planning. A male physician working in the Intensive
Care Unit of an LA County hospital stated:
77

I felt supported by everyone. Admin was providing the necessary PPEs, however we
were short of beds and short on ventilators, I didn’t want to lose a patient or choose who
gets the ventilator or the special bed. Workload had increased in addition to all the extra
measures we had to take to see patients, the administrative duties like data entry, order
entry and so on remained the same. Morale in ICU was low, however we were trying to
celebrate small wins as we were mourning a loss.

In this interview, the physician is expressing the shortage of necessary supplies and
resources as adding to an already stressful situation. He also acknowledges the importance of
acknowledging what is working while it seems that so much is not working as it should.
Similarly, more than 80% of survey participants selected responses that indicate they
experienced increased workload due to the pandemic. More than 84% of survey participants also
selected experiencing a stressful work environment with low morale among healthcare workers.

While the sample size is too few to make assessments of the relationships between data in
this study, the survey participants in figure 20 who identified as Caucasian indicated an increase
in workload at a lower percentage in comparison to participating physicians who did not identify
as Caucasian, in figure 21.
78

Figure 20

Survey results for participants who identified as Caucasian regarding increased workload

Figure 21

Survey results for participants who did not identify as Caucasian regarding increased workload

79

Lack of hospital support or administrative support was not identified by physicians
participating in the survey or the interview as the cause of stressful work environments. Figure

22 demonstrates that the majority of survey participants selected responses that indicate that their
work environment was stressful and morale was low among healthcare workers.

Lack of hospital support or administrative support was not identified by physicians
participating in the survey or the interview as the cause of stressful work environments.

Figure 22

Survey results regarding stressful work environment with low morale

80

Disorder

The exosystem is the impact of the indirect environment in physicians’ development and
contains the formal and informal social structures and cultural values that indirectly affect
physicians (Bronfenbrenner, 1994). For this study, the exosystem may include hospital policies,
expectations, support, or the lack thereof. While the code “disorder” was included in the
microsystem, this study also includes it in the exosystem in regard to the disorder due to a lack of
hospital policies or support during the pandemic. For example, more than 84% of survey
participants somewhat agreed or strongly agreed with the statement of decreased clinical support
due to depleted workforce. Figure 23 demonstrates survey data on question #10 “During the
COVID-19 pandemic, I had less clinical support due to depleted workforce (due to isolation,
illness, death).” Similarly, about 17% of survey participants agreed that the organizations they
worked with were invested in their wellbeing and provided additional support during the
pandemic. Figure 24 below demonstrates survey data on question #14, “The organization(s) I
work with was/were invested in my wellbeing and provided additional support during the
pandemic.”
81

Figure 23

Survey results on depleted workforce

Figure 24

Survey results on organizational investment in physician wellbeing

82

Within the interviews with physicians, four of the five participants described disorder
in the work environment as a contributing factor to stress or burnout levels. A male physician
working the Emergency Room of a LA County hospital stated:

My professional environment in the ER was extremely stressful. Morale was low,
everyone was in fear, every patient was potential COVID, I didn’t trust my PPE and at
times I would have anxiety and had to step away but I had nowhere to go. Hospital was
not prepared to provide us the emotional wellbeing and no strategies in place to help cope
with stress and anxiety. Every single day I felt my wellbeing was at risk, I was exhausted
emotionally and physically. I would push myself to stay strong, patients were scared,
staff were scared. Admin was trying to secure PPEs and put out daily fires with staffing
and workers were calling sick and every day was a challenge.

While the code “disorder” was pulled to describe 80% of the interviews, the code
“collaboration” was coded from 60% of the interviews as a factor in alleviating feelings of
burnout. Collaboration was described by interview participants as working together as a team
with colleagues, having a shared mission and purpose, and having shared experiences that
were not shared by family and friends not working in the frontlines during the pandemic. A
female physician working as an Infectious Disease Specialist in an LA County hospital stated:

Working with colleagues and trying to collaborate our efforts and knowledge brought all of
us closer. We had steady meetings where we discussed certain patients and redesigned our
approach. I would say we all felt exhausted however we all had one goal in common and
that was to take care of our patients and to save lives. We were committed doctors.
83

From the excerpt of the physician interview, it seems that an antidote to the disorder
experienced in the hospital settings during the pandemic was collaboration between physicians,
nurses, administration, and leadership. The physician states that having a shared vision and goal
and working together toward that made her feel like she belonged to a team of committed doctors
and had stronger relationships with them.

Death

In addition to families, the term death was coded from 100% of the surveys as
contributing to feelings of burnout. In this study, the code “death” is in reference to the deaths
of patients and inability to help some patients or save some patient lives. The survey did not ask
participants directly about the volume of patient deaths or the impact of patient deaths on their
stress or experience of burnout. The surveys did not include a question about patient death or
loss of life contributing to burnout. Interview participants, however, described the increased loss
of life among patients and within hospitals as a significant factor contributing to feelings of
burnout.

A female physician working in the Intensive Care Unit of a hospital based in LA County
stated: “I lost several patients to COVID. It was emotionally exhausting to speak to family
members and give them the worst news. I would give my 100% but still outcome could be bad.
There was so much death.” A male physician working in the Intensive Care Unit of a hospital
based in LA County stated: “I lost several patients to COVID and that impacted me emotionally,
and having patients die alone or limited family member was also very disturbing. However,
discharging a COVID patient home to their loved ones was giving me strength and hope and as
a physician I felt I am doing a purposeful work.” A female physician working the Emergency
84

Room of a hospital based in LA County stated: “I did lose several patients to Covid-19, it was the
most difficult days I experienced in my career. Patients dying alone was another big component that
was causing lots of sadness and low morale.” A male physician working in the Emergency Room of
a hospital based in LA County stated: “I lost several patients, patients who came in with very low
oxygen and we had to intubate in ER and transfer to ICU. It was sad not being able to help, it was
stressful not being able to save those lives.” A female physician working as an Infectious Disease
specialist in a hospital based in LA County stated: “I had hard time losing a patient and we did lose
lots of patients. I spent lots of time explaining to patient families and informing them on the progress,
it was hard to lose a patient and I had to remind myself of those who got treated and went home to
their loved ones, which gave me hope.” While two of the five interview participants spoke of patient
deaths being stressful and supplemented these statements with the positive feelings that came from
the lives that were saved and patients who went home, three of the five interview participants only
spoke of the sadness and stress experienced by the number of patient deaths they experienced as well
as feeling unable to help.

Anxiety & Fear

The macrosystem consists of the beliefs, expectations, and lifestyles of the physicians and
their cultural setting (Bronfenbrenner, 1994). In this study, the codes “anxiety” and “fear” are
included within the macrosystem. As the macrosystem includes lifestyle, the codes “exercise”
and “outdoors” are also included in this section. Both codes “anxiety” and “fear” were drawn
from 80% of the interviews as contributing to feelings of burnout. Similarly, about 62% of
survey participants agreed with the statement of experiencing depression during the pandemic.
85

Figure 25 demonstrates survey data in regard to question #11, “I experienced depression
during the COVID-19 pandemic.”

As fear and anxiety were coded as contributing to feelings of burnout, 60% of interview
data demonstrated “exercise” and “outdoors” as helping to alleviate feelings of burnout. This
study considers “exercise” and “outdoors” and lifestyle factors. Along the same lines, 20% of
interview data demonstrates proper “nutrition” as contributing to alleviating feelings of burnout.

Figure 25

Survey results regarding experiencing depression

86

Summary of Findings

Through this study, the researcher sought to understand if the COVID-19 pandemic contributing
to increasing or decreasing physician burnout, as well as the factors that contributed to increased
physician burnout and the factors that contributed to alleviating feelings of burnout. The
interview questions were:

1. What changes were implemented within the hospital because of the
COVID-19 pandemic that either contributed to or helped alleviate physician
burnout?

