Leadership Training and Risk of Burnout

The consequences of burnout among academic medicine faculty can be detrimental to faculty members, patients, organizations, and the healthcare system as a whole.(1–4) One way to mitigate this risk is by investing in career development, which has been linked to faculty vitality and reduced burnout.(5) An example of this investment is leadership training, which offers the opportunity for faculty members to enhance their leadership skills and prepare for more significant leadership roles.

Leadership training programs are common among American Association of Medical Colleges (AAMC) member institutions.(6) Reported outcomes of leadership programs include increased knowledge, skills, efficacy, and personal growth as well as scholarly productivity and career advancement.(7–14)

Less attention has been paid to the link between leadership and physician well-being, however,(15) and the possible impact of leadership training on leaders’ burnout. This is an important area of inquiry given that leaders are an integral part of organizational functioning in academic medicine. Additionally, direct reports who give more positive leadership ratings to supervisors report lower levels of burnout and higher levels of satisfaction with their institutions.(16)

A common method of measuring burnout is the Maslach Burnout Inventory (MBI).(17) The MBI measures three components of burnout: emotional exhaustion, depersonalization, and personal accomplishment. Individuals are considered to be experiencing burnout when they have high levels of emotional exhaustion (lacking emotional energy and losing enthusiasm for work), high levels of depersonalization (feeling disconnected from others and cynical about relationships), and/or low levels of personal accomplishment.

To further evaluate the relationship between leadership training and leaders’ sense of burnout or well-being, we sought to assess the impact of the Columbia Women’s and Children’s Health Faculty Leadership Academy at the Vagelos College of Physicians and Surgeons on participant energy, engagement, and sense of personal accomplishment.

Leadership Academy Program

The Columbia Women’s and Children’s Health Faculty Leadership Academy is a nine-month leadership training program involving mid-level faculty leaders from pediatrics, obstetrics-gynecology, and child psychiatry. Its curriculum draws on behavioral and social science principles to address such issues as time management/delegation, organizational systems, interpersonal styles, change management, negotiation, and talent management. Experts with formal behavioral and social science training facilitate the instruction. Local experts deliver training other content-specific areas such as finance.

As part of the curriculum, participants interview institutional leaders in an attempt to gain insight about the leaders’ responsibilities, challenges, career trajectories, and leadership qualities. Additionally, participants complete the Birkman Method assessment,(18) receive feedback on the results, set personal goals, and consider how individual differences impact group and dyadic functioning.

Methods

Sixty-eight graduates from eight classes (2011–2018) who were employed at the Vagelos College of Physicians and Surgeons (VP&S) were asked to complete an online questionnaire about their experiences in the leadership academy and their current well-being. An additional 10 graduates who were employed in leadership positions at other institutions were not asked to participate due to concerns that their experiences in a new institution could be confounded with their experiences at VP&S. This study was approved by the Institutional Review Board. The participants received an informational sheet; written informed consent was waived.

The questionnaire was based on concepts from the MBI(17) and from the content of 15 previous interviews. Those interviews, the purpose of which was to evaluate the program, were conducted with graduates of the leadership academy (classes 2011–2012) four to five years after they completed the program.

The interviews provided evidence that the program had an impact on all three components of burnout, despite the fact that interviewees were not queried specifically about the relationship of their leadership training to burnout. We used this experience to build the current questionnaire.

The questionnaire was comprised of four sections. In the first section, participants were asked to rate their current level of energy, engagement, and personal accomplishment using a 5-point scale (1 = not at all, 3 = somewhat, 5 = a lot). In the second section, participants were asked to reflect on their year in the leadership academy and rate their overall level of energy, engagement, and personal accomplishment during the year of the leadership academy using the same 5-point scale. Participants also were asked to rate on a 5-point scale the impact of each aspect of the curriculum (content, peer mentoring, the Birkman Method assessment, interviews with institutional leaders, and an independent project) on the three components of burnout. For the institutional leader interview experience, participants were queried only about this activity’s impact on engagement, since it seemed unlikely this activity would affect energy or personal accomplishment.

For the third section of the questionnaire, participants were asked to rate their current overall satisfaction with personal attributes associated with energy (e.g., being reflective/thoughtful), engagement (e.g., engaged with leaders), and personal accomplishment (e.g., confident in handling stressful situations) as compared to before they started the program. All ratings were based on a 3-point scale (1 = less satisfied, 2 = same, 3 = more satisfied).

In the fourth section, participants were asked to use a 5-point scale to rate the degree to which they were satisfied with their current ability to engage in six practices commonly associated with supporting wellness (e.g., be physically active, take time after stressful situations to recover).

Throughout the questionnaire, space was provided for participants to make additional comments. At the end of the questionnaire, they were asked specifically to share their thoughts about the potential role of leadership training in addressing burnout. These comments were reviewed by the authors and common themes were identified.

