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Addressing physician burnout: is there a relationship with leadership behaviors?
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Addressing physician burnout: is there a relationship with leadership behaviors?
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Addressing Physician Burnout: Is There a Relationship with Leadership Behaviors? by James S. Hu 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 December 2021 ii © Copyright by James S. Hu 2021 All Rights Reserved iii Abstract Physician burnout has reached epidemic proportions in the United States. The consequences of physician burnout include lower quality of care, higher costs to society, and personal suffering. Physician leadership training as an organizational intervention can improve the work environment. This study examines leadership behaviors as it relates to burnout in faculty physicians at an academic medical center. A mixed methods study using a quantitative survey and qualitative interviews was conducted. The survey consisted of 50 questions that incorporated the full Maslach Burnout Inventory, a shortened version of the full range of leadership model (MLQ-5X -HSS), and four demographic questions. Anonymized interviews were conducted, and transcribed. Of 1,145 faculty at Academic Health University (AHU), 305 returned surveys for a return rate of 26.6%. The composite burnout rate (53%) and mean burnout scores (25.4) at AHU rate higher than national averages. The transformational leadership behaviors (Idealized Influence Behaviors and Individualized Consideration) and one transactional leadership behavior (Contingent Reward) strongly correlated favorably with all burnout domains. Conversely, lower end transactional leadership behaviors (Management by Exception Passive and Laissez-Faire) correlated unfavorably with all burnout domains. Qualitative interviews identified several work- related factors and leadership behaviors observed in relation to burnout. In conclusion, burnout rates at AHU are higher than national averages and favorable and unfavorable leadership behaviors were identified that correlated with physician burnout. Faculty interviews also identified a lack of agency as one leadership behavior theme that had not been identified in previous studies of physician burnout. iv Dedication To the Front-line Physician and others who serve: “Cure sometimes, treat often, comfort always.” —Hippocrates Circa, 460-377 B.C. v Acknowledgments I want to acknowledge and give special thanks to my dissertation chair, Professor Jennifer Phillips for the guidance and perseverance to see this work to its completion. Your endurance and patience as well as unwavering support helped keep this work on track and, hopefully, consumable for our readers. I look forward to our future discussions on the Clausewitzian Dialectic. A special mention and a heartfelt thank you also go to my dissertation committee. This work began as a raw idea, spurred by my passion for leadership and equity. The thoughtful suggestions from both Professors Alexandra Wilcox and Adrian Donato pushed me to levels I did not think possible. Professor Wilcox, thank you for calling me out on my problem of practice and Dr. Donato, thank you for suggesting I add a qualitative component to understand my problem of practice more deeply. A special thank you and appreciation also goes to my classmates. Cohort 13, I will fondly remember how we started with those failure resumes and ended with those video presentations of our implementation plans. I am proud to have learned and grown with all of you and I appreciate your acceptance into your group of an old guy like me. I want to especially say a personal thank you to my two battle buddies: Janene Batten and Rob Vanderberry. Janene, thank you for keeping me focused during our weekly Sunday Zoom meetings and Rob, thank you for keeping me grounded in the power of humility. Finally, to my dear wife Pamela: This is our third extra degree together and I promise the last. If there was ever a “doctor doctor” in crime you are the one as our walks were like Socratic teaching sessions with me as the student. I am one lucky guy to have found that lifelong soulmate, wife, and mother of our children. 1/0 vi Table of Contents Abstract .......................................................................................................................................... iii Dedication ...................................................................................................................................... iv Acknowledgments........................................................................................................................... v List of Tables ................................................................................................................................. xi List of Figures ............................................................................................................................... xii Chapter One: Introduction to the Problem of Practice.................................................................... 1 Background of the Problem ............................................................................................................ 2 Organizational Context and Mission .............................................................................................. 4 Purpose of the Study and Research Questions ................................................................................ 6 Importance of the Study .................................................................................................................. 6 Overview of Theoretical Framework and Methodology ................................................................ 8 Definitions..................................................................................................................................... 11 Organization of the Dissertation ................................................................................................... 12 Chapter Two: Literature Review .................................................................................................. 15 Historical Context of Burnout ....................................................................................................... 16 From Social Pressures to Research ............................................................................................... 17 The Development of Physician Burnout ....................................................................................... 19 Burnout in Physicians: General Descriptors ................................................................................. 23 Burnout in Physician Trainees: A Window into Possible Causes ................................................ 26 vii Burnout: Other Factors to Consider .............................................................................................. 29 Interventions into Physician Burnout............................................................................................ 30 Individual Based Interventions ................................................................................................. 30 Organization Based Interventions ............................................................................................. 35 Physician Leadership and Physician Burnout ............................................................................... 38 Burnout in Physician Leaders ................................................................................................... 39 Leadership Models and Burnout ............................................................................................... 40 Transformational Leadership and Burnout ............................................................................... 43 Transformational Leadership and Mediators of other aspects of Wellbeing ............................ 45 General Leadership and Physician Burnout .............................................................................. 47 Self Determination Theory: How it relates to Burnout and Transformational Leadership .......... 49 Conceptual Framework ................................................................................................................. 53 Summary ....................................................................................................................................... 55 Chapter Three: Methodology ........................................................................................................ 57 Research Questions ....................................................................................................................... 58 Overview of Methodology ............................................................................................................ 58 The Researcher.............................................................................................................................. 62 Data Sources ................................................................................................................................. 63 Method 1: Survey ...................................................................................................................... 63 Participants ............................................................................................................................ 64 viii Instrumentation ...................................................................................................................... 64 Data Collection Procedures ................................................................................................... 66 Data Analysis ............................................................................................................................ 67 Validity and Reliability ......................................................................................................... 69 Ethics............................................................................................................................................. 71 Chapter 4: Results and Findings ................................................................................................... 73 Response Rate and Demographics of Participants .................................................................... 74 Baseline Burnout Rate at AHU (RQ1) ...................................................................................... 76 Degree of Association Between Leadership Behaviors and Burnout (RQ2) ............................ 79 Leadership Behaviors and Emotional Exhaustion ................................................................. 81 Leadership Behaviors and Depersonalization ....................................................................... 82 Leadership Behaviors and Personal Accomplishment .......................................................... 84 Summary ................................................................................................................................... 85 Demographic Effects on the Leadership Burnout Relationship (RQ3) ..................................... 87 Factors, Sources, and Understanding of Burnout (RQ4) .......................................................... 94 Interview Question 1: What Does Burnout Mean to You? ................................................... 94 Burnout as Aberrant Behavior or Loss of Joy.. ................................................................. 95 Burnout as Lack of Energy or Reserve.. ............................................................................ 97 Burnout as Lack of Effectiveness or Feeling Devalued. .................................................... 98 Interview Question 2: What Factors Contribute to Burnout? .............................................. 101 Extra Work that Lacks Meaning, Appreciation, or Compensation. ................................. 102 Workload, Lack of Support, and Lack of Resources.. ..................................................... 104 Effects of COVID-19 on Burnout. ................................................................................... 106 ix Interview Question 3: What are the Sources Contributing to Burnout? .............................. 109 Internal Sources of Burnout: Hospital or University Administration.. ............................ 109 External Sources: Physician Culture and National Medical Organizations..................... 110 Physician Faculty Understanding of Leadership Behaviors as it Relates to Burnout (RQ5) .. 113 What has Leadership Done to Address Burnout? (Leadership Behaviors Demonstrated) .. 113 Leaders Appear to Lack Agency, Provide Vague Answers, or Demonstrate Unquestioning Compliance. ..................................................................................................................... 113 Leaders Create Sense of Community Through Regular Communication and Meetings.. 115 Wellness and Individual Based Programs........................................................................ 117 If You Had Five Minutes to Advise Your Leaders on Burnout, What Would You Say? (Leadership Behaviors Desired) .......................................................................................... 120 Communication, Moral Support, and Community are Desired. ...................................... 120 Work Support: Compensation, Efficiency, or Other Resources. ..................................... 121 Chapter 5: Discussion and Recommendations ............................................................................ 125 Quantitative Results Discussion .............................................................................................. 125 The Burnout Rate at AHU is Much Higher Than Other Health Care Institutions (RQ1) ... 125 Transformational Leadership and High-end Transactional Leadership Behaviors are Associated with Less Burnout (RQ2) .................................................................................. 127 Demographic Factors Minimally Affect the Burnout-Leadership Behavior Relationship (RQ3) ................................................................................................................................... 132 Qualitative Findings ................................................................................................................ 134 The Meaning of Burnout Aligns with the Categories of the Maslach Burnout Inventory (RQ4) ................................................................................................................................... 134 x Workload and Resources, Work Expectancy, and Lack of Appreciation are Major Factors Associated with Burnout (RQ4) .......................................................................................... 135 The Organization and Culture Are the Sources of Burnout Factors at AHU (RQ4) ........... 140 Leadership Behaviors Identified Include Lack of Agency Among Others (RQ5) .............. 141 Recommendations for Practice ................................................................................................... 145 Recommendation 1: Implementation of Full Range of Leadership Model ............................. 145 Recommendation 2: Developing Agency Through Systems Thinking ................................... 149 Limitations and Delimitations ..................................................................................................... 157 Recommendations for Future Research ...................................................................................... 158 Conclusion .................................................................................................................................. 159 References ................................................................................................................................... 160 Appendix A: 50-Item Survey on Burnout and Leadership ......................................................... 178 Appendix B: Communications and Instructions for Survey ....................................................... 214 Communique 1 (Sent April 12, 2021) ..................................................................................... 214 Communique 2 (Sent April 19, 2021) ..................................................................................... 215 Communique 3 (Sent April 26, 2021) ..................................................................................... 216 Communique 4 (Sent May 3, 2021) ........................................................................................ 217 xi List of Tables Table 1: Data Sources for Research Questions…………………………………………………...57 Table 2: Quantitative Data Analysis……………………………………………………………...63 Table 3: Demographic Statistics of Respondents…………………………………………………69 Table 4: Mean Baseline Burnout Rates at AHU…………………………………………………..71 Table 5: Association of Emotional Exhaustion and Leadership Behaviors……………………….74 Table 6: Association of Depersonalization and Leadership Behaviors…………………………..75 Table 7: Association of Personal Accomplishment and Leadership Behaviors…………………..76 Table 8: Meaning of Burnout……………………………………………………………………..91 Table 9: Factors Related to Burnout……………………………………………………………...97 Table 10: Sources Associated with Burnout…………………………………………………….101 Table 11: Leadership Behaviors Demonstrated…………………………………………………107 Table 12: Leadership Goals of Behaviors Desired………………………………………………112 xii List of Figures Figure 1: The Basic Self Determination Theory and Workplace Model …………………………47 Figure 2: Areas of Work Life Model and Self Determination Theory……………………………50 Figure 3: Conceptual Framework of Transformational Leadership and Burnout…………………52 Figure 4: Relationship of Emotional Exhaustion and Leadership Behaviors by Sex……………..79 Figure 5: Relationship of Depersonalization and Leadership Behaviors by Sex………………….80 Figure 6: Relationship of Personal Accomplishment and Leadership Behaviors by Sex…………81 Figure 7: Relationship of Emotional Exhaustion and Leadership Behaviors by Age Group……...82 Figure 8: Relationship of Depersonalization and Leadership Behaviors by Age Group…………………………………………………………………………………………….83 Figure 9: Relationship between Personal Accomplishment and Leadership Behaviors by Age Group…………………………………………………………………………………….84 1 Chapter One: Introduction to the Problem of Practice This study addresses the problem of physician burnout in the post-training population at an academic health center in the United States. Physician burnout has been described as a negative psychological state of dysphoria that can lead to physical and mental problems (Maslach & Leiter, 2017). Burnout has also been defined in the health care literature as a work related syndrome that includes; emotional exhaustion, depersonalization, and a lack of achievement or accomplishment that can lead to depression and job dissatisfaction, but is distinguishable from these latter consequences as each of these categories (emotional exhaustion, depersonalization, or lack of achievement) can be present or absent in depressed or dissatisfied subjects (West et al., 2018). Surveys of medical student and residents in the United States demonstrate that up to 56% of physicians in training suffer from symptoms of burnout (Moffatt- Bruce et al., 2014). Furthermore, burnout after residency is correlated with stress during residency (Raimo et al., 2018). Research studies of the prevalence of burnout in practicing physicians confirm this high prevalence rate which represents twice the rate of burnout as compared to non-physician occupations (Han et al., 2019). The evidence highlights the need to address the burnout and wellbeing of physicians at multiple levels of a physician's career. If this problem persists, it can exacerbate the cost to organizations and society by increasing the chance of health system related problems such as patient safety, quality, dissatisfaction, and financial costs related to physician turnover and ineffectiveness (Hamidi et al., 2018). Although this study focuses on the post-training population, burnout affects all stages of a physician’s career (Dyrbye et al., 2014). 2 Background of the Problem The problem of burnout can be traced to the 1970s when descriptions of the stressors affecting physicians were broadly characterized. This burnout syndrome, as first described in mental health workers, consisted of exhaustion, disillusionment, and withdrawal (Freudenberger, 1974). Later, in the 1980’s, researchers described burnout as “a syndrome of emotional exhaustion and cynicism that frequently occurs among individuals who do ‘people work’ of some kind” (Maslach, 1993, p.3). In her classic work defining subscales of burnout, Maslach found high reliability and validity with three subcomponents of the burnout syndrome: emotional exhaustion, depersonalization, and a lack of personal accomplishment. This research led to a highly useful instrument to measure burnout in health care workers known as the Maslach Burnout Inventory (MBI). Since the 1980s, research into physician burnout using instruments like the MBI has proliferated. However, the MBI and its variations remain the gold standard for measuring burnout. This survey of 22 items is scored from 0-6 and is divided into three domains with self- reported scales of nine items for emotional exhaustion, five items for depersonalization, and eight items for personal accomplishment (Maslach, 1996). Using versions of the MBI, national studies on physician burnout have varied, but have cited levels greater than 50% as a reliable prevalence rate in various health care systems (Allegra et al., 2005; Shanafelt, Hasan, et al., 2015). Although this is not confirmed in some international studies, in the United States, these studies are consistent with other studies that compare burnout rates amongst physicians relative to other occupations when adjusted for work hours spent. This high prevalence rate of physician burnout can have severe consequences for local and national health care (Williams et al., 2020). 3 The consequences of physician burnout encompass a wide range of effects. Effects on patient care such as suboptimal practice and patient satisfaction, risk to patient safety, and increased risk of malpractice are well documented (Balch & Shanafelt, 2011). In addition, effects on organizational and healthcare system costs are readily apparent as one longitudinal study estimates that a one-point increase in emotional exhaustion or one-point decrease in job satisfaction is associated with a 28% and 67% higher chance, respectively, of reduction in professional effort and work hours over the subsequent year (Shanafelt et al., 2016). Thus, the systemic consequences of physician burnout are substantial. The effects on individual physician health are also significant. These effects can manifest as depression, alcohol abuse, or suicidal ideation (Brown & Trevino, 2009; Oreskovich et al., 2012). It has been estimated that male physicians are at a 40% higher risk for suicide than other males in the population and female physicians are at a 130% higher risk than other females in the population (Center et al., 2003). These alarming findings have led to an abundance of studies attempting to identify potential causative factors that lead to burnout. The past several decades has witnessed an increase in the proportion of physicians employed in large health care organizations. It has been estimated that 75% of physicians in the United States are employed by hospitals, academic medical centers, large group practices, or health maintenance organizations (Hawkins, 2012). This shift from predominantly private and small group practices where physicians were mostly in control to large healthcare organizations where administrators and executives are in control may partially explain some of the stressors on physicians that can lead to burnout. Indeed, large scale implementation of the electronic health record and bureaucratic performance metrics has added to the work burden of physicians leading to symptoms of burnout and dissatisfaction (Friedberg, 2014). However, addressing “effort” 4 related issues only, such as the work burden of documentation into the EHR, misses the other complex nuances related to burnout. Although interventions into improving burnout has focused on structural and individual approaches directed at the affected physician, very little research has focused on physician leadership as a factor in improving burnout (West et al., 2016). Physician leadership is an emerging topic of interest in Medicine. In fact, leadership programs directed at improving leadership skills for physicians have proliferated internationally. Physician leadership programs in the United States have largely been directed at developing leadership competencies (Frich et al., 2015). One criticism of this approach is that the competency approach does not fully address “wicked problems” defined as problems that are so complex that they cannot be addressed by simple linear solutions (Onyura, Crann, Freeman, et al., 2019). Thus, many have advocated for the teaching of theoretical leadership constructs that can adapt to systems related problems that are complex by nature (Pangaro, 2019). Although many leadership models exist, much of the leadership studies on physician outcomes have used the transformational leadership model in addressing outcomes such as burnout and satisfaction (Menaker, 2008). This study will explore the relationship between physician leadership behaviors and the complex problem of physician burnout at an academic medical center in the hopes that it can inform future strategies in mitigating this epidemic. Organizational Context and Mission Academic Health University (AHU), a pseudonym, is an academic health center located in a large urban metropolis. The population that it serves is composed of 48.5% Hispanic or Latino alone, 28.5% White alone, 11.6% Asian alone, 8.9% Black or African American alone, 3.8% Two or More Races, 0.7% American Indian and Alaska Native alone, and 0.2% Native Hawaiian and other Pacific Islander alone (United States Census Bureau, 2019). There are over 5 1000 faculty physicians that oversee three main hospitals and several satellite clinics within a forty-mile radius. The organization provides both clinical care to patients, education to trainees, and research through clinical trials and new drug development. Clinical research, laboratory research, and population science research augment the organization by providing additional capabilities that inform clinical research. The organization therefore has a tripartite mission of providing clinical care to the patient population, research that serves the population and education to medical students, residents, and fellows. The structure of the organization could be described as a matrix medical center. As described by Allcorn (1990), a matrix organization is characterized by a dual reporting structure with authority relations with multiple authorities within a hierarchical pattern of relationships (Allcorn, 1990). Therefore, AHU’s organizational structure has department chairs reporting to two lines of authority: a business or management line of accountability that leads to the Chief Executive Officer (CEO) of the medical center and a professional line of accountability that leads to the Dean of the medical school. The Dean and the CEO of AHU represent two separate lines of authority and are linked in a direct support relationship with each other, but both reports formally to a Provost level CEO of Health Affairs in a more traditional reporting relationship. Below the level of the Department Chair are the Division Chiefs who manage and lead the day-to-day faculty activities related to patient care, education, and research. Because of this dual reporting structure, there is a risk of ambiguity in decision rights as chairs have a dual responsibility of meeting the performance goals of business leaders and the academic goals of their academic leaders. The issue of burnout at AHU is of great importance as physician turnover and well-being are crucial in maintaining a high level of performance in a region that possesses three other academic medical centers that are devoted to similar performance goals. Although wellness programs exist at AHU, few formal studies on 6 burnout and interventions have ever been conducted at this institution. Furthermore, studies on leadership behaviors have never been conducted that relate physician wellness to leadership behaviors. Purpose of the Study and Research Questions The purpose of this study is to identify physician leadership behaviors at an academic medical center that can potentially mitigate the domains of burnout in faculty physicians. The specific research questions that will guide this study are listed below: 1. What is the baseline burnout rate at this academic medical center in faculty physicians? 2. Is there are relationship between perceived physician leadership behaviors and physician burnout? 3. Do demographic factors influence burnout rates and perception of leadership behaviors? 4. How does AHU faculty understand and experience burnout? 5. How does AHU faculty understand their leadership’s behavior in relation to burnout? Importance of the Study The burnout epidemic is a continuing problem both locally and nationally. Nationally, the high numbers of burned out physicians has been estimated to cost up to 4.6 billion dollars per year in costs related to safety, loss of productivity, and turnover to health care organizations (Hartzband & Groopman, 2020). These daunting numbers have placed an emphasis on organizational approaches in addressing this problem as the currently deployed wellness programs aimed at individuals seem to result in more modest benefits in burnout scores (Panagioti et al., 2017). This study that addresses leadership behaviors is timely and important to 7 inform future interventional studies aimed at organizational leadership and in particular physician leadership in developing prevention and treatment approaches to the physician burnout epidemic. 8 Overview of Theoretical Framework and Methodology The relationship between burnout, Self Determination Theory (SDT), and the full range of leadership behaviors will inform the design of this study. Self Determination Theory (SDT) is based on three core needs of motivation: autonomy, belonging or relatedness, and competence (ABC’s) (Deci & Ryan, 2008). This theory gives a useful and comprehensive construct that goes beyond just competence as a motivating factor since many physicians are intrinsically motivated and have a strong need for autonomy and belonging in gaining work satisfaction (Deci, 2005). In addition, the complexities of healthcare have now progressed to the point where physicians must work in teams within larger organizations and therefore individual physicians may have greater requirements to belong or relate to a group. The SDT oriented Areas of Work life model assigns six areas of burnout: manageable workload, control, reward, community, fairness, and values to the ABC’s of SDT (Eliot, 2017). Of interest is that community, fairness, and values alignment (three areas related to belonging) are closely related to leadership as the leader sets the tone for accepting individuals into the group and exhibiting organizational values to followers. Although reward and workload management that can be controlled by the leader contribute to individual feelings of competence, the belonging and autonomy dimensions are areas where leadership can have as much or greater effects as competence. The full range of leadership model that includes transformational leadership behaviors is a model that is useful in burnout as it not only addresses two groups of behaviors consisting of individualized consideration (giving rewards and managing workload), but also addresses the community, values, and fairness dimensions through idealized influence and inspirational motivation (Avolio, 1999). The full range of leadership model of Avolio and Bass includes both transformational leadership and transactional leadership behaviors and is based on the construct and writings of James Macgregor Burns who 9 distinguished transformational leadership behaviors from transactional leadership behaviors and emphasized the “values” component as a salient characteristic of transformational leadership (Burns, 1978). This mixed methods study issued quantitative surveys to a sample of physicians who are not at the Division Chief, Department Chair, or Medical School Dean level of authority within the organization. The surveys measured the level of non-leader physician burnout within the organization and aggregated them into mean scores that reflected their degree of burnout. In addition, the burnout data was further stratified into the three domains of burnout: emotional exhaustion, depersonalization, and degree of personal accomplishment. Data was collected from the non-leader physician participants on the full range of leadership model that included transformational and transactional leadership behaviors of their physician supervisors within the organization. The survey included the full Maslach Burnout Inventory and a modified version of the Multifactor Leadership Questionnaire (MLQ-5X) that excludes three categories of transformational leadership: Inspirational Motivation, Intellectual Stimulation, and Idealized Influence Attributes. It is of note that two of these domains of transformational leadership, Inspirational Motivation and Intellectual Stimulation, represented the least desired traits and behaviors of a sample of Mayo Clinic non-leader physicians (Menaker, 2008). Otherwise, the modified version included all the components of the full range of leadership model including two transformational leadership behaviors (Idealized Influence Behaviors and Individualized Consideration) and all the transactional leadership behaviors (Laissez Faire, Management by Exception Passive, Management by Exception Active, and Contingent Reward). In addition to the quantitative survey, a qualitative interview component was conducted to fully explore the faculty’s understanding of burnout, how it manifests, and any other factors 10 that are associated including leadership behaviors. These interviews were iteratively coded and categorized into themes to further elucidate the nature of burnout and its relationship to leadership behaviors at AHU. 11 Definitions • Autonomy: A basic need of having “ownership” and choice of ones’ actions that is free of being controlled or coerced by internal or external forces (Ryan, 2017). • Belonging or Relatedness: A basic need of having a relationship with a setting or group that is experienced as a feeling of being accepted, included, respected, and contributing or anticipating the likelihood of developing this feeling (Walton, 2017, P.272). • Competence: A condition or quality of effectiveness, ability, sufficiency, or success at doing or performing a task or activity (Eliot, 2017, P.43). • Physician Leaders: For the purposes of this paper, physician leaders are defined as those physicians placed in positions of organizationally appointed authority that include Chiefs of divisions, Chairs of departments, Chief Medical Officer, and Deans of schools. • Academic Medical Center: A tertiary care hospital that is organizationally and administratively integrated with a medical school and is the principal site for education of medical students and postgraduate medical trainees and conducts human subjects research under approved protocols (Joint Commission, 2020) • Burnout: A work related syndrome involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment (Maslach, 1996). • Transformational Leadership: A set of leadership behaviors that was developed by James MacGregor Burns and further described and defined by Bernard Bass that focuses on four dimensions of leadership that motivates followers to reach their fullest potential: Idealized Influence (Attributes and Behaviors), Inspirational Motivation, Intellectual Stimulation, and Individualized Consideration. 12 • Transactional Leadership: A leadership model defined by James MacGregor Burns and further described and defined by Bernard Bass as motivating individuals through exchanges (generally extrinsic motivators) or transactions that are not directed at followers attaining their highest potential but limited to accomplishing a task or goal. Organization of the Dissertation Chapter one provides the reader with a general introduction to the problem of practice and its importance in both the individual and organizational contexts. It also addresses the characteristics of the burnout syndrome and the potential factors that underlie its cause. The design of the study was informed by the theoretical framework of Self Determination theory and this is also discussed in chapters one and two. Because the literature on physician burnout and physician leadership has mostly focused on the individual needs of physician followers as captured by the Individualized Consideration category of the full range of leadership model, the other categories of transformational and transactional leadership behaviors are understudied. This study will include assessments of transactional leadership behaviors and one additional category of transformational leadership in addition to Individualized Consideration: Idealized Influence Behavior. The rationale for selecting the Idealized Influence Behavior category of the full range of leadership model is the emphasis on values, mission, and purpose, all of which are germane to the values and belonging model of the Areas of Work Life model and SDT. Chapter Two reviews the extant literature on physician burnout: its origins, contributing factors, diagnosis, prevention and treatment strategies, and implications. In addition, it reviews the literature on Self Determination Theory and its application to the syndrome of burnout. It includes the conceptual framework that encompasses the broad framework of the full range of leadership model interacting with the work environment and the individual in a triadic 13 relationship that helps illuminate the nature of the problem of burnout and inform potential interventions (Figure 1). Finally, literature on potential burnout interventions is reviewed with an emphasis on organizational leadership approaches. Chapter Three describes the methodology of the study. The chapter includes the assumptions and conceptual framework that informed the study design, a brief description of the researcher, a description of the data sources, a description of the research population, an introduction to the research questions, a description of the instruments used to answer the research question, and a description of the data collection procedures and data analysis. A discussion of the validity and reliability of the instruments is also included in this section as are potential ethical issues related to the study. Chapter Four reports the results of the quantitative survey and qualitative interviews. Based on the size of the cohort, the 50-question survey was sent to 1145 participants. The anticipation of 200 surveys returned was exceeded as a total of 305 surveys were returned and form the basis of the quantitative component of this study. Correlational studies assessing the degree of association between leadership behaviors of the full range of leadership model with the three categories of burnout was reported along with descriptive findings of the sample. In addition, the relationship of leadership behaviors and burnout in relation to demographic factors that include sex, age, specialty type, and seniority is reported. A qualitative component that included 10 physician faculty interviews conducted by an independent interviewer is also reported and organized by content that includes: meaning of burnout, factors associated with burnout, sources of burnout, leadership behaviors demonstrated in relation to burnout, and leadership behaviors desired in relation to burnout. 