Applying Job Demands-Resources (JD-R) Theory to the Understanding of Residency Program Director Well-being

doi:10.21203/rs.3.rs-4131790/v1

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Research Article

Applying Job Demands-Resources (JD-R) Theory to the Understanding of Residency Program Director Well-being

https://doi.org/10.21203/rs.3.rs-4131790/v1

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Background and Objective:

Literature on well-being of physicians and residency program directors (PD), has shown a prevalence of burnout of 50% in physicians, and 20–30% in PDs. However, few studies have explored engagement, or meaningful aspects of a physicians’ work and no study in the PD community. Therefore, this study explored the experiences of PDs and associate program directors (APD) as they encountered burnout, engagement, and every combination thereof.

Methods

A qualitative methodology was utilized to include longitudinal and cross-sectional data collection phases with all participants recruited via email. Phase 1 participants (n = 3) included two PDs and one (APD) from a midwestern university. Phase 1 included three semi-structured interviews and direct observations. Phase 2 participants (n = 5 PDs) completed a single semi-structured interview. All interviews and field notes were analyzed using inductive thematic analysis, with subsequent deductive application of Job Demands-Resources (JD-R) theory.

Results

Findings were multiple sub-themes situated within four major themes: It Takes a Village, Integration of the “Hats” They Wear, Motivation and the Meaning of Their Career, and Coping. Exploring the sub-themes via JD-R theory allowed contextualization of how job demands, job resources, personal resources, job crafting, interact thus adding a broader conceptualization of how PD and APD experienced their roles.

Conclusion

This study describes the experiences of PDs and APDs embedded in their social context of responsibilities. The results indicate an understanding of how the individual experiences their job demands influenced by job and personal resources, and further how proactively engaging with their environment enables for a deeper appreciation of engagement and burnout.

In the Exam Room: The patient goes on to show pictures of them and their grandson on their phone, then starts to tell the story of how when a local college decided to close, the grandson lost their job and school, and his girlfriend left him. The patients’ grandson then went to a local park with his grandfather’s gun and shot himself in the middle of the forehead. The patient in the room proceeds to show us [researcher and participant] the picture on her phone that she took of her grandson lying in the hospital bed, with a tracheostomy, and a bullet wound in the middle of his forehead.

Walking to common staff area: [Participant] says, “I think that is the fourth time I have seen that picture of him lying in the hospital bed, I am not sure how many more times I can see that… I lost a friend [a physician] to a self-inflicted gunshot… while she was talking [referring to patient] I was sending messages to her social worker about how she is revisiting the same stories….” [researchers’ initial thoughts: this is not a “typical” experience for anyone to have. No one expects to see a picture of someone who has a self-inflicted gunshot wound, not to mention once, but this has occurred multiple times, and every time reminds [participant] of her friend that died of suicide of the same manner.] After, [participant] says “I am mentally exhausted…” now she needs to regroup and get onto another patient phone visit as if nothing happened. Observation Participant C (Fieldnote)

This encounter and experience demonstrate the affective aspect of patient-to-clinician encounters which may be a source that depletes mental resources and energy. However, given the time constraints placed on clinicians, there is a scarcity of time to reflect on these emotionally charged experiences. Considering this, how do clinicians replenish those resources to meet the continuous demands requiring mental and physical energy and if not, what may result? The conceptualization of burnout, today defined as “overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment”, (Maslach et al., 2001 pg. 399) often begins with Freudenberger and his work as a counselor in a New York City Free Clinic (Freudenberger, 1974). Presciently, he viewed prevention as an unobtainable goal, stating: “we cannot prevent burn-out, but we can certainly help to avoid it as much as possible and when it does happen to one of us, to admit it, ask others for help and take some time off for ourselves” (Freudenberger, 1974). Within the community of medicine, there has been a recognition and discourse involving burnout, resulting in 182 publications on the prevalence of physician burnout between 1991 and 2018 (Rotenstein et al., 2018). During the same period, the landscape of the US health care delivery system has witnessed numerous changes to include narrowing of insurance networks, increasing financial pressures, utilization of electronic health records (EHR), increased workloads, and reduced physician autonomy(Shanafelt et al., 2017) when adjusting for age, sex, relationship status, and level of education, as well as less satisfaction with work-life integration compared with US working population (Shanafelt et al., 2015; Shanafelt et al., 2019).

Often seen as the opposing construct of burnout, engagement is associated with high levels of energy and identification with one’s work. In other words, when one identifies with their role and the activity of work (Bakker et al., 2008). A paradigm shift in psychology towards a positive framework has led to an investigation of engagement in combination with burnout. As such, studies exploring physician engagement have started to appear in the literature, albeit most have been in European countries. A study exploring engagement in teaching faculty found those with only teaching responsibilities to be most engaged, while adding on research and patient care responsibilities diminished overall engagement scores, and specifically in domains of teaching(Van den Berg et al., 2013). As the authors highlight, these findings call into question the structure of academic medicine for clinicians, based on the three pillars of research, education, and patient care(Van den Berg et al., 2013). In the context of residency program directors (PDs) and associate program directors (APDs), a study of engagement may be particularly salient as they are by the very nature of their position assuming multiple roles and responsibilities in an academic environment.

