Building Clinician Well-Being in Academic Family Medicine: A Mixed-Methods Study of Physician Wellness through Voice and Organizational Redesign

doi:10.21203/rs.3.rs-4831314/v1

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Building Clinician Well-Being in Academic Family Medicine: A Mixed-Methods Study of Physician Wellness through Voice and Organizational Redesign

https://doi.org/10.21203/rs.3.rs-4831314/v1

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Background

Physician burnout is a pervasive challenge facing most health care organizations. The objective of this study is to document perspectives of family medicine physician faculty and administrators on institutional factors contributing to physician burnout and efforts to change organizational structure and processes to enhance physician wellness.

Methods

Twenty family medicine physicians at an academic health system completed semi-structured interviews between November 2021 and January 2022. Interview transcripts were coded thematically. Additional data came from a survey of physicians’ perceptions and experience with departmental wellness-oriented activities and two research needs assessment surveys in 2020 and 2022.

Results

Interviewees reported that faculty leaders’ advocacy regarding a collaborative physician-administration shared governance model was essential in organizational decision-making that directly affected faculty wellness. Joint accomplishment of a well-organized, successful primary care response to the pandemic proved the effectiveness of this new partnership. New programs such as prescription refill support, nurse practitioner inbox coverage, and support from the population health program were regarded as effective in reducing burnout and improving wellness. Wellness survey respondents reported improved levels of wellness. Noted areas for improvement included centralized appointment scheduling and uneven support for the tripartite mission of academic medicine due to competing clinical demands.

Conclusions

Despite the mounting challenges experienced during the COVID-19 pandemic, faculty in the Department of Family Medicine noted enhancement of their well-being. More holistic support for academic physicians, including mentorship and compensation for teaching and research, is needed. Advocacy and subsequent organizational changes provide a model for academic family medicine departments to use to turn pandemic-related adjustments into long-term, wellness-inducing changes.

burnout

academic medicine

organizational redesign

Physician burnout remains an urgent problem in the U.S., with electronic health records, administrative burden, excessive workload, and loss of professional autonomy as contributing factors.^1–5 These systemic issues have come to the forefront and been further exacerbated by the COVID-19 pandemic. Some scholars have focused on academic medicine and the unique struggles therein.⁶ Causes and solutions to excessive burnout during COVID-19 have also been examined.⁷ While many factors contributing to burnout are found in both academic and non-academic settings, top-down organizational structure and additional teaching and research requirements are salient features that are more challenging for academic physicians.^5,8 To date, research has documented the efficacy of different solutions in healthcare settings, including more cultural diversity, greater support from management, providing more social services for patients, and increased staffing, administrative time, and communication.^7,9–13 However, the combined ability of changes in leadership structure as well as institutional investments in team-based care to enhance physician well-being remains understudied.

University of California San Diego Health (UCSDH) has not been spared these challenges in physician wellness. Per a 2018 Press Ganey survey of U.S. healthcare organizations, UCSDH ranked in the bottom 1st percentile for physician engagement and alignment; Family Medicine was one of the lower performing departments.¹⁴ This became a call to action for our institution to address physician well-being in a more systemic fashion. A few departments appointed Wellness Directors, with the Department of Family Medicine being one of the first departments to financially support such a role. Additionally, the establishment of various collaboratives, including the Wellness Steering Committee, Wellness Oversight Committee, Wellness Task Force, and partnerships with the Sanford Institute for Empathy and Compassion have continued to move the needle on initiatives to improve clinician well-being at UCSDH.

In late 2019, a pivotal movement, affectionately referred to as the Primary Care Revolt, took place at UCSDH. In the setting of significant dissatisfaction with the level of physician engagement in primary care operations, physicians serving as the Division Chiefs and the Clinical Services Chiefs of primary care (Family Medicine, General Internal Medicine, and Medicine for Seniors) gathered to propose a new way forward. A letter was written by these primary care leaders and sent to the Dean of Clinical Affairs and CEO of the health system, advocating for a transition to physician-led management of Primary Care. Some of the tenets included appointment of a physician chair of the Primary Care Operations Committee, as well as a Primary Care Service Line Council responsible for strategy, annual goals and review of key performance indicators, with administrative and physician leadership and ad hoc members for various topics, from population health to business development. This proposal was accepted by the administrative leadership and through this organizational redesign of shared governance, clinic-level physician leaders were brought to the table to represent and guide direction of clinical operations with direct impact on physicians’ quality of life at work.

