Introduction

Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and lack of personal accomplishment [1]. Burnout has been further described as a “syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed” [2]. Burnout among emergency physicians is often the highest of any specialty, with a prevalence of 60–70% [3].

Much is known about demographic and other factors associated with the burnout syndrome. Emergency physicians suffering from burnout tend to be earlier in their careers, report increased workloads, and have unhealthy work-life balance [4]. Burnout has been associated with increased medical errors, patient and provider dissatisfaction, increased physician turnover, and worse mental health [5, 6]. Costs associated with physician burnout are approximately $7,600 per physician per year and $4.6 billion on a national scale [4]. Several psychosocial factors have been associated with the burnout syndrome among emergency physicians. In a survey of 88 emergency physicians, increased burnout was associated with less freedom and influence at work, less social support, and poorer mental health [7]. Systemic and institutional factors have also been shown to influence the burnout syndrome, such as excessive workload, burdensome work processes, clerical burdens, organizational support, and leadership culture [5].

Given that burnout is well-described in the literature, this project explored a model of physician thriving, as in, those who are not experiencing burnout and are satisfied both in their work and their life. While many studies have examined burnout, few have investigated physician thriving. Thriving can be defined as a physician who is content with their career choice, their family life, and report a minimal amount of burnout days in a year [8]. Physician thriving emphasizes attributes of well-being and happiness and offers a health model rather than a disease model of physician burnout. A physician thriving model can inform individual practice and shape the work environment.

To explore this concept of physician thriving, we employed a qualitative study among emergency physicians who were satisfied with both their lives and their jobs. Qualitative studies are widely recognized as an important method of exploring novel themes [9]. Specifically, this qualitative study explores factors that influence satisfaction and well-being to construct a model for thriving among emergency physicians.

Methods

Results

There were 25 interviews conducted with emergency physicians across ten hospitals (Table 1). Two physicians contacted by the interviewer met criteria for burnout and were not included in the study, leaving 23 for data analysis. Eight (35%) of the participants held leadership positions: regional director (1), medical director (5), assistant medical director (2). All participants were board certified in emergency medicine. Of the 23 participants, the mean age was 45.4 years old (range 32–65), with 6.7 years in their present job (range 1–25), 17 (73.9%) were men, 13 (56.5%) were Caucasian, 6 (26.0%) were Asian/South Asian, 1 (4.3%) were Latino, and 3 (13.0%) were another ethnicity (Table 1). Ethnicity and gender were similar to other large studies of emergency physicians [17–19]. Data saturation was reached after the tenth interview. None of the physicians met criteria for burnout. The average score for life satisfaction was 8.65 [sd ± 0.93] and for career satisfaction it was 7.46 [sd ± 2.21].

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Table 1. Characteristics of study participants (n = 23).

https://doi.org/10.1371/journal.pone.0279425.t001

Five common themes emerged that were associated with thriving as an emergency physician: 1) expanded horizons, 2) social connections, 3) resilience, 4) balance perspective, 5) qualities of both introversion and extroversion. Finally, emergency physicians noted two common threats to their job and life satisfaction: local hospital administration that was not supportive of their role and the EMR (Fig 1).

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Fig 1. Conceptual model of emergency physician thriving.

https://doi.org/10.1371/journal.pone.0279425.g001

Discussion

This project explores a model of physician thriving among those working in the Emergency Department of several hospitals among a broad cohort of physicians which generally reflect the ethnic diversity of the national emergency physician workforce [17–19]. Thriving physicians tended to have rich social connections, both within and outside their work environments, as well as notable outside interests and hobbies. Further, thriving physicians had an intrinsically motivated sense of balance, perspective, and resilience. While it is conceptually possible for an emergency physician to experience burnout at work and high satisfaction at home, or vice-versa, this project explored a holistic model of both high job and life satisfaction. The Institute of Healthcare Improvement supplements their Triple Aim of healthcare, quality, efficiency, and patient experience, with a fourth aim, physician work satisfaction [20]. We chose to explore a model of high job and life satisfaction. Our model describes the importance of both work and life satisfaction. Several quantitative projects affirm the importance of a balanced work and home life among physicians [21–23].

There are several implications to this project. These interviews were conducted during a relative trough in the COVID-19 pandemic at many of the hospitals. However, the pandemic still was prevalent during this study. We believe this makes these results even more compelling since these physicians met criteria for thriving and were not burned out during a pandemic. These emergent themes–resilience, social connection, outside interests, with personality types of introversion and extroversion–were associated with career and life satisfaction during a particularly stressful period for the healthcare system. Exploring a model of physician thriving is important, especially since many emergency physicians consider leaving the field, especially women in mid-career [24]. While snowball sampling was the appropriate technique for reaching this specialized subpopulation, limitations should be acknowledged. Namely, these participants were a non-random sample [25]. Physicians may have referred participants in their social network, with similar beliefs and ideas. Thus, there may have been themes that were not captured. However, given the diversity of the participants, with ten hospitals represented, and thematic saturation after ten interviews, we believe our sample population represented valid findings.

Can other physicians learn this model, or is well-being intrinsic to the lives of those interviewed? Some personality traits, such as the balance of introversion and extroversion, may be difficult to teach. However, some personal traits such as gratitude, mindfulness and resilience can be fostered through workshops and other programs. Several intervention studies focused on individual skill-building, such as mindfulness and relaxation techniques, have demonstrated an improvement in well-being and reduced burnout [26–30]. However, these studies tend to have only a few participants and be of short duration [29, 30]. The association was often weak or mixed, highlighting the complex nature of burnout and well-being [29, 30]. Yet, cultivating these intrinsic qualities of resilience, perspective, and expanded horizons may attenuate burnout.