2. What factors, particularly physician identity, during the pandemic
impacted the level of burnout physicians experienced?

It was discovered that the microsystem, mesosystem, exosystem, and macrosystems all that
contributed to increased physician burnout or contributed to alleviating feelings of burnout
among physicians. Overall the quantitative survey data and the qualitative interview data
demonstrate that a higher percentage of physicians experience burnout during the COVID-19
pandemic than the pre-pandemic literature suggested of US physicians. The chronosystem
did not seem relevant to this study, which may be due to the short period of time from which
literature and data are drawn on this topic to date. The relationship between the research
literature and the findings of this study will be explored in the following chapter.
87

Chapter Five: Discussion, Conclusion, and Recommendations

This study offers a view into the experiences of physicians working in LA County
hospitals during the COVID-19 pandemic. Using the framework of Bronfenbrenner’s social
ecological systems theory, two research questions were used to guide the study: 1) What
changes were implemented within the hospital because of the COVID-19 pandemic that either
contributed to or helped alleviate physician burnout? and 2) What factors, particularly physician
identity, during the pandemic impacted the level of burnout physicians experienced? A mixed
methods analysis was conducted using the conceptual framework.

As described in Chapter Four, the data demonstrates that this population identified
with increased experiences of physician burnout in general regardless of identity. The data
also showed that the percentage of non-Caucasian identifying physicians experiencing burnout
was higher than that of Caucasian identifying physicians who participated in the survey and/or
interview of this study.

Following the interpretation of findings, this chapter will examine the limitations of
this study. This study will then present recommendations for future research. Lastly, this study
will discuss the implications for hospital-led professional development opportunities that seek
to reduce physician burnout.

Interpretation of the Findings

While existing literature on physician burnout during the COVID-19 pandemic
demonstrates that new stressors and factors during the pandemic have increased existing levels of
physician burnout (Bendix, 2020), data in this area is still developing. Similarly, the data of this
study demonstrates a need for greater research in this area. The results of this study
88

demonstrate similar findings based on percentages as those in much of the recent literature
regarding increased physician burnout due to fear of exposure and infection (Bendix, 2020),
patient deaths, and isolation from family and friends (Saleh, 2020).

Overall, the results of the survey and interviews of this study demonstrated a higher
percentage of burnout for the participating physicians who worked in LA County hospitals
during the COVID-19 pandemic than the percentages in pre-pandemic literature on U.S.
physician burnout. Recent literature also demonstrates that burnout among healthcare providers,
especially during the COVID-19 pandemic, is a major occupational problem (Sultana, 2020).
The American Academy of Family Physicians notes that 64% of U.S. physicians who were
surveyed stated that the pandemic intensified their burnout (American Academy of Family
Physicians [AAFP], 2020).

This study also provided an observation of how physician gender and ethnic and/or racial
identity may play a role in the level of burnout experienced by physicians. The findings were
interpreted using its two questions as a framework. All themes and data codes of this study were
related in that collaboration was related to disorder, death was related to disorder, anxiety and
fear were related to death and to isolation, and so forth.

Findings & Existing Literature: Major Themes

The findings of this study can be understood in relation to the existing literature through
the major themes identified in coding and demonstrated in the word clouds shown in Chapter
Four. The six major themes are: death, isolation, anxiety and fear, disorder and support,
outdoors and exercise, and collaboration.
89

Theme 1: Death

All participants of the interviews stated death as a major contributor to stress and
burnout during the pandemic. Both male and female identifying participants, and Caucasian and
non-Caucasian identifying participants described the theme of death as a contributing factor to
burnout during the pandemic. Existing literature on physician burnout during the COVID-19
pandemic also identifies patient mortality rates as a stressor contributing to physician burnout
(Sultana, 2020). While this study focused on physicians within LA County hospitals during the
pandemic, because the pandemic is global in nature and research on the topic is still underway,
this study does utilize international research on physician burnout during the COVID-19
pandemic throughout chapter five.

This study did not identify literature that recognized patient mortality as a leading cause
of burnout among physicians prior to the COVID-19 pandemic. However, research conducted on
physicians working during the pandemic in the country of Jordan identified patient deaths within
daily practice as a major stressor contributing to physician burnout (Alrawashdeh et al., 2021).
Research conducted on physician burnout during the COVID-19 pandemic in Brazil also states
that working conditions for physicians, including increased workload and high patient death
rates, are contributing to unprecedented levels of burnout for primary healthcare workers (Moura
et al., 2020).
Theme 2: Isolation

Family and the physician are both part of the meso and the micro systems. The
mesosystem contains the interactions and connections between their environments
(Bronfenbrenner, 1994). In the case of physicians during the pandemic, an example of the
90

mesosystem can be the interaction between the physician’s work environment and their children,
such as the fear of exposing their children to the virus because of her work environment. The
microsystem of Bronfenbrenner’s ecological systems theory is shaped by the physician’s
immediate surroundings and the interactions between them, which includes family, home, and
work environment or colleagues. Due to the nature of the COVID-19 as an infectious disease
and the isolation and quarantine of patients, physicians, and citizens alike, there was a disruption
to the physician’s microsystem in that it was best for work and home to not interact. All
participants of the interviews stated that they isolated and/or quarantined and that it was a
contributor to their experience of burnout. Recent literature states that studies have shown
mental health problems among healthcare providers who work among isolated or quarantined
individuals (Sultana, 2020).

Recent research and the findings of this study demonstrate that isolation increased the
experience of burnout among physicians working during the COVID-19 pandemic. The
combined stressors of high workload, fear of infection, and disrupted social support (i.e. isolation
or quarantine) are associated with psychosocial health outcomes for healthcare providers
(Sultana, 2020).

Theme 3: Anxiety and Fear

All participants of the interviews referenced anxiety and fear while working in the
frontlines during the COVID-19 pandemic as a contributor to the experience of burnout. In a
study on physicians working during the COVID-19 pandemic in Jordan, the researchers
describe participant’s feelings:
91

Most of the physicians who participated in the interviews reported fear and anxiety
related to their medical practice amid the pandemic crisis. The fear and anxiety were
mainly a result of their worries about catching the virus and transmitting it to their
beloved family members. This could be expected to act as a contributing factor to their
emotional and mental exhaustion; leaving them more vulnerable to suffer from burnout.
(Alrawashdeh et al., 2021, p. 15)

In other research, such as that cited by Sultana above, the fear of being infected during
the COVID-19 pandemic is listed as a factor contributing to mental health needs of physicians.
Research conducted by Moura lists fear of exposing family members to infection as a
contributing factor to physician mental exhaustion and states that 89% of surveyed physicians
reported fear of transmitting COVID-19 to their families (Moura et al., 2020). The literature by
Alrawashdeh also states that the fear and anxiety felt by physicians was mostly due to fear of
transmitting the virus to family and the home environment (Alrawashdeh et al., 2021) .

Theme 4: Disorder and Support

All interviews were coded as having referenced disorder in the workplace. The majority of
the interviews were coded as having referenced support as a factor helping alleviate burnout or the
lack of support as a factor contributing to burnout. Since workplace disorder and lack of support
generally coexist, this section has combined the two. Recent literature also states that unhealthy
work environments as well as insufficient organizational support are factors contributing to the
experience of burnout among physicians (Alrawashdeh et al., 2021). The same study cites that
work environment is a predictor of burnout and that enhancing the work environment by
addressing common contributing factors can lessen the experience of burnout.
92

Research also states that supportive leadership can be effective in mitigating burnout caused
by workplace stressors (Moura et al., 2020).

Recent literature on physician burnout during the pandemic also states that alleviating
physician burnout must include efforts to improve organizational culture and relieve
workplace stressors (Sultana, 2020). Moura states that the mental effort required to deal with
daily workplace stressors drains employee resources and leads to fatigue and emotional
exhaustion (Moura et al., 2020). Fatigue and emotional exhaustion are recognized as
symptoms of burnout (Shanafelt et al., 2012).

