Actions Reported by Physicians With Large Improvements in Burnout and Professional Fulfillment

Key Points

Question

What specific actions do physicians with large improvements in burnout and professional fulfillment believe contributed to their progress?

Findings

In this qualitative study using a mixed-methods approach of 30 physicians who experienced substantial improvements in burnout and professional fulfillment, 4 categories were reported: active (ie, intentional) work changes, passive work changes, active personal changes, and passive personal changes. The majority of physicians (86.7%) attributed their improved occupational well-being to active work or personal changes.

Meaning

These insights from colleagues who have experienced improvement may be helpful to peers considering actions to enhance occupation well-being.

This qualitative study examines physicians’ specific actions associated with improvement in experiences of burnout and professional fulfillment.

Abstract

Importance

Occupational distress among physicians is a highly prevalent problem that limits the effectiveness of the health care delivery system. While system change is necessary, individual physicians must also consider personal actions to mitigate occupational distress.

Objective

To identify physician actions associated with large-effect-size improvements in burnout and/or professional fulfillment over a 6-month interval.

Design, Setting, and Participants

This qualitative study using a mixed-methods approach recruited US physicians from the American Medical Association Physician Data file. The study used 2 quantitative online surveys that were administered 6 months apart (October 2 to November 13, 2024, and April 2 to May 16, 2025) to identify physicians with large-effect-size (≥0.8 SD) improvement in burnout and/or professional fulfillment. These physicians were subsequently recruited to participate in a qualitative study using structured interviews to identify changes they believed contributed to this improvement.

Main Outcomes and Measures

Burnout and professional fulfillment were assessed using the Stanford Professional Fulfillment Index.

Results

A total of 359 practicing physicians responded to both the baseline and follow-up surveys, among whom 87 (24.3%) had an effect size improvement of 0.8 SD or greater in burnout and/or professional fulfillment and were invited to participate in qualitative interviews. Thirty physicians (20 participants [66.7%] aged 30-49 years and 10 [33.3%] aged ≥50 years; 22 [73.3%] female) completed interviews. Thematically, these physicians reported changes in 4 categories: active (ie, intentional) work changes, passive work changes, active personal changes, and passive personal changes. A majority of participants (26 [86.7%]) reported active work and/or personal changes. Active work changes included changes to workload and work schedule, developing new skills or changing the focus of work, changing job or position, taking on or giving up a leadership position, improving efficiency, and advocating for personal needs. Active personal changes included deliberate changes in mindset, contemplative practices, taking time away, working with a therapist or coach, and prioritizing self-care. Passive work changes occurred independent of action by the individual physician and included new leadership, staffing changes, system-initiated workflow changes, and advances in technology. Passive personal changes were infrequently reported.

Conclusions and Relevance

Physicians with large improvements in burnout and professional fulfillment reported specific actions at work or in their personal life that they believed led to this improvement. These findings suggest that both individual- and system-level changes may be necessary to optimize occupational well-being among physicians.

Introduction

Occupational distress among physicians remains a highly prevalent problem that limits the effectiveness of the health care delivery system.^1,2 Burnout and other forms of occupational distress undermine quality of care,^3,4 increase the cost of care,^5,6,7,8,9 contribute to unprofessional behavior,^9,10,11 and diminish patient experience.^10,11,12 Occupational distress also limits change capacity at a time many organizations must make substantive changes to provide increasingly complex care to a larger number of patients at a lower cost.^13,14

The organization-level causes of physicians’ occupational distress include administrative burden,¹⁵ physician-organization values misalignment,^16,17 lack of agency and control over work,¹⁸ inefficiency in the practice environment,^15,19,20 suboptimal teamwork,^21,22,23,24 moral injury,^25,26,27 mistreatment experiences,^28,29 and a productivity-based compensation model that is misaligned with the nature of physicians’ work.^16,30 Individual factors affected by the work environment also contribute markedly to occupational distress³¹ and include low self-valuation,^32,33 social isolation,^34,35 disappointment in accomplishments,³⁶ and impact of work on personal relationships.² Vanguard organizations use a holistic, system-level approach to address these challenges and have established a leadership structure to drive meaningful change.^{37,38,39,40,41,42,43,44} Early system-based interventions to address root cause contributing factors have shown efficacy and provided proof of concept to spur additional organizational efforts.^{41,45,46,47,48,49,50,51}