This model affirms the findings by quantitative studies. Shanafelt et al who describes several drivers that leaders need to address to improve physician engagement: resources, workload, control/flexibility, work-life integration, social support, meaning in work, organizational culture [31]. This model affirms the findings derived from the lived experience of emergency physicians in this qualitative study. In particular, optimizing the work environment with appropriate resources and workload as well as emphasizing work-place culture through responsive leadership and social support were key drivers in our model. In addition, Lall et al derived a model of job satisfaction from a survey-based study that identified the importance of reducing burnout, opportunities for non-clinical opportunities, optimizing work-conditions, family time, and the electronic medical record, and reducing discrimination [19]. Our qualitative study adds validity to the Shanafelt and Lall models [19, 31]. In addition, our study explores intrinsic features such as resilience, balanced perspective, and being both introverted and extroverted.

Interestingly, thriving physicians described their personality type as having both features of introversion and extroversion. The extroversion may help these physicians to lead in moments of high stress, work well in teams, and connect with patients. The introversion may help them to detach, gain perspective, and recharge. This mixed personality trait is complex. Extroversion has been associated with lower emotional exhaustion among physicians [32]. Introversion among nurses has been associated with increased burnout [33]. In a project evaluating leadership efficacy, introverted leaders tend to perform better than extroverts [34]. Either personality type may be positively adaptive or maladaptive to burnout. This mixed personality type–where physicians described features of introversion and extroversion–has not been well-described in the literature and merits further study.

In addition to intrinsic qualities specific to the physician, there are institutional factors that contribute to thriving: the team-oriented spirit of the local environment as well as institutional support from leadership. Support by shift teammates and institutional leaders confer a sense of individual value and personal encouragement crucial for Emergency Department demands. While these physicians met criteria for thriving, some described poor administration and ineffective leadership in their local hospitals as threats to their well-being. In a multispecialty cohort at a large medical center, Shanafelt et al described a significant association between leadership quality and burnout among physicians. Those physicians who scored their immediate supervisor highly had less burnout and increased job satisfaction [35]. In another cohort study, internists with perceived greater institutional support had a higher job and life satisfaction [14]. In another physician cohort, perceived lack of value-alignment by leadership was also associated with increased burnout [36]. Our qualitative study affirmed the need for effective, value-oriented leadership highlighted in these survey projects.

In a systematic review, among eleven studies that associated burnout and leadership styles, “transformational leadership” was associated with lower levels of emotional exhaustion and higher job satisfaction among behavioral health care workers [37]. Transformational leadership is characterized by, “Individualized consideration, intellectual stimulation, inspired motivation, and idealized influence” [37]. In contrast, a “transactional” leadership style has been associated with increased job dissatisfaction and emotional exhaustion among workers. Transactional leaders assign responsibilities to subordinates and tie rewards and punishments based on those responsibilities. While specific data among emergency physicians is lacking, identifying leaders who exhibit a transformational style may enhance the work environment and improve job satisfaction.

In addition, charting in the electronic medical record and other administrative demands were repeatedly noted as negatively impacting physician thriving. This has been repeatedly borne out in a number of studies. Two qualitative studies among primary care physicians affirmed the findings of this project: greater EMR interaction was association with worse job satisfaction [14, 15]. In a multi-clinic cohort study, primary care physicians with more EMR duties had greater burnout and lower job satisfaction than those with fewer EMR duties [38]. Another physician cohort study from all specialties showed that 70% experienced stress related to technology. More time with the EMR was independently associated with stress and burnout [39]. Optimizing the EMR with improved training or more intuitive processes may attenuate job dissatisfaction. This is an important leading-edge issue for physician well-being that merits intervention trials.

In our qualitative study, these physicians did not cite support derived from professional societies, annual meetings, or other continuing education programs (CME). One study did show that participation in CME’s was associated with less job stress and positive job satisfaction [40]. Of note, our participants did not cite organized religious involvement and other formal social clubs as important to well-being, which has been noted in broader population-based studies [41]. The social connections among these physicians were mostly along informal networks and friend groups rather than intentional participation in social organizations. Friendships have been associated with greater job satisfaction and reduced burnout among physicians but is not widely studied [14]. Religious involvement and spirituality have been widely studied in the general population and found to be associated with many positive mental health benefits, such as depression, anxiety, and burnout [42, 43]. However, religious involvement and spirituality specifically among physicians has not been well studied. One large cohort project among primary care physicians and psychiatrists demonstrated an association with religious involvement and “a sense of call,” but mental health parameters were not investigated [44]. Further study in friendships, religiosity, and other social networks of physicians is warranted.

Conclusions

This project highlights the complexity of physician well-being and job satisfaction. Intrinsic factors, such as resilience and equanimity, interpersonal factors, such as shift-team dynamics, and extrinsic factors such as leadership culture and the EMR all contribute to influence physician job and life satisfaction. This presents a challenge for designing intervention trials, where any one intervention may not have enough impact to affect competing variables. As such, a holistic model, as the one described in this qualitative study, shows promise to inform the necessary work of physician well-being. A multi-faceted approach is necessary to cultivate those individual physician factors, while also optimizing team-dynamics, leadership, and the EMR.

Supporting information