Theme 5: Outdoors and Exercise

The majority of interviews were coded with the themes outdoors and exercise as factors
alleviating the experience of burnout for physicians during the pandemic. While spending time
outdoors and exercise are not directly related to the factors contributing to physician burnout,
recent literature does note the importance of protecting the mental and physical health of primary
healthcare providers as one of the ways in which burnout can be successfully addressed
(Alrawashdeh et al., 2021).

A 2017 study by a team based in Finland found that nature exposure during the workday is
related to occupational health and lower burnout (Hyvonen et al., 2018). The study explains that,
drawing upon Attention Restoration Theory, directed attention, which is used in decision making, is
a limited resource and can be fatigued. Time in nature can then restore the fatigued directed
attention by providing fascination with an element in the environment, the sense of being away, and
compatibility between oneself and the environment (Hyvonen et al., 2018).
93

In a 2016 study, research finds that regular participation in aerobic exercise and/or
strength training are associated with lower burnout risk among medical students in the U.S.
(Dyrbye & Satele, 2016). Other research demonstrates the positive impact of Combined Exercise
Training, a program that combines walking, standing, and sitting in intervals, on decreasing
burnout symptoms and psychological stress among workers in the helping professions (Greco,
2020).

Theme 6: Collaboration

Prior to the pandemic, research on physician burnout identified feelings of not being
supported by hospital administration and leaders as a contributing factor (Patel et al., 2018).
Collaboration between physicians, hospital administration, and leadership can be an important
factor in alleviating burnout symptoms as inclusion has been shown to build trust and feelings of
being supported within organizations (Ely & Thomas, 2020). Interviewees described an
increased sense of purpose when collaborating with colleagues and administration on patient
treatment plans and wellbeing during the pandemic. This collaboration was also stated to have
created a sense of comradery, which may have been particularly important during a time when
most were in isolation or quarantine and away from their usual family support systems. A
female physician participant in this collaboration study, working in the Intensive Care Unit,
shared her feelings during the interview:

Reflecting back helps me cope with my burnout, looking back on how our team
collaborated and how we felt like one unit doing a meaningful work. Reflecting on all the
patients we were able to save and the fight we put out for every patient helps me mitigate the
burnout. (Ely & Thomas, 2020, p. 50)
94

It is important to note that physician autonomy, defined as the perceived degree of control
over one’s work (Vilendrer et al., 2020), was a leading cause of physician burnout prior to the
pandemic. However, it seems that interview participants in this study viewed collaboration as an
extension of autonomy and not as an impediment to their ability to have control over their work.

Physician Identity

The macrosystem consists of the beliefs, expectations, and lifestyle of the physicians
and their cultural setting. The macrosystem is the consistency between the individual’s culture
or subculture and all of the other systems identified within the social-ecological systems theory
(Bronfenbrenner, 1994).The second research question, What factors, particularly physician
identity, during the pandemic impacted the level of burnout physicians experienced?, was also
addressed by this study. During the interviews, difference of experience was based on the
researcher’s observation as questions pertaining to physician identity and experience were not
explicitly stated or implied by participants and therefore not included in the coded themes.

Literature published prior to the pandemic confirms a relationship between physician
gender and levels of burnout (Lee, 2008). While existing research demonstrates that physicians with
marginalized racial or ethnic identities experience lower rates of physician burnout (Garcia

& Shanafelt, 2020), more recent literature based on a study in Canada demonstrates that
physicians with marginalized ethnicities were more likely to feel lower personal accomplishment
than white physicians during the COVID-19 pandemic (Khan & Palepu, 2021). The quantitative
data from this study demonstrates that physicians who did not identify as Caucasian had a greater
percentage of indication that they experienced burnout in comparison to the quantitative data
percentages demonstrated by physicians who identified as Caucasian. The survey data from this
95

study also demonstrates that physicians who did not identify as Caucasian had a greater
percentage of participants select responses that demonstrate having the experience of
becoming more callous toward people since taking the job.

Limitation of the Study

With long standing relationships with LA County based physicians and professional
medical groups and associations, the researcher anticipated nearly 100 participants in the survey
and at least 10 in the interview process. The physician population in LA County working during
the COVID-19 pandemic did not respond to the email invitation to participate in the survey in
the volume that was expected by the researcher, and few followed up to participate in the
interview.

This research project is a mixed methods study with five interview participants and 51
survey participants, and therefore has limitations to take into consideration. As the qualitative
study that relied strictly on data derived from interviews the small sample size and the subjective
coding of themes are limitations. A second limitation of this study is that the quantitative survey
data also has a small sample size.

Additionally, the potential for bias is a limitation of the study. Having only five interview
participants limits the study’s ability to substantiate its findings or observations. Conducting the
interviews by telephone or internet conferencing applications proved limiting as interviewees may
have been more comfortable opening up in person with the researcher. Since interviewees did not
wish to be recorded, the qualitative data relied on field notes taken by the researcher and memory.
These limitations may have contributed to the potential for bias without the researcher’s
96

awareness. These limitations likely have a negative impact on the credibility and
transferability of the study.
Recommendations

This case study was inspired by the literature that 68% of U.S. physicians experience
burnout and that the number is increasing during the COVID-19 pandemic (Shanafelt et al.,
2012), as well as the research demonstrating a significant lack of diversity in hospital leadership
(ACHE, 2020). This study sought to gain additional insight into the factors that both contribute
to and help to alleviate physician burnout. This study’s insight into this phenomenon was
obtained through the lived experiences of the participants, physicians working in LA County
hospitals during the COVID-19 pandemic. Researchers describe recommendations for physician
burnout:

Global evidence indicates the need for adopting multipronged evidence-based approaches
to address burnout during this pandemic, which may include increasing the awareness of
work-related stress and burnout, promoting mindfulness and self-care practices for
promoting mental wellbeing, ensuring optimal mental health services, using digital
technologies to address workplace stress and deliver mental health interventions, and
improving organizational policies and practices focusing on burnout among healthcare
providers. (Sultana, 2020, p. 3)

This section offers recommendations that address the leadership and organizational
gaps that may be influencing physician burnout during the COVID-19 pandemic. This study
used Bronfenbrenner’s Ecological Systems Theory (Bronfenbrenner, 1994) as the conceptual
framework. Bronfenbrenner’s Ecological Systems Theory proposes that inherent qualities of
97

people and the qualities of their environments interact and influence the growth and development
of each (Bronfenbrenner, 1994). The findings of this study validate that there are organizational
policies and practices that can impact physician burnout. This section concludes with
recommendations that address the following areas within Bronfenbrenner’s social systems:
microsystem, mesosystem, and macrosystem (Bronfenbrenner, 1994).

Hospitals ensure and explicitly state that physical safety is the number one priority

In all five interviews conducted, physicians identified personal safety and the safety of
their families as one the biggest stressor during the pandemic since this is what led to long
isolation periods. Survey results identified being infected by COVID-19 as a fear for most
physicians. In addition to the stressors of demanding schedules, increasing amounts of
paperwork, frustrations with third-party funding sources, and increasing regulations, policies,
and procedures (Patel et al., 2018), physicians face further challenges with caring for COVID-19
patients with limited resources while trying to stay healthy themselves (Bendix, 2020).

Continuing to work on the frontlines of the pandemic while losing colleagues to infection,
quarantine, and even death further adds to physicians’ stress and burnout as they fear for the
well-being of their coworkers, families, and their own health (Bendix, 2020).