While such structural efforts are accelerating,^43,52 these changes take time. Even as they partner with their organizations to effect change in professional culture and the practice environment, individual physicians struggling with burnout must also consider personal actions to mitigate occupational distress.^{45,46,53,54,55} Unfortunately, many are choosing to address the problem by reducing clinical work effort,^56,57,58 leaving their current position,^5,12,58,59 or exiting the physician workforce altogether.^57,58

Few studies have longitudinally assessed occupational well-being among physicians and explored the actions taken by those who experienced an improvement in professional well-being.⁶⁰ This study used a mixed-methods approach to identify physicians with large-effect-size improvement in burnout and professional fulfillment over a 6-month interval and to ascertain specific changes that contributed to this improvement through qualitative interviews.

Methods

Study Design and Participants

This qualitative study used a 2-phase mixed-methods approach. The first phase, a quantitative analysis of longitudinal surveys of practicing US physicians, was performed to identify physicians who experienced a large improvement in burnout and/or professional fulfillment. The second phase consisted of qualitative interviews with these individuals. The Stanford University and University of Illinois Chicago Institutional Review Boards reviewed and approved the study, and participants provided electronic and written informed consent. This study followed the Standards of Reporting Qualitative Research (SRQR) reporting guideline.

A national sample of actively practicing physicians from all specialty disciplines was assembled from the American Medical Association Physician Professional Data file, a near-complete record of all US physicians independent of American Medical Association membership. Based on protocol-specified assumptions (eMethods in Supplement 1) and the desire to conduct qualitative interviews of at least 30 physicians with a moderate- or large-effect-size improvement in burnout, a sample of 6000 physicians was invited to participate in the initial survey (eTable 1 in Supplement 1).

Participants were surveyed between October 2 and November 13, 2024. Study details and consent information were provided on the first page of the online survey (eMethods in Supplement 1). The survey collected self-reported demographic information. Race and ethnicity were not included in the survey. Burnout and professional fulfillment were assessed using the Stanford Professional Fulfillment Index, a well-validated and widely used standardized instrument designed to be sensitive to change.^61,62,63 Physicians who responded to the baseline survey were asked to respond to the follow-up survey between April 2 and May 16, 2025. Physicians who completed both surveys received a $50 electronic gift card. Paired responses for burnout and professional fulfillment on these 2 surveys were analyzed as continuous variables to identify physicians with a large-effect-size (≥0.8 SD) improvement in burnout and/or professional fulfillment based on Wilcoxon signed rank test. P ≤ .05 was considered statistically significant. The individuals who met this criterion were invited to participate in interviews (eTable 2 in Supplement 1).

Participation in interviews was voluntary. Physicians who completed the interviews received a $100 electronic gift card. Interviews (average duration of 30 minutes) were conducted via Zoom Workplace, version 6.5.7 (9933) (Zoom Communications, Inc) between June 21 and July 30, 2025. The full interview guide is provided in eTable 3 in Supplement 1. As the central component of the interviews, participants were asked to indicate what changes they believed contributed to their improvement in burnout and professional fulfillment (Table 1). Interviews were recorded and transcribed by a Health Insurance Portability and Accountability Act–compliant, institutionally approved, third-party vendor to create qualitative text for analysis.

Table 1. Interview Questions Analyzed.

Category	Question
General changes	In the past 6 mo, have there been changes that have positively affected your occupational well-being?
Work changes	In the past 6 mo, have there been any changes to the way you work, the focus of your work, and/or the amount of time you work?
Organizational changes	Have there been any changes within your organization that have affected your occupational well-being? How would you describe your current work culture and your relationships at work (leaders, colleagues, peers, learners)? Has anything changed in the past 6 mo?
Work-life integration	What are specific strategies you have used to integrate or balance your personal and professional responsibilities in the past 6 mo?