Recent literature on well-being of physicians in general, and residency PDs specifically, has demonstrated those meeting the criteria of burnout reaching almost 50% in physicians, and 20–30% in PDs. However, few studies have explored engagement, or the positive, meaningful aspects of a physicians’ career, and no studies have explored engagement in the PD and APD community. Therefore, as PDs and APDs form the nucleus of graduate medical education further exploration and understanding of their well-being is justified. As the nucleus of GME, PDs and APDs, maintain the accreditation of their respective programs by meeting ACGME standards, recruit, interview and select residents, oversee resident education through assessment and monitoring of progression, surveys, and teaching of residents. This list is not inclusive of all possible roles and responsibilities and does not include their clinical responsibilities.

To date, there have been ten studies addressing burnout, stress, resiliency, and turnover status in various combinations in residency PDs. When categorized by medical subspecialty, internal medicine (IM) is the most represented with three studies, two studies for pediatrics and family medicine, and one study for each general surgery, radiation oncology, and anesthesiology (Aggarwal et al., 2015; Anderson et al., 2000; Barton & Friedman, 1994; Beasley et al., 2001; De Oliveira Jr et al., 2011; O'Connor et al., 2019; Porter et al., 2018; Psenka et al., 2020; Weiss et al., 1991; West et al., 2013). All ten studies utilized a survey or questionnaire as the data collection method, via cross-sectional quantitative methodology with participants recruited from all US based residency programs. No study explored residency program directors within the same institutional context, nor did any explore engagement.

The primary purpose of this study is to explore and provide rich descriptions of the lived experiences of PDs and APDs within institutional, personal, and societal context as they experience engagement, fulfillment, emotional exhaustion, and depersonalization within their various roles. This study seeks to answer the following research question: How do physicians, with the responsibilities of a PD or APD, experience the whole of their work-life in relation to their well-being, fulfillment, dedication, and meaning of their career? By exploring the lived experience of PDs’, the results of this study may allow for future investigators to develop strategies to retain PDs in their role to provide continuity of leadership and program stability.

This study was approved by the Indiana University Institutional Review Board (IRB#2006206077). A basic qualitative research design was utilized and carried out in two phases (Merriam & Tisdell, 2016). Utilizing basic qualitative methodology is informed by the assumption that “individuals construct reality in interaction with their social worlds” (Merriam & Tisdell, 2016). Further, the overarching purpose of qualitative methodology is to understand the sense making individuals perform to appreciate their lives and imbedded experiences. Phase 1 participants recruited were residency program directors and associate program directors at a large midwestern university. Program directors were recruited via purposeful sampling using the criteria of specialty, location (academic medical center versus community hospital program), length of time in program director position, and self-reported gender obtained through a public facing directory. Phase 2 participants were recruited based on the initial impressions of Phase 1 participant interviews and observations to increase the information power of the sample (Malterud et al., 2016).

Phase 1 data collection (August 2020-July 2021) consisted of field notes from direct participant observation, semi-structured interviews, and collection of institutional and program documents. Participants were observed in patient care settings, residency curricular programing, simulations, faculty program meetings, resident orientation, resident interviews, and research presentations. Field notes created during an observation were subsequently reviewed and updated within 24–48 hours (about 2 days) of the observation. Participants took part in three semi-structured interviews at 6-month intervals where structured questions were asked of all participants, with additional follow-up questions based on prior interviews and experiences during observations. Specific questions enabled participants to describe experiences they perceived as mentally taxing as well as instances of fulfillment and engagement, and to provide general understanding of their role. Documents included Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Graduate Medical Education, yearly ACGME resident survey results, ACGME milestones, publicly available ACGME and school resources. Phase 2 participants took part in a single semi-structured interview between May and June 2021. The interview protocol for Phase 2 participants was based on questions combined from Phase 1 interview protocols and preliminary Phase 1 analysis of interviews 1 and 2 and observational data.

Data analysis included an initial inductive thematic analysis of all transcribed interviews and written fieldnotes (Braun & Clarke, 2006; Hammersley & Atkinson, 2007; LeCompte & Schensul, 2010). The documents were analyzed to provide context and inform findings from interviews and observations. Inductive data analysis was completed in both OneNote (© Microsoft, 2016) and Dedoose (Los Angeles, CA: SocioCultural Research Consultants, LLC, 2021) data management software. Familiarization was conducted through initial readings of transcripts at the interview's immediate end and again, all data was collected and field notes. Initial coding was performed through systematically using the entire data set and creating codes based on interesting features with relevant supporting data (Braun & Clarke, 2006). Categories were created by collating codes and checking that data were consistent across the data. Finally, themes illustrated the overall narrative of the data (Braun & Clarke, 2006)²³. A second deductive step of data analysis was performed utilizing the Job Demands-Resources theory (JD-R) as a framework where inductive themes and subthemes were mapped and applied to a schematic representation of the JD-R theory using both OneNote (© Microsoft, 2016) and Dedoose (Los Angeles, CA: SocioCultural Research Consultants, LLC, 2021) (Bakker & Demerouti, 2014, 2017; Demerouti et al., 2001).

