Correspondence to: Carl Preiksaitis Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Rd, Suite 350, Palo Alto, CA 94304, USA Email: cpreiksaitis@stanford.edu

Received 2024 May 11; Revised 2024 July 18; Accepted 2024 July 18.

Abstract

Objective

Emergency medicine (EM) physicians face high burnout rates, even in academic settings. Research on burnout among EM residency program leaders is limited, despite their role in shaping the training environment and influencing resident well-being. This study aims to measure burnout and professional fulfillment among EM residency program leaders and identify contributing factors.

Methods

A cross-sectional survey using the adapted Stanford Professional Fulfillment Index was conducted in 2023 to assess burnout and professional fulfillment among EM residency program leaders at US programs. The survey, tailored to EM leaders, was distributed to all current EM program directors (PDs) and assistant/associate PDs (APDs) from accredited US programs. Descriptive statistics and odds ratios were used to compare burnout and professional fulfillment across various groups.

Results

A total of 112 of 281 PDs (response rate, 39.9%) and 130 of 577 APDs (response rate, 22.5%) participated. Professional fulfillment was reported by 59.8% of PDs and 58.5% of APDs. Burnout was experienced by 42.0% of PDs and 26.9% of APDs. Higher professional fulfillment correlated with alignment with expectations, positive work environments, and perceived appreciation, while burnout was strongly associated with negative impacts on personal health and relationships. Approximately 27.7% of PDs and 23.8% of APDs expressed an intention to leave their current position within 18 months.

Conclusion

A significant proportion of US EM residency program leaders experience burnout and low professional fulfillment. Addressing well-being in this population has important implications for education and mentorship provided to future physicians in the field.

Keywords: Psychological burnout; Job satisfaction; Internship and residency; Emergency medicine; Psychological well-being

INTRODUCTION

Currently, over half of the physicians in the United States are experiencing burnout, and alarmingly, this rate is on the rise [1,2]. Emergency medicine (EM) reports particularly high burnout rates, with estimates suggesting that as many as 65% of EM physicians feel burned out [2]. Even in academic settings, where faculty may have protected time from clinical duties and opportunities for specialization, 39% of EM faculty members still reported high levels of burnout in a 2019 survey, with more recent studies indicating similar or even higher figures [1,3–7]. Key factors driving burnout among these faculty include a lack of meaningful work, insufficient self-compassion, limited control over work schedules, and unsupportive academic environments [7–9].

EM residency program directors (PDs) in the United States are responsible for overseeing the education and training of residents within accredited programs. This includes curriculum development, mentorship, compliance with Accreditation Council for Graduate Medical Education (ACGME) requirements, and managing the administrative and clinical responsibilities that come with the role. The work environment for US PDs often involves high clinical workload, administrative duties, and significant regulatory compliance, which may contribute to stress and burnout, yet there is little research on the well-being of this population.

A recent study by Agarwal et al. [10] reported high rates of burnout among EM residency program leaders, with 52.9% experiencing burnout. Their study identified key factors contributing to burnout, including clinical work strain, feeling underappreciated, and electronic health record burdens, but did not differentiate between factors related to the clinical environment and those unique to a program leadership role. Studies in fields like internal medicine report burnout rates around 30% among PDs, often leading to resignation from leadership roles [11,12]. In 2023, the ACGME reported an average tenure of 6.6 years for EM PDs, shorter than the 7-year average across other specialties, with 25 programs experiencing leadership changes, which is 9% of all EM programs [13]. Although the optimal tenure for a PD remains undetermined, frequent changes can significantly threaten the stability and quality of residency programs, and burnout may be a contributing factor [14].

Turnover is not limited to PDs; it also affects associate/assistant program directors (APDs), potentially destabilizing the training environment further and increasing stress for the remaining faculty. However, the rates of burnout and turnover among these EM leadership roles have yet to be thoroughly explored. Understanding these issues across all levels of leadership is critical for developing interventions aimed at improving well-being, which is crucial not only for the faculty but also for the potential impact on the EM trainees’ own well-being [15]. Additionally, while much focus has been on burnout rates, there is also an urgent need to measure professional fulfillment in medicine. The factors that contribute to professional fulfillment and how these interact with burnout are not well understood.

