This cross-sectional, anonymous benchmarking survey of medical student directors (MSD),
associate program directors (APD), and program directors (PD) provides a clear marker
of work responsibilities, extracurricular activities, family life, and burnout.
Within academic ophthalmology, MSD, APD, and residency PD help shape curricular decisions,
educational goals, evaluations, mentorship, and future directions under the supervision
of their respective medical schools and departments, with all parties working to ensure
compliance with national accreditation bodies.
During a time of increased emphasis on trainee well-being—now a priority for the Accreditation
Council for Graduate Medical Education (ACGME) and the Association of American Medical
Colleges (AAMC)—there is an increased interest in physician well-being at large. An
inverse marker of well-being is the concept of “burnout.” Though burnout is subject
to and suffers from multiple definitions, it is defined in the International Classification
of Diseases, 11th revision as an occupational phenomenon, a syndrome of chronic work
stress causing professional dysfunction, negativity, mental distancing, and fatigue.[1] Whether reported subjectively or objectively, burnout is a problem for ophthalmologists
both nationally and abroad.[2]
[3]
[4]
[5] Since MSD, APD, and PD guide the development of well-being curricula and evaluate
trainees for the same, the current state of educational leadership well-being is important
to understand.
This anonymous, cross-sectional, survey-based study provides a benchmark of work life,
home life, and burnout metrics of MSD, APD, and PD members of the Association of University
Professors of Ophthalmology (AUPO).
Results
Of 222 total listed MSD (n = 67), APD (n = 46), and PD (n = 109) on the AUPO listserve, 48 completed surveys were received (22%). There were
no incomplete surveys. Of the 48 responders, 13 served as MSD (27%), 7 as APD (15%),
and 32 as PD (67%). This accounted for 19% of listed MSD, 15% of APD, and 29% of PD
queried. Three responders held positions as both MSD and PD; 1 responder served both
as MSD and APD. Of note, the AUPO listserve only allows for a single listed position;
joint positions were uncovered by the survey.
Please see [Tables 1] and [2] for a summary of results.
Table 1
Summary of survey results. Unless otherwise indicated, results are listed as median
(interquartile range)
|
MSD (n = 13)
|
APD (n = 7)
|
PD (n = 32)
|
|
Year served
|
6 (2.5–8.5)
|
3 (1–3)
|
5 (3–12)
|
|
Program coordinator support
|
85%
|
71%
|
100%
|
|
Very satisfied with coordinator
|
73%
|
60%
|
53%
|
|
Monthly hours spent on position
|
10 (4–15)
|
15 (10–20)
|
30 (20–40)
|
|
Weekly hours, direct patient care
|
22.5 (20–30)
|
22.5 (10–30)
|
20 (10–25)
|
|
Weekly hours, procedures or surgery
|
7 (5–8)
|
8 (5–15)
|
8 (4.5–11)
|
|
Weekly hours, resident supervision
|
10 (10–20)
|
30 (16–30)
|
15 (7–22)
|
|
Weekly hours, administrative tasks
|
8 (8–10)
|
6 (5–10)
|
10 (7–18)
|
|
Weekly hours, research/other
|
2 (2–4)
|
3 (1–5)
|
2 (1–5)
|
|
Receipt of stipend
|
62%
|
57%
|
88%
|
|
Average stipend ($)
|
$19,125
|
$18,250
|
$41,741
|
|
Weeks of call coverage per year
|
6 (3–7)
|
8 (4–9)
|
4.5 (2–6.5)
|
|
Hours sleep, weekday
|
6.5
|
7
|
6.8
|
|
Hours sleep, weekend
|
7
|
7
|
8
|
|
Perform exercise weekly
|
100%
|
71%
|
84%
|
|
Have children at home
|
85%
|
100%
|
72%
|
Abbreviations: APD, associate program director; MSD, medical student director; PD,
program director.