During the pandemic, administrative and leadership support can be demonstrated through
ensuring that physicians always have access to personal protective equipment and that
physicians have appropriate access to testing and vaccinations. Additionally, self-care initiatives
and trainings during the pandemic may help physicians focus on their own safety and wellbeing
as well. Prioritizing physician physical safety will also include ensuring that physicians spend
time outdoors during the workday and maintain healthy exercise habits. The interview data
98

demonstrated that time outdoors and exercise helped to alleviate physician burnout, and
research supported these findings.
Hospitals ensure that physicians are represented at decision-making meetings

Survey and interview results identified feelings of lack of hospital leadership and
administration support for physicians. Inclusion, beyond simply increasing numbers of diverse
members, have been shown to build trust and feelings of being supported within organizations
(Ely & Thomas, 2020). Diversity and inclusion drive innovation in organizations (Kalina, 2019).
Traditionally, most learning and development programs developed and implemented to decrease
physician burnout focused on the physicians and teaching them skills such as stress
management (Kannampallil et al., 2020).

Having physician representation in decision-making meetings may drive innovative
solutions and decrease physician burnout. As survey data demonstrates collaboration as a factor
helping to alleviate physician burnout during the pandemic, inclusion efforts that create
collaboration can help reduce physician burnout.

Hospitals need to communicate their commitment to diversity, equity, and inclusion and

ensure that their actions are aligned with the commitment

Survey results demonstrated that a higher percentage of participating physicians
experienced a lack of feeling supported by hospital administration and leadership. Research
from the American Hospital Association in 2019 demonstrates that 89% of all hospital CEOs
were white (ACHE, 2020). Research demonstrates that an organization’s long-term success is
undermined when leadership is made up of like-minded people as this undermines the ability to
be innovative and evolve through changing dynamics (Kalina, 2019). Health care facilities can
99

ensure their competitiveness and reduce physician burnout by creating and maintaining an
inclusive environment (Kalina, 2019), which refers to incorporating the ideas, perspectives, and
contributions of everyone on the diverse team (Kalina, 2019).

Communicating and aligning with an organizational DEI commitment can resolve workflow
challenges and create greater collaboration, helping to reduce physician burnout. Diverse leadership
will also help to ensure that diverse physician populations are represented in leadership, which may
contribute to alleviating any discrepancies that may exist in experiencing burnout between physicians
with marginalized identities and physicians with dominant identities.

Hospitals need to promote physicians and administration with diverse backgrounds,

perspectives, and experience to ensure greater equity across the organization

Current research explains the benefits of diversity among organizational leadership, yet
racial, ethnic, and gender diversity among hospital leadership has made little progress
(Livingston, 2018). One of the interview participants of this who identified as a Latino male
stated being overworked because his supervisor asked him to take on an increasing number of
patients and shifts and he did not want to say no to his supervisor. The survey data of this
demonstrates that participating physicians who identified as Caucasian reported greater numbers
increased workload due to the pandemic than participating physicians who did not identify as
Caucasian. It is uncertain whether the difference in data is due to cultural differences in reporting,
differences in organizational seniority or medical specialty, or to other reasons. The conflicting
data demonstrates that further research into the demographics of hospital supervisors is
necessary, as is research into promotion practices and how physicians with marginalized
identities can become promoted into hospital leadership roles. In order to create greater diversity
100

among hospital leadership and administration, there must be organizational in promotion
policies and procedures change.
Implications for Positive Organizational Change

There are many factors credited with contributing to physician burnout, which, prior to
the pandemic, was understood as the effect of cumulative stress from significant changes in
society, the medical profession and the healthcare system (Rothenberger, 2017). Stress is
described as a general reaction that occurs in response to different stressors (Bieliauskas, 2020)
and research has found that physicians with more exposure to stressors, demonstrate more
symptoms of burnout (Lee, 2008). It follows then that as the COVID-19 pandemic has created
more stressors for physicians, the symptoms of burnout among physicians has increased. In fact,
recent research demonstrates that the pandemic is causing increased exposure to stressors for
physicians and therefore higher rates of burnout (Gibson, 2021).

This study has many implications for positive organizational change. Developing an
understanding of what factors contribute to and alleviate physician burnout during the COVID-19
pandemic, allows for improved organizational policies and procedures as well as burnout
interventions. Further research in these areas is capable of raising awareness of the consequences
of physician burnout, predictors of burnout, and successful solutions to burnout.

The six themes that emerged from this study are death, isolation, fear and anxiety,
disorder and support, outdoors and exercise, and collaboration. Each of these themes highlight
the contributing factors to burnout and the additional efforts that need to be made by all
stakeholders involved in the creation and consequences of physician burnout. These stakeholders
include physicians, patients, hospital administration, hospital leadership, and the communities.
101

The findings of this study imply that physicians cannot be expected to perform the
majority of the factors that are found to help alleviate physician burnout. For instance,
collaboration, spending time outdoors, and exercising are the three factors identified as helping
to reduce the experience of burnout among physicians during the COVID-19 pandemic. While
collaboration requires leadership, physicians, and hospital administration, spending time
outdoors and exercising is seemingly up to the individual physicians although physicians need
support from other stakeholders to maintain these practices.

This study concludes that more research in regard to what prevents physicians from being
able to regularly spend time outdoors during the workday and to exercise regularly so that
hospital administration and leadership can remove the barriers to doing so or provide
supplemental resources to support these activities for physicians on a regular basis. It may be
important to note that while these practices are found to be helpful in alleviating burnout among
professionals in regular times, they may be of greater importance during crises situations, such
as a pandemic, and that such crises may create circumstances that are even more difficult to
overcome in order to accomplish these practices regularly.
Summary

To address the impact of the COVID-19 pandemic on physician burnout, the researcher
drew upon Bronfenbrenner’s Ecological Systems Theory (Bronfenbrenner, 1994).
Bronfenbrenner’s Ecological Systems Theory proposes that inherent qualities of people and
the qualities of their environments interact and influence the growth and development of each
(Bronfenbrenner, 1994). Through this framework, human development is viewed through the
way in which the most immediate communities to the broader social and cultural environments
102

all influence one another. The quantitative and qualitative data of this study aligned with
Bronfenbrenner’s theory as the data demonstrates the interconnectedness of the pandemic’s
impact on physician burnout and the ways in which this differed for physicians based on a
number of factors, including living arrangements, family responsibilities, racial and/or ethnic
identity, gender identity, medical specialty, and so forth.

Bronfenbrenner’s theory enabled the examination of the relationships between the
COVID-19 pandemic and physician burnout rates, which provided a closer look at how the
pandemic influenced physicians differently. Using Bronfenbrenner’s theory as the conceptual
framework of this study allowed the researcher to approach the research questions, 1) What
changes were implemented within the hospital because of the COVID-19 pandemic that either
contributed to or helped alleviate physician burnout?, and 2) What factors, particularly
physician gender, racial, or ethnic identity, during the pandemic impacted the level of burnout
physicians experienced?, literature review, and the qualitative and quantitative data of this study
with an understanding of the interrelated nature of these factors. For instance, the lack of
diversity in hospital leadership may have influenced the changes that were implemented in the
hospital and these changes may have impacted physicians differently based on their individual
backgrounds, identities, and perspectives. As the literature reviewed for this study confirms the
lack of diversity in leadership and the need for greater research in the area, this study’s
recommendations for hospital leadership and administration taking a more involved approach to
alleviate physician burnout and the recommendation for more in-depth research is aligned with
the current literature on the topic.
103

Conclusion

The findings of this study indicate a need for change within hospitals in the areas of
collaboration and communication, prioritizing physician health and wellbeing, and diversity,
equity, and inclusion efforts. If the goal is to reduce physician burnout rates, especially during
times of crises such as the COVID-19 pandemic, then organizational changes are necessary.

Many of these changes involve a change in approach that must include change at the
leadership level. Research demonstrates that hospital leadership is lacking diversity, which may
be a factor contributing to the need for greater collaboration between physicians and between
physicians and hospital administration and leadership. Survey data also demonstrated a need for
physician exercise and time spent outdoors during the workday. The reasons that physicians are
not able to practice these regularly may change if hospital leadership changes its approach to
prioritizing physician health and wellbeing.