We aimed to explore both the rate of burnout and the level of professional fulfillment among EM residency program leaders, as well as the factors contributing to these outcomes.

METHODS

Ethics statement

This study was granted an exemption from review by the Stanford Institutional Review Board. All participants provided informed consent.

Study design and participants

We conducted a cross-sectional survey to evaluate burnout, professional fulfillment, and their contributing factors among EM residency program leaders.

Survey development

In order to measure both burnout and professional fulfillment, we used the Stanford Professional Fulfillment Index (SPFI) [16]. Unlike traditional tools like the Maslach Burnout Inventory, which incurs costs and focuses only on burnout, the SPFI is freely available and assesses both burnout and professional fulfillment [17,18].

Following best practices in survey design [19,20], we adapted the SPFI tailored by Lu et al. [3] for general EM faculty to fit EM residency program leaders. Our adaptation included 16 items from the original SPFI focused on burnout and professional fulfillment tailored to the APD/PD role (e.g., “I feel happy at work” became “I feel happy while working as APD/PD”). We additionally modified the questions focused on interpersonal relationships with patients to be focused on relationships with trainees (e.g., “less empathetic with patients” became “less empathetic with trainees”). The scoring system remained consistent with the original SPFI, where higher scores on the burnout subscale indicate higher burnout and higher scores on the professional fulfillment subscale indicate greater professional fulfillment. We structured all questions on a 5-point Likert scale. Based on previous studies, we scaled professional fulfillment and burnout scores to a maximum of 10 and defined scores above 7.5 as indicative of professional fulfillment and those above 3.325 as indicative of burnout [21].

Building on the work of Lu et al. [3], our study team, which consisted of experts in residency program leadership and physician well-being, developed additional indices to measure factors potentially linked to burnout or professional fulfillment. These included four questions focused on the work environment, one question about ACGME accreditation responsibilities, one question about resident burnout, seven questions about the impact on health and personal relationships, four questions about perceived appreciation, and three questions about alignment between initial expectations and actual experiences. New indices were measured on a 5-point Likert scale and scaled to a maximum score of 10. We applied reverse scoring to some indices for consistent interpretation (lower scores indicating negative sentiment).

After initial testing within the study team, we conducted a pilot test with four former program leaders using “think aloud” methods to validate response processes, which led us to refine the wording and format (Supplementary Material 1).

Study setting and population

We targeted all current EM residency program leaders (PDs and APDs) from ACGME-accredited programs in the United States that participated in the 2023 Match or were military programs.

Survey distribution

From September to November 2023, we distributed the survey using Qualtrics Survey Tools (Qualtrics). We gathered contact information from residency program websites, faculty directories, and residency coordinators. We tagged surveys with details such as program duration, hospital affiliation, and geographic region using designations from a prior study to analyze these factors without identifying respondents [22]. We also used a follow-up questionnaire to gather more contacts. Employing a modified Dillman method, we sent weekly recruitment emails for 3 weeks [23]. We did not offer any compensation for participation.

Statistical analysis

We only included fully completed surveys in our analysis. We calculated the number of eligible PDs from those programs that participated in the 2023 Match, including military programs. To identify the number of APDs, we used program websites and direct contacts with program coordinators, or we resorted to the minimum required number per program size as specified by the ACGME when direct confirmation was unavailable [14].

To ensure the representativeness of our survey responses, we conducted a wave analysis, which hypothesizes that individuals who responded late to the survey may be similar in characteristics to those that did not respond [24]. This analysis involved comparing the burnout and professional fulfillment scores of individuals who responded later than one standard deviation from the average response time against the rest of the population using t-tests (Supplementary Table 1). To check for sample representativeness, we used the chi-square test to compare characteristics of programs from which we received responses to those of the entire sample population.

We used descriptive statistics, chi-square test, Fisher exact test, Cramér V, and linear regression to analyze the data. For age data, we used the Mann-Whitney U-test for comparisons and rank-biserial correlation to measure effect size. We checked internal consistency with Cronbach α and measured associations with t-tests, Cohen d effect sizes, and logistic regression models, including demographic controls. Intentions to step down from role were similarly analyzed. All analyses were conducted using R ver. 4.3.3 (R Foundation for Statistical Computing).