Results

Fifty-five graduates (81%) responded to the questionnaire. Demographic characteristics are presented in Table 1. Recipients of the questionnaire were represented by gender and academic rank consistent with the percentage in the entire sample. For purposes of determining whether any of the outcomes were related to demographic characteristics, we compared outcomes by gender, academic rank, taking on a new leadership position, being promoted, and class block (first two blocks compared to block three).

Two of the participants did not complete the questionnaire beyond reporting on their current level of energy, engagement, and sense of personal accomplishment. An additional four participants failed to participate beyond the questions referring to the impact of specific aspects of the leadership program on energy, engagement, and personal accomplishment. Another two participants quit after completing the section on personal attributes. Participants occasionally omitted answers to individual items. Participants who skipped items are not included in the denominator when determining percentages for the questions they skipped.

Overall Well-Being

The participants rated their overall well-being during the year they participated in the leadership academy and their current well-being (see Table 2). In general, the participants described similar levels of well-being across both time points. The scores of the eight participants who failed to complete the questionnaire were not different from those who completed the entire questionnaire.

Effect of Program Curriculum on Burnout Components

The means and standard deviations across the five aspects of the program curriculum for each component of burnout during the year of the leadership academy were calculated (see Table 3). When examining the means for each burnout component by demographics, we noted no relationship with gender, class year, academic rank, new leadership position, or promotion. Across aspects of the program curriculum, the means for burnout components ranged from 2.9 (1.1) (Birkman on personal accomplishment) to 4.0 (0.9) (peer mentoring on energy).

With the exception of working on the leadership project, when participants rated aspects of the program’s impact, they gave the highest scores for energy, followed by engagement, and then personal accomplishment. For working on the leadership project, the biggest impact was on energy, but working on the project had a greater impact on personal accomplishment than on engagement.

Personal Attributes Associated with Burnout Prevention

Because so few participants reported being less satisfied with personal attributes since the leadership academy, we dichotomized the outcome to be more satisfied versus the same or less satisfied.

Compared to before they started the leadership academy, participants’ current level of satisfaction with the energy (n = 8), engagement (n = 5), and personal accomplishment attributes (n = 5) ranged from 22 percent more satisfied with the energy attribute of “being focused and able to concentrate” to 88 percent more satisfied with the energy attribute of “being mindful about personal strengths and weaknesses” (see Table 4).

Considering the mean in each category, the mean for personal accomplishment attributes was 60 percent more satisfied, the mean for engagement attributes was 58 percent more satisfied, and the mean for energy attributes was 53 percent more satisfied.

Examination of the mean percentage endorsed for energy attributes, engagement attributes, and personal accomplishment attributes disclosed no relationship with gender, class year, academic rank, taking on a new leadership position, or being promoted.

Ability to Engage in Wellness Practices

The mean scores for how satisfied participants were with their current ability to engage in the six wellness practices ranged from 2.9 (1.3) for current satisfaction with the ability to take time to recover after stressful situations to 3.6 (1.0) for current satisfaction with the ability to seek coaching or mentoring advice (see Table 5). The mean level of satisfaction across all wellness practice items was 3.2 (0.8).

Overall Perceptions of the Leadership Academy Experience

Across the open-ended responses, participants reported that the leadership academy had a positive impact on energy, engagement, and personal accomplishment. Participants linked each aspect of the curriculum to different components of burnout, such as in the example of the Birkman.

One participant noted the effect of the Birkman on their sense of engagement, stating, “The Birkman allowed me to engage differently, understanding how I typically respond to circumstances.” Another participant noted the effect of the Birkman on their energy, commenting, “The Birkman allowed me to learn about myself and have different insights, which I found valuable and energizing.” A third participant explained how it affected their sense of personal accomplishment, stating, “The Birkman was validating and affirming. It somehow helped me better measure myself against my own strengths/vulnerabilities rather than against others or a fantasy-version of myself.”

Similarly, the participants linked each component of burnout to different aspects of the curriculum. For example, when looking at personal accomplishment, one participant remarked, “I found the peer mentoring to be personally rewarding in the self-improvement that I achieved and also in those who I was able to help/mentor ... ”; a second stated, “I accomplished a lot with my project so this resulted in a large sense of accomplishment.”

Beyond their comments about burnout, the participants described the importance of their connection to their classmates. They described their peers as offering knowledge, advice, support, and a sense of camaraderie. Sometimes this information was presented in the form of a global comment, such as, “The important thing for me was [to be] able to connect with people, develop mutually beneficial relationships.” Others were more specific about the benefits of the class composition, such as the participant who wrote, “The opportunity to see others embrace things I already knew and to learn from each others’ projects was priceless. Learning within a multi-disciplinary class made the appreciation of similarities and differences between the interests and challenges facing all of us in our pursuit of success.”

