Exiting Medicine Faculty Want the Organizational Culture and Climate to Change

Abstract

National data indicate about 50% of junior faculty leave a School of Medicine (SOM) within eight years of hire. The long-term goal of the study was to determine innovative strategies for promoting SOM faculty retention. The study objective was to determine factors influencing SOM faculty to exit, and what would encourage them to stay or return. All faculty exiting the University of New Mexico (UNM) SOM were surveyed and their responses analyzed to the following items: (a) If something could have been done differently that might have resulted in staying at UNM, what would it have been? (b) What would need to change at UNM SOM for you to return? and (c) general comments offered. Qualitative analysis of open-ended responses used an iterative process and systematic thematic approach and NVivo software. 173 faculty respondents surveyed between July 2017 and June 2019 included 86 women, 33 non-Caucasians, and 14 Hispanics. A total of 110 faculty reported an MD degree and 117 were assistant professors. Seventy-eight faculty were on clinician educator track. The 367 responses to the three questions were categorized into 10 themes. The most common themes included (a) people (leadership and others) and workplace culture (25.1% of responses); (b) extent of career support and resources (15.3%); (c) organizational systems and administration (13.6%); and (d) faculty feelings of autonomy and value (10.9%). Exiting faculty frequently discussed the need for a change of leadership and changes in organizational climate and culture, which may have influenced their willingness to stay or to return to UNM SOM. To retain faculty, SOM leaders need to strengthen and/or modify organizational climate and culture components. Innovative strategies for this purpose may include organizational interventions followed by evidence-based leadership training programs, and the use of exit surveys for monitoring interventions.

Background

Faculty are the cornerstones of academic medicine, yet half of new assistant professors leave Schools of Medicine (SOMs) within eight years of hire, (Liu & Morrison, 2014) and 57% leave within 10 years (Alexander & Lang, 2008). Some studies show women and racial/ethnic underrepresented minorities (URM: Hispanic, African-American, American Indian/Alaska Native, and Hawaiian/Pacific Islander) may be at particularly high risk for attrition (Brod et al., 2017; Liu & Morrison, 2014). Inadequately mentored faculty are less likely to stay in academic careers, demonstrate lower productivity on promotion metrics, and have lower satisfaction with their careers (Cohen, 1998; Mahoney et al., 2008; Nivet et al., 2008; Pololi et al., 2010).

The challenges of retaining faculty are great for SOMs in the Southwestern US, which are medium-sized and serve diverse, underfunded, rural, and underserved communities, with significant proportions of racial/ethnic URM faculty (Rodriguez et al., 2014). Based on the University of New Mexico (UNM) SOM faculty database, resignation and total attrition (resignation, retirement, or death) rates for all non-volunteer faculty were 8.5% and 10.1% respectively for Fiscal Year 2019. UNM SOM is an ideal place to study faculty retention since 55.3% of its 1,100 faculty are women and/or racial/ethnic URM (49.6% and 15.7% respectively) at a minority-serving institution in a minority-majority state. Given the minimum cost of clinical staff turnover represents a loss of >5% of the total annual operating budget at the UNM Hospital (Waldman et al., 2010), and that a SOM estimated that it cost $69 million to support a cohort of new faculty hires in basic science over seven years (Dorsey et al., 2009), the institution can scarcely afford the cost of faculty attrition. Therefore, retention is a critical issue for the SOMs locally, regionally, and nationally (Alexander & Lang, 2008; Krebsbach & Ignelzi, 1999).

An organization’s ability to retain its employees depends on its climate and culture. Organizational climate is defined as the shared perceptions of and the meaning attached to policies, practices, and procedures employees experience, and the behaviors they observe getting rewarded and those that are supported and expected (Schneider et al., 2013). Organizational culture is defined as the unspoken rules, values, and beliefs that may influence faculty behavior and engagement (Schneider et al., 2013; Schneider et al., 2017). Although organizational climate includes factors that are more visible and easier to assess and change than organizational culture, the two constructs are often used interchangeably and their components are difficult to distinguish. The overall organizational climate and culture is actually a collection of local climates and cultures (microclimates or microcultures), and the local climate or culture of the organization most proximal to an individual may be more important than the overall climate and culture of the parent organization. Organizational leaders play a crucial role in establishing and reinforcing values-based organizational climate and culture (Grojean et al., 2004).

The long-term goal of this study is to determine innovative strategies for promoting SOM faculty retention. The objective of this study is to determine factors influencing SOM faculty decisions to exit, and what factors would encourage them to stay or return by doing a qualitative analysis of open-ended faculty exit survey questions.

