Addressing Burnout and Enhancing Well-Being Among Academic Physicians: A Call for Future Research and Organizational Support

Abstract

Description

Burnout among academic physicians, who navigate multiple roles beyond the clinical environment, is a pressing issue. However, the factors driving burnout among academic physicians are not fully understood. Prior research has revealed differences in burnout dimensions between clinical and basic science faculty, but the impact of balancing research, education, and clinical demands on academic physicians is still unclear. This knowledge gap negatively affects the clinical, translational science, research, and medical education workforces and has particular implications for minoritized and marginalized groups working in academic medical centers. Creating a culture of well-being has been vital in addressing burnout. Further research is needed to explore the unique experiences and demands of academic physicians— particularly those from minoritized and marginalized backgrounds—and to develop effective strategies to promote well-being as they balance diverse roles and contexts. This commentary highlights gaps in understanding burnout among academic physicians and proposes guidelines for future research as well as strategies to improve well-being at academic medical centers.

Introduction

Burnout in physicians is a profound and persistent problem exacerbated during and in the aftermath of the COVID-19 pandemic. In 2021, physician burnout spiked, with 62.8% of physicians reporting at least 1 element of burnout compared to 38.2% in 2020.¹ Burnout is defined as a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job.² Maslach and colleagues have identified 3 elements of burnout: emotional exhaustion, depersonalization (cynicism), and a lack of personal accomplishment (professional efficacy).³ The personal consequences of burnout in physicians include decreased productivity, job dissatisfaction, risk of motor vehicle accidents, poor self-care, depression, substance abuse, and suicidality.^4,5 Burnout is also associated with adverse effects on patients, the health care workforce (physician and non-physicians), and health care costs in addition to negative impacts on physician health.⁵ Burnout has been studied extensively over the last 60 years. A database search conducted on February 4, 2024, revealed the vast and rapidly growing volume of burnout literature over the past decades. The first published study on burnout emerged in 1967. However, it was not until recent years that research on this critical workplace issue increased exponentially. In 2022 alone, there were 2786 peer-reviewed articles examining burnout, more than double the publications from the 2 years prior. Reflecting a surging interest in this topic, a search indexed 28 259 studies on burnout by early February 2024. Even in the first 33 days of 2024, 396 new publications highlighted burnout’s prevalence. Publications specific to physician burnout were first seen in 1981 and have increased, with 7633 publications between 1981 and 2023.

However, despite this proliferation of research, there have not been commensurate improvements in addressing burnout, especially within health care systems (Figure 1). Although a growing body of research has examined causes, correlations, and consequences of physician burnout, little is known regarding burnout among academic physicians, who balance research, education/teaching, and clinical responsibilities. A meta-analysis by Prentice et al revealed variances in burnout profiles and levels across medical specialties.⁶ Their findings highlight that physicians are not a monolith when it comes to burnout; rather, the drivers and manifestations differ across specialties.⁶ This outcome suggests that solutions to physician burnout cannot take a one-size-fits-all approach. Instead, interventions must account for the nuanced, specialty-specific factors influencing burnout in order to address this critical issue impacting academic physician well-being.

Figure 1.

This figure illustrates the number of publications on physician burnout indexed in PubMed from 1981 to 2023.

Throughout this article, we use the term “academic physicians” to describe doctors who not only provide direct patient care but also actively engage in academic duties such as teaching/education, administrative education (residency and fellowship leadership), research, and scholarly activities. Academic physicians typically work in academic medical centers, teaching hospitals, or university-affiliated health care institutions, but they are not limited to those environments. Many other terms describe the work conducted by these professions, including physician-scientist, clinician-educator, scholar-practitioner, and medical educator. However, each of these terms has its own scope of practice and duties. We utilized the more inclusive term “academic physician” to identify physicians who do any academic tasks in addition to direct patient care.

The aims of this commentary are (1) to highlight gaps in the literature related to burnout in academic physicians and (2) to identify the next steps for future research. Decreasing burnout and improving the well-being of academic physicians requires intentionality and consideration of their multiple roles as well as the intersection of demands from the multiple environments in which they work (eg, clinical, research, education/teaching, promotion, personal life).

There is a significant gap in the literature related to the well-being of graduate medical education (GME) training leadership with limited data related to burnout of residency and fellowship program directors. O’Connor et al reported that one-third of medicine residency program directors experience burnout.⁷ The Accreditation Council for Graduate Medical Education (ACGME) provides limited tools to aid training leadership to cope with the demands related to supporting trainees during this shifting culture. The literature is clear about the challenges and needs to improve well-being, yet the path is not as clear.