Furthermore, a Primary Care Redesign initiative was developed, including more robust team-based care and support from Population Health Services in UCSDH, as well as restructured compensation to prioritize quality of care over volume of visits (Fig. 1). The overall vision of the Primary Care Redesign is to decrease the amount of “below-license” work and improve physician autonomy, while also improving quality of care.

Also in 2019, in recognition of the need to support the research mission of the department, a Vice Chair for Research was appointed to strengthen research capacity. The aim of this study was to examine the impact of such initiatives designed to improve physicians’ quality of life at work, as well as identify continued unmet needs in physician well-being.

Twenty semi-structured key informant interviews of Department of Family Medicine (DFM) faculty were conducted between November 2021-January 2022 by the Family Medicine Wellness Director (JC), with the assistance of a qualitative researcher (JR). Interview invitations were sequentially extended to colleagues in the department, with attention given to representation of diversity in clinic site, academic rank, gender, and ethnicity. Interviews were recorded, transcribed verbatim, and analyzed in Dedoose 9.0.54 (Los Angeles, CA) with iterative rounds of coding until thematic saturation was reached. Additional meetings with the Family Medicine Clinical Services Chief as well as the Director of Primary Care Operations provided clarifications on changes in primary care and Family Medicine over the last several years.

A survey regarding Wellness Director programming and various Primary Care Redesign initiatives was also disseminated to DFM faculty just prior to the interviews (in August 2021). Furthermore, we report findings from two research needs assessment surveys of DFM faculty, one conducted in July 2020 (N = 34) and the other in January 2022 (N = 38). Responses to both surveys were thematically analyzed to inform discussions on scholarly needs of faculty as it relates to physician well-being.

Key Informant Interviews and Wellness Director Programming Survey

Our in-depth interviews with key informants and survey responses provided compelling insights. Of the 18 participants who responded to our question about their wellness level, 15 said their wellness has either improved or remained stable from before the COVID-19 pandemic. This positive change was attributed to several key factors, including a fundamental shift in governance and the Primary Care Redesign initiative. However, several ongoing challenges were also highlighted, including centralization, lack of standardization, staff shortages, and inadequate support.

Governance

For those who specifically noted an improvement in their wellness, a majority (n = 9) of respondents attributed improvement to a change in governance from a top-down approach where the non-physician administrative director for operations was managing physicians and staff to one that is more collaborative where physician and administrator serve as co-leaders. The current administrative Director of Primary Care Operations was described as a “wonderful partner,” with one respondent stating, “we’re truly a team.” Additionally, two respondents flagged new leaders’ ability to bridge business interests and faculty’s professional interests. The new leadership knows how to “cross both worlds.” Two other respondents reported a general sense of improvement, with one stating that “it’s so much better than it used to be.” Interestingly, of the minority of respondents who endorsed lower morale in the workplace, they were unaware of these changes in leadership and governance.

Primary Care Redesign

Of the nine primary care redesign initiatives, five received overwhelmingly positive feedback, one received overwhelmingly negative feedback, and three received mixed feedback. This was largely echoed by responses to the Wellness Director Programming survey (29 respondents, approximating 70% of active clinical faculty in the department) (Fig. 2). Customized appointment templates, nurse practitioner inbox coverage, improving patient access, the prescription refill team, and Population Health Services received mainly positive feedback. The most common reasons for favorable views of these programs are that they allow for more physician autonomy, save time for physicians, reduce physician workload, and provide these benefits without sacrificing quality of care for patients.

The prescription refill team and inbox coverage by nurse practitioners are the two most widely praised aspects of the redesign. Time saving was widely noted. If refill and inbox coverage were not in place, it “would definitely add on one or two hours a day if you’re covering somebody else.” Not only does the prescription refill support decrease non-face-to-face work (or Pajama Time¹⁵), but also helps physicians stay up to date with evidence-based surveillance strategies and appropriate deprescribing that might otherwise be missed. Several respondents noted that they take “a ton of stress off”, allowing faculty to go on vacation or attend on the inpatient wards service without having to worry about checking their inbox or asking a colleague to cover.

The Population Health team is also held in high regard. Respondents highlight patient outreach by Population Health as having improved quality of care without creating more work for physicians. However, some concerns are raised about patient eligibility constraints due to insurance coverage for population health services, as well as the need for clearer communication with clinicians about their outreach with patients.

