Program and Institutional Coordinator Well-Being: Results From a National Survey

Abstract

Purpose

This study explores the mental health and well-being, overall job satisfaction, likelihood to leave position, and perceptions of job satisfiers and stressors and dissatisfiers in a national sample of program and institutional coordinators in graduate medical education (GME).

Method

Between August and September 2022, 11,887 program and institutional coordinators and managers with email addresses listed in the Accreditation Council for Graduate Medical Education database were emailed a survey link. The survey queried mental health using the Patient Health Questionnaire 8 depression scale, Generalized Anxiety Disorder 7, and a 2-item burnout scale derived from the Maslach Burnout Inventory; overall satisfaction with work; likelihood to leave work; and drivers of satisfaction and dissatisfaction.

Results

A total of 6,372 coordinators and managers responded to the survey, with 1,367 (23.9%) reporting moderate to severe depression symptoms on the Patient Health Questionnaire 8 and 1,767 (30.4%) reporting moderate to severe anxiety symptoms on the Generalized Anxiety Disorder 7. A total of 2,183 respondents (38.4%) screened positive for burnout, 1,288 (20.4%) reported being dissatisfied or very dissatisfied with work, and 1,510 (27.9%) reported being likely or very likely to leave their job in the next year. Positive interactions with administrative staff, residents, fellows, faculty, and program leadership were the highest ranked drivers of job satisfaction. Tracking down residents, fellows, and faculty to complete required tasks, low pay, overall workload, level of detail to manage, time pressure, lack of appreciation by faculty, and sense of entitlement of residents were leading job dissatisfaction drivers.

Conclusions

Coordinators are vitally important members of the GME community who play critical roles in supporting the GME enterprise. This study aims to raise awareness of the challenges and struggles faced by coordinators to lead to improvements in their job satisfaction, mental health, and well-being.

The mental health and well-being of residents and faculty have been concerns for more than a decade. The Accreditation Council for Graduate Medical Education (ACGME) common program requirements were revised in 2018 to include a significant number of new requirements focusing on faculty and resident well-being and enhancing the clinical learning environment.¹ Other organizations, such as the American Medical Association and the National Academy of Medicine, have added their voices to encourage greater attention to the ongoing problems of burnout and mental health problems of physicians.^2,3 This attention has resulted in numerous well-being interventions, research studies, commentaries, and models. One constituency in graduate medical education (GME) that has not received this degree of attention is institutional and program coordinators, who play vital roles in managing residency and fellowship programs and supporting trainees.

The roles and responsibilities of coordinators have become increasingly complex in recent years. Coordinators are responsible for a broad group of job duties, including but not limited to the following: scheduling, credentialing, human resources issues, education management, management of resident and faculty evaluation systems, recruiting and onboarding, accreditation activities, and planning of well-being activities.⁴ More informally, coordinators may play a critical role in providing emotional support and serving as mental health first responders for residents experiencing mental health struggles and/or personal crises.

These job demands and responsibilities have the potential to have a negative effect on program coordinator well-being, but relatively few studies of coordinator mental health have been performed. A national study of family medicine program coordinators conducted in 2017 using the modified burnout scale of the Professional Quality of Life Scale found that 24% of coordinators met the criteria for high burnout.⁵ A study of obstetrics and gynecology coordinators found that 39% met the criteria for high work-related burnout as measured by the Copenhagen Burnout Inventory.⁶ Ewen et al⁷ used the Copenhagen Burnout Inventory to examine burnout scores across the academic year in a national sample but did not specify cutoffs, so the incidence of burnout was not determined in this study. Because of concerns that job stressors could be negatively affecting coordinator well-being, we designed a survey to explore the following in a national sample across all specialties: mental health and well-being, specifically depression, anxiety, and burnout rates; overall job satisfaction and likelihood to leave positions; and perceptions of job satisfiers and stressors and dissatisfiers.

Method

Between August and September 2022, a survey link (SurveyMonkey Inc., San Mateo, California) was sent via email to 11,887 program and institutional coordinators and managers whose email addresses were listed in the ACGME database. Language explaining the anonymous and voluntary nature of the survey data collection was posted on the survey landing page. This project was deemed exempt from human subjects review following an expedited review by the American Institutes for Research.