Future research studies should focus on what contributes to physician burnout, what
alleviates physician burnout, what barriers exist to implementing the practices that alleviate
physician burnout, and how to reduce the stressors contributing to physician burnout.

Additionally, future research to focus on how burnout is experienced differently based on
physician identity and how stressors contributing to burnout may be impacting physicians
differently based on identity. Finally, future research students should focus on how to improve
diversity within hospital leadership, how to create greater equity among physicians, and how to
foster more inclusive cultures within hospital organizations.

This study explained how five physicians working in LA County hospitals during the
COVID-19 pandemic experienced burnout, what contributed to their increased burnout and what
104

helped alleviate feelings of burnout. This study also collected data on 51 physicians working
within LA County hospitals and how they experienced burnout during the pandemic.

The six themes coded from the data death, isolation, fear and anxiety, disorder and
support, outdoors and exercise, and collaboration highlighted the responses of the participants.
This study revealed that the recommendations of prioritizing physician health and wellbeing,
ensuring the physicians are represented at decision-making meetings, and committing to
diversity, equity and inclusion efforts can help alleviate feelings of burnout among physicians,
especially during times of crises, such as the COVID-19 pandemic.

By considering the results of this case study along with the increasing

research in the literature of physician burnout, it is evident that there are many organizational
challenges that need to be addressed in order to reduce rates of physician burnout.
105

References

Adler-Milstein, J., Zhao, W., Willard-Grace, R., Knox, M., & Grumbach, K. (2020).
Electronic health records and burnout: Time spent on the electronic health record after
hours and message volume associated with exhaustion but not with cynicism among
primary care clinicians. Journal of the American Medical Informatics Association,
27(4), 531–538. https://doi.org/10.1093/jamia/ocz220

Alrawashdeh, H. M., Al-Tammemi, A. B., Alzawahreh, M. Kh., Al-Tamimi, A., Elkholy, M.,
Al Sarireh, F., Abusamak, M., Elehamer, N. M. K., Malkawi, A., Al-Dolat, W., Abu-
Ismail, L., Al-Far, A., & Ghoul, I. (2021). Occupational burnout and job satisfaction
among physicians in times of COVID-19 crisis: A convergent parallel mixed-method
study. BMC Public Health, 21(1), 811. https://doi.org/10.1186/s12889-021-10897-4

American College of Healthcare Executives. (2018). A Comparison of the Career Attainments of
Men and Women Healthcare Executives. Retrieved from https://www.ache.org/learning-
center/research/about-the-workplace/gender-studies/a-com parison-of-the-career-
attainments-of-men-and-women-healthcare-executives.

American College of Healthcare Executives. (2020). Increasing and sustaining racial/ethnic
diversity in healthcare leadership. Retrieved from

https://www.ache.org/about-ache/our-story/our-commitments/policy-
statements/increasin g-and-sustaining-racial-diversity-in-healthcare-management

Barnet ‐Verzat, C., & Wolff, F. (2008). Gender wage gap and the glass ceiling effect: A firm-
level investigation. International Journal of Manpower, 29(6), 486–502.
https://doi.org/10.1108/01437720810904185
106

Barkholz, D. (2017). Gender pay gap still a stark reality for healthcare executives,

employees. PressReader.com - Digital Newspaper & Magazine subscriptions. Retrieved

from https://www.pressreader.com/usa/modern-healthcare/20170724/281745564447596

Bendix, J. (2020). Fanning the flames: The impact of COVID-19 on physician burnout.
https://www.medicaleconomics.com/view/fanning-the-flames-the-impact-of-covid-19-
on-physician-burnout

Berg, Sara (2019). Why women physicians are more likely to experience burnout. American

Medical Association.

https://www.ama-assn.org/practice-management/physician-health/why-women-physician

s-are-more-likely-experience-burnout

Bieliauskas, L. A. (2019). Stress and Its Relationship to Health and Illness. Routledge.
https://doi.org/10.4324/9780429307737

Bower, G. G. (2008). Mentor Functions and Outcomes: Advancing Women within Leadership
Positions in the Health and fitness industry. Advancing Women in Leadership, 28, 1.

Bronfenbrenner, U. (1994). Ecological Models of Human Development.
International Encyclopedia of Education, Vol. 3, 2nd. Ed.

Bronfenbrenner, U. (1997). The ecology of human development experiments by nature
and design. Harvard University Press.8703731

Cantor, J. C., & Mouzon, D. M. (2020). Are Hispanic, Black, and Asian Physicians Truly Less
Burned Out Than White Physicians?: Individual and Institutional Considerations. JAMA
Network Open, 3(8), e2013099–e2013099.
107

https://doi.org/10.1001/jamanetworkopen.2020.13099

Cheeseman, D. (2019). College degree widens gender earnings gap. United States

Census Bureau. Retrieved from census.gov/library/stories/2019/05/college-degree-

widens-gender-earnings-gap.html.

Cheeseman, D. & Christnacht, C. (2019). Your health care is in women’s hands. United
States Census Bureau. http://census.gov/library/stories/2019/08/your-health-care-in-
womens-hands.html.

Clerkin, C. (2017). What Women Want—And Why You Want Women—In the Workplace. 28. Cook,
T. M., & Lennane, S. (2021). Occupational COVID-19 risk for anaesthesia and intensive

care staff – low-risk specialties in a high-risk setting. Anaesthesia, 76(3), 295–300.
https://doi.org/10.1111/anae.15358

COVID-19 is increasing physician burnout. (2020). Retrieved January 28, 2022, from
https://www.aafp.org/journals/fpm/blogs/inpractice/entry/covid_burnout_survey.html

Creswell, J. W. (2014). Research design: qualitative, quantitative, and mixed methods

approaches. 4th ed. Thousand Oaks, California: SAGE Publications.

Downs, J. A., Reif, L. K., Hokororo, A., & Fitzgerald, D. W. (2014). Increasing women in
leadership in global health. Academic Medicine: Journal of the Association of American
Medical Colleges, 89(8), 1103–1107. https://doi.org/10.1097/ACM.0000000000000369

Drury, B. J., & Kaiser, C. R. (2014). Allies against Sexism: The Role of Men in
Confronting Sexism: Allies against Sexism. Journal of Social Issues, 70(4), 637–
652. https://doi.org/10.1111/josi.12083
108

Dyrbye, L. N., Satele, D., & Shanafelt, T. D. (2017). Healthy Exercise Habits Are Associated With
Lower Risk of Burnout and Higher Quality of Life Among U.S. Medical Students.
Academic Medicine, 92(7), 1006–11. https://doi.org/10.1097/ACM.0000000000001540

Duehr, E. E., & Bono, J. E. (2006). Men, Women, and Managers: Are Stereotypes
Finally Changing? Personnel Psychology, 59(4), 815–846.
https://doi.org/10.1111/j.1744-6570.2006.00055.x

Ecological systems theory. (2021). In Wikipedia.
https://en.wikipedia.org/w/index.php?title=Ecological_systems_theory&oldid=10386773 51

Elton, J., & O’Riordan, A. (2016). Healthcare disrupted: Next generation business models and
strategies (1st edition). Wiley.

Ely, R. & Thomas, D. A. (2020). Getting serious about diversity: enough already with the

business case. Harvard Business Review. https://hbr.org/2020/11/getting-serious-about-
diversity-enough-already-with-the-business -case

Emanuel, E. J., & Pearson, S. D. (2012). Physician Autonomy and Health Care Reform. JAMA,
307(4), 367–368. https://doi.org/10.1001/jama.2012.19

Freund, K. M. (2020). Gender Equity in Leadership: SGIM, It’s Our Problem! Journal
of General Internal Medicine, 35(6), 1631–1632. https://doi.org/10.1007/s11606-
020-05710-8

Gannotta, R. (2020). How the Healthcare Industry Will Change Post-COVID-19. Orange
County Business Journal, 43(18), 35–35.
109

Garcia, L. C., Shanafelt, T. D., West, C. P., Sinsky, C. A., Trockel, M. T., Nedelec, L.,

Maldonado, Y. A., Tutty, M., Dyrbye, L. N., & Fassiotto, M. (2020). Burnout,

Depression, Career Satisfaction, and Work-Life Integration by Physician Race/Ethnicity.