Resource nurses (circulating nurses to assist clinicians and medical assistants in their clinic workflows), right sizing patient panels, and Flow (a Lean Six Sigma^16,17 approach to quality improvement in healthcare delivery) received mixed assessment. The Care Navigation Hub – a “one-call resolve” strategy utilizing a symptom-focused call escalation matrix with scheduling and triage escalation protocols – received mostly negative comments. According to respondents, the Care Navigation Hub has been a source of centralization and depersonalization, lackluster communication with the physician, and poor triage: “It feels very clunky and conveyor belt.” Centralization, while often seen as better for business from an efficiency/cost-savings perspective, is frequently cited as a complicating factor for physicians in delivering care. Having patients triaged by staff who are not intimately familiar with them negatively influences continuity of care^16–18 and can lead to more emergency department and urgent care visits.

Tepid reactions to resource nurse and right sizing patient panels were mostly due to concerns about implementation and execution. Flow received mixed reviews from respondents, though no one gave it a flat-out negative rating (of note, one-third of respondents had not yet integrated Flow into their practice). The overwhelming response was that Flow is a good idea that has been insufficiently implemented: “I thought it was a good thing. I think it's just become very difficult to sustain it.” Inconsistent staffing was raised as an issue in sustaining Flow concepts, and this grievance speaks to larger concerns about staff support that came up throughout the interviews.

Changing the compensation plan from an RVU-based model to a salary program was also well-received, with one respondent saying that the salary plan “takes [lack of control over RVUs] stress away from me.” Physicians felt they could focus on the quality of their work rather than the quantity. This change in payment incentive has shown some encouraging results – operational data demonstrate that all the goals with the Primary Care Redesign (improving access, quality and experience) are being met. Patient continuity has improved from 58th to 78th percentile over the last two years, patient experience data has improved from 43rd percentile to 84th percentile, and quality measures in diabetes and hypertension control have also improved.¹⁹ Furthermore, leading indicators of health care savings at UCSD Health have been very positive, supporting the idea that these initiatives have shown a positive impact on patients, physicians, and health system (Fig. 2).

Need for Comprehensive Support

When asked what the department could do to better support primary care physicians, most respondents suggested different forms of support to ease workload. There was a shared sense that the workload for primary care physicians continues to be quite high, even with several measures to offload this burden. Concerns regarding a lack of standardized training and poor conveyance of performance expectations to MA/LVN staff has led to a situation where some clinicians are saddled with work below their license. Suggestions for how to ease workload requirements include staff support, which takes the form of back-office support, scribes, EMR support, and administrative support.

At a more general level, respondents expressed a desire to be valued. This came through most sharply in the context of parity with subspecialists, “They get the new buildings…they get as much time as they want with patients. They have scribes or one-to-one nursing…They have administrative assistants.” Concerns were voiced by several interviewees regarding unequal distribution of resources compared to subspecialty departments and the need for more equitable distribution of resources. Such concerns about inequity echo back to the larger theme of insufficient resources being allocated to primary care (Table 1).