Theoretical Framework

Job Demands-Resources (JD-R) theory was developed to encompass several aspects of work conditions (Bakker & Demerouti, 2017; Demerouti et al., 2001). The first proposition of JD-R theory is that working conditions are identified into one of two categories: either job resources or job demands, with job demands as a predictor of exhaustion and job resources a predictor of “(dis)engagement” (Bakker & Demerouti, 2017). In addition, this theory proposes job resources buffer the effects of job demands, thus the higher the demands the more salient job resources become (Bakker & Demerouti, 2017). Furthermore, job resources have a motivational effect when job demands are high. Therefore, a combination of high demands and high resources is often referred to as an active job, thus motivating employees to learn new skills and take on challenges (Bakker & Demerouti, 2017; Karasek Jr, 1979). In addition, JD-R theory proposes individuals are not passive participants in their work environment, instead those engaged employees proactively gain resources, and hence, engagement via job-crafting. The same is true for those under stress as they perceive and create more job demands over time via self-undermining behaviors (Bakker & Demerouti, 2017; Bakker & Wang, 2020). Applying JD-R theory to PDs and APDs informed how they experienced job demands in a complex work environment as physicians, all while having multiple roles and (potential) access to resources from their institution, department, team, and self. Furthermore, as part of the evolving theoretical understanding JD-R theory sees that individuals have an active input into their work environment via job crafting. Job-crafting is defined as, “proactive changes employees make in their job demands and resources,” which is based off the concept proposed by Wrzesniewski and Dutton (2001).

One of the initial definitions of engagement, in a work context, was proposed by Kahn (1990) and is the self-assessment of work context where one may ask: “how meaningful is it for me to bring myself in this performance?”, and “how safe and available am I to do so?” Thus, how the individual unconsciously assesses the situation will result in how they view the psychological conditions of meaningfulness, safety, and availability. These psychological conditions shape the individual’s psychological presence (i.e., the experiential state of engagement with dimensions of attentiveness, connection, integration, and focus) which will further shape personal engagement (Kahn, 1990, 1992). If the focus is on psychological presence, as Kahn (1992 pg. 342) states, “the whole person [needs] to be taken into account in framing theory and research.” To understand the experiences of the whole person, “experiences are empirically documented with qualitative data that provide thick, rich, descriptions of individuals and their social systems” (Kahn, 1990). This underlying recursive model of psychological presence informed the methods of data collection, specifically through semi-structured interviews and observation in the participant’s social context, and the final stage of deductive data analysis.

Trustworthiness

Several strategies were utilized to ensure the trustworthiness and credibility of this study including triangulation of methods and data, prolonged engagement with phase 1 participants, and reflexivity. Specifically, triangulation of methods entailed observation, semi-structured interviews, and document analysis which allowed follow-up on contradictions or similarities in what people say they do versus what they practice. Furthermore, Denzin and Lincoln (2018) describe three-dimensions where triangulation may occur and for this study include: time (interviews and observations across time), space (observations of participants in various environments), and person (multiple participants). With the researcher as the instrument in qualitative research, it was important and necessary to state their positionality regarding the research to promote integrity and demonstrate reflexivity (Merriam & Tisdell, 2016). As such, the researchers both have experience as either current or former program directors of graduate programs, and from an epistemological standpoint adhere to subjectivist and social constructivists paradigms.

Participant demographics can be found in Table 1. Interviews lasted between 60–90 minutes (about 1 and a half hours) and each observation lasted between 30minutes and 3 hours.

Table 1

Participant Demographics
Phase 1
Number of Participants	Years in PD or APD role	Location	Data Collection
3	2–15	Academic Medical Center	3 semi-structured interviews; 35 observations totaling 91 hours; program specific documents
Phase 2
5	3–20+	Academic Medical Center and Community Based	1 semi-structured interview

After initial inductive data analysis (see Table 2), the subthemes and sub-subthemes were deductively applied to the JD-R theory schematic to provide context and a depth of appreciation for the experiences of the participants. The four major themes from the inductive analysis have been nested into JD-R theory categories which will assume the role of major themes (i.e., job demands, job resources, job crafting, self-undermining) with the subthemes supporting the JD-R theory constructs. For this study, the subtheme roles fall into one or more characteristic as physical, psychological, social, or organizational aspect requiring output of energies (supporting sub-subthemes administrator, advocate, educator, clinician, “tax”, and role conflict).