JAMA Network Open, 3(8), e2012762.

https://doi.org/10.1001/jamanetworkopen.2020.12762

Gazelle, G., Liebschutz, J. M., & Riess, H. (2015). Physician Burnout: Coaching a Way Out.
Journal of General Internal Medicine, 30(4), 508–513.
https://doi.org/10.1007/s11606-014-3144-y

Gibson, J. (2021, April 2). Tackling physician burnout during a pandemic. Medical Economics.

Retrieved January 29, 2022, from

https://www.medicaleconomics.com/view/tackling-physician-burnout-during-a-pandemic

Greco, G., Cataldi, S., & Fischetti, F. (2020). Combined Exercise Training Improves Work-
Related Burnout Symptoms And Psychological Stress: A Randomized Controlled Study:
1702 Board #296 May 28 9:30 AM - 11:00 AM. Medicine & Science in Sports &
Exercise, 52(7S), 458. https://doi.org/10.1249/01.mss.0000678904.77818.e8

Hansen, V., & Pit, S. (2016). The Single Item Burnout Measure is a Psychometrically
Sound Screening Tool for Occupational Burnout. Health Scope, 5(2), Article 2.
https://doi.org/10.17795/jhealthscope-32164

Hartzband, P., & Groopman, J. (2020). Physician Burnout, Interrupted. The New England
Journal of Medicine, 382(26), 2485–2487. https://doi.org/10.1056/NEJMp2003149

Hauser, M. C. (2014). Leveraging women’s leadership talent in healthcare. Journal of
Healthcare Management / American College of Healthcare Executives, 59(5), 318–322.
110

Hoyt, C. L., & Murphy, S. E. (2016). Managing to clear the air: Stereotype threat, women,
and leadership. The Leadership Quarterly, 27(3), 387–399.
https://doi.org/10.1016/j.leaqua.2015.11.002

Hughes, R. L., Ginnett, R. C., & Curphy, G. J. (2009). Leadership enhancing the lessons of
experience. McGraw-Hill.

Hyvönen, K., Törnroos, K., Salonen, K., Korpela, K., Feldt, T., & Kinnunen, U. (2018). Profiles

of Nature Exposure and Outdoor Activities Associated With Occupational Well-Being

Among Employees. Frontiers in Psychology, 9.

https://www.frontiersin.org/article/10.3389/fpsyg.2018.00754

Kalaitzi, S., Czabanowska, K., Azzopardi-Muscat, N., Cuschieri, L., Petelos, E., Papadakaki, M.,

& Babich, S. (2019). Women, healthcare leadership and societal culture: A qualitative

study. Journal of Healthcare Leadership, 11, 43–59.
https://doi.org/10.2147/JHL.S194733

Kalina, P. (2019). Increase inclusion to decrease physician burnout and increase wellness.
Journal of Hospital Management and Health Policy, 3(0), Article 0.
https://doi.org/10.21037/jhmhp.2019.07.01

Kannampallil, T. G., Goss, C. W., Evanoff, B. A., Strickland, J. R., McAlister, R. P., & Duncan,
J. (2020). Exposure to COVID-19 patients increases physician trainee stress and burnout.
PLOS ONE, 15(8), e0237301. https://doi.org/10.1371/journal.pone.0237301

Khan, N., Palepu, A., Dodek, P., Salmon, A., Leitch, H., Ruzycki, S., Townson, A., & Lacaille,
D. (2021). Cross-sectional survey on physician burnout during the COVID-19 pandemic
111

in Vancouver, Canada: The role of gender, ethnicity and sexual orientation. BMJ Open,
11(5), e050380. https://doi.org/10.1136/bmjopen-2021-050380

Kurapati, Rajeev (2020). How hospital administrators can combat provider burnout and improve
the organizational bottom line. Physician Leadership. Retrieved from
https://www.physicianleaders.org/news/how-hospital-administrators-can-combat-
provider -burnout-and-improve-the-organizational-bottom-line

KPMG International (2015). KPMG women’s leadership study: Moving women forward
into leadership roles. Retrieved from KPMG.com/WomensLeadership.

Lee, F. J., Stewart, M., & Brown, J. B. (2008). Stress, burnout, and strategies for reducing
them What’s the situation among Canadian family physicians? Canadian Family
Physician, 54(2), 234-e5.

Moura, E. C. D., Furtado, L., & Sobral, F. (2021). THE BURNOUT EPIDEMIC DURING
THE COVID-19 PANDEMIC: THE ROLE OF LMX IN ALLEVIATING
PHYSICIANS’ BURNOUT. Revista de Administração de Empresas, 60, 426–436.
https://doi.org/10.1590/S0034-759020200606

Linzer, M., Levine, R., Meltzer, D., Poplau, S., Warde, C., & West, C. P. (2014). 10 Bold Steps
to Prevent Burnout in General Internal Medicine. Journal of General Internal Medicine,
29(1), 18–20. https://doi.org/10.1007/s11606-013-2597-8

Livingston, S. (2018). Racism Is Still a Problem in Healthcare’s C-Suite: Efforts Aimed at
Boosting Diversity in Healthcare Leadership Fail to Make Progress. Journal of Best
Practices in Health Professions Diversity, 11(1), 60–65.

Loria, K. (2019). The future of healthcare leadership. Managed Healthcare Executive. 29(9).
112

Mansour, M., & Shor, R. (2015). Health Care in Transition. Journal of the American College
of Cardiology, 66(16), 1837–1838. https://doi.org/10.1016/j.jacc.2015.08.841

Maslach, C., & Leiter, M. P. (2021, March 19). How to Measure Burnout Accurately and

Ethically. Harvard Business Review.

https://hbr.org/2021/03/how-to-measure-burnout-accurately-and-ethically

Mathews, S. C., & Pronovost, P. J. (2008). Physician Autonomy and Informed Decision Making:
Finding the Balance for Patient Safety and Quality. JAMA, 300(24), 2913–2915.
https://doi.org/10.1001/jama.2008.846

Maxwell, J. A. (2013). Qualitative research design: An interactive approach (3 edition).
SAGE Publications, Inc.

McDonagh, K. J., Bobrowski, P., Hoss, M. A. K., Paris, N. M., & Schulte, M. (2014). The
Leadership Gap: Ensuring Effective Healthcare Leadership Requires Inclusion of
Women at the Top. Open Journal of Leadership, 3(2), 20–29.
https://doi.org/10.4236/ojl.2014.32003

McMillen, C. W. (2016). Pandemics: A Very Short Introduction. Oxford University Press,
Incorporated. http://ebookcentral.proquest.com

Merriam, S. B., & Tisdell, E. J. (2015). Qualitative Research: A Guide to Design
and Implementation. John Wiley & Sons, Incorporated.

Michael, E. (2020). Survey reveals impact of COVID-19 pandemic on physician mothers.