RESULTS

Characteristics of the study population

Of the 281 eligible EM residency PDs, 112 responded to the survey (response rate, 39.9%). Among the 577 identified APDs, 130 participated (response rate, 22.5%). We excluded 33 incomplete surveys from the analysis, and the remaining surveys were fully completed. Our wave analysis indicated no significant differences in the levels of burnout and professional fulfillment between late respondents and the rest of the group, suggesting that nonresponders likely mirrored our respondents. Our sample closely resembled the total population in terms of program location, hospital affiliation, and training duration, providing evidence for its representativeness.

Most PDs were men (64.3%) and White (81.3%), whereas APDs had a more balanced gender distribution with slightly more women (50.8%) and a majority identifying as White (75.4%) (Table 1). PDs generally were older and had held their positions longer than APDs. Most respondents from both groups were from 3-year, university-affiliated programs.

Table 1.

Participant characteristics

Main outcomes

PDs reported an average professional fulfillment score of 7.49±1.85 of 10, with 67 of 112 (59.8%) feeling professionally fulfilled (Table 2). APDs scored similarly on professional fulfillment, averaging 7.24±1.97 of 10, with 76 of 130 (58.5%) reporting fulfillment (Table 3). However, burnout scores differed: PDs averaged 3.19±1.66 of 10 with 47 of 112 (42.0%) experiencing burnout, while APDs scored lower at 2.61±1.88 of 10, with only 35 of 130 (26.9%) experiencing burnout (P=0.01).

Table 2.

Characteristics of program directors stratified by professional fulfillment and burnout (n=112)

Table 3.

Characteristics of assistant/associate program directors stratified by professional fulfillment and burnout (n=130)

Burnout and professional fulfillment rates were consistent across demographic groups. However, among PDs, women were significantly more likely to experience burnout compared to their male counterparts (60.0% vs. 31.9%, P<0.01). This gender disparity in burnout did not appear among APDs. We observed no significant differences in professional fulfillment or burnout related to program duration, region, or hospital affiliation, and no correlation between years in a position and either burnout or professional fulfillment.

Additional factors

Our adapted indices showed strong internal consistency, with Cronbach α values ranging from 0.74 to 0.86. Factors contributing to higher professional fulfillment included alignment with expectations, positive work environments, and perceived appreciation (Table 4). Conversely, negative impacts on personal health and relationships, misalignment with expectations, and lack of support were strongly associated with burnout. Those reporting professional fulfillment and lower burnout scored higher across all additional indices that were examined (Table 4). However, significant differences emerged between PDs and APDs. PDs reported significantly lower scores than APDs in the impact of work on health and personal relationships (6.63 vs. 7.59, P<0.01), indicating a greater toll on well-being. ACGME accreditation responsibilities (4.71 vs. 6.88, P<0.01) were more impactful for PDs than APDs, as was the degree to which resident burnout impacted well-being (4.66 vs. 5.65, P=0.02).

Table 4.

Additional factors associated with professional fulfillment and burnout

After adjusting for gender, race, and age, higher scores in alignment with expectations, work environment support, and the impact of work on health significantly correlated with professional fulfillment for both PDs and APDs (Fig. 1). Conversely, lower scores in these areas were most associated with burnout.

Fig. 1.

Odds ratios (95% confidence interval) for additional factors associated with professional fulfillment and burnout, from a survey of emergency medicine residency program leadership. ACGME, Accreditation Council for Graduate Medical Education; PD, program director; APD, assistant/associate program director.

Intention to leave position

Approximately 27.7% of PDs and 23.8% of APDs planned to leave their current position within the next 18 months (Table 1). Compared to those planning to stay, those intending to leave reported significantly lower professional fulfillment (PD: 70.4% vs. 32.3%, P<0.01; APD: 65.7% vs. 35.5%, P<0.01) and higher burnout rates (PD: 34.6% vs. 61.3%, P<0.01; APD: 18.2% vs. 54.8%, P<0.01) (Tables 2, 3). There were no significant differences based on gender, race, or age. For APDs alone, those who intended to leave were in their current role for a significantly longer period than those who did not intend to leave (7.06 years vs. 4.10 years, P<0.01).