Data Analysis

Thematic analysis of interview transcripts was subsequently conducted using both deductive and inductive methods.^60,64 A constructivist approach involving independent review and scoring of transcripts, team discussions, evaluation of the interpretations, and development of consensus was used to identify key themes.⁶⁵ Interviews were independently coded by 2 investigators (B.H. and N.K.M.) using Dedoose, version 10.0.23 (Sociocultural Resource Consultants, LLC) qualitative software. Discrepancies in coding between the 2 investigators were discussed and resolved by consensus. The codes were organized into categories and subdomains within the qualitative software. The thematic analysis focused on identifying strategies and specific actions individual physicians may take to improve occupational well-being. Themes and representative quotes were subsequently shared with coauthors, resulting in additional discussion regarding subdomains and grouping of themes and subdomains.

Results

A total of 484 physicians responded to the baseline survey in 2024, of whom 359 (74.2%) responded to the follow-up survey in 2025. Among the follow-up survey respondents, 87 physicians (24.3%) with large-effect-size (≥0.8 SD) improvement in burnout and/or professional fulfillment were invited to participate in the interviews (eTable 2 in Supplement 1). Of these individuals, 30 (aged 30-49 years, 20 participants [66.7%]; aged ≥50 years, 10 participants [33.3%]; 22 female [73.3%] and 8 male [26.7%]) completed qualitative interviews. The personal and professional characteristics of participants are provided in Table 2.

Table 2. Characteristics of Physicians Participating in Interviews (N = 30).

Characteristic	Physicians, No. (%)		Difference	Effect size change	P value
	Baseline	Follow-up
Practice setting
Nonacademic private practice or group	15 (50.0)	NA	NA	NA	NA
Academic medical center	14 (46.7)	NA	NA	NA	NA
Veterans hospital	1 (3.3)	NA	NA	NA	NA
Sex
Female	22 (73.3)	NA	NA	NA	NA
Male	8 (26.7)	NA	NA	NA	NA
Age group, y
30-39	14 (46.7)	NA	NA	NA	NA
40-49	6 (20.0)	NA	NA	NA	NA
50-59	5 (16.7)	NA	NA	NA	NA
≥60	5 (16.7)	NA	NA	NA	NA
Relationship status
Single	9 (30.0)	NA	NA	NA	NA
Married	20 (66.7)	NA	NA	NA	NA
Partnered	1 (3.3)	NA	NA	NA	NA
Work time, median (IQR), h/wk	50.0 (40.0 to 60.0)	50.0 (40.0 to 60.0)	0 (−4.5 to 5.0)	0.04	.89
Clinical work, median (IQR), %	77.5 (58.8 to 95.0)	82.0 (60.3 to 95.0)	0 (−5.0 to 4.8)	−0.12	.64
Burnout score, mean (SD)a	4.1 (2.2)	2.8 (1.8)	−1.4 (1.4)	−0.99	<.001
Professional fulfillment score, mean (SD)b	5.2 (2.2)	6.9 (1.7)	1.7 (1.6)	1.06	<.001
Impact of work on personal relationships score, mean (SD)c	3.5 (2.5)	2.6 (2.3)	−0.9 (2.3)	−0.39	.04

Abbreviation: NA, not applicable.

^a Range of 0 to 10; scores ≥3.3 indicate high levels of burnout.

^b Range of 0 to 10; scores ≥7.5 indicate high levels of professional fulfillment.

^c Range of 0 to 10; scores ≥6.0 indicate high adverse impact of work on personal relationships.

Saturation of themes was achieved after approximately 20 interviews. Thematically, physicians with improved occupational well-being reported changes in 4 categories: active (ie, intentional) work changes by the physician, passive work changes, active personal changes, and passive personal changes (Figure). The majority (26 [86.7%]) of physicians with large-effect-size improvement reported active work and/or personal changes.

Figure. Schematic Diagram of the 4 Categories of Change Strategies.

Active Work Changes

Intentional work changes made by the individual physician were reported by 12 participants (40.0%). This category had several domains, including changes to workload and work schedule, developing new skills and/or changing the focus of work; changing job or organization, taking on or giving up a leadership position, improving efficiency, and advocating for personal needs (Table 3).

