Challenging work is part and parcel of residency training. But when unnecessary obstacles make a resident’s job more difficult, removing those hindrances will do more to prevent or mitigate burnout than any yoga class or golf outing ever could.
“We support individual, social and other well-being initiatives in many ways, but that's not what we're talking about here. We want to create a workplace that is supportive of well-being as opposed to the place residents have to leave to find it,” said Gregory Guldner, MD, vice president of academic affairs for HCA Healthcare’s graduate medical education (GME) program. “Environmental workplace interventions are proving to have bigger impact than the individual interventions.”
Nashville-based HCA Healthcare is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Dr. Guldner recently spoke at an AMA Insight Network program about HCA Healthcare’s system-wide efforts to improve well-being and reduce burnout among its residents, ones inspired by workplace psychological theories.
“These theories aren’t new,” he said. “We have a lot of internal and external data behind them.”
Among other benefits, members of the AMA Health System Program have access to the AMA Insight Network’s Quality, Safety and Equity community. This virtual forum provides an opportunity for like-minded leaders from across the country to hear more examples of how leading health systems are finding innovative ways to address health care inequities in their communities.
Health care organizations know that physician burnout demands attention, despite some recent improvement. AMA-exclusive data showed residents in 2024 reporting higher job satisfaction, lower burnout and a greater sense of being valued by their organization than in the previous year. Burnout rates for practicing physicians also have fallen from high-water marks seen during the COVID-19 public health emergency.
But too many residents and practicing physicians still live with burnout, and the resultant effects have downstream negative consequences for physicians and their families.
That’s why, as the leader in physician well-being, the AMA is reducing physician burnout by removing administrative burdens and providing real-world solutions to help doctors rediscover the Joy in Medicine®.
Psychology underpins well-being
HCA Healthcare’s work yielded significant and surprising results, Dr. Guldner said. After a pilot program in the emergency medicine residency program resulted in favorable responses on Accreditation Council for Graduate Medical Education (ACGME) resident surveys for five consecutive years, HCA Healthcare expanded and scaled it.
The ideas behind their efforts were based on two psychological theories of what creates workplace well-being: self-determination theory and job demands-resource theory.
The latter “is really a model that helps, in particular, talk about burnout,” Dr. Guldner explained. In the theory, there are two processes at work—job demands and job resources. The demands can lead to burnout and resources help engagement.
“We think of job demands as anything that takes energy, whether that's physical energy or psychological energy,” he said.
But all job demands aren’t created equal. So-called “challenge job demands,” he said, “are things that help push us a little bit and help us grow.” Those are common experiences for residents, who are learning new skills and expanding their understanding of medicine every day.
The more damaging job demands are called “hindrance job demands,” which “take extra effort to deal with because they don't have an understanding that they lead to anything,” Dr. Guldner said, giving as an example a broken otoscope in an exam room.
Job resources—which can be practical resources such as more support staff for physicians or psychological resources such as a sense of meaning or purpose—can offset some job demands but can’t compensate for hindrances.
“You can give me two more people in my exam room, but if my otoscope is still broken, it's still broken,” Dr. Guldner said.
Finding autonomy for residents
Self-determination theory posits that everyone has a deep need for autonomy, belonging and competence.
“Especially in the work environment, the degree to which the work environment supports those three needs is the degree to which you flourish. And to the extent those needs are thwarted, you'll have distress,” Dr. Guldner said.
Autonomy, though, “doesn't mean that I have entirely agree with something. It just means that I understand it. I support it. I see the value in it.”
Autonomy-building efforts can be “as simple as just teaching our faculty to say something like: What do you want to do? That sounds really basic for the non-GME folks, but in the GME world, it's really common for a resident to present a case and the attending says: Oh, just do this,” Dr. Guldner said. “And that may have been exactly what the resident wanted to do anyway, but they didn't even get a chance to say it.”
The AMA gives health care organizations a vital tool in learning about their residents’ experience, which can help attract and retain them after their training ends.
With the Organizational Biopsy, the AMA offers a set of services for health systems and organizations. This includes a well-being assessment tool developed to support holistically measuring and taking action to improve well-being in an organization.
The Organizational Biopsy helps assess progress in four domains:
- Organizational culture such as leadership, teamwork and trust.
- Practice efficiency, which includes workflows and team structure and stability.
- Self-care such as managing post-traumatic stress, post-traumatic growth and work-life balance.
- Retention, which means keeping physicians in practice.
Also explore the AMA STEPS Forward toolkit, “Resident and Fellow Well-Being: Optimize Well-Being at Work for Physician Learners,” which outlines key steps that should be taken to address resident burnout.
More meaningful changes
Back at HCA Healthcare, Dr. Guldner said tackling even small job hindrances can have a big impact on resident burnout and well-being.
He said that physicians “often would much prefer to have hindrance job demands dealt with rather than focus on things like resiliency or mindfulness training. Especially in a situation where you spend a lot of time at work, which would be residency training, for example, those hindrance demands become more and more important.”
Though an investment is required, HCA Healthcare has found it a worthwhile one.
“There is a cost in the sense that we’ve got to more quickly identify needs and fix the otoscope,” Dr. Guldner said. “But at the same time, that otoscope is causing other problems in the environment, as well. And so it has to be fixed as soon as possible. The pebble has to come out of the shoe.”
