Role of a Pediatric Department Chair: Factors Leading to Satisfactionand Burnout

EATHER

A. M

HILLIPS

, MD, MPH, B

ONITA

TANTON

, MD, B

ARRY

UCKERMAN

, MD,

AND

F. B

RUDER

TAPLETON

, MD

Objective

To determine factors associated with satisfaction and burnout in pediatric department chairs.

Study design

A 1-time online survey of 250 current and former pediatric chairs who were members of Association of Medical School Pediatric Department Chairs anytime between 1993 and 2005. The questionnaire included demographics,satisfaction levels, stress experienced, and time spent on various work activities. We also included the Maslach Burnout Inventory—Human Services Survey and the abbreviated Workplace Climate Questionnaire. Burnout was deﬁned as highscores on the depersonalization or emotional exhaustion subscales of the Maslach Burnout Inventory—Human ServicesSurvey.

Results

Our response rate was 62%; most chairs (65%) reported being very satisﬁed with their job. Approximately 30% of chairsfor

5yearsexperiencedburnout,comparedwith15%ofchairswhoheldtheirpositionsfor

5years(

.05).Factorsassociated with burnout included years as chair (odds ratio [OR], 0.9; 95% CI, 0.80-0.99),

1 night worked per week (OR,5.9; 95% CI, 1.5-22.9), high workload (OR, 3.0; 95% CI, 1.3-6.7), and lack of supportive work environment (OR, 2.2; 95%CI, 1.1-4.2).

Conclusion

Steps should be taken to decrease burnout in chairs, including policies that promote physician well being asintegral to successful departments.

(J Pediatr 2007;151:425-30)

he role of academic pediatric department chair has slowly evolved from a largely teaching, scholarly leadership role tomore of an executive management position.

This evolution has been inﬂuenced by the growth in faculty numbers, thecomplexity of providing specialty pediatric clinical services in highly competitive markets,the challenging NationalInstitutes of Health funding environment, and the added administrative responsibilities for chairs.

Recently , Stapleton et alreported that an average of 17% of North American academic pediatric chairs leave their position each year.

They also noteda paucity of women chairs and a shorter tenure for women chairs than for their male counterparts. Turnover in departmentalleaders can create signiﬁcant instability, and replacement requires signiﬁcant faculty time and institutional resources. Althoughthis turnover rate is similar to other senior academic leadership positions, factors contributing to pediatric chair satisfaction and job burnout have not been studied.Burnout is a psychological syndrome characterized by chronic interpersonal stressorsat work. The 3 dimensions of burnout are emotional exhaustion, feelings of cynicism anddetachment (depersonalization), and a sense of ineffectiveness and lack of accomplish-ment.

Unlike depression, burnout only describes a person’s relationship to his or her work.

Burnout in physicians has been related to suboptimal patient care, poor health,sleep disturbances,and impaired job performance and may increase the risk of substanceabuse problems.

4-7

Most academic pediatric chairs in North America are members of the Associationof Medical School Pediatric Department Chairs (AMSPDC). We conducted an anony-mous web-based survey of members of AMSPDC to determine the prevalence of burnoutand how burnout related to the roles and responsibilities of chairs and to chair turnover.On the basis of earlier research in this ﬁeld, we hypothesized that burnout may beassociated with high workload, lack of mentorship, time spent in less rewarding tasks

aWCQ Abbreviated version of the WorkplaceClimate QuestionnaireaAWQ Abbreviated version of the Approaches to Work QuestionnaireAMSPDC Association of Medical School PediatricDepartment ChairsDP DepersonalizationEE Emotional exhaustionMBI-HSS Maslach Burnout Inventory—Human ServicesSurvey OR Odds ratioPA Personal accomplishmentFrom the Department of Pediatrics, Uni-versity of Washington School of Medicine,Seattle, WA (H.M., F.B.S.); Department of Pediatrics, Wayne State University Schoolof Medicine, Detroit, MI (B.S.); Departmentof Pediatrics, Boston University School of Medicine (B.Z.), Boston, MA.Submitted for publication Aug 17, 2006;last revision received Jan 9, 2007; acceptedMar 12, 2007.Reprint requests: Heather A. McPhillips, De-partment of Pediatrics, Children’s Hospitaland Regional Medical Center, 4800 SandPoint Way NE G0061, Seattle, WA 98105.E-mail: heather.mcphillips@seattlechildrens.org.0022-3476/$ - see front matter Copyright © 2007 Mosby Inc. All rightsreserved.10.1016/j.jpeds.2007.03.016

425

(administrative workload), and personal work styles.