Table 1

Themes from Key Informant Interviews (N = 24)
Governance/Leadership	Primary Care Redesign	Valuing Academic Primary Care Faculty
Change in Governance “…we kind of cycled through some leadership that kind of just, in a step-ways fashion, improved with their, you know, ability and willingness to listen and not just speak for the organization and those above them.” “And I think that that structure of peer to peer is a much, much easier than hierarchies of going up. And then you never get there anyway.” “… it's definitely gotten to a much more collaborative point now, and I do think a huge, huge part of that is [the Director of Primary Care Operations]...he's an amazing, amazing advocate…”	Prescription Refill Team “If you ask me for improvements, I think that one great improvement has been, for example, the pharmacy refills has been really to me a real sense of wow, I don't have to do these. And that is great.” “Love that. Actually was a total game-changer for physician wellbeing.” “I think that the Pharmacy Refill Program is one way that they really try and support Primary Care and kind of like not have us just doing sometimes what feels like mindless work.”	Understanding Primary Care “… there's been a big pivot towards making an actual effort to support primary care…And even center primary care, you know, in the organization much more. So, that has been huge for me because I spent a long time feeling like we were just sort of turning patients on the side with not much ... support.” “I think, all things considered, being a major academic medical center, I do truly feel like they are holding true to their word…giving more support and emphasis to Primary Care, understanding positive patient outcomes.”
Leadership Qualities “I think the big thing is, you know, the simple stuff that people always say, like being able to just see who these people are, like, you actually know – if you hear their name, you know what they look like, you've maybe had more than just like a big meeting, like, introduction to them, like you've maybe had a one-on-one conversation with them, so they're, like, in our spaces, meeting us.” “On the ground leadership that is constantly asking for feedback and actually putting feedback into action and not just being all talk.” “And they are working, I don't want to say for but definitely alongside of us but not over us, not dictating what happens in the world that we live in. I think it's more about troubleshooting, making our lives as fulfilling as they can be, prioritizing patient care, like all of that. I see that.”	NP Inbox Coverage “So, I definitely see a change in that. Having a nurse practitioner to cover our inboxes when we're on vacation. Also, they – a lot has been just a really good support, rather than having each other cover the inboxes. Because that would definitely add on one or two hours a day if you're covering somebody else. And it's also just nice because I think that provides better access to care. So. then you don't feel – I don't feel as pressured to squeeze people in.” “So I mean, before, we would have to cover our own inbox or ask a colleague... And every clinic kind of did it differently and every team did it differently. But you would, therefore – on top of all the work you'd have to do, you might have to cover an inbox of a colleague. And so the fact that you can go on vacation and come back to an empty inbox and you're very well covered and that you don't put that work on somebody else is huge.”	Clinical Workload/Staff Support “I would say that the amount of things I need to do per patient continues to go up. And that is something that drives me absolutely insane.” “We get more and more stuff that needs to be done. More questionnaires. More things that some of it definitely is useful, some of them is not.” “...the fact that I have my same nurse all the time every time, me personally, that is the biggest piece of wellness in clinic, and I know some people don't get that same experience and benefit, and it's very difficult to be in clinic without the same, you know, partner.” “If everything around me that supports me in taking care of [the] patient is working well, I can get through it.”
Institutional Pandemic Management “UCSD did a phenomenal job with COVID. I think we had information immediately, I think we, you know, you know, very quickly the clinics were not – were not seeing, you know, COVID symptom patients in clinic.” “I feel like there's a lot of things that I've seen in my time here over the ten years and then probably more recently in the last couple of years, especially during the time of COVID, where there's been a good amount of support. “I mean I think that UCSD did an absolute A, triple-quadruple-plus job of managing this whole pandemic.”	Centralization “To me, my perception is that care nav is putting a physician further, further away from our patients. Because ... It takes too many intermediaries between the physician and the patients. And as you know as the information trickles down, it changes and it may not be exactly what the patient needs. And I had hoped that we'd have in-house directly working hand to hand with a doctor instead of going through all these other secondary people.” “I think, in general, that's been helpful in triaging various concerns. Of course, there's always room for improvement. And that would be potentially – I don't know. I think it can frustrate some patients of having to go through phone tree and leave several messages to be able to get an answer.”	Medical Education & Scholarship “And if you have to take your time to do the work of teaching, you should not be penalized against the clinical work.” “The medical school wants you to teach, but teach for free, basically. Or if you need to do any university service or if you're going to do any research, or you do any other project, it's pretty much on your own, which I think is really hard.” “I feel like it's almost like we have two positions. We have our position within UC San Diego Health and the clinician who we are, and then we have this position of all of this academic faculty requirement. And I don't think there's much communication between those two.”

Interviewees also noted the unique requirements of academic physicians, highlighting inadequate support for teaching and scholarly activities. While faculty generally enjoy being involved in medical education, several noted a financial disincentive to teach, as it is paid at a lower rate as clinical work. Regarding research, many interviewees admitted to not knowing how to carry out scholarly activities: that “the actual research part of it, the pragmatic part, we don't really have a lot of experience with nor a lot of time.” Lack of mentorship was also raised: “I think I would benefit from more mentorship guidance on how to turn ideas into something…scholarly.” Among those who have research experience, a late career faculty spoke about previously having had little support for practice-based research but he is seeing the positive change occurring now with financial investment in research infrastructure.