Table 2

Results of Inductive Data Analysis
Theme	Subtheme	Description	Exemplar Quote
Integration of the “Hats” they Wear	Roles	How the participants experienced their various roles, responsibilities, tasks, both work and personal, and how the roles integrate, add, detract, and make whole their lived experience as a PD or APD. Roles entail being an advocate, educator, administrator (with interrelated tasks [Figure 1]), clinician and overall workload.	“Now I think there's plenty of ways to [mentor]. I think the hardest thing is its sort of leading a horse to water, but you can't make them drink. So, I am trying to figure out how to convey that message to the residents of what they need to have and how I can make the path but that they need to also participate in the path to accomplish what they want. So, I think that's probably what the biggest challenge and maybe the biggest frustration is. When you're a parent and you say, ‘don’t do this or else.’ You say that 27 times and they do it. So, from a resident standpoint, it’s helping people figure out what they want to do with their future and then creating the path to get there. Sometimes the second part is harder to do. It's not always clear so not everybody believes me.” Interview Participant A
	Integration	Defined how the participants molded each of their responsibilities into a whole, at times demonstrating role conflict, and integration of work, family, and personal time through boundaries of connectivity	“I think it's always tricky to figure out how to meet patient's needs and not burn ourselves out, so I've seen one aspect, you know people who are very comfortable using the EMR and I actually have a diverse patient population that uses my EMR, I have people who I mean, they have, a certain level of literacy, they may have very low health literacy but they, certainly have a high level of literacy because they can send me messages on an iPad, find it really challenging meet them where they are, like they're sending you multiple texts and essentially it's a text and that's creating a lot of work for me.” Interview Participant C
Motivation and the meaning of their career	Autonomy	Experience of being intrinsically motivated to perform tasks that promoted individual growth and growth of their residency program.	“If I want to work on an initiative and this initiative fills a hole and fills an educational need. I can do it. I mean I have such free rein. Sometimes I feel guilty because it's not like, oh, I'm just kind of stuck in what I need to get done.” Interview Participant C
	Opportunities for growth	Utilizing the mindset of wanting to continually improve and self-educate was just as crucial for this growth to occur, i.e., a growth mindset.	“I'm always excited to see what we come up with next, because we have this wonderful ability to do these small group sessions with, residents 8 to 14, which is so sweet to be able to do that. And so that's sort of an ongoing curricular thread we couch it in wellness, but it's really about sort of communication and about the hidden curriculum, there's always other aspects of the curriculum that aren't necessarily taught, and so we wanted to bring those aspects out. You know could be debriefing losses or mistakes or, mental health, wellness, I was so excited about that.” Interview Participant C
	Value	Personal morals and ethos, and how these are viewed as congruent or incongruent with the organization, society, or healthcare delivery systems at large.	“Working in an [large system] really aligns with my values because I want to, educate, motivate, diagnose, and treat. And keep it as narrow as I can. I don't want to be talking about insurance. I don't want to be talking about formularies. I am not the person to give to go in depth with dietary exercise.” Interview Participant C
	Purpose	The “why” participants pursued their career path, and it was often through mentors or others influential persons early their career development. Then recognizing their niche and utilizing the skill set to career fit.	“I've always loved my educators. I think I've always looked up to my educators so much that I have always had this feeling that I'd love to be in the role that I've always looked up to so much.” Interview Participant G “It aligns super well, and I realize this all the time because I work in a situation where I'm on a team, and so it can turn out that with a lot of things that I am an expert and [other things I turn] over to my team members. So, I am not very good with memorizing formularies. You know I think my triage nurses are better at triage than I am, like, who really needs to be taken care of today. I would go crazy if I had to do all my own triage and social work. I'm not great at assessing social determinants of health and putting them in a hierarchy and getting them to where they need to be.” Interview Participant C
	Task Significance	Describes experiences when participants found moments of joy and satisfaction in their work to buoy against the more challenging aspects, to lead to moments of complete absorption in a task.	“I'm deeply passionate about education…So coming to residency, this was my first exposure to academics, and I absolutely fell in love with it. The transfer of information that comes with staying up to date. Seeing a variety of pathologies and really the mentorship from my faculty was incredible and I knew that I had to be a part of it.” Observation Participant B (direct quote)
It Takes a Village	Presence of Community	Entailed the building and maintenance of relationships at levels within the organization to enable PDs and APDs to experience a sense of community and support which can be drawn upon to accomplish assumed roles. This is accomplished through relationships, specifically those with their support team, department chair and leadership, and peers and colleagues.	“Yeah, our program coordinator is amazing. I would argue I have probably the best coordinator in the country. She's very technologically savvy. She's very creative. She's very educated. She's talented and can take the ball and run with it. You know, she's not a [specialist], but she's everything else. And so, I think that's helpful.” Interview Participant A I would say that is the sustaining group. We had an in-person meeting this year, which we were right on the cusp of meetings sort of happening again. It was in April, and it sounds silly but honestly seeing other program directors and having a drink with somebody else who's doing the same, I think it's meaningful and it's good to be on the inside of that a little bit. Interview Participant A
	Breakdown of Community	Failure of communication between these various parties (i.e., institution, ACGME) was manifested as breakdown in understanding as to what was required of participants to meet accreditation requirements, especially with the fluid situation of COVID-19, and as frustration in a large academic institution where disparate parts are not communicating.	“No, I wouldn't say the ACGME is particularly good at communicating things, you know they send broad communications to everyone. And so, for example this year. There were some proposed program requirement changes that were proposed in December, and then there was a period of comment, and that comment period closed at the end of January. And then there was no other conversation. And then the new requirements were July 1 and it was all buried in the bottom of an email that you know all these proposals for all the programs with proposed requirements, now have new requirements. Right so it's not like they send any specific information to specific relevant programs if that makes sense.” Interview Participant A
Coping	Feedback	Included external confirmation, advice, and compliments from either a formal survey completed by residents or through anecdotal accounts from residents, leadership, and colleagues. It provided a sense of pride and satisfaction for participants through knowing they contributed in some way in the residents fulfilling their career goals.	“I think, residents in general have been appreciative of the efforts of the program, just to keep them afloat. And I think that's been beneficial to hear they know that they're cared for.” Interview Participant A
	Cynical	Expressed through pessimistic and skeptical experiences, to the extent that conducting roles were inhibited by the organization's inertia.	“I must spend all kinds of space in ACGME explaining how we're dealing with a violation [citation of program requirement]. And the next year you get the same violation, and even though you've explained what you've done, the outcomes are way better. If the residents don't change their answers on the survey, then you still get cited if the [ACGME] doesn't read any of the crap that you write.” Interview Participant A
	Self-care	A multi-faceted construct where the participants attended to their mental, physical, and spiritual well-being. Both experienced through acts of positive and negative self-care or positive framing.	I think burnout, teaches us something too, like there's value in and I don't know that we're ever going to get rid of it [burnout] so I think we have to learn to cope with it and find those times that give us life. Interview Participant B
	Tax	Experienced as doing the tasks they have to do in order to be able to engage in roles or tasks the participants found meaningful.	“I can think probably one on one mentorship is actually the most satisfying. I do love the teaching aspect. My practice drives the teaching aspect, I love my patients. There's a lot about clinical care that's annoying and not very satisfying. And me and my colleagues bitch about it all the time, but that to me, gives me my admission ticket to teaching, and my teaching gives me my admission ticket to mentoring. So, it's interesting how I sort of put up with the EMR because I can have meaningful patient interactions because I must do to that to be a practicing clinician. I feel I must teach well, and I must be in that situation to mentor, I think of it as a highlight builds on each other.” Interview Participant C
	Emotional Intelligence	Manifested as empathy, towards patients, residents, and colleagues, and growing through experiences allowing them to reflect and gain insight into their own behaviors.	“You know, time helps too, because you develop a bit of a thicker skin, your first few patients that you talk to are devastating and over time, I don't know why. I've always been one to wear my heart on my sleeve, so I don't know how I have sort of developed that skin. But I think just doing it over and over. And now I've learned that there are better ways to do it. But I think it's gotten a lot easier. I think, practice, and then listening and knowing how to be silent.” Interview Participant C