14 Chapter Five discusses the findings in the context of the extant literature. It integrates the findings of the quantitative survey and qualitative interviews of this study to give a clearer understanding of burnout unique to AHU. Since the study was conducted during the COVID-19 Pandemic, a summary of findings related to the pandemic’s effects on burnout at AHU was also included. As all studies are subject to certain limitations, these limitations are also discussed in this chapter, Finally, recommendations for further research and organizational improvement based on the study’s findings are discussed in this chapter. These recommendations and implementation plans and programs include an evaluation component to ensure adequate monitoring of progress of these recommendations. 15 Chapter Two: Literature Review The consequences of physician burnout affect multiple stakeholders including hospital organizations, patients and communities, private insurers, government agencies, as well as the physicians themselves. Therefore, it is important to understand the history, nature, and potential causes of physician burnout so that better solutions to this national problem can be developed. Despite the deployment of wellness programs aimed at the individual physician, the burnout rate remains at close to 50% (West et al., 2016). Therefore, in addition to individual approaches to improving physician burnout, some have advocated for an organizational based approach that could at least augment the plethora of individual based programs currently in existence (Shanafelt & Noseworthy, 2017). The following literature review provides a brief historical review of burnout to help distinguish the syndrome from other similar stress-related reactions such as job dissatisfaction and to provide a context to help understand this phenomenon as it relates to the current environment. Following this historical review, the pertinent literature pertaining to the nature and potential causes of physician burnout will be reviewed. These studies on the nature and causes of physician burnout include cohorts from both physicians in training and practicing physicians from a wide variety of specialties that reveal an understanding of the unique burnout features of each study population. The final section on physician burnout focuses on the interventional literature and its effectiveness on preventing and treating burnout with an emphasis on individual and organizational based approaches. After reviewing the burnout literature, the review explores the relationship between organizational leadership and burnout with an emphasis on the role that physician leadership plays in addressing burnout. This section of the review discusses the extant literature on physician leadership behaviors and organizational outcomes that include burnout or other 16 wellness measures such as job satisfaction and work engagement. This section on physician leadership will include a description of transformational leadership and the full range of leadership model as proposed by Bass and Avolio (1999) and how it relates through Self Determination Theory to burnout and wellness. Historical Context of Burnout The term burnout was first systematically described by the American clinical psychologist, Herbert Freudenberger in 1974 while working in a free clinic in New York City (Shaufeli, 2017). In his original descriptions, Freudenberger described a condition he observed in workers where the clinical demands related to the nature of the work combined with the inadequacy of resources available resulted in a state of emotional exhaustion. Furthermore, Freudenberger described this chronic condition as leading to cynicism and even depression as workers who were perceived as being intrinsically motivated spent a high amount of emotional energy and personal investment in their jobs only to feel spent in the end (Freudenberger, 1974). In addition to describing the syndrome, Freduenberger also recommended preventative strategies that focused mainly on work restructuring such as shorter work hours that could improve the work environment and lead to less burnout. These original descriptions of burnout led to further study on both the nature and causes of burnout as well as potential preventative strategies. According to Heinemann (2017), the initial descriptions from observers of this phenomenon, suggested a more organizational or workplace related phenomenon as opposed to a particular type of individual stress response. These original descriptions of the syndrome from clinical psychology eventually led to further research and development of instruments to measure burnout more precisely. 17 From Social Pressures to Research Following World War II, many experts in the field of burnout had identified several factors that may have contributed to the development of the burnout syndrome. In a description of societal influences on American workers, Farber (1983) found that due to the disconnectedness and alienation from communities and a shift of the American public to identifying work as the source of their accomplishments, an expectation was held that work could take the place of community as the main source of personal fulfillment. This shift to the workplace as the source of fulfillment combined with the movement of many in the workforce into the human service sector during the 1960’s War on Poverty, led to a growing segment of the population becoming more vulnerable to the effects of burnout. According to Schaufeli (2017), those that entered employment in the human services sector eventually became disillusioned and frustrated at the futility of their efforts in significantly improving poverty. Furthermore, as the need for standardization in these human services professions grew, these professions became more bureaucratized thus leading to even more frustration and alienation (Schaufeli, 2017). This perceived loss of autonomy, combined with a general trend toward a decline in the societal perceptions of professional expertise further placed stress on professionals as their prestige and status waned which predisposed the American worker to greater amounts of burnout (Cherniss, 1980). Therefore, according to Schaufeli (2017), three societal factors that included: a large population influx of idealistic workers into the humanistic professions, the shift in the focus of accomplishments from the community to the workplace, and the loss of perceived prestige from the bureaucratization of the profession, resulted in the common occurrence known as burnout in the United States during the 1970’s. 18 As this trend toward burnout became more evident, clinicians began to describe it in case reports and observations of professions such as health care, social work, and education (Shaufeli, 2017). These descriptive studies, however, largely lacked a theoretical basis to explain the symptoms and signs of burnout and therefore attempts to manage it were mostly empirical and anecdotal (Maslach, 1993). In the 1980s, the social psychologist, Christina Maslach and others began to study this burnout phenomenon more formally through questionnaires and interviews that eventually led to tools and instruments that more precisely defined and described burnout. Maslach was especially interested in how people at work coped with emotional arousal and how these adaptations affected their emotions and behaviors (Maslach, 1993). These observations combined with her personal encounters with poverty lawyers who were familiar with the burnout syndrome and who were similarly frustrated at attempts to fix the War on Poverty further led to the development and expansion of the burnout concept into other professions besides healthcare and social work. In what Maslach (1993) described as the empirical phase of research, a plethora of books and articles described conceptual models of the syndrome that led to the search for empirically validated and standardized measures of the burnout phenomenon. Studies that led to the establishment of today’s gold standard definition of burnout came about on research that differentiated the phenomenon from job dissatisfaction and depression. The burnout syndrome was not simply a temporary situation as job dissatisfaction may often be but seemed to be a chronic condition that was a response to chronic job stress and dissatisfaction. Although related, job dissatisfaction did not completely describe this syndrome. Depression, similarly, did not fit the new syndrome as depressive individuals would associate their mood with all phases of life instead of just work. Therefore the modern conceptual construct was developed of a syndrome 19 that is characterized by dysphoric symptoms that develop in response to work-related issues that results in emotional exhaustion, depersonalization, and low personal accomplishment .This differentiation from depression however has come under scrutiny as the emotional exhaustion domain of burnout seems to overlap with many International Classification of Disease (ICD) diagnoses that include diagnoses of depression and other exhaustion syndromes such as chronic fatigue syndrome (Doerr, 2017). However, the overall clinical literature has recommended against burnout being included as a psychopathological disorder and instead have kept burnout as a separate and distinct non-pathological entity. The Development of Physician Burnout Studies on physician burnout have been ongoing since the first descriptions of burnout in the 1970’s. Analysis of distress in physicians however has been ongoing for over a hundred years prior to the initial descriptions by Freudenberg. In a study at the Royal College of Surgeons of England, male medical students studied between the years 1839 and 1859 were found to have suicide rates 25 times higher than the average suicide rate of the general population (Gunnell, 2010). This troubling statistic was also confirmed in the United States as a public health article published in 1922 showed that American physicians committed suicide at more than twice the rate than the next highest group, judges (Hubbard, 1922). Attributions of these suicide rates were directed to individual factors surmising that somehow those who chose the medical profession may have some predisposing traits that made them especially vulnerable to stressors in the work environment (Shortt, 1979). Over the ensuing years after the Maslach Burnout Inventory was developed in 1981, studies on burnout led to more nuanced causal explanations of this phenomenon. 20 Despite the high number of studies on physician burnout, large scale regional and national studies documenting physician burnout rates were only recently published in the first decade of 2000. One study of Canadian physicians conducted by the Canadian Medical Association found that 48% to 55% of physicians had the advanced phases of burnout (Boudreau, 2006). In the United States Shanafelt (2012) distributed a survey to over 27,000 physicians in the U.S. population and found a 45% rate of burnout in the 7,288 physicians who responded (Shanafelt, 2012). This was compared to a sample of the general US population and the rate was found to be thirty percent higher for physicians than the comparison population. Not only were the burnout rates higher for physicians compared to the general population but compared to the population with advanced degrees (those with a master’s degree or doctoral degrees), physicians were at a significantly higher overall risk for burnout compared to those comparison populations (OR=1.40, p=.01, 1.5, p=.04, respectively). Of note, in this study, front line physicians in Emergency Medicine, Family Medicine, and Internal Medicine were at the highest risk for burnout, while those in Preventive Medicine and Pediatrics were at the lowest risk. These studies reveal not only the uniquely high prevalence of burnout in physicians, but also important clues as to their causes that deserve further study and are addressed in the following review. Before moving to the contemporary review of the burnout literature, one study deserves mention as a rebuttal to the trait attribution conclusion reached by Shortt (1979) where he concluded that the high suicide rates in physicians may be related to individual traits inherent in the physician psychological makeup. In a relatively recent study of matriculating medical students at six medical schools, surveys collected during medical school orientation examined several mental health indicators, including burnout. The survey results were compared to a 21 similar survey collected from a matched cohort of non-medical students. The findings demonstrated that across several indicators of wellness including burnout, depression, mental, emotional, physical, and overall quality of life measures, medical students scored significantly better than their non-medical school counterparts on all these measures (Brazeau et al., 2014). Therefore, although this study was relatively small and cross sectional in design, it does suggest that perhaps future physicians may not possess traits that predispose them to later burnout and, as the authors suggest, the work environment may play a more significant role in causing burnout later in a physician’s career. The suggestion by Schauefeli (2017) that other factors aside from the immediate work environment play a role in physician burnout has been discussed earlier, however, the importance of the imposition of the electronic health record into the daily work life of the physician cannot be underestimated. The large-scale adoption and universal implementation of the electronic health record has been a well-documented factor that increases physician burnout (Eschenroeder et al., 2021; Melnick et al., 2020). This policy that originated from the American Recovery and Reinvestment Act (ARRA) of 2009 was designed to improve healthcare through enhanced documentation. This policy, though not an absolute mandate, incentivized organizations to adopt the electronic health record by 2015 (Services, 2009). The ARRA, however, was met with much resistance from physicians and health care workers and its implementation seemed to not only increase the workload of physicians, but also seemed to affect their autonomy in the workplace as greater amounts of time were spent documenting in the health record with correspondingly less time devoted to direct patient care and other requirements that were deemed meaningful to caring for patients (Hartzband, 2020; Melnick et al., 2020; Shanafelt et al., 2016). These changes in the work environment and its effects on 22 burnout through increased workload and changes in the nature of the physician patient interaction represented an important factor in the worsening wellness of physicians. Additional societal sources of burnout were connected to other changes in health policy. Many believe that the burnout syndrome was and is related to other long-ranging changes in the health care system that preceded the mandate of the American Recovery and Reinvestment Act (ARRA). Berwick (2016) described changes in the incentivization of physicians as being incongruent with historical norms of the profession when physicians evaluated their own work rather than non-physicians. The loss of control and judgement of work quality had now become the province of administrators whose judgment of physician’s performance was based on numbers of patients seen and revenue generated rather than the quality of patient care rendered (Berwick, 2016; Foundation, 2010). These major changes in health policy led to newer reimbursement models which then led to the need for greater administrative support that resulted in physicians combining into larger group practices or hospital-based organizations that were characterized by a more complicated bureaucratic structure. The consequence of this trend to combine with larger groups of physicians and administrative support was a physician loss of autonomy and control (Olson et al., 2019). Overall, these changes in the healthcare environment, and systems accordingly led to additional stressors that led to a higher chance of burnout (Jha, 2018) Therefore according to Jha (2018), addressing these larger systemic issues will require a different understanding of the secondary effects brought on by changes in the macroenvironment (i.e. national policy changes) and approaches to mitigating burnout will require a whole organizational approach rather than purely individual approaches. 23 Burnout in Physicians: General Descriptors Although physician burnout remains a problem in the United States, and there remains a myriad of reasons for this epidemic, the most recent surveys indicate a complex emerging picture. In a survey of physicians in the United States, Shanafelt (2019), invited 30,456 physicians to participate in a burnout questionnaire using the Maslach Burnout Inventory (MBI) (Shanafelt, West, et al., 2019). Although only 17.1% responded to the initial survey, a secondary survey sent to a sample of 476 non-respondents that resulted in a 52.1% response rate. The two groups did not significantly differ in their burnout scores thus suggesting the validity of the original sample. The overall combined cohort reported a 43.9% burnout rate in at least one domain of the MBI. As part of this survey, researchers conducted a multifactorial analysis correcting for age, sex, relationship status, and hours worked per week, and compared burnout rates with the general U.S. population. The investigators found that physicians demonstrated a statistically significantly higher odds ratio (OR) for burnout (OR=1.39, p<.001). As part of this study, burnout rates were compared across different subspecialties in medicine with results showing clear differences in the rates of burnout between specialties with Emergency Medicine and Obstetric Gynecology showing the highest rates of burnout compared to Preventive Medicine and the Pediatric subspecialties which showed the lowest rates of burnout in this study. Although the limitations of this study include the relatively small sample size and a relatively low percentage of respondents, the results reveal consistency with prior studies on burnout rates in the physician population and suggest differing rates of burnout among specialties that warrant further investigation into possible factors unique to each specialty. To understand some of these unique contributors to burnout in specific specialties, Shanafelt et al. (2016) studied Emergency Room physicians and work factors associated with 24 burnout with this group and compared them to other specialties (Shanafelt et al., 2016). In this study, satisfaction with work-life integration was measured and found to be twice as high for Emergency Room physicians compared to Obstetrics-Gynecology physicians despite both having similarly high overall burnout rates. These disparate findings of burnout attribution between specialties would suggest that the nature and causes of burnout are uniquely different for each specialty. The authors did not propose reasons for this discrepancy but suggested further study into these differences. In another study of neurointerventional radiologists, Fargen (2019) found similarly unique findings associated with this physician specialty (Fargen et al., 2019). In this study of 320 physician members of the major U.S neurointerventionalist societies, Fargen (2019) analyzed the 56% of respondents who met the MBI criteria for burnout. There were no correlations of burnout with training background, practice setting, call frequency, or the presence of a senior partner, however, feeling underappreciated by hospital leadership (OR = 3.71; p<.001) and covering more than one hospital (OR = 1.96; p=.01) were significantly correlated with a higher odds ratio of burnout. Although one could conclude that covering more than one hospital could hamper work-life integration the issue of feeling underappreciated by hospital leadership is an entirely different etiologic category than work-life balance and, according to the authors, warrants further study. In another study of general internal medicine Veterans Affairs physicians conducted by the Association of Chiefs and Leaders in General Internal Medicine (ACLGIM), a ten-item survey measuring stress, burnout, and work conditions such as the experience with the electronic medical record (EMR) was given to 1,235 internal medicine recipients at 15 medicine divisions. This study done by Linzer (2016) involved distribution of surveys to 1,235 physicians with a response rate of 47% (Linzer et al., 2016). A burnout rate of 38% was noted and associated with 25 high stress and low work control, with over half describing too much time spent at home performing tasks on the electronic medical record. In addition, high stress, and low values alignment with leaders also was statistically significantly correlated with burnout. Although the ten-item questionnaire specifically highlighted EMR use as a work condition factor that is related to burnout several other studies have similarly documented a high rate of dissatisfaction associated with workplace factors such as the burdensome use of the EMR (Friedberg, 2014). In this mixed methods study of 30 physician practices in six states, a total of 656 physicians answered a semi- structured questionnaire on satisfaction and factors that influence satisfaction. An overwhelming number identified the EMR as the source of dissatisfaction. Furthermore, when queried for reasons behind the dissatisfaction with EMR’s, many stated the problem was not with the idea and intent of EMR implementation, but problems with the usability of the EMR that left little time and energy in addressing the more meaningful parts of clinical practice (Friedberg, 2014). Therefore, the authors concluded that alleviating the unique problems associated with EMR use and changing workload volume in the primary care work settings should be considered in any wellness initiatives for primary care physicians such as Family Practitioners or Internists. Studies of physicians in General Surgery have demonstrated other unique sources of burnout. Factors such as gender, younger age, fewer years in practice have been previously reported and correlated with burnout in a systematic review of general surgeons (Dimou et al., 2016). These studies universally identify a poor work-life balance as a major cause for burnout; however, studies to identify sources or potential causes of burnout appear uniquely different in surgery compared to other specialties. Lu (2020) interviewed fourteen full-time female faculty surgeons and nine males at an academic medical center to gain a better understanding of burnout 26 causes in surgeons. The participants were asked questions with regards to work-life balance and causes of burnout. For both male and female faculty in this qualitative study, lack of control with work-life balance was a common theme, however, females were more likely to report gender bias in the workplace as a risk factor for burnout while males were more likely to report guilt over complications related to patient care as their source of burnout. These findings in practicing surgeons are clearly of a different nature than those of internists as gender bias was not previously reported in other subspecialties. Therefore, clarification of these unique factors should be sought to understand the sources and causes of these burnout factors in surgeons. The authors suggest that the drivers of gender bias could include issues related to the dual role of a female surgeons who are not only expected to perform in the workplace, but also are the primary source for domestic responsibilities. As this dual role responsibility can affect the perception of gender bias in the workplace, the authors conclude that interventions that address direct gender bias from colleagues and patients should be further explored. Burnout in Physician Trainees: A Window into Possible Causes The literature on causes of burnout in residents may illuminate further the nature and possible sources of burnout in the physician population. Although some studies indicate that the burnout rate is higher in trainees, these studies have been confounded by the lack of comparative data to faculty or attending physicians in the same system. One study compared burnout rates in trainees to faculty in the Wichita-Kansas area to ascertain relative burnout rates and causes (Ofei-Dodoo et al., 2019). In this study done in the Kansas -Wichita school of medicine system, 13 residency programs were given an abbreviated Maslach Burnout Inventory questionnaire (MBI) and were analyzed for differences in burnout scores of faculty and residents. This study demonstrated that of the 43% of respondents that met the criteria for burnout, the rates of 27 burnout among residents were higher than those of faculty (51% vs. 31%; p<.05). In another study of anesthesia resident wellbeing across all ACGME sites in Pennsylvania, a significant difference in the ACGME well-being survey scores were found among 371 responding residents and 277 faculty member (Adams et al., 2019) This latter study showed a statistically higher mean score on a 5-point Likert scale of wellbeing in six of the 12 wellbeing questions compared to residents. Though not conclusive, data from these two studies suggest that baseline burnout and wellbeing rates may differ between the attending or faculty physician populations with the possibility that residents have higher burnout rates and lower wellbeing rates. According to Ofei- Dodoo et al. (2018), these differences could inform future approaches to burnout mitigation in both the resident and non-training populations that include individual approaches to wellbeing (i.e., work life balance) or systems modifications in the work environment. As previously described by Lu et al. (2020), non-training female physicians who were burned out experienced greater gender bias in the workplace. An exploration into the surgeon training population may reveal certain clues that could better identify the drivers of this bias. In a cross-sectional study by Hu et al. (2019), over 7,000 residents were surveyed for burnout using the MBI. The respondent rate was 99% with 7,409 total residents answering the questionnaire after completion of the annual in-service exam for trainees. This survey also looked at mistreatment and abuse of surgical trainees in the work environment with additional survey questions addressing depression and suicidal thoughts. A multivariate logistic model was applied to better isolate variables related to burnout. The findings demonstrated that out of 7,409 residents from all 262 surgical residency programs, 31.9% reported discrimination based on gender, 16.6% reported racial discrimination, 30.3% reported verbal or physical abuse or both, and 10.3% reported sexual harassment. Women reported higher rates of mistreatment, with 65% 28 reporting gender discrimination and 19.9% reporting sexual harassment (Hu et al., 2020). Whereas patients or their family members served as the sources of most of the gender and racial discrimination, residents identified attending surgeons as the most frequent source of sexual harassment and abuse. This study clearly illustrates an extreme difference in sources and drivers of burnout and health care leaders should inquire further into the work environment of surgical residents. Although similar studies of this magnitude have not been reported in the other subspecialties, it would be of interest to study other populations with similar probing questions on the work environment, including harassment or even unpleasant work environments that are less than collegial or inclusive. Burnout in this study was 38.5%, but residents reporting exposure to discrimination abuse or harassment of at least a few times a month were more likely to report symptoms of burnout (OR 2.94) or suicidal thoughts. Women were more likely to report burnout symptoms (42.4% vs. 35.9%) with the differences compared to males being no longer evident after correcting for harassment. Thus, the sources of burnout in surgeons, and especially women surgeons are especially noteworthy, and intervention strategies addressing the cultural environment are needed. To further explore the complexities of female gender related associations with burnout, other studies that include surgical and non-surgical trainees have been completed. In a study of first year and second year nephrology fellows, 808 participants were surveyed, of whom 347 participated. The rate of burnout for the entire cohort based on a two-item questionnaire numbered 30% which represented a lower rate than most trainee surveys (Agrawal et al., 2020). Multivariate analysis showed that female gender, poor work-life balance, and a disruptive work environment correlated with burnout. Unfortunately, the study could not specify reasons for the work environment correlation or the nature of the poor work environment but appeared 29 consistent with gender related burnout factors previously identified in surgical studies, namely, poor work-life balance. In another study of surgical residents and faculty who participated in the Flexibility in Duty Hours Requirements for Surgical Trainees (FIRST) trial, investigators conducted a semi-structured interview of 42 faculty and 56 residents. The investigators then analyzed transcripts using a thematically categorized constant comparative approach. The thematic categories that related to burnout in females included a lack of female mentorship, dual role responsibilities, gender bias, and differences in approach to patient care compared to their male counterparts (Dahlke et al., 2018). Based on the above two studies, gender differences in burnout attribution vary between specialties but seem to cluster around several themes that include work life balance, the presence or absence of female mentors or leaders, and inclusion into the work community. Burnout: Other Factors to Consider The reasons and nature of physician burnout represent a heterogeneous mixture of potential causes and drivers that vary between medicine specialties. In studies of both national and regional populations, a general understanding of the nature and causes of physician burnout at the individual and organizational level can be ascertained. These individual and organizational factors that contribute to burnout can also represent responses to the overall national and health care environment where accountability for safety and cost represent major political concerns and are expressed in health care policies that can have a major impact on physician work life. In a study by Rothenberger (2017), the investigators conducted a comprehensive review of all studies related to burnout from 2000-2017 (Rothenberger, 2017). The findings demonstrated that commonly found individual related factors such as work overload and lack of control, represented significant concerns, but also revealed issues of values alignment with the 30 organization such as a lack of fairness and conflicting personal and organizational values such as covering up mistakes and blaming others for poor patient outcomes. The authors also indicated that major healthcare legislation over the past 30 years had contributed to burnout by changing reimbursement rates and expanding the requirements for proper documentation thus limiting physician autonomy even more. These changes affect physicians in different ways and interventions to help mitigate these effects on physician wellness are needed. Interventions into Physician Burnout The literature describing the nature and factors related to burnout has led to several interventional strategies that are designed to improve wellbeing in physicians’ emotional health. Most of the studies have focused on attempting to prevent and reduce the percentage of physicians with burnout. These interventions have focused on mainly wellness interventions such as developing skills in stress management and self-care training, communication skills training, and mindfulness strategies. These studies have suffered from designs that are mostly descriptive, cross-sectional, and non-comparative in nature. These interventions are reviewed here to help inform future interventional strategies in mitigating burnout. These interventions can generally be divided into two types: individual-based interventions and structural or organizational type interventions (West et al., 2016). Individual Based Interventions Burnout reduction strategies that focus on the individual have showed a modest decrease in burnout scores (West et al., 2016). In a systematic review and meta-analysis that covered the period from the inception of the respective databases selected to January of 2016, West et al. analyzed all interventional studies on physician burnout. The studies included only those involving physicians and excluded studies containing medical students and ancillary staff 31 participants. The search identified 2,617 articles and was assessed by two independent reviewers for proper design and interventions with appropriate externally validated measures of burnout. After review, 15 randomized trials that included 716 physicians and 37 cohort studies that included 2,914 physicians met the inclusion criteria that specified physician subjects only and validated burnout measurements. The results demonstrated an overall decreased burnout score from 54% to 44% (p<.001) using the interventions identified that included all individual and organizationally based strategies. However, when comparing individual-based strategies with organizational or structural strategies there was a significantly greater benefit with organizationally based strategies when overall burnout scores were measured. The authors concluded that given the heterogeneity of the study designs and the paucity of direct comparisons in this metanalysis between organizationally based and individually based interventions, the superiority of organizational approaches could not be firmly established, but instead recommended that combined (individual and organizational) approaches be instituted for future study. Despite the modest effect of individual based strategies relative to organizational (including structural) strategies in affecting overall burnout, examination of one domain of burnout (i.e., emotional exhaustion or depersonalization only) yielded different results. The same study by West et al. (2016) looked at the individual intervention strategies’ effects on specific burnout domains and found a statistically significantly decreased mean emotional exhaustion score from 23.82 points to 21.17 points (p<.0001). In addition, a decreased depersonalization score from 9.05 to 8.41 (p=.01) was also noted for individually focused interventions. Comparing individual based strategies to organizational and structural interventions, no significant difference in the contributions of each type of intervention on 32 specific domains of burnout were found. thus, suggesting that individual based strategies may have a greater effect on individual components of burnout as opposed to aggregated burnout scores. The authors acknowledge the limitations of the study that include short follow up periods, lack of uniform reporting of demographic data, selection bias, and the unknown confounders that can affect the results of non-randomized cohort studies included in this meta- analysis. Regardless of these limitations, the studies identified in this meta-analysis establish a useful baseline to develop future studies for comparison. The types of individually targeted intervention strategies identified in the previous metanalysis included stress reduction, communication skills, and mindfulness programs. The suggestion that these programs decrease burnout have been published in several other studies as well. In a smaller metanalysis that included 1,024 physicians and physician trainees, Regehr (2014) looked at twelve studies that included 1,024 participants that included medical students, physicians in training, and attending physicians (Regehr et al., 2014). These studies also included single arm cohort studies and randomized studies with particular attention to mindfulness meditation studies, psychoeducation, and communication interventions. Overall burnout scores showed a decrease of 0.38 (95% CI, 0.49-0.26) when using any of these interventions. This study did not report whether the entire burnout domain or part of it was used in this study. In one of the few individual based interventions using a longitudinal study design, a mindfulness intervention was incorporated and given to a single cohort of physicians over an 8-week period and then followed by a maintenance program over ten months (Krasner, 2009). The overall burnout scores as measured by the overall MBI showed improvement in all three domains including the depersonalization score (p<.0001). The main limitation of this study was the low participation rate as only 70 physicians participated out of 871 invited and the lack of follow up 33 data that assessed the persistence of the effect after the mindfulness sessions were completed. Thus, there exists ample exploratory data to suggest a modest benefit to individual cognitive, behavioral, and mindfulness-based interventions. Although the sustainability over time of individual based interventions remains to be proven, another approach using coaching as an intervention was recently studied. In this study, coaching was defined as an action that focuses on future goals and actions as opposed to mindfulness, which generally addressed past and present issues. In this recently completed study by McGonagle (2020), a randomized trial of 59 primary care physicians was conducted with 29 physicians receiving six sessions in a three-month period immediately and 30 placed on a waiting list who received the intervention later (McGonagle et al., 2020). This positive psychology-based intervention was focused on goals of improving the workplace and addressing workplace problems. Burnout scores were rated on a modified MBI scale assessing the effects of coaching on primary care physicians between the two groups (immediate intervention vs delayed intervention). The results demonstrated a statistically