DISCUSSION

Our study emphasizes the importance of understanding the factors that affect the well-being of EM residency program leaders. These leaders bear unique responsibilities, making their well-being vital not only for themselves but also for their significant influence on the next generation of EM physicians.

We found that 59.8% of PDs and 58.5% of APDs reported professional fulfillment and that 42.0% of PDs and 26.9% of APDs experienced burnout. These figures show a notable contrast to the 2022 data on all academic EM physicians, where 38.7% reported professional fulfillment and 39.1% experienced burnout [3]. In our study, both PDs and APDs reported higher levels of professional fulfillment. However, the rates of burnout varied: PDs were more affected than the general academic EM population, while APDs were less affected.

The significant levels of professional fulfillment observed among both PDs and APDs are noteworthy. A 2002 study also reported high satisfaction among residency program leaders, although it did not examine burnout [25]. Mentoring trainees and witnessing their development likely contribute to a strong sense of purpose, which can enhance fulfillment. Despite this, burnout may still occur alongside these positive experiences [12]. Notably, PDs face a higher risk of burnout compared to APDs, likely due to the increased stress and responsibilities associated with their leadership role.

Our data indicated that duration in position did not correlate significantly with either burnout or professional fulfillment, suggesting that the effects are more likely influenced by individual experiences and specific job characteristics than by time. Both burnout and a lack of professional fulfillment were strong predictors for leaders considering leaving their positions, underlining that dissatisfaction may drive such decisions.

We also found notable differences between PDs and APDs in terms of burnout, particularly among female PDs who reported significantly higher rates of burnout than their male counterparts. This finding aligns with previous studies that highlighted higher burnout rates among female emergency physicians and pointed to potential gender disparities in academic promotion and retention within the EM workforce [26–30]. Despite these disparities, we observed no significant gender differences in intention to leave their positions, suggesting other factors at play.

The study identified key factors associated with burnout, including the negative impact of work on personal health and relationships, misalignment with initial job expectations, and lack of perceived appreciation. These factors significantly predicted burnout and influenced professional fulfillment but in the opposite direction. The strongest predictor of burnout was the adverse impact of work on personal health and relationships, reinforcing the importance of personal resilience and boundary-setting [31,32].

Moreover, alignment with initial job expectations played a crucial role in both professional fulfillment and burnout, suggesting that clear job descriptions and career trajectory alignment are essential. Similarly, perceived appreciation and a supportive work environment significantly impacted both burnout and professional fulfillment. These findings underscore the need for supportive leadership and a wellness-centric culture in the workplace [33–36]. However, adequate support could refer to personnel, time, resources, or other elements, so examining what factors are more important for program leaders requires further investigation.

Our findings contrast with those from Agarwal et al. [10], who reported a higher burnout rate (52.9%) and a lower rate of professional fulfillment (23.0%) among a group recruited through an educational leadership listserv. The study specifically included elements of burnout related to clinical care, which we deliberately excluded from our analysis. Additionally, their study used a smaller sample and relied on a listserv for distribution, which limited their ability to describe their sampling frame and did not allow for analysis of nonresponse bias. These methodological distinctions likely contribute to the differences in our results. However, our research concurs with the importance of factors such as the work environment, appreciation, and impact on health and personal relationships in influencing burnout.

Our findings resonate with studies across various specialties, revealing that burnout is not unique to EM PDs. Similar burnout rates ranging from 20% to 44% have been reported among PDs in internal medicine, anesthesia, family medicine, and psychiatry [37–40]. While these studies used different burnout assessment tools, they consistently highlight common contributing factors, including heavy administrative burdens, inadequate support and appreciation, and detrimental impacts on personal health and well-being. Furthermore, our finding that burnout is a strong predictor of intention to leave a leadership position is mirrored in studies of psychiatry, anesthesiology, and internal medicine PDs [37–39]. This underscores that addressing burnout is critical for retaining experienced leaders across medical specialties.