Fur-thermore, burnout may lead to turnover in department chairs.Our survey results have identiﬁed a number of features of thecurrent work practices of pediatric chairs that are highly associated with stress and burnout. Understanding thesestressors might allow for greater focus on training or repri-oritization in an effort to prolong the satisfaction and tenureof chairs.

METHODS

We conducted a cross-sectional survey of current andformer pediatric department chairs to determine factors asso-ciated with job satisfaction and burnout. We obtained namesand e-mail addresses of former and current pediatric depart-ment chairs who were members of AMSPDC anytime be-tween 1993 and 2005. An e-mail was sent to all 250 addressesrequesting participation in an anonymous web-based survey to determine factors associated with high turnover in pediatricdepartment chairs. The link to the survey and instructions toaccess the survey were included in the e-mail. Reminders weree-mailed twice to the entire cohort after the initial contactrequesting their participation. Participants were assured of theanonymity of their responses.

Survey Instrument

The web-based questionnaire contained 3 sections and35 major questions, 9 of which asked for multiple responses.Former chairs were instructed to answer the questions as they pertained to their time as chair. The first section asked de-mographic information, including age at appointment aschair, marital status during appointment, sex, and positionbefore becoming chair. The second section contained ques-tions pertaining to job characteristics and job satisfaction. These questions included multiple choice questions on num-ber of vice-chairs, association with a free-standing children’shospital, work hours including nights per week worked and vacation time, size of department, and time spent on variousadministrative, teaching, and clinical duties during a typicalmonth as chair. Overall satisfaction with aspects of beingchair and stress experienced with aspects of being chair wereassessed by using a 5-point rating system (not at all satisfiedto very satisfied and not at all stressful to very stressful). Thefinal section included 3 validated instruments: the MaslachBurnout Inventory—Human Services Survey (MBI-HSS),

an abbreviated version of the Approaches to Work Question-naire (aAWQ), and an abbreviated version of the WorkplaceClimate Questionnaire (aWCQ).

All these instrumentshave been previously validated in surveys of physicians in a variety of specialties.

Survey Measures

The primary outcome of interest was physician burnouton the MBI-HSS. The MBI-HSS contains 3 subscales: emo-tional exhaustion, depersonalization, and personal accom-plishment. The emotional exhaustion (EE) subscale measuresself-reported feelings of being emotionally overextended andexhausted by work. The depersonalization (DP) subscalemeasures unfeeling and impersonal responses toward peoplethe respondent is providing service for including clinical care,teaching, and mentoring. The personal accomplishment (PA)assesses feelings of competence and achievement in working with people. The MBI-HSS contains 22 items scored on aLikert-type scale of 0 to 6. Responses are then summed foreach subscale to reach a total score for EE, DP, and PA. Totalscores in each subscale can then be categorized as low, aver-age, or high on thebasis of normative data from the MBI-HSS for medicine.

Maslach deﬁnes burnout as scores in thehigh range in both EE and DP and scores in the low range inPA. Earlier studies in physicians have found that burnoutmay exist in the setting of average to high scores in PA.

6,11,12

Onthe basis of other studies of physician burnout, we deﬁnedburnout as scoring in the high range on either the EE subscaleor the DP subscale.

6,13

We hypothesized that both workload and work style would be associated with burnout in physicians. To measure work style, we used the aAWQ, which has been described indetail elsewhere.

The questionnaire consists of 13 questionsdivided in 3 scales measuring different approaches to work:deep, surface-rational, and surface-disorganized. The deepscale assesses intrinsic motivation and inclination to engage inmeaningful learning. The surface-rational scale assesses pref-erence for memory and detailed, highly-structured work. Thesurface-disorganized scale contains questions related to beingdisorganized, impulsive, or using ineffective work habits. Tomeasure workload, we used the 9-item aWCQ. Similar to theaAWQ, the aWCQ is divided into 3 subscales: workload,choice-independence, and supportive-receptive. The work-load scale assessed perceptions of heavy workload by depart-ment chairs. The choice-independence scale assessed the de-gree to which the chair felt he or she controlled what work todo and how to do it. The supportive-receptive scale as-sessed whether the chair’s colleagues were supportive andhelpful and whether he or she felt that his/her interests andideas were taken seriously. In both questionnaires, respon-dents were asked to assess their level of agreement witheach statement on a 4-point Likert scale. Responses werethen summed for each of the 3 subscales to give a totalscore. To test the association with burnout, we dividedeach of the subscales’ total scores in tertiles for both theaAWQ and the aWCQ.