A key resource for clinician well-being is the American Medical Association’s (AMA) Steps Forward website.⁸ This site offers resources to improve clinical practice efficiency, including multiple toolkits to improve well-being in the clinical environment. However, to our knowledge, there are no comparable resources to aid in improving the efficiency of the research environment and the flow between research, teaching/educational, administrative education, and clinical spaces. In order to create similar tools to support academic physicians in spaces outside of clinical work, it is critical to better understand the job demands of holding multiple roles on burnout and resources to aid with reducing burnout.

Gaps in the Research Literature

Academic physicians perform tasks that create an intersection of pressures beyond the clinical environment. A recent review revealed that few studies have examined the direct relationship between academic physicians’ multiple roles and burnout.⁹ Other studies have shed light on the academic physician experience more broadly. For example, studies investigating differences between clinical and research physician faculty revealed higher rates of exhaustion among clinical versus basic science faculty; however, no differences emerged in other dimensions of burnout, such as cynicism and professional efficacy.¹⁰ Studies focused on post-secondary faculty (ie, faculty at universities or colleges) burnout revealed detrimental effects of adverse job demands and lack of resources.¹¹ Teaching-research conflict has been positively linked to job burnout.¹² Academic physicians holding roles within GME as educators and administrators have a growing number of pressures. This role requires substantial educational support, and the shifting landscape has made this increasingly challenging. As Lisa Rosembaum illuminated in her 2024 New England Journal of Medicine article “Being Well While Doing Well—Distinguishing Necessary from Unnecessary Discomfort in Training,” attending to trainee wellbeing has become more difficult for physician-educators.¹³ Like Rosembaum, we have also noticed rising tensions stemming from learners advocating more forcefully for their needs. This tension has elevated distress levels among academic physician leaders who must balance learner well-being, patient care demands, and health system requirements. Though supportive in principle, implementing trainee well-being initiatives has become complex. More research is needed to identify the resources required to uphold care standards while preventing supervisor burnout and ethical conflicts. Despite the challenges that are presented by holding education and administrative roles in training programs, there is evidence of protective effects from working with trainees. Lagina et al found that interactions with learners were a source of professional joy.¹⁴ Overall, we need to understand these dynamics much better to improve the well-being of academic physicians, as well as the learners they support.

Very few studies have investigated the cumulative impact of research, clinical, education, and administrative educator (residency or fellowship program leader) demands. Lee et al proposed that the job demands and available resources for academic physicians may be more complex than the literature suggests.¹⁵ The interviews within their study highlight the demands of academic physicians, and that the roles of clinician, educator/administrator, and researcher often are in conflict with each other. Perumalswami et al assessed burnout in physician-scientists using the Copenhagen Burnout Inventory (CBI) scale, which includes subscales measuring work-related burnout, personal burnout, and client/patient-related burnout.¹⁶ Their study revealed that greater time spent on parenting and domestic tasks, less vacation time, more time spent on patient care, and negative perceptions of the work climate were associated with increased burnout. ¹⁶ Messias and colleagues also used the CBI to measure burnout across their academic health center, comparing biomedical scientists, physicians, nurses, and residents.¹⁷ They found nurses to have the highest prevalence of personal burnout, basic scientists to have the highest level of patient/client-related burnout, and residents to have the highest work-related burnout. Patient/client-related burnout in the CBI is physical and psychological exhaustion, which is perceived as related to the person’s work with patients/clients. For basic scientists, this burnout could be related to work with research volunteers, funding agencies, inspectors, suppliers, and governmental agencies.¹⁷ This conclusion leads us to the question of how does burnout affect academic physicians who may fit into more than one role?

