Anesthesiology residency program director burnout.

Abstract

To evaluate work-related stress as well as personal factors associated with professional burnout in program directors of anesthesiology.
Survey instrument.
Academic anesthesiology department.
Anesthesiology residency program directors (n = 132).
A 5-part structured, open-ended questionnaire evaluating program and respondents' demographic information, work-related stressors, assessment of control of respondent's personal life using the modified efficiency scale, the Maslach Burnout Inventory-Human Services survey (MBI-HSS), and assessment of spousal/significant relationship support.
100 program directors (76%) responded to the survey. Twenty respondents met the criteria for high burnout risk, and an additional 30 were at risk of developing burnout. Twenty-two directors reported the high likelihood that they would step down in one to two years. Forty-three percent who reported the high likelihood of stepping down stated they were significantly affected by job-related stressors compared with 18% who reported a lower likelihood of stepping down (P = 0.03). Program directors who scored in the high burnout risk category were more likely to report lower current job satisfaction (P < 0.005) and an increased likelihood of stepping down in the next two years (P = 0.009). Logistic regression analysis identified compliance issues, self-assessment of effectiveness, family/significant other support, perceived impact of stressful factors, and current job satisfaction as predictors of high burnout. The model had a sensitivity (95% CI) of 0.55 (0.34 to 0.74) and specificity of 0.99 (0.92 to 1.0) for predicting high burnout risk.
Fifty-two percent of anesthesiology program directors are at high risk for developing burnout syndrome. Job-related stress, especially with administrative duties regarding compliance, was predictive of burnout among program directors.

Full text

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Original contribution
Anesthesiology residency program director burnout☆
Gildasio S. De Oliveira, Jr MD (Instructor)a, Marcela D. Almeida MD (Clinical Associate)b,
ShireenAhmadMD(AssociateProfessor)a,PaulC.FitzgeraldMS,RN(ResearchAssociate)a,
Robert J. McCarthy PharmD (Research Professor)a,⁎
aDepartment of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
bDepartment of Psychiatry, University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
Received 24 August 2010; revised 1 February 2011; accepted 2 February 2011
Keywords:
Anesthesiologists;
Anesthesiology program
directors;
Medical education;
Residency;
Work stress
Abstract
Study Objective: To evaluate work-related stress as well as personal factors associated with professional
burnout in program directors of anesthesiology.
Design: Survey instrument.
Setting: Academic anesthesiology department.
Subjects: Anesthesiology residency program directors (n = 132).
Measurements: A 5-part structured, open-ended questionnaire evaluating program and respondents'
demographic information, work-related stressors, assessment of control of respondent's personal life
using the modified efficiency scale, the Maslach Burnout Inventory-Human Services survey (MBI-
HSS), and assessment of spousal/significant relationship support.
Main Results: 100 program directors (76%) responded to the survey. Twenty respondents met the
criteria for high burnout risk, and an additional 30 were at risk of developing burnout. Twenty-two
directors reported the high likelihood that they would step down in one to two years. Forty-three percent
who reported the high likelihood of stepping down stated they were significantly affected by job-related
stressors compared with 18% who reported a lower likelihood of stepping down (P = 0.03). Program
directors who scored in the high burnout risk category were more likely to report lower current job
satisfaction (P b 0.005) and an increased likelihood of stepping down in the next two years (P = 0.009).
Logistic regression analysis identified compliance issues, self-assessment of effectiveness, family/
significant other support, perceived impact of stressful factors, and current job satisfaction as predictors
of high burnout. The model had a sensitivity (95% CI) of 0.55 (0.34 to 0.74) and specificity of 0.99
(0.92 to 1.0) for predicting high burnout risk.
Conclusions: Fifty-two percent of anesthesiology program directors are at high risk for developing
burnout syndrome. Job-related stress, especially with administrative duties regarding compliance, was
predictive of burnout among program directors.
© 2011 Published by Elsevier Inc.
1. Introduction
Anesthesiology program directors are responsible for
overseeing thesuccessful training of thefuture generationsof
anesthesiologists. Among their professional responsibilities
☆Financial Support: Department of Anesthesiology, Northwestern
University.
⁎Corresponding author. Tel.: +1 312 926 9015; fax: +1 312 926 8341.
E-mail address: r-mccarthy@northwestern.edu (R.J. McCarthy).
0952-8180/$ – see front matter © 2011 Published by Elsevier Inc.
doi:10.1016/j.jclinane.2011.02.001
Journal of Clinical Anesthesia (2011) xx, xxx–xxx