Statistical Analysis

All statistical analyses were performed with Stata soft- ware version 8. The primary hypothesis tested was that chairs with



5 years experience are more likely to experience jobburnout. Assuming a rate of burnout in experienced chairs of 10%, we had 0.80 power to detect a 2-fold increase in burnoutin less-experienced chairs. Descriptive statistics were used tocharacterize the overall sample. We used

tests to compareparametric means and



tests to determine associations incategorical variables. The Fisher exact test was used to com-

426 McPhillips et al The Journal of Pediatrics • October 2007

pare categorical variables when a given cell size was



5.Pearson correlation coefﬁcients were used to determine cor-relations between total scores on subscales of the MBI-HSSquestionnaire and on the aWCQ and aAWQ. Logistic re-gression was used to determine factors independently associ-ated with physician burnout when bivariate analysis showedan association with a

value



.10.

Human Subjects

The study was granted exempt status by the Children’sHospital and Regional Medical Center (Seattle) InstitutionalReview Board.

RESULTS

From the 250 e-mail addresses available from theAMSPDC membership ﬁle, 238 electronic questionnaires were successfully sent to recipients. There were 148 respon-dents to the survey, for a response rate of 62%.

Demographics and Job Characteristics

The mean age at appointment to chair was 50 years(SD, 5.1 years). Most current chairs were men (88%), spe-cialty trained (97%), and served as either division chief (46%)or vice chair (35%) before becoming chair. Forty-one percent of department chairs reported being associated with a free-standingchildren’s hospital. There were no significant differences be-tween current chairs and former chairs, with the exception of specialty training before becoming chair ( Table I). Chairs reported an overall high level of satisfaction withtheir job; of the 144 respondents to the career satisfactionquestions, 65% responded that they were very satisfied withbeing chair, and 30% stated that they were somewhat satisfied with being chair overall. More than 60% of chairs respondedthat they were very satisfied with their roles teaching, men-toring students, and mentoring faculty. The highest degreesof dissatisfaction were reported in the categories of fundrais-ing (33% minimally satisfied), academic writing (31% mini-mally satisfied), and balancing work and family (20% mini-mally satisfied).Chairs responded that they spend most of their time ina typical month on administration, with 61% of respondentsstating they spend



40% of their time in this area. Mostchairs reported spending



10% of time in a typical month onroles in which they reported the highest degree of satisfaction:mentoring students (93%), mentoring faculty (82%), andteaching (59%).

Factors Associated with Burnout

Overall, both former and current pediatric departmentchairs experienced low levels of burnout in their role as chair. There was no signiﬁcant difference between former and cur-rent department chairs in percent burnout or factors associ-ated with burnout. There was also no difference observed inpercent burnout between men and women chairs (20% mencompared with 21% women were experiencing burnout). Atotal of 137 respondents completed all questions on the MBI-HSS. Of those respondents, 17% scored high on the EEsubscale, 13% scored high on the DP subscale, and 32%scored low on the PA subscale. Fifteen of 137 respondents(11%) scored high on both EE and DP, and all 15 of thoserespondents scored average (N



11) or low (N



4) on PA.Overall, 27 respondents (20%) met criteria for burnout—15respondents scored high on both EE and DP, 9 scored highon EE alone, and 3 scored high on DP alone.Several factors were signiﬁcantly associated with burn-out in our analysis ( Table II). Respondents who had been chair for



5 years had a signiﬁcantly higher percentage of burnout compared with respondents who had been chair for



5 years (29% versus 15%,



.05). When compared withchairs in their positions for



5 years, less experienced chairs were more likely to report working longer hours overall—80% worked



70 hours compared with 56% of more experiencedchairs (



.05). Work hours were significantly associated with burnout. Chairs who reported longer hours in the office,more hours worked away from home or office,



1 evening per week spent at work-related events, and less vacation per year were more likely to experience burnout than chairs whoreported working fewer hours in these categories and taking

Table I. Demographics of current and formerpediatric department chairs

Currentchair(N



92)Formerchair(N



51)Total(N



144)N (%) N (%) N (%)

Mean age inyears atappointmentas chair (SD)49.8 (5.1) 49.8 (6.0) 49.8 (5.4)Median numberof years aschair7 (0.5 to 28) 10 (2 to 26) 7.5 (0.5 to 28)Male sex 81 (88.0) 47 (92.2) 128 (89.5)Specialty training* 89 (96.7) 44 (86.3) 133 (93.0)Prior positionFaculty 9 (9.8) 5 (9.8) 14 (9.8)Division chief 42 (45.7) 25 (49.0) 67 (46.9)Vice chair orchair32 (34.8) 15 (29.4) 47 (32.9)Dean 2 (2.2) 3 (5.9) 5 (3.5)Other 7 (7.6) 3 (5.0) 10 (7.0)Full-time faculty