Job Demands as Administrator

The role as administrator (see Fig. 1 for interrelation of administrative tasks) was viewed as an overarching role with many interrelated and at times competing demands, often in a never-ending cycle, as one participant stated:

It just feels like you're never caught up. We do our orientation and graduation in June and then July is like the first month of clinical things… then jump right into interview season… a little bit of a break, January, February, into the spring, to regroup until you focus on maybe program improvement. Interview Participant B

Building further on the variety of tasks, often nested within those tasks is dealing directly with managing of persons, residents, staff, faculty, and colleagues. As stated by the following participant:

It takes a fair amount of time. A lot of my buddies… we say instead of being called program directors, we should be called HR directors which is really what we are, so it takes a fair amount of time to be an HR director. Interview Participant E

To meet this time demand, PDs and APDs participants were allotted a portion of their full time equivalent (FTE) towards administrative time. Furthermore, it was a requirement stipulated by the ACGME to allot PD and APDs a portion of their time towards the program. Of note, each specialty accredited by the ACGME has a unique allocation of FTE allotted for the PD and subsequently differing FTE amounts for the support team (i.e., program coordinators, APDs).

Job Demands as Educator

The role as an educator described how participants strike a balance between providing and creating a safe, inclusive, and non-threatening learning environment with all the appropriate resources and opportunities, all the while expanding, challenging, and pushing residents to become the best autonomous physician. This balance was viewed as a challenge to push the residents beyond their comfort zone to facilitate growth while maintaining a psychological safe space for their residents, as a stated by one participant:

That's the thing, [residents] are vulnerable. We must treat them like trainees, but they could still get sued. They're building a reputation in residency that may follow them and they must realize that. It only gets harder once you're out [of residency]. They think they are overwhelmed with responsibilities and stress [now] - they have no idea. Interview Participant B

Furthermore, embedded within and inseparable from the educator role is that of a mentor, by providing the guidance and feedback necessary for the residents’ growth (Table 2). As a mentor and educator, appreciating when to provide advice or allow the resident to learn through their own experience was a challenge with the added complexity of needing to advocate for the residents to ensure they have a safe and inclusive learning environment.

Job Demands as Clinician

The role as a clinician was the anchor role as the reason why participants went into medicine was to provide compassionate care for patients. As such, to assume other roles one had to first assume the role of a clinician. A recognized aspect of the clinician role were the inherent failures and successes, and how one learned the emotional skills to manage those outcomes successfully, as a participant stated:

That's part of training… in [specialty] we are accustomed to… the ups and downs, and that's part of the resilience that you must build, and we must recognize that for every bad thing there are 10 good things in [specialty] and it’s not that you see the bad thing in front of you way more than you see the good things. Again…. Its part of the expectation of the job to be honest. Can I give you a specific technique [for handling stressors or setbacks]? No, I can tell you that it's just, it's part of life. Interview Participant A

This dichotomy of experiencing a feeling of both satisfaction and emotional fatigue from a similar situational context (i.e., being a clinician) was best demonstrated by a participant in their clinical context. This experience was described in detail in the fieldnote at the beginning of the article which was immediately followed by a phone visit with a patient who recently lost their partner. Of note, the participant’s tone, pace, and empathy towards the patient was fully present in the moment described below:

Towards the end of the conversation, the patient must have said something in the sense that he appreciates all the [participant] does for him as a patient and she responds “thank you, you mean a lot to me too… are you still working in your woodshed?... Keep doing things. I know you are missing [name of spouse].” Observation Participant C (Fieldnote)

These two patient encounters occurred within a 30-minute timeframe on a typical afternoon and demonstrated how the role as a clinician may at times giveth mental energy and taketh away feeling at times of mental exhaustion.