Table 3. Active and Passive Work Changes.

Theme and subdomain	Exemplar quotes
Active work changes
Changes to workload and work schedule	“My schedule changed. I think that’s what made the biggest difference.” “I don’t work at night nearly as much, and I do more remote work. The focus is more 100 000-foot and less direct patient care.
Developing new skills and/or changing focus of work	“Yes, 2 things impacted me during that time period [during which well-being improved]. One was that I saw a transition in my day-to-day activities that revolved around quality improvement. I took a series of courses to educate [myself] and give me a network of people doing the same work.…Two is, I partnered with a colleague to create a coaching for leadership program for women faculty, and so I created my own group of peers.” “One of the major reasons that I switched subspecializations is because, in my prior specialization, I had no control of my schedule. I was taking a lot of call. I didn’t know what my schedule would be until days before the schedule came out. It was very difficult to even just take care of myself in terms of appointments. There was no flexibility in the schedule. I had to be there when I was there.”
Changing job or organization	“The biggest change is leaving that old job, the ‘private equity firm.’” It was a national company that was completely disregarding paying me. Really egregious-type things happened. Since then, I’ve joined another group, the smaller independent physician-owned group.” “In this new job, I have a day a week which is an easier day for me. I feel like it’s a little bit of an improvement in my work-life balance to have a day at home. I also feel like I’m doing something meaningful by reaching out to people across the state…who can’t have good access to us. [chuckles] That’s a big piece of what is a positive for me.” “I’m switching clinic sites, and I think that really is a big contributing factor in terms of the amount of protected time off I have, and so that really has been the biggest change.” “By changing my position and changing the amount of support and time that I got for my new position, that made it much more reasonable, so that I could actually do it on my allocated FTE [full-time equivalent] time and not at home late at night.”
Taking on or stepping away from a leadership role	“I’ve taken on more of a leadership role and I feel that maybe my higher-up leaders are listening more to my input.” “With me stepping down as APD [associate program director], someone else obviously took that position. The 2 people that took my 1 position are my mentees. That in and of itself made me proud to see that I’m going to miss what I do, but the fact that it’s helping others that I’ve been mentoring climb that professional ladder, made me feel happy about that decision.” “When I talked to our director now, there’s talk of me making an associate director position for clinical research, which is what I think we really need.”
Improving efficiencies (streamlining processes, delegating, outsourcing) and advocating for individual needs at work	“I don’t get pulled away for dealing with, say, nurses unhappy that they want to leave, things like that....By outsourcing, the management component now is off my plate. Every day, I just come and see my patients while this company basically takes care of that. We get updated quarterly in terms of what’s going on. There are some costs associated with that, but then I think it’s worthwhile. I think we’re more productive now as physicians, my partners and I. I think we’re able to focus on what we do best and let the other experts take care of the rest.” “In the past 6 mo, my clinical volume has grown a lot. The amount of time I work has probably increased significantly, but I think with that comes—just like I was saying, the workflow has also smoothed out that even though I’m working more hours, it does feel easier.” “For me to connect on that level with [leaders], I think that was very meaningful in a way. That helped me build more confidence in myself, in the work I’m doing. It gave me more meaning to the work I’m doing, it gave me recognition, and it has helped bridge the gap from going, quitting medicine, leaving [my organization], to finding a happy solace ground and actually building up on it. That has been very meaningful.”
Passive work changes
Changes in leadership	“We’ve had more consistency in the way we, as physicians, interact with our leadership team and less just chaos.” “The dean of the college of medicine one day just happened to…run into me in the hallway, and he gave me feedback to say…‘You are not afraid to speak your voice and your mind, even if it’s different from what other people are saying, or they’re intimidated to speak up.’ He’s like, ‘Don’t ever lose that attribute. That is something that we really appreciate, especially as a higher executive leadership.’ They need those voices, those perspectives. I’m like, ‘Oh, thank you.’” “I’d say [leadership’s] investment in my passions, my goals, and wanting to support that from leadership down. You can feel that. It’s not just…in the work and my professional goals, but also in my outside goals. They always mention, ‘We want to make sure you can take care of what you ultimately want to be as a person,’ which is a good wife, a good mother, a good daughter, a sister, or whatnot. They really try to establish that balance.”
Changes in staffing	“It’s nice when you have enough people around you.” “I think to that same point is they have enough colleagues in my specialty. That I think is a big one. To talk about the flipside of things is not having enough colleagues to the point where there’s an excessive number of patients crying out for help, and you’re just physically incapable of addressing thousands of people. I think recently, my group having enough people in our specialty combination of doctors and midlevels, that’s also healthy.” “I do really appreciate my team. I love the nurses that I work with. I love the other physicians in my team and the ability to collaborate on patient care. Like I said, I also really love education.”
Changes in processes, resources, and technology	“I now have an electronic medical record [EMR] that’s much more efficient for me as a dermatologist…now I’m using a dermatology-focused EMR, and that’s just so much easier.” “Initially, I was really resistant because I’m really efficient with my notes, really efficient. After getting [ambient artificial intelligence documentation], the fact that I can spend so much time—direct eye contact with my patients—I don’t even have to log in. I just click ‘record’ on my phone…I just walk into the room, sit down, look at my patient directly, and I say, ‘Hey, what’s going on?’ It’s just a conversation.…I feel like they feel more comfortable, and they feel like I’m more connected to them.” “I’ve been exploring a bit more of integration of AI [artificial intelligence] into my workflow. I’ve started to explore a bit more of how to more efficiently like photo documents. If I do endoscopy, how can I capture those images more efficiently, so that it doesn’t disrupt the workflow…so that I have a much more quick, efficient understanding of what’s going on?”