High burnout and low professional fulfillment are major concerns, especially among EM physicians. Our study highlights that EM residency PDs experience higher burnout levels compared to their junior leadership team members. Key factors like alignment with expectations, supportive work environments, and perceived appreciation strongly influence professional fulfillment. Conversely, burnout is associated with negative health impacts, strained personal relationships, and a greater likelihood of leaving a position within 18 months. These findings emphasize the urgent need for targeted strategies to improve well-being and job satisfaction among EM residency PDs, which is crucial for both their health and the effectiveness of their mentorship for future physicians.

This study has several limitations. Recruiting residency program leadership was challenging; our method of extracting information from websites and contacting coordinators may not have fully engaged all potential participants. We dichotomized burnout and professional fulfillment scores for comparison with previous studies, which might oversimplify these complex constructs. Our low response rate may introduce potential bias in our study results. While our wave analysis suggests that nonresponders are likely similar to respondents, the limited response rate still poses a risk of nonresponse bias, affecting the generalizability of our findings. The asynchronous nature of the study limited our ability to conduct real-time interviews, potentially affecting the depth of subjective insights. Additionally, we did not consider the impact of vacations, leaves, or sabbaticals on burnout recovery [41]. Lastly, conducting the survey during the residency interview season may have affected both participation and responses due to the increased workload on program leadership at that time.

Although many EM residency program leaders report professional fulfillment, burnout is a significant issue, particularly for program directors, suggesting that unique aspects of leadership roles may either exacerbate or mitigate burnout. These insights highlight the critical need for strategies specifically designed to support EM residency program leaders’ well-being. Improving the well-being of these leaders is crucial, as they directly impact the quality of education and mentorship for the next generation of physicians in EM.

Notes

Author contributions

Conceptualization: CP, AA, TMC, MG, AGL, AL; Data curation: CP, AL, KNW; Formal analysis: CP; Investigation: CP, AL, KNW; Writing–original draft: CP, AL; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

Michael Gottlieb is an editorial board member of this journal, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. The authors have no other conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Acknowledgments

The authors wish to thank Michael A. Gisondi (Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, CA, USA) for his guidance and assistance with designing this study.

Data availability

Data analyzed in this study are available from the corresponding author upon reasonable request.

Supplementary materials

Supplementary Material 1.

Survey instrument.

ceem-24-255-supplementary-Material-1.pdf

Supplementary Table 1.

Wave analysis results

ceem-24-255-supplementary-Table-1.pdf

Supplementary materials are available from https://doi.org/10.15441/ceem.24.255.

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Notes

Capsule Summary

What is already known

Burnout is prevalent among emergency medicine physicians, with existing research overlooking the specific challenges faced by individuals in roles with distinct responsibilities, such as residency program leaders.

What is new in the current study

This study highlights that most emergency medicine residency program leaders experience professional fulfillment, yet a significant number also report burnout, particularly program directors. It emphasizes the need for targeted interventions to support the well-being of these pivotal educational figures.

Characteristic	Program director (n=112)	Assistant/associate program director (n=130)
Age (yr)	45 (41–52)	38 (36–43)
Gender
Women	40 (35.7)	66 (50.8)
Men	72 (64.3)	64 (49.2)
Nonbinary/third gender	0 (0)	0 (0)
Race/ethnicity
Asian	5 (4.5)	9 (6.9)
Black/African American	0 (0)	6 (4.6)
Hispanic/Latino	4 (3.6)	5 (3.8)
Middle Eastern/North African	1 (0.9)	2 (1.5)
White	91 (81.3)	98 (75.4)
Multiple races	7 (6.3)	7 (5.4)
Not disclosed	4 (3.6)	3 (2.3)
Years in current position
<1	10 (8.9)	22 (16.9)
1–4	41 (36.6)	48 (36.9)
5–9	39 (34.8)	40 (30.8)
10–14	11 (9.8)	14 (10.8)
>15	11 (9.8)	6 (4.6)
Intention to leave position
Yes	31 (27.7)	31 (23.8)
No	81 (72.3)	99 (76.2)
Duration of program (yr)
3	79 (70.5)	97 (74.6)
4	33 (29.5)	33 (25.4)
Hospital type
Community	34 (30.4)	44 (33.8)
County	17 (15.2)	20 (15.4)
Military	1 (0.9)	1 (0.8)
University	60 (53.6)	65 (50.0)
Region
East North Central	20 (17.9)	22 (16.9)
East South Central	4 (3.6)	7 (5.4)
Mid Atlantic	17 (15.2)	31 (23.8)
Mountain	6 (5.4)	3 (2.3)
New England	11 (9.8)	10 (7.7)
Pacific	14 (12.5)	13 (10.0)
South Atlantic	28 (25.0)	19 (14.6)
Territory	1 (0.9)	1 (0.8)
West North Central	5 (4.5)	12 (9.2)
West South Central	6 (5.4)	12 (9.2)