Relevant Models of Physician Burnout

There are multiple models for understanding physician burnout¹⁶ that can guide research on burnout in academic physicians and aid in finding solutions. The Stanford Model of Professional Fulfillment proposed 3 drivers of physician well-being: culture of well-being, workplace efficiency, and personal resilience.¹³ A culture of well-being is defined as a set of normative values, attitudes, and behaviors that promote self-care, personal and professional growth, and compassion for colleagues, patients, and self. Workplace efficiency is enhanced when there is adequate support in terms of resources to sustain quality, productivity, and work-life balance for both clinical and administrative workloads. Practice efficiency includes workplace systems, processes, and practices that promote safety, quality, effectiveness, positive patient and colleague interactions, and work-life balance.¹⁴ Personal resilience demonstrates personal qualities that enable someone to adapt well in the face of stress and adversity.¹⁵ Roslan et al used a meta-synthesis to develop a concept of physician resilience.¹⁸ Their synthesis “identified resilient physicians as individuals who are determined in their undertakings, have control in their professional lives, reflect on adversity, utilize adaptive coping strategies, and believe that adversity provides an opportunity for growth.”¹⁸ Completion of an intensive year-long curriculum that included mindfulness, communication, and self-awareness in primary care physicians was associated with a reduction in burnout.¹⁹ The Stress Management and Resilience Training (SMART) program is another resource for improving physician resilience.²⁰ While results from a randomized control trial did not reveal statistical differences between the groups, physicians in the active group demonstrated improvements in resilience.²⁰

The National Academy of Medicine (NAM) describes a model of burnout in which there are 3 interacting system levels—frontline care delivery, health care organization, and external environment—where the experiences of physicians and the nature of the work contribute to burnout and professional well-being. Decisions made within these levels of the system impact the work factors that clinicians experience.²¹ This model breaks the work factors into job demands and resources. According to Sinsky et al, burnout occurs when job demands outweigh job resources. Job demands include clinical work, administrative burden, technology burden, length of workday, and patient complexity. Job resources include having adequate support, meaning in work, autonomy, mastery, relationships, and effective technology.²² This job demands versus resources is a simplistic, yet powerful way to understand burnout.

Multiple strategies have been used by organizations to improve physician resilience, which have included peer mentoring and coaching. However, emphasizing resilience at only the individual level ignores the structural and systemic factors that contribute to burnout. Organizational resilience is another framework for addressing physician well-being on dimensions, such as maintaining explicit and frequent communication, recognizing individuals’ gifts, promoting a shared vision, and a community’s sense of belonging.^23,24 Of the strategies used to address physician burnout, organization-based interventions yield greater efficacy compared to those directed solely at individual physicians.²⁵ This outcome necessitates learning more about how organizations can improve the culture of well-being and work-place efficiency for academic physicians. No research has fully evaluated these factors in a way that gives guidance about how we can create a culture of well-being and workplace efficiency that is inclusive of the multiple job demands and work environments of the academic physician. Therefore, the next step in advancing the research is to understand the factors driving burnout.

Burnout is likely to be exacerbated in academic physicians from minoritized and marginalized groups.^26,27 For example, 2 studies suggested that minoritized racial/ethnic groups of physicians and learners were less likely to experience burnout relative to their non-Hispanic and White peers.^28,29 However, these findings counter anecdotal evidence from the lived experiences of minoritized learners and physicians.³⁰ In fact, a study aimed at understanding the experiences of minoritized medical students found they had a lower sense of personal accomplishment and quality of life than non-minoritized students.³¹ Other studies have found that lack of inclusion and equity in the learning environment decreases the attractiveness of a career in medicine for students who hold identities underrepresented in medicine,³² and racism increases the level of stress in emergency physicians.³³ In a cross-sectional study, LGBTQ+ students had less favorable perceptions of the medical school learning environment relative to heterosexual students.³⁴ There was also a correlation between the negative perceptions of the medical school learning environment and increased burnout among LGBTQ+ students.³⁴ These findings among minoritized and marginalized medical students may have similar implications for minoritized and marginalized faculty working in academic medical environments. A recent literature review of racial/ethnic differences in burnout of physicians had inconclusive results about differences in burnout among underrepresented minorities in medicine and non-underrepresented minorities in medicine.³⁵ More studies are needed to help us understand the nature of burnout within minoritized and marginalized academic physicians. Additionally, these studies will help us understand if burnout is expressed differently (eg, somatic symptoms, attrition, requests for leaves of absence) in minoritized academic physicians given the greater number of concerns they face in academic medical environments, which may not be adequately captured in currently used measures of burnout. Other well-known stressors in the environment for underrepresented academic physicians have been overlooked within measures of burnout, such as racism, sexism, gender discrimination, tokenism, isolation, and lack of inclusion and social support.³⁵ The challenges of minoritized and marginalized academic physicians increase their job demands, and an obligation exists to provide accurate and accessible resources to improve their well-being.