Changes to Workload and Work Schedule

The most common active work changes involved adjustments to workload or work schedule, including allocating time for administrative tasks and reducing full-time equivalent status. For example, one physician spoke about transitioning to less than full time: “I have made steps to decrease my FTE [full-time equivalency]. Partially to make sure that I have time with my family.” Other physicians also reported changing the volume of patients cared for each day.

Developing New Skills and/or Changing the Focus of Work

Several physicians reported developing new skills and/or changing the focus of their work. One stated, “I was working on organizational behavior–type learning to get better at managing people…and being able to communicate more effectively with people whose points of view might differ from mine.”

Changing Job or Organization

Some physicians reported changing their job or role within their organization or moving to a new organization expressly to improve professional satisfaction. One physician stated, “I have changed jobs where I’m getting more support and mentorship.” Another said, “I still do what I do but in a different company. That has definitely helped me in work-life balance for sure.”

Taking on or Stepping Away From a Leadership Role

A subset of physicians reported taking on or giving up a leadership role. One physician noted, “Now that I think about that timeframe [when burnout improved], it’s most likely attributed to the change in my position within the academic leadership.” Another noted a newfound sense of purpose when given the opportunity to lead teams and initiatives: “I think there’s a bit more appreciation for other skills, leadership skills that I have that can help the actual organization.…There’s been some positive progress and a bit of recognition in that standpoint.”

Improving Efficiencies: Streamlining Processes, Delegating, and Outsourcing

Many physicians improved efficiency at work by implementing new workflows and leveraging team-based care. One noted, “[I am] trying to change some of my work practices in terms of how I do some of my day-to-day work and how I delegate some activities to some other colleagues.” Some physicians reported outsourcing operational functions (eg, personnel management, billing) to focus more on patient care. Others described allocating time to complete documentation without distractions, such as “setting a specific time to complete certain tasks and then trying to focus on what is important and what is needed.”

Advocating for Individual Needs at Work

Some physicians reported that engaging with their leader to discuss their experience enabled them to advocate for personal needs. One physician shared, “I was definitely at a point where I was getting burnt out…that’s when I was like, ‘Okay, I’m going to put it out on the line. I’m going to explain my concerns. If they want to be open to those discussions, great. We can figure out what needs to change. Otherwise, it might be a situation where I just have to leave the environment,’ which I’m glad that wasn’t the situation.”