significant decrease in burnout that was sustained at the 6-month time point (p=.003) when compared to the control group. This study’s limitations mainly surrounded the modified burnout scale used that was not clearly described, as well as the possibility that the effects of coaching did not reflect the direct effect of coaching, but possibly the indirect effects of broad participation in decision making in workplace restructuring improvements which reflect more of an organizational intervention as opposed to an individual one. Nonetheless, this study’s findings offer a unique option that addresses individual wellness and collective stakeholder input. Despite the popularity of mindfulness and stress reduction programs that are aimed at individuals or small groups, one of the biggest barriers to its widespread benefit is the low 34 participation rate of physicians in these programs. Several studies have identified this barrier as physicians have identified several reasons for not participating. In the training population, Westercamp (2018) surveyed residents in 94 psychiatry programs and 255 responses were returned that contained responses as to barriers to participation in wellness programs (Westercamp et al., 2018). The actual participation rate in wellness programs was approximately two percent and reasons that were given for not participating included: a lack of awareness of the existence of wellness programs, concerns of shifting workload to their co-residents, and concerns that participation would be a show of weakness to their leaders. An unfortunate finding was that those that were burned out perceived higher barriers to access to wellness programs compared to those that were not burned out. A second large study by Feeney (2016) surveyed non-consultant hospital physicians’ responses to stress reduction programs using a 25-item questionnaire distributed to 4074 physicians in 58 hospitals (Feeney et al., 2016). The 707 respondents stated that the inability to take time off (60%), letting teammates down (90%), and difficulty taking call (85.9%) were primary reasons for not accessing stress reduction programs even though they were available. These behaviors that deny self-help by physicians have been described previously and have been attributed to a unique feature of physician culture that is adopted and fostered, especially during training years. This internalization of a culture of self-denial is further inculcated by the professions’ norms of caring for patients at all costs even to the detriment of one’s own health (Wessely A. Gerada, 2013). According to Shanafelt et al. (2019), changing the physician culture in addressing their own wellness will require significant organizational commitment from not only local health care organizations but also from the professional organizations themselves who often communicate a message that cultivating self-compassion 35 and self-care will lead to lower standards and less commitment from professionals (Shanafelt, Schein, et al., 2019). Organization Based Interventions Given the barriers to individual based strategies and their demonstrated modest success in mitigating burnout, other systematic reviews found that directed organizational factors offer a more effective option in decreasing burnout (Panagioti et al., 2017). In this metanalysis, 19 studies were identified that either possessed a randomized trial design or a controlled pre - intervention and post intervention measurement design. These studies included 1500 physicians and standard mean differences were measured in just the emotional exhaustion domain of the MBI. The overall change in burnout scores demonstrated significantly lower standard mean decreases (SMD) in burnout scores for organizational interventions compared to controls overall (SMD = - 0.29; 95% CI, -0.42 to -0.16). A subgroup analysis comparing organizational interventions to individual based interventions showed larger effects of the former approach (SMD = -0.45 vs -0.18; p=.04). In the metanalysis by West (2016) which did not find significant differences between organizational and individual based interventions in isolated domain scores, workload mitigation and improvement in work processes along with shorter work shifts or rotations had the greatest effect on the overall burnout scores in the identified interventional studies. Similarly, in the study by Pangioti et al. (2017) the greatest organizational benefit appeared to be in simple reductions in workload or schedule changes. These workload and process interventions included processes that improved the interaction of physicians with the electronic health record as well as modifying the work schedule to better accommodate physicians (Friedberg, 2014). Therefore, the data based on the two largest systematic reviews to date showed modest improvements in burnout from the current individual based interventions 36 and that organizational based interventions seem to have a greater effect. Although the authors from both metanalyses acknowledge that firm conclusions cannot be drawn from the available evidence, they do support the idea that their findings are consistent with other’s contention that burnout is a problem of the work environment and that healthcare interventions should be directed at the organizational level (Lown, 2015; Ruotsalainen, 2015). As most of these studies analyzed quantitative data, an examination of the qualitative studies may reveal further ideas as to effective intervention strategies. In a study by Dillon (2019), 15 physicians in primary care, and two non-physician system leaders were interviewed for an understanding of workplace problems that could be related to burnout (Dillon et al., 2020). These 15 physicians were composed of 9 medical group leaders and six who were not in leadership roles. The findings showed the expected workplace problems that had been identified previously in this review including issues with the electronic health record as well as problems with work life balance. However, other problems cited that contributed to burnout were related to organizational structure and culture. Besides the frustrations of the efficiency and clerical work burden of the health care delivery systems, physician leaders and non-leaders cited the culture and values of the organization as a problem. A consistent issue was the incongruence of performance metrics emphasizing business measures for success instead of quality of care and patient doctor relationship metrics. Another area of frustration expressed by physician leaders was the lack of support from bosses and staff with regards to leadership training and mentorship to effectively lead the group. The leaders felt that these omissions led to a feeling of alienation and isolation that contributed to the leader’s own feelings of burnout. These findings that relate the need for adequate physician leadership training regarding organizational interventions to 37 wellbeing outcomes is one of nine organizational strategy priorities in the Stanford leadership model for mitigating burnout (Shanafelt & Noseworthy, 2017). To better understand potential study designs that could inform future organizational intervention studies on burnout, a few longitudinal studies demonstrating long-term benefits will be reviewed here. In one study, Dunn (2007) employed a longitudinal survey design and administered a questionnaire to 22-32 physicians between 2000- 2005 in a new suburban practice (Dunn et al., 2007). The participants were asked to fill out three questionnaires to determine the perceived amount of physician control over the work environment and to assess the degree of order in the work environment. These questionnaires that assessed physicians’ impressions of clinical aspects of work included group meetings to elicit physician concerns and attempted to address possible solutions to work concerns depending on the questionnaire results. Interventions included work customized to meet physician goals, flexibility in scheduling, office design improvements, and improving staff skills and capabilities that included implementing medical assistant and hospitalist programs to relieve the work burden of physicians especially around clerical duties. The participation rates for each year dropped to 90% by 2005, but adequate participation was noted throughout most of the five-year study. Burnout scores for the participants showed steady improvement in the emotional exhaustion category with the mean emotional exhaustion score of 27-29, decreasing to 21 by 2005 (p=.002). This study was mainly limited by the small size of the sample and the possibility that the turnover of participants may have selected out a group of physicians that were more likely to score more favorably on the burnout surveys. Despite these limitations, the authors concluded that studies on larger cohorts over time are feasible and may help validate interventions such as group decision making on 38 immediate workplace issues. In addition, the authors note that workplace improvements along with the process of including participants may act additively to enhance physician wellbeing. Physician Leadership and Physician Burnout Aside from the work process aspect of organizational intervention, physician leadership behaviors have been studied to ascertain whether leadership behaviors of physicians are correlated with the wellbeing of the physicians they lead at the organizational leadership level. In a study of 2813 physicians (72% response rate) at Mayo Clinic, physician supervisors were rated on 12 leadership dimensions and a composite leadership score was calculated. These scores were correlated with the two burnout domains of emotional exhaustion and depersonalization. After adjusting for age, sex, duration of employment at Mayo clinic, and specialty, it was found that a one-point increase in composite leadership score was associated with a 3.3% decrease in the likelihood of burnout (p <.001) and a 9% increase in the likelihood of satisfaction (Shanafelt, Gorringe, et al., 2015). In a previous study by the same group at Mayo Clinic, Menaker (2008) sent a questionnaire to 314 physicians in the department of medicine and asked them to fill out a Multifactor Leadership Questionnaire consisting of 22 questions regarding their physician leader’s leadership behaviors. The non-leader physician participants assessed the four domains of transformational leadership (TFL) behaviors and ranked the most desirable domains of leadership behaviors that were exhibited by their immediate physician leader (Menaker, 2008). These supervisor behaviors were then correlated with physician job satisfaction. The two TFL behaviors that most correlated with satisfaction were in the domains of individualized consideration and idealized influence. These two studies represent the most detailed studies on physician leadership behaviors and outcomes of physician well-being and establish a baseline for future studies on the role of physician leadership behaviors as an organizational intervention on 39 physician wellbeing and burnout. The current study will address the relationship of two domains of transformational leadership behaviors (Idealized Influence and Individualized Consideration) as well as four domains of transactional leadership with burnout. The remaining review will focus on leadership as it relates to burnout. Burnout in Physician Leaders Another aspect of burnout in physician followers is the possibility that the physician leaders may themselves be burned out. This was alluded to in the previous study by Dillon (2019) where many of those physicians interviewed identified a lack of mentorship and training in leadership as a contributor to their feelings of burnout (Dillon et al., 2020). The prevalence of academic chair burnout has been identified in the past. In a cross-sectional study of obstetrics and gynecology physician chairs in the United States, burnout, as measured by the MBI showed a decrease in chair burnout when compared to a similar survey done over a decade earlier (Gabbe et al., 2018). Despite this improvement, a high rate of inefficacy was attributed to the physician leaders that the authors reported as possibly related to administrative factors that were beyond the chair's control. The burnout domains showing improvement in these chair respondents included the emotional exhaustion and depersonalization components, but high levels of low personal achievement continued to be reported thus offering a unique profile of burnout in physician leaders. This finding was corroborated in a survey of another group of physician leaders in otolaryngology. In this study of head and neck surgeon leaders at an academic institution, burnout domains in emotional exhaustion and depersonalization were similarly low to moderate with the worst score, again, shown in the personal accomplishment area. These leaders reported budget issues and dean conflicts as sources of major concern that contributed to their sense of low accomplishment (Golub et al., 2008). A similar finding of low accomplishment 40 scores was found in a survey of ophthalmology chairs (Cruz et al., 2007). In this study of 101 chairs from the US and Canada, only 9% met the criteria for overall burnout based on the MBI, but 56% of all those surveyed showed low personal achievement scores. These findings illustrate a unique burnout problem with physician leaders as many exhibit feelings of inefficacy that could affect their behavior toward the organizations that they lead or their own personal wellbeing. Although studies on physician leader well-being verify some evidence of burnout, these effects on organizational outcomes are unknown. In a recent study at Stanford University, physician leaders were queried for their degree of professional fulfillment, self-care practices and burnout scores and the findings were correlated with independently assessed leadership behaviors that were exhibited and evaluated by physicians not in leadership positions (T. Shanafelt et al., 2020). The study included 1285 physician leaders and the physicians they led with data collected in a one-month period between April and May 2019. The results demonstrated a correlation between perceived desirable leadership behaviors with burnout as a one-point increase in burnout scores of leaders translated to a 0.19-point decrease in the perceived leadership score by the physician evaluators. The authors interpreted these findings as significant and estimate that about 10% of a leader’s effectiveness could be explained by their own level of burnout and well-being. This study builds on literature that suggests that wellness behaviors of supervisors correlate with performance behaviors by those they supervise (Hsu et al., 2018). Leadership Models and Burnout Recent interest in physician leadership has spawned a growth of physician leadership programs across the United States. According to Stoller (2018) health care organizations lag 41 behind other corporations in developing leaders with only 57% of responding organizations reporting an existing leadership program in 2012 (Stoller, 2018). However, interest in developing physician leadership programs has grown as the American College of Graduate Medical Education has now recognized the inclusion of leadership training as a component of the medical training curriculum based on the aims and goals of the teaching institution (Education, 2020). These leadership courses have mixed outcomes but generally are popular and desired by many physicians in training as well as early, mid, and senior faculty physicians (Frich et al., 2015). These leadership courses have largely been criticized for their lack of a leadership theory that can inform and guide physician leadership (Pangaro, 2019). In addition, the lack of systemic level conceptual thinking hinders the achievement of organizational outcomes and therefore represents another area that leadership programs can show improvement. Onyura (2019) in a systematic review of leadership programs identified these two weaknesses: a lack of leadership theory and a lack of systems-based thinking, as weaknesses in physician leadership curricula in the United States and Canada (Onyura, Crann, Freeman, et al., 2019). The lack of focus on conceptual and theoretical leadership underpinnings and the lack of training on systems level problems make addressing complex problems such as burnout challenging. As many have viewed physician leadership development as a vital organizational intervention to physician wellness, sound leadership training based on theory is attractive in grounding physician leaders in a leadership construct that can address burnout systemically through the use of several theories that range from individual to shared leadership behaviors (Pangaro, 2019). Given this need for physician leadership models that can span the individual to shared leadership models, some authors have suggested that two leadership models could best fit the 42 physician wellness need: Transformational Leadership (TFL) and Servant Leadership (Olson et al., 2019; Shanafelt & Noseworthy, 2017). The transformational leadership model was first introduced by James Macgregor Burns in 1978. Burns described and contrasted transformational leadership to transactional leadership and identified transformational leadership as “raising the level of motivation and morality in both the leader and the follower and tries to help followers reach their fullest potential” (Burns, 1978, p.20). Transactional leadership on the other hand focuses on exchanges between leaders and followers that do not necessarily compel followers to achieve their greatest potential. Instead, the transactional approach mainly focuses on performance in exchange for reward. While these external rewards are a common part of management, the employee literature suggests that employees prefer managers or leaders to demonstrate leadership behaviors that encourage creativity, recognize accomplishments, build trust, and inspire collective vision (Deci, 2017). These descriptions form the basis of transformational leadership behaviors that are conceptualized in four domains: Idealized Influence, Inspirational Motivation, Intellectual Stimulation, and Individualized Consideration. According to Swenson (2016): Individualized Consideration, which seeks to develop abilities, engage perspectives, and understand aspirations; Idealized Influence which provides a sense of mission and purpose greater than self-interest, instills pride, and builds respect; and Intellectual Stimulation defined as questioning assumptions and seeking differing perspectives, were the most important domains with respect to physician wellbeing. Servant leadership according to Swensen possesses many of the components of Individualized Consideration but focuses more on serving with humility to create a community of self-actualizing people with lesser emphasis on organizational goals compared to TFL. Both models are useful to inform organizational approaches to burnout, however, because TFL and its 43 derivative model known as the full range of leadership model cover a broader range of leadership styles and behaviors, TFL and its accompanying full range of leadership model offers a more comprehensive construct to address the issue of leadership and burnout in physicians. Furthermore, certain transactional leadership behaviors have been shown to also correlate with improved burnout in the non-physician population and therefore a model that accounts for both types of leadership behaviors can more fully address the relationship of leadership behaviors and burnout (Albrecht, 2015, Avolio, 1999). Transformational Leadership (TFL) and Burnout The effects of TFL on burnout have been studied in several work contexts. In a study of hospital physician residents, TFL induced lower measures of burnout in residents through the mediator of perceived ethical behavior of their immediate leaders. In this study by Okposo (2017), 203 residents were given a questionnaire that included questions of their level of burnout, general self-efficacy, and perceived supervisor support borrowing from the individualized consideration portion of the Multiple Factor Leadership Questionnaire (MLQ-5X). The results of this study demonstrated a strong negative correlation between high ethical behavior of leaders and emotional exhaustion with a high positive correlation with personal accomplishment on the burnout domain. No correlation on depersonalization was seen in this study. These effects were felt to be mediated though perceived supervisor support and values alignment through ethical behavior and general self-efficacy (Okpozo et al., 2017). In another study looking at ethical behavior, it was noted that ethical behavior was related to trust and that this affected these pharmaceutical company employees’ burnout scores, deviant behavior assessments, and task performance evaluation. The authors opined that through less surface acting and more genuine acting by employees who thought their leaders were ethical less emotional exhaustion would 44 ensue (Mo & Shi, 2015). The authors found that those employees that had higher levels of trust in their leaders exhibited less surface acting if they perceived their leaders as behaving ethically. Therefore, it appears that transformational leadership can have a positive effect on burnout symptoms through ethical behavior and the subsequent downstream effects of building trust that can lead to more authentic interactions that require less energy expenditure by employees and therefore less emotional exhaustion. Although transformational leadership is widely studied and seems to be associated with improving burnout, it is not clear that certain forms of transactional leadership are not effective as well. Some have suggested that transactional behaviors can also have a positive effect on follower’s burnout symptoms. In a study on non-physician employees in the hotel industry in Cyprus, transactional leadership behaviors were significantly correlated with the personal accomplishment domain of burnout. Still, it was not significantly correlated with emotional exhaustion and depersonalization (Zopiatis & Constanti, 2010) . In this study of 130 hospitality workers, a strong negative association with transformational leadership behaviors was found in the two domains, emotional exhaustion and depersonalization, and a positive association was found for personal accomplishment. In another study of 205 business leaders and managers from a variety of fields, it was found that the leaders that showed TFL behaviors exhibited through emotional self-regulation more deep and authentic acting as opposed to transactional leaders who exhibited more surface acting (Arnold et al., 2015). Although this study did not reflect follower’s burnout scores, it suggests that managers and leaders who undergo this process of self-regulation in exhibiting deep acting may be less burned out and more likely to be effective in their role as leaders. Of further interest, was that the transactional component of leadership in the form of Laissez Faire leadership through genuine emotion was related as well to 45 less burnout in this study (Arnold, et al., 2015). This study highlights the fact that perceived leadership is complex and even some forms of transactional leadership may be beneficial in mitigating burnout. A similar finding of the benefits of transactional leadership was observed by Kanste (2007) in a study of hospital nurses where transactional leadership styles were associated with protection from the depersonalization component of burnout (Kanste, Kyngas, et al., 2007) . These studies highlight the value of the full spectrum of leadership survey (MLQ-5X) as transactional leadership can also have positive influences on burnout. Further study is needed to understand the role of the full range of leadership model that include transformational and transactional leadership behaviors and their effects on burnout. Transformational Leadership and Mediators of other aspects of Wellbeing With the publication of numerous correlational studies on the effects of transformational leadership on burnout, one area of research examines how these behaviors may be mediated in affecting other measures of wellbeing. Despite the paucity of studies on transformational physician leadership and wellbeing, surrogates such as job satisfaction and employee wellbeing have been completed that identify some potential mediators of burnout. In a study by Kelloway (2012), a sample of 436 field workers in a large Canadian telecommunications organization were given a survey to rate their satisfaction with their immediate supervisors in relation with three transformational leadership domains (Kelloway et al., 2012). Transformational leadership was measured on an abbreviated 20-item scale extracted from the MLQ-5X survey. Trust in leadership measured by a four-item questionnaire of Cook and Wall’s original six item questionnaire concurrently was measured with the MLQ-5X leadership questionnaire, and a psychological wellbeing questionnaire. The results demonstrated that employee psychological wellbeing was correlated with TFL and that trust was a strong mediator of TFL and wellbeing. 46 Furthermore, this trust was not related to the liking of the leader’s personality by the respondent but seemed to be tied to the dimensions of TFL specifically. Although the specific domains of TFL were not correlated in the multifactorial analysis, combining the TFL domains into a composite value did correlate with overall wellbeing. Thus, it is not known whether Individualized Consideration., for example, was the driving force for psychological wellbeing as opposed to, Idealized Influence Behavior, however, there is a suggestion that TFL overall does mediate through trust, the overall wellbeing of employees in this study. Of note, in the physician study conducted by Shanafelt (2017) the full range of leadership behaviors was not examined with regards to burnout and satisfaction, but rather a more limited range of leadership behaviors that demonstrated some aspects of transformational leadership, mainly, Individualized Consideration. Although it is not clear which domain of TFL is important in building trust, future studies assessing other transformational leadership domains (i.e., Idealized Influence and Individualized Consideration) in isolation can help elucidate and potentially focus leadership behaviors to just a few of the domains of TFL. Transformational Leadership also seems to have a sustainable effect on employee wellbeing through its influence on innovation in the work climate. In a longitudinal study of 342 respondents at a Swedish social service organization; TFL behaviors of their supervisors, affective wellbeing of participants, and a perceived climate of innovation were measured. The results showed a strong correlation between TFL and a positive climate of innovation and problem solving that translated into a climate of wellbeing that was sustained beyond one year from initial entry into the study (Tafvelin et al., 2011). This study showed that TFL in the form of employee engagement and innovation can improve and sustain employee wellbeing. Again, however, the TFL domains could not be separated from the positive outcomes of the composite 47 TFL scores, and thus single domains could not be associated with the sustained outcome. One could hypothesize that just Intellectual Stimulation is needed to sustain the workforce’s wellbeing as the demonstration of collective problem solving was noted, however, one could not rule out the role of Individualized Consideration where treating others as individuals rather than just members of a group could also be playing a role in the positive wellbeing experienced by the participants. Other studies on TFL and burnout have demonstrated similar benefits from mediators such as openness to experience and thriving at work, a positive spiritual work climate, participative decision making, and other influences on the work environment that relate to employee wellbeing (Kanste, Miettunen, et al., 2007; Lewis & Cunningham, 2016; Stordeur et al., 2001). Taken together, the results of these studies on wellbeing and the few studies on burnout can provide a rationale for the utility of examining the full range of leadership behaviors that include both TFL and transactional leadership behaviors in improving the work climate and form a basis for developing a conceptual framework that relates physician leadership behaviors and physician burnout. General Leadership and Physician Burnout The literature on leadership and physician burnout is limited to studies on “administrative leaders” as opposed to physician leaders. In the study of neurointerventionalists cited previously, a 39-question online survey that captured the relationship between burnout and questions about non-physician leadership practices demonstrated a high rate of burnout for those being led. In this national physician survey of neurointerventionalists, 56% of participants showed a high overall burnout score as measured by the MBI. The 320 physicians surveyed reported a feeling of underappreciation by hospital leadership that correlated with burnout with a higher odds ratio 48 of this association compared to those not burned out (OR=3.71; p<.001). Ironically, receiving additional compensation for night call was independently associated with a protective effect against burnout, perhaps due to this being a form of recognition as the authors note that the domain of low personal accomplishment was a major contributor to overall burnout score in this study (OR=0.70; p=.05) (Fargen et al., 2019). In another previously cited study of burnout in family practice physician faculty and residents from the Kansas School of Medicine Wichita system, 439 residents and faculty were compared for levels of burnout to each other. Forty-three percent of all surveyed met the criteria for burnout with residents showing higher burnout rates compared to faculty (51 vs. 31% p<.05) with poor morale and unrealistic expectations of faculty cited as major factors associated with burnout (Ofei-Dodoo et al., 2019). Although these two studies did not set out to assess leadership behaviors and burnout among physicians, they do demonstrate several facets of leadership that may require further exploration: the role of contingent rewards for services and the impact of the work environment on physician burnout. In another study of cardiologists, the Mini-Z inventory on burnout was given to measure emotional exhaustion and sent to 10,798 cardiologists, of which 2313 returned surveys. The rate of burnout was 23.7%% in this sample, with 73.2% not reporting burnout. Independent factors associated with burnout were the expected lack of control over workload, hectic work environment, misalignment of values, family responsibilities hindering professional work, intent to renegotiate for support staff, and insufficient documentation time. However, of interest was the finding that encouragement for a career in cardiology, positive modeling through mentorship, and fairness in treatment was associated with a lack of burnout (Mehta et al., 2019). These factors clearly indicate that the work environment is important and suggests that modeling, 49 mentorship, and a fair work environment are also important factors associated with improving physician burnout rates. These studies suggest that physician burnout may be associated with more than just transactional leadership in the form of pay for performance, but also may be related to issues of fairness in the workplace and role modeling from mentors and leaders. Self Determination Theory: How it relates to Burnout and Transformational Leadership The previous literature review covered a wide array of items and issues related to burnout and transformational leadership. To better understand the theoretical underpinnings of their relationship, an understanding of motivational needs of followers is needed to inform the current study as well as future studies relating to the topics of leadership and wellness. Self Determination Theory (SDT) is a human motivation theory that serves as a useful theoretical construct that frames the needs of individuals into three categories: autonomy, belonging or relatedness, and competence or self-efficacy (Leiter, 2017). In a recent update, the relationship of SDT to the workplace confirmed its usefulness and validity to outcome variables in the workplace such as performance and health and wellness (Deci et al., 2017). It further validated independent variables that relate to managerial or leadership influences on the workplace environment and categorized them as needs supporting or needs thwarting. This simple conceptualization links leadership behaviors (independent variables) to health and wellness (dependent variables) through the medium of basic needs satisfaction (autonomy, burnout, and competence) and support for autonomous motivation (Figure 1). 50 Figure 1 The Basic Self Determination Theory and Workplace Model Note. The Basic Self Determination model conceptualizes the workplace context as needs supporting or needs thwarting. Note that the independent variables such as transformational leadership behaviors can affect the work context and is placed as a needs supporting independent variable (see text). The mediators of these influences are basic needs satisfaction (autonomy, belonging, or competence) or motivations (autonomous or controlled). These two categories of mediators can be either satisfied or thwarted and can lead to success or failure in achieving health and well-being. Adapted from “Self Determination Theory in Work Organizations: The State of a Science,” by E.L Deci, A.H. Olafsen, and R.M. Ryan, 2017, Annual Review of Organizational Psychology and Organizational Behavior, 4(1), p. 23. (https://doi.org/10.1146/annurev-orgpsych-032516-113108). This model that links the factors influencing the work environment to the outcomes of performance and well-being through psychological needs and autonomous motivation has been evaluated and applied in several interventional studies. One study looked at an abbreviated eight 51 question transformational leadership safety questionnaire and correlated this with trust and autonomous motivation of employees at a construction site with the main performance related measured outcome being safety observing behavior (Conchie, 2013). The authors found that TFL behaviors that emphasized and communicated safety resulted in employees exhibiting and engaging in more safety behaviors at the worksite (performance outcome). This study further determined that the mediator of autonomous motivation of employees was related to employees’ trust in the leader that influenced a safe environment for employees to bring up safety issues in the workplace. In another study of 769 employees of a manufacturing company, a survey measuring transformational leadership behaviors and employee proenvironmental behaviors demonstrated that employees that felt values congruence with their leaders demonstrated greater amounts of proenvironmental behaviors and attitudes (Graves, 2013). These two studies demonstrated that the medium of autonomous motivation could link the effects of TFL on the work environment and performance outcomes. Studies linking TFL with work engagement and job autonomy have also been performed that show that the greater the perceived job autonomy of workers, the greater the work engagement of employees (Gozukara, 2015; Kovjanic, 2012). Therefore, multiple studies linking TFL to performance and wellness outcomes have been conducted that identify the mediating interplay of work area dynamics (values congruence, job or work autonomy, and trust), basic psychological needs satisfaction, and autonomous motivation as contributing components to employee wellness (Deci et al., 2017). In an attempt to further clarify and elucidate the components of the work environment that might mediate outcomes, Leiter developed a conceptual model that describes each work area in an employees work life and associates each with the components of SDT (autonomy, belonging, and competence) (Leiter, 2004). This model, known as the areas of worklife model 52 breaks down the areas of work life into six broad categories: workload, control, reward, community, fairness, and values (Figure 2). These work areas in turn align with the motivational needs described in SDT and thus provide a useful link to understand the work environment and how lack of satisfaction in one area of worklife tracks to an area of psychological need that needs fulfillment (Figure 2). This model has been tested and validated in multiple scenarios. One study evaluated the effects of improvement in workload management on self-efficacy and burnout in a cohort of Canadian and Spanish nurses. The results demonstrated that better workload management resulted in greater self-efficacy and less exhaustion with indirect beneficial effects on cynicism and inefficacy (Leiter, 2008). The study also demonstrated that the greater the values congruence between the organization and the workers in the work environment the less the emotional exhaustion, cynicism, and inefficacy perceived by nurses. The author’s interpretation of these results is consistent with the areas of work life model where better workload management improves feelings of competence (self-efficacy) and perceived values congruence affects all domains of burnout (autonomy, belonging, and competence). In another study of 2,536 Canadian physicians, a similar survey was completed on areas of worklife, and similar findings of less emotional exhaustion relating to a manageable workload and values congruence correlated with all domains of burnout (Leiter et al., 2009). Overall, these studies contributed to the development of a two-process model that relates lower emotional exhaustion to workload management (energy process) and a values process that directly links to all three domains of burnout. 