Many organizations have worked to improve the culture of well-being by creating organizational support for physicians. Professional medical and health organizations such as the American Heart Association have implemented tools to guard against academic physician burnout by providing program development coaching or assisting with the early identification of mentors.³⁶ Coaching has been found to reduce levels of burnout in female resident physicians and reduce emotional exhaustion and overall burnout in 6 sessions for a cohort of physicians.^37,38 There is also preliminary evidence for the benefits of peer mentoring circles on promotion support and resources for academic physician faculty members.²⁶ While the positive impact of mentoring is known, a recent study identified key actions that academic medical centers can take to improve mentoring of physician-scientists who are underrepresented in medicine, including universal training to reduce bias and discrimination, financial counseling and support, measurement and compensation of diversity-related service activities, and uniform policies about mentorship and promotion across departments, mentoring, and mentor training.³⁹

As shown in Figure 2, drivers of academic physician burnout may fall into 3 distinct or overlapping categories: clinical, research, and education/teaching (inclusive of education administrative roles). Our knowledge of drivers of burnout for physicians within clinical environments has grown, and we acknowledge the roles of the electronic health record,⁴⁰ an emphasis on productivity, compensation structures, patient portal management, scheduling, staffing, team-based care, and various specialty-related challenges.⁵ Our next step is to learn potential drivers for burnout in the research and educational environment. Drivers of burnout in the research environment may include the unpredictability and difficulty of securing funding from agencies, institutional review board (IRB) processes, balancing clinical effort, buying out of clinical (or teaching) time, pressure to maintain publishing productivity, and research environment factors (eg, use of tools, equipment, tech support, managing laboratory staff and relationships).³⁴ Possible key drivers in the education and training environment include administrative and management challenges for residency or fellowship program directors and associate directors, uncompensated service activities (eg, committees, advisement), the impact of teaching on clinical and/or research productivity, course preparation and grading, and lack of resources (eg, technology, space).

Figure 2.

A Venn diagram showing clinical, research, and education/teaching drivers of academic physician burnout. Abbreviations: EHR = electronic health record; IRB = institutional review board

These categories—clinical, research, and education/teaching—also share similarities in drivers of burnout or job demands. For example, academic physicians supervise and mentor trainees and students in both clinical and educational settings, which results in playing multiple roles, such as listening to concerns, problem-solving issues, and advocating for needs. In both clinical and research settings involving working on teams, academic physicians may face conflict between faculty or administrative and support staff. Within research and educational settings, where working hours are often not as clearly defined as they are in clinical settings, academic physicians may experience difficulties with protecting their time. Clinical, research, and education/teaching settings share drivers of burnout, including concerns about tenure and promotion as well as management of the flow between different environments (eg, receiving communications about patient emergencies during protected research time).

Directions for Future Research

Resources developed must include guidance for organizations to support academic physicians and their intersection of identities, such as gender, race, sexuality, and ability. While burnout has been studied extensively, there has been a lack of impact on interventions given the continued and growing burnout rates. There are several systematic reviews and meta-analyses that shed light on interventions with small but meaningful impacts.^41–45 Panagioti et al (2017) reported that evidence from their meta-analysis “suggests that recent intervention programs for burnout in physicians were associated with small benefits that may be boosted by adoption of organization-directed approaches.”⁴¹ Organizational approaches that showed promising outcomes include elements such as adjusting workload or schedule and communication, teamwork, and quality improvement. Physician-directed interventions include mindfulness-based stress reduction programming, contemplation-meditation, communication skills training, stress management skills training, debriefing and focus groups, all of which have varying levels of effectiveness in reducing burnout. Most recently, Haslam et al completed a systematic review and meta-analysis of randomized trials on interventions to reduce physician burnout.⁴⁶ Of the 31 studies included, they found that it is unlikely the changes in burnout as measured by the Maslach Burnout Inventory result in “overall significant numerical improvements in emotional exhaustion and depersonalization; however, likely minimal meaningful changes in clinical burnout.”⁴⁶ Interventions included in the meta-analysis were coaching, discussion groups, drugs (cannabinol), education on stress reduction/coping strategies, mindfulness/meditation/yoga, and schedule changes.⁴⁶

Additional evidence for the need for action and improved research in this area is the decreasing interest in research careers among graduating medical students. There is a steady decline in doctors applying for the National Institutes of Health loan repayment program support, an increase in age at first R01 grant success, and fewer physicians reporting research as their primary work activity.⁴⁷ While multiple factors contribute to this trend, deficiencies within an organization’s culture of well-being and workplace efficiency have roles to play that are not well understood and may be impacting the shortage of academic physicians doing research. To this end, we propose several directions for future research, outlined in Table 1.