The impact of leadership training on burnout prevention sometimes occurred beyond the year of the course. This is reflected by the person who said, “… Much of what [I] got out of the leadership course has led to an improved sense of personal accomplishment AFTER the leadership course but not necessarily during the course.” Another noted, “I think understanding the roles of leaders in the institution as well as the overall concept of leadership has helped me be more understanding when dealing with leadership challenges. Overall the academy taught me to be to be more deliberate in my career choices.” However, this same participant noted that some of the academy’s positive effects were not sustained over time due to day-to-day work stressors, stating, “The academy was helpful in energizing me, especially during the year in which I participated and did allow me to better understand the leaders I interact with on a daily basis. However, this was not sustained as it cannot counteract the daily feeling of burnout when there is not enough support to perform the job.”

Moreover, some participants reported concerns regarding the continuing systemic challenges in the work environment, which are associated with risk of burnout. For example, one participant commented, “Having energy is one thing but sustaining energy against a constantly shifting situation, walls put up with unbelievable red tape at this institution is very difficult.” And another stated, “I think that I could accomplish more if I were not so burdened (time and effort) with everyday administrative responsibilities.”

Thoughts on Leadership Training and Burnout Prevention

At the conclusion of the questionnaire, participants were asked to share additional thoughts regarding the potential role of leadership training in preventing or ameliorating burnout. Recognizing that the leadership academy is an individual-level intervention, the participants recommended including content about how to juggle multiple projects, learning to say “no,” and presenting global concepts such as “encouraging anti-burnout awareness and fostering it in others.” One participant recommended educating leaders about factors that contribute to burnout at the organizational level, noting, “It is important for leaders to be aware of systemic factors frequently contributing to burnout and potential cost of not being intentional about it.”

Summary

Consistent with the findings from a review of leadership programs,(8) the participants reported having an overall positive experience in the leadership academy and were generally satisfied with all aspects of the curriculum.

Our results suggest participants perceive leadership training as promoting positive outcomes associated with reducing the risk of burnout and enhancing wellness, even when this was not originally a stated goal of the program. It is likely that this impact could be enhanced by offering graduates continued opportunities to participate in training in order to provide maintenance of the benefits.

In this evaluation, it was difficult to determine if certain aspects of the curriculum had a more powerful impact than others or if certain components of burnout were differentially impacted. In addition, we saw no evidence that specific characteristics of participants were associated with a greater impact on burnout or wellness. This may be in part due to the study’s small sample size, given that others have found differences in burnout risk based on gender, academic rank, career stage, and job responsibilities.(19–25)

The participants also reported, on average, being only “somewhat satisfied” with their current ability to implement wellness practices. It is difficult to know if the leadership academy had an impact on wellness practices given the lack of a comparison group and pre- and post-test data for this sample; however, the participants’ comments suggest that despite gaining feelings of energy, engagement, and accomplishment from the leadership academy, they continue to struggle with the systemic issues that have led to concerns about burnout at a national level.

Limitations

Although the results of this evaluation suggest that the leadership academy had an impact on burnout prevention and wellness, there are several limitations. As noted by Dannels and colleagues,(7) it is difficult to measure the impact of leadership programs, and few have measured variables beyond participant satisfaction.(6)

This study lacks a comparison group, the questionnaire does not have normative data, and we do not know about the participants’ level of burnout prior to the program. The data were collected about one program in one institution. Additionally, the majority of the participants were chosen to participate because they already were viewed positively. We do not know the impact of the program on those who left the institution; however, all 10 left to take on increased leadership positions such as division chief, associate dean, or department chair. Another limitation is that the results were limited by recall bias and questionnaire fatigue.

Finally, the questionnaires focused on subjective data. In the future, finding new ways of assessing burnout, wellness, and leadership success that are more objective would enhance the research. Thus, future evaluations should measure burnout and wellness over time with objective measures, across institutions, and among faculty with or without additional leadership training.

Next Steps

The findings from this evaluation suggest that burnout prevention could be incorporated more intentionally in leadership training, which some training programs have begun to implement. For example, Johnson & Johnson’s Human Performance Institute has an entire curriculum devoted to training “corporate athletes.”(26–28) This program links the stamina and energy needed to be a leader to that of elite athletes, with the requisite need for energy management (including the elimination of multi-tasking), fuel, and recovery. Given our participants’ desire for help juggling projects and saying no to opportunities, the wellness skills taught by programs such as Johnson & Johnson’s could be integrated more intentionally into academic medicine leadership training.

Another way that burnout prevention could be integrated into leadership programs is by incorporating it into content that focuses on organizational strategy and strategic planning, which many such programs already offer.(29) Providing participants with an overview of the organizational causes of burnout and challenging them to incorporate reduction of burnout risk in their leadership projects could be a novel way of increasing the focus on burnout prevention.

Given the results of this evaluation, we believe that intentionally including wellness promotion and burnout prevention in leadership programs may have a positive impact on leaders, their supervisees, and the organization as a whole. Thus, we advocate for incorporating content on burnout and its causes into these programs as well as encouraging participants to implement leadership projects that take burnout into consideration at both individual and organizational levels.

Conflicts of Interest and Source of Funding: None to report

Acknowledgement

We appreciate the support of the Department of Pediatrics at Columbia University and of New York-Presbyterian Morgan Stanley Children’s Hospital.

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