Methods

Study theoretical framework

This qualitative descriptive study was designed for theory generation rather than theory testing, and as such, did not use an explicit theoretical framework.

Study procedures

From July 2017 to June 2019, all non-voluntary faculty leaving the SOM were required to complete a mandatory exit survey. The instrument was administered in two steps: (a) online, using the Research Electronic Data Capture or REDCap database (Harris et al., 2009), supplemented by (b) an interview by a Dean at the Office of Faculty Affairs and Career Development at the SOM, who reviews the online responses and adds additional details/clarifications to the REDCap database.

The qualitative portion of the exit survey requested responses to the following items:

1. If something could have been done differently that might have resulted in staying at UNM, what would it have been?

2. What would need to change at UNM School of Medicine for you to return?

3. General comments by faculty member.

Analysis

Content analysis of open-ended responses to the qualitative questions used an iterative process with a systematic thematic approach, using NVivo software (QSR International). NVivo initially auto-coded responses to open-ended questions and then a qualitative researcher used a systematic iterative process to manually code text into a separate coding structure to identify final themes. Upon completion of coding, NVivo was used to perform matrix queries to identify quote density across codes and response distribution of subgroups.

The UNM Human Research Protection Office, which served as the Institutional Review Board of record (HRPO 17–347), approved this study.

Results

The 173 faculty respondents surveyed between July 1, 2017 and June 30, 2019 included 86 women (49.7%), 33 non-Caucasians (19.1%), and 14 Hispanics (8.1%). 110 faculty (63.6%) reported an MD degree and 117 (67.7%) were assistant professors. Seventy-eight faculty (45.1%) were on clinician educator track, 45 were tenure track (26.0%), 17 research track (9.8%) and 13 flex track (7.5%).

Qualitative analysis identified 10 themes from the 367 responses to the three questions asked. As shown in Table 1, the four most common themes included (a) people (leadership and others) and workplace culture (25.1% of responses), (b) extent of career support and resources (15.3%), (c) organizational systems and administration (13.6%), and (d) faculty feelings of autonomy and value (10.9%). These four themes are components of SOM culture and climate. Concerns around diversity, an important component of an organizational climate/culture, was not a commonly cited theme for leaving (1.4%).

Table 1:

Themes and Number of Quotes from Exiting Faculty Surveys Related to Faculty Attrition, After Excluding the Response of “Nothing”

Theme	Description of theme	N quotes
People and culture	References to people (leadership/non-leadership) and culture of workplace.	92 (25.1%)
Support or resources	Regarding amount of support or resources (not necessarily or explicitly financial).	56 (15.3%)
System and administration	General comments about UNM or departments; includes policy and departmental changes.	50 (13.6%)
Faculty autonomy and value	Faculty perception of having a voice or autonomy, others’ responsiveness to their concerns, and feelings of value.	40 (10.9%)
Opportunity for growth	Opportunity for promotion or change job duties at UNM or elsewhere.	37 (10.1%)
Financial	Includes personal compensation and departmental or position funding.	34 (9.3%)
Personal family issues	Related to personal or family issues, including spousal job.	24 (6.5%)
Mentorship	Related to mentorship.	13 (3.5%)
Retirement	Reason for leaving is retirement.	8 (2.2%)
Diversity	Related to faculty diversity or treatment/consideration of minorities and/or women.	5 (14%)

Table 2 indicates these themes are variably distributed across major departments, implying microclimates or microcultures (i.e., the climate or culture of the organization most proximal to an individual) may be more important than the overall climate and culture of the parent organization. Women or URM faculty demonstrated no noticeable difference in responses than men or non-URM faculty respectively.

Table 2:

Variation in Distribution of Quotes Related to Dominant Themes Across Departments

	Clinical departments (N quotes)						Basic science departments (N quotes)
Department	Anesthesiology	Dental Medicine	Emergency Medicine	Family & Community Medicine	Internal Medicine	Psychiatiy and Behavioral Sciences	Biochemistry & Molecular Biology	Cell Biology & Physiology
Average faculty size	57	9	82	78	265	88	12	12
People and culture	0	5	1	3	25	6	12	5
Support or resources	2	2	2	0	17	3	11	7
System and administration	1	0	2	1	12	3	5	3
Autonomy and Value	0	1	0	1	10	3	9	1
Opportunity for growth	2	1	3	5	7	2	2	1
Financial	1	3	1	3	8	0	7	2
Personal and family issues	2	2	1	2	4	0	1	1
Mentorship	1	0	0	0	4	0	2	2
Retirement	0	0	0	0	3	0	1	1
Diversity	0	1	0	0	2	0	1	0
TOTAL	6	8	5	11	38	5	23	8