Job Resource Relationships

Job resources refer to those “physical, psychological, social, or organizational aspects of the job that are functional in achieving work goals, reduce job demands and the associated physiological and psychological costs, or stimulate personal growth, learning and development” (Demerouti et al., 2001 pg. 501). The subtheme presence of community encompassed the experience of community support that were either physical (support team assuming tasks and duties), psychological (peers and colleagues locally and nationally as “sounding boards”), social (professional organizations as a “sustaining group”), and organizational (department chair and leadership providing protected time, tangible support, and autonomy). This participant described multifaceted support system created via the relationships formed:

I mean there's not a job you can do by yourself. The program director for [specialty] is a good friend… that I can always bounce things off. Nationally I have developed several relationships and have good sounding boards all over the place and different people for different things like the rest of life. Interview Participant A

All participants recognized a support team as vital to the success of the program and ultimately how the participants role as PD or APD was perceived as fulfilling. One integral part of this support team was the program coordinator, who were universally recognized as key to a well-functioning program. Highlighting the recognition to the importance of a program coordinator by PDs is exemplified by this statement:

We hired a very talented program coordinator, but she started in November. I feel if I was in my role for five years or had a program coordinator who's in their role for 10 years, the job would take up a third of the time. Interview Participant H

Having the support and confidence in an individual to complete tasks or projects in an autonomous fashion allowed the PD and APDs to utilize their finite time and energy toward other tasks. Further, psychological resources, or the supporting group, were the PDs and APDs peers and colleagues, clinicians, clinician educators, and other PDs and APDs. Importantly, when these relationships were lacking it was apparent, as a participant described when there is the loss of relationship and connection based on the conditions of virtual meeting:

What's interesting is that before COVID it was hard to get people all in the meeting at the same time because of competing clinical responsibilities and just general life business. Now you can get everybody in the same Zoom room, but most people don't have their camera turned on, and you have no idea if they're paying attention or contributing… there's no sense of personal connection in that situation. Interview Participant G

Of note, this participant made it a point to have their interview for this study conducted in person. Participants stated their community was fractured due to the COVID-19 pandemic, and thus, experienced a loss of meaning when their connection with a resident was lost. This multifaceted support system goes beyond what was described in the above quotes to include chief residents, department chair, and personal resources such as partners, children, or friends.

Job Crafting

Job-crafting considers participants free will and input they have on their working environment as not merely passive recipients of their environment. The guidance and framing of the participants input into their environment were informed by their values (Table 2). If values provided their guidance, then their purpose provided the “why” to pursue those values in their career path, and it was often through mentors or others influential persons early their career development. Nested within the participants' purpose was the establishment of a niche, or a unique skill set to which they could apply those strengths to their career through skill set to career fit. The niche is exemplified by the statement of a participant finding the academic environment in line with here value and purpose as described:

I just loved the environment of academic medicine. The transfer of information and hierarchy, staying up with guidelines, mentoring and teaching. I fell in love with academics as a concept in residency. Interview Participant B

Further, having the awareness of their strengths, being able to be in a situation and space to enhance the strengths allowed the participants to be at their best. (See Table 2 for exemplar quote)

When combining all their input and self-awareness of strengths, participants with a niche were able to assign task significance or those experiences when participants found moments of joy and satisfaction in their work to buoy against the more challenging aspects. Specifically, since participants all had an inherent interest in education, those moments of educating residents were a source of significance, as stated:

The thing I enjoyed most from an educational standpoint is educating. It's sitting with residents and teaching…It's so much easier and it feels more rewarding to see the light go on in people's eyes when they understand the concept or they're as excited about a diagnosis as I am. Educationally I love the opportunities for education that come up in my clinical day. Interview Participant G

Therefore, having their values inform a purpose which further drove them to find their niche and career fit enabled participants to have access to those significant tasks which provided meaning, partially through active and proactive choices by the participants.

Self-Undermining

Contrasting those proactive choices leading to task significance, the converse are those self-undermining actions “that create obstacles that may undermine performance” (Bakker and Costa, 2014, pg. 115). Themes which supported this construct were negative self-care and cynicism. Specifically, cynicism centered around both clinical responsibilities, to include the organizational structure, and graduate medical education (GME) accreditation. One participant described cynicism towards their clinical environment:

This all contributes to what I refer to as ‘the 100 email problem.’ When I need something done or changed, I am doing a mental calculus. I would love for this thing to be better for both me and for the patients, but it would require 100 emails on my part. I'm just not going to invest that kind of time. A lot of my colleagues have workstations at home. I started emailing the one IT person, and we got about three or four emails in, the ball was in his court, and he never got back to me. This sounds like a 100-email problem. I'm not going to do it again. I will drive. It will take less time for me to drive into work every day. Now you're hearing, the more bitter. Cynical. Interview Participant G

This group of PDs and APDs expressed how they initiated their development of a professional identity in a different generation, within an era of greater expectation of work hours and perceived minimal time for self-care. A participant described how her training affects how she perceives the new generation of residents’ and how this contrast:

I come from the generation, a sandwich generation, as far as medical education goes. I was trained by the giant who would round with an IV in their arm, sick, and that is bullshit. I'm never going to do that. But that was sort of the expectation, and now I'm training a generation that thinks that is just mythology. I feel like I'm saying, ‘I remember working 110 hours a week. That was awful and was ridiculous, and I learned nothing except these people are evil.’ It's funny I've learned what not to do, and now I'm learning what to do and that truly is integration… but integration of work and humanness, I think is what it takes. Interview Participant C

Thus, self-undermining behaviors and job-crafting encapsulated the participants' experiences in how they proactively modified their work environment and how their work environment may have initiated the negative response.