Table 1.

Directions for Future Research on Academic Physician Burnout

Directions for Future Research
Identification of research- and educational/teaching-related drivers of burnout.
Development and optimization of research tools for assessing clinician well-being (eg, American Medical Association’s Steps Forward).
Qualitative studies about the lived experiences of academic physicians who are balancing multiple roles and its impact on burnout.
Quantitative studies to test the direct effects of clinical, research, and educational/teaching drivers of academic physician burnout.
Examination of how academic physicians’ identities, particularly marginalized identities, affect the experience of burnout.
Studies on the effect of organizational interventions and supports on reducing burnout (eg, peer mentoring circles, mentoring programs).
Identification of factors that foster academic physician resilience as part of a strengths-based approach to well-being.

One possible reason for the difficulties in this area is the lack of research funding for burnout. More recently, we are seeing a growing national interest and support for a better understanding of burnout and well-being. In January 2022, the Health Workforce Resiliency Awards (HRSA) announced $103 million in American Rescue Plan funding toward burnout and promoting mental health in the health workforce.⁴⁸

The National Academy of Medicine launched an action collaborative on clinician well-being and resilience in 2017 and published a national plan for health workforce well-being in October 2022.⁴⁹ This plan provides national support and resources for organizations to improve clinician well-being. The ACGME provides guidelines and some support in the form of resources to improve well-being for programs and individuals within graduate medical education.⁵⁰

Organizational lead support on academic physicians’ burnout and well-being is an important element necessary to improve the culture of well-being. Support will aid with avoidance of placing all of the responsibility on administrators to develop system-level interventions, which create increased job demands. Organization-led initiatives that cultivate personal resiliency are fundamental to creating a culture of well-being. However, future research should extend these findings by examining whether such interventions reduce future risk of burnout in academic physicians and determine the factors that make these interventions well-suited to support the multiple facets of academic physicians’ lives while being inclusive of those who are underrepresented in academic medicine.

The outcome of research should aid in the development of accessible tools for improving academic physician well-being, similar to the AMA Steps Forward website. Soliciting and implementing feedback from academic physicians will facilitate optimizing existing tools and piloting new ones that meet academic physicians’ needs. To create similar tools to support academic clinicians in spaces outside of clinical work, we must understand the direct relationship between the multiple roles of the academic physician and burnout. Therefore, a thorough knowledge and understanding of the existing literature and its limitations on this topic is needed.

Qualitative and self-report survey studies of burnout that include these factors are necessary to understand the lived experience of academic physicians. Future research to improve the well-being of academic physicians should involve in-depth studies of the lived experience of academic physicians and factors that impact their burnout and well-being. Future research should aim to understand the experience of academic physicians seeking promotion as well as identify the stress points and barriers within these processes and any drivers of burnout that exacerbate this stressor. For example, future research questions for qualitative research should include exploring how interactions between multiple roles and identities impact burnout, how accreditation requirements (eg, residency leadership surveys) impact academic physician well-being and work engagement, and how promotion status and the promotion process affect faculty members’ well-being. This research will aid us in finding answers to improve systems and processes, leading to improved organization-based strategies.

Conclusion

As it relates to well-being, systems are slow to change, which is evident by extensive burnout research and publications with limited actionable solutions and continued high levels of burnout. Recent movements at the national level, such as the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience, give us hope that change is possible. The long-term goal is to build well-being strategies that include everyone within our academic medical communities. Any meaningful changes we make will come first from understanding the impact these factors have on well-being. Supporting academic physicians will have a global impact on our health care systems as they represent touchpoints between critical aspects of our organizations (ie, research and training future physicians). The answer to the questions posed in this article will produce solutions capable of driving meaningful change that support academic physicians and reduce burnout for other educators, clinicians, and administrators. To reduce academic physician burnout and support their well-being, we must better understand the global job demands within our clinical academic environments. In particular, there is a need to understand the intersection of clinical, research, education/teaching, promotion, and personal life demands of academic physicians. In order to be effective, efforts to promote well-being must reach the various spaces where academic physician faculty spend their time, including where they work, live, and rest.

Funding Statement

Dr Lee has received grants from the National Institutes of Health (NIH) and the American Heart Association. Dr Stroud has received grants from the NIH. Preparation of this manuscript was supported by American Heart Association 23CDA1039160 and NIH 1P20GM139767 to SYL, and NIH U24ES0285607 and 1P20GM139767 to LRS.