Table 2
Summary of survey results for combined groups
|
Combined groups
|
|
Take clinical work home
|
65%
|
|
Weekly hours spent on clinical work at home
|
4
|
|
Take administrative work home
|
79%
|
|
Weekly hours spent on administrative work at home
|
5
|
|
Stay late for add-on cases
|
58%
|
|
Come in outside of call
|
62%
|
|
Block time for introspection/meditation
|
19%
|
|
Pursue hobbies
|
73%
|
|
Have a significant other
|
100%
|
|
Significant other works
|
75%
|
|
Have children living at home
|
79%
|
All groups (medical student director, associate program director and program director)
were combined for these results.
Work Benchmarks
Duration of Service
The median MSD duration of service is 6 years (interquartile range: 2.5–8.5). The
median APD service is 3 years (1–3). The median PD service is 5 years (3–12). There
was a nonsignificant trend for greater number of years served as PD (p = 0.1).
Program Coordinator Support
Program coordinators work with 85% of MSD, 71% of APD, and 100% of PD. Due to survey
anonymity, it is not possible to discern whether an APD and PD from the same program
were replying to this question.
For those MSD with a program coordinator, meetings are most often held weekly (31%),
as opposed to biweekly (15%) or monthly (15%), though there is a wide range with some
meeting daily and others meeting variably depending on the time of year. Seventy-three
percent are very satisfied with their program coordinator, with the remainder moderately
satisfied.
For those APD with a program coordinator, meetings are most often held biweekly (43%),
with the remainder meeting weekly or monthly (14% each, respectively). Sixty percent
are very satisfied with their program coordinator, 20% moderately satisfied, and 20%
very dissatisfied.
For PD, the majority meet with a program coordinator weekly (47%), as opposed to daily
(22%), twice weekly (3%), biweekly (16%), or monthly (13%). Fifty-three percent are
very satisfied, 16% moderately satisfied, 6% neutral, 16% moderately dissatisfied,
and 6% very dissatisfied with their program coordinator.
Allocation of Workhours
In terms of monthly administrative time directed toward the position, the median spent
by an MSD is 10 hours (4–15), an APD 15 (10–20), and a PD 30 (20–40); PD spend more
time on administrative duties than APD and MSD (p = 0.0008).
In a typical week, an MSD spends a median of 22.5 hours (20–30) on direct patient
care, an APD 22.5 (10–30), and a PD 20 (10–25). An MSD spends a median of 7 hours
(5–8) on procedures and surgery, an APD 8 (5–15), and a PD 8 (4.5–11). An MSD spends
a median of 10 hours (10–20) on direct resident supervision, an APD 30 (16–30), and
a PD 15 (7–22). An MSD spends a median of 8 hours (8–10) on administrative tasks,
an APD 6 (5–10), and a PD 10 (7–18). An MSD spends a median of 2 hours (2–4) on other
nonadministrative, nonclinical tasks (i.e., research), an APD 3 hours (1–5), and a
PD 2 hours (1–5). There is no statistically significant difference in any of these
time allotments between groups. Combining all three groups, 65% take home clinical
work, spending on average 4 hours weekly at home on clinical tasks, and 79% take administrative
work home to complete, spending on average 5 weekly hours at home on administrative
tasks ([Fig. 2]).
Fig. 2 Clinical and administrative work at home. (A) Sixty-five percent of respondents take clinical work home; (B) Seventy-nine percent of respondents take administrative work home.
With rare exception (1 MSD, 1 APD, and 6 PD), survey respondents perform a variety
of other tasks for their department ranging from nontitled educational activities,
to financial, office, or hospital committee service. No respondents listed themselves
as department chairs, but three self-identified as vice-chairs without further elucidation
as to whether this was specifically related to education.
Eighty-one percent of all survey responders receive a stipend for their role(s); if
performing more than one role, only a single answer counted toward the overall average
with “yes” trumping “no.” Upon subanalysis, 62% of MSD receive a role-related stipend,
with an average annual stipend of $19,125; 57% of APD receive a stipend, with an average
annual stipend of $18,250. Eighty-eight percent of PD receive a stipend, with an average
annual stipend of $41,741. One PD did not list a discrete stipend but does receive
20% full-time effort support. Those PD who are also MSD did not receive stipends for
their roles as MSD.