53 Figure 2 Areas of Work life Model and Self Determination Theory Note. The categories of Self Determination Theory are conceptualized according to areas of worklife. Note that the values component of areas of worklife correspond to all three categorical needs of Self Determination Theory. Adapted from “Motivation, Competence, and Job Burnout,” by M.P. Leiter and C. Maslach, 2017, Handbook of Competence and Motivation, Second Edition, p.374. (ISBN: 9781462529605). Conceptual Framework Based on Self Determination Theory and its links to transformational leadership behaviors and outcomes, a conceptual model can be developed that relates independent variables (transformational leadership behaviors: Idealized influence and Individualized Consideration) and dependent variables (burnout). The areas of worklife model further conceptualizes the work environment based on six areas of worklife and is usefully placed in the workplace context on the side of the independent variables where needs supporting leadership behaviors such as TFL can exert beneficial effects on each of these components of the work environment. This effect then influences the satisfaction of the basic psychological needs of autonomy, belonging, and 54 competence as well as the support of autonomous motivation. After satisfaction of these needs and support of autonomous motivation, burnout can be influenced through an improvement in the three domains of burnout (Emotional Exhaustion, Depersonalization, and Self-Inefficacy). In a further refinement of the SDT and areas of worklife models, the two-process model is adapted to the TFL influences of Idealized Influence Behavior (IIB) and Individualized Consideration on both the energy process and the values process (Figure 3). Since these two domains of TFL included in this study exert their effects through the support of autonomy as well as belonging and competence, the two TFL domains (Idealized Influence and Individualized Consideration) are represented in both the energy process as well as the values process (Figure 3). In addition to the description of TFL’s effects on burnout, potential interventions (individual based interventions) at various points in the conceptual framework are highlighted that express the idea that when combined with TFL, individual based interventions, can lead to synergistically beneficial effects on burnout. For example, in addition to the beneficial effects of transformational leadership behaviors on the work environment, individualized interventions in improving coping and resilience can augment these initial effects and lead to further decreases in exhaustion of the employee or in this case, the physician work force. Another example would be the encouragement of participation in workplace communities that could augment the TFL behaviors that can further enhance values congruence and lead to greater amounts of lowered burnout. The current study addresses the relationship of the full range of leadership behaviors as defined by Avolio and Bass (1999) and burnout and further explores the effects of transactional leadership behaviors on burnout of physicians at an academic medical center. 55 Summary The existing literature demonstrates the mitigating effect of transformational leadership behaviors on burnout in industries and occupations other than those involving physicians. The studies of transformational leadership effects on physician burnout are mostly limited to a few correlational studies with the largest studies performed by a single institution in both trainees and practicing physicians. Therefore, the transferability of these leadership findings to physician burnout at other institutions remains to be proven. Furthermore, although these studies on burnout in physicians have shown a positive effect of the Individualized Consideration component of the transformational leadership model on physician burnout, no study looking at other domains of transformational leadership such as Idealized Influence Behaviors have been completed in the context of burnout. In addition, there remains the question as to whether transactional leadership can also mitigate burnout in physicians. This study seeks to assess the relationship of the entire spectrum of leadership behaviors from transformational to transactional leadership on physician burnout at an academic medical center. 56 Figure 3 Conceptual Framework of Transformational Leadership and Burnout Note. This conceptual model highlights the influence of two transformational leadership behaviors, idealized influence, and individualized consideration, on the three categories of burnout. The combined effects of these two transformational leadership behaviors exert their effects through the energy dynamic (highlighted in red and purple) and the values dynamic (highlighted in blue). Note the comparatively wider effect of the values dynamic on all domains of burnout as well as the interaction between the categories of burnout with each other. Because the categories of burnout affect each other, meeting the needs of workload through the energy dynamic can influence depersonalization and inefficacy. Adapted from “Motivation, Competence, and Job Burnout,” by M.P. Leiter and C. Maslach, 2017, Handbook of Competence and Motivation, Second Edition, p.375. (ISBN: 9781462529605). 57 Chapter Three: Methodology The purpose of this study is to identify physician leadership behaviors that correlate with physician burnout symptoms at an academic health center. It further seeks to understand how this academic health center’s physician faculty understands the burnout phenomenon and factors associated with burnout and those leadership behaviors that associate with burnout. Therefore, this study employed a mixed methods design that incorporated two components: a quantitative survey and a qualitative interview. The previous chapter reviewed the basic research questions of leadership behavior that are associated with burnout symptoms as well as those behaviors that are not. This methodology section describes the data sources, study participants, instrumentation, data collection processes, data analysis scheme, validity and reliability, and ethics of the study. Because this study relates two variables, the full range of leadership behaviors and burnout, a quantitative study design was employed using a survey distributed to the physician participants at this academic institution. It concurrently interviewed a sample of 10 physician faculty members using an independent interviewer (KK) not affiliated with AHU to preserve anonymity. A redacted transcript was provided to the investigator that removed any identifying information. Since physician burnout data had not been collected in the past at the institution being studied, document analysis was not available to inform the design of the study. In the next section, the positionality of the principal investigator of this study was discussed, including ways of mitigating the inherent biases associated with this positionality. The study was approved by the Institutional Review Board (IRB). 58 Research Questions 1. What is the baseline burnout rate of faculty at this academic institution? 2. Is there a relationship between perceived physician faculty leadership behaviors and physician faculty burnout? 3. Do demographic factors of the faculty population influence the relationship of leadership behaviors to burnout? 4. How does physician faculty understand burnout and those factors and sources related to burnout? 5. How does physician faculty understand leadership behaviors as it relates to burnout? Overview of Methodology The purpose of this study is to assess the baseline burnout rate at this academic medical center and to correlate physician leadership behaviors to physician burnout. It also explores how the physician faculty understands the meaning of burnout, the factors and sources related to burnout, and the leadership behaviors that are exhibited in relation to burnout. The site of this study is a large metropolitan academic medical center that is composed of three major hospitals whose core physician activities involve clinical, educational, and research areas. The quantitative survey component of the study was distributed to all faculty physicians who were involved in health care at AHU. The Pediatric Department was excluded from this sample, since almost all pediatric faculty members practiced at a hospital that was not part of AHU’s organization. The data collection method used a 50-question survey that included the full 22 item Maslach Burnout Inventory and a modified version of the Multifactor Leadership Questionnaire (MLQ-5X) (24 items) (Avolio, 2004; Maslach, 2018). The modified MLQ-5X survey included two categories of transformational leadership behaviors, Idealized Influence Behaviors (IIB) and Individualized 59 Consideration (IC) and excluded the Inspirational Motivation, Intellectual Stimulation, and Idealized Influence Attributes components of the full MLQ-5X questionnaire. The survey’s question items were not altered, and the modified version only excluded those categories described above. In addition to the MBI and modified MLQ-5X survey questions, four demographic questions were also included (Appendix A). The quantitative survey on burnout (Maslach Burnout Inventory) was chosen because of its prior reliability and construct validity as applied to multiple health care scenarios including private, public, and academic institutions. In addition, extensive use has established a national standard of reference for burnout rates to which the results of this study could be compared. Therefore, in addressing the first research question, the Maslach Burnout Inventory provided a validated and reliable instrument to measure baseline burnout rates amongst physicians in an academic environment and can be compared to national standards that include health care organizations. In addressing the second research question (Is there a relationship between perceived physician leadership behavior and physician burnout?), a modified MLQ-5X version of the Full Range of Leadership Model was used to distinguish transactional leadership behaviors and transformational leadership behaviors. This model was chosen for three reasons: first, the full range of leadership model captures several leadership behaviors that include the entire spectrum of leadership behaviors; second, the model conforms well to the conceptual framework derived from Self Determination Theory; and third, the model has been extensively studied in the field of burnout with internal reliability and validity measured and validated extensively in previous studies. The modified MLQ-5X survey containing six categories of leadership behaviors consisting of four question items each were not altered in the current study and therefore the prior reliability and discriminant validity would also apply to this modified version. 60 The third research question (Do demographic factors of the faculty population influence the relationship of leadership behaviors and burnout?) was addressed with four additional demographic questions in the 50 questions survey (Table 1). These included sex, age, years of practice after training, and type of specialty practice. The fourth and fifth research questions focus on how faculty physicians at AHU understand the meaning of burnout, the factors associated with burnout, the sources of burnout, and how leadership addresses burnout. The five interview questions and follow up questions were designed to help elucidate how faculty experience burnout and how they perceive how their leaders intervene to address the problem. The interview questions are as follows: • What does burnout mean to you? • What factors lead to or are associated with burnout? • What are the sources of these burnout factors? • What has leadership done to address burnout? • If you had five minutes to advise your leaders on burnout, what would you say? These interview questions were delivered and conducted by an independent interviewer (KK) who was not affiliated with AHU. The interviewer was instructed to redact the transcript for any identifying information and to deliver the redacted transcript to the principal investigator of the study. The process of selection for interviewees used a random online number generator that provided 70 numbers. These numbers were correlated with a corresponding faculty member’s number from a list of 1145 faculty members who were consecutively numbered on a data sheet provided by the Dean’s office. An email request was sent to these randomly selected faculty members and given the email address of the independent interviewer. The identities of ten voluntary participants were not revealed to the principal investigator. The interviews were 61 captured on Zoom videoconferencing platform (Zoom Video Communications Inc., 2020) and the recordings were stored separately in a secure platform space that was not accessible to the principal investigator. This study was approved by the Institutional Review Board. Table 1 Data Sources for Research Questions Research questions Survey Survey Survey Interview RQ1 Quantitative MBI RQ2 Modified MLQ-5X Quantitative MBI RQ3 Modified MLQ-5X Quantitative MBI Demographic Survey RQ4 Semi-Structured Interview RQ5 Semi-Structured Interview 62 The Researcher As I am both the principal investigator of this study and a senior faculty member within the organization, several disclosures are needed. As the fellowship director of one of the medicine programs, inherent biases may surface that relate to leadership behaviors of Chiefs or Chairs that might influence the interpretation of data. This bias would be especially evident in the interpretation of the qualitative interviews as I may favor certain leadership behaviors over others and choose to include them in the results. This bias was overcome by having multiple sources evaluating the data that include the independent interviewer member checking for accuracy. Because the study examined leadership behaviors of immediate supervisors who generally underwent little leadership training, assumptions by me that physicians require more leadership training could bias the design of the study and the questions selected in the questionnaire. This could represent a confirmation bias as defined by Nickerson (1998) as the researcher could have a bias toward existing information that describes physician leaders as having certain characteristics that impede leadership development (Stoller, 2009). In this study it could bias the interpretation of the data as my inherent bias that physician leaders are transactional as opposed to transformational could impede results and interpretation. This concern is largely reconciled by the distribution of the questionnaire and interview requests to all participants at AHU and the quantitative nature of the study that is randomly distributed and anonymized as to identifying information. Other quantitative research biases are mitigated through the use of two questionnaires that are well validated and reliable with minimal alteration as discussed previously. The Maslach Burnout Inventory questionnaire was given with no modification. The modified Full Range of 63 Leadership Model questionnaire only excluded three categories of leadership behaviors, but the remaining six categories regarding content or subscale measurement were unaltered. The reasons for modification were solely for purposes of brevity to enhance participation rates as incorporating the entire 36 question survey may result in fewer participants. My position as a program director could bias my perception that residents and fellows are more burned out than faculty members. Although the participants in this study were all post training members, junior faculty members could be construed as being more burned out than others, therefore analysis could extensively focus on this subgroup that could influence the selection of data to report. This bias can be overcome by the having several researchers from the doctoral program read the data and comment on any biases that may be discordant with the results. In addition, the qualitative component of the study is anonymized so that characterization and identification of the participants being interviewed is not possible (i.e., age of participant or post training experience). Data Sources The data sources were drawn from a sample of 305 responding physician faculty who answered a survey that was distributed to 1,145 faculty members at AHU. The surveys were distributed to all 1,145 faculty members identified in a roster of all faculty provided by the Dean of the School of Medicine’s office and requests for interviews were conducted from a randomly selected group of participants as described previously. More detailed descriptions of the study methods will follow in subsequent sections. Method 1: Survey The email addresses of physicians were identified through a global email address list provided by the Dean of the School of Medicine’s office. The list was modified to reflect only 64 those faculty members who were part of AHU. Since the Pediatric department practiced outside of AHU, those faculty members were excluded from the study. A fifty-item questionnaire was distributed by email through the Qualtrics portal with an accompanying introductory paragraph that described the purpose of the survey, the intended audience, and simple instructions on completion of the survey. In addition, a statement of Institutional Review Board approval accompanied the instructions (Appendix B). Participants The participants in this study consisted of faculty physicians at an academic medical center. This represented a random sample of physician participants as defined by Creswell (2018) since each participant in this sample had an equal chance of participating in the study. The total number of participants to which questionnaires were distributed was 1,145 faculty members. The participants belonged to all 18 clinical departments except pediatrics and excluded physicians in formal positions of authority such as the chief, chair, dean, and center director levels of leadership. The reason for exclusion of pediatricians was due to their lack of affiliation with AHU. Instrumentation The two instruments used for the quantitative survey included the 22-item Maslach Burnout Inventory, a modified version of the Multi-Leader Questionnaire (MLQ-5X), and four demographic questions. This modified MLQ-5X also known as the full range of leadership model, consisted of 24 question items that corresponded to 6 categories of leadership: Idealized Influence Behaviors (IIB), Individualized Consideration (IC), Contingent Reward (CR), Management by Exception Active (MBEA), Management by Exception Passive (MBEP), and Laissez-Faire (LF). These questions were combined into one survey that included four 65 demographic questions (Appendix A). The items and subscales in each of these categories were not changed and therefore the established reliability was preserved. The rationale for selecting the Maslach Burnout Inventory is its external reliability in health care workers and its internal validity and external validity across industries (Mind Garden, 2018). The types of questions in the MBI discriminate three components of burnout and include: emotional exhaustion, depersonalization, and loss of efficacy or competence. The MBI-HSS (Health Services Survey) is the validated survey that was used and expresses the category of loss of efficacy or competence as lack of accomplishment. The ratings scale of each question and domain are standardized across industries and therefore findings in this study could be compared to a normative sample of similar institutions. The interview questions also answer questions and issues directly surrounding the practice of clinical medicine in terms of emotional exhaustion, depersonalization, and lack of accomplishment. The MLQ-5X also known as the full range of leadership model similarly has internal construct validity as it relates to discriminating transactional leadership behaviors from transformational leadership behaviors. In a study by Avolio (1999), the discriminant validity of the MLQ questionnaire of each of the types of leadership behaviors were significant for all domains of the questionnaire except for the Individualized Consideration domain and Contingent Reward domain (see further discussion in section on validity and reliability). The non- discriminant validity of these two domains, one belonging to the transformational domain and one belonging to the transactional domain, was one of the major criticisms of the model. When the model was tested using a three-factor model that grouped the higher order transformational factors (Idealized Influence, Inspirational Motivation, and Intellectual Stimulation) and compared it to the second higher order factors (Developmental Exchange) that consisted of 66 Individualized Consideration and Contingent Reward leadership, the discriminant validity of these groupings was confirmed (Avolio, 1999). This led to a three-factor conceptualization of the full range of leadership model that included Inspirational Motivation, Idealized Influence, and Intellectual Stimulation as one aggregate category, Individualized Consideration and Contingent Reward into a development exchange category, and Management by Exception Active, Management by Exception Passive, and Laissez Faire leadership as lower transactional categories. In the only physician study on transformational behaviors and burnout where leaders were evaluated by non-leader physicians, the use of Individualized Consideration was the primary domain used that correlated with less burnout (Shanafelt, 2016). Of interest, this study noticeably excluded all the first higher order factors Idealized Influence, Inspirational Motivation, and Intellectual Stimulation) as well as the other transactional leadership behaviors such as Management by Exception Active, Management by Exception Passive, and Laissez Faire leadership behaviors. Therefore, the current study that included one higher order leadership behavioral category, Idealized Influence Behavior, and the developmental domain (IC and CR), as well as the lower transactional leadership domains adds new information to the growing body of literature on physician leadership behaviors and burnout. Data Collection Procedures The survey was distributed between April and May 2021. The method for administering the survey followed the suggested procedures of Creswell (2018) and was completed in one months’ time. An initial email was sent to 1,145 faculty members and consisted of a short preamble describing the background and intent of the survey and brief instructions for completion (Appendix B). The second email reminder was sent one week later with an update on the initial response to the survey. A third email distribution occurred one week later indicating 67 the progress and closure date of the survey. A final email distribution was sent one week later indicating the closure date of the survey. These email distributions were conducted using the Qualtrics distribution platform. The qualitative component of the study was conducted on the Zoom platform. The independent interviewer conducted the interview on a protected Zoom account and the files were securely stored. The storage, confidentiality, and disposal of the videos and transcripts conform to IRB guidelines at AHU. Out of 70 randomly selected faculty members from a list of faculty members provided by the office of the Dean of Medicine, an open and voluntary appointment was arranged with ten interviewees with the independent interviewer. The 30-minute interview was conducted anonymously by the interviewee and only a redacted transcript was provided to the principal investigator. The transcript was redacted by the interviewer for any identifying information. Data Analysis The survey variables assessed were expressed as means with standard deviations calculated for each item. These variables were compared using appropriate correlative statistics using the Qualtrics platform and analyzed for effect size and statistical significance. A multivariate analysis using SPSS software was used to analyze demographic factors and its effects on the relationship of the burnout categories (dependent variables) and leadership categories (independent variables). The Quantitative Measurements of Research Questions table identifies the independent and dependent variables to be measured for each research question (Table 2). In addition, the table identifies the statistical tests that were used to analyze correlations between the variables. 68 The interview transcripts were organized, coded, and analyzed using an iterative method. The ATLAS.TI 9 qualitative data analysis software (ATLAS.TI 9 Windows, 2021) was used to collect, store, code, and analyze the transcripts for themes that best describe the understanding of burnout and leadership of the participants. 69 Table 2 Quantitative Data Analysis Plan Research Question Independent Variable Level of Measurement Dependent Variable Level of Measurement Statistical Test What is the baseline rate of burnout? N/A Maslach Burnout Inventory Proportion calculation To what degree do leadership behaviors correlate with burnout? Multifactor Leadership Questionnaire Maslach Burnout Inventory Pearson coefficient What are the relationships of various demographic factors to burnout? Demographic questions on questionnaire and Multifactor Leadership Questionnaire Maslach Burnout Inventory Multivariate regression analysis Validity and Reliability The internal validity and reliability of both the Maslach Burnout Inventory and the Multi- Leadership Questionnaire-5X have been studied and confirmed across industries and countries in previous studies (Avolio, 2004; Maslach, 2018)). Reliability for this study was insured with adherence to collection methods and processing of data into a de-identified data base using standardized procedures in the Qualtrics platform. The internal reliability or consistency of this quantitative study followed strict adherence to the uniformity of collection methods and documented the population being studied and reported any alterations in methods including any new IRB amendments that significantly affected the design of the study. 70 Clear communication with instructions on survey completion and especially emphasizing the evaluation of the physician supervisor’s leadership behaviors will be made clear in the instructions to reduce ambiguity as to whose leadership behaviors are being surveyed. Although the construct validity of the full MBI has previously been described, shorter versions have also been validated in studies in health care (West et al., 2012). For physicians, measurement of single items in two burnout domains, emotional exhaustion, and depersonalization, has been shown to correlate well with the entire 22-item MBI; however, in this study all 22 items of the MBI will be used mainly because the accomplishment or competence domain is an important part of the conceptual framework of this study. External validity for the full range of leadership model (MLQ-5X) has been demonstrated in many studies ranging from outcome studies of military effectiveness in combat scenarios to acceptability of the legitimacy of coordinators in health care environments (Bass, 2000; Molero, 1994). Because previous studies demonstrated a question of discriminant validity between Individualized Consideration (a transformational leadership domain) and Contingent Reward (a transactional leadership domain), the three-factor model that separates higher order transformational domains from the developmental/contingent reward domain was developed (Avolio, 1999). This model identified three categories of behaviors: Transformational, which included idealized influence, inspirational motivation, and intellectual stimulation; Developmental Exchange, which included Individualized Consideration and Contingent Reward, and Corrective/ Avoidant, which included Management by Exception Passive and Active plus Laissez Faire leadership behaviors. Although this three-factor model showed better discriminant validity, Avolio (1999) still maintained that the original six factor model should be kept with the understanding that contingent reward may represent a higher order transactional leadership 71 behavior that forms a basis for trust as the consistent abiding to promises inherent in contingent reward can reach higher order intrinsic motivations beyond just transactional exchanges. Based on these findings of the construct validity of the full range of leadership model, an abbreviated MLQ-5X questionnaire that does not modify the content or subscale measurements of the categories was used to measure leadership behaviors. As the previous construct of the question items and subscales of each leadership category are unaltered, previous internal reliability and validity studies that establish the trustworthiness of the scale would apply to this abbreviated version. The Idealized Influence Behavior and Individualized Consideration components that align with the conceptual framework of this study, are unaltered as are the remaining four transactional leadership components of the MLQ-5X. Since values congruence is an important part of the conceptual model of this study, Idealized Influence Behaviors with its question items regarding values was chosen as a transformational leadership behavior along with Individualized Consideration. The qualitative interviews were validated through multiple methods including the use of different methodologies (i.e., data from quantitative survey), use of theory including Self- Determination Theory undergirding the Maslach Burnout Inventory, and source checks (committee chair, interviewer, and colleagues). In addition, where needed member checks, followed to help clarify meaning and intent of the interview narratives. Ethics My responsibility to the participants was to ensure that they understood the voluntary nature of the study and that all measures to protect participant’s anonymity were upheld. In addition, the principles as outlined in the code of ethics governing research as stipulated by the American Educational Research Association (AERA) were followed. These include maintaining 72 confidentiality and anonymity of participants, safe and anonymized storage of data with de- identification of participant’s data, discussion of possible uses of the information collected, verification of the IRB process with the sponsoring institution, and full disclosure of any conflicts of interest (Association, 2011). Because of the nature of this study where participants are rating their supervisors, strict adherence to anonymity was followed with the design of the study to include all non-surgical and surgical specialties that ensured any identifying demographic data was redacted. Specifically, since I am a senior faculty member in the Department of Medicine and the Program Director of one of the medicine programs, voluntary participation was emphasized in the preamble to the survey. The qualitative interview component of the mixed methods study was conducted by an independent interviewer who is not part of this institution and who has no conflict of interest with AHU or me. 73 Chapter 4: Results and Findings The results and findings of the study are reported in five main sections aligning with the study’s five research questions. The first three research questions are answered primarily through quantitative data. The fourth and fifth research question are answered primarily through qualitative data. The first section presents the results in answer to the first research question, what is the baseline burnout rate at AHU? It will include demographic data and response rates of the survey and will mainly consist of descriptive statistics. The baseline burnout rates are expresssed both as as a mean score for the sample and a percentage rate above a commonly accepted cutoff level that defines burnout. The second section includes mainly quantitative data and answers the second research question: to what degree do leadership beahaviors correlate with burnout? Because the findings demonstrate statistically significant correlations between almost all aspects of the the full spectrum of leadership behaviors and all domains of burnout, this section is presented in three tables corresponding to each dependent variable, emotional exhasution, depersonalization, and personal accomplishment. The third section analyzes the results of demographic factors and its inflluence on the leadership behaviors and burnout relationship using mutlifactorial analysis. This section includes graphic depictions of the relationships between burnout categories and leaderhip behaviors according to sex and age group. The fourth section aligns with the fourth research question: How does AHU understand the meaning, factors, and sources related to burnout. Because the qualitative interviews for this research question were broken down into three interview questions, this section will be categorized by the three areas of content of the reseach questions: meaning, burnout factors, and burnout sources. The final section that focuses on how faculty understand leadership behaviors 74 as it relates to burnout focuses on two subections aligning with the two interview questions: Leadership Behaviors Demonstrated and Leadership Behaviors Desired. The fourth and fifth sections consist of mostly qualitative data and will be expressed by tables categorizing the prevaling themes extracted from the 10 interview participants. Response Rate and Demographics of Participants Between April 12 th , 2021 and May 7 th , 2021, 1,145 surveys were distributed to faculty physicians at AHU, and 305 were completed for an overall response rate rate of 26.6%. The demographic groups are shown in Table 3: the physicians identifying themselves as belonging to medical practice was 56.7% compared to 23.6% identifying as surgical and 19.7% identifying as other. The age groups showed an equal number of faculty that were 0-6 years out and over 19 years out of their training with considerably fewer particpants in the 7-12 or 13-18 year categories. There were more male respondents compared to female respondents (51.8% vs. 44.3%). The age groups most highly respresented were between ages 40-55 with the 56 and older age group being least represented (42.6% vs. 25.2%, respectively). The demographic proportions of the entire population of AHU faculty are presented in bold type in Table 3 (E. Whalen, personal communication, July 19, 2021). As shown, there was a slightly greater proportion of female faculty in the sample compared to the overall AHU population (Table 1). The rest of the demographic data showed a slight over representation of faculty who identified as surgery and slightly greater proportion in the 40-55 year old age group compared to the AHU population. No data were available for years of practice after training; therefore, no demographic comparsion was made to the total population at AHU. 75 Table 3 Demographic Statistics of Respondents (N = 305) Note: The percentages of the sample and AHU population are depicted in parentheses above with the AHU population percentages depicted in bold. Data for years of practice post training were not available. NA=Not Availaible. Characteristics Category n (% of N) Age group 25-39 (yrs) 40-55 (yrs) 56 or older (yrs) 98 (32) (40) 130(43) (38) 77 (25) (22) Practice category Medical Surgical Other 173 (57) (55) 72 (24) (32) 60 (19) (13) Years of practice post training 0-6 (yrs) 7-12 (yrs) 13-18 (yrs) 19 years or more (yrs) 97 (32) (NA) 59 (20) (NA) 49 (16) (NA) 98 (32) (NA) Sex Male Female Prefer Not to Say 158 (52) (62) 135 (45) (38) 8 (3) (NA) 76 Baseline Burnout Rate at AHU (RQ1) The baseline burnout score is depicted in Table 4 and expressed as a mean score for each of the categories of burnout. It is important to note that there is not an absolute mean cut off score that proves a group or individual is burned out. Instead mean scores and percentages of participants scoring above a certain score were used for comparison across normative samples and are included in this analysis for reference. The sample mean represented in the parentheses of Table 4 is a normative sample taken from a sample of health care organizations who took the Maslach Burnout Inventory-Health Services Survey and includes their standard deviations (Maslach, C. etal., 2018). The summative method was used where the scores of each item corresponding to each category are summed into a total score and reported as the sum of all the items. For example, emotional exhaustion consists of nine items and each item is scored on a 7-point scale ranging form 0 to 6. Therefore, the score range for emotional exhaustion would be 0-54, for depersonalization, which contains five items with a range of 0-30, and personal accomplishment with its eight items scores in a range of 0-48. The emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA) scores were expressed using the summative method with each category of burnout expressed as the sum of the items in the survey corresponding to each category. It is standard that each category score be reported separately and not as a composite score of all categories (i.e sum of EE + DP + PA). It is also important to note that higher scores on the EE and DP categories correspond to higher burnout and lower PA scores correspond to higher burnout. The mean emotional exhaustion score at AHU was higher compared to the mean “sum” score of a comparative sample of health care organizations in the United States. As shown in 77 Table 4, the mean emotional exhaustion score at AHU is higher compared to mean scores of a normative sample of similar instituitions in the United States (25.4 vs. 22.1, respectively). The means of the depersonalization and personal accomplishment categories were similar to those compared to the national means of the same comparative sample. Therefore, AHU seems to have a higher burnout rate, which is largely driven by emotional exhausiton when compared to a comparative sample of health care organizations in the United States. Table 4 Mean Baseline Burnout Rates at AHU Burnout domain N M SD 95% CI [LL-UL] Emotional Exhaustion (EE) 217 25.4 (22.1) 13.9 (9.53) 23.55-27.23 Depersonalization (DP) 274 6.4 (7.1) 5.9 (5.22) 5.69-7.08 Personal Accomplishment (PA) 266 35.8 (36.5) 8.0 (7.34) 34.85-36.76 Note: The mean score from the study are presented with its standard deviation and 95% confidence intervals shown in the respective columns. The mean scores and standard deviations from a normative sample of large health care institutions in the United States are shown in parentheses. The confidence intervals were not included in the comparative sample. From C. Maslach, S.E. Jackson, M.P. Leiter, W.B. Shaufeli, R.L. Schwab, 2018, Maslach Burnout Inventory Manual, Fourth Edition, p.25 (www.mindgarden.com). 78 In analyzing the emotional exhaustion (EE) score further, the percentage of respondents showing a score of 27 or greater was 45% and those showing a score of greater than 36 was 25%. The burnout literature typically does not include percentages of participants scoring 36 or greater in their reporting; however, this score is included in this analysis since it corresponds to the burnout scale frequency of one time per week (Maslach, 2018). The summative score of greater than 27 is commonly defined as burnout based on comparative data with healthcare institutions and based on tertiles that cuts off the top tertile at 27 or above (West et al., 2018). In a univariate analysis of demographic factors of the sample at AHU as it relates to emotional exhaustion, age group and sex demonstrated a significant difference in the means. The age group greater than 56 showed a lower mean burnout score compared to the 25-39 and 40-55 year old age groups (EE score of 21.3 compared to 27 and 26 respectively, p< 0.1), and females showing a higher mean emotional exhaustion score than males ( EE score 27.3 vs 23.9, p<0.1). The depersonalization (DP) category as measured at AHU scored a mean that was slightly below the mean of other health care organizations in the same normative sample described in the emotional exhaustion section and in Table 4. However, the percentage of faculty respondents who scored 10 or greater was 25%. In analyzing further the number of faculty who scored below 27 in EE, but 10 or above in DP, an additional 13 faculty members were identified. In combining the percentage of faculty who scored 27 or higher in EE with those that scored 10 or higher in DP (excluding those that scored 27 or higher in EE) a composite burnout rate of 53% was determined at AHU. Therefore despite the relatively modest mean DP scores, 25% of faculty at AHU would qualify as burned out since 25% of faculty had a DP score of 10 or greater. The personal accomplishment (PA) mean score of 35.8 was slightly below the mean of the normative mean used in this study. The cutoff score of 33 or below was used as the threshold 79 for burnout from the compartive literature (West et al., 2018). Analysis of the percentage of faculty that scored 33 or below in personal accomplishment in this study showed a rate of 31%. Because this measure is seldom used for comparison in physician studies of burnout, further subcategorization was not carried out, and the scores were not added to the EE and DP scores. In summary, the baseline burnout rates at AHU are higher than national means of similar institutions in the United States for EE, but not for DP and PA. The national mean score for EE, based on a more recent sample of physicians, was 23.2 and DP was 6.8 (Shanafeltet al., 2019). The proportion of burned out physician faculty at AHU, based on cut off scores of greater than or equal to 27 in EE and greater than or equal to 10 in DP, was 53%. Of note, comparative studies of burnout rates in the United States that measure a combined burnout score that includes EE and DP show an average score of 43.9% (Shanafelt, West, et al., 2019). Therefore, AHU rates higher both in mean burnout scores for EE and percentage of faculty that are burned out compared to national samples. Degree of Association Between Leadership Behaviors and Burnout (RQ2) The leadership categories for the modified full range of leadership model included in this study were: Idealized Influence Behavior (IIB), Individualized Consideration (IC), Contingent Reward (CR), Management by Exception Active (MBEA), Management by Exception Passive (MBEP), and Laissez Faire (LF). A detailed description of the validity and reliability of the adopted scales used in this study is located in Chapter 3. These six leadership categories were analyzed for their relationship to each of the categories of burnout: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). The findings are shown in Tables 5, 6 and 7. The sub-sections below discuss the results of the quantitative analysis examining the relationship between the full range of leadership model categories and the three categories of 80 burnout: Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA). 81 Leadership Behaviors and Emotional Exhaustion As shown in Table 5, the relationship of EE with all categories of leadership behaviors were highly statistically significant. Idealized Influence Behavior (IIB), Individualized Consideration (IC), and Contingent Reward (CR) all correlated significantly with lower emotional exhaustion (EE). Furthermore, the effect size as measured by the Pearson Coefficient showed moderate effect sizes that ranged from – 0.425 for Contingent Reward (CR) behavior to – 0.387 for Individualized Consideration (IC) with Idealized Influence (IIB) showing an effect size between these two variables (-0.393, p < .00001). Management by Exception Active (MBEA) also had a smaller but significantly negative correlation with EE (Effect Size - 0.217, p=.002). The lower level leadership behaviors of MBEP and LF, both showed positive correlations with EE (i.e. MBEP and LF correlated with higher burnout scores). Management by Exception Passive (MBEP) showed a small but significant correlation with greater EE, and Laissez Faire leadership behaviors demonstrated a higher effect size on EE (0.225, p = .001 and 0.344, p <.00001, respectively). This study’s results indicate transformational leadership behaviors (IIB and IC) correlated with all domains of burnout as did one transactional leadership behavior, CR. Management by Exception Active (MBEA), another transactional leadership behavior, showed a weaker but statistically significant beneficial effect on emotional exhaustion (EE). The lower transactional level behaviors of MBEP and LF had a positive association with EE. 82 Table 5 Association of Emotional Exhaustion and Leaderhip Behaviors (N = 217) Leadership behavior Effect size (Pearson’s r) p value 95%CI effect size Idealized Influence (IIB) -0.393 p < 0.00001 -0.503-to -0.271 Individualized Consideration (IC) -0.387 p < 0.00001 -0.497 to –0.265 Contingent Reward (CR) -0.425 p < 0.00001 -0.531 to -0.306 Management by Exception Active (MBEA) -0.217 p = 0.002 0.345 to 0.081 Management by Exception Passive (MBEP) 0.225 p = 0.001 0.089 to 0.353 Laissez-Faire (LF) 0.344 p < 0.0001 0.215 to 0.461 Note: This table shows the association of Emotional Exhaustion (EE) with leadership behaviors using the full range of leadership model. Idealized Infuence (IIB), Individualized Consideration (IC), and Contingent Reward (CR) showed negative correlations with Emotional Exhaustion. Management by Exception Passive (MBEP) and Laissez-Faire (LF) showed positive correlations. Management by Exception Active (MBEA) showed a smaller, but statistically significant, positive correlation with Emotional Exhasution. Leadership Behaviors and Depersonalization In examining associations with Depersonalization (DP), leadership behaviors showed a similar pattern as EE (Table 6). As shown, the negative association with DP was true for IIB, IC, and CR with moderate effect sizes of -0.330, -0.339, and -0.45, respectively, and all were highly statistically significant (p < 0.00001). As opposed to EE, MBEA behavior was not statistically significantly correlated with DP (p = 0.16). Similar to the relationship with EE, MBEP and LF behaviors showed positive effects on DP with effect sizes of 0.341 and 0.374 that were highly 83 statistically signficant (p < .00001). Therefore, the effects of the transformational leadership behaviors of IIB, IC, and the transactional leadership behavior CR correlated with favorable effects on the Depersonalization category of burnout, and lower level transactional leadership behaviors had either no effect or had an unfavorable effect on the Depersonalization category of burnout. Table 6 Association of Depersonalization and Leaderhip Behaviors (N=274) Leadership Behavior Effect Size (Pearson’s r) p value 95% CI Effect Size Idealized Influence (B) -0.330 p < 0.00001 -0.434 to -0.217 Individualized Consideration -0.339 p < 0.00001 -0.496 to -0.292 Contingent Reward -0.345 p < 0.00001 -0.448 to -0.233 MBEA -.0885 p = 0.16 -0.209 to 0.035 MBEP 0.341 p < 0.0001 0.277 to 0.445 LF 0.374 p < 0.0001 0.262 to 0.475 Note: This table shows the association of Depersonalization with Leadership Behaviors. Idealized Infuence (B), Individualized Consideration, and Contingent Reward showed negative correlations with Depersonalization while MBEP and LF showed positive correlations. MBEA = Management by Exception Active, MBEP = Management by Exception Passive, LF= Laissez- Faire. 84 Leadership Behaviors and Personal Accomplishment Personal Accomplishment (PA) scores also followed a similar pattern as with EE and DP. The effect sizes of IIB, IC, and CR were comparatively weaker on PA than their effect sizes on EE and DP, but were still highly statistically significant (p < .00001). The leadership behavior of MBEA, similar to its association with DP but in contradiction to its association with EE, showed no statistically significant correlation with PA. The two lower level leadership behaviors, MBEP and LF, showed a smaller (compared to EE and DP), but significant, negative correlation with PA (greater burnout). Therefore, as expected and predicted by the conceptual framework, transformational leadership behaviors IIB and IC correlated with lower burnout scores (positive correlation with PA) in the category of PA. Management by Exception Active (MBEA), also as expected, had no effect, and the lower level transactional behaviors (MBEP and LF) correlated with higher burnout scores (i.e. negative correlation) in the PA category. Contingent Reward (CR), again unexpectedly, correlated with a lower burnout score for PA (i.e. positve correlation). 85 Table 7 Association of Personal Accomplishment and Leadership Behaviors (N = 266) Leadership Behavior Effect Size (Pearson’s r) p value CI Effect Size Idealized Influence (B) 0.293 p < 0.00001 0.177 to 0.401 Individualized Consideration 0.277 p < 0.00001 0.161 to 0.386 Contingent Reward 0.291 p < 0.00001 0.175 to 0.399 MBEA 0.107 p = 0.0894 -0.016 to 0.227 MBEP -0.158 p = 0.0121 -0.276 to -0.0349 LF -0.173 p = 0.006 -0.291 to -0.0498 Note: This table shows the association of Personal Accomplishment with Leadership Behaviors. Idealized Infuence (B), Individualized Consideration, and Contingent reward showed positive correlations with Personal Accomplishment while MBEP and LF showed negative correlations. MBEA = Management by Exception Active, MBEP = Management by Exception Passive, LF= Laissez-Faire. Summary In conclusion, IIB, IC, and CR all correlated negatively with two categories of burnout (EE and DP), and MBEP and LF correlated positively with the same two categories. These findings are consistent with the predictions of the conceptual framework discussed in Chapters 2 and 3 where the two transformational leadership behaviors, IIB and IC, would translate to lower burnout scores whereas transactional leadership behaviors would either have no effect or worsening effects on burnout categories. 86 However, the consistent beneficial effects of CR, a transactional behavior, on burnout was not predicted by the conceptual model, but was consistent with the three factor construct discussed in the methods section where CR segregated with IC in previous confirmatory factor analyses (Avolio, 1999). Similar to IIB and IC, CR exerted similar effects on all categories of burnout as the two transformational leadership behaviors evaluated. The leadership behavior labeled Management by Exception Active (MBEA) correlated negatively with EE as well, but MBEA had no association with DP or PA. Thus although, one cannot rule out the possibility that MBEA may truly correlate with less burnout at AHU, its relationship is weaker and only was signficant with one category of burrnout. Therefore, the correlational findings only partially support the conceptual model as, at AHU, despite the strong correlations of two higher order leadership behaviors with lower burnout and the strong correlations of lower level transactional leadership behaviors with more burnout. The associations of Contingent Reward and Management by Exception Active with favorable effects on burnout were unexpected. In answer to research question number two, data from this study suggests a beneficial relationship of transformational leadership behaviors on burnout and a detrimental effect of lower level transactional leadership behaviors on burnout. In addition, favorable relationships with burnout are suggested with CR behaviors. Management by Exception Active has mostly no relationship with burnout, but in this study a small beneficial effect was seen with one category of burnout Emotional Exhaustion. The research question overall was answered in the affirmative as leadership behaviors have a strong relationship with burnout: both transformational leadership behaviors (IIB and IC) and one transactional leadership behavior (CR) strongly correlated with less burnout, and the lower transactional leadership behaviors correlated with greater burnout. 87 Demographic Effects on the Leadership Burnout Relationship (RQ3) The demographic variables that showed a statistically significant difference on the univariate analysis for emotional exhaustion were analyzed for their effects on the relationship between burnout categories and leadership behaviors. The two demographic factors that were statistically significantly different in the emotional exhaustion domain of burnout scores were: sex (male vs. female) and age group (three categories: 56 or older, 25-39, and 40-55). These two demographic factors were analyzed using a multifactorial regression analysis. The findings are shown in Figures 4-9. The figures represent the relationship of leadership behaviors and burnout categories broken down by sex and age groupings. When comparing the groups, there was no statistically significant difference between the groups with regards to the correlation of burnout scores and leadership behaviors, except for Depersonalization (DP) where the leadership behavior of MBEP showed a statistically significant higher correlation in females compared to males (p =.028). Othewise demographic variables did not seem to affect the relationship between leadership behaviors and burnout. 88 Figure 4 Relationship of Emotional Exhaustion and Leadership Behaviors by Sex (N = 217) Note: This figure shows the relationship between leadership behaviors and Emotional Exhaustion according to sex. There was no statistically significant difference in the Emotional Exhaustion and leadership behavior relationship when comparing males and females. 89 Figure 5 Relationship of Depersonalization and Leadership Behaviors by Sex (N = 274) Note: This figure shows the relationship between leadership behaviors and Depersonalization (DP) according to sex. There was a significant difference in the Depersonalization (DP) and leadership behavior relationship between males and females for Management by Exception Passive (MBEP). All other leadership behaviors showed no difference in their relationship to depersonalization between males and females. 90 Figure 6 Relationship of Personal Accomplishment and Leadership Behaviors by Sex (N = 266) Note: This figure shows the relationship between leadership behaviors and Personal Accomplishment (PA) according to sex. There was no significant difference in the Personal Accomplishment (PA) and leadership behavior relationship between males and females. 91 Figure 7 Relationship of Emotional Exhaustion and Leadership Behaviors by Age Group (N = 217) Note: This figure shows the relationship between leadership behaviors and Emotional Exhaustion (EE) according to age group. There was no significant difference in the EE and leadership behavior relationship between age groups 56 and older and younger than 56. 92 Figure 8 Relationship of Depersonalization and Leadership Behaviors by Age Group (N = 266) Note: This figure shows the relationship between leadership behaviors and Depersonalization (DP) according to age group. There was no significant difference in the DP and leadership behavior relationship between age groups 56 and older and younger than 56. 93 Figure 9 Relationship between Personal Accomplishment and Leadership Behaviors by Age Group (N = 266) Note: This figure shows the relationship between leadership behaviors and Personal Accomplishment (PA) according to age group. There was no significant difference in the PA and leadership behavior relationship between age groups 56 and older and younger than 56. In conclusion, the demographic factors of sex and age grouping did not reveal significant differences between demographic groups with the exception that the relationship between MBEP behaviors and Depersonalization (DP) was significantly stronger in the female subgroup compared to the male subgroup. The implications of this finding are not clear, but the positive 94 correlation of MBEP behaviors with Depersonalization (DP) in women would imply that leaders who exibit more MBEP behaviors lead to more burnout in females but not males. Therefore, in answer to research question three, the relationship between leadership behaviors and burnout mostly did not differ based on demographic factors. Factors, Sources, and Understanding of Burnout (RQ4) All 10 faculty interviews were completed by the independent reviewer (KK). These interviews lasted between 30 to 40 minutes in length. The first interview was conducted on March 28 th , 2021; the tenth and final interview was conducted on May 5 th , 2021. The findings, organized by interview question, were subdivided into common themes. If at least half of the 10 interviewees mentioned simlar content in their responses to the interview questions, this was identified as a theme and is expressed in the Tables 9 through 12. Other categories of responses that did not meet the 50% threshold to define a theme were only included in the corresponding text of results if 40% of the interviewees expressed similar or related content. Because these interviews were conducted during the COVID-19 pandemic, a section under burnout factors specifically addressing the pandemic as a possible factor is included. It should be noted that the interview questions did not specifically ask a question about how the pandemic may have influenced their burnout; however, this discussion is included because 40% of the respondents alluded to the pandemic during the interviews without necessarily invoking this as a factor in causing burnout. Interview Question 1: What Does Burnout Mean to You? Three of the most common themes expressed by the 10 interviewees in response to interview question number one were aberrant behavior or lack of joy, a lack of energy or reserve, and lack of effectiveness (Table 9). Aberrant behavior or negative feelings towards work was 95 cited by 80% of interviewees, loss of energy or reserve was cited by 50% of the interviewees, and content corresponding to lack of achievement or accomplishment was expressed by 50% of the interviewees. These themes are described in the following sections and in Table 9. Burnout as Aberrant Behavior or Loss of Joy. The most frequently cited theme regarding what burnout meant to faculty involved allusions to behaviors or feelings that the interviewees witnessed or felt. These behaviors were directed at, not only patients, but also coworkers. Interviewee number 5 described the meaning of burnout in terms of aberrant behavior when one coworker would “call me out publicly at a meeting even though I was his leader for things he didn’t really understand.” Interviewee number 5 goes on to describe another instance of aberrant behavior where a coworker “wouldn’t even turn around to look at me to say hi…usually, people turn around and make eye contact.” Interviewee 7 described aberrant behaviors in terms of mood changes and behaviors where not only people withdraw but also act out, “I think…for some of my other colleagues’ burnout also means that I feel like they become really crabby and kind of angry all the time.” Interviewee number 8 further elaborates on colleagues withdrawing from engagement with work when it expresses itself as a “general feeling of … like I am cooked… I am not doing anything to help.” A loss of joy or desire to show up to work was another characterization of aberrant behaviors or feelings of loss of joy that led to aberrant behaviors, according to the interviewees. Since all these interviewees related a loss of joy in work to aberrant behaviors, the two were combined into one theme. As interviewee number 4 expressed burnout means “not enjoying or finding satisfaction in what I do.” Interviewee number 4 further elaborated on the consequences of lacking joy in work that results in a poor work life balance due to the inability to “fully relax because it takes so long to relax after coming home from a stressful day that it eats into my spare 96 time… from the overall more negative vibes and positive vibes in terms of work.” Interviewee number 7 described the lack of joy as a lack of interest “in why you were attracted to medicine in the first place…you start to think about why I am doing this job, should I move on?” This description of burnout was also common to interviewee number 8 when they described burnout as “doing the job without feeling the joy.” Interviewee 7 also described the consequences of this in terms of behaviors where those that are burned out could lose patience with patients, “professionally, you know the kinds of conversations that you might have just kind of like being short with people…on the patient care side.” Therefore, according to participants, a lack of joy often manifests as aberrant behavior toward work and can manifest in aberrant behavior toward patients as well as coworkers. Other manifestations of burnout in terms of aberrant behaviors or feelings that lack joy was described by interviewee number 2 when a loss of joy resulted in non-engagement: I would say that I would not really get much joy out of work …just be sort of going in and punching the clock and leaving and really not thinking about it at all when I'm out there… and thinking about it maybe three negative thoughts too much. Interviewee number 6 also detailed burnout as a feeling similar to that described by interviewee number 2: when you have a feeling of, you know, not yourself, you're tired, you're sort of overwhelmed and I think you feel sort of depersonalized you know you don't feel like you normally feel. I think it's different than simple fatigue or busy-ness. I think it's just you know you've been pushed to a point where you don't feel like yourself. Interviewee 10 finally very succintly stated, “It's like a desire to not be there anymore.” They went on to describe this feeling as “when you don’t want to do your job anymore. Where you 97 know the the negatives are more than the positives and it's just not worth it… and maybe I don’t go to work tomorrow.” These statements illustrate the connection between feelings related to lack of joy and behaviors that result from it. According to these participants, these behaviors could manifest in overt displays of angry moods or more subtle passive-aggressive behaviors, such as not volunteering for extra work or tasks and not being engaged in work. In all of these cited examples the issue of lack of joy or not wanting to come to work were discussed in the context of aberrant behavioral manifestations. Burnout as Lack of Energy or Reserve. Fifty percent of the faculty described the meaning of burnout as a lack of energy or feeling tired, emotionally drained, or lacking reserve. Two examples are cited in Table 8. Interviewee one describes burnout as emotional drains with the statement, “I think emotionally… I feel somewhat drained… you know physically feel tired.” Interviewee number 5 discussed how work can result in less reserve and then adding extra duties and more meaningless work can result in an empty reserve that can lead to other behaviors of burnout. In these two examples, a lack of energy or reserve was a common understanding of burnout. In another instance that cited fatigue as a defining burnout feature, interviewee number 6 described burnout as “a feeling of, you know, not yourself, you’re tired, you’re sort of overwhelmed.” Interviewee number 8 also alluded to a lack of reserve when they said, “I think, going through things but potentially lacking the sort of the reserve, or the, you know that kind of feeling that resilience, I guess can lead to burnout.” Interviewee number 8 also described the burnout feeling as a general feeling of being “cooked.” Finally, the fifth interviewee who referred to the meaning of burnout in terms of a lack of energy or reserve was interviewee 98 number 2. They discussed how the push to see more patients and the stress of potential medical liability could make physicians feel stress and worry as “it really contributes… how many patients in a day… you get tired or worried that when you get tired you’re going to make a mistake and miss something.” Therefore, a second theme that resonates with the faculty at AHU is the idea that fatigue or tiredness is an inherent part of burnout either from too much workload from seeing patients or possibly stress related to other expectations, such as legal liability. Burnout as Lack of Effectiveness or Feeling Devalued. The other emergent theme in the interviewee’s descriptions of burnout relates to self-inefficacy and feeling devalued. In describing burnout in the context of trainees or junior level mentees, interviewee number 6 discussed how certain physicians might work to the point of ineffectiveness when burnout is described in situations where “if you are doing a job and you’re not getting the response that you want… the results of what you are aiming to… can also lead to burnout.” In a similar idea, interviewee number 9 described burnout as a process when one is “working to the point where you are no longer effective… where (one) is not getting the satisfaction for the job that you are doing.” Interviewee number 1, when describing clinical work, mentioned that work is very hard; however, they also stated that physicians may not feel very productive: “I feel I’m very busy but not very productive… of course sometimes I have to say I may feel kind of frustrated.” The interviewee continued to express frustration with the feeling that things can be run “more effectively.” Finally, interviewee number 9 described burnout as “working to the point where you’re no longer effective and you feel that you’re working too hard for what you had signed up for.” Interviewee number 9 further placed this in the context of working without being “compensated properly” or “not getting the satisfaction for the job you’re doing.” Therefore, some respondents understand burnout as ineffectiveness while performing their work activities. 99 The sense of lack of self-efficacy can also manifest as a feeling of being devalued (Sibeoni et al., 2019). As interviewee number 3 described burnout, as a feeling of being devalued, which I think for me, it is feeling, feeling burnt out because I'm doing things I shouldn't be doing or things I'm doing that aren't being reimbursed either sort of financially rewarded either sort of financially or even like spiritually and emotionally…so for me it's my, it's my time and… I am feeling devalued. This sense of devaluation described by interviewee number 3 was also reminiscent of a feeling of lack of appreciation for hard work that leads to a sense of not being recognized or valued, especially, with regards to the incessant calls from patients who devalue your time. As described by interviewee number 10,“this sort of emotional frustration that goes on with that, that despite me working so hard it is unappreciated… and…patients are still upset.” Therefore, these feelings of inefficacy or being devalued as a physician can occur in the context of work where the performance goals set by the organization can be overwhelming or the unrealistic expectations of patients for physician availability, even after hours, can be daunting and lead to feelings of ineffectiveness. 100 Table 8 Meaning of Burnout (N = 10) Themes Frequency (%) Quotation Example 1 Quotation Example 2 Aberrant behavior or loss of joy 80 “I think you… go into medicine… and when people get burned out… they go through the motions” “I had one person who would call me out publicly or at a meeting. I had another person who wouldn’t turn around to look at me and say hi.” Lack of energy or reserve 50 “I think emotionally… I feel somewhat drained …you know physically feel tired.” “Everything is effortful, and my emotional reserve is very thin” Lack of effectiveness or feeling devalued 50 “If you are doing a job and you’re not getting the response that you want…the results of what you are aiming to… can also lead to burnout… if you’re not getting what you want.” “It is working to the point where you are no longer effective.” Note: The % cited column represents the percentage of interviewees that cited the theme in their interview narrative. 101 Interview Question 2: What Factors Contribute to Burnout? The three most common factors that contributed to burnout, as cited by interviewees, centered around two themes and one additional category that did not meet the 50% threshold to be labeled a theme. These themes are: 1.) extra work that lacked meaning, appreciation, or compensation; 2.) workload, lack of support, and lack of resources; and 3.) the COVID-19 pandemic (Table 9). The differentiation of the first and second themes mainly centered on the context of the interviewee statements. For example, one interviewee described how the extra workload of performing extra compliance tasks as a nuisance, but when describing compensation, allusions to a lack of recognition and appreciation were concomitantly mentioned. The interviewee (#7) only discussed the need for compensation indirectly as the main idea of this comment was the extra work and lack of recognition as opposed to compensation (Table 9). An example of compensation categorized as “workload or work resources” is shown in the comment of interviewee number 3 who mentions how the electronic medical record has led to extra administrative work (Table 9). In this context, interviewee number 3 discusses a workplace health care delivery factor (the electronic medical record) and the consequences of excessive patient access to physicians that has resulted in more work. In this interview, the discussion centered on the need for more resources in terms of help and even more compensation for the extra work that resulted from the greater access to physicians through the electronic medical record portal. Although both interviewees discuss compensation, the context of both statements, differ in their meaning as interviewee number 7’s statement refers to a relational theme (appreciation, recognition, and compensation) whereas interviewee number 3’s statement refers to a work process or resources theme (more labor and monetary resources). 102 Finally, as only two themes were identified in this section, an additional section regarding the COVID-19 pandemic effects on burnout was added. No direct questions were asked of the pandemic’s effects on burnout, but 40% of the interviewees did mention its presence indirectly. Of note, none of the interviewees cited the COVID-19 pandemic as a factor in burnout (Table 9). Extra Work that Lacks Meaning, Appreciation, or Compensation. A commonly cited theme that led to burnout was mentioned by half of the interviewees in the sample. This factor was grouped as extra work that was not felt to be important to a practicing physician, such as taking online courses for sexual harassment training, extra call weekends that were not expected, and other work that was not appreciated or compensated. For example, Interviewee number 4 described one burnout associated factor as “doing work that is not compensated for… work that is expected to be a certain way and isn’t.” that results in more time spent on weekends and less personal time. The interviewee further elaborated that the extra work resulted from a discordance in expectations of the workload where, “my colleagues I have seen working too many weekends, working on call too frequently, or working very long-time intensive hours without a lunch break.” Of interest, interviewee number 4 did not discuss this extra work in terms of resources or support, but rather as “extra work” that is absorbed by the physician’s personal time. Interviewee number 7 further described this unappreciated task of taking additional online courses when they lament. It was like two years ago so apparently; they think that I need a reminder refresher ... You know I kind of felt like we are not actually being paid for or, we can’t see the link between being paid for and doing all of the extra computer work. As Interviewee 7 described this extra work as superfluous, the interviewee further elaborated that this factor of burnout might be better mitigated if “we should be paid for the time 103 we spend teaching and designing lectures, designing programs, running those programs, taking care of patients, taking night call.” Therefore, a common factor associated with burnout by these two interviewees was the extra unexpected and uncompensated workload that results in less personal time and a sense that the extra work is meaningless and unappreciated. Another theme that is related to work that is unappreciated was expressed by interviewee number 9 when work is described as a “lack of appreciation and lack of positive reinforcements” in the performance of “mundane” work. In clearer terms, interviewee number 9 described the work as a “fast road to burnout” when “day in and day out type of work… they’re doing the same thing they’re asked to do more and more each year each month with the same salary.” In a similar theme, Interviewee number 2 described how frustrating it is that the organization continues to add clinical work without increases in pay when the individual expectations are to have a balance of clinical activities and research activities: “it’s an ongoing thing where it’s constantly adding more clinical duties without compensatory increases in your pay…if I wanted to do that, I would not be at an academic place.” These comments from these two interviews demonstrate themes that relate to both mundane or meaningless work that is unrewarding and the expectations of the proper clinical to academic work that make work more meaningful or desirable. Similar themes of appreciation and expectations of the proper work balance are expressed by interviewees number 2 and 8. Interviewee number 2 further described how despite this “ push” to see more patients without giving the compensation for unexpected work, administration exacerbates the added stress of work on the physician by issuing a patient evaluation form that assesses the quality of the patient-physician encounter that seems to contradict the push to see more volume while not providing the time needed for quality care: “ some of the evaluation 104 methods, for instance, one of the big questions … does your doctor spend enough time with you?” seems to contradict … those sorts of contradictory pushes really are frustrating… and lead to burnout.” Another comment related to the expectations of work in an academic environment was expressed by Interviewee number 8 as a major factor of burnout in an academic environment was not having “academic opportunities” or support for engagement in these academic opportunities by “others” and elaborated that the junior faculty are more susceptible to this factor because “I am at a place where I can say no to things.” In these two interviews, allusions to lack of appreciation from patients and an imbalance of clinical work support relative to academic work support highlight the factors that continue to surface: lack of appreciation and an imbalance of expected work activities with regards to clinical work and academic work. In summary, participants cited extra work activities that are discordant with their expectations as major factors contributing to burnout. Faculty described work balance between clinical activities, education, and research as well as superfluous or mundane work as major factors in burnout. The next theme captures burnout factors as workload that is not supported by resources or support and relate more to health care operations efficiency and effectiveness as described by participants. Workload, Lack of Support, and Lack of Resources. A related theme associates the factor of uncompensated work to the need for more support. Five of the 10 interviewees identified lack of support from the organization as a major contributing factor to burnout. In relation to the work becoming less meaningful, interviewee number 5 cited the support structure as an important factor in contributing to burnout when colleagues are “stretched thin” stating, “you add to the unappreciated work a support structure around you, to enable you to do your work effectively is diminished” then burnout will occur. Interviewee number 6 described 105 multiple factors, such as trainees having different ways of individually dealing with stress, but then cited the need for support systems to mitigate burnout, “support systems, not having a good enough support network around you can be difficult.” Interviewee number 6 further elaborated that an individual’s perspective of how to deal with work stress can be related to the work environment that these individuals inhabit where resources, such as mentors, are not readily available that can guide them through stressful times. The issue of support also manifested as the need for documentation where support for this function could be mitigated if one could share the burden with “a really good scribe or really good physician assistant” to help with documentation according to interviewee number 5. Interviewee number 3 further elaborated on the lack of support and resources in reference to the “boundarylessness” of the electronic medical record, “so those of us in primary care don’t have the assistants and other people answering them (messages), other specialties do…our medical assistants handle some of them… but... apparently, I answer 118 messages a day.” Finally, interviewee number 1 discussed the long hours spent at work and the inefficiencies of the health care delivery system in relation to support needed for documentation and billing. An example expressed by interviewee number 1 were the technical problems associated with the dictation system that led to frustration and inefficiencies in documentation. Another problem with the delivery system was related to the ineffectiveness of scheduling where some patients required extra time due to the unique nature of their health problems and could not be fit into a typical “15-minute” time slot. To interviewee number 1, these health care delivery problems could be better dealt with if “management’s operational efficiency… in a partnership with physicians” were more aligned. 106 In summary, health care delivery and discordance with the number of resources needed to deliver care effectively and efficiently was a commonly cited factor for burnout. Most of the resources needed concerned support for clerical, technical, or message answering. Of interest was the fact that the interviewees did not cite the electronic medical record per se as a factor in burnout, but they pointed to the consequences of the electronic medical record, such as the increased number of patient messages or clerical support needed for adequate documentation. No comments regarding the quality of the patient doctor interaction regarding the electronic medical record were noted. Effects of COVID-19 on Burnout. The effects of the COVID-19 pandemic on burnout were mentioned by four of the 10 interviewees, but none of the interviewees cited this factor as being associated with burnout. In general, the overall allusions to the pandemic demonstrated little impact on burnout. In fact, some of the interviewees viewed the pandemic as having a favorable impact on their perceptions of burnout. Interviewee number 3, for example, stated in response to a clarifying follow up question how “COVID cured my burnout because I switched to telemedicine.” They later discussed the main reason for burnout being the patient and professional expectations to listen to all complaints, including the mundane ones, such as topics governing weight loss. Interviewee number 2 similarly discounted the effects of the pandemic when they mentioned how COVID may have changed things in terms of getting together for company events, but the pandemic did little to change the real issues: “I mean they were outside of COVID … tried to have departmental things in person and social events to try and build morale and it helped, but … the very next day you are back to the old grind.” Interviewee number 9 in discussing the work life factors associated with driving a long distance to work 107 stated, “you know COVID changed it a little bit… I am home earlier, and the traffic is not that bad.” The only interviewee that may have alluded to COVID as having a negative impact was interviewee number 7 who stated “it could also be post COVID… I just don’t really want to do anything new.” Interviewee 7 went on to describe how they felt “pushed to do lots of new stuff because there are a lot of changes going on in our…. contract.” However, the interviewee further elaborated: At the height of COVID when we were at our tightest that the funny part because of the height of COVID we only had one job and that was to take care of patients … everything else fell away and now that COVID has receded a little bit and normality is… established, all the problems … are now coming out.” In summary, despite the COVID pandemic and its recent effects on jobs and home life, there appears to be little, if any ill effects on burnout at AHU from the perspective of the interview participants. The participants differed in their perceptions of how the pandemic affected burnout; however, none cited this as a factor. Instead, the primary responses alluded to underlying work factors as major contributors to burnout. 108 Table 9 Factors Associated with Burnout (N=10) Themes Frequency (%) Quotation Example 1 Quotation Example 2 Extra work that lacks meaning, appreciation, or compensation 60 “I understand HIPAA…and Sexual Harassment… they think I need a refresher…these are things that… we are not actually being paid for.” “… lack of appreciation and lack of positive reinforcements… its mundane, you know every day they’re doing the same thing … to do more and more.” Workload, lack of support, and lack of resources 50 “…it’s the boundarylessness of the electronic medical record, it’s the access that patients… there are no boundaries… so it’s the amount of time… answering messages, doing refills, it never ends.” “I think. Operational efficiency… we are always required to document… record keep… and bill… and that takes time… worse time allocated for patient care.” COVID-19 0 See text for discussion See text for discussion Note: The % cited column represents the percentage of interviewees that cited the theme in their interview narrative. The COVID-19 factor was included in this table for purposes of comparison but did not rise to the threshold of being a theme. It was not cited as a contributing factor by any of the interviewees but was indirectly mentioned by four of the 10 interviewees. 109 Interview Question 3: What are the Sources Contributing to Burnout? The sources identified by the interviewees that led to burnout could be categorized into two themes: internal sources and external sources. Internal sources included the hospital, university, or leadership. External sources referred to the physician culture, health policy, or national medical organizations. Another emergent category identified by participants could be described as individual factors, such as internal resilience or work life balance, but this category was only cited by two of the 10 interviewees and will not be discussed further in the following sub-sections. Internal Sources of Burnout: Hospital or University Administration. The source of burnout for half of the interviewees was hospital administration or the University. Interviewee number 1 gave an example of how the issue of inefficiency in care delivery was caused by difficulties in documentation, especially the dictation system that was attributed to the hospital administration. Interviewee number 2, in an expression of frustration over the proper balance of clinical work and research, stated the source of this frustration was the administration’s push to do more work to generate revenue for the University. Interviewee number 4, in describing how time needed to accomplish work tasks exceeded expectations, lamented that the “behind the scenes” administration was the source of this unexpectedly increased workload. When addressing this issue of excessive time spent on work activities, interviewee number 4 would attribute this problem to administration because a “critical mass” of complaints would be needed to affect any change in time allotted to accomplish clinical tasks. Interviewee number 9 cited leadership or the immediate supervisor as the source as it is expected from this faculty member that the leader “creates the environment” for well-being. Finally, interviewee number 10 cited the administration as the source of workplace frustrations, such as requests for more workspace 110 to accommodate physicians. Interviewee number 7 also cited the university as the source for meaningless compliance training requirements in the form of sexual harassment modules or brain death modules that seem to be a waste of time to them. Overall, the source of factors leading to burnout for many of the faculty could be attributable to the internal organization. Hospital administration, the University, and the immediate leaders as representatives of the higher administration were all implicated as the ultimate source of burnout by half of the faculty interviewees. External Sources: Physician Culture and National Medical Organizations. The other theme relating to sources of burnout that the interviewees identified was described as sources that were external to the organization. These external sources generally aggregated to health care trends, the culture of physicians, or healthcare policy or norms outside of the organization. Interviewee number 6 described a medical community culture that expects workers to work at a certain speed and progress at a certain rate as one source of burnout. This faculty member cited the need for the mentors or educators in medicine to pay attention to individual needs and learning progression as individuals may learn at different “speeds.” Interviewee number 6 further elaborated the discordance between the cultural expectations of medicine and individual needs that could lead to “struggle” of the trainee or junior faculty member in adapting to an environment of high expectations. Certainly, the expectation by the culture of being a physician can be immutable as interviewee number 6 lamented that the attitude of physicians could be summed up by the following sentiment in describing the cultural attitude of forbearance: “I grew from it and even though it’s probably not the best thing, you know it’s like a badge of honor that I did it.” Another interviewee cited the expectation of working from home as part of the physician culture when interviewee number 2 stated, “You have to do your clinical work, but 111 then you have other responsibilities that need to get done,” and as work requirements extend to home life it becomes “normal reality you can’t really call it like a blip anymore.” Another external source of burnout included the expectations of academic medicine as cited by interviewee number 8: “Certainly, there is just kind of a spectrum of academic work… your clinical work, might be reviewing a paper or something, you know some responsibility that beyond that part of the position … not a [University name removed] mandate” (Table 10). Similarly, external sources were vaguely identified by interviewee number 7 as the source of meaningless compliance training in answer to a query about the source of these work requirements: “So that is a global problem across the U.S., the American College of Physicians is trying to figure out how to reimburse.” Finally, interviewee number 3, in reference to frustrations with the extra workload brought on by the electronic medical record, stated that in addition to administration as a source, this problem also was a “global problem” and was hopeful that an external medical organization, such as the American College of Physicians, could develop a reimbursement model in answer to the problem. In summary, the sources of the factors related to burnout could be thematically categorized as external sources outside the organization or internal organizational factors. Some faculty would cite both external and internal sources, but most cited just one source. Other sources that were not discussed included individual factors, such as the motivation to go into medicine in the first place (Interviewee number 6) or individual wellness habits (interviewee number 8). These latter sources were not discussed due to the few interviewees that attributed burnout to these individual sources. 112 Table 10 Sources Associated with Burnout (N = 10) Themes Frequency (%) Quotation Example 1 Quotation Example 2 Hospital or university administration 60 “I think its hospital administration, university administration… the constant push for … more work… not necessarily to do my research… just do clinical care for the revenue it generates for the university.” “It’s the administration … to have 100% completion of these modules… It’s kind of both because a lot of the compliance issues have to do with protecting the university.” Physician culture or national organizations 50 “Certainly, there is just kind of a spectrum of academic work… your clinical work, might be reviewing a paper or something, you know some responsibility that beyond that part of the position … not a USC mandate.” “So that is a global problem across the U.S., the American College of Physicians is trying to figure out how to reimburse.” Note: The % cited column represents the percentage of interviewees that cited the theme in their interview narrative. 113 Physician Faculty Understanding of Leadership Behaviors as it Relates to Burnout (RQ5) The physician faculty’s understanding of leadership behaviors related to burnout is organized by two categories aligned to the two interview questions that supported this research question: Leadership Behaviors Demonstrated and Leadership Behaviors Desired. The leadership behaviors demonstrated aggregated into three themes: lack of agency or unquestioning compliance, regular communication and meetings, and referral to wellness or individual based programs. The two thematic categories of Leadership Behaviors desired were 1.) Communication, moral support, community, and feeling heard and work support and 2.) Compensation, time, effectiveness, and resources. What has Leadership Done to Address Burnout? (Leadership Behaviors Demonstrated) This section describes the responses to the question of how observed leadership behaviors were understood by faculty. The categories described by faculty clustered around three themes in relation to their leadership: a lack of agency, frequent communications and meetings, and referral or allusions to wellness education programs. It should be noted that this section is organized by the predominant themes, but also includes the sentiments of faculty as to whether these behaviors were felt to be helpful to their perceived burnout or not. These sentiments were only included to provide context of the quote and should not be construed as a leadership behavior that was desired. The leadership behaviors desired is addressed in the second sub-section of this research question. Leaders Appear to Lack Agency, Provide Vague Answers, or Demonstrate Unquestioning Compliance. The most common answer to leadership behaviors demonstrated in response to burnout invoked the idea of leaders having a lack of agency, described also as an inability or unwillingness, to address the pressing factors that led to burnout. Interviewee number 114 4, for example, in discussing items such as patient scheduling flexibility described how leaders demonstrate genuine concern, but “sometimes they can’t do a lot about it” (Table 11). Interviewee number 4 further elaborated that those leaders “might say, well, I will bring that to the higher ups… they also maybe can’t do anything… and that needs to go further up the chain of command.” When asked who these individual decision makers were, interviewee number 4 went on to say, “the chair of the department and I don’t really know who he responds to.” In a similar theme, interviewee number 7 cited an instance when additional on-line compliance training was required in addition to greater administrative work activities and lamented “well they can’t do anything about it, they are not the ones coming through” (Table 11). This interviewee further elaborated on advice to the leadership on how to deal with this issue by saying; “I would say look at this university over here… it’s just similar to ours, they don’t require their faculty to do ABC and D.” These two examples demonstrate a perception of a lack of agency as a leadership behavior in dealing with common burnout factors, such as flexibility in scheduling and extraneous work such as meaningless compliance courses. The observed leadership behaviors seem to participants as feckless gestures of compliance and appeasement in addressing important front line physician issues. Connected to the perception of leaders lacking agency, participants described leadership behavior observed as that of an unwillingness to take problems to higher ups. When addressing the issue of too many calls from patients from the newly opened patient portal, interviewee number 10 remarked “when clinic leadership management would meet with the doctors to discuss this type of issue… the answers… we have to take it to… unnamed individuals for this sort of thing” was viewed suspiciously. Interviewee number 10 further elaborated that they get discouraged from this lack of initiative to advocate for these concerns to the organizational 115 decision makers since “it doesn’t matter anyway or whatever you say it doesn’t go anywhere, anywhere… why even bother.” In this instance it appeared that this lack of initiative or agency led to the interviewee not trusting their leadership, “I think that a lack of transparency of… (is) what’s really going on here.” Interviewees number 1 and 2 discussed this lack of agency in more neutral terms. Interviewee number one referred to the fact that leadership could address burnout better by addressing the “root cause” of burnout, but they reflected that leaders somehow seem to always ignore these issues. Interviewee number 2, in a testimonial to solutions to the problem of an imbalance of clinical to research work activities, stated that the root of this burnout problem is “fixable but at a much higher level.” In total, six of the 10 interviewees referred to leadership behaviors demonstrating an unwillingness or inability to address important wellness issues. This lack of agency led to a spectrum of reactions from the interviewees ranging from a lack of trust in their leadership (interviewee number 10) to detached acceptance (interviewee number 2). From the interview sample, it is not clear whether this perceived lack of agency among leaders as described by the participants resulted from a lack of knowledge or motivation from leaders or originated from structure or policies of the organization. Further research would be needed to explore this phenomenon from the perspective of leadership. Leaders Create Sense of Community Through Regular Communication and Meetings. Another group of common leadership behaviors described by participants related to the category of communication and frequent meetings that led to a sense of community and shared understanding. Interviewee number 2 stated “I mean they should, or we do have regular meetings and they try to address concerns, which is some of them are going to be impossible to 116 address adequately” (Table 11). The interviewee went on to elaborate on these behaviors as mostly being a response to the need to generate money and to keep the department in the “black.” In a similar sentiment, interviewee number 3 discussed how leadership “engages in meetings and conversations and talk about… assistant coverage” of extraneous work activities, but then laments that “nothing is happening.” However, this interviewee did acknowledge that “they at least engage in conversations” (Table 11). Another interviewee described how in one correspondence to the group, leaders addressed burnout by saying they will go to the higher administration to discuss the problem: Sometimes they might say well I will bring that up to the higher up’s and we’ll see what we can do… but generally I feel that the leaders are sympathetic and feel that this is a real issue, but they can’t always change it. Interviewee number 5 mentioned continued individual availability and access as another leadership response. In one instance, as interviewee number 5 described an instance of an individual meeting through personal communication: I think that the response I saw was continued availability, you know I can call and get a meeting if I need to… increased availability more in a broader way to set up weekly meetings initially and then every other week meetings and then monthly meetings. Therefore, communication both through individual meetings and group meetings, seem to be a common leadership behavior that was demonstrated as described by faculty. Interviewee number 8 also mentions individual meetings or “check ins” that were witnessed from leadership. Overall, most of the faculty acknowledged an appreciation of the group and individual meetings. These leadership behaviors were generally felt to inspire motivation among the participants due to their respective leader’s genuine concern for their welfare. These behaviors 117 were generally welcomed by the participants who identified them as present. Additionally, these behaviors are distinguishable from the lack of agency discussed by other participants, where most of the reactions were negative when this behavior was described. Wellness and Individual-Based Programs. When describing other leadership behaviors demonstrated by physician leaders in response to burnout, the interviewees described the referral or suggestions for participation in wellness programs. Five of the 10 interviewees identified that their leadership would either individually or collectively encourage participation to engage in wellness programs both as a prevention or therapeutic intervention. Interviewee number 1 discussed how leadership would generally give “wellness tips… some… talks” (Table 11). Interviewee number 1 further elaborated that these responses to burnout through “wellness tips” were mostly of superficial and of skeptical value: “I am not quite sure how helpful these programs are when addressing the ‘root cause’ would be much more effective.” A similar sentiment was expressed by interviewee number 2 when describing an organization-sponsored “wellness week” and the participation of faculty in such activities as yoga, which the interviewee did not participate in because they were “not very flexible.” Others describe referrals to wellness programs in a more general sense where the higher leadership made wellness programs available to the faculty. In a comment about the usefulness and availability of these programs, interviewee number 9 discussed how on a group and organizational level, communications with regards to wellness were readily available when they mentioned how “overall as an institution I do see AHU trying to create a better environment for people to prevent burnout.” They continued to state that these resources seemed to be useful. The interview data suggest observed leadership behaviors in response to burnout commonly resort to referral to institutional wellness programs that have mixed reviews from the 118 participants in terms of effectiveness. The overall sentiment from the participants seems to view this leadership behavior as helpful but not significantly impactful on burnout. Interviewee number 6, when describing their leaderships’ responses to burnout mentioned that some leaders might be “ more into it” than others: “I think everyone is trying to figure it out or meeting with psychologists…with education specialists… there is a subset of leaders who are very much into it… others are like hey… I did it… they’ll grow stronger for it” (Table 11). Overall, wellness programs seemed to be appreciated, but participants did not feel this behavior of offering and suggesting participation in the programs to be effective enough to address the burnout problem fully. Most of the interviewees seemed to view wellness in a very abstract sense in that it was sponsored by the institution but not necessarily by their immediate leadership. Although these leadership behaviors were observed by 50% of interviewees to be prevalent within the organization, it appeared that none of these participants actively participated in these wellness programs. 119 Table 11 Leadership Behaviors Demonstrated (N=10) Themes Frequency (%) Quotation Example 1 Quotation Example 2 Lack of agency. unquestioning compliance 60 I feel that they are genuinely concerned…, but sometimes they can’t do a lot about it. Sometimes they might say well, I will bring that to the higher ups… unfortunately the higher ups may not be invested… I feel that the leaders are sympathetic … but they can’t always change it.” “Well, they can’t do anything about it, they’re not the ones coming through… how have they responded. they just say oh not again like unfortunately have to do it because the university requires us to have 100% compliance.” Communication, meetings, and community 50 “I think they try… zoom social events… Uber eats. In person… social events… to try and build morale… it helped but still very next day your back at the grind.” “I mean we do have regular meetings… to address concerns.” “We’re going to try and get somehow … a PA to cover… we appreciate you; we know you’re still doing more work and doing more work… and… nothing is happening…but they do at least engage in conversations.” Wellness and individual based programs 50 “I think … they would emphasize wellness tips and talks… I am not sure how helpful these are… in a theoretical and in a well-being sense.” “I think everyone is trying to figure it out or meeting with psychologists meeting with education specialists… there is a subset of leaders who are very much into it… others are like hey… I did it… they’ll grow stronger for it.” Note: The % cited column represents the percentage of interviewees that cited the theme in their interview narrative. 120 If You Had Five Minutes to Advise Your Leaders on Burnout, What Would You Say? (Leadership Behaviors Desired) The leadership behaviors desired centered on two themes. The first theme converged on a relational theme of communication, moral support, and increasing efforts to include faculty in the decision-making process. The second equally important theme was a more transactional theme that suggested behaviors that would result in providing more resources in the form of compensation, labor resources, or wellness resources. Communication, Moral Support, and Community are Desired. Leadership behaviors or actions that were recommended or desired by participants reiterated many of the leadership behaviors that were described by as demonstrated by leaders. These categorical themes centered on communication, moral support, and community. The fact that over 60% of the interviewees mentioned these behaviors as desirable attests to the importance that providing resources, the second theme that emerged, is not the only form of leadership behavior that is desired by faculty. In discussing moral support for faculty, interviewee number 5 mentioned how if appointed as the leader, one should ask “how can I support you? What can I do for you?... check in with people… connection with people, meet every one of them like every month or every two months in smaller groups.” In similar words, the interviewee continued the moral support theme by saying “words of affirmation and appreciation” are important leadership behaviors. In another allusion to boosting morale, interviewee number 9 discussed how team members shouldn’t always feel that they cannot have a good time at work: People work hard around me, and I can probably do a better job… make sure that it’s not all work, we sometimes sit and … just talking… its very therapeutic … at the end… of the day, to just be sitting… laughing and smiling… it’s okay not to be working. 121 Interviewee number 9 further discussed improving morale by not expecting people to work as hard as you and try your best to “make them feel heard” and accepted into the group. Through these behaviors interviewee number 9 emphasizes the need to develop relationships with the group that goes beyond just work-related activities. An associated group of leadership behaviors that were expressed as desired among the participants surrounded the idea of leaders making them feel included and involved in the decision-making process. Interviewee number 10, referring to the feeling that leadership is not being transparent, recommended that listening, communicating, and being transparent are needed of leaders. Interviewee number 10 went on to say that people need to feel like they are being heard and included in the decisions and “being talked to instead of being talked at.” Interview number 1, expressing a feeling of being ignored, also described frustrations in immediate communication in stating that leaders should know “what is really going on.” Finally, interviewee number 6 discussed how giving constructive feedback to trainees should start by building trust through mentorship, so that those mentees understand that honest feedback is for their benefit and growth. In conclusion, relationship building through communication, acceptance into the group community, and non-work activities represents a group of leadership behaviors that were demonstrated by physician leaders at AHU. These noted behaviors occurred in several contexts including individual meetings, group meetings, and social events. These behaviors that attempted to build relationships were identified as desirable by the interviewees. Work Support: Compensation, Efficiency, or Other Resources. The other theme that participants cited as important for their overall well-being related to leaders providing additional resources such as compensation, efficiency interventions, or other resources. Interviewee number 122 3, in the context of expectations for physicians to answer emails from both patients and administrators, stated, “I would say figure out a way to compensate, those of us in primary care… because remember we asked for raises.” They went on to further elaborate that: For me it comes back to the fact that nobody ever takes into account the time and commitment it takes to answer messages so I guess I would say you need to figure out how to financially compensate positions year after year and give them an incentive structure to do so. Interviewee number 9 emphasized the need for proactive compensatory assessments when it is related that a researcher on the team is working extra hard and is deserving of some compensation in the form of not just monetary compensation but by giving a title: “you know you can’t get bonuses in these types of positions, so you can change your job title so without telling her I am looking into changing your job title to a different category” (Table 12). Interviewee number 1 discussed how some would like leadership to behave in response to the problem of lack of effectiveness in clinic by granting more time to see problem patients when they relate overall, due to the high volume of patients, “we are required to do more with less time.” Interviewee number 1 further related that a lack of efficiency in clinic due to a poorly functioning dictation system should be addressed immediately with technical support. Interviewee number 1 opined further how faculty should “readily talk to administration” and have the problems “taken care of right away.” Technical or clerical support was also mentioned by two other interviewees as something they desired leaders to provide. In dealing with the high clinical workload and lack of support in clinic, interviewee number 7 described how nurse practitioners, physician assistants, and scribes could help the clinic move much easier and could take the writing load off physicians “so that it 123 is no longer on your own back to do all these patient notes yourself.” Finally, interviewee number 8 described how leadership could provide more resources and assistance in the form of “childcare (for) sick kids, and work that is satisfying.” Interviewee number 4 similarly alluded to a theme where more time resources could be allocated like a “wellness day like Kaiser” to the faculty to account for the unexpected time demands of clinical work. These allusions to leadership behaviors desired in the form of providing resources were a commonly cited theme by half of the interviewees. From the perspective of the participants, the provision of resources could be time, additional labor, or compensation for additional work activities performed. Overall, these additional resources were felt to add not only to the effectiveness and efficiency of clinics, but also to the well-being of physicians in helping to reduce their burnout. 124 Table 12 Leadership Goals and Behaviors Desired (N=10) Themes Frequency (%) Quotation Example 1 Quotation Example 2 Communication, moral support, community, and feeling heard 50 “I realized I didn’t really ask them are you feeling burnout. How can I support you? What Can I do for you… check in with people… connection with people, meet every one of them like every month or every two months in smaller groups” “People work hard around me, and I can probably do a better job… make sure that it’s not all work, we sometimes sit and … just talking… its very therapeutic … at the end of the day, to just be sitting… laughing and smiling… it’s okay not to be working.” Work support, compensation, time, efficiency, or resources 50 “I think it would be more about… available resources. How do we assist with childcare… if your child is sick?” “I would say figure out a way to compensate those of us in primary care… nobody ever takes into account the time and commitment to answer messages… need to figure out how to financially compensate year after year.” Note. The % cited column represents the percentage of interviewees that cited the theme in their interview narrative. 125 Chapter 5: Discussion and Recommendations The following discussion is organized into four sections based on the five research questions. First the quantitative section will discuss the baseline burnout rate, the relationship of leadership behaviors to burnout, and the demographic factors that affect the leadership-burnout relationship. The second section organizes the qualitative findings by research question and further subcategorizes this section into interview questions. The research question number four pertaining to how faculty understands burnout is divided into three subsections: meaning of burnout, factors associated with burnout, and sources of factors related to burnout. The final section corresponding to research question number five is combined into one section: leadership behaviors demonstrated and desired. This section corresponds to the two leadership questions: what leadership behaviors were demonstrated and if you had five minutes to tell your supervisor about burnout, what would you say? After the discussion section, recommendations, conclusions, and limitations and delimitations are discussed. Quantitative Results Discussion The quantitative discussion discusses the results in the context of the conceptual framework and the related literature. Where appropriate, the qualitative findings are integrated into each section to better clarify the unique local feature identified in each subsection. The sections and subsections are titled by the predominant theme that emerged in response to each research question to better focus the discussion. The Burnout Rate at AHU is Much Higher than Other Health Care Institutions (RQ1) The most recent survey of U.S. physicians taken between 2014 and 2017 revealed a physician burnout rate of 43.9% as measured by the combined emotional exhaustion and depersonalization scores of the Maslach Burnout Inventory (Shanafelt, West, et al., 2019). In this 126 study, the use of an emotional exhaustion score of 27 or greater was combined with a depersonalization score of 10 or greater to yield a percentage of respondents who were deemed to be burned out. It is noteworthy that all specialties were included in the national survey by Shanafelt, West, et al. (2019), and that this overall burnout score represented an improvement from a similar survey that was conducted between 2011 and 2014 where the percentage of U.S. physicians meeting at least one measurement of burnout numbered 54.4% (Shanafelt, Hasan, et al., 2015) . In this current study at AHU, the aggregate burnout rate measured 53.4% with a mean score of 25.4 on emotional exhaustion and 6.4 in depersonalization. In the same 2014-2017 U.S. survey by comparison, a mean emotional exhaustion score of 23.2 and depersonalization score of 6.8 was noted. Therefore, despite an overall trend of improving burnout rates between 2014 and 2017 in the United States, AHU demonstrates a relatively high physician burnout rate compared to the U.S. population. There are several possible confounding explanations for the higher rate of burnout at AHU. One could be selection bias defined as an error in the selection of groups in a study that may not be representative of the population (National Cancer Institute, 2021). As pediatricians were excluded from this survey, this could have selected out specialties that were more prone to burnout than that of the national survey that included pediatricians. In the U.S. survey of 2017 (Shanafelt, West, et al., 2019), pediatricians scored on the lower end of the burnout scale, but only by a few percentage points (40% vs. 43.9%). Therefore, the exclusion of pediatricians in this sample is not likely to have affected the survey results significantly. Furthermore, the national survey included only 27% that were identified as academic institutions, which at least in one study in the literature, showed lower burnout rates than national averages and could balance out the mildly elevating effects of the pediatric faculty’s exclusion from the study (Windover et 127 al., 2018). In the Windover et al. (2018) study at Cleveland Clinics, an academic medical center, the overall burnout rate as measured by the Maslach Burnout Inventory combining emotional exhaustion scores greater than 27 with depersonalization scores greater than 10, resulted in a total burnout rate of 35%. In this study only seven percent of participants were pediatricians. Therefore, the high burnout rate at AHU is not likely to be explained by selection factors identified in this study. It was also noted that the percentage of females in this sample was overrepresented compared to the overall population at AHU (45% vs. 38% respectively). As demonstrated in a univariate analysis, women showed a significantly higher mean burnout score for emotional exhaustion than men (27.3 vs. 23.9, p<.1). These findings could bias the results as females in national surveys of physician burnout are at a higher odds ratio of being burned out compared to males (Shanafelt, West, et al., 2019). Thus, part of the higher mean burnout rate at AHU could be related to the slightly higher female representation in the sample than the entire AHU population. It is noteworthy that the Cleveland Clinic study (Windover et al., 2018) showed no difference in burnout scores between females and males. Therefore, even if the higher rate of burnout in females did confound the results of the overall burnout score at AHU, it should still not be discounted as a non-issue that should not be further explored. As will be discussed further in the qualitative findings’ discussion, one of the factors that related to burnout was unequal pay compensation in salaries of female physicians compared to males at AHU. Transformational Leadership and High-end Transactional Leadership Behaviors are associated with Less Burnout (RQ2) Physician leadership and its relationship to physician wellness outcomes have not been extensively studied. In one study at Mayo Clinic, only the transformational domains of the full 128 range of leadership model were evaluated (Menaker, 2008). In the Mayo Clinic study, correlations with a two-item satisfaction questionnaire were concurrently completed using four transformational leadership behaviors: Inspirational Motivation, Intellectual Stimulation, Idealized Influence Attributes and Behaviors, and Individualized Consideration. The results demonstrated that the strongest associations with satisfaction were leadership behaviors corresponding to Idealized Influence Attributes and Individualized Consideration. Ironically, the two leadership behaviors that were most often displayed, but least desired among the participants were Intellectual Stimulation and Inspirational Motivation. The authors in this Mayo Clinic study concluded that physician leaders should focus on developing their followers while also teaching and coaching them to enhance work satisfaction. It should be noted that the full range of leadership model was not implemented in the Mayo Clinic study; therefore, it is not known whether transactional leadership behaviors would correlate as well with satisfaction. In a second study at the same institution assessing physician leadership behaviors on burnout, Shanafelt et. al (2015) issued a 10-item leadership survey that assessed various leadership behaviors, such as career development discussions, encouragement to suggest ideas for improvement, inspiration to put forth best efforts, recognition for a job well done, and keeping faculty informed about organizational events. These leadership behaviors that resembled mostly the Individualized Consideration category of the full range of leadership model were assessed for their association with burnout and satisfaction. In Shanafelt et al.’s (2015) internal survey of leadership behaviors, it was found that all the question items correlated with better burnout scores and satisfaction. The authors found that about 11% of the burnout variation could be explained by certain leadership behaviors. These two studies established a baseline for future 129 leadership studies on burnout in physicians and spawned a series of studies looking at leadership behaviors and burnout in the physician population. In the current study at AHU, the strong and extensive correlations with leadership behaviors and burnout confirm past studies’ findings of these correlations and add further information to the literature on physician leadership and burnout. Specifically, three domains of leadership using the full range of leadership model are most notable: Idealized Influence Behaviors (IIB), Individualized Consideration (IC), and Contingent Reward (CR). All three of these leadership categories correlated with favorable effects on burnout. The effects on burnout of the transformational leadership behaviors (IIB and IC) were both predicted by the conceptual framework as IIB and IC both were predicted to positively affect the values component of the Areas of Worklife Model, which in turn would favorably affect all categories of burnout. The fact that IIB can affect burnout through the values component is consistent with the question items that relate to mission, purpose, and values; however, the IC category affecting all domains of burnout perhaps is a bit more surprising. Since the IC question items mostly align with individual development issues, the question arises how these individual development questions relate to values alignment. The values relationship to IC could be explained from another recent study by Shanafelt et al. (2021) that evaluated the mediator of “values alignment” with leadership behaviors and burnout by adding an internally validated values alignment questionnaire. In the Shanafelt et al. (2021) study of physicians, an internally validated values alignment questionnaire was given to a sample of 1285 physicians; correlations were made with burnout and leadership behaviors that aligned mostly with the Individualized Consideration category of the full range of leadership model (Shanafelt et al., 2021). Their study on Stanford University 130 affiliated physicians included 117 physician leaders who were evaluated by at least five physicians that they led. The study results showed that aggregate leadership behavior scores correlated with the mean values alignment score (r=0.53; p<.001), and these correlations also included less burnout and more professional fulfillment. The authors concluded that values alignment, as viewed from the follower’s perceptions of their leaders, was important in connecting favorable leadership behaviors and followers job satisfaction. In examining the leadership behavior questionnaire used to measure leadership behaviors by Shanafelt et al. (2021), most of the 9-item questionnaire aligns with items in the Individualized Consideration category of the full range of leadership model. One item, “my immediate supervisor recognizes me for a job well done” could be construed as aligning with the Contingent Reward category of the full range of leadership model. It is of interest that only one item could be construed as values aligning with IIB in the full range of leadership model: “my immediate supervisor treats me with respect and dignity.” Therefore, the study by Shanafelt et al (2021) on values alignment suggests that IC, through values alignment, is related to wellness and less burnout. Although the authors do not address how the leadership question items relate to values alignment, it is plausible that the act of discussing career development goals, encouraging ideas for improvement, and empowering participants to do their jobs more effectively could lead to a more values aligned relationship between the supervisor and faculty participant. The finding in this study of a strong correlation of a transactional leadership behavior, Contingent Reward, with less burnout, although not predicted by the conceptual model, was not completely unexpected since prior studies indicated that the CR category may co-segregate with IC in multiple study populations (Avolio, 1999). This finding from Avolio et. al. (1999) has led to a proposed three factor model that categorizes the original full range of leadership model 131 behaviors into a Transformative Domain (II, IS, IM), a Developmental Domain (IC, CR), and a Passive Corrective Action Domain (MBEA, MBEP, and Laissez-Faire). The developmental domain of IC and the association of CR could be explained by the frequent and consistent rewards being given in return for task accomplishment that could result in a leader-follower trust relationship that then aligns with a higher order transformational leadership behavior such as Idealized Influence Behavior (i.e. ethical promise keeping) (Avolio, 1999). Therefore, the robustness and consistent associations of all domains of burnout with high end leadership behaviors (IIB, IC, and CR) indicate that a range of leadership behaviors could be effective at AHU. The proposed mediators could be related to values alignment if one considers that CR could lead to IIB over time through the building of trust through promise keeping and consistent fulfillment of contingent rewards. Certain lower end leadership behaviors, as predicted by the conceptual framework, either had no effects or detrimental effects on burnout. The Management by Exception Active (MBEA) category had a weak, but significant, effect on emotional exhaustion, but MBEA did not demonstrate any association with the other two domains of burnout. This weak effect of MBEA on burnout is not inconsistent with findings in the literature as one study in nurses found a weakly protective effect on nurse burnout but was statistically insignificant (Kanste, Kyngas, et al., 2007). The qualitative interviews did not reveal any clues as to how MBEA preference could be explained, but one cannot rule out that this minimal effect on burnout is not real. Further qualitative studies could reveal possible reasons behind this small association of MBEA and burnout. The other lower end leadership behaviors had a consistently detrimental relationship to burnout. Management by Exception Passive and Laissez-Faire leadership behaviors all correlated 132 with worse burnout scores for EE, DP, and LA that were predicted by the conceptual framework. In examining the leadership items related to MBEP, the question items seem to describe a reactive leader who does not get involved in problems until serious consequences arise while the LF leader completely avoids any problems or issues whether present or not. The consistent associations with more burnout indicate that AHU physician faculty desire greater proactive involvement in leadership activities for their overall well-being. In summary, leadership behaviors at AHU clearly are associated with burnout symptoms. Higher order leadership behaviors through values alignment can explain the beneficial effects on burnout and are consistent with the conceptual model. The lower leadership behaviors and their detrimental effects on burnout are also evident, but the current study does not address how these lower end behaviors negatively affect burnout. The effects of the full range of leadership model on burnout, aside from the transformational leadership behaviors, have never been studied or reported in the literature in the physician population. These findings should be considered in future studies and training curricula for physician leaders as a range of leadership behaviors may be beneficial to mitigate burnout. In addition, identifying leadership behaviors to avoid could also have a beneficial effect. Demographic Factors Minimally Affect the Burnout-Leadership Behavior Relationship (RQ3) In the univariate analysis of burnout between demographic groups at AHU, sex and age groupings showed significant differences in burnout with regards to emotional exhaustion. Females showed higher burnout scores compared to males, and the age group 56 or greater showed lesser burnout scores compared to those age groups less than 56 years of age. Both findings are not inconsistent with the literature. At least in one study, both female sex and age greater than 65 were associated with greater and less burnout rates, respectively (Shanafelt, 133 West, et al., 2019). As discussed later in the qualitative section of this chapter, the lack of equitable compensation for females compared to males may be one factor associated with higher burnout at AHU in this demographic group. In addition, the finding of older age having less burnout may relate to two findings cited in the qualitative interviews. One relates to the idea that junior faculty generally must accept certain duties that may be thrust on them by supervisors without the option to decline and the idea that junior physicians may be more involved with issues related to home life, such as the raising and caring for young children. These two demographic findings were therefore examined for their effects on the leadership-burnout relationship. As shown in Figures 4 through 9, the effects of sex and age grouping greater than 56 on the leadership- burnout relationship was insignificant for all associations except for the relationship of Management by Exception Passive (MBEP) and Depersonalization. Females notably showed a positive association, or more depersonalization, in the presence of MBEP leadership behaviors whereas males did not show this relationship. This disparate finding insinuates that reactive leadership behaviors, as exemplified by MBEP leadership behaviors present at AHU, is less tolerable to females than males and may be reflective of female’s expectations that leaders should be more proactive in addressing problems in the work environment. This idea that higher transformational leadership expectations by females for their leaders could be inferred from a study that used the full range of leadership model and assessed leadership behaviors attributed to females and compared these to those attributed to men (Silva, 2017) . In this study of Sri Lankan employees, male and female leadership styles were rated using the full range of leadership survey. Females showed much more frequent transformational leadership behaviors than males and less transactional leadership behaviors. One of the 134 interpretations of the study’s finding was that female leaders exhibited this behavior to overcome obstructions to their activities and goals due to a biased work environment that favored male leaders over female leaders. The idea that females feel more challenged by bias and obstructions in the work environment is consistent with some findings in the physician workforce as some females have cited gender bias from both colleagues and patients as a source of their work- related stress (Hu et al., 2019). Although these sex-based biases have been reported, it is not known if a more proactive transformational style or higher order transactional style of leadership is preferred by women physicians. Further studies regarding the aversion to MBEP type leadership behaviors are needed to better clarify this finding. Qualitative Findings The quantitative surveys established the significantly high baseline rates of burnout and the strong relationship of burnout with leadership behaviors at AHU. It further analyzed demographic factors and found little effect on the leadership-burnout relationship at AHU. A deeper understanding of burnout at AHU through confidential qualitative interviews was conducted to understand how AHU understands burnout and to identify those unique factors and sources associated with burnout. In addition, leadership behaviors demonstrated and desired by physician faculty were explored and are discussed together under one section. Therefore, what follows is a discussion that is organized around research question number 4 (RQ4) and research question number 5 (RQ5). The Meaning of Burnout Aligns with the Categories of the Maslach Burnout Inventory (RQ4) The Maslach Burnout Inventory separates burnout into three domains: Emotional Exhaustion, Depersonalization, and Lack of Accomplishment. These domains are captured by survey questionnaire items that correspond to each of the domains mentioned. The understanding 135 of the meaning of burnout from the 10 interviewees at AHU aligns well with this three-domain construct. At AHU, these three categories were expressed as a lack of energy or reserve for Emotional Exhaustion, aberrant behavior for Depersonalization, and lack of effectiveness or feeling devalued for Lack of Accomplishment. Although the preciseness of these associations is confounded by subjectivity, these broad themes are consistent with similar themes and quotations described in the literature. For example, in one study of rheumatologists, burnout was described as a “demotivational state characterized by low energy levels” (Kumar et al., 2020, p. 5). Other studies describe burnout as a sense of not feeling valued at work (Dillon et al., 2020), which in this current study was expressed by one of the interviewees. In the study by Dillon et al. (2020), aberrant behaviors were also described that were related to Emotional Exhaustion or possibly Depersonalization when one interviewee described their observations of other colleagues; “I have a lot of colleagues that are really burned out. They’re just like, I come and do my work, and I go home. I can’t engage any more than that. They’re just fried.” (Dillon et al, 2020, p. 263) Therefore, the meaning of burnout derived from the themes of this current study coincides with both the domains of the Maslach Burnout Inventory and the descriptions in prior literature on the meaning of physician burnout. The meanings attributed to burnout by this study’s interview participants are not unique to AHU. In addition, these descriptions align with the conceptual framework that separates the burnout domains into the three broad categories of burnout. Workload /Lack of Resources and Misaligned Work Expectations /Lack of Appreciation are Major Factors Associated with Burnout (RQ4) The factors that led to burnout in AHU faculty cluster around two major themes: misaligned work expectations that lacked meaning, appreciation, or compensation; and workload 136 that lacked support in the form of resources. Since the interviews in this study were conducted during the COVID-19 pandemic and specifically during the resolution of the second surge during the time frame November 2020 to March 2021, a separate category was included in the discussion to ascertain the pandemic effects on the understanding of factors that led to physician burnout at AHU. The lack of influence of the pandemic on burnout was a notable finding in this study as was the fact that only two themes or factors were identified as leading to burnout. The two themes that were identified in the current study that led to burnout contrasts with the typical three themes identified in qualitative studies identified in the literature. In one of the largest meta-analyses of qualitative articles related to physician burnout and stress factors associated with burnout, the three themes identified were categorized as: organizational factors, relational factors, and individual factors (Sibeoni et al., 2019). The relational category in this construct corresponds to the first category identified as a theme in this study at AHU: misaligned work expectations that lack meaning, appreciation, or compensation; while the second theme (workload, lack of support, and lack of resources) corresponds to organizational factors as interpreted by Sibeoni et al. (2019). The relative absence of narrative content corresponding to individual factors or work-life balance factors in the current study was notable as only two of the 10 interviewees mentioned work life balance, home, or individual factors as affecting their perceptions of burnout. This latter finding may reflect either a sampling bias or could reflect the fact that AHU offers a host of wellness and mindfulness programs that the interviewees could have regarded as adequately addressing the individual burnout issues and therefore did not require further elaboration. In addition, the context of the questions that relate leadership to burnout may have primed the 137 interviewees to answer the burnout factor questions in the context of the organization and not the individual. The two factors identified (Workload/Lack of Resources and Misaligned Work Expectations/Lack of Appreciation) that led to burnout contained some unique features related to AHU that had previously not been identified in the literature. The two largest studies on physician burnout mostly sampled physician health organizations that were heavily “fee for service” organizations or teaching hospitals (Olson et al., 2019; Sibeoni et al., 2019). None specifically stated that they included heavily managed care insured institutions or safety net hospitals, which AHU faculty’s scope of practice expand to. Therefore, AHU being a safety net hospital as well as a private hospital that accepts the entire range of insured patients may not represent many of the health organizations cited in the literature. This could partly explain some of the unique responses to interview questions on factors related to burnout as illustrated below. As an example of a unique response at AHU, most of this study’s interviewees cited the “boundarylessness” of the electronic medical record and its associated workload in the form of patient messages and phone calls as a burnout factor, however, as opposed to much of the qualitative literature, none of the interviewees alluded to the lower quality of the doctor-patient interaction that may have resulted from simultaneous engagement with the electronic medical record. The other factor contributing to burnout was the misalignment of work expectations and lack of appreciation. The balance between expected clinical activities versus research activities as well as the requirement to spend excessive time on meaningless tasks (i.e., online compliance courses) represents other unique features of misaligned expectations. The discrepancy in work expectations, in particular, of the faculty member and the organization exemplifies a unique feature of this factor where the promised expectation of protected research time may not 138 materialize. Instead, there was an increase in clinical responsibilities and the requirement to spend excessive time on meaningless tasks which furthermore was not appreciated by the organization. Another important issue that seems, in some respect, unique to AHU is the discrepancy in pay between the female faculty and male faculty. Since this latter issue in the context of greater burnout rates in females at AHU could be a driving factor, greater attention should be paid to remuneration discrepancies related to sex. With trends toward increasing females in the workforce, attention to other discrimination factors toward females may also be warranted at AHU and other institutions as well (Dillon et al., 2020). The COVID-19 pandemic seemed to have very little influence on burnout at AHU. In answer to the open-ended question “what factors relate to burnout,” no respondent cited the COVID-19 pandemic directly as a factor associated with their perception of burnout. There were indirect references to the pandemic and burnout cited by several of the interviewed faculty. These allusions to the COVID pandemic ranged from thoughts related to behavioral changes, such as not volunteering for added duties, to improved burnout from a sense of clear purpose and mission in serving the public during a pandemic. These findings are consistent with the recent literature. In a focus group study of 25 oncologists performed at Memorial Sloan Kettering hospital in New York, themes that were associated with positive effects of the pandemic were identified (Hlubocky et al., 2021). The opportunity for renewal, restoration, and growth as well as potential financial compensation through telemedicine was cited as positive factors. Some of the negative effects reported in that study were concerns of adequate personal protective equipment, disruptions in cancer care delivery, and overall stress related to isolation from colleagues and trainees. Although some of these similar themes of social isolation were cited by 139 this study’s participants, the responses never cited these conditions as significant contributors to burnout. The consistent minimization of the effects of the pandemic by AHU faculty on burnout is therefore not unlike much of the findings in the literature. The other explanation for the minimal effect of the pandemic on burnout at AHU could be selection bias. Studies of other specialties suggest that certain types of providers that are directly engaged with care of the COVID patient experience stress and burnout differently. In two studies of frontline workers in the intensive care unit (ICU), a high burnout rate was found using the Copenhagen Burnout Inventory (Hussain et al., 2021). In that study, the main reason cited by the providers for burnout was a lack of faith in the National Institutions of Health guidelines and the lack of adequate personal protective equipment. In another study of French fron- line physicians and non-front line physicians, it was noted that frontline workers had higher burnout scores compared to non-front line colleagues (Di Giuseppe et al., 2021) . Therefore, selection bias for those that are not involved directly with COVID-19 care cannot be totally ruled out as a reason for the lack of attributions to the pandemic as a factor in burnout. In summary, the factors that were associated with burnout follow similar themes cited in the literature with a few notable exceptions. At AHU, the discrepancy in female to male compensation; the balance between clinical, education, and research work activities; and the excessive online course instruction may represent unique opportunities to improve the work environment at AHU. Job resources that include assistance with excessive documentation and patient access issues, though not unique to AHU, are also common factors related to burnout. It is important to note that these factors were cited thematically as primary factors associated with burnout and appeared to not have been influenced by the COVID-19 pandemic. 140 The Organization and Culture Are the Sources of Burnout Factors at AHU (RQ4) The sources of the factors leading to burnout as identified by this study’s interviewees mostly alluded to internal organizational sources, such as the administration or the university, as well as external factors, such as professional organizations or the general physician culture. These findings are consistent with other literature that cites the organization as the source of work conditions that can lead to burnout. In the study by Sibeoni et al. (2019), the qualitative evidence informed a model that held that the organization was the source of burnout and that the relationships of the group mollified the effects of burnout through group interaction. The final protective defenses found by Sibeoni et al. (2019) were the individuals’ own coping mechanisms. External factors outside of the organization were largely non-existent in the Sibeoni et al. (2019) study, but Dillon et al. (2020) alluded to external factors, such as the physician culture and the changing demographics of the physician work force, as sources affecting burnout within organizations. At AHU, these external sources also included professional organizations mentioned by the participants, such as the American College of Physicians (ACP), but as opposed to the Sibeoni et al. (2019) and Dillon et al. (2019) studies, the ACP was felt to be an external organization that was viewed as an advocate for physician wellness instead of a source of burnout. Other studies and editorials allude to government policies, the proliferation of third party insurers, and the increasing bureaucratization of medicine as external drivers of burnout (Berwick, 2016). Although many of these sources were not mentioned in the small interview sample at AHU, physician culture was cited as another source separate from the organization or university. 141 As published by Gazelle, et al. (2015), physician culture that promulgates a culture of self-denial and obligations to the patient at all costs to the exclusion of one’s own well-being is prevalent in health care. This issue of self-denial that is characteristic of the physician culture has been cited by others as a source of burnout (Shanafelt, Schein, et al., 2019). Common personal characteristics of physicians that are characterized by perfectionism, compulsiveness, guilt, and self-denial may predispose physicians to burnout (Gazelle et al., 2015). Though some have asserted that this is a trait of physicians, others cite the culture as unforgiving in terms of its requirement for sacrifice and are a major source of burnout in physicians (Shanafelt, Schein, et al., 2019). At AHU, this culture manifests as organizational expectations of physicians that any new tasks that is brought on by the electronic health record will be eventually assumed by faculty physicians and perceptions that trainees should absorb the same self-denial behaviors as the faculty. In conclusion, burnout factors and sources of these factors seem consistent with the extant literature. Since the organization is a major source of stress and burnout for the individual physicians, it seems reasonable to explore the faculty’s understanding of organizational leadership as it relates to burnout. The quantitative results of this study showed a clear relationship between burnout and certain leadership behaviors. The following section addresses the issue of how physicians understand their physician leaders’ behaviors toward burnout. Leadership Behaviors Identified Include Lack of Agency among Others (RQ5) Thus far the current study has identified through quantitative surveys, strong associations to improved burnout with high end leadership behaviors that include two transformational leadership behaviors and one transactional leadership behavior. Conversely, two lower end transactional leadership behaviors were found to have consistently detrimental effects on 142 burnout. This section combines the findings from analysis of interview data of two leadership questions: “what has leadership done to address burnout?” and “if you had five minutes to advise your leaders on burnout, what would you say?” The following discussion includes both leadership behaviors demonstrated, and leadership behaviors desired in the context of the how AHU faculty perceives these behaviors. The most frequently cited theme regarding leadership behaviors demonstrated was the idea that the physician leaders lacked the agency to deal with burnout problems. Although the full range of leadership model does not include a category for agency, evidence exists that leaders that possess less agency demonstrate a lower frequency of transformational leadership behaviors. The connection of agency, both personal agency and collective agency, to self- efficacy has been well described by Bandura (2000) and is useful in understanding the issues of lack of agency and burnout (Bandura, 2000). In a synthesis of studies that addressed the antecedents of transformational behaviors, Sun et al (2017) identified six studies that correlated low levels of leadership self-efficacy with a lower frequency of transformational leadership behaviors. These studies that involved the field of education evaluated teachers and administrators and compared their self-efficacy scores with perceived leadership behaviors assessed by those they led (Sun, 2017). These consistent findings of low self-efficacy and less frequently displayed transformational leadership behaviors can partially explain the understanding of AHU physicians that connect a lack of agency with burnout. How leader self- efficacy leads to lower transformational leadership behaviors is not clear, however, studies on burnout in the leaders themselves may lend insight into this relationship. The correlation of the degree of leader burnout and leadership behavior was evaluated in a study of physician leaders and those they supervised at Stanford University Health System. The 143 study analyzed physician leaders self-reported burnout and fulfillment scores and correlated these scores with leadership effectiveness scores obtained from those that the leaders supervised. The results demonstrated a strong negative correlation between leadership burnout and the leadership effectiveness scores, thus, showing evidence that the leaders, who themselves may be burned out display less desirable leadership behaviors (T. D. Shanafelt et al., 2020). Therefore, two lines of evidence could explain how leadership agency can affect the well-being of those they lead: the data showing an association of lowered self-efficacy and less frequent displays of transformational leadership behaviors and the data showing the association of higher leadership burnout and less desirable leadership behaviors. One can therefore imagine a scenario where leaders’ lack of self-efficacy could lead to a sense of lack of accomplishment that can then lead to less desirable leadership behaviors and greater burnout in those that are led. The current study’s design did not allow for such a correlation between agency, transformational leadership behaviors, and burnout, but further study examining this association may clarify the role of leadership agency and wellness in those being led. The second set of leadership behaviors identified by the participants surrounded the relationship theme of frequent communication, meetings, or community events to foster group cohesion and morale. These behaviors were viewed favorably by the faculty and seem to align well with the IC category that focuses on “understanding the needs of each follower and works continuously to get them to develop their full potential” (Avolio, 2004, p. 53). This set of leadership behaviors demonstrated could also be categorized as IIB since one question item relates to the importance of “having a collective sense of mission” (Avolio, 2004, p. 103). The IIB category of transformational leadership behaviors could also be expressed as the organizing of ceremonial events, such as graduations, that help foster a sense of organizational belonging 144 and values alignment among the faculty and could serve as a reminder that the mission and values of an academic medical center are to teach and develop trainees. Therefore, the favorable feelings of the relationship aspect of leadership are an important theme expressed by AHU’s faculty. The final set of leadership behaviors that were cited by 50% of the interviewees converged on the theme of individual wellness. In general, referral to these programs as a leadership behavior was viewed neutrally and, in some cases, negatively by the interviewees. Although some of the interviewed faculty felt it was important, most felt that these leadership behaviors were inauthentic reactive gestures that did not address the immediate problem. Some also were skeptical of the wellness program’s effectiveness in solving the long-term issues of burnout. Therefore, in this context, the leadership behavior reported could be thought of as a reactive behavior that resembled Management by Exception Passive behavior that is best characterized by the question item “waits for things to go wrong before taking action.” In summary, the two leadership behaviors desired by faculty centered on: frequent communication, moral support, and feeling heard; and providing work support, compensation, time, efficiency, or resources. The theme of lack of agency represents an unexpected finding in this study that has not been reported in the literature but is an important feature at AHU as it was perceived as an undesirable behavior in over half of the interviewees. As lack of agency does not conform to any of the full range of leadership categories, explanations as to its effects on burnout warrants further study including studies on whether lack of agency and feelings of self-inefficacy in leaders leads to undesirable leadership behaviors. 145 Recommendations for Practice The purpose of this study was to identify leadership behaviors of physician leaders that associate with burnout in the physician population so that an optimal work environment can be created. Four major findings that emerged from this study included; transformational leadership and high-end transactional leadership behaviors were associated with less burnout, low-end transactional leadership behaviors were associated with greater burnout, organizational and professional expectations of faculty led to conflicts in work activities that were deemed ineffective, inefficient, unappreciated, uncompensated, or devoid of meaning, and physician leaders were perceived as lacking agency to affect changes relating to the sources and factors of burnout. The two recommendations below address these key findings. Recommendation 1: Implementation of Full Range of Leadership Model to Physician Leadership Training The results of this study showed a strong correlation between three leadership behaviors that resulted in less burnout and two leadership behaviors that correlated with more burnout. The theoretical construct of the full range of leadership model therefore remains a valid foundational model that is applicable at AHU. Because one of the transactional leadership behaviors, Contingent Reward, also demonstrated a strong correlation with less burnout, the value of understanding the complete underlying leadership theory and concept of the full range of leadership model is warranted. An emphasis on understanding the full range of leadership model is further justified by some of the converse leadership findings of this study: the unfavorable association of lower-level transactional leadership behaviors and burnout. The first 146 recommendation, therefore, is to integrate the full range of leadership model and its underlying theory into physician leadership training at AHU. The evidence that transformational leadership behaviors correlate with burnout and wellness are abundant (Arnold, 2017; Guevara, 2019; Hildenbrand et al., 2018; Kelloway et al., 2012). Several studies that included health care providers also demonstrated its beneficial effects (Guevara, 2019; Menaker, 2008). However, despite the abundance of evidence of its efficacy, it is not clear that training of leaders on the conceptual underpinnings of the transformational leadership model will result in significantly favorable outcomes (Frich et al., 2015). Effective physician leadership has been recognized as an important factor in the success of health care organizations in particular quality improvement outcomes such as in diabetes or pediatric care (Aarons et al., 2016; Berghout et al., 2017). In response to this need, many organizations have implemented physician leadership training into their educational programming (Frich et al., 2015; Onyura, Crann, Tannenbaum, et al., 2019). A review of these studies, however, identified the lack of training on the theoretical foundations of leadership behaviors as a weakness in extant courses (Onyura, Crann, Tannenbaum, et al., 2019). According to the authors, the need for understanding the underlying theory of leadership is vital to continued growth and improvement of individual leader skills as it relates to individual or heroic leadership models on the one hand and shared or distributive leadership models on the other. A deeper understanding of leadership theory therefore would translate to a more effective approach to solving complex systems problems such as physician burnout. The full range of leadership model and its underlying theory and concepts therefore are vital components of successful leadership training programs that aim to improve organizational outcomes such as physician burnout and its consequences. 147 The implementation plan for this recommendation will consist of several phases that will follow the logic model and program theory of implementation (Figure 10). The logic model is a simple construct that divides the phases of an implementation program into several parts. The first part consists of gathering resources and stakeholder input that will contribute to and enable the program to function. The second part identifies the needed activities of the program in the context of the short term and long-term outcomes that are envisioned to decrease physician burnout including longer term implications such as reduced physician turnover through an improved work environment (Savaya & Waysman, 2005). After communication with major stakeholders and approval from the Dean’s office, activities and materials will be gathered to develop a curriculum that aligns with the desired outcomes. These outcomes of lowered burnout and improved wellness in faculty physicians will represent the long-range goals along with related metrics, such as decreased physician turnover and downstream cost benefits from lower turnover and higher engagement. Other issues to consider, besides the content and the delivery of the curriculum, are costs and resources, the physical environment, and the proper tone and expectations of the mostly adult learners involved in leadership training. After identifying the resources, staffing, and budget needs relating to the course activities, a communication strategy with course participants and stakeholders will ensue. The communication will be conducted via individual emails approximately three months prior to conducting the course with reminders sent at two-week intervals for two months then weekly for the final month to the participants. During this three-month period, the course director and staff will meet weekly to determine the proper evaluation methods and questions that align with the objectives of the course. In addition to the email communications, announcements to physician 148 leaders will be made through the department at monthly department meetings and the quarterly Dean’s meetings through the Department Chairs. The evaluation plan focuses on outputs, short- and long-term outcomes, and long-term impact (Figure 10). The outputs of the program will focus on satisfaction and knowledge assessment of the participants. After each session a questionnaire related to satisfaction of content, delivery, and suggested improvement will be collected from the participants. These initial questionnaires will serve as formative assessments of the program. The proposed schedule for the curriculum will consist of two four-hour biweekly sessions monthly for 12 months. Each month a single immediate output questionnaire will be taken evaluating the two four-hour sessions and reviewed by the program director and staff. Another short-term survey will be taken every three months and will take on the format of a summative assessment of leadership behaviors taken from, not only the course participants, but also the staff members of the divisions and departments who would observe any changes in leadership behaviors. This quarterly survey will therefore represent a summative assessment of the participant’s behavior of transferring leadership knowledge and skills to the workplace. The long-term outcomes will measure wellness in the faculty physician population that includes burnout, engagement, and turnover after the 12-month course is completed. The long-term impact of the program (i.e., faculty turnover) will be compared to national performance standards of similar healthcare organizations. 