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are the recruitment of new residents, development and
supervision of an education curriculum, scheduling clinical
coverage, and assurance of compliance guidelines from the
Accreditation Council of Graduate Medical Education
(ACGME) and specialty board requirements. In addition,
they are frequently called on for guidance by the house
staff and occasionally to address behavioral problems
among residents.
Burnout is a work-related psychological syndrome
characterized by emotional exhaustion, low personal accom-
plishment, and depersonalization [1]. Burnout differs from
depression in that it is limited to the work environment;
depression involves both professional and personal life.
Clinical manifestations of burnout are commonly nonspecif-
ic and include fatigue, sleep and eating disorders, headache,
and emotional instability. It is also associated with impaired
job performance, and it may contribute to alcoholism and
drug addiction [1]. The prevalence of burnout is higher
among individuals whose job involves interactions with
people, eg, physicians, nurses, and social workers [2].
Leadership burnout may not onlyaffect the individual but the
whole health care organization [3]. It is conceivable that
program directors are at high risk of developing burnout as a
result of the high amount of personal interaction involved in
the demands of their job.
The objective of this study was to evaluate work-related
stress as well as personal factors associated with professional
burnout in anesthesiology program directors. We adapted a
cross-sectional survey similar to one that we used to evaluate
burnout in anesthesiology department chairpersons [4].
2. Materials and methods
The study was approved by the Institutional Review
Board of Northwestern University. A cross-sectional nation-
wide survey was sent to 132 program directors in the United
States. The distribution list was created using the 2009-2010
Directory of the American Medical Association section of
Graduate Medical Education. The survey was created using
SurveyMonkey software (SurveyMonkey Com LLC, Port-
land, OR, USA). To promote the confidentiality of the
respondents, the survey was configured to delink the
responses from the e-mail address. The participants who
did not respond to the electronic questionnaire were mailed a
copy of the survey with a self-addressed return envelope
addressed to the primary investigator.
The questionnaire was comprised of 51 questions divided
into 5 parts. The first nine questions were designed to capture
demographic information (Table 1). The second part of the
survey listed potential stressors that may have impacted the
program director's job in the last year (Table 2). Respondents
were asked to rank the effect of the stressor on a Likert scale,
from “not at all” to “extreme amount” and rank how these
stressors had affected them. Current job satisfaction was
assessed, as well as that perceived one and 5 years earlier, as
was program director satisfaction relating to the balance of
personal and professional lives, using a Likert scale ranging
from “very satisfied” to “very dissatisfied”. Program
directors were asked the likelihood that they would resign
in the next one to two years, ranging from “not likely” to
“extremely likely”. The third portion of the survey assessed
the program director's opinion regarding their control over
professional life, using a modified self-efficacy scale [5]. A
score ranging between 7 and 35 was calculated based on the
responses. Respondents also ranked their effectiveness as a
program director on a scale ranging from 0 (“least effective”)
to 100 (“most effective”).
Table 1
Characteristics of anesthesiology program directors
Age (yrs; n)
33 to 44
45 to 50
51 to 55
55 to 65
Gender (n)
Male
Female
Years of service as program director (n)
1 to 2
3 to 5
6 to 10
N 10
Number of residents in program (n)
b 25
25–42
43–60
N 60
Hours worked per week (n)
23 to 55
56 to 60
61 to 70
71 to 80
Percentage of time devoted to patient care: (n)
0 to 20
21 to 40
41 to 60
61 to 80
81 to 100
Administration
0 to 20
21 to 40
41 to 60
61 to 80
81 to 100
Research
0 to 20
21 to 40
Support group for program director through graduate medical
education office (n)
Yes
No
26
26
23
23
72
28
26
26
33
14
24
26
28
21
26
36
26
10
5
18
35
36
5
19
14
31
7
2
92
8
16
83
2G.S. De Oliveira, Jr et al.