This study presents the lived experiences of PDs and APDs in the context of their multifaceted work lives as they navigated integration of their multiple professional roles with their home, personal, and family lives. Appreciating the moments in time, areas of interest, and interactions with residents as experiences of exhaustion, stress, and strain in addition to experiences of significance, fulfillment, satisfaction, and motivation furthers the understanding of how they experience their responsibilities as a PDs. Situating this study in the context of burnout allows for a starting point for the discussion of the sources of burnout in physicians, in general, and PDs specifically. However, no study has explored how PDs and APDs experience their given responsibilities in terms of exhaustion, stress, or strain, while also considering the experience of fulfillment, motivation, and dedication.

This study demonstrates the importance of nuance and context of job demands where not all are inherently detrimental or consuming of mental energies. To illustrate, the role as administrator required sustained psychological effort to navigate the psychological, social, and organizational aspects of the residency program, thus fitting the definition of a job demand (Bakker & Demerouti, 2017). Exploring a specific subtheme of role as administrator, specifically navigating resident morale and behavioral matters further places the subtheme into context for this specific job demand. First, it may be viewed as a challenge demand, if experienced to be rewarding and fulfilling to guide, mentor, and coach a resident confronted with struggles. For the effort expended in guiding and mentoring the resident, with the effort ultimately leading to a positive outcome the demand was viewed as rewarding and fulfilling, even though it required mental effort. This phenomenon was demonstrated in a study by Bakker and Sanz-Vergel (2013) of home health-care nurses where emotional demands were viewed as challenging demands, in the context of having available personal resources of self-efficacy and optimism. Further, personal resources were positively related to work engagement when emotional demands were high (Bakker & Sanz-Vergel, 2013). Conversely, this same job demand may become a hindrance job demand the behavioral matters are mentally exhausting with no positive resolution and consume considerable psychological effort (Bakker & Demerouti, 2017; Cavanaugh et al., 2000; McCauley et al., 1994; Podsakoff et al., 2007). This context specific and nuanced appreciation of the participants experience is exemplified in the opening monologue of this manuscript. However, further studies are warranted to explore if challenging and hindrance demands are moderated by occupational sector or by personal characteristics.

A job resource experienced by participants was the presence of community, and specifically those relationships within the community that enabled participants to achieve work goals and reduce jobs demands of excess workload, organizational tasks, and communication with colleagues. Further, the support team was experienced as a way for the participants to achieve what they valued most in their work and to engage in what they found fulfilling, that most often being an educator or providing patient care. Moreover, these relationships provided a source of belongingness, or relatedness. Research supporting community support as way of mitigating stressors is found with (Baumeister & Leary, 1995 pg. 508) as they state: “research shows that people who do not have adequate supportive relationships experience greater stress than those who do. In part, this is because having other people available for support and assistance can enhance coping and provide a buffer against stress.” This is further supported by self-determination theory where belongingness (i.e., a member of a community), along with autonomy and competence are identified as basic psychological needs (Ryan & Deci, 2000). It was unclear whether feelings of stress, anxiety, or depression resulted, but a sense of community, and by proxy, belongingness, was an aspect of their career the participants stated they sought and utilized.

“Because employees never experience work overload isolated without having some kind of support or interaction… it is prudent to examine combinations of work characteristics when explaining the experience of job stress” (Bakker et al., 2005 pg. 178). JD-R theory also proposes an interaction between job demands and resources on the overall well-being of the individual where job resources buffer the impact of job demands (Bakker & Demerouti, 2014). Bakker et al. (2005) demonstrated job resources such as social support, autonomy, performance feedback, and opportunities for development mitigated job demands such as work overload, emotional demands, and work-home interference on the outcome of exhaustion. A second interaction is an amplification process on motivation where job resources become more “salient and have the strongest positive impact on work engagement [motivational process] when job demands are high” (Bakker & Demerouti, 2014 pg. 11). PDs and APDs’ in this study experienced multiple interrelated roles with associated tasks (job demands) embedded in a community of support (resources), and when present, resources were able to mitigate those job demands. Specifically, when taking on the role of administrator and addressing the tasks of recruitment and interview process of potential residents, the job resources of relationships mitigated work overload the task of interviewing and recruitment may have induced. This is exemplified by contrasting the two PDs’ experiences with their program coordinator where having an effective coordinator mitigated some of the demands of the interview process but having a newly hired coordinator dramatically increased the PD workload. Thus, one case illustrates the experience of a job resource (i.e., relationships) buffering or mitigating a job demand (i.e., interview process), and the other an experience of an absence of a job resource with a loss of this buffering effect.

Relationships with the department chair and leadership demonstrated tangible support and were an organizational resource that enabled the participants to feel successful and achieve educational goals of their respective residency programs. Specifically, for PDs and APDs, removing or mitigating all job demands which may lead to strain and ultimately burnout is not obtainable nor feasible. However, recognizing what PDs and APDs individually experience as job demands along with an appreciation of their experience with job and personal resources, may allow for a collaborative effort between the PD and APD with their department or institutional leadership. This partnership may enable both to develop potential avenues to gain resources to buffer job demands or even potentially amplify challenge demands with appropriate resources. Fassiotto et al. (2018) described a pilot program to ultimately mitigate burnout which was customized to each faculty’s goals and used coaching, work support (e.g., writing/editing, lab management), home support (e.g., meals, errands, housecleaning) to allow faculty to adjust their time allocation to meet workload of teaching/mentoring, research, clinical, and service/administrative time. Although, not grounded in JD-R theory, Fassiotto et al. (2018), provided resources for faculty to meet job demands and found an increase in satisfaction and a decrease in postponing or avoiding vacation and health habits (Fassiotto et al., 2018). Although they did not measure how this intervention mitigated stress and burnout, it nonetheless demonstrates the effectiveness of developing an individualized approach in providing job resources to meet job demands.