The survey (Supplemental Digital Appendix 1 http://links.lww.com/ACADMED/B655) queried mental health using the Patient Health Questionnaire 8 (PHQ-8) depression scale, the Generalized Anxiety Disorder 7 (GAD-7) scale, and a 2-item burnout scale (Mind Garden Inc., Palo Alto, California) derived from the Maslach Burnout Inventory; overall satisfaction with work; likelihood to leave work; and drivers of satisfaction and dissatisfaction.^8–10 We opted to use the PHQ-8 rather than the PHQ-9 because we did not want to include a question about suicidality in an anonymous survey in which targeted follow-up with mental health resources would not be possible. We created questions about work satisfaction, likelihood to leave work, and drivers of satisfaction and dissatisfaction using 5-point Likert scales. For the drivers of satisfaction items, the survey prompt read, “For each of the following factors, rate the degree to which they produce personal feelings of satisfaction with your work.” For the drivers of dissatisfaction items, the prompt read, “For each of the following factors, rate the degree to which they produce personal feelings of stress, distress, or discouragement.” The survey also queried gender identity, race and ethnicity, educational attainment, job title, medical specialties of managed programs, number of trainees in managed programs, and years of experience.

Data were compiled and analyzed with SAS Enterprise software, version 7.11 (SAS Institute Inc., Cary, North Carolina). For the previously validated anxiety and depression scales, validated cutoff points and ranges of severity were used to demonstrate differences across respondents. For the PHQ-8, a score of 4 or lower represented no depressive symptoms, a score of 5 to 9 represented mild symptoms of depression, a score of 10 to 14 represented moderate depressive symptoms, a score of 15 to 19 represented moderately severe depressive symptoms, and a score of 20 or greater represented severe depressive symptoms. For GAD-7, a score of 4 or lower represented minimal anxiety, a score of 5 to 9 represented mild anxiety, a score of 10 to 14 represented moderate anxiety, and a score greater than 14 represented severe anxiety. Odds ratios in the prevalence of anxiety, depression, and burnout by race and ethnicity, educational attainment, and gender identity were also compared. For these comparisons, an odds ratio with a 95% CI that did not cross 1.0 when compared with the reference population was considered a statistically different prevalence.

Results

A total of 6,372 coordinators and managers responded to the survey for a response rate of 54%; however, the true response rate cannot be determined because the survey may have been forwarded to coordinators in non–ACGME-accredited programs. Of the 6,372 respondents, 5,192 (81.5%) identified as female, 3,703 (58.1%) as White, and 5,304 (83.2%) as having an associate’s degree or higher level of education (Table 1). A total of 4,604 respondents (82.4%) reported their job title as program coordinator or program manager, 180 (3.2%) as assistant or associate program coordinator or assistant or associate program manager, 340 (6.1%) as institutional coordinator or institutional manager, and 466 (8.3%) as another job title.

Table 1.

Respondent Characteristics, 2022 Program and Institutional Coordinator Survey

Characteristic	No. (%) of respondents (N = 6,372)
Gender identity
Female	5,192 (81.5)
Male	264 (4.1)
Othera	22 (0.3)
Declined to report	129 (2.0)
Missing	765 (12.0)
Race and ethnicity
Asian	207 (3.2)
Biracial or multiracial	206 (3.2)
Black	511 (8.0)
Hawaiian or Pacific Islander	20 (0.3)
Latinx	586 (9.2)
Native American	26 (0.4)
White	3,703 (58.1)
Other	36 (0.6)
Declined to report	305 (4.8)
Missing	772 (12.1)
Educational attainment
High school	301 (4.7)
Associate’s degree, certification, or undergraduate coursework	1,729 (27.1)
Bachelor’s degree	1,891 (29.7)
Graduate coursework	413 (6.5)
Master’s degree	1,159 (18.2)
Doctorate degree	112 (1.8)
Missing	767 (12.0)

^aIncludes individuals who reported their gender identity as agender, genderqueer, gender nonconforming, nonbinary, transgender, or other.

A total of 1,367 respondents (23.9%) reported moderate to severe symptoms of depression on the PHQ-8, and 1,375 (24.1%) reported mild depressive symptoms (Table 2). A total of 1,767 respondents (30.4%) reported moderate to severe symptoms of anxiety on the GAD-7, and 1,596 (27.5%) reported mild symptoms of anxiety. Responses to the 2-item burnout scale are given in Table 2. A total of 2,069 respondents (36.3%) reported experiencing emotional exhaustion, meeting the established criteria for feeling “burned out” at least once per week. A total of 1,093 respondents (19.2%) reported depersonalization, meeting the established criteria of “becoming callous toward people” at least once per week. Overall, the burnout rate of the sample population was 38.4% (n = 2,183), defined as respondents reporting emotional exhaustion, callousness, or both at least once per week.

Table 2.