Call Coverage
Over the course of a year, an MSD spends a median of 6 weeks (3–7) covering call,
an APD 8 weeks (4–9), and a PD 4.5 weeks (2–6.5); there is no statistically significant
difference found between groups.
Whether or not they are on call, when looking at all groups combined and examining
a typical month, 42% never stay late for an add-on case, 42% stay late one to two
times per month, 13% three to four times per month, and 4% at least five times per
month. When not covering call, in any typical 3-month period, 38% never come in for
patient calls, 33% come in one to two times, 19% three to four times, and 10% at least
five times ([Fig. 3]). There is no statistically significant difference found between groups.
Fig. 3 Coming in when not on call. Respondents frequently contribute to patient care outside
of routine workhours outside of the call schedule.
Extracurricular Benchmarks
Sleep Hygiene
The average MSD sleeps a median of 6.5 hours during the week, and 7 on weekends, an
APD 7 hours for both, and a PD 6.8 during the week and 8 on weekends.
Time for Self
All groups have ∼1 hour of time to themselves daily, without family or work commitments.
Exercise
One-hundred percent of MSD exercise in some fashion weekly, as opposed to 71% of APD
and 84% of PD. The MSD, APD, and PD groups perform a median of 0 hours of strength
training weekly (0–1 for each group); 31, 29, and 34% of MSD, APD, and PD, respectively,
perform strength training, with a combined average of 1 hour weekly. Cardiac activity
was queried as mild, moderate, or high intensity. The MSD, APD, and PD groups perform
a median of 0 hours (0–2), 1 hour (0–5), and 0.1 hours (0–3) of mild cardiac activity,
respectively; 0 hours (0–2), 0 hours (0–2), and 1 hour (0–3) of moderate cardiac activity,
respectively; and 0 hours (0–2), 1 hour (0–1), and 0 hours (0–2) of high cardiac activity,
respectively. There is no statistically significant difference in exercise frequency,
performance of strength training, or intensity of cardiac activity between groups.
Introspection and Meditation
Only 19% of total respondents block time for introspection or meditation, the majority
of these weekly (56%) or daily (22%).
Hobbies
In contrast, 73% enjoy a hobby, spending on average of 11 hours monthly on it. Of
note, “hobby” was interpreted widely, including spending time with family, cooking,
home maintenance, music and the arts, exercise, golfing, traveling, reading and video
games, shopping, and flying.
Family
One-hundred percent of survey respondents have a significant other. Seventy-five percent
of these significant others work, and of those significant others who work, 50% have
flexible hours. When performing subgroup analysis, there is no statistically significant
difference found in terms of significant other work status or workhour flexibility.
In combined analysis, 79% have children who live at home. Of those children at home,
68% are in kindergarten or younger, 47% are in elementary school, and 23% are in middle
school or high school. Among MSD, 85% have children at home; of those MSD with children,
100% have children in kindergarten or younger, 73% have children in elementary school,
and 36% in middle school or higher. Among APD, 100% have children living at home;
86% have children in kindergarten or younger, 57% have children in elementary school,
and none have children in middle or high school. Seventy-two percent of PD have children
living at home, 61% have children in kindergarten or younger, 48% have children in
elementary school, and 30% have children in middle or high school. When performing
subgroup analysis, there is no statistically significant difference in terms of children
living at home, or in educational level of children living at home.
Burnout Surveys
Two surveys were used to query study subjects: a more positively-worded CTL survey
and the MBI.
The CTL survey allows for a range of responses correlating to never, rarely, sometimes,
frequently, usually, and always ([Fig. 4]). It demonstrated, on average, that all subjects usually love their job, are invigorated
by teaching, find that their position gives their medical career a sense of direction
and meaning, brings satisfaction, suits subjective strengths, and connects them with
their organization's values and similar peer leaders in the organization in a positive
manner. Subjects frequently are excited to go to work in the morning. There is no
statistically significant difference between MSD, APD, and PD in survey responses.
Fig. 4 Responses to the Center for Teaching and Learning (CTL) Survey. This heatmap demonstrates
a generally positive attitude toward work.