One way to build or create an ideal environment is through job-crafting, which is an individual-level intervention, usually initiated by the employee. However, organizations (e.g., AMC leadership) may stimulate “job crafting behavior that is beneficial for both the employees and the organizations by showing individuals how they can craft their job” (Bakker & Costa, 2014). Participants job-crafted through selection of research projects, curricular initiatives, establishing a working environment conducive to their perceived strengths, and cultivating relationships they found mutually beneficial. Gordon et al. (2018) explored the outcomes of performing a job crafting intervention on “medical specialists” and nursing participants. The intervention in their study included three-hour workshops where participants were informed and trained on job crafting strategies to include seeking challenges and resources and reducing job demands in addition to sharing learning narratives (Gordon et al., 2018). The intervention concluded with participants constructing a “personal crafting plan” which was used by the participants to implement specific crafting actions over a three-week period” (Gordon et al., 2018). This study demonstrated a net positive effect in self-motivated behaviors, well-being, and performance via job redesign facilitated by job crafting (Gordon et al., 2018). Future studies could explore a job crafting intervention for PD or APD that promotes reflection on their proactive abilities to inform the development of a job crafting plan and experimental reflection to promote well-being. An approach comparable to Gordon and colleagues (Gordon et al., 2018) intervention could be utilized to “offer individuals more job control and utilize their knowledge as the experts” via emphasizing reflections and the influence of both management and participants (Gordon et al., 2018). Thus, participants “may either craft their daily work environment and mobilize their job resources or run into trouble because of their high level of exhaustion” (Bakker & Costa, 2014).

Limitations

Transferability of this study is limited as it was conducted at one institution, albeit within differing departments and geographical separation. Thus, one must be guarded in generalizing the results as they are unique to these individuals in the given, time, context, and setting. However, by providing rich descriptions and selecting participants from differing specialties, departments, locations, and genders, one can evaluate how their unique experiences may be transferable to other PDs and APDs at the same institution or more broadly to other institutions, who may have had similar experiences, job demands and resources. Further, the use of a theoretical framework, and investigation of how persons experience burnout, engagement, and general well-being (or unwell being) in context of their lived experience may improve transferability to others in exploring these phenomena.

Participants were invited for this study using purposeful sampling to promote diversity by specialty, location, gender, length of tenure, and to include underrepresented in medicine in the sample. A self-selection bias by participants may limit the sample in how authentically it represents the diversity of the PDs and APDs at this institution. Further, those who chose to participate may have an inherent interest, bias towards, and intimate knowledge of physician well-being, specifically burnout and engagement. Conversely, those who declined participation or were not recruited may have differing experiences as well.

Lastly, the data for this study was collected during the COVID-19 pandemic, thus it may be contended that this exacerbated the participants’ experiences of negative well-being. A recent meta-analysis of burnout of physicians during the COVID-19 pandemic concluded levels of burnout varied among front-line versus second-line health care workers, early versus late pandemic, and by geographical location (Macaron et al., 2022). As such, it is impossible to disentangle the potential impacts of the COVID-19 pandemic, but it does not and should not diminish the participants’ experience and may have allowed the participants to reflect on their overall state of well-being more honestly.

This study highlights that a thoughtful consideration of the experiences of PDs and APDs in their roles and how it relates to their affective state of exhaustion, cynicism, career fulfillment, meaning, and overall well-being is needed to further understand the complex phenomenon of burnout and engagement (Leiter & Maslach, 2017). Thus, exploring both positive and negative states of how one feels about their work is “complex and indeterminate” and “progress in this arena may not come from assessing the presence of absence of a specific state” (Leiter & Maslach, 2017 pg. 57). The results of this present study demonstrate the unique and context specific way the same role can be both fulfilling, meaningful, and satisfying and at the same time being exhausting, and mentally draining; thus, appreciating the nuance of their experience, and not binarizing. Leaders in academic medicine, department heads, PDs, APDs, and other stakeholders in graduate medical education, may want to explore both personalized and institutional approaches to burnout and engagement that are holistic and tailored approach to individual and institutions community milieu.

Author Contribution

K.R. developed the conceptual basis of the research, performed field work, interviews, and data analysis. J.B. consulted on conceptual basis and offered guidance on data analysis. K.R. wrote first draft of manuscript with J.B. editing, revising, and providing guidance for manuscript completion.

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No competing interests reported.

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Applying Job Demands-Resources (JD-R) Theory to the Understanding of Residency Program Director Well-being

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Introduction

Methods

Theoretical Framework

Trustworthiness

Results

Job Demands as Administrator

Job Demands as Educator

Job Demands as Clinician

Job Resource Relationships

Job Crafting

Self-Undermining

Discussion

Limitations

Conclusions

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Author Contribution

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