Passive Work Changes

Passive work changes were reported by 8 participants (26.7%) and included evolution of the work environment that occurred independent of action by the individual physician. This category included domains such as new leadership, staffing changes, system-initiated workflow or process changes, and advances in technology or resources (Table 3). One physician attributed their improvement simply to gaining experience: “[A]s a new attending, everything seemed hard at first…because in a new institution that I’m not used to, with workflow and support staff that I’m not familiar with, I think everything did feel more difficult in the beginning, whereas I think now just the workflow works a little bit better.”

Changes in Leadership

Several physicians reported that a leadership change at work had resulted in an improvement in their occupational well-being. One physician noted, “There was a shift in just the overall leadership within the academic administration.”

Changes in Staffing

Some physicians identified improved staffing as a key contributor to their improved occupational well-being. Such improvements included filling empty positions, adding incremental staff, enhancing support through professional development of existing staff, and working with the same coworkers more consistently. One physician stated, “I currently have really good staff, which is huge.” Another shared, “[I now] have enough colleagues in my specialty. That I think is a big one…the flipside of things is not having enough colleagues to the point where there’s an excessive number of patients crying out for help, and you’re just physically incapable of addressing thousands of people.” This category also included having enough colleagues and staff to take time off: “You can take vacations and PTO [paid time off] without somebody being like, ‘Oh, but there’s not enough doctors.’”

Changes in Processes, Resources, and Technology

Many participants discussed the positive impact of new technological support, including artificial intelligence (AI) tools. Referring to ambient AI documentation support, one physician noted, “[I]t’s a game-changer. I think that’s the biggest thing in my burnout; having this, it’s the singular thing.” Another physician spoke about enhanced support for documentation: “That has actually been very nice. Although there’s a lot that probably could be better with it, I think, again, that light at the end of the tunnel of some of the documentation burden is going to be decreased. It’s helpful.”

Active Personal Changes

Active personal changes were reported by 14 participants (46.7%). This category included changes in mindset, contemplative practices, taking time away, working with a therapist or coach, and prioritizing self-care (Table 4).

Table 4. Active and Passive Personal Changes.

Theme and subdomain	Exemplar quotes
Active personal changes
Changes in mindset	“I think some people see work as work and find joy and positivity outside of work and have those activities outside of work to help them fill their cup. I think I have those things, too. I think that’s a very specific practice that I don’t know if a lot of people do because I think everyone’s just go, go, go, that I don’t think people really take too much time to reflect.” “Between my first survey and my survey…6 mo later, I think it was more of emotional intelligence and also recognizing some of the things that I was ignoring for a while. For me to be able to pick up some of those things…helped me innovate and helped me rediscover myself in quite a few different ways.” “For my own health and well-being, I have had to decide within that system how am I going to adapt and stay focused and happy.” “I’ve had to change my goals and redefine what it means to be successful at what I do. I think I’ve been able to do that more over the last 6 mo than I was maybe when I first started out.” “I think I have more of an orientation toward teamwork, or on a bell curve, I’m higher on an orientation toward teamwork and collaboration. Being able to reorient to that is really helpful in preventing burnout.”
Contemplative practices and relaxation methods	“What I changed was that time period, when I’m putting on this eyeshadow and thinking about how I’m going to do something different or creative with it, or whatever, I now spend some time positively reflecting on myself, positive encouragement, whether it’s a little bit of meditation, a bit of prayer, a mixture of both, or just a time to actually smile. I feel like smiling does a lot for you. Those few minutes each day, I try not to be hurried in that moment and give that moment to myself, which I didn’t use to do.” “It’s in probably the last 2 mo. Trying to let things—knowing I can’t control everything, recognizing what I can, and then trying to have a more positive attitude and manifest things being better, if you will.”
Taking time away	“I’m traveling more. When I travel, I’m not taking my computer. Every time I used to travel, I took my computer everywhere. I’m not doing that, so when I’m traveling, I’m trying to focus. I’m trying to put my phone down. I’m trying to work on my relationships with people that I care about.” “Definitely the amount of time that I work. I took almost 3 mo off when my litter of Labrador puppies was born.” “I got to take a short sabbatical.” “I think part of it might be with vacations. I took most of my vacations the latter half of October, November, and December [the interval between survey when scores improved].”
Working with a therapist or coach	“I am involved in therapy, and I think work is an issue that I bring to therapy often.…I’m just learning how to manage those stressors better.”
Prioritizing self-care and personal relationships	“Also, just changes, again, as I mentioned in my personal life, I think. I’m in a relationship, and the relationship is going really well. I think that has a lot to do that bleeds into my professional fulfillment.” “I tried to work out regularly. That’s probably the only thing. My kids are a little bit older so that’s helpful.” “Yes. I always try to always have a good social network, whether it’s at work and definitely outside of medicine, for sure, to balance. We always make time, even if it’s a few, to get together. Then working out or exercise definitely helps for me, myself, to create that balance, and having a supportive husband.” “Compared to where I was, things are excellent. I’ve now learned that it’s just a continual process of self-improvement. I think I’m good at identifying areas I need to work on. I have the resources now in my life to be able to address them....I’m just so happy that I made the changes that I did.” “Then I probably exercise 4 or 5 times a week.”
Passive personal changes
Kids becoming more self-sufficient	“I’m also sleeping better because my baby is now sleeping better. Things at home affect my ability to be fully present at work, too.” “There’s always choices, but I didn’t have the flexibility. My kids were not in elementary school where I could pick them up, and they would have done their middle school and high school in the same place. It all happened as they were much younger, so that made things challenging.”