Selected Survey Scales and Items, 2022 Program and Institutional Coordinator Survey

Scale	No. (%) of respondents (N = 6,372)
Depression measured by PHQ-8 depression scale8 (n = 5,713)
None	2,971 (52.0)
Mild	1,375 (24.1)
Moderate	753 (13.2)
Moderately severe	406 (7.1)
Severe	208 (3.6)
Anxiety measured by GAD-7 anxiety scale9 (n = 5,805)
None	2,442 (42.1)
Mild	1,596 (27.5)
Moderate	911 (15.7)
Moderately severe	NA
Severe	856 (14.7)
Emotional exhaustion (feeling burned out) on the 2-item burnout inventory (n = 5,705)
Never	467 (8.2)
Few times a year or less	1,592 (27.9)
Once a month	613 (10.7)
Few times a month	964 (16.9)
Once a week	426 (7.5)
Few times a week	945 (16.6)
Every day	698 (12.2)
Depersonalization (callous toward people) on the 2-item burnout inventory (n = 5,699)
Never	2,268 (39.8)
Few times a year or less	1,242 (21.8)
Once a month	445 (7.8)
Few times a month	651 (11.4)
Once a week	303 (5.3)
Few times a week	467 (8.2)
Every day	323 (5.7)
Overall satisfaction (n = 6,309)
Very dissatisfied	251 (4.0)
Dissatisfied	1,037 (16.4)
Neither satisfied nor dissatisfied	1,096 (17.4)
Satisfied	2,916 (46.2)
Very satisfied	1,009 (16.0)
Likelihood to leave position (n = 5,409)
Very likely	764 (14.1)
Likely	746 (13.8)
Neither likely nor unlikely	1,327 (24.5)
Unlikely	1,044 (19.3)
Very unlikely	1,528 (28.2)

Abbreviations: GAD-7, Generalized Anxiety Disorder 7; NA, not applicable; PHQ-8, Patient Health Questionnaire 8.

Odds ratios for screening results positive for depression, anxiety, and burnout by race and ethnicity, educational attainment, and gender identity are detailed in Supplemental Digital Appendix 2 (at http://links.lww.com/ACADMED/B656). Briefly, no statistical differences in depression, anxiety, and burnout were observed based on gender identity. Some statistically significant differences were found based on race and ethnicity as well as educational attainment. Potential additional confounders, such as age and years of experience, however, complicate the drawing of clear conclusions from these results, and more detailed analysis of the association between demographic characteristics and the prevalence of screening results positive for depression, anxiety, and burnout is beyond the scope of this study.

A total of 1,288 respondents (20.4%) reported being dissatisfied or very dissatisfied with work, 1,096 (17.4%) reported being neither satisfied nor dissatisfied, and 3,925 (62.2%) reported being satisfied or very satisfied with their current work situation. When asked how likely they were to leave their position in the next year, 1,510 (27.9%) reported that they would be likely or very likely, 1,327 (24.5%) responded they were neither likely nor unlikely, and 2,572 (47.5%) reported they were unlikely or very unlikely (Table 2).

Drivers of satisfaction and dissatisfaction are listed in ranked order in Table 3, with the most highly endorsed drivers of satisfaction and dissatisfaction listed first. Positive interactions with administrative staff, residents, fellows, faculty, and program leadership were the highest ranked drivers of job satisfaction. Other notable contributors to satisfaction included experiencing self-efficacy and meaning during work as well as flexibility of work schedules. On the other end of the job satisfaction spectrum, tracking down residents, fellows, and faculty to complete required tasks were leading drivers of job dissatisfaction (Table 3). Other drivers of dissatisfaction included low pay, overall workload, level of detail to manage, time pressure, a lack of appreciation by faculty, and a sense of entitlement by residents and fellows.

Table 3.

Drivers of Satisfaction and Dissatisfaction, 2022 Program and Institutional Coordinator Survey (N = 6,372)

Item	Mean response
Satisfiersa
Interactions with residents and fellows	4.25
Interactions with program leadership (PDs, APDs)	4.19
Sense of self-efficacy at work	3.96
Interaction with other administrative staff	3.88
Interactions with faculty	3.87
Flexibility of work schedule	3.86
Sense of meaning in work	3.83
Ability to set priorities	3.74
Benefits	3.71
Challenges	3.58
Interactions with departmental leadership	3.55
Sense of work-life balance	3.45
Overall workload	3.40
Pay	3.08
Drivers of dissatisfactionb
Tracking and reminding faculty to complete tasks	2.43
Pay	2.59
Tracking and reminding residents to complete tasks	2.71
Overall workload	2.85
Level of detail to manage at work	3.11
Time pressure	3.23
Lack of appreciation by faculty	3.24
Sense of entitlement of residents	3.30
Sense of entitlement of faculty	3.38
Lack of appreciation from residents	3.42
Deadlines	3.48
Lacking a sense of community	3.49
Limited ability to have input over responsibilities	3.54
Repetitive nature of work	3.57
Limited sense of meaning	3.66
Lack of respect from faculty	3.71
Lack of respect from residents	3.71
Lack of respect from program leadership	3.85
Social isolation	3.86
Being mistreated by faculty	3.90
Being mistreated by program leadership	4.27
Being mistreated by residents	4.27

Abbreviations: APDs, assistant program directors; PDs, program directors.