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The fourth part of the survey included 12 questions from
the Maslach Burnout Inventory-Human Services Survey
(MBI-HSS) [1]. The Maslach survey was shortened to 12
questions to reduce questionnaire burden and to follow the
same methodology that we used to evaluate burnout in
academic chairs [4]. The MBI-HSS was calculated using
proportional scoring, with burnout syndrome considered to
be present when the responder reported a high score in
emotional exhaustion (N 26) and depersonalization (≥ 10)
and a low score in personal accomplishment (b 32).
The fifth part of the survey included 6 questions adapted
from previous studies that evaluated the program director's
support from his or her spouse/significant other and family
[4,6-10]. Responses were ranked on a 5-point Likert scale,
from “never” to “always”. Summation of the responses
yielded a score ranging from a low of 6 (indicating minimal
support) to a maximum of 30 (indicating maximum support).
Current self-evaluation of the level of satisfaction was
compared with responses regarding satisfaction 5 years earlier,
using the Wilcoxon signed-rank test. Characteristics of
respondents who reported a moderate to high likelihood of
stepping down from the job within two years were compared
withthosewhoreportedalowerlikelihoodofresignation,using
a χ2statistic or the Mann-Whitney U test. Similarly,
respondents whose scores indicated a high risk of burnout on
the Maslach scale were compared with those with low to
moderatehigh risk,usingaχ2statistic ortheMann-Whitney U
test. Maslach subscale scores among the risk of burnout-
indexedgroupswerecomparedusingtheKruskalWallisHtest.
Factors associated with a high risk of burnout (P b 0.1) were
entered into a binary logistic regression model. The model was
fitted using stepwise backward elimination with removal
testing (P N 0.1) based on the probability of the likelihood-
ratio statistic. The overall predictive value of the model was
assessed as the area under the receiver operator characteristics
curve of burnout risk predicted by the model versus that
predicted by the Maslach scale. The risk ratio for Likert scale
variables identified in the logistic model was calculated as the
ratio between the group and all lower groups and above and
below the median value for interval data. Sensitivity,
specificity, and the positive likelihood of test positive were
calculated using standard formulae. Data were analyzed using
NCSS 2007 version 7.1.19 software (release date 11/19/2009;
NCSS LLC, Kaysville UT, USA) and PASW Statistics 18
(release date 11/13/2009; SPSS, Inc., Chicago, IL, USA).
3. Results
One hundred program directors responded to the survey,
72 via the electronic version and 28 through the mail,
corresponding to a response rate of 76%. Four surveys had
insufficient response for adequate analysis of burnout.
Distribution of characteristics of program directors and
their positions are shown in Table 1. There was no difference
in the median number of work hours by gender (P = 0.41) or
duration of appointment (P = 0.27). The median number of
residents in programs in which program directors devoted
less than 40% of their time to administration was 42 (24 to
56), equal to the number [42; (27 to 68)] in programs for
which program directors devoted more than 40% of their
time to administration (P = 0.49).
Responses to questions that examined stressful issues
occurring in the year before the survey was conducted are
shown in Table 2. Thirty-eight program directors noted that
these stressors affected them only to a slight degree, while 36
reported being moderately affected, and 24 responded that
they were largely to extremely affected. Twenty-seven
respondents reported high job satisfaction currently. Thirty-
three program directors reported a decrease but only
8 reported an increase in job satisfaction compared with
one year ago (P b 0.005). Twenty-nine of the 55 respondents
who had been program directors for 5 or more years reported
decreased job satisfaction compared with 5 years earlier (P b
0.005). Forty-three respondents reported dissatisfaction or
high dissatisfaction with regard to the balance between their
personal and professional lives, but only 23 reported the
same degree of dissatisfaction with their salary. The median
[interquartile range (IQR)] composite score of the modified
Table 2
Perceived impact of stress-provoking issues experienced by program directors during the year prior to survey
Number of respondents Perceived impact by program directors
None/slightModerate Large-extreme
Violence at workplace
Sexual harassment
Accreditation Council for Graduate
Medical Education issues
Substance abuse
Compliance issues
Resident recruitment
Resident dismissal
Disputes with chair
Malpractice
99
99
99
99
95
30
1
4
0
1
30 40
99
99
99
98
98
99
75
56
59
84
79
97
20
21
25
9
15
1
5
23
16
7
6
2
Data are presented as percentages of respondents.
3Residency program director burnout

