Career Satisfaction and Burnout among American Muslim Physicians

Background  Career satisfaction and burnout among physicians are important to study because they impact healthcare quality, outcomes, and physicians' well-being. Relationships between religiosity and these constructs are underexplored, and Muslim American physicians are an understudied population. Methods  To explore relationships between career satisfaction, burnout, and callousness and Muslim physician characteristics, a questionnaire including measures of religiosity, career satisfaction, burnout, callousness, and sociodemographic characteristics was mailed to a random sample of Islamic Medical Association of North America members. Statistical relationships were explored using chi-squared tests and logistic regression models. Results  There were 255 respondents (41% response rate) with a mean age of 52 years. Most (70%) were male, South Asian (70%), and immigrated to the United States as adults (65%). Nearly all (89%) considered Islam the most or very important part of their life, and 85% reported being somewhat or very satisfied with their career. Multivariate models revealed that workplace accommodation of religious identity is the strongest predictor of career satisfaction (odds ratio [OR]: 2.69, p  = 0.015) and that respondents who considered religious practice to be the most important part of their lives had higher odds of being satisfied with their career (OR: 2.21, p  = 0.049) and lower odds of burnout (OR: 0.51, p  = 0.016). Participants who felt that their religion negatively influenced their relationships with colleagues had higher odds of callousness (OR: 2.25, p  = 0.003). Conclusions  For Muslim physicians, holding their religion to be the most important part of their life positively associates with career satisfaction and lower odds of burnout and callousness. Critically, perceptions that one's workplace accommodates a physician's religious identity associate strongly with career satisfaction. In this era of attention to physician well-being, the importance of religiosity and religious identity accommodations to positive career outcomes deserves focused policy attention.


Introduction
Providers' career satisfaction correlates with healthcare outcomes, patient satisfaction, and providers' retention. 1,2 Career satisfaction is defined in many ways, [3][4][5][6] and is impacted by individual, occupational, and systemic factors. Career satisfaction is defined as the overall contentment with one's choice of occupation and is often used interchangeably with job satisfaction, where workplace conditions and dynamics have a huge influence on that sense of contentment. 7 Career satisfaction is a worker's sense of achievement and success on the job and the collection of feelings and beliefs that people have about their current job. It is perceived to be directly linked to productivity and personal well-being. 6 Career dissatisfaction and burnout are at their peak in our healthcare system during the current pandemic leading to a great loss of practicing clinicians. 8,9 A growing body of research shows that burnout among healthcare providers is highly prevalent. System changes, organizational support, workload, collegiality, and individual physician-specific factors contribute to burnout. 10 In addition to higher morbidity and mortality in patients, physician burnout has been linked to self-reported errors and high turnover. 11,12 Callousness is an advanced stage of burnout 13 in the clinical context, often used as an indicator of malignant burnout and associated with poorer outcomes. 14,15 Whereas 70% of individuals in the United States are religiously affiliated, 16 religiosity's effect on career satisfaction is inadequately studied. 17,18 Studies show that religious beliefs impact work and patient care attitudes, contribute to a sense of personal accomplishment, 19 and build resilience among clinicians. 20 Muslim physicians are underrepresented in research, 21 though they comprise greater than 5% of the US healthcare workforce, 22 and religiosity impacts their professional life in many ways. 23 Moreover, in the past two decades, American Muslim clinicians have experienced more racialization, 24 and discrimination in the workplace 25,26 hence, they may be at higher risk of burnout and scrutiny. 27 To fill in critical gaps in the literature regarding religiosity, religious identity, and how that impacts career satisfaction, burnout, and callousness, we examined predictors of career satisfaction, burnout, and callousness among a national sample of Muslim American physicians.

Materials and Methods
This study is a secondary data analysis of a national survey of Muslim American physicians carried out by one of the authors (AIP) in 2013. Since study methods are described in detail elsewhere, [28][29][30] only the most critical features are noted below. This study received human subjects research approval from the Institutional Review Board of the Biological Sciences Division at the University of Chicago.