Characteristic	Professional fulfillment				Burnout
Characteristic	With^a) (n=67, 59.8%)	Without (n=45, 40.2%)	P-value	Effect size	With^a) (n=47, 42.0%)	Without (n=65, 58.0%)	P-value	Effect size
Age (yr)	46 (41–52)	45 (41–50)	0.32^b)	0.06^b)	44 (41–49)	46 (41–52)	0.23^b)	–0.07^b)
Gender			0.84^c)	0.04^c)			<0.01^c)	0.27^c)
Women (n=40)	23 (57.5)	17 (42.5)			24 (60.0)	16 (40.0)
Men (n=72)	44 (61.1)	28 (38.9)			23 (31.9)	49 (68.1)
Race/ethnicity			0.99^c)	0.11^c)			0.33^c)	0.23^c)
Asian (n=5)	3 (60.0)	2 (40.0)			2 (40.0)	3 (60.0)
Black/African American (n=0)	0 (0)	0 (0)			0 (0)	0 (0)
Hispanic/Latino (n=4)	3 (75.0)	1 (25.0)			1 (25.0)	3 (75.0)
Middle Eastern/North African (n=1)	1 (100)	0 (0)			0 (0)	1 (100)
White (n=91)	54 (59.3)	37 (40.7)			36 (39.6)	55 (60.4)
Multiple races (n=7)	4 (57.1)	3 (42.9)			5 (71.4)	2 (28.6)
Not disclosed (n=4)	2 (50.0)	2 (50.0)			3 (75.0)	1 (25.0)
Years in current position			0.30^c)	0.22^c)			<0.01^c)	0.34^c)
<1 (n=10)	7 (70.0)	3 (30.0)			1 (10.0)	9 (90.0)
1–4 (n=41)	26 (63.4)	15 (36.6)			19 (46.3)	22 (53.7)
5–9 (n=39)	18 (46.2)	21 (53.8)			22 (56.4)	17 (43.6)
10–14 (n=11)	8 (72.7)	3 (27.3)			1 (9.1)	10 (90.9)
>15 (n=11)	8 (72.7)	3 (27.3)			4 (36.4)	7 (63.6)
Intention to leave position			<0.01^c)	0.35^c)			0.02^c)	0.24^c)
Yes (n=31)	10 (32.3)	21 (67.7)			19 (61.3)	12 (38.7)
No (n=81)	57 (70.4)	24 (29.6)			28 (34.6)	53 (65.4)
Burnout score	2.46±1.39	4.27±0.03	<0.01^b)	–0.62^b)	4.77±0.99	2.05±0.02	<0.01^b)	1.00^b)
Professional fulfillment score	8.71±0.96	5.67±0.04	<0.01^b)	1.00^b)	6.38±1.68	8.29±0.07	<0.01^b)	–0.59^b)