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efficacy scale, 20 (18-23), corresponded to a feeling of a
moderate level of control by the program directors over their
professional life, and the median (IQR) self-assessment of
effectiveness, 80 (75 to 88), suggests that the program
directors viewed their impact in a predominantly favorable
manner. The median (IQR) score for family/significant other
support was 21 (19 to 24) and did not differ between male
and female program directors (P = 0.19).
Twenty-two program directors reported the high likeli-
hood of stepping down in one to two years. There were no
differences in age (P = 0.55), gender (P = 0.52), years as a
program director (P = 0.88), rating of self-effectiveness (P =
0.11), satisfaction with the balance between personal and
professional lives (P = 0.42), or dissatisfaction with their
salary (P = 0.65) in the respondents reporting a high or very
high anticipated likelihood of stepping down compared with
those with a lower likelihood of doing so. Ten of the 22
(43%) program directors reporting a high likelihood of
stepping down indicated that they were significantly affected
by job-related stressors compared with 14 of the 77 (18%)
who reported a lower likelihood of stepping down (P = 0.03).
Twenty anesthesiology program directors met the criteria
for high burnout, with an additional 30 scoring in the
moderate-high burnout group (high risk of developing
burnout) (Fig. 1). Median (IQR) subscale scores for
emotional exhaustion, personal accomplishment, and deper-
sonalization were 34 (23 to 41), 36 (29 to 44), and 8 (5 to 12).
Emotional exhaustion scores were more likely to be elevated
in program directors who reached the moderate risk index of
burnout. Depersonalization scores increased and personal
accomplishment scores decreased as the risk reached the
moderate-high level. Program directors who scored in the
high burnout risk category were more likely to report lower
job satisfaction and the increased likelihood of stepping
down in the next two years (Fig. 2).
Respondent characteristics that were associated with high
burnout risk compared with those scoring at low to moderate
levels of burnout are shown in Table 3. Age, gender, years as
a program director, hours worked weekly, and number of
residents in the program did not differ between program
directors in the high and lower burnout risk categories. High-
burnout program directors scored lower with regard to self-
reported support from family/significant other, self-assessed
effectiveness, and modified efficacy scale scores compared
with respondents in the low to moderate risk group. High-
Fig. 1
anesthesiology program directors.
Distribution of burnout based on the Maslach scale among
Fig.2
between the high-burnout and lower-burnout risk index groups.
Comparison of the self-reported likelihood of stepping down asa program director (P= 0.009)and current job satisfaction (P b0.005)
4G.S. De Oliveira, Jr et al.

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burnout respondents also reported a higher perceived impact
of stressful factors, as well as a greater impact of ACGME
issues, compliance, and dispute with their chairs relating to
issues about their position.
Multivariate analysis identified compliance issues, self-
assessment of effectiveness, family/significant other support,
and perceived impact of stressful factors and current job
satisfaction as independent risks for high burnout (Table 4).
The overall predictive value of the model (area under the
receiver operator characteristics curve) was 0.77. Sensitivity
[(95% confidence interval (CI)] of the model was 0.55 (0.34
to 0.74) and specificity was 0.99 (0.92 to 1.0). The likelihood
ratio (95% CI) of a positive test predicting high burnout was
41.8 (8.2 to 747.5).
4. Discussion
The important finding of this study is the high incidence of
burnout (21%) among anesthesiology program directors in the
United States. When considering the program directors who
are at high risk for developing the syndrome (defined by a
Maslach score of moderate-high burnout), the number reaches
52%.Programdirectorsofanesthesiologyconstantlydealwith
the challenges of running an educational program, including
processing frequent changes in compliance and requirements
of the ACGME, and addressing disciplinary actions for
residents regarding clinical competence or inappropriate
interpersonal relations, which may be very time consuming
and frequently involve difficult interactions. They are also
expected to recruit the “best and the brightest” residents,
another task that may generate a great amount of stress.
Disputes with their department chair were associated with
increased burnout risk. Most important, the perception that
these stressors affected program director performance was a
critical indicator of increasing burnout risk.
The emotional exhaustion subscale of the Maslach
burnout index scale was most affected by increasing levels
of the burnout index. This finding is similar to that of
Anderson et al [11] in their study of residency directors of
surgery. Those researchers showed a 25% rate of a high
subset score for emotional exhaustion [11]. They also found
Table 3
Characteristics associated with a high risk of burnout
Risk of burnoutP-value
Low to moderateHigh
Support from family
Perceived impact of stressful factors on program directors
minimal
moderate
significant
Compliance issues
minimal
moderate
significant
ACGME issues
minimal
moderate
significant
Perceived effectiveness (%)
Modified efficacy scale (7 to 35)
Dispute with Chair
minimal
moderate
significant
22 (19 to 25)18 (16 to 19)
b 0.0001
34
30
12
1
6
12
b 0.0001
46
18
12
6
3
11
0.002
27
24
25
80 (75 to 90)
20 (19 to 25)
1
5
14
73 (66 to 84)
19 (17 to 20)
0.004
0.006
0.01
62
8
5
12
7
1
0.01
Data are reported as medians (interquartile ranges) or numbers.
ACGME = Accreditation Council for Graduate Medical Education.
Table 4
Multivariate predictors of high burnout risk
P-valueRisk ratio (95% CI)
Perceived impact of stressful factors
significant
Current job satisfaction
neutral
low
Compliance issues
significant
Self-efficacy score
low (b 80)
Family/significant other support score
low (b 21)
0.02 4.1 (1.3 to 25.1)
0.04
0.01
7.3 (1.1 to 47.8)
9.6 (1.5 to 59.6)
0.045.2 (1.1 to 24.6)
0.074.1 (0.9 to 19.6)
0.094.7 (0.8 to 27.8)
Risk ratio was calculated as the ratio for the highest compared with all
lower groups for ordinal data and for above and below the median value
for interval data.
5Residency program director burnout