People and Culture

Respondents overwhelmingly discussed the need for a change with people (particularly leadership) and workplace culture. “[My] reasons for leaving are mostly with the unit leadership and departmental culture. These challenges don’t seem to resolve, as education-focused faculty before me were not happy either.” Many participants said things like, “Leadership needs to change,” for them to consider coming back to UNM. This included all levels of leadership (clinical and academic) and all levels of the Health Sciences Center (HSC; i.e., division/department, hospital, SOM, and HSC as a whole). People identified numerous characteristics of leadership to change, including increasing the level of professionalism and the need to stop (in themselves) or address (in subordinates) passive aggressive behavior, favoritism, blame, abuse, bullying, and disrespectful behavior. One participant summarized this as, “Take care of abuse, bullying, disrespectful and unprofessional and unethical behavior by someone in leadership.” Another said, “…I perceived that I was in a hostile work environment and could not pursue any of my career goals…” Faculty referred to a problematic workplace culture in clinical, teaching, and research workplaces, desiring a “more physician-friendly environment,” “a culture of true collaboration rather than a hierarchical one,” a stronger focus on patients and their needs, and promotion of “the pursuit of excellence rather than the maintenance of the status quo…” Many participants wanted better communication and feedback and to be treated fairly by their superiors. They requested greater faculty engagement, transparency, and accountability for everyone.

Support or Resources

Participants mentioned the general need for more support and resources (not necessarily or explicitly financial) at clinical, teaching, and research workplaces. One participant said, “I had a sub-optimal experience and did not reach out early enough to seek help. It was not clear to whom to turn to. I hope that next time a position like this is offered, expectations are made clear and support (human, $$, and structural) is given to the new hire.” Specifically, some participants wanted more support for practice management, staff, structural resources, physician faculty, Veterans Administration (VA)-based faculty, university clinics, and patients. One person suggested an “improved vision for surgical efficiency and more resources for patient ‘wellness’ including nutrition, weight-loss, pre-op optimization, etc.” Another wanted a more “prompt response to patient safety concerns; having the resources needed to improve quality of care; improved staffing.”

Some participants discussed needing support and resources in the areas of education, training, and guidance. This includes “support education for psychologists,” and support, training, and guidance in one’s leadership position: “Support from the department with regard to leadership position I was put in without adequate training/guidance.” Some said they wanted “better professional,” “additional administrative,” and “more staff support,” “…and more faculty in this division to share the workload.” Specific examples included “hiring of [physicians] for critical areas of service” and “adequate clinical coverage by hiring faculty.” Several wished to expand or enhance their department or division with staff/faculty and space; some wanted their department to provide better clinical support. There were several complaints about the hospital environment. One person said, “As a physician, I felt little support from [the hospital]. The workspace was oppressive, there was a lack of physician-specific amenities, including private space to meet and convene.” Another said they wanted a “new and vastly better, larger hospital. Better physician amenities.” Yet another said the hospital needed “work space and computers at ASAP. Nursing staff have new desks, new computers, adequate chairs. [Faculty] do not…”

Several respondents said they wanted “more research support” in general. Others said they specifically wanted more value for and access to research, biostatistics support, and research personnel. One said they “received very sloppy research mentoring and little to no support navigating research system.” Others stated the “Value for research and researchers has to increase” and the need for “improved provider/faculty (access/support) to patient data for research and quality improvement purposes.”

System and Administration

People spoke of the need for systemic change at UNM, HSC, or departments in general, including departmental autonomy or collaboration and policy. Respondents discussed things that need to be changed within their “area,” which includes their division, department, school, and the hospital. Some suggested creating and communicating a clear mission and vision: “The program would need to have a clear mission for how to achieve its mission and a comprehensive strategic plan in place for leaders and staff to use as a guide.” Others suggested restructuring their colleges/schools and departments. “UNM should consider consolidating at the flagship UNM hospital rather than stretching staff to the VA and costing academic time.” “Physical Medicine, Physical Therapy and Occupational Therapy should be combined into its own College of Rehabilitation Sciences, each should be its own Department.”