These findings are further corroborated by the 2020 and 2022 research needs assessment surveys, which suggest some plausible impact of various research support initiatives, implemented in the intervening time. This is illustrated in a comment from the January 2022 faculty research survey, “The support and opportunities provided by the FM Division of Research are impressive and are truly important in helping us become/continue to be physician scholars.” Furthermore, while needs for “project management” support is a prominent theme in both surveys, responses to the July 2020 survey had more requests for grant opportunities, whereas responses to January 2022 survey suggest more emphasis on research staff, project coordinators and statistical analytical personnel, indicating a positive progression in research engagement (Table 2).

Table 2

Faculty Research Needs Assessment Survey Themes
2020 Survey	Quotes	2022 Survey	Quotes
Mentorship and Coaching (N = 23)	“A "safe space" for mentorship - I feel quite self conscious coming up with my proposals as I still really don't think of myself as a "real researcher" and I would really love to be able to run by work by someone who can review it and provide detailed feedback” “Coaching & Support to create & write viable proposals.”	Project Management (N = 10)	“we need to develop our SRA personnel.” “we need more support. help with IRB writing, help with abstract writing, help with looking for statistician support, help with project management”
Funding for Research Time (N = 12)	“More financial support from the Medical School for this work” “Supported time for research.”	Mentorship and Coaching (N = 8)	“Better access to department mentors who want to mentor and are able to mentor.” “Have staff to assist with the research process from start to finish. Have workshops on how to develop our ideas from start to finish.”
Project Management (N = 11)	“Clinical Research coordinator/admin support” “assistance and support with submitting an IRB proposal including writing the proposal and revision”	Communication (N = 8)	“Keep running list of ongoing research topics and those looking for collaboration” “Still have questions at times and don't know who/where/how to get answers or direction”
Statistics (N = 9)	“I worry about needing help with research design and especially anything statistics related.” “Education on designing research, access to time for it and ease of connecting to statistic support”	Funding for Research Time (N = 7)	“Fund 5–10% with accountability being 1 or 2 grant submissions” “great service, time is an issue only”
Collaboration (N = 6)	“Linking me with others with shared research interests” “More teamwork vis a vis data collection and analysis”	Statistics (N = 5)	“Statistical support, particularly for clinicians” “More assistance with biostatistics, study design”
Time (N = 6)	“Time is always the most limited factor” “Set Aside Time”	Dissemination (N = 2)	“Help with taking our clinical QI and pop health projects to writing and publishing about them.” “More direct mentorship on publication & grant writing”

The relentless waves of the COVID-19 pandemic have posed an enduring threat to the well-being of healthcare professionals worldwide. However, what stands out is the overarching consensus among the UCSD Department of Family Medicine faculty members: they reported that their overall well-being either remained stable or remarkably improved in the face of this global health crisis. There has clearly been a sea change in workplace morale at UCSDH, and several themes contributed to the stars aligning in support of physician well-being. Timing is everything, and the emergence of the Primary Care Revolt ahead of a global pandemic couldn’t have been more opportune. Physicians’ self-advocacy in the face of extensive frustration created a new path. The shift to shared governance with increased physician agency in clinical operations served as a powerful example of a physician-driven initiative that was ultimately embraced by administration and folded into the Primary Care Redesign principles. Furthermore, new engaged administrative leaders, who play a critical role in Primary Care Operations, helped create a partnership between the clinical and business sides of service delivery. While the interests of physicians and health care administrators are often at odds, the organization has successfully aligned these interests in support of a common goal of improved health care delivery and physician well-being.

The institutional focus for the last few years has been on reducing the clinical burden of work through Primary Care Redesign; while some interventions have missed the mark, the overall benefit has been palpable. Effectively utilizing team-based care in ambulatory care practice can decrease clinicians’ burden of work and improve quality of life at work, even in the face of significant challenges such as the COVID-19 pandemic. Prescription refill support and inbox coverage for physicians were two of the most impactful interventions. However, shortcomings in communication remain a focus of several ongoing pressure points. The centralized Care Navigation Hub has been identified as problematic, with a unifying theme being the negative effect of centralization on patient care. In a perfect world, the Primary Care Redesign would have been a bedrock of a “culture of support” from the outset, but in the interest of centralization and focus on practice efficiency strategies, personal touch and adequate embedded support were lost. Furthermore, some felt that while the idea of ancillary population health services of social work, case management, and pharmaceutical management is a good one, the communication from these team members regarding the efforts they were making was seen as suboptimal, which could complicate care delivery. As for Flow, the idea of lean, highly reliable health care delivery models has great potential to improve the physician, staff and patient experience, but adequate and sustained continuity support staff is essential to its success and maintenance. Furthermore, while respondents describe autonomy as paramount to physician wellness, they also report the need for greater standardization. Health systems should be cognizant of this, ensuring that there is uniformity throughout a department or division while preserving the right of the physician to still maintain some autonomy.