Changes in Mindset

Many physicians reported intentional shifts in mindset as key to improved occupational well-being. These mindset shifts included cultivating a positive outlook, embracing change, and intentionally investing in others. Many physicians reported the importance of recognizing their self-worth apart from professional accomplishments (ie, self-valuation). As one physician articulated this shift, “I’ve also been able to separate my identity from work.…It’s work that I do that’s fulfilling. It pays me well. It keeps me busy and occupied, but it’s not like…shortcomings feel personal to me anymore.”

Contemplative Practices and Relaxation Methods

Contemplative practices and relaxation methods were also frequently reported as having helped with improving burnout and professional fulfillment. One physician reported the calming benefits of deep breathing: “I think, as simple as deep breathing, a lot of breathing exercises during the cases when it becomes challenging, and being aware of the situation, being in the moment.” Another noted, “One of my colleagues [who was] trying to be happier [and] combat burnout [and] I talked about meditating. I’ve tried to do that or be more purposeful, like when I’m going to work, about thinking about things.”

Taking Time Away

Many physicians described taking time off (eg, vacations with family, medical leave, sabbatical) during the interval in which scores improved. A common sentiment was described by one physician: “I think a lot of [what] contributes to occupational distress is the emotional burden that goes on when you’re doing our line of work. People come in with their burdens and their pains and their struggles, and sometimes their frustrations, and you’re just taking that on every 20 minutes. I found that having a break from that is greatly helpful.” Another physician noted, “During the summertime, I work a little bit less because I have some more activities with my family, kids are out of school. That helps with well-being because you plan more trips.”

Working With a Therapist or Coach

Several physicians mentioned working with a therapist or coach. Referring to their work with a therapist, one said, “We spend a lot of reflective time. I’m in my own treatment…a lot of the work involved is understanding your own reaction to things and understanding like the transference and countertransference involved. Knowing where to take a step back and when to escalate.”

Prioritizing Self-Care and Personal Relationships

Prioritizing self-care and personal relationships were frequently reported as active personal changes: “I am also somebody who really values my own health, and being able to spend time exercising is a really good stress relief for me…I think really helps just recenter me.” Other physicians mentioned characteristics or beliefs that have helped them through hard times, including faith, resilience, patience, and a strong work ethic.

Passive Personal Changes

Passive personal changes were also reported to contribute to improvements in burnout and professional fulfillment, although this category was reported by only 2 participants (6.7%). Examples included evolution in personal life demands and responsibilities that occurred naturally with time (eg, kids becoming more self-sufficient) (Table 4).