Some participants wanted to stop “sharing” clinicians with the VA, have “more focus on patient care,” create more services for patients, and addressing overcrowding in the hospital. One participant recommended a “dedicated team to address overcrowding and to rapidly facilitate moving admitted patients to the [relevant areas of the hospital].” Some participants disliked inflexible departmental policies that prevented some types of research and better patient care. Others did not like the requirement to work at a hospital location other than their choosing. One respondent said, “[I] was somewhat disappointed with departmental requirements to work at [another hospital location]…”

Others said there needed to be “significant improvements in infrastructure” (e.g., information technology), better organized and user-friendly processes for IRB approval and data use agreements. One participant stated:

I attempted to initiate a research project by proposing to analyze a publicly available, retrospective database of national hospital discharge data… I was told that I required IRB approval; this is by definition an exempt project, but despite this it took 3 months and a multitude of confusing emails and attempts to obtain ‘approval.’ It was an exercise in dysfunctional bureaucracy and institutional indifference to research in general.

Many participants discussed the need to allow departmental autonomy with the ability to create policies, make decisions, and develop programs based on needs. They wanted transparency with administration for it to negotiate and create goals/requirements through a collaborative effort with clinics and departments. One participant wanted “clarification and integration of goals between hospital and SOM as it affects clinics and faculty.” Another participant wanted “the [department] and [clinic] being able to negotiate and communicate better FTE balance, pay, work load vs academic load.”

Faculty Autonomy and Value

Many respondents felt their concerns or opinions were undervalued, and wanted more autonomy. One participant said, “I am certain that this web-based survey is the first time that anyone asked why I am leaving UNM.” To return to the university, another said, “I would need to be in a group of people who truly valued my unique skills and respected my 30 years of experience.” Someone else said they needed “greater faculty recognition; greater retention efforts on part of the University by not taking existing faculty for granted…” Others said, “Value for research and researchers has to increase” and needed more “responsiveness to concerns, which often went without any response at all,” and, “More autonomy in developing and running clinical programs for underserved.”

Discussion

Content analysis indicates that exiting SOM faculty recommend changes in organizational climate and culture, which may have influenced their willingness to stay or to return to the organization in the future. Many faculty wanted a change of leadership for them to consider coming back to UNM. To retain faculty, SOM leaders need to strengthen and/or modify organizational climate and culture components, paying specific attention to organizational leadership. Our findings also suggest that diversity is a strength of the climate and culture of UNM SOM, as suggested by the low proportion of diversity-related themes (1.4%) noted in Table 1. This research addresses a new area of science, the study of organizational climate and culture at SOMs, to help solve a challenging problem impacting the nation’s biomedical workforce.

A cross-sectional survey of 319 faculty exiting UNM SOM performed from 2009 to 2017 noted ‘departmental leadership’ as one of top four reasons why faculty leave (Sood et al., 2018). Current and previously published data underlie the role leaders play in retaining faculty at the SOM. Leaders committed to retention stress the following activities: a) build ‘social capital’ or relationships that make organizations work effectively; b) set the tone for a respectful, inclusive climate and culture that values and recognizes excellence (Grojean et al., 2004); c) establish structured faculty mentoring programs with monitoring of objective outcomes; and d) demonstrate a high degree of emotional intelligence. The chief components of emotional intelligence among leaders (i.e., self-awareness, self-regulation, motivation, empathy, and social skill) are directly tied to workplace outcomes, including retention, in a study of nurses (Wang et al., 2018).

While organizational climate and culture needs to change, too often leaders revert to old ways of doing things, and organizations do not change despite carefully thought interventions at the individual level. Six common barriers to change described in the literature include: (a) unclear direction on strategy and values, which often leads to conflicting priorities; (b) senior leaders who don’t work as a team and haven’t committed to a new direction or acknowledged necessary changes in their own behavior; (c) a top-down or laissez-faire style by the leader, which prevents honest conversation about problems; (d) a lack of coordination across businesses, functions, or regions due to poor organizational design; (e) inadequate leadership time and attention given to talent issues; and (f) employees’ fears of telling the senior team about obstacles to the organization’s effectiveness (Beer et al., October 2016). The business literature indicates that the problems of organizational behavior and performance stem from a poorly designed and ineffectively managed system, rather than from individual deficiencies. Instead of targeting the individual for change, the primary target for change and development should be the organization, followed by training for individuals in leadership positions (Beer et al., October 2016). Such training could include evidence-based leadership training and mentoring programs, including training in emotional intelligence. Finally, interventions need to be monitored using a combination of appropriate short-term, intermediate term, and long-term instruments. Unfortunately, no such validated instruments currently exist. There is a need to develop, validate, and use organizational climate and culture assessment tools for short-term and intermediate-term monitoring. Our study also indicates a possible utility of exit surveys for monitoring long-term impact of organizational interventions, in promoting retention of faculty at SOMs. There is a need for further studies of organizational climate and culture at SOMs to help address the ongoing attrition of the nation’s biomedical workforce.