Women in Medicine Summit.

https://www.healio.com/news/primary-care/20201013/survey-reveals-impact-of-covid19-

pandemic-on-physician-mothers
113

Noland, M., & Moran, T. (2016, February 8). Study: Firms with More Women in the C-Suite Are

More Profitable. Harvard Business Review.

https://hbr.org/2016/02/study-firms-with-more-women-in-the-c-suite-are-more-profitable

Olds, Richard (2019). U.S. healthcare system needs more diversity. Clinton Herald. April 19.
https://www.clintonherald.com/opinion/columns/u-s-healthcare-system-needs-more-
diver sity/article_f0c9b722-feff-5814-b9ad-e56bdaeedd8b.html

Patel, R., Bachu, R., Adikey, A., Malik, M., Shah, M., & Patel, R. (2018). Factors related
to physician burnout and its consequences: A review. Behavioral Sciences, 8(11).
https://doi.org/10.3390/bs8110098

Panagioti, M., Geraghty, K., Johnson, J., Zhou, A., Panagopoulou, E., Chew-Graham, C., Peters,
D., Hodkinson, A., Riley, R., & Esmail, A. (2018). Association Between Physician
Burnout and Patient Safety, Professionalism, and Patient Satisfaction: A Systematic
Review and Meta-analysis. JAMA Internal Medicine, 178(10), 1317–1331.
https://doi.org/10.1001/jamainternmed.2018.3713

Parks-Savage, A., Archer, L., Newton, H., Wheeler, E., & Huband, S. R. (2018). Prevention
of medical errors and malpractice: Is creating resilience in physicians part of the
answer? International Journal of Law and Psychiatry, 60, 35–39.
https://doi.org/10.1016/j.ijlp.2018.07.003

Patel, R. S., Bachu, R., Adikey, A., Malik, M., & Shah, M. (2018a). Factors Related to
Physician Burnout and Its Consequences: A Review. Behavioral Sciences, 8(11), 98.
https://doi.org/10.3390/bs8110098
114

Powell, A., Savin, S., & Savva, N. (2012). Physician Workload and Hospital Reimbursement:
Overworked Physicians Generate Less Revenue per Patient. Manufacturing & Service
Operations Management, 14(4), 512–528. https://doi.org/10.1287/msom.1120.0384

Romanelli, J., Gee, D., Mellinger, J. D., Alseidi, A., Bittner, J. G., Auyang, E., Asbun, H., &
Feldman, L. S. (2020). The COVID-19 reset: Lessons from the pandemic on Burnout
and the Practice of Surgery. Surgical Endoscopy, 1–7. https://doi.org/10.1007/s00464-
020-08072-8

Roth, L. M. (2016). A Doctor’s Worth: Bonus Criteria and the Gender Pay Gap among American
Physicians. Social Currents, 3(1), 3–23. https://doi.org/10.1177/2329496515603728

Rothenberger, D. A. (2017). Physician Burnout and Well-Being: A Systematic Review
and Framework for Action. Diseases of the Colon & Rectum, 60(6), 567–576.
https://doi.org/10.1097/DCR.0000000000000844

Saldaña, J. (2016). The coding manual for qualitative researchers (3E.). SAGE.

Saleh, M. (2020). A Double Whammy: The COVID-19 Pandemic and Burnout in
Medical Professionals. Lean Forward-Harvard Medical School, 1-5.

Schor, N. F. (2019). Women in medical school leadership positions: Implications for research.
Annals of Neurology, 85(6), 789–792. https://doi.org/10.1002/ana.25478

Serafini, K., Coyer, C., Speights, J. B., Donovan, D., Guh, J., Washington, J., & Ainsworth, C.
(2020). Racism as Experienced by Physicians of Color in the Health Care Setting.
Family Medicine, 52(4), 282–287. https://doi.org/10.22454/FamMed.2020.384384

Shanafelt, T. D., Balch, C. M., Bechamps, G. J., Russell, T., Dyrbye, L., Satele, D., Collicott,
P., Novotny, P. J., Sloan, J., & Freischlag, J. A. (2009). Burnout and Career Satisfaction
115

Among American Surgeons. Annals of Surgery, 250(3), 463–471.

https://doi.org/10.1097/SLA.0b013e3181ac4dfd

Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., West, C. P., Sloan, J.,

& Oreskovich, M. R. (2012). Burnout and Satisfaction With Work-Life Balance
Among US Physicians Relative to the General US Population. Archives of Internal
Medicine (1960), 172(18), 1–9. https://doi.org/10.1001/archinternmed.2012.3199

Shanafelt, T. D., Dyrbye, L. N., Sinsky, C., Hasan, O., Satele, D., Sloan, J., & West, C. P.
(2016). Relationship Between Clerical Burden and Characteristics of the Electronic
Environment With Physician Burnout and Professional Satisfaction. Mayo Clinic
Proceedings, 91(7), 836–848. https://doi.org/10.1016/j.mayocp.2016.05.007

Shanafelt, T. D., Dyrbye, L. N., & West, C. P. (2017). Addressing Physician Burnout: The
Way Forward. JAMA, 317(9), 901–902. https://doi.org/10.1001/jama.2017.0076

Shanafelt, T. D., Gorringe, G., Menaker, R., Storz, K. A., Reeves, D., Buskirk, S. J., Sloan, J. A.,

& Swensen, S. J. (2015). Impact of organizational leadership on physician burnout
and satisfaction. Mayo Clinic Proceedings, 90(4), 432–440.
https://doi.org/10.1016/j.mayocp.2015.01.012

Shaw, M. E., Fulton, J., & Shaw, M. E. (2015). Mentorship in Healthcare (2nd ed.).
M&K Update Ltd.

Silver, J. K., Ghalib, R., Poorman, J. A., Al-Assi, D., Parangi, S., Bhargava, H., & Shillcutt, S. K.
(2019). Analysis of Gender Equity in Leadership of Physician-Focused Medical
Specialty Societies, 2008-2017. JAMA Internal Medicine, 179(3), 433–435.
https://doi.org/10.1001/jamainternmed.2018.5303
116

Starr, P. (1982). The Social transformation of American medicine. Cambridge, Massachusetts,
Basic Books. 30 -50.

St. George’s University (2021). The importance of diversity in healthcare: Medical professionals

weigh in. Medical Practice.

https://www.sgu.edu/blog/medical/pros-discuss-the-importance-of-diversity-in-health-car

e/

Sultana, A., Sharma, R., Hossain, M. M., Bhattacharya, S., & Purohit, N. (2020). Burnout
among healthcare providers during COVID-19: Challenges and evidence-based
interventions. Indian Journal of Medical Ethics, 05(04), 308–311.
https://doi.org/10.20529/IJME.2020.73

Swensen, S., Kabcenell, A., & Shanafelt, T. (2016). Physician-Organization Collaboration

Reduces Physician Burnout and Promotes Engagement: The Mayo Clinic Experience.

Journal of Healthcare Management, 61(2).

https://journals.lww.com/jhmonline/Fulltext/2016/03000/Physician_Organization_Collab

oration_Reduces.8.aspx

Taylor, C. A., Taylor, J. C., & Stoller, J. K. (2009). The Influence of Mentorship and
Role Modeling on Developing Physician–Leaders: Views of Aspiring and
Established Physician–Leaders. Journal of General Internal Medicine, 24(10),
1130–1134. https://doi.org/10.1007/s11606-009-1091-9

Tomioka, K., Morita, N., Saeki, K., Okamoto, N., & Kurumatani, N. (2011). Working hours,
occupational stress and depression among physicians. Occupational Medicine (Oxford,
England), 61(3), 163–170. https://doi.org/10.1093/occmed/kqr004
117

Treadwell, H. M. (2019). Wages and Women in Health Care: The Race and Gender Gap.
American Journal of Public Health, 109(2), 208–209.
https://doi.org/10.2105/AJPH.2018.304866

Vilendrer, S. M., Asch, S. M., Anzai, Y., & Maggio, P. (2020). An Incentive to
Innovate: Improving Health Care Value and Restoring Physician Autonomy
Through Physician-Directed Reinvestment. Academic Medicine, 95(11), 1702–
1706. https://doi.org/10.1097/ACM.0000000000003650

Walden, J., MD. (2016). An Overlooked Cause of Physician Burnout. Family
Practice Management, 23(1), 6–7.