Discussion

While meaningful structural changes have begun to be implemented across health care organizations,^37,41,52 many individual physicians need immediate help and desire insight regarding what actions might be helpful. This qualitative study using a mixed-methods approach involved structured interviews of physicians with large-effect-size improvements in burnout and/or professional fulfillment to identify changes they believed contributed to improved occupational well-being. While physicians reported both active and passive work and personal changes as contributing to improvement, the overwhelming majority emphasized active changes.

Forty percent of physicians with large-effect-size improvements reported active work-related changes, which often involved a job change (eg, moving to a new organization), taking on or stepping down from a leadership role, or shifting to less than full-time work. Notably, many of the active work-related changes involved physician-initiated structural changes to workflow (eg, blocking time on their calendar for documentation or administrative tasks) and outsourcing of nonclinical tasks (eg, office management, billing, personnel management). Several physicians reported engaging leadership to advocate for new resources or structural changes and collaborating with these leaders to improve the work environment. These latter actions, in which individual physicians took initiative that catalyzed system change, illustrate the intersection between system and individual interventions to improve occupational well-being.

Approximately 1 in 4 physicians who experienced large-effect-size improvements attributed the improvement to changes at work that occurred without a direct action on their part (ie, passive work change). Themes in this category included a change in leadership and changes in staffing (eg, filling an open position, adding new physicians or support staff). System-initiated improvement to workflows or provision of additional support resources were also frequently noted in this category. Consistent with the empirical evidence,^{49,66,67,68,69} ambient AI documentation support was one frequently noted support resource. In many ways, the changes described in this category affirm the benefit of system-level interventions to improve occupational well-being, although in some cases, they occurred independent of organizational action (eg, an early-career physician becoming more efficient with experience).

Active personal changes were reported by nearly half of physicians with large-effect-size improvements in burnout and professional fulfillment, including changes in mindset. Some physicians described shifting from a mindset of self-worth contingent on their professional identify and accomplishments (ie, my value as a human being is based on the fact that I am a physician) to a more holistic view (I have value as a human being; practicing medicine is an important part of who I am, but not the only part). Changes in mindset also involved intentional efforts to look at work in new ways (ie, embracing change) or a shift in focus at work (eg, embracing teamwork, development of others [colleagues, coworkers, trainees]). Incorporation of contemplative practices (eg, self-awareness, focusing on the moment, an attitude of curiosity rather than judgment), an approach supported by empirical evidence,^70,71,72 was another frequently reported theme in the category of active personal change. Other active personal changes connected to improvement in occupational well-being included intentional and strategic use of time away from work and greater emphasis on self-care and personal relationships. Consistent with the results of controlled trials,^73,74,75,76 in a number of cases, physicians reported that working with a therapist or professional coach had helped effect change.

Limitations

Our study had several important limitations. First, as is typical with national physician surveys,^77,78,79,80 participation in the survey phase of the study was low. Although this low participation raises the possibility of response bias, the purpose of the survey was not to define the prevalence of burnout and professional fulfillment in a representative sample of physicians but, rather, to identify physicians with large improvements in occupational well-being to participate in interviews. Second, while we identified changes reported by physicians with large improvement in these domains, causality cannot be determined beyond that the participating physicians believed that these changes contributed to their improvement. Third, the majority of the physicians interviewed were women, raising questions regarding generalizability of some findings to men.

Conclusions

This qualitative study using a mixed-methods approach including both longitudinal surveys and qualitative interviews found that physicians with large-effect-size improvements in burnout and/or professional fulfillment were typically able to identify specific actions at work and in their personal lives that they believed led to the improvement. Insights from these physicians may be helpful to colleagues who are considering taking action to improve occupational well-being. Ultimately, both individual- and system-level actions may be necessary to reduce occupational distress and promote professional fulfillment among physicians.

Supplement 1.

eMethods.

eTable 1. Demographic Characteristics of the Survey Population

eTable 2. Demographic Characteristics of Individuals Invited to Participate in Interviews and Those Who Participated

eTable 3. Full-Length Interview Guide

Supplement 2.

Data Sharing Statement