^aMean responses are based on the following scoring for satisfiers: 1, not at all; 2, slightly; 3, somewhat; 4, moderately; and 5, a great deal.

^bMean responses are based on the following scoring for drivers of dissatisfaction: 1, a great deal; 2, moderately; 3, somewhat; 4, slightly; and 5, not at all.

Discussion

A relatively high proportion of coordinators screened positive for depression, anxiety, and burnout. These rates appear to be somewhat lower than those seen in residents and practicing physicians, while mirroring anxiety rates and slightly exceeding depression rates in the general population.^11–14 Pulse mental health surveys conducted by the Centers for Disease Control and Prevention (CDC) during the COVID-19 pandemic used the PHQ-2 and GAD-2 to estimate the prevalence of depression and anxiety over 2-week periods. In the CDC study,¹⁵ during the period closest to the time of administration of the coordinator survey, 28.3% of overall respondents and 31.7% of female respondents to the general population survey screened positive for anxiety compared with 30.4% of coordinators. For depression, 22.0% of overall respondents and 23.3% of female respondents in the general population screened positive for depression compared with 23.9% of coordinators. Although it would have been preferable to have identical measures of depression and anxiety for the general population, the best dataset for the period in which the coordinators were surveyed was the pulse survey performed by the CDC, and the PHQ-2 and the GAD-2 have similar performance characteristics and sensitivities as the PHQ-9 and GAD-7.^16,17 Direct comparison between the measures should be viewed with some caution, however.

A substantial number of coordinators report dissatisfaction with their jobs, and our survey found that 27.9% report being likely or very likely to leave their position in the next year. Although our study was not able to determine actual quit rates, this likelihood-to-leave figure is alarmingly high, and this potential turnover rate should be of great concern. Coordinator turnover can pose a significant problem for residency programs given the critically important roles coordinators play in managing programs and supporting program directors and residents. This potential consequence is not needed, however, to justify greater attention to coordinator well-being. As members of our GME community and simply as human beings, coordinators deserve our collective support and attention to their challenges and needs.

The dissatisfiers and stressors that are ranked highly by coordinators are potential targets for well-being interventions. Strikingly, the first and third highest ranked dissatisfiers and stressors were reminding and tracking down faculty and residents to complete their required duties. Informal conversations with coordinators indicate that some programs have systems in place that reduce this burden on coordinators. Efforts need to be made to identify and disseminate exemplary practices that reduce these specific stresses. Dissatisfaction with pay was the second highest ranked dissatisfier or stressor. The role of coordinator has become increasingly complex in recent years, and analyses should be performed by human resource offices, when needed, to assess whether individual coordinators are being appropriately compensated when compared with other staff within that institution.

Overall workload and level of detail to manage were perceived as high sources of stress by coordinators. Efforts need to continue to be made to reduce unnecessary demands and develop information technology systems that facilitate work, rather than complicate or hinder it. Finally, culture in the workplace, specifically lack of appreciation by faculty and sense of entitlement by residents and faculty, was cited as a significant stressor. Residents and faculty (and other staff) need to recognize the challenging nature of the program coordinator role and do what they can to demonstrate support and express appreciation.

Efforts need to be made not only to reduce stressors and dissatisfiers in the work setting but also to enhance the satisfiers. Of note, although interactions with residents, fellows, and faculty were cited as sources of stress and distress, these relational elements were also the highest rated satisfiers. Trainees and faculty should build on these positive relational elements and recognize how important they are as sources of work satisfaction for coordinators. Appreciation for coordinators can also be conveyed in more formal ways through award programs and staff recognition days. Efforts can and should also be made to provide flexibility in work schedules and support a sense of meaning and purpose. The challenges to mental health faced by coordinators are unlikely to be limited to the GME arena, and consideration should also be given to creating positive work environments for staff who work in undergraduate and continuing medical education.

This study has limitations. Although a 54% response rate is relatively high for a national survey, this response rate may be inaccurate because the survey link may have been forwarded to coordinators and managers who work in programs that are not accredited by the ACGME. It is also possible that nonresponders may have answered the questions differently than responders, so nonresponse bias is a possibility. In addition, the survey was administered at one point in time, and depression, anxiety, and burnout rates may be different at other times of year. The survey was distributed in August, a relatively quiet time in the academic year, in hopes of increasing response rates, and depression, anxiety, and burnout may well be higher at other, more demanding times of the year, such as recruitment season and the start of the academic year.

Conclusions

Coordinators are vitally important members of our GME community who play critical roles in supporting the GME enterprise. They deserve our attention, our respect, our appreciation, supportive work environments, and compensation commensurate with the level of work they are performing. We hope the results of this survey will raise awareness of their challenges and struggles and can lead to improvements in their job satisfaction, mental health, and well-being.