Participant Recruitment and Data Collection
Since national databases of physicians, like the American Medical Association Masterfile, do not collect data on reli-gious affiliation, we drew upon the membership of the Islamic Medical Association of North America (IMANA; n ¼1968 members in 2013) to draw a national cross-section of Muslim physicians. A random sample of 746 members was selected for receiving a mailed questionnaire. Of these 120 were excluded due to nonworking addresses, decedent status, or those not practicing medicine and no longer identifying as Muslim, leaving us with a sample size of 626 potential respondents. This group received up to three mailed survey questionnaires with escalating fiscal and gift incentives for completion and intermittent postcard and email reminders.

Survey Instrument and Key Measures
The questionnaire included extant validated measures as well as items created de novo. The questionnaire underwent cognitive pretesting with a group of Muslim clinicians and an expert panel review prior to finalization. Outcome domains were career satisfaction, career burnout, and callousness toward people. The perceived career satisfaction was assessed by adapting an item previously used by Nunez-Smith et al. 31 This item stated "thinking very generally about your satisfaction with your overall career in medicine, would you say that you are currently…" with response categories are appropriate Likert type scale from very dissatisfied to very satisfied. Burnout and callousness were measured by items from West et al's work. 32 The items read "Thinking generally about your overall career in medicine, would you say that currently i) I feel burned out from my work ii) I have become more callous toward people since I took this job." Each item had a 7-point frequency response scale from never to every day.
The primary predictor domain was physician religiosity measured by different constructs. Religious importance 33 was measured with the question "How important would you say your religion is in your life?" with responses from "not important" to "the most important part of my life." This question has been used in multiple physician surveys assessing religion-associated variations in physicians' clinical practices. 34,35 Religious practice was measured with five items. The first three assessed the frequency with which participants (a) attended congregational worship (daily to less than once per year), (b) performed Islamic ritual prayers (five times per day to never), and (c) read the Qur'an (daily to never). The fourth item assessed the extent to which the participant keeps the Ramadan fasts (strictly to not at all), while the fifth item assessed adherence to Islamic legal injunctions regarding the consumption of meat (participants reported whether they would eat meat slaughtered according to Islamic law, kosher meat, any meat aside from pork, or did not eat meat). To assess their religious appearance, we asked male respondents whether they wore a beard and female respondents whether they wore a hijab. We also asked about sectarian affiliation within Islam (Sunni, Shi'ite). Other predictor domains were perceived religious discrimination at the workplace, religious accommodation at the workplace, and discrimination-related job turnover. 30 Finally, the questionnaire captured conventional sociodemographic descriptors (gender, age, ethnic/racial background, country of medical school matriculation, and generational status in the United States) and practice-level data (years in medical practice, medical specialty, primary work setting, and the percentage of Muslim patients in each participant's practice).

Data Analyses
Independent double data entry was performed in Research Electronic Data Capture (REDCap) databases, 36 and crosscompared with original surveys to resolve discrepancies. Where possible, variables were transformed for ease of interpretation in the following ways: (i) dichotomizing agreement and satisfaction scales, (ii) collapsing response categories where responses totaled less than 5% of the sample into adjacent categories, and (iii) dropping the "other" response category if this category held less than 5% of the sample. A religious practice variable was a summed score of the five items noted above. After generating descriptive statistics, we used chi-squared tests and simple logistic regression to test bivariate associations between each predictor and outcome variable. Given the exploratory nature of assessing relationships between our variables of interest, bivariate associations significant at the level of p-value less than 0.10 were moved forward into final multivariate logistic regression models for each outcome measure, where the conventional p-value less than 0.05 threshold indicated a significant association.
With respect to career satisfaction, 216 respondents (85%) were somewhat or very satisfied with their overall career (see ►Table 4). In terms of burnout, there was a diversity of experiences, with 59 (23%) respondents reporting feeling burnt out once a week or more, and 48 (19%) never experiencing it (see ►Table 5). Similarly, there was a diversity of experiences with callousness, most (165, 65%) never felt this way, but some (21, 8%) experienced it once a week or more (see ►Table 6).
Concerning the perceived impact of religious identity on relationships with colleagues, 9% of respondents felt that their religious identity negatively influenced relationships with colleagues, while 68% felt it was a positive influence.