Waldman, D. A., Berson, Y., & Keller, R. T. (2009). Leadership and organizational
learning. Leadership and Organizational Learning, 20(1), 1–3.
https://doi.org/10.1016/j.leaqua.2008.11.007

West, C. P., Dyrbye, L. N., Satele, D. V., Sloan, J. A., & Shanafelt, T. D. (2012). Concurrent
Validity of Single-Item Measures of Emotional Exhaustion and Depersonalization in
Burnout Assessment. Journal of General Internal Medicine : JGIM, 27(11), 1445–1452.
https://doi.org/10.1007/s11606-012-2015-7

West, C. P., Prof, Dyrbye, L. N., Prof, Erwin, P. J., MLS, & Shanafelt, T. D., Prof.
(2016). Interventions to prevent and reduce physician burnout: A systematic
review and meta-analysis. The Lancet (British Edition), 388(10057), 2272–2281.
https://doi.org/10.1016/S0140-6736(16)31279-X

World Health Organization (2012). Gender and Health Workforce Statistics.

http://www.who.int/hrh/statistics/spotlight2/en.
118

Appendix A: Survey Questions

*Questions 1 – 16 are answered from “strongly disagree through strongly agree”

1. I had sufficient PPEs accessible to me during the COVID-19 pandemic

2. I was fearful of being infected by COVID-19

3. I was concerned with transmitting COVID-19 to my family

4. I had to isolate myself from my family

5. My workload increased due to the COVID-19 pandemic

6. My income was negatively impacted by the COVID-19 pandemic

7. During the COVID-19 pandemic, I spent less time with my family and more time with
patients

8. I experienced childcare issues because of the COVID-19 pandemic

9. During the COVID-19 pandemic, my work environment was stressful and morale was
low among healthcare workers

10. During the COVID-19 pandemic, I had less clinical support due to depleted workforce
(due to isolation, illness, death)

11. I experienced depression during the COVID-19 pandmeic

12. I had suicidal thoughts during the COVID-19 pandemic

13. Seeking mental and emotional support during the COVID-19 pandemic was important to
me

14. The organization(s) I work with was/were invested in my wellbeing and
provided additional support during the pandemic

15. The COVID-19 vaccine helps resolve the spread of the virus quickly
119

16. I am looking forward to getting the COVID-19 vaccine myself, or I have gotten
the vaccine myself

17. I feel burned out from my work (question from MBI).

a. Never

b. A few times a yar or less

c. Once a month

d. A few times a month

e. A few times a week

f. Everyday

18. I have become more callous towards people since I took this job (question from MBI).

a. Never

b. A few times a yar or less

c. Once a month

d. A few times a month

e. A few times a week

f. Everyday

19. Are you employed by a hospital?

a. Yes

b. No

20. With which gender do you identify?

a. Male

b. Female
120

c. Non-binary

d. Decline to state

21. What is your age?

a. Between 20 and 30

b. Between 31 and 40

c. Between 41 and 50

d. Between 51 and 60

e. 61 or above

22. How many years have you been a healthcare provider?

a. 1 to 5 years

b. 6 to 10 years

c. 11 to 20 years

d. 21+ years

23. With which race and/or ethnicity do you identify?

a. African

b. African American

c. American Indian or Alaska Native

d. Asian

e. Caribbean

f. Caucasian

g. Native Hawaiian or Other Pacific Islander

h. Southwest Asian or North African
121

i. Multiracial

j. Multiethnic

24. Would you like to participate in an interview that further asks about your experience as
a physician during the COVID-19 pandemic?

a. Yes

b. No
122

Appendix B: Interview Questions

1. Can you give me an example of how your overall professional life was impacted by the
pandemic?

2. Can you give me an example of how your relationships with your loved ones were
impacted?

3. In what ways was your professional environment impacted?

4. At any time did you feel that your wellbeing was at risk in your work environment? In
what ways?

5. Did you feel supported in your work environment? From PPE access to emotional
wellness, workload support, overall morale.

6. Can you describe the greatest professional challenge you experienced during the
pandemic?

7. Did you lose a patient to COVID-19? Can you share how you coped with the loss?

8. At any point, did you feel burned out? If so, can you describe some of the symptoms you
experienced?

9. Have you implemented any practices or routines to help mitigate the impact of burnout?

Abstract (if available)

Abstract Physicians are experiencing higher levels of burnout than any other profession. While this has been true since research on professional burnout began decades ago, it is becoming increasingly true during the COVID-19 pandemic. Physician burnout has a significant impact on physicians, patients, physician and patient families, hospital administration and leadership, and the communities that the hospitals and physicians serve. Physician burnout negatively impacts physician mental and emotional wellbeing, physical health, career longevity, hospital revenue and physician turnover, patient wellbeing, patient mortality, and even physician mortality. Previous and current research and literature demonstrate that physician burnout disproportionately affects female physicians more than male physicians. This was a mixed-methods research study that includes a literature review, qualitative data through interviews, and quantitative data through surveys. This study was conducted for physicians who worked during the COVID-19 pandemic in a hospital setting within LA county. There was a total of 51 physicians who participated in the survey for this study and five physicians who participated in the interviews for this study. The overarching focus of this study was to understand what changes during the COVID-19 pandemic were implemented by hospital leadership that either contributed to or helped alleviate physician burnout. The recommendations of this study are to further research how physician identity impact physician burnout and in what ways hospital leadership can contribute to alleviating physician burnout.

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Physician burnout in the COVID-19 pandemic: Healthcare organization and leadership implications for patient care and clinical team leadership with nurses

PDF

The impact of COVID-19 on the wellbeing of veterinarians

PDF

Well-being among Black female managers in retail banking during COVID-19

PDF

Physician burnout during a global pandemic: an evaluation study

PDF

Frontline workers serving students: a study on the well-being of student affairs professionals during the COVID-19 pandemic

PDF

Well-being, employee effectiveness, and organizational support: community college administrators during the COVID-19 pandemic

PDF

The impact of virtual clinical education during the COVID-19 pandemic on nursing graduates in the hospital setting

PDF

Leadership practices impacting Minnesota school principals’ employee well-being and burnout during the pandemic

PDF

Navigating the storm: the impact of Hawaiian culture on stress, burnout, and retention of Hawaii’s acute care nurses during the COVID-19 pandemic (2020–2022)

PDF

COVID-19 pandemic: the impact on the Napa Valley wine industry workers

PDF

COVID-19's impact on Christian cross-cultural workers

PDF

Why are they still here: a look at employee retention amidst the COVID-19 pandemic

PDF

Organizational levers for frontline health care employee well-being in long-term care

PDF

The impact of the COVID-19 pandemic on K–12 public school districts in southern California: responses of superintendents, assistant superintendents, and principals

PDF

The impact of the COVID-19 pandemic on K–12 public school districts in southern California: responses of superintendents, assistant superintendents, and principals

PDF

Addressing physician burnout: is there a relationship with leadership behaviors?

PDF

Military spouse well-being during the COVID-19 pandemic

PDF

The impact of the COVID-19 pandemic on K-12 public school districts in southern California: responses of superintendents, assistant superintendents, and principals

PDF

The impact of the COVID-19 pandemic on K–12 public school districts in southern California: responses of superintendents, assistant superintendents, and principals

PDF

The impact of the COVID-19 pandemic on K–12 public school districts in southern California: responses of superintendents, assistant superintendents, and principals

Asset Metadata

Creator Markarian, Ramella (author)

Core Title The impact of the COVID-19 pandemic on physician burnout in LA County Hospital settings

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2022-08

Publication Date 08/06/2022

Defense Date 01/18/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag COVID-19,gender diversity,inclusion,OAI-PMH Harvest,pandemic,physician burnout,physician well-being

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Min, Emmy J. (committee chair), Adibe, Bryant (committee member), Crawford, Jenifer (committee member)

Creator Email rmarkari@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC111376201

Unique identifier UC111376201

Legacy Identifier etd-MarkarianR-11114

Document Type Dissertation

Format application/pdf (imt)

Rights Markarian, Ramella

Type texts

Source 20220806-usctheses-batch-971 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu