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Physician burnout during a global pandemic: an evaluation study

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Physician burnout during a global pandemic: an evaluation study

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Physician Burnout During a Global Pandemic: An Evaluation Study
by
Michael Allen Grace

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

May 2021

© Copyright by Michael Allen Grace 2021
All Rights Reserved

The Committee for Michael Allen Grace certifies the approval of this Dissertation

Monique Claire Datta
Anna Marie Roman
Bryant Adibe, Committee Chair

Rossier School of Education
University of Southern California
2021

iv
Abstract
Physician burnout within the United States healthcare system is a complex problem. It is well
established that the issue is widespread with far-reaching consequences. This study aims to
identify the extent of physician burnout at an organization during the COVID-19 pandemic and
the factors causing the burnout. The importance of resilience and coping skills in mitigating
burnout is also analyzed. A quantitative survey that incorporated components of various
psychometrically validated research instruments was administered to physicians of the
organization during the fall of 2020. Ecological systems theory served as the theoretical
framework for the study to capture elements causing burnout from the various environmental
domains that comprise physicians’ professional and personal lives. The results unveiled high
survey respondent burnout, with the most significant causes attributed to organizational factors.
Additionally, the results showed only a minor relationship between high degrees of resilience
and coping skills and lower burnout levels. This study's findings suggest physician burnout can
be reduced by improving organizational leadership and developing cultures that are supportive,
engaging, and attentive to physician needs.
Keywords: physician burnout, COVID-19 pandemic, ecological systems theory,
resilience, leadership

v

Dedication
To my maternal grandmother, who before her passing, said to me when I was a young child,
“Mikey, when I am not here, you need to promise me that you will get an education and make
something of yourself.” I hope my academic journey culminating with this dissertation and
doctorate degree would have made her proud.

vi

Acknowledgements
As a healthcare administrator, I have always had a passion for partnering with physicians
to do what I can to help others. I wanted to be a physician, but my unsuccessful attempts at
undergraduate biology, chemistry, and genetics led me to the business side of medicine, where I
have worked for the past 28 years. During this time, I have had the privilege of working side-by-
side brilliant physicians and talented non-physician providers, where I have witnessed both the
good and bad of the United States healthcare system. The past five years have been particularly
challenging for physicians as physician burnout has reached alarming levels across the United
States. The COVID-19 pandemic in 2020 only worsened the problem. I believe physicians are
the foundation on which clinical excellence and patient healing are based. As such, I would like
to acknowledge all physicians who have cared for patients during the pandemic, especially those
who took time out of their hectic schedules to assist in my research to make this dissertation a
reality.
In addition, I wish to acknowledge:
▪ My mother who always does the best she can for our family and me.
▪ Patti and Tanner who stood by me, supported, and motivated me through my doctoral
journey.
▪ Dr. Bryant Adibe, Dr. Monique Datta, and Dr. Anna Roman for their steadfast
guidance, support, and fellowship throughout the dissertation process.
▪ Dr. Joon Lee who took a chance on me as a young, aspiring administrator and has
been a tremendous mentor enabling me to find and always maintain my true north.
▪ The Dean of University East College of Medicine, who, like me, appreciates the
importance of robust administrator and physician collaboration.
vii

▪ The Physician Burnout Taskforce members of University Physician Group whose
compassion and commitment to their patients and peers is truly laudable.
▪ The Sisters of Mercy and pastoral care team at my former hospital who motivated me
to complete my dissertation in practice in a way important to me, even if it would
ultimately lead me to a career change.
▪ Everyone who has believed in me and inspired me to become a better person and
leader.
To all the above, I am eternally indebted to you, and I thank you all.

viii

Table of Contents

Abstract .......................................................................................................................................... iv
Dedication ........................................................................................................................................v
Acknowledgements ........................................................................................................................ vi
List of Tables ................................................................................................................................. xi
List of Figures ............................................................................................................................... xii
List of Abbreviations ................................................................................................................... xiii
Introduction to the Problem of Practice ...........................................................................................1
Context and Background of the Problem ...............................................................................1
Purpose of the Project and Research Questions .....................................................................3
Importance of the Study .........................................................................................................3
Description of Stakeholder Groups ........................................................................................5
Stakeholder Group for the Study ...........................................................................................5
Stakeholder Performance Goals .............................................................................................5
Overview of Theoretical Framework and Methodology .......................................................6
Review of the Literature ..................................................................................................................7
History of Burnout .................................................................................................................8
Professional Burnout in Healthcare .....................................................................................11
Causes of Physician Burnout ...............................................................................................12
Consequences of Physician Burnout ....................................................................................17
Strategies to Address Physician Burnout .............................................................................19
Conclusion ...........................................................................................................................22
Conceptual Framework ..................................................................................................................22

ix

Methodology ..................................................................................................................................25
Research Setting...................................................................................................................27
Data Sources ........................................................................................................................27
Participants ...........................................................................................................................28
Instrumentation ....................................................................................................................28
Data Collection Procedures ..................................................................................................29
Data Analysis .......................................................................................................................29
Validity and Reliability ........................................................................................................30
Findings..........................................................................................................................................31
Participating Stakeholders ...................................................................................................32
Survey Participants ..............................................................................................................32
Statistical Validity and Reliability of the Conceptual Framework ......................................33
Research Question 1: What is the Prevalence of Physician Burnout at an Academic
Medical Center, Multispecialty Physician Group Practice? ...............................................35

Research Question 2: What are the Causes of Physician Burnout at an Academic
Medical Center, Multispecialty Physician Group Practice?................................................38

Research Question 3: How, if at all, do Individual Resilience and Coping Strategies
Mitigate Physician Burnout and Enhance Physician Well-Being?.....................................57

Summary .............................................................................................................................61
Recommendations for Practice ......................................................................................................62
Recommendation 5: Prioritize a Culture Committed to Physician Wellness .....................63
Recommendation 4: Improve Support Staffing ..................................................................64
Recommendation 3: Provide Physician Support, Training, and Education for Electronic
Health Record Duties ..........................................................................................................66

x

Recommendation 2: Increase Physician Engagement and Autonomy ................................67
Recommendation 1: Improve Leadership Communication ................................................68
Implementation and Evaluation Plan ..................................................................................71
Limitations and Delimitations .............................................................................................72
Recommendations for Future Research ..............................................................................73
Conclusion ..........................................................................................................................74
References ......................................................................................................................................76
Appendix A: Definitions ................................................................................................................96
Appendix B: The Researcher .........................................................................................................97
Appendix C: Protocol - 2020 University Physician Group (UPG) Provider Wellness Survey .....98
Appendix D: Ethics ......................................................................................................................119
Appendix E: UPG Physician Responses to Copenhagen Burnout Inventory Questions .............120
Appendix F: UPG Non-Physician Provider Burnout Scores .......................................................130
Appendix G: UPG Clinical Provider Self-Reported Burnout Scores ..........................................131
Appendix H: Multiple Linear Regression Analysis of Predictor Variables ................................132

xi

List of Tables
Table 1: Organizational Mission, Overall Performance Goal, and Stakeholder Goals ..6

Table 2: Data Sources ...................................................................................................27

Table 3: Demographic Overview of Survey Participants .............................................32

Table 4: Internal Consistency Reliability Scores ..........................................................34

Table 5: UPG Physician CBI Calculated Burnout ........................................................36

Table 6: UPG Physician AMA Mini Z Self-Reported Burnout ....................................37

Table 7: UPG Physician Top Self-Reported Causes of Burnout ..................................39

Table 8: UPG Physician Self-Reported Burnout by Age ..............................................55

Table 9: Pearson’s Correlation Coefficients for Burnout Predictor Variables .............56

Appendix E: UPG Physician Responses to Copenhagen Burnout Inventory Questions ...120

Table F1: CBI Calculated Non-Physician Provider Burnout ........................................130

Table F2: UPG Non-Physician Provider Total AMA Mini Z Reported Burnout .........130

Appendix G: UPG Clinical Provider Self-Reported Causes of Burnout ...........................131

Appendix H: Multiple Linear Regression Analysis of Predictor Variables ......................132

xii

List of Figures
Figure 1: Conceptual Framework ..................................................................................24

Figure 2: Correlation Analysis: CBI and AMA Mini Z Burnout Scores .......................38
Figure 3: Correlation Analysis: CBI Burnout and Leadership Communication ............41
Figure 4: Correlation Analysis: CBI Burnout and Gratitude .........................................43
Figure 5: Correlation Analysis: CBI Burnout and Inadequate Support Staffing ...........45
Figure 6: Correlation Analysis: CBI Burnout and Lack of Autonomy ..........................47
Figure 7: Correlation Analysis: CBI Burnout and Family-Related Stressors ................48
Figure 8: Correlation Analysis: CBI Burnout and Administrative Burden ...................50
Figure 9: Correlation Analysis: CBI Burnout and Electronic Health Record Burden ...51
Figure 10: Correlation Analysis: CBI Burnout and Political/Societal Factors ................53
Figure 11: Correlation Analysis: CBI Burnout and the COVID-19 Pandemic ...............54
Figure 12: UPG Physician Brief Resilience Scale Scoring .............................................58
Figure 13: UPG Physician Brief Resilient Coping Scale Scoring ...................................59
Figure 14: Correlation Analysis: CBI Burnout and Resilience .......................................60
Figure 15: Correlation Analysis: CBI Burnout and Coping Skills ..................................61

xiii

List of Abbreviations
ACA Patient Protection and Affordable Care Act
AMA American Medical Association
CBI Copenhagen Burnout Inventory
EAP Employee Assistance Program
EHR Electronic Health Record
MBI Maslach Burnout Inventory
PFCC Patient and Family-Centered Care
UECM University East College of Medicine (a pseudonym)
UPG University Physician Group (a pseudonym)

1

Introduction to the Problem of Practice
Physician burnout is a serious problem throughout the United States healthcare system.
The problem is complex, multifactorial, and not easily solved (National Academy of Sciences,
2019). Physician burnout is ubiquitous as research shows that at any given time, over 50% of
physicians have symptoms of burnout and are generally frustrated with their jobs (Dewa et al.,
2017; Dyrbye et al., 2017; Moss et al., 2016; Shanafelt et al., 2019). Burnout is defined as a
condition of general job dissatisfaction characterized by emotional exhaustion, a low sense of
personal accomplishment, and cynicism (Shanafelt & Noseworthy, 2017). The National
Academy of Medicine (2019) suggests that physician burnout in the United States has progressed
to the level of a public health concern. The Academy’s proclamation came before the
coronavirus COVID-19 pandemic emerged to exacerbate the problem and further test the
resiliency of physicians. The operational and psychological challenges created by the pandemic
have worsened the problem of physician burnout (Fessell & Cherniss, 2020; Fiorillo &
Gorwood, 2020; Shah et al., 2020). Addressing the issue is important due to its far-reaching
implications. Physician burnout has consequences to others beyond the physicians themselves.
Other impacted parties include physicians’ families, patients, coworkers, and society members in
general (Drummond, 2017; Hernandez et al., 2016; Privitera et al., 2014).
Context and Background of the Problem
The organizational setting of the research project is an academic medical center located
in the Eastern United States. An academic medical center is a hospital integrated with a medical
school where medical student education, training of medical residents and fellows, and research
occur as part of the organizational mission (Joint Commission International, 2020). Physicians at
academic medical centers face unique workplace challenges that can lead to burnout. These
2

centers have tripartite missions that encompass clinical workloads, research duties, and teaching
responsibilities, often leading to conflicting priorities for physicians (Del Carmen et al., 2019).
This study examines University Physician Group (UPG). UPG, a pseudonym, is a multispecialty,
employed physician practice located at the academic medical center. University East College of
Medicine (UECM), another pseudonym, is a medical school affiliated with the academic medical
center.
In September of 2019, UPG queried its physicians and learned that over 70% of them
were experiencing symptoms of burnout (UPG Survey, 2019). The dean of UECM, who
spearheaded the study, proclaimed the results to be alarming and vowed to take action to
improve the situation (Anonymous, personal communication, May 27, 2020). The dean
elaborated that additional work was needed to identify the specific causes of the burnout and
what mitigation strategies could be developed to address the problem. The dean welcomed the
completion of this dissertation in practice to continue the improvement effort.
The mission of UPG is to improve the health of community residents through excellence
in health profession education, community service, research, and accessible patient care (UPG
Mission Statement, 2021). UPG has developed an operational goal to enhance physician wellness
by reducing physician burnout to no more than 40% by December 31, 2022. The American
Medical Association published national average physician burnout rate provided the basis for the
goal (American Medical Association, 2020). As physician burnout has become more commonly
recognized as a significant problem in the healthcare industry, organizations like UPG have
become increasingly interested in its pervasiveness and how to address the problem (Babbott et
al., 2017; Del Carmen et al., 2019; Dyrbye et al., 2017, Shanafelt & Noseworthy, 2017). This
study focuses not only on the prevalence of physician burnout but also the causal factors and
3

opportunities to enhance physician well-being, as stated by study participants. The analysis also
includes inquiry into the realms of individual resilience and coping skills and what impact these
traits have on the prevalence of burnout.
Purpose of the Project and Research Questions
This project aims to evaluate the prevalence, causes, and potential solutions to address
physician burnout at an academic medical center during the coronavirus COVID-19 pandemic.
Del Carmen et al. (2019) convey the challenges physicians face in academic medical centers due
to these organizations being characterized by multiple and often competing job demands and
priorities. This dissertation in practice focuses on the various environmental factors that
contribute to physician burnout and how, if at all, resilience and coping strategies mitigate the
existence of burnout and enhance physician well-being. The research questions guiding the study
are as follows:
1. What is the prevalence of physician burnout at an academic medical center,
multispecialty physician group practice?
2. What are the causes of physician burnout at an academic medical center, multispecialty
physician group practice?
3. How, if at all, do individual resilience and personal coping strategies mitigate physician
burnout and enhance physician well-being?
Importance of the Study
The National Academy of Medicine (2019) contends that the learning that has occurred
about physician burnout's epidemiology and etiology has elevated the problem to a public health
concern. The Academy further states that initiatives to address the challenge need to become
national and organizational priorities. Physicians who experience burnout are subject to poor
4

health and disease, including high blood pressure, depression, drug and alcohol addiction, and
suicide risk (Drummond, 2017). Additionally, compared to the general population, suicide rates
of male physicians are up to 70% higher, while suicide rates of female physicians are up to 400%
higher (Duarte et al., 2020; Hampton, 2005; Shepherd et al., 2020). Physician burnout is critical
to address because its ramifications impact not only the physicians themselves but also others.
Physician burnout's negative consequences impact patients, family members of
physicians, and individuals with whom physicians work (Privitera et al., 2014). Patients
receiving care from physicians experiencing burnout are subject to lower-quality care,
experience a higher likelihood of medical errors, and are subject to higher malpractice risk
(Drummond, 2017). Moreover, patients often require longer recovery times after hospital
discharge when cared for by physicians experiencing signs and symptoms of burnout
(Halbesleben & Rathert, 2008). Family members of physicians often serve as the support system
for physicians who are experiencing burnout. However, physicians’ families are often ill-
equipped to provide the necessary help and suffer negative consequences themselves from the
problem (Petronio, 2006). Family members of physicians with burnout often report their own
increased irritability, higher emotional despair, and declines in physical intimacy (“Your Family
Feels the Fallout,” 2018). Physicians dissatisfied with their work lives are more likely to
experience domestic and intimate partner violence in their personal lives (Hernandez et al.,
2016). The work families of burned-out physicians are also subject to undesirable consequences.
Hospitals, clinics, and other work settings in which burned-out physicians practice have higher
nurse turnover rates and poor employee morale (Austin et al., 2017; Owens et al., 2017). Lastly,
physicians who are unhappy with their jobs and display signs and symptoms of burnout often
provide lower-quality care (Dewa et al., 2017; West et al., 2018).
5

Description of Stakeholder Groups
Stakeholder groups are defined as members within an organization that contribute to and
are impacted by the organization's established goals (Clark & Estes, 2008). The stakeholder
groups of interest in this study are UPG physicians, UPG non-physician providers, and the
executive leadership team of UPG. Non-physician providers at UPG are physician assistants,
certified registered nurse practitioners, and psychologists. UPG non-physician providers work
closely with UPG physicians and experience the same stressors and therefore are susceptible to
burnout. In addition to enhancing physician wellness, the dean of UPG is interested in improving
the wellness of non-physician providers. The executive leadership team of UPG includes the
dean and various vice president-level executives who lead and manage the physician practice
plan.
Stakeholder Group for the Study
The stakeholder group of focus for this study is UPG physicians, but information will
also be provided on UPG non-physician providers. Together, UPG physicians and UPG non-
physician providers will be termed “UPG clinical providers.” During a brief assessment of
clinical provider burnout in 2019, the dean of EUCM learned that just over 70% of UPG clinical
providers were experiencing symptoms of burnout. The 2019 survey did not allow for stratifying
the results between physicians and non-physician providers. This dissertation in practice will do
so while concentrating on UPG physicians.
Stakeholder Performance Goals
Table 1 provides the organization’s mission statement, overall organizational
performance goal, and individual stakeholder performance goals pertaining to burnout at UPG.

6

Table 1
Organizational Mission, Overall Performance Goal, and Stakeholder Goals
Organizational Mission

The mission of UPG is to improve the health of community residents through excellence in
health professions education, community service, research, and accessible patient care.

Overall Performance Goal

UPG will reduce clinical provider burnout within its workforce to a rate of no more than 40%
by December 31, 2022.

Physician Goal
By December 31, 2022,
40% or less of all UPG
physicians will be
experiencing burnout.

Non-Physician Provider Goal
By December 31, 2022, 40% or
less of all UPG non-physician
providers will be experiencing
burnout.

Executive Team Goal
By June 30, 2021, the UPG
Executive Team will develop
and implement a formal
operational plan to reduce
clinical provider burnout.

Overview of Theoretical Framework and Methodology
The theoretical framework guiding the study is ecological systems theory. Urie
Bronfenbrenner (1979) developed ecological systems theory explaining how multiple
environmental mechanisms coalesce and impact human behavior. The theory offers a framework
through which one can examine an individual’s interactions and relationships with elements
located within various environmental layers (Christensen, 2010). These tiers are the
microsystem, mesosystem, exosystem, macrosystem, and chronosystem (Bronfenbrenner, 1979;
Hertler et al., 2018). Ecological systems theory is appropriate for studying physician burnout due
to the complexity of the environments in which physicians live and work. The National
Academy of Medicine (2019) details how physicians' immediate frontline care delivery settings,
characteristics of the organizations in which physicians work, and external environmental factors
7

all impact physician burnout and wellness. Applying ecological systems theory to evaluate
physician interaction with various environmental factors provides insight into the causes of
physician burnout and, importantly, how to improve the situation.
The method used in the study is a quantitative survey administered to UPG employed
physicians. The research instrument first assesses the prevalence of burnout by adapting items
from the Copeland Burnout Inventory tool. The survey includes questions that ascertain
respondents' views on various elements in their professional and personal environments,
emphasizing variables in Bronfenbrenner’s defined microsystem and exosystem. Additionally,
the survey incorporates the Brief Resilience Scale (Smith et al., 2008) and Brief Resilient Coping
Scale (Sinclair & Wallston, 2004) to obtain information on respondent resiliency and coping
abilities. Statistical analyses show the linkage between the environmental elements and the
determined presence and degree of physician burnout. The inquiry also shows how resilience and
coping strategies are related, if at all, to burnout. Additionally, the survey enables respondents'
input on what they feel could be done to improve work environments and enhance physician
wellness.
Review of the Literature
This literature review examines the origin of burnout with specific concentration in the
healthcare field, explores the causes of physician burnout, discusses the consequences of
physician burnout, and presents strategies developed to address the problem. The review begins
with a summary of the history of burnout, including an overview of various tools that assess
burnout prevalence. Next, burnout is examined through the lens of ecological systems theory.
Finally, the literature review explores methodologies used to mitigate burnout and enhance
physician wellness.
8

History of Burnout

Burnout is a syndrome studied and debated over time. The existence of burnout dates to
the Old Testament of the Bible, with the prophet Elijah suffering from intense exhaustion, deep
despair, and social disengagement (Muheim, 2012). While often confused with the medical
condition of chronic fatigue syndrome, professional burnout's phenomenology carries a
psychological etiology (Leone et al., 2009). Moreover, the World Health Organization (2019)
defines burnout not as a medical condition but as an occupational phenomenon resulting from
chronic and unmanaged workplace stress. The history of modern burnout research traces to
society's transformation from an industrial culture to a service economy in the last quarter of the
20
th
century (Schaufeli et al., 2008). Literature written and studies completed during that time
disclose the origin of the phenomenon.
Modern-day burnout is a well-studied concept, with research inception occurring in the
mid-1970s. Psychoanalyst H.J. Freudenberger became known as the father of contemporary
burnout research through his work in New York City free drug clinics (Muheim, 2012).
Freudenberger identified that most clinic volunteers experienced emotional depletion, lack of
energy, and other psychosomatic symptoms after working for several months (Freudenberger,
1974). In 1976, social psychologist Christina Maslach completed pioneering research on burnout
through her studies on human service workers, which led to the development of one of what
would become several instruments to assess burnout.
Various survey instruments exist to determine the prevalence of burnout. These include
the Maslach Burnout Inventory Human Services Survey for Medical Professionals, the Bergen
Burnout Inventory, the Copenhagen Burnout Inventory, the Oldenburg Burnout Inventory, and
the Stanford Professional Fulfillment Index (National Academy of Sciences, 2019). While these
9

survey instruments identify the existence of burnout, most do little to ascertain the precise causes
of the burnout, nor do they procure information from survey respondents on how to improve the
situation (Pervez & Halbesleben, 2017). A summary of the burnout survey instruments,
including their specific utilities, is next provided.
Maslach Burnout Inventory (MBI)

The MBI was the first method of burnout measurement developed on a comprehensive
qualitative research platform (Maslach & Leiter, 2016). The MBI measures the three dimensions
of exhaustion, cynicism, and professional efficacy and is one of the most used methods to assess
professional burnout (Schaufeli et al., 2009). The MBI has been used effectively in health care
research, including a study of over 1,500 nurses across 23 hospitals in which better nurse staffing
ratios positively correlated with lower amounts of job burnout and higher nurse job satisfaction
(Liu et al., 2018). Moreover, Shah et al. (2019) used the MBI to identify the prevalence of
burnout within an anesthesiology group at an academic medical center. While the MBI is the
most widely used tool to assess burnout, several other prominent burnout measurement tools are
available.
Additional Burnout Measurement Tools

While the MBI is widely known as the vanguard measurement tool, other prominent
burnout measurement tools exist. These tools vary concerning what burnout dimensions are
measured and in overall popularity (Maslach & Leiter, 2016). The National Academy of
Medicine (2020) states the various available tools have unique advantages and disadvantages,
with some more appropriate for specific populations and settings. Additional measurement tools
include the Bergen Burnout Inventory, Copenhagen Burnout Inventory, Oldenburg Burnout
Inventory, and the Stanford Professional Fulfillment Index.
10

Bergen Burnout Inventory (BBI)
The BBI assesses three dimensions that contribute to burnout. These items are exhaustion
at work, cynicism towards the meaning of work, and feelings of inadequacy at work (Feldt et al.,
2014). The tool measures burnout in various occupations and has been proven valid and reliable
in both research and occupational health contexts (Salmela-Aro et al., 2011).
Copenhagen Burnout Inventory (CBI)
The CBI measures burnout in the realms of personal burnout, work-related burnout, and
burnout caused by interacting with clients (Kristensen et al., 2005). The developers of the CBI
sought to differentiate between the physical and psychological causes of burnout while
mitigating the perceived weaknesses of the MBI tool, which at the time of CBI development had
been utilized in over 90% of the burnout studies conducted across the world (Kristensen et al.,
2005).
Oldenburg Burnout Inventory (OLBI)
The OLBI assesses disengagement from work and two dimensions of exhaustion
(Maslach & Leiter, 2016). Halbesleben and Demerouti (2005) demonstrated how the inclusion of
positively and negatively framed inquiries differentiated the OLBI from previously established
burnout tools. In their validation study, the researchers revealed the OLBI to be a reliable, valid,
and consistent burnout measurement tool.
Stanford Professional Fulfillment Index (PFI)
The PFI assesses burnout in the dimensions of exhaustion and disengagement as well as
professional fulfillment (National Academy of Medicine, 2020). Trockel et al. (2018) determined
that the PFI is a valid measurement tool that assessed professional satisfaction in addition to
11

burnout. Furthermore, the researchers illustrated how the PFI burnout measures correlated highly
with measures included within the widely utilized MBI.
Professional Burnout in Healthcare

Much professional burnout research has focused on careers in the healthcare field due to
the prevalence of job-related stressors in medical occupations. In his seminal work,
Freudenberger (1974) identified burnout to be highly correlated with working in professions that
require individuals to express empathy. Reith (2018) indicated over half of all physicians and
one-third of all nurses experience signs and symptoms of burnout. Numerous other types of
healthcare professionals experience burnout.
Burnout in Medical Professions

Various studies document the prevalence of burnout in healthcare occupations. White et
al. (2019) disclosed up to 55% of nurses experience signs and symptoms of burnout. The
researchers specifically identified a correlation between poor work conditions and higher
burnout. Furthermore, higher levels of professional burnout in nurses were determined to be
associated with poor patient outcomes, including higher patient mortality (Welp et al., 2014).
Medical residents also experience a high degree of burnout. In their research study, Holmes et al.
(2017) identified 69% of medical residents with burnout, with 17% also screening positive for
depression. Rivosecchi et al. (2019) completed a multi-hospital burnout analysis on clinical
pharmacists in which the researchers disclosed 83% of survey respondents had moderate to
severe burnout. Burnout is also widely prevalent in health care social work professionals due to
the stressful nature of the work and associated compassion fatigue (Cocker & Joss, 2016; Denne
et al., 2019; Ostadhashemi et al., 2019). While the latter examples illustrate the commonness of
burnout across medical professions, physicians experience burnout broadly and consistently.
12

Physician Specific Burnout

Physician burnout is a well-documented problem. Research shows that over 50% of
practicing physicians have burnout symptoms at any given time (Dewa et al., 2017; Dyrbye et
al., 2017; Moss et al., 2016; Shanafelt et al., 2019). Burnout rates are closely correlated with
overall job dissatisfaction. Shanafelt et al. (2012) found four out of every 10 physicians
expressed general dissatisfaction with their jobs. The high prevalence of physician burnout
merits systematic investigation into the causes of the problem to lessen burnout and enhance
physician wellness.
Causes of Physician Burnout

Ecological systems theory is a practical model to analyze the causes of physician burnout.
The theory describes how factors in multiple environmental layers exist and contribute to
psychological well-being and human development (Bronfenbrenner, 1979). Diverse
multifactorial relationships between physicians, their work environments, and external
environments influence the incidence and prevalence of physician burnout.
Individual Factors
The inherent traits of individuals influence the prevalence of physician burnout. How one
reacts to stressors that exist in everyday life plays a significant role, and physicians vary in their
ability to deal with these stressors (National Academy of Sciences, 2019). The individual
characteristics of personality, self-efficacy, and introversion all influence physician burnout.
Personality is the individual differences that exist in characteristic patterns of feeling, behaving,
and thinking (American Psychological Association, 2020). Raymond et al. (2018) explained that
personality influences the types of careers people choose, impacts how people experience
anxieties, and affects the coping strategies individuals use to manage stress. The authors
13

elaborated on how the personality trait of neuroticism, a quality characterized by anxiety,
irritability, and low self-esteem, is known to be an essential risk factor for the presence of
burnout. Similarly, Carver and Conner-Smith (2010) proclaimed that individuals with personality
traits compatible with resilience are less likely to experience burnout. Self-efficacy and
introversion are also correlated to burnout. Yao et al. (2018) disclosed low self-efficacy in
inherent medical professional job duties to be associated with high levels of burnout. The
algorithm developed showed high levels of stress, low self-efficacy, and introverted personalities
to be the top three factors in predicting burnout. Individual resilience and coping skills can also
play a role in the existence of burnout.
Physician resilience and stress mitigation strategies can impact vulnerability to burnout.
Szanton and Gill (2010) described resilience as the ability to remain positive and sustain well-
being while under adversity. Guo et al. (2018) demonstrated the importance of resilience in their
research, which showed higher resilience levels to be associated with lower levels of burnout.
Similarly, research studies have shown physicians who adopt task-focused stress coping
strategies such as exercise, taking part in hobbies, and spending time with family and friends are
at a lower risk of experiencing burnout (Balayssac et al., 2017; Oskrochi et al., 2016).
Microsystem Influences

Microsystem factors have a significant impact on physician burnout as they define the
immediate social context of individuals (Lomas, 2019). Microsystem influences on physician
burnout include their patients, families, peers, and work settings. The nature of physician work
itself can contribute to burnout. Higher workloads are associated with increased levels of
physician burnout and physical fatigue (Shirom et al., 2010). Drummond (2015) showed that
dealing with sick, scared, and dying people is emotionally draining work from a cognitive
14

perspective. Work setting influences include factors specific to the job as well as organizational-
centric elements.
Kristensen et al. (2005) identified that working directly with clients may cause burnout.
The researchers defined client-related burnout as the degree of exhaustion caused by working
with customers. For physicians, the customers are patients. The interactions physicians have with
patients can impact the well-being of both the physicians and the patients (Hines et al., 2017).
Physicians' microsystems also include their family members and peers, both of which impact
physical and emotional well-being. Wang et al. (2012) revealed family factors that interfere with
physicians' work to be positively correlated to the prevalence of exhaustion and cynicism in
physicians.
Factors in physician workplaces also play a role in the existence of physician burnout.
These organizational-specific factors include job demands and job resources. Excessive job
demands and inadequate organizational resources can be psychological stressors and contribute
to burnout (National Academy of Sciences, 2019). Organizational culture, value alignment,
administrative burden, communication, gratitude, and trust in leadership are also essential
factors. The conceptual framework of this study incorporates these elements as guiding
principles.
Mesosystem Interactions
In ecological systems theory, the mesosystem consists of associations between the
elements that make up the microsystem (Bronfenbrenner, 1979). For physicians, these
associations include patient family involvement in patient care and peer engagement in work
environments. Patient and family-centered care (PFCC) is an approach to patient care centered
on partnerships among physicians, patients, and families. The goals of PFCC are to achieve
15

better medical outcomes, improve care experiences, use resources efficiently, and enhance
physician satisfaction (Institute for Patient and Family-Centered Care, 2020). PFCC increases
family member involvement in the treatment of patient medical conditions, which can add
complexity to physician work. Additionally, peer interactions and perceptions of work
environments can directly influence physician behavior, attitudes, and productivity (Williams,
2020).
Exosystem Elements

Elements in the external environment of physicians in which they have no direct
interaction also impact physician burnout. A significant amount of literature exists on how
regulatory requirements, laws, and bureaucratic pressures contribute to physician burnout
(Drummond, 2015; Privitera et al., 2014; Shanafelt et al., 2012). One regulatory requirement
widely discussed is the electronic health record and whether it is helpful or detrimental to
physician clinical workflows. Babbott et al. (2014) noted that electronic health record use
correlates to higher physician burnout levels. Electronic health records also create the need for
physicians to work outside of the workplace to keep up with documentation requirements. In
their research, Arnt et al. (2017) revealed that the average physician spends over an hour each
night after work on electronic health record tasks, including needed chart reviews and record
keeping. Documentation requirements created by regulatory rules engender the need for
physicians to spend time completing work tasks other than providing direct patient care.
Sinsky et al. (2017) showed that physician requirements to follow regulatory rules for
patient documentation led physicians to spend more time completing paperwork than caring for
patients. Other research showed physicians to be frustrated with Medicare and other payer
reimbursement protocols, which included declining payment levels and the need to prospectively
16

garner approval from insurance companies before being able to provide care to patients (Dyrbye
et al., 2013). Such restrictions on physicians’ ability to practice medicine can often lead to job
dissatisfaction and burnout (Shirom et al., 2010). Rabatin et al. (2016) divulged external
environment-imposed requirements on doctors to be perceived by physicians themselves as
creating hostile work environments, which in turn led to a higher likelihood of burnout and
desire to leave the medical profession.
Macrosystem Aspects

Macrosystem elements include overall societal attitudes and perceptions of the physician
occupation. Society expects competence, compassion, and a high amount of personal integrity
from physicians (Old et al., 2011). The public also expects physicians to be engaged and
involved in community activities and affairs (Cruess & Cruess, 2008; Novosel & Kohn, 1979).
Such expectations on an already demanding workload can worsen physician burnout.
Cultural demands on physicians include the expectation that physicians conduct
themselves with a high amount of empathy while working intensely. Lafreniere et al. (2016)
noted an association between patient perception of physician empathy and the level of burnout
experienced by physicians. The researchers conducted a multilevel regression analysis in which a
positive correlation was determined between high amounts of physician depersonalization and
greater degrees of empathy expressed to patients. Physicians are also expected to work hard and
make personal sacrifices, which can lead to stress and burnout (Frank, 2017).
Chronosystem Features

The chronosystem deals with elements of time, including transitions and shifts during life
(Sincero, 2012). Educational requirements and job demands can create challenges at many stages
of physicians’ lives. Research has shown that the total required years of education needed to
17

become a physician contributes to burnout. Shanafelt et al. (2017) illustrated in a multivariate
analysis that individuals with a Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine
(D.O.) degree are more likely to experience burnout than individuals who have no degree, a
bachelor’s degree, or a master’s degree. The age of physicians has also been an essential factor in
the incidence and prevalence of burnout. Dyrbye et al. (2014) reported that physicians age 55
and younger are 200 times more likely to experience burnout than those age 56 and older. Also,
the researchers noted physicians with children age 21 and younger to be at significantly
increased odds of experiencing burnout.
Chronosystem elements for physicians also include the passage of the Patient Protection
and Affordable Care Act (ACA) of 2010 and the novel coronavirus COVID-19 pandemic of
2020. The ACA impacted physician work by implementing new measures aimed to increase
patient access to care, reduce health care spending, and improve quality (Doran et al., 2017). The
strain on resources and psychological impact COVID-19 imposed on physicians may have long-
term implications on physician wellness and physician burnout prevalence (Shah et al., 2020).
Early indications are that the pandemic is having a detrimental impact on physician well-being
(Fessell & Cherniss, 2020; Fiorillo & Gorwood, 2020).
Consequences of Physician Burnout
Physicians who experience burnout are subject to personal poor health and disease,
including high blood pressure, depression, drug and alcohol addiction, and suicide risk
(Drummond, 2017). Importantly, physician burnout has implications beyond the negative impact
on the physicians themselves. The negative consequences of physician burnout can affect
physician families, coworkers, and patients (Privitera et al., 2014). Physician families often serve
as the support system for physicians who are experiencing burnout. However, they can often not
18

provide the assistance necessary and frequently end up with negative consequences themselves
from the problem (Petronio, 2006). Family members of physicians with burnout often report
increased irritability, higher emotional despair, and declines in physical intimacy ("Your Family
Feels the Fallout," 2018). Hernandez et al. (2016) revealed physicians who are dissatisfied with
their work lives are more likely to experience domestic and intimate partner violence in their
personal lives. The work families of burned-out physicians are not spared from associated
undesirable consequences. Hospitals, clinics, and other work settings in which dissatisfied
physicians practice are more likely to have higher nurse turnover rates and poor employee
morale (Austin et al., 2017). Such work environments can contribute to inferior patient care.
Research has shown that the quality of patient care, in general, is lower when the care is
provided by physicians who have symptoms of burnout and are unhappy with their jobs (Dewa et
al., 2017; West et al., 2018). The negative consequences to patients from physician burnout can
include lower quality of care received, more medical errors, and increased malpractice risk
(Drummond, 2017). Halbesleben and Rathert (2008) disclosed that physician burnout contributes
to longer needed recovery times for patients after being discharged from the hospital.
Furthermore, burnout comes with negative financial consequences for organizations.
Physician burnout generates deleterious fiscal impact in several ways. Han et al. (2019)
demonstrated that physician burnout is costing the United States approximately $4.6 billion per
year. The cost includes missed physician work due to leaves of absence, lower productivity, and
turnover. A study of physicians at the Mayo Clinic revealed that each 1-point increase in burnout
was associated with a 30%–50% increase in likelihood physicians would purposely reduce their
productivity over the following two years (Shanafelt et al., 2016). Productivity reduction came in
the form of more time away from work and less exerted effort, leading to less organizational
19

revenue and lower profitability. The American Medical Association (2018) created an online
calculator that enables the cost of physician burnout to be estimated at the individual
organization level. The tool calculates the average cost to replace each physician that leaves an
organization due to burnout to be $25,000. Physician burnout is financially detrimental to
organizations. The fiscal aspect, coupled with the many other harmful implications, demonstrates
the need to develop strategies to address the problem.
Strategies to Address Physician Burnout
The importance of dealing with physician burnout has resulted in research studies to
determine approaches to address the issue. Several studies have focused on improvements in
physician involvement in their own personal wellness. Montgomery (2016) showed that
physicians taking a more active role in their health and wellness effectively reduces burnout.
Wellness enhancement can be achieved through physicians being willing to participate in well-
being initiatives and is influenced by the environments in which physicians work. Several
research studies have identified that physicians rely on support structures that include personal
relationships and spirituality to improve their personal wellness (Arnold et al., 2018; Doolittle,
2020; Weiner et al., 2001). The consistent finding in these studies was that physicians who
actively engage in improving their well-being through engagement with support structures in
their lives experienced increased job satisfaction and less burnout.
Shapiro et al. (2019) developed a physician wellness model closely resembling Maslow's
hierarchy of needs in which a tiered approach is advocated to address physician burnout. The
authors intimated the importance of organizational leaders to first address physician health and
wellness before considering all others' needs, including the needs of patients. Bohman et al.
(2017) discussed the importance of creating wellness cultures in which physicians can work. The
20

authors defined a culture of wellness as one that incorporates policies and behaviors that promote
caring for oneself, professional growth, and compassion. The importance of selecting and
cultivating leaders who value these characteristics was also stressed as leadership itself has been
shown to influence physician burnout and job dissatisfaction (Shanafelt et al., 2015; Wallace &
Lemaire, 2007; Williams et al., 2007).
Enhancing organizational leadership is another approach to reduce physician burnout.
Shanafelt et al. (2015) identified that improving the leadership skills of those who directly
supervise physicians results in lower physician burnout rates. The researchers completed a
multivariate analysis that assessed the presence of physician burnout while simultaneously
having the physicians rate the leadership qualities of their supervisors. The results showed the
perception of better leadership to be directly correlated to lower physician burnout, with each 1-
point increase in leadership score associated with a 3.3% decrease in burnout. Furthermore,
organizations with leaders who communicate well and engage physicians may experience lower
amounts of physician burnout. Wallace and Lemaire (2007) illustrated that physician job-related
stress could be lessened by engaging physicians directly in developing organizational goals and
decision-making. Organizations that understand the value of engaging physicians are often those
that also strive to create work environments where physicians have direct involvement in
decisions that impact their work lives.
Creating professional environments that foster work-life balance and autonomy at work is
another strategy to reduce physician burnout. Patel et al. (2020) disclosed the lack of work-life
balance caused in part by administrative burden led physicians to experience greater degrees of
burnout while simultaneously resulting in their family lives suffering and personal hobbies being
abandoned. Conversely, Shirom et al. (2010) identified greater degrees of work-life balance and
21

higher amounts of autonomy at work to be associated with lower levels of burnout and reduced
physical fatigue. Rothenberger (2017) demonstrated an effective strategy to improve physician
wellness is enabling physicians to devote 20% of their work time to activities that are especially
meaningful to them, further exhibiting the utility of autonomy. Organizations that facilitate work
environments that enhance personal resilience and access to self-care are often considered
healthier workplaces and ones that enhance physician wellness.
Improving individual resiliency and augmenting self-care are methods organizations use
to address physician burnout. Resiliency is the ability to bounce back from stressful
circumstances by being adaptable and positive in response to change and diversity (Stanford
Medicine, 2020). However, many organizations offer resiliency training to physicians with
mixed results. Sood et al. (2014) found the Stress Management and Resiliency Training
(SMART) program effectively improves physician resiliency, leading to decreased stress and
anxiety. The researchers completed a single-blind trial with a control group to ultimately disclose
a statistically significant improvement in perceived stress, anxiety, and quality of life for those
physicians completing the SMART program when compared to those in the control group that
did not. Conversely, Dyrbye et al. (2017), in a longitudinal study, observed that a mandatory
mindfulness-based stress management course did not lead to measurable improvements in the
reduction of physician burnout. Self-care is defined as any activity that one undertakes to protect
or enrich mental, emotional, or physical health (Michael, 2018). Activities such as seeking
preventative medical care, participating in exercise and fitness health, and eating a healthy diet
can improve physicians’ ability to be most effective when caring for others (Ghossoub et al.,
2018; Kuhn & Flanagan, 2017). Physicians sometimes receive organizational attempts to
enhance personal resilience and improve access to self-care with skepticism, viewing such
22

efforts as a blaming the victim approach to improving the situation (Rozario, 2019). Enhancing
resilience and increasing self-care are more effective when combined with sincere organizational
efforts to optimize work environments and enhance organizational cultures (Shanafelt &
Noseworthy, 2017).
Conclusion
In summary, physician burnout is a complex problem that merits further investigation and
intervention. While the concept of burnout is not new, the prevalence of burnout amongst
physicians has risen to the level of a national health concern. The condition results in negative
consequences to physicians themselves, their families, and others. Several strategies have been
used to address physician burnout with varying degrees of success. The purpose of this
dissertation in practice was to identify the prevalence of physician burnout, establish the causes
of the burnout, and determine what can be done to improve the situation at an academic medical
center multispecialty physician group. The following describes the methodological framework
that guided the investigation.
Conceptual Framework
Ecological systems theory (Bronfenbrenner, 1979) offered the foundation for the
conceptual framework of the study. The prevalence of burnout at the individual physician level,
causes of burnout due to elements in immediate physician environments, and external
environmental factors were examined. Emphasis was placed on organizational-specific
influences. These organizational variables included items that embody the corporate culture,
including personal and organizational value alignment, leadership communication, job
engagement, gratitude, and trust. Whether these organizational-specific factors are perceived
positively or negatively were assessed in tandem with the external environmental factors
23

contributing to physician burnout. The physicians reside at the center of the conceptual
framework with their individual resiliencies and abilities to cope with stressors that cause
burnout.
Organizational cultures play a significant role in the behavior of employees. Schein
(1990) noted that an organization's values and beliefs guide the way individuals interact with
each other and behave while at work. Value alignment is described as the congruency of personal
values to the values espoused by the organization in which one works (Posner, 2010). Rich et al.
(2010) defined job engagement as the investment of individuals' complete selves into their roles.
Lanham et al. (2012) proclaimed the importance of proper workplace reward, recognition, and
gratitude by showing a correlation between low workplace gratitude and higher emotional
exhaustion, and lower job satisfaction. Lastly, organizational trust is the positive expectations
that employees have about multiple organizational members' intents and behaviors based on
corporate roles, relationships, experiences, and interdependencies (Shockley-Zalabak et al.,
2000).
Grant and Osanloo (2014) state that the conceptual framework of a research study should
portray how the researcher believes a problem can best be explored as well as the relationship
between different variables within the study. Complementary to ecological systems theory, this
study's conceptual framework incorporated elements from various environmental layers and how
these elements coalesce to influence physician burnout. These factors from the environment,
specific items unique to individual physicians, and the consequences and learnings that result
guided the research plan. The illustration of the conceptual framework in Figure 1 symbolizes
this philosophy.

24

Figure 1
Conceptual Framework

25

Methodology
This study's methodological design was a quantitative survey administered to all UPG
physicians and non-physician providers utilizing a census sampling approach (N =140). The
survey was conducted over a three-week period in the fall of 2020, which coincided with an
influx of COVID-19 patients at the academic medical center where the clinical providers work.
The UPG Physician Burnout Taskforce leader sent multiple periodic email reminders to the
clinical providers to complete the survey, and the dean of EUCM personally contacted clinical
providers to ask for their support in completing the survey. These efforts led to 119 completed
surveys (response rate = 85%), which statistically yielded a 99% confidence level and a 5%
margin of error (Raosoft, 2021).
The study's target population consisted of employed physicians of a multispecialty
physician group at an academic medical center. The sampling approach incorporated a single-
stage, universal methodology that encompassed the total physician census of the organization (N
= 98) along with the total non-physician providers (N = 42). The single-stage method was
appropriate due to having access to the entire populace of eligible clinical providers (Creswell &
Creswell, 2018). The quantitative approach for this research project was justified as quantitative
methods are best used for collecting data from large groups and are the preferred way to collect
opinions, attitudes, and sensitive information anonymously (R. Sanchez, personal
communication, March 7, 2020). Furthermore, quantitative surveys allow data to be obtained in a
way that permits the completion of statistical analyses that result in valid and reliable findings
that can be scaled to other similar survey populations (Creswell & Creswell, 2018).
The quantitative survey included questions to determine the prevalence of physician
burnout, the specific causes of physician burnout, and, from the view of the survey participants,
26

what actions can be taken to mitigate physician burnout and enhance physician wellness. The
survey adapted questions from the Copenhagen Burnout Inventory (CBI) tool and added content-
specific questions to acquire data consistent with the study’s conceptual framework. The CBI
tool measures burnout in the specific areas of personal burnout, work-related burnout, and
burnout caused by interacting with clients (Kristensen et al., 2005). Components of The Brief
Resilience Scale (Smith et al., 2008) and Brief Resiliency Coping Scale (Sinclair & Wallston,
2004) were adapted and included in the survey instrument to allow for statistical analysis on
resiliency and coping skill influences on the existence of burnout. Several open-ended survey
questions were included in the survey to solicit input on participants' views on the most effective
way to enhance physician wellness at UPG. These open-ended questions provided rich data
similar to interview data and were coded using Atlas Ti, providing a quasi-qualitative
methodology to the research project. Additionally, the survey collected various demographic
elements, including age, gender, medical specialty, and length of time employed at the
organization, enabling stratification and data analysis by demographic segment. The research
questions and data sources for the study are summarized in Table 2.

27

Table 2
Data Sources
Research Questions Quantitative Survey
RQ1: What is the prevalence of physician burnout at an academic
medical center, multispecialty physician group practice?
X
RQ2: What are the causes of physician burnout at an academic
medical center, multispecialty physician group practice?
X
RQ3: How, if at all, do individual resilience and personal coping
strategies mitigate physician burnout and enhance physician
well-being?
X

Research Setting
The research occurred at a multispecialty physician group practice located at an academic
medical center in the Eastern United States. The physician group is named University Physician
Group (UPG), a pseudonym to protect its anonymity. At the time of the investigation, UPG
employed 98 physicians and 42 non-physician providers across 10 different medical specialties.
The research participants were physicians with either a Doctor of Medicine (M.D.) or Doctor of
Osteopathic Medicine (D.O.) degree, psychologists, physician assistants, and certified registered
nurse practitioners. Information about the researcher in this study is provided in Appendix B.
Data Sources
The project's primary data source was a quantitative survey administered to UPG
physicians and UPG non-physician providers during the fall of 2020. The survey instrument is
provided in Appendix C. The study also incorporated secondary data analysis by reviewing the
results obtained from a brief inquiry that assessed clinical provider burnout at UPG in the fall of
2019. The 2019 questionnaire provided an overall baseline measure of clinical provider burnout
of UPG as well as high-level information on what may have been causing burnout at the time.
28

These results served as the foundation for assessing improvement from baseline in the 2020
survey.
Participants
Study participants included two of the three main stakeholders: UPG physicians and UPG
non-physician providers. While the focus of this dissertation in practice is physician burnout, the
inclusion of non-physician providers provided valuable information to the EUCM dean. The
non-physician provider information also enabled completing statistical analyses on the
similarities and differences between the two groups. Pazzaglia et al. (2016) state the importance
of administering surveys at less busy times for respondents to achieve higher response rates. This
project's timing did not permit adherence to the latter. The survey occurred during the COVID-
19 global pandemic, specifically when the UPG clinical providers were caring for large numbers
of COVID-19 positive patients. The providers’ engagement coupled with the leadership of the
EUCM dean and physician burnout taskforce enabled an overall survey response rate of 85%,
which is a testament to the importance of this study to UPG.
Instrumentation
The survey instrument incorporated 38 questions that obtained information about the
prevalence of burnout, the factors causing the burnout, and the respondents' views on their
resiliency and coping abilities. An additional three open-ended questions provided insight into
what survey participants felt could be done to reduce burnout and improve wellness at UPG.
Lastly, the survey collected demographic information from the survey participants that enabled
statistical analyses to be completed on the survey participant population's specific demographic
segments. In total, the survey took approximately 10 minutes for participants to complete.
29

The survey design provided answers to the three research questions and mirrored this
study's theoretical and conceptual frameworks. Elements from the various environmental layers
of ecological systems theory were assessed on how, if at all, they contribute to physician burnout
and impact physician wellness. Specific questions on individual resiliency and coping strategies
allowed for correlation analyses to be completed on what association, if any, existed between
burnout and resiliency with the survey participants. Information procured from survey
respondents regarding their views on reducing burnout and enhancing wellness at UPG provided
rich data that was coded to determine frequencies. This qualitative-like information also offered
insight to guide recommendations for improvement.
Data Collection Procedures
Study participants received the survey electronically by email on October 31, 2019,
immediately after a faculty meeting during which the dean of EUCM previewed the survey and
implored participation. Various reminders were sent to the survey population to complete the
survey over the next sixteen days before the survey's close on November 16, 2019. Robinson and
Leonard (2019) note the importance of sufficient and engaging reminders to survey audiences
that include a brief overview of the survey's purpose, instructions on how to complete the survey,
the deadline for the survey responses, and contact information should respondents have questions
regarding the study. The survey process incorporated all the aforementioned elements.
Data Analysis
The researcher analyzed data from the 2020 survey using the IBM Statistical Package for
the Social Sciences (SSPS) software and Qualtrics Stats iQ. Pearson’s correlation coefficient
calculations were completed between the physician burnout results and numerous variables
included within the survey instrument to determine the most significant factors contributing to
30

UPG physician burnout. Linear regression analyses were completed after the correlation
calculations to determine lines of best fit for predicting future burnout based upon the association
between the various independent variables and the dependent variable of burnout. Data analysis
also involved calculations in Microsoft Excel, including tabulating the Copenhagen Burnout
Inventory scores and descriptive statistics calculations.
Secondary data analysis was also a key component of the study. In September of 2019,
UPG sent an internally created survey to its physicians and non-physician providers that included
a question from the American Medical Association (AMA) Mini Z burnout tool, which measures
overall burnout. The AMA Mini Z is a short, 10 question survey that assesses job satisfaction,
stress, and electronic health record use efficacy (Mayzell & Normand, 2020). The researcher in
this dissertation in practice reviewed and analyzed the results of the 2019 questionnaire and
various historical materials from the UPG physician burnout taskforce. In addition, the
researcher participated in the UPG physician burnout taskforce meetings and activities during the
time of his research, which provided invaluable insight for this study.
Validity and Reliability
Validity and reliability are essential considerations in quantitative studies. Reliability
refers to the consistency of survey results, while validity refers to whether a study measures what
it intends to measure (Salkind, 2014). Reliability increases as the confidence level increases and
the margin of error decreases (Pazzaglia et al., 2016). This study's survey achieved a confidence
level of 99% and a 5% margin of error (Raosoft, 2020). Survey responses were maximized by
allowing anonymous submissions, sending advance communication to potential respondents on
the purpose and importance of the survey, and distributing frequent reminders.
31

Studies on the three survey tools' psychometric properties adapted and adopted for use in
this research study have yielded favorable results. The Copenhagen Burnout Inventory
demonstrates content validity, internal consistency, and test-retest reliability when assessing
burnout (Fong et al., 2014; Mahmoudi et al., 2017). The Brief Resilience Scale shows
convergent validity, discriminant validity, and construct validity when measuring resiliency
(Kyriazos et al., 2018). Finally, Limonero et al. (2014) determined that the Brief Resilient
Coping Scale generates consistent reliability and temporal stability in assessing coping
tendencies.
Findings
The purpose of this project was to determine the prevalence of physician burnout at an
academic medical center, the causes of the burnout, and whether individual resiliency and coping
skills influence burnout. Study participants completed a quantitative survey during the fall of
2020 to answer the following research questions:
1. What is the prevalence of physician burnout at an academic medical center,
multispecialty physician group practice?
2. What are the causes of physician burnout at an academic medical center, multispecialty
physician group practice?
3. How, if at all, do individual resilience and personal coping strategies mitigate physician
burnout and enhance physician well-being?
The ecological systems-based conceptual framework of this study provided the
foundation for the survey design. This section provides the results and findings while
establishing the basis for recommendations moving forward. The segment begins with a
demographic overview of the survey participants. Statistical properties of various adapted survey
32

instruments used to create the conceptual framework for this study are next analyzed to establish
validity and reliability. Information is next presented that answers each of the study’s three
research questions. Findings are delivered through the lens of ecological systems theory with
causes of physician burnout identified in the microsystem, exosystem, macrosystem, and
chronosystem. Individual factors are next analyzed on how, if at all, resiliency and coping skills
impact the existence of burnout. Finally, this section concludes with an overall summary of the
findings serving as the basis for the subsequent recommendations.
Participating Stakeholders
Participating stakeholders in this study were UPG physicians and UPG non-physician
providers, consisting of physician assistants, certified registered nurse practitioners, and
psychologists. When referred to as one entire group in these findings, UPG physicians and UPG
non-physician providers are termed “UPG clinical providers.” The results in this section will
focus primarily on physicians with UPG non-physician provider data incorporated in appendices.
Survey Participants
The quantitative survey utilized universal census sampling of UPG clinical providers (N
= 140) with an equal opportunity for each provider to participate. Key demographic
characteristics of the survey participants (n = 119) are provided in Table 3.
Table 3
Demographic Overview of Survey Participants
Characteristic n % n (119)

Professional Position
Physician
Non-physician Provider
Chose not to Answer

84
26
9

70.6
21.8
7.6

Gender
Male
Female

41
56

34.5
47.0
33

Characteristic n % n (119)
Non-Binary
Chose not to Answer
0
22
0.0
18.5

Age
25 to 39
40 to 54
50 to 69
70 and Over
Chose not to Answer

48
45
15
1
10

40.3
37.8
12.6
0.9
8.4

Ethnicity
White
Black or African American
Hispanic/Latino/Spanish Origin
Asian
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Other
Chose not to Answer

72
3
3
13
0
0
8
20

60.5
2.5
2.5
10.9
0.0
0.0
6.8
16.8

Household Status
Living with a Significant Other
Not Living a With Significant Other
Chose not to Answer

95
12
12

79.8
10.1
10.1

Medical Specialty
Behavioral Medicine
Family Medicine
Internal Medicine-General
Internal Medicine-Subspecialty
Obstetrics and Gynecology
Pathology
Pediatrics
Radiology
Surgery-General
Surgery-Surgical Subspecialty
Other
Chose not to Answer

7
29
4
11
5
3
11
1
9
4
7
28
5.9
24.4
3.4
9.2
4.2
2.5
9.2
0.9
7.6
3.4
5.9
23.4

Statistical Validity and Reliability of the Conceptual Framework
The Copenhagen Burnout Inventory, Brief Resilient Coping Scale, and Brief Resiliency
Scale are quantitative survey instruments with proven psychometric properties (Fong et al., 2014;
Kyriazos et al., 2018; Limonero et al., 2014). Components of these tools populated the survey
34

instrument designed for this study. Additional survey questions mirrored the conceptual
framework and included multiple inquiries into autonomy and perceptions about the electronic
health record.
Internal consistency reliability is an important measure that determines whether and how
strongly items in a scale correlate and accurately test the same construct (Salkind & Frey, 2020).
Cronbach's alpha is a statistical test that measures internal consistency reliability. Cronbach’s
alpha scores, referred to as reliability coefficients, range from .00 to +1.00 and are higher when
more certainty exists that individual items within a scale relate to one another. Cronbach alpha
scores of .70 and higher are considered acceptable for proving strong internal consistency
reliability (Salkind & Frey, 2020). All adapted scales used in this study’s survey instrument rated
adequate in internal consistency reliability except for the Copenhagen Burnout Inventory scale
that measures client-related burnout, which computed slightly below the .70 threshold (α = .60).
Table 4 provides the Cronbach Alpha scores for the various scales used in this study.
Table 4
Internal Consistency Reliability Scores

Scale

N
Number of
Items
Cronbach’s
Alpha (α)
Copenhagen Burnout Inventory – Individual Burnout 119 3 .76
Copenhagen Burnout Inventory – Work-related Burnout 115 4 .85
Copenhagen Burnout Inventory – Client-related Burnout 114 3 .60
Brief Resilient Coping Scale 110 3 .76
Brief Resiliency Scale 111 3 .85
Autonomy 113 2 .71
Electronic Health Record Responsibilities 112 4 .82

35

Research Question 1: What is the Prevalence of Physician Burnout at an Academic
Medical Center, Multispecialty Physician Group Practice?
Two methodologies determined the prevalence of physician burnout at UPG in this study.
The first methodology incorporated scoring from the Copenhagen Burnout Inventory (CBI)
components of the survey instrument. The second methodology was the self-reported burnout
levels as stated by survey participants when answering the AMA Mini Z question embedded
within the survey. The CBI measures burnout in three areas: individual burnout, job-related
burnout, and burnout from working with clients. This study adopted three questions from the
CBI individual burnout scale, four questions from the job-related burnout scale, and three
questions from burnout from the working with clients scale, which in this case, the clients were
patients. The CBI incorporates a Likert scale in which answers of “Always” are considered
severe burnout, responses of "Often" are regarded as high burnout, answers of “Sometimes” are
deemed to be moderate burnout, replies of “Rarely” are considered low burnout, and answers of
“Never” are considered no burnout. Scoring of the CBI revealed a total UPG physician burnout
prevalence of 66.5% comprised of moderate burnout (35.0%), high burnout (25.9%), and severe
burnout (5.6%). Table 4 encapsulates the CBI results. UPG physician responses to each CBI
question can be found in Appendix E.

36

Table 5
UPG Physician CBI Calculated Burnout
Response
Always Often Sometimes Rarely Never
CBI Item n % n % n % n % n % M SD
Individual
Burnout
9 3.6 70 27.8 84 33.3 63 25.0 26 10.3 2.9 0.8
Job
Related
Burnout
15 4.5 95 28.4 112 33.4 88 26.3 25 7.4 3.0 0.8
Patient-
related
Burnout
23 9.2 52 20.7 97 38.6 63 25.1 16 6.4 3.0 0.7
CBI Total 47 5.6 217 25.9 293 35.0 214 25.5 67 8.0 3.0 0.6

Self-reported burnout results from the AMA Mini Z tool yielded similar physician
burnout prevalence. Scoring using the AMA Mini Z tool ranges from not experiencing any stress
or burnout (Likert scale score = 1) to total burnout where the responder has or plans to seek help
(Likert scale score = 5). This study's findings are that 57.2% of UPG physicians are experiencing
at least some amount of burnout, with the statistical mode being significant burnout (n = 25).
Overall, respondents scored high in self-reported prevalence of burnout (M = 2.9, SD = 1.2),
consistent with the CBI findings. Table 6 summarizes the prevalence of physician burnout at
UPG when considering the results from the question adopted from the AMA Mini Z tool.

37

Table 6
UPG Physician AMA Mini Z Self-Reported Burnout

Survey Item Response Likert Scale Score n % N = 84

Q.30 Using your own
definition of burnout,
please select one of the
following that best
describes you at the
current time

No Stressors or Burnout
Slight stress; No Burnout
Slight Burnout
Significant Burnout
Complete Burnout

1
2
3
4
5

15
21
18
25
5

17.9
25.0
21.4
29.8
6.0

Note. M = 2.88, SD = 1.16
Physician burnout at UPG ranges from 57.2% to 66.5%, depending on which measure is
used to determine prevalence. An analysis comparing the CBI and AMA Mini-Z tools'
correlation produced a strong positive correlation, r(111) = .77, p < .001. Figure 2 provides the
correlation of the CBI and AMA Mini Z scales used in this study.

38

Figure 2
Correlation Analysis: CBI and AMA Mini Z Scores

Note. y = 1.3875x – 1.2931; r
2
= .59
Analyzing the CBI and Mini Z scoring for UPG non-physician providers reveals higher
burnout amounts. UPG non-physician provider burnout measured 75.8% when using the CBI
results and 69.2% when considering the AMA Mini Z question scoring. Appendix F includes the
detail for the UPG non-physician provider burnout scores.
Research Question 2: What are the Causes of Physician Burnout at an Academic Medical
Center, Multispecialty Physician Group Practice?
This study's survey instrument incorporated questions to determine the causes of
physician burnout consistent with ecological systems theory. Questions were also included that
allowed participants to list and rank the items that cause personal stress and burnout feelings.
39

The Likert scale questions in the survey instrument provided quantitative data to complete
correlation and regression analyses. Also, several open-ended survey questions provided content-
rich data from survey participants on their opinions in certain areas. The results of the study
revealed a wide range of factors that are causing physician burnout at UPG. Moreover, the
statistical analysis uncovered stronger correlations between certain predictor variables and
burnout.
Self-Reported Causes of Burnout
Question 31 of the survey instrument queried respondents to identify the items that cause
their burnout. Question 32 then asked the respondents to rank the items cited in Question 31 in
order of importance from the item causing the most amount of burnout to the least. UPG
physicians most often cited limited support staffing at their workplace as the reason for
experiencing burnout. The top results from physician respondents to this inquiry are summarized
in Table 6. Appendix G provides the results for this question for all UPG clinical providers.
Table 7
UPG Physician Top Self-Reported Causes of Burnout
Survey Item Response
n Times
Cited as a
Reason
for
Burnout
n Times
Cited as
Top Reason
for
Burnout
% Times
Cited as
Top
Reason for
Burnout
Q.34 For the amount of
burnout that you just
self-identified, what
would you say is/are
the cause(s) of the
burnout (choose all that
apply)?

Limited support staffing at
my workplace

Electronic Health Record
(EHR) Requirements

The COVID-19 Pandemic

Administrative Burden
(e.g., payor authorizations,

32

27

26

10

5

1

31.3

18.5

3.8

40

Survey Item Response
n Times
Cited as a
Reason
for
Burnout
n Times
Cited as
Top Reason
for
Burnout
% Times
Cited as
Top
Reason for
Burnout
regulatory requirements,
CMS compliance, etc.)

The need for improved
communication at my
workplace
25

20
3

1
12.0

5.0

The remaining findings for the causes of physician burnout are presented in the various
ecological systems theory realms mirroring this study's conceptual framework while utilizing the
results from the Copenhagen Burnout Inventory component of this study. Quantitative data from
the Likert scale survey instrument and qualitative information obtained from the three open-
ended survey questions are presented. Pearson’s correlation coefficients show the relationship
between variables discovered to be causing physician burnout at UPG. Scatterplot diagrams are
provided depicting actual survey results. Additionally, linear regression analysis lines of best fit
are overlayed onto the scatterplot diagrams to illustrate the likelihood that the data collected can
accurately predict the future occurrence of burnout based upon the independent variable in each
scenario (Salkind & Frey, 2020).
Microsystem Influences on Physician Burnout
In ecological systems theory, microsystem factors can significantly influence physician
burnout because they define physicians' immediate social environments (Lomas, 2019).
Statistically significant microsystem influences on physician burnout established in this study
were the work-related factors of leadership communication, gratitude, support staffing, and
autonomy. Family-related stressors were not found to be statistically significant but are included
41

in the findings due to their importance in the ecological systems theory framework. Incorporating
the various microsystem influences as independent variables with the dependent variable of
physician burnout enabled Pearson correlation coefficients to be calculated.
Leadership Communication
The Pearson correlation test results yielded a strong negative relationship between
effective leadership communication and physician burnout, r(81) = -.56, p < .001. As respondent
ratings of the effectiveness of leadership communication increased, burnout decreased. The
determined effect size of .56 and coefficient of determination of .32 from the linear regression
imply a significant relationship between the variables. Figure 3 displays the correlation and
regression line.
Figure 3
Correlation Analysis: CBI Burnout and Leadership Communication

Note. y = -1.0642x + 6.0579; r
2
=

.32
42

Specific comments provided to open-ended questions in the survey included many about
the need to improve leadership communication. One respondent stated, “The shift to a more
hierarchical rather than flat organization has led to poorer communication in my opinion, and
important discussions and decisions seem more exclusive rather than inclusive.” A second
respondent opined, “UPG’s communication has, at least in my department, gotten worse over the
past year.” Other comments were, “I feel like a lot of steps have been taken to improve initial
communication, however follow-up communication and tracking of changes implemented could
still use improvement” and “All levels of administration are disorganized on most measures of
administrative performance, including communication.” Finally, a respondent added,
“Communication here is the worst I have experienced in a healthcare setting.”
Gratitude
Pearson correlation test results indicated a strong negative association between gratitude
and physician burnout, r(81) = -.54, p < .001. As respondent ratings of feeling appreciated by the
organization increased, burnout decreased. The determined effect size of .54 and coefficient of
determination of .30 from the linear regression suggest a meaningful relationship between the
variables. Figure 4 displays the correlation and regression line.

43

Figure 4
Correlation Analysis: CBI Burnout and Gratitude

Note. y = -1.067x + 6.3497; r
2
=

.30
Survey respondents provided numerous comments about their perceived lack of
appreciation from the organization. Question 40, which inquired about what specific actions
UPG could do to improve physician wellness, produced the comment, “I think they (UPG)
should provide some kind of compensation for working through the pandemic for those of us
working directly with it to show appreciation and keep us satisfied.” A second response was:
For my personal wellness, I need to know that providers and staff voices are heard in the
strategic planning process and that there will be training of leaders so we can optimize
talents and resources. We cannot just keep wringing dedication out of people, then
wonder why they lose patience with the organization.
44

Finally, one responded added:
Once upon a time, we were compensated for the time we spent outside of the open clinic
time. Now, it's just considered "part of the job" (insert shoulder-shrugging emoji here).
Honestly, I care less about the money and more about going home to my family so that I
can unplug, rest, recharge, and reconnect with those that buoy me through the stressors
and hardships in life. This is not rocket science, but it bears reiterating. Care for the staff
that you have so that we can care for each other, for our patients, and for the community.
Support Staffing
The Pearson correlation indicated a positive association between the unavailability of
adequate support staff and physician burnout, r(82) = .43, p < .001. As respondent ratings of
disagreeing that appropriate support staff are provided to do their jobs increased, physician
burnout increased. The effect size of .43 and coefficient of determination of .19 from the linear
regression implies a medium relationship between the variables. Figure 5 displays the
correlation.

45

Figure 5
Correlation Analysis: CBI Burnout and Lack of Adequate Support Staffing

Note. y = 0.9445x + 0.755; r
2
=

.19
Specific comments provided to open-ended question 40 of the survey, which asked for
specific ways in which UPG can improve to reduce burnout, included several about staffing. One
respondent noted, “I get lost and discouraged regarding management’s decisions that create
staffing failures and go against our goals of providing excellent care to the community.“ A
second survey participant added, “It is simply maddening to have a mid-level management
person tell the doctors that we have plenty of staff to work with when we know this is nowhere
near true.” A third physician stated, “Having quality support staff is key for a busy primary care
physician. I don’t have that.” A fourth respondent uttered:
46

We need more support staff. Pay them the market rate for the area. I don't care what other
companies do regarding this if it doesn't work here; it is wrong to expect medical
assistants to make three dollars less per hour when they can go across the street and get
more money. Please pay them according to the area market, not the state market.
Finally, a fifth survey participant said, “More staff would allow doctors more time to be doctors,
talk to patients, and make high-level decisions.”
Autonomy
The Pearson correlation results indicated a positive association between perceived lack of
autonomy and physician burnout, r(82) = .42, p < .001. As respondent ratings of the lack of
autonomy increased, so did burnout. The determined effect size of .42 and coefficient of
determination of .18 from the linear regression imply a medium relationship between the
variables. Figure 6 displays the correlation and regression line.

47

Figure 6
Correlation Analysis: CBI Burnout and Perceived Lack of Autonomy

Note. y = 0.867x – 0.1907; r
2
=

.18
Specific comments provided to open-ended survey questions concerning lack of
autonomy at UPG included the statement, “Administration needs to allow more autonomy and
the capability to run the clinic the way we see fit.” A second physician added, “UPG
management is hyper-controlling and does not allow me to simply work with my staff in the
clinic and control our own workflow." A third comment was, “A lot of my frustrations would be
improved if leadership at upper and mid-management treated me and trusted me as a professional
who is trying to provide the best possible patient care.” Finally, a fourth responded added:
I would like the ability to make changes in my schedule, whether it is the length of the
patient appointments or putting in hold spots for follow-up or same day appointments as I
see fit, without having to get two, three, or four different levels of management to
approve it.
48

Family Factors
Pearson’s r was calculated to assess the relationship between physician burnout and
stressors caused by family factors. The Pearson correlation revealed no meaningful relationship
between family factors and physician burnout at UPG, r(82) = .15, p =.160. The determined
effect size of .15 and coefficient of determination of .02 from the linear regression imply no
statistically significant relationship between the variables. Figure 7 displays the results of the
analysis.
Figure 7
Correlation Analysis: CBI Burnout and Family-Related Stressors

Note. y = 0.3075x + 2.3169; r
2
=

.02

49

Exosystem Influences on Physician Burnout

Elements in the external environment of physicians in which they have no direct control
can influence physician burnout. Administrative burden, regulatory requirements, and mandated
use of the electronic health record have negatively impacted physician wellness (Babbott et al.,
2014; Drummond, 2015; Shanafelt et al., 2012). In this study, the statistically significant
exosystem influences on physician burnout were determined to be administrative burden and use
of the electronic health record.
Administrative Burden
Pearson correlation test results indicated a positive correlation between perceived high
levels of administrative burden and physician burnout, r(82) = .37, p < .001. As respondent
ratings of administrative burden causing stress increased, so did physician burnout. The
determined effect size of .37 and coefficient of determination of .14 from the linear regression
implies a medium relationship between the variables. Figure 8 displays the correlation analysis.

50

Figure 8
Correlation Analysis: CBI Burnout and Administrative Burden

Note. y = 0.6438x + 1.6322; r
2
=

.14
Electronic Health Record Burden
Pearson correlation test results determined a positive correlation between electronic
health record burden and physician burnout, r(82) = .39, p < .001. As respondent ratings of
burden from electronic health record responsibilities increased, burnout also increased. The
determined effect size of .39 and coefficient of determination of .15 from the linear regression
implies a medium relationship between the variables. Figure 9 displays the results of the
analysis.

51

Figure 9
Correlation Analysis: CBI Burnout and Electronic Health Record Burden

Note. y = 0.6165x + 2.0699; r
2
=

.15
Specific comments provided to the open-ended questions in the survey included several
about electronic health record challenges. One physician stated, “We need to decrease the in-
basket EHR burden and provide me time to do my job.” A second respondent noted, “Increased
clinical IT/EPIC staff are needed to optimize EHR improve orders, referrals, reduce redundancy
of messages and notifications when a patient is discharged and sees specialists. I even get my
own discharges sent to me.” A third physician articulated, “Give us more time to complete notes,
our in-basket, constant messages as well as paperwork for physical exams, pre-operation
clearances, return to work, and prior authorizations. There is just too much.” A fourth survey
respondent said, “All the time wasted doing EHR duties of what is simply expected of support
52

staff in private practice is complete torture and totally nonproductive taking away from
meaningful patient care.”
Macrosystem Influences on Physician Burnout
Macrosystem elements that can impact physician burnout include political and societal
factors. The research in this study was conducted during the fall of 2020, a time of great political
distress and social unrest. A contentious election year, numerous examples of social injustice,
and ongoing political dynamics relating to the COVID-19 pandemic all existed during the
research study. Pearson correlation test results showed a positive correlation between the
negative impact of political and social factors and physician burnout, r(82) = .39, p < .001. As
respondent ratings of being negatively impacted by political and social factors increased, burnout
escalated. The determined effect size of .39 and coefficient of determination of .15 from the
linear regression implies a medium relationship between the variables. Figure 10 displays the
results of the analysis.

53

Figure 10
Correlation Analysis: CBI Burnout and Negative Political/Societal Factors

Note. y = 0.5634x + 2.201; r
2
=

.15
Chronosystem Influences on Physician Burnout
In ecological systems theory, the chronosystem deals with time elements, including
transitions and shifts during life (Bronfenbrenner, 1979; Sincero, 2012). A major chronosystem
factor occurring during this research study was the COVID-19 pandemic. Additionally, Dyrbye
et al. (2014) showed that physician age often is a significant chronosystem factor affecting
burnout, with younger physicians more likely to experience burnout. The impact of the COVID-
19 pandemic and differences in UPG physician burnout by age were analyzed in this study.

54

The COVID-19 Pandemic
Pearson correlation test results demonstrated a positive correlation between the negative
impact of the COVID-19 pandemic and physician burnout, r(82) = .38, p < .001. As respondent
ratings of being negatively affected by the pandemic amplified, burnout increased. The
determined effect size of .39 and coefficient of determination of .19 from the linear regression
imply a medium relationship between the variables. Figure 11 displays the results of the analysis.
Figure 11
Correlation Analysis: CBI Burnout and the COVID-19 Pandemic

Note. y = 0.6555x + 1.7523; r
2
=

.19

55

Specific comments provided to the open-ended questions in the survey relating to the
COVID-19 pandemic included, “Whatever your views are about the handling of COVID-19,
how can you say to the people on the front lines of an outpatient clinic you need to see all
patients inside just like we did before COVID" and “The volume of patient emails and telephone
messages since the COVID pandemic has increased substantially to the point that I don't feel that
I can complete both my notes and my in-basket in the same day.”
Physician Age
Results of this study revealed no appreciable difference in physician burnout at UPG by
age. Physicians age 25–39, 40–54, and 55 and above self-reported burnout at 57.2%, 58.8%, and
57.2%, respectively. Table 8 provides the detail by UPG physician age category.
Table 8
UPG Physician Self-Reported Burnout by Age
Physician Age
33: Using your own definition of burnout, please
select one of the options below:
Total 25 - 39 40 - 54 55 +
n 83 35 34 14
I am not experiencing any major stressors or
burnout.
18.1% 20.0% 20.6% 7.1%
I am under stress and don't have as much energy as
I once did, but I don't feel burned out.
24.1% 22.9% 20.6% 35.7%
I feel slightly burned out and have one or more
symptoms such as exhaustion, cynicism, etc.
21.7% 20.0% 23.5% 21.4%
I am experiencing significant burnout and think
about work-related frustrations a lot.
30.1% 28.6% 32.4% 28.7%
I am completely burned out and am at the point
where I have or may seek help.
6.0% 8.5% 2.9% 7.1%
M 3.0 3.0 3.0 3.0
SD 1.2 1.3 1.2 1.0

56

Relative Importance of Predictor Variables on Physician Burnout

A multiple linear regression analysis was completed to analyze each statistically
significant predictor variable's importance on causing physician burnout when considering all
others. The analysis crossed ecological system theory realms to determine the most significant
factors driving physician burnout at UPG. The correlation matrix of burnout predictor variables
yielded a high correlation between lack of leadership communication and lack of gratitude. To
mitigate the multicollinearity impact in the multiple regression, these two predictor variables
were combined into one covariate (Tomaschek et al., 2018). Table 9 provides the overall
correlation coefficients of the independent predictor variables.
Table 9
Pearson’s Correlation Coefficients for Burnout Predictor Variables

Variable

1

2

3

4

5

6

7

8

9
1. Lack of
Communication
-
2. Lack of Gratitude .81
***
-
3. Inadequate Staffing -.32
***
-.34
***
-
4. Lack of Autonomy -.49
***
-.52
***
.32
***
-
5. Family Stressors -.08 .02 -.06 .01 -
6. Administrative Burden -.21
*
-.15 .34
***
.28
**
.27
**
-
7. Electronic Health
Record Duties
-.11 .01 .30
**
.15 .19
*
.40
***
-
8. Political and Societal
Factors
-.21
*
-.23
*
.24
***
.10 .02 .23
*
.31
***
-
9. COVID-19 Impact

-.29
**
-.24
*
.17 .09 .23
*
.33
***
.27
**
.53
***
-
*p < .05. **p < .01. ***p < .001.

57

A meaningful regression equation was found (F (7,72) = 9.678, p = .009) with an r
2
of .49. In the
multiple regression model, the combined predictor variable of lack of communication and
gratitude was determined to be the most statistically significant covariate of all explanatory
variables. Detailed results of the multiple linear regression are provided in Appendix H.
Research Question 3: How, if at all, Do Individual Resilience and Personal Coping
Strategies Mitigate Physician Burnout and Enhance Physician Well-Being?
The National Academy of Medicine (2019) narrated how physicians vary in their ability
to deal with stress. Positively coping with stressors and sustaining personal well-being while
under adversity, often termed resilience, is suspected of lowering burnout (Guo et al., 2018).
Additionally, individuals that rate high on their ability to cope with hardship have been shown to
experience less burnout (Balayssac et al., 2017; Oskrochi et al., 2016). This study incorporated
elements of the Brief Resilience Scale (Smith et al., 2008) and Brief Resilient Coping Scale
(Sinclair & Wallston, 2004) to measure UPG physician resilience and coping skills. Correlation
and regression analyses were completed to determine how, if at all, resilience levels and coping
skills influence the existence of physician burnout at UPG.
Brief Resilience Scale Results
Scoring for the Brief Resilience Scale is defined as the following: 1.00–2.99 equals low
resilience, 3.00–4.30 equals normal resilience, and 4.31–5.00 equals high resilience. Overall,
UPG Physicians scored normal to high on resilience (M = 3.8, SD = 0.9), with 59.5% of
respondents scoring between 4.00–5.00. The UPG physician results on the Brief Resilience Scale
yielded a negatively skewed distribution with a mode score of 4.00. Figure 12 summarizes the
Brief Resilience Scale results for UPG physicians.

58

Figure 12
UPG Physician Brief Resilience Scale Scoring

Brief Resilient Coping Scale Results
The Brief Resilient Coping Scale component of the survey instrument incorporated three
questions to measure respondent coping skills. Scoring for the Brief Resilient Coping Scale is
determined by summing respondent results to all questions with the following ranges
determining overall coping ability: scores of 3.00–9.75 indicate low resilient coping, scores of
9.76–12.00 indicate medium resilient coping, and scores of 12.01–15.00 indicate high resilient
coping. UPG Physicians scored mainly medium in resilient coping (M = 10.4, SD = 2.5), with
68.3% of respondents having scores within the 7.90–12.99 range. Figure 13 summarizes the
Brief Resilient Coping Scale results for UPG physicians.

59

Figure 13
UPG Physician Brief Resilient Coping Scale Scoring

Impact of Resilience on Physician Burnout
The Pearson correlation confirmed a negative association between one’s level of
resilience and burnout, r(82) = -.40, p < .001. As respondent levels of resilience increased, there
was a corresponding decrease in burnout. The determined effect size of -.40 and coefficient of
determination of .16 from the linear regression suggest a moderate relationship between the
variables. Figure 14 provides the correlation between resilience and physician burnout and the
regression line of best fit.

60

Figure 14
Correlation Analysis: CBI Burnout and Resilience

Note. y = -.05516x + 5.4166; r
2
=

.16
Impact of Coping Skills on Physician Burnout
Pearson correlation test results demonstrated a slight negative correlation between an
individual’s coping skills and burnout. As respondent ratings of being able to cope with adverse
events increased, burnout decreased, but only to a small degree (r(82) = -.24, p < .001). Figure
15 displays the results of the analysis.

61

Figure 15
Correlation Analysis: CBI Burnout and Coping Skills

Note. y = -0.9111x + 13.134; r
2
=

.06
While this study's findings indicate burnout is negatively correlated with resiliency and
coping skills, the results are not prodigious. The coefficients of determination from the linear
regressions are low. Moreover, the high levels of respondent resiliency and coping skills suggest
total burnout would be lower if resiliency and coping skills significantly reduce burnout.
Summary

The results of this study revealed that physician burnout is a problem with various causes.
The ecological systems-based framework proved creditable in analyzing the problem as
contributors were found from the different environmental layers which constitute the theory.
Many of the statistically significant causes of physician burnout determined in this study were
62

organizational factors. Lack of communication and gratitude from leadership were determined to
be the most statistically significant predictors of physician burnout, followed by the lack of
adequate support staffing. In the multiple linear aggression analysis across all statistically
significant predictor variables, lack of leadership communication, lack of gratitude, and the
COVID-19 pandemic together accounted for nearly half of the burnout being experienced by
UPG physicians. The outcomes in this study suggest individual organizations may reduce
physician burnout through constructive organizational change and leadership that is committed
to creating cultures that support physicians. These findings serve as the basis for the
recommendations section that follows.
Recommendations for Practice
The prior section presented the results of the quantitative study completed to assess
physician burnout at UPG. The findings aligned with the literature review component of this
dissertation in practice, which provided a solid foundation of knowledge and enabled the creation
of the conceptual framework. The research in this study revealed statistically significant findings
in ecological systems theory's various environmental realms, with the majority residing in the
microsystem focused on work settings and organizational factors. Presented in this section are
recommendations that can enhance physician wellness at UPG and reduce burnout. The
recommendations are provided to address the most significant findings and drivers of UPG
physician burnout. The ecological system layers that each recommendation impacts are also
noted to align with this study’s conceptual framework. While all important, the recommendations
are provided in descending order based upon their ability to reduce burnout at UPG, consistent
with this study's findings.

63

Recommendation 5: Prioritize a Culture Committed to Physician Wellness
The research findings validate the literature review supported notion that organizational
cultures committed to wellness are essential in combating physician burnout. Burnout can be
lowered through an organizational commitment to change in which physicians' emotional needs
are acknowledged, and well-being is prioritized. Shapiro et al. (2019) documented the
importance for organizations to prioritize physician wellness. Creating a culture of wellness
involves physicians' willingness to participate in wellness initiatives and is influenced by the
organizational environments in which physicians work (Bohman et al., 2017). A wellness culture
incorporates policies and behaviors that promote caring for oneself, professional growth, and
compassion.
The emotional challenges created by the COVID-19 pandemic and political and societal
factors can be mitigated by creating a physician-centric employee assistance program (EAP), a
common feature included within wellness cultures. Such programs have proven successful in
helping physicians cope with the stressors created by elements encountered in the ecological
systems macrosystem and chronosystem constructs where physicians have engagement without
the ability to directly control outcomes (Callahan et al., 2018; Rosenstein, 2019; Shanafelt et al.,
2017). Political and societal factors and the COVID-19 pandemic scored as moderate
contributors to burnout at UPG. Programs effectively dealing with political and societal factors
often include actions that limit a physician’s intake of media while developing and maintaining a
routine of healthy activities (Boston University, 2021). The program at UPG should consider this
fact while addressing several other key issues.
64

Additional important aspects of a successful physician EAP are eliminating barriers to
service access and making sure the physicians know the service's availability and merits.
Convenience is another essential element. Physician EAP programs are often able to be accessed
online. Moreover, resources are available through professional societies such as the American
Medical Association and Institute for Healthcare Improvement (Rosenstein, 2019). Many
physicians avoid accessing EAP services due to feelings of shame and fear of lack of
confidentiality (Hill, 2017). Physician employee assistance programs have been proven
successful when operated and led by physicians creating a peer-to-peer environment in which
confidentiality is maintained and considered a sacred component of the programs (Wu et al.,
2020). The physician EAP program development at UPG should consider and address the factors
detailed in this recommendation for practice. Creating a culture committed to physician wellness
will address items contributing to burnout in the physicians’ microsystem, macrosystem,
exosystem, and chronosystem.
Recommendation 4: Improve Support Staffing
The need to improve support staffing was the top self-reported reason for burnout in this
study. When analyzed quantitatively, staffing remained a prominent and statistically significant
issue contributing to burnout. Enhancing staffing will require a financial investment as findings
in this study indicated a shortage of adequate support staff in the physicians' work environments.
Improving staffing will require efforts in the areas of hiring additional support staff, training
staff, and retaining staff.
Hiring Additional Support Staff
Additional support staff should be added to UPG physician offices using benchmark
analyses and physician input to determine the appropriate amount. Several benchmark databases
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exist to validate appropriate levels. These include the Medical Group Management Association,
American Medical Group Association, and the American Medical Association. Two metrics that
should be used are the number of support staff per physician and the percentage of revenue spent
on staff salaries.
Training Staff
This study's findings included several comments about the staff's inability to perform at
levels that provide proper assistance to the physicians. UPG should prioritize the need for staff
competence with additional training provided as needed. Recruiting and hiring the most talented
employees possible must also be a priority. UPG should conduct a review of staff performance
issues to determine what factors are creating the performance gaps. Items relating to knowledge,
motivation, and organizational factors should be reviewed and addressed (Clark & Estes, 2008).
Retaining Staff
UPG physicians identified staff retention as a significant issue, with 37.2% of survey
respondents strongly agreeing that it is a problem and 24.8% somewhat agreeing that it is a
problem. The inability to retain staff can contribute to burnout, reduce productivity, and lead to
low engagement among the employees who remain with an organization (Markovich, 2019).
UPG should develop a comprehensive plan to improve staff retention. Successful staff retention
programs include improving employee onboarding at the time of hire, ensuring compensation
and benefits are competitive, incorporating recognition and reward systems, and developing
flexible work arrangements that consider the staff's needs (Half, 2020). Improving support
staffing at UPG will address factors contributing to burnout in the physicians' microsystem.

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Recommendation 3: Provide Physician Support, Training, and Education for Electronic
Health Record Duties
This study's results showed that duties associated with completing electronic health
record (EHR) responsibilities contribute to physician burnout at UPG. The findings are
consistent with those discovered in other research detailed in this dissertation in practice's
literature review section. UPG physicians stated a strong preference for augmenting the amount
of support available to assist with EHR duties. UPG should make improvements in both EHR
usability and efficiency.
The usability of the EHR at UPG can be improved by providing physician training and
education. More robust knowledge on how to appropriately use the EHR technology can reduce
physician frustration and burnout (Babbott et al., 2014). Training opportunities should emphasize
a mastery-based approach to learning and limit cognitive load. Moreover, to be most effective,
assessing the UPG physicians’ current EHR knowledge should be conducted before training with
the subsequent education tailored to specific needs. Mayer (2011) emphasized the importance of
understanding learners’ prior knowledge by stating that it is the most important thing to know
when making instructional design decisions. Consideration should also be given to including
formative assessment during the training (Kirkpatrick, 2006).
The EHR's efficiency can be improved by catering the clinical information system to
streamline workflows and enhance the physicians' experience while using the technology. The
process, often termed optimization, is often overlooked by organizations (Monica, 2018). UPG
administration, information systems representatives, and physicians should establish a task force
to define and develop needed EHR enhancements to improve workflow and reduce burden.
Finally, UPG should invest in a program to provide medical scribes in physician clinics. Medical
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scribes are personal assistants to physicians who gather information about patients and perform
EHR documentation duties on their behalf (Scribe America, 2021). Scribes complete clerical and
documentation tasks that otherwise would need to be completed by physicians themselves
(Jason, 2021). These tasks include managing EHR messages, commonly known as "the inbox,"
which 48.7% of UPG physicians rated as unmanageable. Incorporating this recommendation at
UPG will enable physicians to spend more time caring for patients, enhance the overall
efficiency of patient care, and reduce the physician EHR burden. Providing support for
physicians with EHR-related duties will address exosystem factors contributing to UPG
physician burnout.
Recommendation 2: Increase Physician Engagement and Autonomy
Efforts should be undertaken to engage physicians directly in decision-making and
provide greater autonomy in their daily work lives. The high response rate to the survey used in
this dissertation in practice indicates UPG physicians have a significant interest in the subject of
burnout. Involving the physicians in enhanced ways is vital because effective change
management includes involving people directly within the change process (Kotter, 2012).
Physician job-related stress and burnout can be lowered by engaging physicians directly in
developing organizational goals and decision-making (Wallace & Lemaire, 2007). The UPG
physician burnout task force should create focus groups comprised of physicians who
participated in this research study to obtain more detailed information on thoughts and
suggestions to improve physician involvement in UPG policy development and operational
procedures.
UPG should develop operational planning groups with high amounts of physician
involvement for each of the main recommendations for improvement. The groups would include
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teams that focus on emotional support initiatives, processes for limiting the electronic health
record burden, improving support staffing, and defining specific enhancements for leadership
communication and gratitude. While the anonymity of the completed survey prevents
individually identifying survey participants who felt strongly on various issues, volunteers to
participate in improvement activities can be solicited by area of interest.
UPG physicians expressed the need for greater autonomy and personal control in the
workplace. Limiting work hours and offering flexible work arrangements can lower physician
burnout (Shanafelt & Noseworthy, 2017). UPG leadership should include physicians in
developing work schedules and exploring initiatives that provide greater work-life balance.
High-performing organizations prioritize understanding and responding to their employees'
needs (Bolman & Deal, 2017). Augmenting engagement by including physicians directly in the
development of change initiatives while providing greater autonomy will address items causing
burnout in the physicians’ microsystem, macrosystem, exosystem, and chronosystem.
Recommendation 1: Improve Leadership Communication
The top two statistically significant burnout drivers in this study were ineffective
leadership communication and lack of gratitude. High multicollinearity existed (r = .81) for the
communication and gratitude predictor variables suggesting that the two constructs are
interrelated and act in concert. The significance of this finding suggests perceived gratitude can
linearly be predicted from the level of communication effectiveness with a substantial degree of
accuracy (Young, 2017). Therefore, improving leadership communication will reduce physician
burnout and also likely increase perceived gratitude. UPG should undertake several initiatives to
improve leadership communication.

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Define Effective Leadership Communication
UPG should conduct a more in-depth study of what survey respondents believe to be
effective leadership communication. Lack of communication is often associated with the need
for greater leadership visibility (Clavelle, 2012). The literature review in this dissertation in
practice found that organizations with leaders who communicate well experience lower rates of
physician burnout (Shanafelt et al., 2015; Wallace & Lemaire, 2007; Williams et al., 2007). UPG
needs to emphasize the importance of selecting and cultivating leaders who are visible and
communicate effectively.
Develop Routine Communication Sessions
UPG should develop ongoing communication sessions that are attended and led by UPG
leadership and open to physicians. The sessions should be scheduled at times convenient to
physicians and offer either in-person or virtual attendance. Agenda topics for the meeting should
include querying the physicians in advance for items of interest and specific issues they would
like discussed and presented. The sessions should be recorded and made available to physicians
who are unable to attend.
Create a Structured Leadership Rounding Program
Structured leadership rounding can improve both visibility and communication.
Structured programs work best when they include and have the commitment from the top leaders
of an organization. UPG should develop a rounding program in which senior executives visit
each of the physician practice locations at least three times per year. Visit times should be
arranged in advance when the physicians are available and able to interact with leadership.
Effective leadership rounding often requires the flexibility of senior leader schedules to meet
physicians' needs. Such rounding often needs to occur early or late in the day and not during
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times which physicians are routinely caring for patients. Structured rounding programs improve
communication in the workplace and overall clinical provider satisfaction (Blake & Bacon,
2020; Olsen et al., 2019).
Reduce Reliance on Email as a Communication Median
UPG should limit the use of email as the primary method of communicating with
physicians. Email that is lengthy, not of interest to recipients, and delivered during times of high
workload are often unread and ignored by recipients leading to missed transfer of information
and often perceptions of lack of communication (Smit et al., 2017). While convenient for
distributing messages to large groups, email should not be viewed as effective communication.
When email is used to share pertinent information, other communication media should be used in
tandem.
The recommendations provided in this section are not mutually exclusive. The results of
Pearson's r correlation calculations between covariates in this study suggest that improvements in
leadership communication may lessen burnout associated with other predictor variables. Most of
the statistically significant causes of physician burnout identified were organizational factors that
can be altered through leadership commitment to change and investment in necessary resources.
This dissertation in practice's literature review section revealed that improving physicians'
supervisory leadership is directly related to lower physician burnout rates (Shanafelt et al., 2015).
While physician burnout is a widespread problem, it can be effectively addressed at the
individual organization level through compassionate and supportive leaders who are committed
to change that cultivates cultures of wellness and physician engagement. A formal leadership
communication enhancement plan should be included as part of the overall implementation and
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evaluation plan for reducing physician burnout at UPG. Improving leadership communication
will address factors causing burnout in the physicians' microsystem.
Implementation and Evaluation Plan
The recommendations for reducing physician burnout at UPG should be included in a
formal implementation and evaluation plan. The implementation process should incorporate
Kotter's 8-Step Model for leading change (Kotter, 2012). The procedure consists of eight steps:
1) establishing a sense of urgency; 2) creating a guiding coalition; 3) developing a vision and
strategy; 4) communicating the vision for the change; 5) empowering broad-based action; 6)
generating short term wins; 7) consolidating gains to produce more change; and 8) anchoring the
change within the culture. Reducing physician burnout at the organizational level will require
effective change management, and the Kotter model has been proven effective in the healthcare
field (Baloh et al., 2018; Small et al., 2016).
The implementation component of the plan also needs to incorporate SMART goals
aimed at achieving each recommendation. SMART goals are specific, measurable, attainable,
relevant, and time-based (CFI, 2021). UPG should develop goals for all stakeholders to close the
gaps that exist from the current state to the desired future state. A dyad structure should be
established with a physician and administrative lead identified as partners and sponsors for each
recommendation. The dyads should routinely report progress to the overall UPG physician
burnout taskforce.
Lastly, ongoing evaluation of progress toward achieving the goals is needed. Kirkpatrick
(2008) developed a four-level evaluation system that can be used to evaluate the progress made
at UPG in reducing physician burnout. The levels are reaction, learning, behavior, and results.
Reaction evaluation incorporates assessing the level of motivation and value experienced by
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individuals involved in the change effort. Learning evaluation measures the effectiveness of the
initiatives during implementation and whether stakeholders understand the objectives. Behavior
evaluation monitors whether individuals are acting in the ways necessary to effectuate the
desired change. Finally, results evaluation measures whether the change initiative successfully
produces the desired results. The development of a formal implementation and evaluation plan
with clear stakeholder goals aligned with the overall organizational goal to reduce physician
burnout will increase the likelihood of success in lowering UPG physician burnout (Clark &
Estes, 2018).
Limitations and Delimitations
This study had several limitations and delimitations. The limitations included the overall
size of the survey population (N = 140). Moreover, the survey solicited information on individual
feelings toward various aspects of personal lives and workplaces, which can fluctuate over time
(Piazza et al., 2016; Ritter et al., 2016). Individual levels of burnout and resiliency can change
from one period to the next (Dunford et al., 2012). This study, therefore, provided a snapshot of
the prevalence of burnout and causes at a specific point in time, specifically during the fall of
2020. Another limitation of the study was that Likert scale survey responses were treated as
interval levels of measurement in several statistical analyses. While a common practice in social
science research, it is sometimes debated whether Likert scale responses can be converted to
numbers with full interval properties (Wu & Lueng, 2017).
The study's delimitations included that the research incorporated only a quantitative
survey with no ability to query respondents for additional information. The quantitative only
design methodology was justified due to the sensitive information obtained during a hectic time
for survey participants. The COVID-19 pandemic challenged frontline healthcare workers during
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the fall of 2020. The study methodology enabled respondents to participate quickly in an
anonymous manner. The anonymity allowed for eradicating possible concerns of retaliation from
the participating organization on participants who provided honest responses that may be viewed
as unfavorable by the organization. Finally, the survey incorporated three known survey
instrument components while thoroughly adding specific questions to represent the study's
conceptual framework. While needing to be listed as a delimitation, this unique approach to
survey design could also be viewed as a strength of this study by providing insight into how, if at
all, resiliency and coping strategies impact the existence of burnout. The dean of EUCM intends
to continue to use the survey instrument moving forward to monitor progress in reducing burnout
and provide a basis for ongoing longitudinal research.
Recommendations for Future Research
The results of this study provide several opportunities for future research. The findings
showing high scores in resiliency and coping skills but also high levels of burnout merits further
inquiry. The significant association determined between leadership communication and gratitude
also warrants further study. Moreover, research should be completed using a larger population.
While the robust physician response rate (85.7%) enabled statistically significant results to be
calculated for this study, the overall physician survey population (N = 98) is relatively small.
Future research should also consider incorporating a broader Likert scale to enhance the validity
associated with converting Likert scale responses to interval data. Finally, this study's results
suggest a more in-depth, quantitative analysis across multiple settings is justified to study
organizational-specific versus external environmental factors that contribute to and cause
physician burnout.

74

Conclusion
Physician burnout is a serious problem that is complex and not easily solved. This study's
results affirm that there are multiple contributing factors to burnout, which challenges the ability
to solve the problem swiftly and comprehensively. However, this study provided insight into
how vital organizational factors are in the existence and prevalence of physician burnout. The
need for improved leadership communication and perceived lack of gratitude were more
significant drivers of burnout than items such as administrative burden, electronic health record
challenges, and even the harmful psychological impact of the COVID-19 pandemic. The
leadership characteristics of physician supervisors play a significant role in the presence of
burnout. The results of this study provide a call for leadership action in healthcare
administration.
Healthcare administrators should prioritize creating healthier work environments for
physicians. Theodore Roosevelt said, “Nobody cares how much you know, until they know how
much you care.” Leaders in healthcare organizations need to understand the problem of
physician burnout and take action to reduce it. Leaders need to care. The results of this study
suggest that improvements can be made at the individual organizational level through a
commitment to change and leadership that respects physicians. Healthcare administrators should
view physicians as partners, not resources. Physician burnout can be addressed through
organizational leadership that is genuinely concerned about the welfare of physicians. Poor
physician health outcomes, medical errors, and physician suicides induced by burnout can all be
avoided if organizations can improve their cultures and healthcare administrative leaders are
willing to change.
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Some healthcare leaders will be unwilling to change, some healthcare leaders will
reluctantly change, and some healthcare leaders already care enough to select physician burnout
as a problem of practice for their doctoral dissertation and choose not to return to their employer
post-sabbatical due to what they learned while conducting their research. Organizational change
is warranted, organizational change is possible, and organizational change provides hope for
solving the problem of physician burnout.

76

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Appendix A: Definitions
Academic Medical Center: A hospital integrated with a medical school where medical student
education, training of medical residents and fellows, and research
occur as part of the organizational mission (Joint Commission
International, 2020)

Burnout: A condition of general job dissatisfaction characterized by
emotional exhaustion, cynicism, and inefficacy that frequently
occurs in human service professions (Shanafelt & Noseworthy,
2017).

Clinical Providers: A combination of physicians and non-physician providers.

COVID-19: Coronavirus disease 2019 caused by severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2).

Non-Physician Provider: Individuals who are not physicians but provide billable clinical
services to patients: psychologists, certified registered nurse
practitioners, and physician assistants.

Pandemic: A disease occurring over a wide geographic area, such as multiple
countries or continents, and typically affecting a significant
proportion of the population.

Resilience: The ability to handle stressful events without harmful personal
impact.

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Appendix B: The Researcher
The researcher in this study was a president and Chief Executive Officer (CEO) of a
hospital located 210 miles from the academic medical center in which the research participants
worked. At the time of the study, the researcher had 28 years of experience in the healthcare
field, including 10 years as a physician practice administrator. The researcher was on a sabbatical
during the research study to mitigate potential conflicts and power dynamics. While the study
participants had no relationship or reporting responsibilities to the researcher, positionality,
power dynamics, and bias were considerations that needed to be ruminated due to the
investigator being an executive at a similar organization (Creswell & Creswell, 2018). The
quantitative survey was administered in partnership with the dean of UECM and the academic
medical center's physician burnout taskforce. Additionally, the investigation’s design provided
complete anonymity to survey participants by incorporating anonymous responses with no
individual participant tracing to the completed surveys. Survey administration with the support
of the dean and the burnout taskforce coupled with the anonymity of participant responses,
appropriately addressed potential concerns of positionality, power dynamics, and bias (Merriam
& Tisdell, 2017).

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Appendix C: Protocol
2020 University Physician Group (UPG) Provider Wellness Survey

Dear University Physician Groups (UPG) Provider:

You are invited to complete a confidential survey about physician/provider wellness and burnout
at UPG. The survey is being conducted by a doctoral student at the University of Southern
California (USC) as part of the student's dissertation. The purpose of the survey is: (1) to help
UPG leadership better understand the prevalence of physician/provider burnout; (2) to identify
factors contributing to physician/provider burnout; and (3) to inform and guide the ongoing
development and implementation of interventions to prevent physician/provider burnout.

The survey will take approximately 10 minutes to complete and may be completed on either a
computer or mobile device. Individual survey responses will be confidential with data and
recommendations presented to UPG leadership in aggregate with no information provided that
could potentially identify individual survey respondents. Additional information on your rights
as a survey participant can be found on the USC Information Sheet for Exempt Research, which
was provided as an attachment to the email that contained this survey link.

Please complete the survey by Monday, November 16, 2020.

Thank you in advance for your willingness to participate in this important project.

Instructions:

After completing a page, click on the arrow at the bottom right-hand corner to advance through
the survey. You may also utilize the back arrow if you wish to change a previous response.

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For the survey items below, please choose the response that best describes you at the current
time.

Q1 I feel exhausted.
o Always (1)
o Often (2)
o Sometimes (3)
o Rarely (4)
o Never (5)

Q2 I feel weak and susceptible to illness.
o Always (1)
o Often (2)
o Sometimes (3)
o Rarely (4)
o Never (5)

Q3 I think, " I can't take it anymore."
o Always (1)
o Often (2)
o Sometimes (3)
o Rarely (4)
o Never (5)

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Q4 I feel weary at the beginning of my day at the thought of another day of work.
o Always (1)
o Often (2)
o Sometimes (3)
o Rarely (4)
o Never (5)

Q5 My work frustrates me.
o Always (1)
o Often (2)
o Sometimes (3)
o Rarely (4)
o Never (5)

Q6 I have enough energy for family and friends when I am not working.
o Always (1)
o Often (2)
o Sometimes (3)
o Rarely (4)
o Never (5)

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Q7 On average, I spend the following amount of time working from home each week, not by
choice, but due to the need to keep up with my job duties.
o Less than 3 hours (1)
o 3 to 5 hours (2)
o 6 to 10 hours (3)
o 11 to 15 hours (4)
o Over 15 hours (5)

Q8 I feel burnt out because of my work.
o Always (1)
o Often (2)
o Sometimes (3)
o Rarely (4)
o Never (5)

Q9 I find it frustrating working with my patients.
o Always (1)
o Often (2)
o Sometimes (3)
o Rarely (4)
o Never (5)

102

Q10 Working with my patients energizes me.
o To a very high degree (1)
o To a high degree (2)
o To a moderate degree (3)
o To a low degree (4)
o Not at all (5)

Q11 I feel that I give more than the satisfaction that I get back from working with my patients.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

Please rate your level of agreement with the following statements:

103

Q12 The COVID-19 pandemic has negatively impacted my personal wellness.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

Q13 Current societal and/or political factors are causing me stress.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

Q14 My current family responsibilities create stress for me.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

104

Q15 My colleagues and coworkers are a source of positivity for me.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

Q16 Academic Medical Center East's organizational values and goals align well with my
personal values and goals.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

Q17 Academic Medical Center East's leadership communicates effectively on items that are
important to me.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

105

Q18 Academic Medical Center East's leadership appreciates the work that I do.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

Q19 I am motivated to do the best job possible for Academic Medical Center East.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

Q20 I am empowered to do my job with an appropriate amount of autonomy.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

106

Q21 Considering the need for appropriate patient access, I have an acceptable amount of control
over my work schedule.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

Q22 I am provided with the appropriate amount of staffing to do my job.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

Q23 Staff turnover in my office/clinic is excessive and creates problems for me.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

107

Q24 My clinical schedule affords me adequate time to appropriately care for the needs of each
patient.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

Q25 The Electronic Health Record (EHR) helps me do my job efficiently.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

Q26 Obligations created by the Electronic Health Record (EHR) create stress for me.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

108

Q27 My Electronic Health Record (EHR) workload, including in-basket responsibilities, is
manageable.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

Q28 I receive adequate support for my Electronic Health Record (EHR) required tasks and
responsibilities.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

109

Q29 Administrative burden (e.g. payor preauthorization requirements, regulatory obligations,
etc.) causes me stress.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

Q30 Using your own definition of burnout, please select one of the options below:
o I am not experiencing any major stressors or burnout. (1)
o I am under stress and don't have as much energy as I once did, but I don't feel burned out.
(2)
o I feel slightly burned out and have one or more symptoms such as exhaustion, cynicism,
etc. (3)
o I am experiencing significant burnout and think about work-related frustrations a lot. (4)
o I am completely burned out and am at the point where I have or may seek help. (5)

Skip To: Q36 If Using your own definition of burnout, please select one of the options below: = I
am not experiencing any major stressors or burnout.
Skip To: Q36 If Using your own definition of burnout, please select one of the options below: = I
am under stress and don't have as much energy as I once did, but I don't feel burned out.

110

Q31 For the amount of burnout that you just self-identified, what would you say is/are the
cause(s) of the burnout (choose all that apply):
▢ The COVID-19 pandemic
▢ Current societal and/or political factors
▢ My family responsibilities
▢ Lack of autonomy and personal control at my workplace
▢ Limited support staffing at my workplace
▢ Lack of peer/social support
▢ Electronic Health Record (EHR) requirements
▢ The need for improved communication at my workplace
▢ The region's chronic disease burden and socioeconomic determinants of health
▢ Administrative burden (e.g., required payor authorizations, regulatory
requirements, CMS compliance, etc.)
▢ Racism, bias, and/or microaggression
▢ Foreign national and/or immigration challenges
▢ Other (please specify below)
________________________________________________

Carry Forward Selected Choices - Entered Text from "For the amount of burnout that you just
self-identified, what would you say is/are the cause(s) of the burnout (choose all that apply):"

111

Q32 For the causes of burnout you have selected, please rank them below in order of causing
most stress to you to the least with the highest stress producer first. Please rank them by dragging
and dropping them in your preferred order.

______ The COVID-19 pandemic
______ Current societal and/or political factors
______ My family responsibilities
______ Lack of autonomy and personal control at my workplace
______ Limited support staffing at my workplace
______ Lack of peer/social support
______ Electronic Health Record (EHR) requirements
______ The need for improved communication at my workplace
______ The region's chronic disease burden and socioeconomic determinants of health
______ Administrative burden (e.g. required payor authorizations, regulatory requirements,
CMS compliance, etc.)
______ Racism, bias, and/or microagression
______ Foreign national and/or immigration challenges
______ Other (please specify below)

Please consider how well the following statements describe your behavior and actions.

Q33 I tend to bounce back quickly after difficult times.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

112

Q34 I have a hard time making it through stressful events.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

Q35 I tend to take a long time to get over setbacks in my life.
o Strongly agree (1)
o Somewhat agree (2)
o Neither agree nor disagree (3)
o Somewhat disagree (4)
o Strongly disagree (5)

Please choose how each of the following statements best describes you:

113

Q36 I look for creative ways to alter difficult situations.
o Describes me extremely well (1)
o Describes me very well (2)
o Describes me moderately well (3)
o Describes me slightly well (4)
o Does not describe me (5)

Q37 Regardless of what happens to me, I believe I can control my reaction to it.
o Describes me extremely well (1)
o Describes me very well (2)
o Describes me moderately well (3)
o Describes me slightly well (4)
o Does not describe me (5)

Q38 I believe I can grow in positive ways by dealing with difficult situations.
o Describes me extremely well (1)
o Describes me very well (2)
o Describes me moderately well (3)
o Describes me slightly well (4)
o Does not describe me (5)

114

Please provide below additional specific thoughts you would like to add to the 2020 UPG
Provider Wellness Survey.

Q39 What aspects, if any, of working at Academic Medical Center East do you find to be most
supportive of your personal well-being?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Q40 If there was something Academic Medical Center East could do to improve your overall
wellness, what would that be?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Q41 If you would like to provide additional comments or experiences about your personal
stressors and/or suggested areas for improving wellness, please do so below. This would include
your thoughts on any specific way(s) Academic Medical Center East could address perceived
inequities or injustices related to your workplace or patients.
________________________________________________________________
________________________________________________________________
________________________________________________________________
115

______________________________________________________________
_______________________________________________________________

For research purposes, please provide the following demographic information. The information
provided is confidential and will enable comparisons to national trends and allow for identifying
specific and targeted actions for improving wellness at UPG.

Q42 Professional position:
o Physician
o Non-physician provider

Q43 Work Status:
o Full-time
o Part-time

Q44 Average hours worked each week on UPG job duties, including time spent working at
home:
o Under 20 hours
o 20 to 40 hours
o 41 to 50 hours
o 51 to 60 hours
o Over 60 hours

116

Q45 Total years as a practicing physician/provider:
o Up to 5 years
o 6 to 15 years
o 16 to 25 years
o 26 and more years

Q46 Total years as practicing clinical provider (not including residency, education, etc.) at
Academic Medical Center East:
o Less than two years
o Two years and over

Q47 To which gender identity do you most identify?
o Male
o Female
o Non-binary
o Prefer not to say

117

Q48 Age:
o Under 25
o 25 - 39
o 40 - 54
o 55 - 69
o 70 or older

Q49 Ethnicity: (Choose All That Apply)
▢ White
▢ Black or African American
▢ American Indian or Alaska Native
▢ Hispanic/Latino/Spanish Origin
▢ Asian
▢ Native Hawaiian or Pacific Islander
▢ Other (please specify)
________________________________________________

Q50 Current household status:
o Living with a significant other
o Not living with a significant other

118

Q51 Current dependent family member status:
o Responsible for one or more dependents or family members
o Not currently responsible for one or more dependents or family members

Q52 Medical specialty*:
*For confidentiality purposes, please note that data will not be aggregated by specialty unless
there are at least five responses in the specialty.
o Anesthesiology
o Behavioral Medicine
o Family Practice
o Internal Medicine - General
o Internal Medicine - Other Medical Subspecialty
o Neurology
o Obstetrics & Gynecology
o Pathology
o Pediatrics
o Radiology
o Surgery-General
o Surgery-Other Surgical Subspecialty
o Other
o Prefer not to answer

You have reached the end of the survey. When you click the submit button below, your survey
will be recorded.

119

Appendix D: Ethics
Ethics, positionality, and power dynamics were important considerations for this study
due to the researcher being a President and Chief Executive Officer of a hospital. It was
important for the researcher to be on a sabbatical and therefore not actively employed in a
position of organizational power when the research was conducted. Positionality and power
dynamics were mitigated through this approach. To ensure ethical practice, the survey was
administered through the Qualtrics software platform to provide complete anonymity and
confidentiality to the survey participants. Survey respondents were provided with the USC
Information Sheet for Exempt Research, which achieved informed consent and detailed their
rights as survey participants. While it was unlikely that the research would harm anyone, it was
necessary to acknowledge that identifying negative views towards the organization and feelings
of contempt from a specific physician could impact the physician if the organization took a
vindictive and punitive approach when learning of the study results. For the latter reason, the
confidentiality of the individual research participant responses was prioritized. Merriam and
Tisdell (2016) state that ethical practice is all about the researcher’s own ethics and values. The
survey used in this dissertation was conducted ethically and morally, mirroring the researcher’s
personal values of authenticity, dignity, compassion, and respect.

120

Appendix E: UPG Physician Responses to Copenhagen Burnout Inventory Questions

Q3 - I feel exhausted.

Answer % Count
Always 7.1 6
Often 48.8 41
Sometimes 30.9 26
Rarely 11.9 10
Never 1.2 1
Total 100 84

121

Q4 - I feel weak and susceptible to illness.

Answer % Count
Always 1.2 1
Often 13.1 11
Sometimes 35.7 30
Rarely 36.9 31
Never 13.1 11
Total 100 84

122

Q5 - I think, " I can't take it anymore."

Answer % Count
Always 2.4 2
Often 21.4 18
Sometimes 33.3 28
Rarely 26.3 22
Never 16.6 14
Total 100 84

123

Q6 - I feel weary at the beginning of my day at the thought of another day of work.

Answer % Count
Always 2.4 2
Often 32.1 27
Sometimes 28.6 24
Rarely 28.6 24
Never 8.3 7
Total 100 84

124

Q7 - My work frustrates me.

Answer % Count
Always 8.3 7
Often 34.5 29
Sometimes 36.9 31
Rarely 17.8 15
Never 2.5 2
Total 100 84

125

Q8 - I have enough energy for family and friends when I am not working.

Answer % Count
Always 13.2 11
Often 38.5 32
Sometimes 32.5 27
Rarely 14.5 12
Never 1.2 1
Total 100 83

126

Q10 - I feel burnt out because of my work.

Answer % Count
Always 5.7 5
Often 32.2 27
Sometimes 35.7 30
Rarely 20.4 17
Never 6.0% 5
Total 100 84

127

Q11 - I find it frustrating working with my patients.

Answer % Count
Always 2.5 2
Often 9.5 8
Sometimes 44.0 37
Rarely 32.1 27
Never 11.9 10
Total 100 84

128

Q12 - Working with my patients energizes me.

Answer % Count
To a very high degree 2.4 2
To a high degree 31.4 26
To a moderate degree 40.9 34
To a low degree 22.9 19
Not at all 2.4 2
Total 100 83

129

Q13 - I feel that I give more than the satisfaction that I get back from working with my patients.

Answer % Count
Strongly agree 22.6 19
Somewhat agree 29.8 25
Neither agree nor disagree 30.9 26
Somewhat disagree 11.9 10
Strongly disagree 4.8 4
Total 100 84

130

Appendix F: UPG Non-Physician Provider Burnout Scores
Table F1

CBI Calculated Non-Physician Provider Burnout

CBI Item Response
Always Often Sometimes Rarely Never
n % N n % N n % N n % N n % N M SD
Individual
Burnout 5 6.4 23 29.5 34 43.6 14 17.9 2 2.6 3.2 0.9
Job
Related
Burnout 6 5.8 36 34.6 39 37.5 19 18.3 4 3.8 3.2 0.9
Patient
Related
Burnout 3 3.8 14 17.9 37 47.4 19 24.5 5 6.4 2.9 0.9
CBI Total 14 5.4 73 28.1% 110 42.3 52 20.0 11 4.2 3.1 0.9

Table F2

Total UPG Non-Physician Provider AMA Mini Z Respondent Reported Burnout

Survey Item Response Likert Scale Score n % N = 26

Q.30 Using your own
definition of burnout,
please select one of the
following that best
describes you at the
current time

No Stressors or Burnout
Slight stress; No Burnout
Slightly Burnout Out
Significant Burnout
Complete Burnout

1
2
3
4
5

2
6
9
8
1

7.7
23.1
34.6
30.8
3.8
Note. M = 3.0, SD = 1.0

131

Appendix G: UPG Clinical Provider Self-Reported Causes of Burnout

Survey Item Response
n Times
Cited as a
Reason
for
Burnout
n Times
Cited as
Top Reason
for
Burnout
% Times
Cited as
Top
Reason for
Burnout
Q.34 For the amount of
burnout that you just
self-identified, what
would you say is/are
the cause(s) of the
burnout (choose all that
apply)?

Limited support staffing at
my workplace

The COVID-19 Pandemic

The need for improved
communication at my
workplace

Electronic Health Record
(EHR) requirements

Lack of autonomy and
personal control at my
workplace

44

40

36

31

30

13

2

4

6

4

29.5

5.0

11.1

19.4

13.3

132

Appendix H: Multiple Linear Regression Analysis of Predictor Variables

Coefficients
a

Model
Unstandardized Coefficients
Standard
Coefficients
t B Std. Error Beta
1 (Constant) 8.01 2.90 2.65
Combined
Communication &
Gratitude
1.85 .69 .27 2.64
COVID 1.46 .71 .21 2.05
Political & Societal .65 .71 .09 .91
Autonomy 1.12 .50 .23 2.24
Staffing .59 .48 .12 1.22
EHR .65 .61 .10 1.07
Admin Burden .24 .58 .04 .42

Coefficients
a

Model p-Value
95.0% Confidence Interval for B
Lower Bound Upper Bound
1 (Constant) .009 2.04 13.98
Combined Communication &
Gratitude
.010 .45 3.24
COVID .044 .04 2.87
Political & Societal .363 -.77 2.08
Autonomy .028 .12 2.12
Staffing .224 -.37 1.56
EHR .288 -.56 1.88
Admin Burden .675 -.91 1.40

a. Dependent Variable: Total Copenhagen Burnout Inventory (CBI) Burnout

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Asset Metadata

Creator Grace, Michael Allen (author)

Core Title Physician burnout during a global pandemic: an evaluation study

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 04/13/2021

Defense Date 03/31/2021

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

Tag COVID-19 pandemic,ecological systems theory,leadership,OAI-PMH Harvest,physician burnout,resilience

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Adibe, Bryant (committee chair), Datta, Monique Claire (committee member), Roman, Anna Marie (committee member)

Creator Email gracem@usc.edu,mikegrace@zoominternet.net

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-440718

Unique identifier UC11667206

Identifier etd-GraceMicha-9435.pdf (filename),usctheses-c89-440718 (legacy record id)

Legacy Identifier etd-GraceMicha-9435.pdf

Dmrecord 440718

Document Type Dissertation

Rights Grace, Michael Allen

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

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