The MBI for Educators asks a series of 22 questions designed to gauge burnout on three
scales: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment
(PA). Subjects select from the following responses: never, a few times a year or less,
once a month or less, a few times a month, once a week, a few times a week, and every
day. Higher scores on the emotional exhaustion and depersonalization scales, and lower
scores on the personal accomplishment scale, indicate greater degrees of burnout on
a burnout continuum. As per the MBI group, there is no discrete cut-off representing
“definitive burnout.”
Out of seven total, average Maslach scores for grouped subjects are 3 for EE, 1 for
DP, and 5 for PA, respectively. When subdivided into leadership positions, there is
no statistically significant difference between the groups.
Conclusion
Though this cross-sectional, anonymous benchmarking survey of MSD, APD, and PD on
the AUPO listserve is limited by its response rate, the survey provides a clear marker
of work responsibilities, extracurricular activities, family life, and a low tendency
toward burnout. With rare exception, all leadership positions proved remarkably similar
in terms of work expectations and home life.
All educational leaders balance a wide variety of work-related duties, encompassing
clinical, educational, research, and administrative tasks. For the vast majority,
this includes administrative work beyond that of their leadership title. APD and MSD
spend less time on tasks related to their title in a given month than PD, but typical
weeks are fairly similar no matter the position. Perhaps this reflects bursts of PD
output required over the course of several week periods, as opposed to more similarly
aligned sustained output among all three groups. PD stipends are, on average, more
than double that of MSD or APD, perhaps reflecting this difference in monthly output.
The majority reported adequate amounts of sleep. Though sleep needs are highly individualized,
there is evidence that at least 7 hours of sleep nightly is acceptable.[6] However, time spent exercising is relatively small. In comparison, a study of more
than 3,000 Canadian physicians demonstrated an average of 4.7 hours of weekly exercise,[7] and a study of nearly 500 American cardiologists demonstrated the majority exercised
at least three times a week.[8]
A majority of respondents have children at home; the majority of these children are
in kindergarten or younger. It is not clear whether child age is related to leadership
being overall younger, or whether leadership tends to defer childbearing to a later
age. Though 100% of respondents have a significant other, half of the 75% of working
spouses have flexible hours. This would indicate that having a significant other with
a flexible schedule (either not working or flexible workhours) is in some way associated
with successful procurement and/or retention of educational leadership titles, perhaps
related to the presence of young children.
The CTL survey demonstrates relatively positive job satisfaction across the board,
with all leadership groups usually loving their job and teaching, finding meaning
and satisfaction in their positions, and frequently being excited to go to work in
the morning. Because this survey asks generally positively directed questions, it
is interesting to compare it to the generally negatively directed questions of the
MBI. It is reassuring that all groups were generally scoring low for DP and high for
PA, though moderately for EE (1/7, 5/7, and 3/7, respectively). While there is no
discrete cutoff for burnout according to the MBI,[9] these scores appear to correlate with the positive responses on the CTL.
Ophthalmologists at large appear to have relatively higher rates of subjective or
objective burnout than those reported here. A survey of 133 ophthalmologists in Quebec
found ∼35% “reported high levels of burnout and psychological distress,” which was
mainly attributed to shortage of ophthalmologists with increasing demand for the same,
high team turnaround, and budgets.[5] A survey of 297 ophthalmologists in India revealed that 25% subjectively described
themselves as nearly or being “burnt-out.”[3] According to the Medscape Ophthalmologist Lifestyle, Happiness & Burnout Report
2019, 34% are suffering from burnout (lower than overall physician average of 44%),
with similar rates of overall depression compared with the average physician (11%
colloquially and 3% clinically depressed).[2] A large number of factors appear to contribute to physician burnout, most prominently
bureaucratic tasks, government regulations, increasing computerization, and reimbursement.[2] Other fields have also examined burnout in educational leadership with variable
subjective and objective indicators. A positive burnout response was noted in up to
27% of surveyed Family Medicine PD,[10] 21% of Anesthesia PD,[11] up to 25% of General Surgery PD,[12] 29% of IM PD,[13] and 62% of IM MSD (clerkship directors).[14]
A modified MBI survey of 101 chairs of academic ophthalmology departments demonstrated
9% to have burnout, though only 9% showed no characteristics of burnout on any portion