Characteristic	Professional fulfillment				Burnout
Characteristic	With^a) (n=76, 58.5%)	Without (n=54, 41.5%)	P-value	Effect size	With^a) (n=35, 26.9%)	Without (n=95, 73.1%)	P-value	Effect size
Age (yr)	39 (36–43)	38 (35–42)	0.22^b)	0.05^b)	37 (36–42)	39 (36–43)	0.34^b)	–0.02^b)
Gender			0.86^c)	0.02^c)			>0.99^c)	0.01^c)
Women (n=66)	38 (57.6)	28 (42.4)			18 (27.3)	48 (72.7)
Men (n=64)	38 (59.4)	26 (40.6)			17 (26.6)	47 (73.4)
Race/ethnicity			0.86^c)	0.02^c)			0.49^c)	0.19^c)
Asian (n=9)	7 (77.8)	2 (22.2)			1 (11.1)	8 (88.9)
Black/African American (n=6)	3 (50.0)	3 (50.0)			1 (16.7)	5 (83.3)
Hispanic/Latino (n=5)	2 (40.0)	3 (60.0)			3 (60.0)	2 (40.0)
Middle Eastern/North African (n=2)	1 (50.0)	1 (50.0)			1 (50.0)	1 (50.0)
White (n=98)	58 (59.2)	40 (40.8)			26 (26.5)	72 (73.5)
Multiple races (n=7)	3 (42.9)	4 (57.1)			2 (28.6)	5 (71.4)
Not disclosed (n=3)	2 (66.7)	1 (33.3)			1 (33.3)	2 (66.7)
Years in current position			0.78^c)	0.16^c)			0.78^c)	0.12^c)
<1 (n=22)	16 (72.7)	6 (27.3)			4 (18.2)	18 (81.8)
1–4 (n=48)	23 (47.9)	25 (52.1)			13 (27.1)	35 (72.9)
5–9 (n=40)	25 (62.5)	15 (37.5)			13 (32.5)	27 (67.5)
10–14 (n=14)	10 (71.4)	4 (28.6)			3 (21.4)	11 (78.6)
>15 (n=6)	2 (33.3)	4 (66.7)			2 (33.3)	4 (66.7)
Intention to leave position			<0.01^c)	0.26^c)			<0.01^c)	0.35^c)
Yes (n=31)	11 (35.5)	20 (64.5)			17 (54.8)	14 (45.2)
No (n=99)	65 (65.7)	34 (34.3)			18 (18.2)	81 (81.8)
Burnout score	1.71±1.15	3.86±1.99	<0.01^b)	–0.65^b)	5.09±1.50	1.69±0.95	<0.01^b)	1.00^b)
Professional fulfillment score	8.54±0.93	5.41±1.54	<0.01^b)	1.00^b)	5.25±1.86	7.97±1.43	<0.01^b)	–0.76^b)

Factor	Professional fulfillment				Burnout
Factor	With^a)	Without	P-value^b)	Effect size^c)	With^a)	Without	P-value^b)	Effect size^c)
Program director (n=112)
Positive work environment	6.25±1.94	4.38±1.90	<0.01	0.97	4.68±1.85	6.09±2.13	<0.01	–0.70
Impact on health and personal relationships	7.15±1.78	5.87±1.69	<0.01	0.74	5.66±1.60	7.34±1.69	<0.01	–1.01
Perceived appreciation	6.67±1.87	5.18±1.77	<0.01	0.81	5.23±1.90	6.68±1.78	<0.01	–0.79
Alignment with expectations	6.67±1.75	4.74±1.33	<0.01	1.21	5.05±1.53	6.50±1.83	<0.01	–0.85
ACGME accreditation responsibilities	5.11±2.97	4.11±2.73	0.09	0.35	4.04±2.93	5.19±2.81	0.05	–0.40
Resident burnout	5.19±2.80	3.89±2.53	0.02	0.48	3.56±2.64	5.46±2.57	<0.01	–0.73
Assistant/associate program director (n=130)
Positive work environment	6.46±1.80	4.62±2.03	<0.01	0.97	4.23±2.09	6.24±1.84	<0.01	–1.05
Impact on health and personal relationships	8.33±1.55	6.57±2.08	<0.01	0.98	5.50±2.09	8.37±1.25	<0.01	–1.89
Perceived appreciation	6.80±1.86	4.85±1.77	<0.01	1.07	4.54±1.97	6.53±1.82	<0.01	–1.07
Alignment with expectations	6.75±1.83	4.52±1.76	<0.01	1.24	4.17±2.17	6.44±1.73	<0.01	–1.22
ACGME accreditation responsibilities	7.76±1.90	5.65±2.80	<0.01	0.91	5.43±3.06	7.42±2.08	<0.01	–0.84
Resident burnout	5.99±2.52	5.19±2.65	0.07	0.31	4.64±2.51	6.03±2.54	0.01	–0.55