The need for comprehensive support of academic physicians emerged organically in several interviews and bears further study. Academic physicians have a myriad of identities and responsibilities — not only as clinicians, but as educators and scholars. Being asked to take on additional academic responsibilities with insufficient training, preparation, and compensation is a source of burnout, especially when added to under-resourced clinical operations. Institutional investment to support all three missions (clinical, teaching, and scholarly work) is imperative to support a thriving faculty physician workforce.

Taken together, our findings bolster existing evidence in favor of burnout prevention strategies such as management support, physician autonomy, providing social services for patients, and increased staffing, administrative time, and communication.^7,12,13 Our findings also support the claim that COVID-19 offered a strategic opening to continue advancing physician wellness efforts, with more attention being given to the mental, physical, and emotional wellbeing of providers.¹⁸ Future studies should evaluate a variety of approaches to striking a balance between clinical practice standardization and autonomy in burnout prevention programs. More research is needed to determine how best to organize triage and call centers to minimize the unintended negative consequences of centralization. Lastly, evidence on effectiveness of ways to support academic physicians in their research and teaching pursuits is needed. In addition to financial resources and technical support, research mentors and robust research team support are needed in academic health systems.

This study carries some limitations. It focused on a single department within one academic health system, which may limit the generalizability of findings. The experience of the pandemic might have influenced the interpretation of the long-term impact of certain measures; benefits may have been more pronounced when the healthcare system was not in crisis mode. Nevertheless, this study contributes to the literature by highlighting the effects of faculty advocacy for shared governance and institutional investments in team-based care in improving physician well-being. We find that greater autonomy and reduced workload while maintaining quality of care are key pillars to improving physician wellness.

Investing in practice efficiency strategies is an investment in wellness culture. Physicians cannot and should not attempt to do it all – valuing physicians through empowerment, resource provision, and infrastructure is essential for the well-being of academic physicians. Furthermore, healthcare organizations that can quickly adapt and meet the dynamic needs of both physicians and patients in times of crisis proves to be a crucial asset in supporting the well-being of the healthcare workforce. Going forward, it is an open question whether the post-COVID emphasis on physician wellness will endure.¹⁸ Our findings can inform other institutions on how to effectively take advantage of the opportunity to sustain burnout-prevention efforts well into the future.

Ethics approval and consent to participate
This study was reviewed and certified as exempt from IRB review by the University of California San Diego’s Human Research Protections Program (reference # 210815XX).

Survey respondents provided consent to participate through an online Qualtrics survey, and key informants provided verbal consent to participate in the Zoom interviews.

Research was conducted in accordance with the Declaration of Helsinki.

Consent for publication
Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Competing interests
The authors declare that they have no competing interests.

Funding
This research was supported by the Pilot Research Program at UCSD School of Medicine’s Department of Family Medicine.

Authors’ contributions

JC conceptualized the research project, crafted the survey, conducted interviews and served as primary author of the manuscript. JR helped conduct interviews, coded the qualitative data thematically, and contributed to the manuscript writing. MT helped with data analysis and interpretation, contributed to the manuscript writing, and provided ongoing mentorship and feedback through the duration of the study. All authors read and approved the final manuscript.

Acknowledgements

This work would not have been possible without the twenty key informants from the University of California San Diego’s Department of Family Medicine, who were critical in providing their perspectives on both personal and systems issues impacting their well-being.

We are grateful for the additional insights and historical context offered by our clinical leaders, Mr. Matthew Satre and Dr. Cassandra Morn.

We appreciate Dr. Gene Kallenberg and Dr. Sheldon Morris for helpful comments on an earlier version of this paper.

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Meeting and internal data review with Matthew Satre, Director of Primary Care Operations.

No competing interests reported.

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Building Clinician Well-Being in Academic Family Medicine: A Mixed-Methods Study of Physician Wellness through Voice and Organizational Redesign

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Background

Methods

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Key Informant Interviews and Wellness Director Programming Survey

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Primary Care Redesign

Need for Comprehensive Support

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