of the modified MBI, which in turn was based on a paper examining burnout among gynecology
leadership.[4] It is impossible to precisely compare with the ophthalmology chair survey, which
used a modified and presumably shortened version of the MBI and thus would have different
score cutoffs. However, if one assumes that dividing maximal answer scales into thirds
is a reasonable indication of low, moderate, or high EE, DP, and PA, one can attempt
to compare with the ophthalmology chair survey. Accordingly, there were no respondents
meeting high levels of EE and DP with low PA in this study, and thus none demonstrating
burnout. Additionally, 25% of respondents showed low levels of EE and DP and high
PA, or the equivalent of no burnout characteristics whatsoever. However, it is important
to emphasize “that there is no definitive score that ‘proves’ a person is ‘burned
out’” according to formal MBI guidelines.[9]
Our survey results correlate with a high sense of job satisfaction and career meaning
on the CTL. Thus, it would appear that significant involvement in ophthalmic academic
life is either a predictor of physician resilience and well-being, an incubator of
it, or some combination of the two. A 2017 meta-analysis examining individual versus
organizational efforts to reduce burnout in physicians demonstrated both types of
efforts could allow for statistically significant improvement in burnout rates; however,
organizational efforts were more widely impactful.[15] For example, efforts at re-examining schedules/templates, improving teamwork and
communication, and a sense of increased job control allowed for larger burnout impact
than individual changes in behavior or mindfulness.[15] In the cohort studied herein, one might theorize an increased baseline sense of
control over individual roles and communication with members of the academic and administrative
team (including coordinators, trainees, chairmen and the medical school). One might
also consider purposeful schedule management to help keep burnout rates low. Two comments
from the survey demonstrate realistic frustration balanced with continued love of
the position. One respondent reports that secretarial tasks such as creating schedules
and ensuring faculty and trainees complete assignments and form submissions to the
GME or ACGME offices “take away time from focusing on the bigger picture and making
meaningful changes to the program.” Another respondent finds that while s/he “[loves]
my job and [gets] satisfaction from it, it often feels there is a wall of obstruction
keeping me from doing it and doing it well. The burnout in other faculty make doing
my job harder – the teaching suffers and a few soldiers carry on. The institution/department
is revenue centered. The time for teaching is shrinking while the stress is increasing
so people are not doing a good job. They recognize it but there are no good solutions.”
There are two limitations to this study: the survey response rate and the difficult
balance of anonymity. The survey response rate (22%) likely reflects limitations on
survey delivery by listserv policy, as well as the length of the survey. In an effort
to maintain complete anonymity in a relatively small educational leadership group,
there were no survey queries regarding age, gender, region, program size, and medical
school size. Questions of gender have become particularly critical recently, and at
this point would be particularly relevant to pursue in future study—specifically,
subjective perceptions regarding gender and work life. As gender was not queried,
it is unclear whether the relative similarities among all leadership positions exist
despite gender imbalances between positions, or because most subjects are of the same
gender. There were at least two respondents who keenly felt the pressure of gender
disparities. One remarked that any expressed frustrations in the survey were due to
“the staggering expectations that are placed upon young mothers in academic medicine,”
as opposed to her specific educational leadership position; though she wished she
could be less clinically active while her children are young, she feels there is no
“mechanism in academic medicine to enable this without penalizing [her] career.” Another
respondent wrote that “women are more likely to not have a supportive flexible partner,
and are more likely to do more “free” work, getting compensated less for things like
[being] PD or even for their clinical work.” A third respondent of unclear gender
commented that his/her “career was pretty much on hold during the years when [2] children
were more dependent on [him/her] for care…Support systems for parents can also help
prevent burnout and enhance job performance.” While this survey was not created to
capture these questions, and because the survey truly did preserve anonymity, an additional
follow-up query regarding gender is not feasible with the current data. A future survey
regarding gender dynamics in educational leadership would be timely and critical.
In conclusion, this benchmark survey demonstrates that MSD, APD, and PD are intensively
involved in both their work and home lives, with a seemingly high correlation of sense
of worth both personally and in their careers.
