Burnout in GME: It's Not Just a Physician Problem

We all think we know what program administrators (PAs) do. We have either seen or actually written PA job descriptions and understand that our programs would be lost without them. Yet do we understand how stressful the PA role is? If we recognize that the PA role is demanding and can lead to job-related burnout, are we implementing evidence-based preventive approaches and solutions? We do know that the problem appears to be prevalent: In 2017, Fountain and colleagues reported that 76% of their PAs expressed burnout, while 59% considered resigning from their position in the past year.¹ Acknowledging the scope of the PA role will lead to greater understanding of the specific risks for PA burnout.

Studies also have suggested that PAs play a key role in preventing, recognizing, and alleviating resident and fellow stress.² For trainees, the PA may play the role of confidante, life coach, grief counselor, peacemaker, surrogate family member, cheerleader, car rental agent, relationship consultant, and career advisor. Carson and colleagues found that 72% of PAs spent more than 10% of their time focused on resident well-being.³ These responsibilities are often not found in the formal job descriptions, which typically include tasks that support critical program functions; these daily, monthly, and annual duties are essential to a program's success as well as continued accreditation.

In addition to routine responsibilities, certain times of the year confer enormous additional work and potential stress. For example, consider the end of an academic year in June and the new academic year that starts July 1. During this time, in addition to ongoing work, the typical PA is responsible for managing the biannual clinical competency committee, the subsequent semiannual meetings for each trainee with the program director, the program evaluation committee's annual program evaluation, the graduation ceremonies and exit activity for trainees leaving the program, and preparation and collection of the contracts and required onboarding materials for trainees entering the program.

The “July phenomenon” tests even the strongest and most experienced PA with a resulting fatigue uniquely associated with orientation. Graduate medical education (GME) activities in June and July require constant emotional, intellectual, and physical commitments. Some programs will also undergo site visits in June or early July, which require PAs to prepare themselves, program directors, faculty, and trainees for the efforts required to achieve successful site visits. The unexpected often occurs as well. Recently, a PA shared a story in which she was called by the Employee Health Service (EHS) to troubleshoot a situation during resident orientation. An incoming trainee had brought 2 young children to the appointment. As most PAs would do in this situation, she said, “I'll be right there,” and immediately left for EHS. She returned to the GME office with an infant strapped to her chest and a toddler riding in a stroller. Needless to say, the work planned for the next few hours had to wait. PAs characteristically do whatever it takes to keep both trainees and the GME program functioning smoothly.

Little by little these “extra” responsibilities can add up to burnout, especially when PAs feel they have tremendous responsibility but limited authority. “Burnout is a state of emotional, physical, and mental exhaustion caused by excessive and prolonged stress. It occurs when you feel overwhelmed, emotionally drained, and unable to meet constant demands. As the stress continues, you begin to lose the interest and motivation that led you to take on a certain role in the first place.”⁴ An article in this issue of the Journal of Graduate Medical Education by Ewen and colleagues, “Residency and Fellowship Program Administrator Burnout: Measuring Its Magnitude,” examined the prevalence of PA burnout with the Copenhagen Burnout Inventory. The researchers found that burnout scores were higher among PAs who considered leaving their positions.⁵ While there are far more studies aimed at preventing, alleviating, and reversing burnout in physicians, data on PA job stress, burnout, and its consequences are still in its infancy. Ironically, PAs who are highly involved with trainee wellness initiatives are also at high risk of burnout, most likely attributable to handling additional residency minutiae.² Addressing physician burnout is thus likely to enhance additional PA burnout.

I live in Tampa, Florida, where 2 years ago we were threatened by Hurricane Irma. Irma changed her mind about striking the east coast of Florida, shifting her path first to the west coast, and eventually stormed through central Florida. From minute to minute I learned how flexible one must be to manage plans with an overwhelming plethora of constantly changing data. This can be analogous to the PA role. Some items demanding a PA's attention cannot wait until tomorrow, which leads to unpredictably late nights. This lack of control in combination with extremely high stakes—trainee well-being and program success—results in high stress.

The most interesting and promising among the findings from Ewen and colleagues is that there may be a direction to follow. Eighty-six percent of all respondents reported their institution does not yet offer wellness programs for PAs, while 76% would be interested in attending if they did. A 2018 study found that PAs in one institution experienced improvements in mental quality of life, resiliency, stress, and sleep scores as a result of attending PA-focused wellness programs.⁶ Once established, a national PA burnout database may facilitate studies of the elements contributing to and the solutions for PA stress, burnout, and resilience that are currently being aggressively studied in physicians. Let's move PAs to the front of the line for this important work.