“Houston: We have a problem!” Well-Being Parameters and Intention to Leave Current Institution Among Academic Physicians.

Meryl William DO, Frances Chen MD, Elizabeth O’Brien MD

In today’s PAAD, Ligibel et al.,¹ using a survey of  37,511 attending-level, academic medical specialists report that more than a third of respondents report moderate or greater intention to leave (ITL) medicine and that burnout and professional fulfillment were strongly associated with ITL.  Of note, the response rate was high (18,719 or 50.7%), which in my experience is much higher than the typical response rate in most survey studies.  Further, this study was conducted before COVID and did not include non-academic physicians, so the results almost certainly underestimate the true scope of this crisis. And anesthesiology reported the highest rate of ITL at 46.8% (95% CI, 42.5%-51.0%)!

I’ve asked Drs. Meryl William, Frances Chen and Elizabeth O’brien of the Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine to review this paper for the PAAD readership.  Myron Yaster MD

Original Article

Ligibel JA, Goularte N, Berliner JI, Bird SB, Brazeau CMLR, Rowe SG, Stewart MT, Trockel MT. Well-Being Parameters and Intention to Leave Current Institution Among Academic Physicians. JAMA Netw Open. 2023 Dec 1;6(12):e2347894. doi: 10.1001/jamanetworkopen.2023.47894. PMID: 38100103; PMCID: PMC10724765.

Physician wellness and burn out has been at the forefront of our minds both before and after COVID-19. The pandemic exposed and exacerbated cracks in the foundation of physicians’ everyday practice, with perhaps, anesthesiologists being one of the most vulnerable groups. Afonso et al.² examined US attending anesthesiologist burnout in the post-pandemic era and found 59% were at high risk for burnout, 36% were likely to leave their position within 2 years, and 25% had reduced clinical weekly hours within the year.  This has led, in part, to what Sinskey et al.³ have termed “the wicked problem” of physician well-being; a term “coined in the 1970s and refers to social or cultural problems that are ill-defined and inherently unsolvable.” ³ Today’s PAAD covers an article that surveyed physicians from 15 different academic organizations aimed at appraising rates of physicians’ intention to leave (ITL) to better glean factors influencing current burnout, turnover, and professional fulfilment.¹

The authors conducted a cross-sectional study by survey, sponsored by the Professional Well-being Academic Consortium (PWAC), a group of academic medical centers working together toward the common goal of examining determinants affecting physician well-being, burnout, and professional fulfilment. The survey was distributed between October 2019 and June 2021, notably just before the COVID-19 pandemic began through the peri-pandemic period. The primary survey outcome utilized the Professional Fulfilment Index (PFI), a validated, reliable tool that weighs burnout and professional fulfilment, as well as an independent question related specifically to ITL. Multiple specialties and subspecialties were included. Participants also ranked measures of personal-organizational values, self-valuation, COVID-19 organizational support, and overall supportive leadership behaviors. Logistic regression was used to test the association between ITL and these known determinants of well-being.

So what did they find?  The survey had a response rate of 50.7% and included 18,719 attending-level physicians from 15 academic institutions. 6903 (37.9%) met criteria for burnout, 7301 (39.3%) met criteria for professional fulfillment, and 15890 (84.9%) chose to respond to the ITL portion of the survey.  The demographic cohorts with a higher incidence of burnout included female gender (42.2% of women vs 33% of men), younger age (40.6% aged 39 years and younger, 40.5% aged 40 to 59 years, and 23.2% aged 60 years or older), and non-White non-Asian races (40.1% other races, 37.3% White, 32.8% Asian). In regard to professional fulfillment, the rates were almost the exact opposite of those for burnout; the demographic groups with lower burnout scores had higher professional fulfillment scores. Predictably, an increase in burnout and a decrease in professional fulfillment are directly associated with ITL. Institutional factors inversely associated with ITL included supportive leadership behaviors, peer support, personal-organizational values alignment, perceived gratitude, COVID-19 organizational support, and electronic health record helpfulness. Depression and negative impact of work on personal relationships were directly associated with higher ITL scores. Amongst all the medical specialties surveyed, anesthesiology had the highest rate of ITL (46.8%), followed by gastroenterology (41.3%), thoracic surgery (40.2%), neurological surgery (40%), critical care (39.8%) and radiology (39.8%). (Figure)

The highlighted factors associated with lower ITL provide specific targets for intervention that institutions can address. These elements demonstrate, as Sinskey et al.³ noted, that well-being initiatives have to include systems-level interventions. Early efforts to tackle physician wellbeing focusing solely on individual interventions, such as meditation and physical fitness, failed to understand the impact of chronic stress from the workplace environment. Without institutional-level change, the vicious cycle of burnout continues, leading to high attrition, staffing shortages, and a loss of knowledge, experience, and mentorship.  

Notably, this study did have several limitations. Since it was conducted between 2019 and 2021, the impact of the COVID-19 pandemic cannot be taken lightly. Furthermore, it was only administered at academic institutions and may not be representative of physicians in the private sector. As it was based on self-reported data and not all questions required a response, there may have been a sampling bias. It raises an important question - are physicians less or more likely to respond to a survey if they are burned out? The survey also did not elucidate the next steps of those reporting ITL (ex. retire, leave medicine, move to a different practice setting, etc..).

As noted by the authors, ITL and poor physician well-being are issues that appear here to stay. Afonso et al.² also reported in their study that staffing shortages had more than doubled in 2022 compared to 2020 (78.4% vs 35.1%). The data suggesting even worse physician shortages in the future are staggering. The AAMC published an executive summary in 2021 estimating physician shortages varying from nearly 38,000 up to 124,000 physicians by 2034 in the US.^1,4 The field of medicine, and specifically the field of anesthesiology and pediatric anesthesiology, will have to continue to recognize and address this “wicked problem” if we hope to see future generations carry out this important work.

What are your thoughts?  Send your comments to Myron who will post in a Friday Reader Response.

References

1.          Ligibel JA, Goularte N, Berliner JI, et al. Well-Being Parameters and Intention to Leave Current Institution Among Academic Physicians. JAMA network open 2023;6(12):e2347894. (In eng). DOI: 10.1001/jamanetworkopen.2023.47894.

2.          Afonso AM, Cadwell JB, Staffa SJ, Sinskey JL, Vinson AE. U.S. Attending Anesthesiologist Burnout in the Postpandemic Era. Anesthesiology 2024;140(1):38-51. (In eng). DOI: 10.1097/aln.0000000000004784.

3.          Sinskey JL, Margolis RD, Vinson AE. The Wicked Problem of Physician Well-Being. Anesthesiology clinics 2022;40(2):213-223. (In eng). DOI: 10.1016/j.anclin.2022.01.001.

4.          IHS Markit Ltd, Dall T, Reynolds R, et al. The Complexities of Physician Supply and Demand: Projections From 2019 to 2034. (https://www.aamc.org/media/54681/download).