Predictors of Career Satisfaction
The strongest predictor of overall career satisfaction was the belief that one's workplace accommodated their religious identity (odds ratio [OR]: 2.69, p <0.015). Respondents who

Discussion
Our national survey shows that religiosity boosts career satisfaction and guards against career burnout and callousness that echo the extant literature as well. [37][38][39] It is no surprising that workplace accommodation of physicians' religious identity contributed to the highest odds of career satisfaction for American Muslim physicians. The importance of religiosity to healthcare workers is not alike for all religious backgrounds. Muslim physicians were found to value religiosity most and deem it as foundational to their well-being compared to physicians from other religious affiliations. 40 This inherent individual construct comes at no cost to the healthcare system, and while these findings are intuitive to interpret, it appears challenging to implement in healthcare systems. 41 Providing the opportunity to Muslim physicians to practice their faith fosters career satisfaction and well-being. Our participants' struggle to find time for prayers predicted career burnout as well as career satisfaction that reflects the interconnectedness of both burnout and satisfaction even if they may not fall on a linear spectrum. 42 Younger age with fewer years in clinical practice significantly predicted career burnout among Muslim physicians.
Physician's age was not a consistent predictor of burnout in the literature but when it was associated, younger age and fewer years in clinical practice were likely to coincide with career burnout. 43,44 This could be a result of the increased administrative load, being on the learning curve to acquire expertise and accomplish tasks, and longer working hours negatively impacting work-life balance. 45 For Muslim physicians, it can be rather confounded by inadequate mentorship, sponsorship, or equitable support from workplaces compared to their physician counterparts.
Those who graduated from US medical schools were less likely to experience career burnout, which may be attributed to their acquaintance with the healthcare system, mentorship networking, and English proficiency with no accent. However, our finding is not consistent with the literature reviewed 46 international medical graduates' experiences may need further research to unpack. 47 It is worth reading about how Muslim international medical graduates may share their equivocal experiences in cultural exchange.
Workplace camaraderie and collegiality can manifest in many ways; Muslim physicians who reported religiosity positively influenced their work relationships were more satisfied in their careers compared to those who reported that their religiosity places them under greater scrutiny. Those who reported being under greater scrutiny are more likely to experience career burnout, and those who reported that their religiosity negatively influenced their work relationship were more prone to callousness. Active involvement and inclusion of Muslim clinicians in organizational cultures, 48 providing professional growth and development resources, 49 and examining the diversity and inclusivity of performance evaluation strategies can improve their workplace experiences. 50  Majoritarianism prevails in the healthcare ecosystem as it does in policymaking, which is palpable in the underrepresentation of Muslim healthcare workers and what may exclusively matter to them. One of the Healthy People 2030 goals is to strengthen the workforce by promoting health and well-being as a high-priority public health issue that does not yet have evidence-based interventions developed to address it. 51 Our study findings suggest that workplace accommodations of religious practice would boost Muslim clinicians' well-being and career satisfaction. 52,53 Given the biases and discrimination pressures that Muslims now face in the United States, focusing policy attention on accommodating Muslim physicians' religiosity is important to enhance their career satisfaction and counteract burnout.
We have developed cutting-edge technology in biomedicine but have had less success in addressing our spirituality. Looking at the issue of physician burnout through the prism of rational problem-solving will highlight that the problem needs to be tackled by incorporating preventative strategies such as mentorship, inclusion, and embracing diversity in addition to developing curative strategies. More importantly, the interventions need to be introduced early in careers rather than at the breaking point. 54

Limitations
As with any survey-based research, our findings should be interpreted in light of the limitations of the measures used. In particular, the measure of practice-based religiosity represented a summed score of different Islamic practices with variable significance. We acknowledge other practices could have been measured, yet our measure mirrored existing practice-based religiosity measures used in other population research. Further research should explore how various practices associate with career satisfaction, callousness, and burnout.

Implications
Our national survey of Muslim physicians shows that religiosity positively influences career satisfaction, and potentially reduces career burnout. Workplace accommodations of their religiosity highly predict career satisfaction, whereas being exposed to scrutiny at work and being alienated due to their religiosity predispose them to career burnout and callousness. The Healthcare system should aim toward inclusive workplaces through accommodating religious identity, counteracting occupational scrutiny, and offering cultural training. Although this cross-sectional study cannot         be used to make definitive causal inferences, physicians who consider themselves religious are more likely to embrace their careers when workplaces cater for them and are rooted in an inclusive environment that would shield them from burnout and callousness.