149 Figure 10 Illustration of Logic Model Note: This illustration of a logic model shows the step wise progression from assessing the inputs (resources needed for program development), developing program activities, measuring immediate outputs, measuring initial and intermediate outcomes, and measuring long-term outcomes. From “The Logic Model: A Tool for Incorporating Theory in Development and Evaluation Programs,” by R. Savaya and M. Waysman, 2005, Administration in Social Work, 29(2), p.88, (https://doi.org/10.1300/J147v29n02_06). Recommendation 2: Developing Agency Through Systems Thinking The qualitative interviews identified relationship-based leadership behaviors as highly desirable in mitigating burnout. By understanding the conceptual underpinnings of transformational leadership behaviors (a relationship-based set of behaviors) through formal training and practice as outlined in recommendation number one, physician leaders will be able to build on these desirable leadership behaviors to increase the faculty’s sense of wellness and belonging. This study also identified a lack of agency in AHU physician leaders’ ability to effectively address issues of burnout in faculty physicians, according to the participants. This lack of agency can not only affect the leaders own sense of self-efficacy leading to less than desirable leadership behaviors, but this lack of agency could also affect the procurement of 150 needed resources that the faculty identified as another factor contributing to burnout. While the qualitative interviews provided several clues as to the origins of this lack of agency, no clear attribution could be made as to whether this lack of agency was related to a lack of leader knowledge, motivation, or organizational issues since physician leaders were not included as participants in this study. The extant literature, however, contains numerous examples that allude to all three of these considerations (knowledge, motivation, and organizational issues) as possible explanations for this lack of physician leadership agency. These explanations include such issues as; difficulties with boundary crossing across both horizontal and hierarchical boundaries, difficulties with shared leadership activities, and identity issues that manifest as tensions resulting from a clash of values of clinician identities and leadership identities (Onyura, Crann, Freeman, et al., 2019). Systems thinking is one approach to overcoming these physician leader challenges. According to one Canadian study, systems thinking by understanding one’s role within the context of a broader health system, could help leaders navigate organizational tensions and loyalties to better align with organizational efforts (Marchildon, 2016). This greater systems awareness could then result in greater competence in navigating the complex system of an academic health center to identify knowledge capabilities and resources that could help mitigate or solve complex problems such as physician wellness at both the local and systemic wide levels. (Onyura et al, 2019). The second recommendation, therefore, addresses these systems issues and focuses on the introduction and development of systems thinking in physician leaders to enhance agency through improved understanding of organizational systems. The current system at AHU resembles a matrix organization as discussed earlier that corresponds to a least two lines of 151 accountability, the business line of accountability and the academic line of accountability. The basic structural components of AHU’s organizational systems, or units, resemble the line and staff model contained within a larger organizational matrix model. These two basic organizational components (the line and staff model and the matrix organization) represent two important components that physician leaders should better understand to develop an organizational (systems) approach to address physician wellness. The Line and Staff Model, a model commonly used at AHU, and the Viable Systems Model (VSM) are two simple organizational constructs that are useful for practitioners in learning and applying systems thinking to leadership activities. Not only have these two systems constructs demonstrated their utility in diagnosing and solving problems in other health care systems, but their simplicity and familiarity to some of AHU’s leaders offer promise in adding to the organizational knowledge base of physician leaders in the development of systems thinking as applied to the unique problems and tensions at AHU (Allcorn, 1990, Lame, 2017, Sun et al 2017). The Line and Staff Model is a standard organizational construct that was conceptualized in the early 1900’s (Plant, 1983). In response to the rapid industrialization of businesses in producing goods and services, organizations adapted to this demand by creating several alternative organizational structures to meet the demands of an increasingly complex work force that performed tasks that required both expert knowledge and managerial skills. According to Plant (1983), the formal organizational theoreticians then developed a new leadership model that emphasized a division of labor around expertise in the form of advisors (referred to as staff), and managers (referred to as the line) with the line retaining formal decision-making authority. Therefore, the Line and Staff Model has endured until today and remains one of the preferred 152 models of health care, sometimes referred to as matrix, organizations and represents a basic structure that is recursive throughout an organization. As described by Plant, the Line and Staff Model contain noticeable barriers and requires organizations to adapt their structures to their own environment depending on the function and culture of their respective organizations. Despite these challenges to effective implementation, the traditional advisory functions of the staff still endure today and can be recognized as human resources, operations and planning, and resources and finances (Plant, 1983). A recapitulation of the Logic Model for implementation of the Line and Staff Model concepts will include additional stakeholder groups. These additional stakeholder groups include the staff members of the respective physician leader participants and representative senior leaders and staff at both the executive and academic levels of leadership. After the curriculum and educational plans and activities are developed with additional stakeholder input, evaluation using a similar formative and summative assessment scheme as recommendation number one will be implemented. To better facilitate and achieve maximal agency in affecting the complex problems and issues surrounding wellness at AHU, an understanding of the larger organizational system is also needed. Although a better understanding of the Line and Staff Model will be helpful to a leader’s sense of agency by integrating staff expertise into the planning and decision making to achieve objectives such as physician wellness at the local level, a better contextual understanding of the entire organization is needed to leverage existing available resources to attend to the complexities of physician wellness both locally and systemically. The recognition that physician leaders require a better understanding of systems thinking to better achieve goals and objectives has been previously mentioned. According to Onyura et al. (2019), systems thinking require that 153 physician leaders understand their role as leaders in the context of the surrounding system. This system could be the organizational system itself in which the leaders and their sub-organizations exist or the organizational macrosystem which includes the strategic environment of government policy and managed care. According to others, the understanding of these complex systems are needed to better address intractable problems that are not amenable to simple linear solutions (Pangaro, 2019). A useful model that gives a simple conceptualization of such a complex system is the Viable Systems Model (VSM). The VSM is a model that simplifies the structure of an organization into five systems (Akmal et al., 2021; Lame, 2017). These five systems and their relationships are illustrated in Figure 11. The basic concept illustrates the separation of systems that coordinate and regulate each of the primary systems. The primary systems in this model as applied to AHU would be system one which is involved with producing a good or service and systems four which interacts with the environment to help systems one produce its good or service. At AHU, this product could be a healthy patient or a service such as a surgical procedure. Systems four, which in the case of AHU, represent the business functions of the organization receives input from the environment and other internal systems including systems 5 (the governing element) to produce its own output (i.e., profit and resources) that can feed into the operations component (system 1) or to the environment (i.e., shareholders or the University). It is important to understand that each of these primary systems (system 1 and system 4) interact with the environment and each other to produce an output. The other important element is a recursive element that is shared between systems in the organization. In AHU’s case, this recursive element is the line and staff unit of each sub-system. The usefulness of the VSM model has been demonstrated in health care 154 systems where it has been used to diagnose inefficient communication and coordination in the context of improving quality health care (Akmal et al., 2021). As a component of the leadership training program, physician line leaders and staff will engage every two months with executive and academic leaders and their respective staffs to establish relationships and to work collectively on organizational level issues that relate to achieving organizational objectives such as physician wellness. These two-hour sessions are designed to familiarize the physician leaders and their staffs to the other organizational components at AHU and to apply the concepts of the line and staff and VSM models. These two- hour sessions will be evaluated with similar surveys described in recommendation one but will also include organizational communication metrics, such as the frequency that division level staff and line were included in the decision-making process of executive or high-level academic decisions. These formative assessments will occur every two months after the two-hour sessions with summative assessments on outcomes performed every six months that will focus on systems thinking and their related behaviors. Again, these evaluation steps will follow the Logic Model in its evaluation of program outputs and outcomes. In summary, recommendation two provides practical team learning exercises that integrate the concepts of systems thinking into the full range of leadership model. This second recommendation combines the concepts of the Line and Staff Model and the Viable Systems Model to enhance the physician leader’s agency in dealing with the complex problem of burnout and physician wellness. Applying the two conceptual systems models to local problems such as physician burnout promises to result in not only direct benefits to the faculty members of the sub-organization that the physician leaders lead through resource attainment but can also provide 155 shared knowledge and resources across the organization through cross organizational communication and cooperation of both the line and staff. Figure 11 Viable Systems Model Note. The main features of the Viable Systems Model (VSM) include: the operations system (system 1) that is interested in creating a valuable product, the development system (system 4) that is concerned with the future of the organization, and the monitoring and regulating functions to ensure vision, policy, and activities are aligned (systems 2 and 3). System 5 is concerned with 156 governance, but system 1 and 4 are the only ones that interact with the environment. The other important feature is that each of these subsystems contains a recursive element that is duplicated in each system. The corresponding systems at AHU are academic health systems output (system 1), business systems output (system 4), and a recursive element (line and staff) in each system. From “Combining the Viable System Model and Kotter’s 8 Steps for Multidepartment Integration in Hospitals,” by G. Lame, O. Jouini, and J.S. Cardinal, 2017, Federal Bank of St. Louis, p.3 (https://hal.archives-ouvertes.fr/hal-01519593) 157 Limitations and Delimitations This study has several limitations. First, the cross-sectional design of this study does not allow for attributions to causality. Longitudinal study designs in the future with appropriate leadership interventions that are implemented with surveys before and after the intervention may clarify the effects of leadership behaviors on burnout and causality inferences could be better assessed (Rindfleisch, 2008). Secondly, AHU is an academic health institution that is uniquely situated in a large metropolis with a component of its mission to provide health care to a safety net hospital. Therefore, extrapolation of these findings to other institutions should be made with caution as the dynamics related to burnout in physicians who care for both private patients and indigent patients may not be the same as those institutions where physicians typically work in one type of environment that does not include safety net hospitals (Worcester, 2018). Third, unforeseen selection factors could have skewed the population demographics taking the survey. Although a slightly higher female to male ratio participated in the study, the proportions are comparable to other studies in the literature. In addition, since the investigator is a faculty member of the Department of Medicine, a higher number of respondents may have answered the survey from the “Medicine” specialties as opposed to the other specialties. However, as medicine is one of the largest departments at AHU and the combined “Surgery” and “Other” specialty sites nearly equaled the number of “Medicine” respondents, the sample seems overall well balanced especially when compared to other academic institutions whose published surveys possess similar proportions of sexes and medical specialties as in this study (Shanafelt, et al. 2019; Windover et al. 2018). Fourth, The COVID-19 viral pandemic has placed health care workers in an especially stressful position at the time of this writing. Since March of 2020 until March of 2021, the physicians at AHU have experienced two pandemic surges in the county and have 158 altered their lifestyles and work habits to accommodate the consequences of the pandemic. Although the 10 interviewees did not cite the pandemic as a factor in burnout at AHU, the small sample size may have limited adequate representation of the entire faculty population’s sentiments Recommendations for Future Research Future studies on leadership behaviors and burnout in the physician population should focus on some of the specific leadership behaviors that lead to burnout. This study identified leadership agency as a theme associated with burnout that was not addressed by the conceptual model as only two transformational leadership categories were incorporated into the survey. Future studies using a leadership agency category or survey should be incorporated in association with wellness metrics, such as burnout. It would be of interest if the Intellectual Stimulation category of the full range of leadership model aligns with the lack of agency category. These studies should be designed in a longitudinal fashion to verify the sustained effects of the intervention (Rindfleisch, 2008). For example, a leadership course that incorporates Intellectual Stimulation training into a curriculum could be compared to one that does not in order to evaluate if this intervention affects the perception of agency by the participants over a protracted time interval after the course is completed. Research on the perception of leader agency as a mediator of leadership behaviors could be another avenue for future research. The Management by Exception Passive (MBEP) category of leadership should also be explored in the context of wellness as in this study, MBEP showed a significantly different relationship with burnout in females compared to males. This relationship should be further explored in the physician population using both qualitative methods to identify potential 159 factors that could be intervened on such as worklife balance or perceived negative biases in behavior toward females compared to males. Conclusion The purpose of this study was to identify leadership behaviors that could improve or mitigate against physician burnout at an academic medical center. Although there exists abundant literature confirming the effects of certain transformational leadership behaviors on wellness, few have examined the effects of a full range of leadership behaviors on wellness in a physician population (Deci et al., 2017; Guevara, 2019). This is the first study to examine the full range of leadership behaviors of physician leaders as it relates to burnout by faculty physicians who were in a non-leadership role. The findings of this study not only confirm the beneficial effects of two transformational leadership behaviors on physician burnout but identify a new transactional leadership behavior that also correlates with lower burnout. Similarly, the qualitative interviews revealed several themes that were previously identified in the body of literature concerning physician burnout, however, the study also identified a new theme in the context of burnout: the lack of physician leader’s agency for affecting change in the work environment (Dillon et al., 2020; Sibeoni et al., 2019; West et al., 2016). Mitigating burnout in the physician population is vital for the sustainment and viability of the nation’s health system. The economic costs and potential quality of care costs related to physician burnout has been previously described (Hamidi et al., 2018; Han et al., 2019). Therefore, both organizational and individual based interventions are greatly needed to intervene on this problem. The literature on individual based interventions acknowledges the benefit of programs aimed at individual wellness and resiliency, however in order to maximize the effects 160 of wellness interventions, a need for organizational commitment and interventions is also required (West et al., 2016). Physician leadership training as an organizational intervention and its effects on wellness and performance is a growing area of interest as several studies have suggested a benefit of effective physician leadership on physician wellness (Shanafelt, Gorringe, et al., 2015). However, data on the effectiveness of these physician leadership courses on mitigating burnout and other outcomes is still debatable. Some of the criticisms of these leadership courses revolve around the lack of a theoretical construct to help guide the curriculum and the lack of training on complex systems thinking to help physician leaders deal with complex problems such as physician wellness (Onyura et al., 2019). The current study revealed that a theoretical leadership construct built around the full range of leadership model could lead to improved wellness outcomes such as burnout. Furthermore, the role of physician leader agency in addressing burnout issues in the work environment could serve as a focus for developing a complexity thinking curriculum that is grounded in a complex problem of practice, physician burnout. The current health care environment faces many challenges and is undergoing rapid changes. The growing population health needs, rapid progression of medical and technological breakthroughs, and changes in health care organizational structure and reimbursements have placed a significant strain on the individual physician and other health care workers. Solutions to the growing problem of meeting the wellness needs of the physician workforce require a commitment from physician leaders that mirrors the commitment to their patients. 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Perspect Med Educ, 8(3), 133-142. https://doi.org/10.1007/s40037-019-0517-2 Oreskovich, M. R., Kaups, K. L., Balch, C. M., Hanks, J. B., Satele, D., Sloan, J., Meredith, C., Buhl, A., Dyrbye, L. N., & Shanafelt, T. D. (2012). Prevalence of alcohol use disorders among American surgeons. Arch Surg, 147(2), 168-174. https://doi.org/10.1001/archsurg.2011.1481 Panagioti, M., Panagopoulou, E., Bower, P., Lewith, G., Kontopantelis, E., Chew-Graham, C., Dawson, S., van Marwijk, H., Geraghty, K., & Esmail, A. (2017). Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis. JAMA Intern Med, 177(2), 195-205. https://doi.org/10.1001/jamainternmed.2016.7674 Pangaro, L. N. (2019). Leadership education for physicians-how it fits in their culture. Perspect Med Educ, 8(3), 131-132. https://doi.org/10.1007/s40037-019-0521-6 Plant, J. F. (1983). Line and Staff. In T. D. Lynch (Ed.), Organization Theory and Management (pp. 191-216). Routledge. https://doi.org/https://doi.org/10.4324/9781003065104 (1983) (Reprinted from 14 August 2020) 173 Raimo, J., LaVine, S., Spielmann, K., Akerman, M., Friedman, K. A., Katona, K., & Chaudhry, S. (2018). The Correlation of Stress in Residency With Future Stress and Burnout: A 10- Year Prospective Cohort Study. J Grad Med Educ, 10(5), 524-531. https://doi.org/10.4300/JGME-D-18-00273.1 Regehr, C., Glancy, D., Pitts, A., & LeBlanc, V. R. (2014). Interventions to reduce the consequences of stress in physicians: a review and meta-analysis. J Nerv Ment Dis, 202(5), 353-359. https://doi.org/10.1097/NMD.0000000000000130 Rindfleisch, A., Malter, A.J., Ganesan, S., Moorman, Christine. (2008). Cross-Sectional Versus Longitudinal Survey Research: Concepts, Findings, and Guidelines. Journal of Marketing Research, XLV 261-279. Rothenberger, D. A. (2017). Physician Burnout and Well-Being: A Systematic Review and Framework for Action. Dis Colon Rectum, 60(6), 567-576. https://doi.org/10.1097/DCR.0000000000000844 Ruotsalainen, J., Verbeek JH, Marine, A, Serra, C. (2015). Preventing Occupational Stress in Healthcare Workers. Cochrane Database Syst. Reviews, 4, CD002892. Services, C. f. M. M. (2009). Medicare and Medicaid Health Information Technology: Title IV of the American Recovery and Reinvestment Act. Retrieved 5/8 from https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-health-information- technology-title-iv-american-recovery-and-reinvestment-act Shanafelt, T., Trockel, M., Rodriguez, A., & Logan, D. (2020). Wellness-Centered Leadership: Equipping Health Care Leaders to Cultivate Physician Well-Being and Professional Fulfillment. Acad Med, Publish Ahead of Print. https://doi.org/10.1097/ACM.0000000000003907 174 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 Clin Proc, 90(4), 432-440. https://doi.org/10.1016/j.mayocp.2015.01.012 Shanafelt, T. D., Hasan, O., Dyrbye, L. N., Sinsky, C., Satele, D., Sloan, J., & West, C. P. (2015). Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc, 90(12), 1600-1613. https://doi.org/10.1016/j.mayocp.2015.08.023 Shanafelt, T. D., Makowski, M. S., Wang, H., Bohman, B., Leonard, M., Harrington, R. A., Minor, L., & Trockel, M. (2020). Association of Burnout, Professional Fulfillment, and Self-care Practices of Physician Leaders With Their Independently Rated Leadership Effectiveness. JAMA Netw Open, 3(6), e207961. https://doi.org/10.1001/jamanetworkopen.2020.7961 Shanafelt, T. D., Mungo, M., Schmitgen, J., Storz, K. A., Reeves, D., Hayes, S. N., Sloan, J. A., Swensen, S. J., & Buskirk, S. J. (2016). Longitudinal Study Evaluating the Association Between Physician Burnout and Changes in Professional Work Effort. Mayo Clin Proc, 91(4), 422-431. https://doi.org/10.1016/j.mayocp.2016.02.001 Shanafelt, T. D., & Noseworthy, J. H. (2017). Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc, 92(1), 129-146. https://doi.org/10.1016/j.mayocp.2016.10.004 Shanafelt, T. D., Schein, E., Minor, L. B., Trockel, M., Schein, P., & Kirch, D. (2019). Healing the Professional Culture of Medicine. Mayo Clin Proc, 94(8), 1556-1566. https://doi.org/10.1016/j.mayocp.2019.03.026 175 Shanafelt, T. D., Wang, H., Leonard, M., Hawn, M., McKenna, Q., Majzun, R., Minor, L., & Trockel, M. (2021). Assessment of the Association of Leadership Behaviors of Supervising Physicians With Personal-Organizational Values Alignment Among Staff Physicians. 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(2019). Quick Facts, Los Angeles city, California. Retrieved 5/8 from Wessely A. Gerada, C. (2013). When Doctors Need Treatment: an Anthropological approach to why doctors make bad patients. British Medical Journal, 347, f6644. West, C. P., Dyrbye, L. N., Erwin, P. J., & Shanafelt, T. D. (2016). Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. The Lancet, 388(10057), 2272-2281. https://doi.org/10.1016/s0140-6736(16)31279-x 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. J Gen Intern Med, 27(11), 1445-1452. https://doi.org/10.1007/s11606-012-2015-7 West, C. P., Dyrbye, L. N., & Shanafelt, T. D. (2018). Physician burnout: contributors, consequences and solutions. J Intern Med, 283(6), 516-529. https://doi.org/10.1111/joim.12752 Westercamp, N., Wang, R. S., & Fassiotto, M. (2018). Resident Perspectives on Work-Life Policies and Implications for Burnout. Acad Psychiatry, 42(1), 73-77. https://doi.org/10.1007/s40596-017-0757-6 177 Williams, E. S., Rathert, C., & Buttigieg, S. C. (2020). The Personal and Professional Consequences of Physician Burnout: A Systematic Review of the Literature. Med Care Res Rev, 77(5), 371-386. https://doi.org/10.1177/1077558719856787 Windover, A. K., Martinez, K., Mercer, M. B., Neuendorf, K., Boissy, A., & Rothberg, M. B. (2018). Correlates and Outcomes of Physician Burnout Within a Large Academic Medical Center. JAMA Intern Med, 178(6), 856-858. https://doi.org/10.1001/jamainternmed.2018.0019 Worcester, J., D'Afflitti, J., Pace, C., Lee, K., Lasser, K.E. (2018). Achieving Productivity Expectations Among General Internal Medicine Cliniciansat an Urban Safety-Net Academic Medical Center. The Journal of Medical Practice Management, 34(3), 190- 195. Zopiatis, A., & Constanti, P. (2010). Leadership styles and burnout: is there an association? International Journal of Contemporary Hospitality Management, 22(3), 300-320. https://doi.org/10.1108/09596111011035927 178 Appendix A: 50-Item Survey on Burnout and Leadership 1. What is your age group? o 25-39 o 40-55 o 56 older 2. In which category do you practice? o surgical o medical o other 179 3. How long have you been practicing after training? o 0-6 years o 7-12 years o 13-18 years o 19 years or more 4. What is your sex? o Male o Female o Non-binary / third gender o Prefer not to say 180 The next 22 questions use a scale from never to every day. Please answer questions as it relates to your work with both patients and coworkers. 5. I feel I'm working too hard on my job. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 181 6. I feel fatigued when I get up in the morning and have to face another day on the job. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 182 7. Working with people directly puts too much stress on me. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 183 8. I feel burned out from my work. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 184 9. Working with people all day is really a strain for me. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 185 10. I feel used up at the end of the workday. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 186 11. I feel emotionally drained from my work. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 187 12. I feel I'm at the end of my rope. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 188 13. I feel people blame me for some of their problems. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 189 14. I don't really care what happens to some people in my work environment o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 190 15. I worry that this job is hardening me emotionally. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 191 16. I feel I treat some people as if they were impersonal objects. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 192 17. I've become more callous toward people since I took this job. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 193 18. I feel frustrated by my job. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 194 19. I feel exhilarated after working closely with my patients and coworkers. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 195 20. I feel I am positively influencing other people's lives through my work. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 196 21. I have accomplished many worthwhile things in this job. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 197 22. I can easily understand how my patients and coworkers feel about things. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 198 23. I deal very effectively with the problems of my patients and coworkers. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 199 24. I feel very energetic. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 200 25. I can easily create a relaxed atmosphere with my patients and coworkers. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 201 26. In my work I deal with emotional problems calmly. o Never o A few times a year or less o Once a month or less o A few times a month o Once a week o A few times a week o Every day 202 The next 24 questions relate to leadership behaviors displayed by your Chief or Chair. The response options are arranged from " not at all" to " frequently, if not always". 27. My Chief/Chair treats others as individuals rather than just as a member of a group. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 28. My Chief/Chair spends time teaching and coaching. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 203 29. My Chief/Chair considers an individual as having different needs, abilities, and aspirations from others. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 30. My Chief/Chair helps others to develop their strengths. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 204 31. My Chief/Chair talks about my most important values and beliefs. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 32. My Chief/Chair specifies the importance of having a strong sense of purpose. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 205 33. My Chief/Chair considers the moral and ethical consequences of decisions. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 34. My Chief/Chair stresses the importance of having a collective sense of mission. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 206 35. My Chief/Chair discusses in specific terms who is responsible for achieving performance targets. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 36. My Chief/Chair expresses satisfaction when others meet expectations. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 207 37. My Chief/Chair makes clear what one can expect to receive when performance goals are achieved. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 38. My Chief/Chair provides others with assistance in exchange for their efforts. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 208 39. My Chief/Chair concentrates his/her full attention on dealing with mistakes, complaints, and failures. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 40. My Chief/Chair keeps track of all mistakes. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 209 41. My Chief/Chair directs his/her attention toward failures to meet standards. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 42. My Chief/Chair focuses attention on irregularities, mistakes, exceptions, and deviations from standards. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 210 43. My Chief/Chair delays responding to urgent questions. o Not at all o Once in a while o Sometimes o Fairly often o Frequently if not always 44. My Chief/Chair avoids making decisions. o Not at all o Once in a while o Sometimes o Fairly often o Frequently if not always 211 45. My Chief/Chair is absent when needed. o Not at all o Once in a while o Sometimes o Fairly often o Frequently if not always 46. My Chief/Chair fails to interfere until problems become serious. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 212 47. My Chief/Chair waits for things to go wrong before taking action. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 48. My Chief/Chair shows that he/she is a firm believer in “If it ain’t broke, don’t fix it.” o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 213 49. My Chief/Chair demonstrates that problems must become chronic before he/she takes action. o Not at all o Once in a while o Sometimes o Fairly often o Frequently, if not always 50. My Chief/Chair avoids getting involved when important issues arise. o Not at all o Once in a while o Sometimes o Fairly often o Frequently if not always 214 Appendix B: Communications and Instructions for Survey Communique 1 (Sent April 12, 2021) Dear Faculty Member, I want to alert you to an important study that could help us understand our faculty's wellness and the impact of physician leadership on this wellness. The results of this study will be shared with faculty as well as the Dean's Office with the intent of improving our organization. This study aims to gather survey and interview data on faculty burnout and assess how leadership behaviors affect it. This is the survey portion of the study as the interview portion has already been completed. The study is completely anonymized and confidential and has been vetted through the IRB (UP-20-01358). This study was developed by me, a fellow USC physician in oncology, as part of a dissertation requirement for a Doctorate in Organizational Change and Leadership. It is not part of the recently closed SCORE survey. It should take only 5-10 minutes to complete and will greatly contribute to our understanding of the organizational culture at USC Medicine. Again, thank you for your participation. Sincerely, James S. Hu MD Doctoral Candidate Organizational Change and Leadership Rossier School of Education 215 Communique 2 (Sent April 19, 2021) Dear Faculty, Thank you for reading this email and considering my 2nd request for completion of this important study on Leadership and Burnout. For those of you who have already completed this survey, thank you for your quick and honest responses. As this survey has only been open for one week, I am extremely encouraged by the response thus far as nearly half of the needed respondents have completed the survey. I just want to reiterate that the insights gained in this survey can potentially improve the leadership culture at USC Medicine as it relates to, not just burnout, but the entire spectrum of wellness at our institution. As such, it is important to get a representative sample from our faculty to add validity to this study, so I am asking those who have not completed the survey to strongly consider this completion request as this is an opportune moment in our history. As I mentioned, the survey is completely anonymous and confidential and has been vetted through the IRB (UP-20-01358). It should take 5-10 minutes to complete. The results of this study will be shared with faculty and the Dean’s office and, in fact, will be incorporated into my dissertation for public viewing. As a front-line clinician, I am dedicated to making this study meaningful for all of us. Thank you again for your contributions! Best, James Sincerely, James S. Hu MD Doctoral Candidate Organizational Change and Leadership Rossier School of Education 216 Communique 3 (Sent April 26, 2021) Dear Faculty, Thank you for reading this email and considering participation in this important survey on leadership and burnout. We have received over two hundred and fifty fully completed responses thus far and anticipate a robust sample size from which to draw important conclusions regarding the leadership culture of USC Medicine. For those of you who have already completed this survey, thank you for your participation as it will contribute greatly to improving the leadership culture of our institution. For those who have not completed this survey, I only ask for 5-10 minutes of your time to add to the growing body of data that your colleagues have contributed to that will help us understand ourselves and how we can improve as an organization. As I mentioned in prior emails, the survey is completely anonymous and confidential and has been vetted through the IRB (UP-20-01358). The results of this study will be shared with faculty and the Dean’s office and will be incorporated into my dissertation for public viewing. This survey was specifically designed with the front-line physicians in mind to inform meaningful change. Thank you again for your contributions! Best, James Sincerely, James S. Hu MD Doctoral Candidate Organizational Change and Leadership Rossier School of Education 217 Communique 4 (Sent May 3, 2021) Dear Faculty, Thank you to those who have participated in the Leadership and Burnout survey. For those who have not yet taken the survey, please consider taking 5-10 minutes of your time in contributing to the growing body of data on this important topic. We have received 280 responses thus far and hope to achieve over 300 responses by the time of survey closure on the 7 th of May this Friday. As I mentioned previously, your participation in this survey represents one portion of a study that seeks to understand the leadership culture at USC Medicine as it relates to burnout. This survey portion will collect aggregated data on leadership behaviors prevalent at USC Medicine and seek to assess the relationship between these behaviors and burnout. The study also contains a qualitative component where ten of our randomly selected and anonymized faculty have agreed to a 30-minute interview that is designed to explore a deeper understanding of how we, the faculty, process and understand burnout and leadership. This data will be available online as part of a dissertation requirement for a doctorate degree in Organizational Change and Leadership (IRB # UP-20-01358). It will also be shared with the faculty and Dean’s office with the hopes that it will inform our future leadership culture. Thank you again for your consideration and time! Best, James James S. Hu MD Doctoral Candidate 218 Organizational Change and Leadership Rossier School of Education
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Hu, James Shun Dah
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Addressing physician burnout: is there a relationship with leadership behaviors?
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Rossier School of Education
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Doctor of Education
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Organizational Change and Leadership (On Line)
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2021-12
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