Faculty in academic medicine experience multiple demands on their time at work and at home, which are sources of stress and dissatisfaction, compromising the success of individual faculty and their institutions. Indeed, physician burnout has risen to alarming levels, affecting half of all U.S. physicians.1 Consequences of burnout and job dissatisfaction in academic medicine include disruptive behavior, increased medical errors, poor clinical management, and patient noncompliance and dissatisfaction.2–5 Although research has focused on the individual’s resilience in combating physician burnout, broader cultural and system factors may outweigh the impact of personal resilience in contributing to professional wellness or burnout.6 Thus, employers clearly have an obligation to support programs and policies that prevent burnout and increase professional fulfillment. Critical mediators that predict physician burnout and professional disengagement include perceived work control, work–home interference, and home support.7–9 We present results from a pilot program designed to address these mediators and promote a culture of flexibility and professional fulfillment within an academic medical center.
Identified Barriers to Faculty Success
In 2010, the Stanford University School of Medicine (SSoM) convened a taskforce to diagnose the state of faculty work–life flexibility. The taskforce (led by H.V. and C.S.) consisted of SSoM faculty across ranks and in both the basic and clinical sciences (including J.R.) as well as senior leaders from Stanford University’s WorkLife Office, schoolwide faculty development efforts, and a community-based physician. The taskforce employed an innovative approach melding traditional and human-centered design methodologies to understand the challenges for biomedical faculty. Using multiple approaches, including a benchmarking survey across 10 leading academic medical centers, published research, focus groups, ethnography, and human-centered design methodology,10 the taskforce identified two major domains of conflict that drove the intervention design.
Despite institutions’ significant investments in flexibility policies, work–life conflict remains challenging for faculty and causes many recent graduates to opt out of academia.11 Although institutions offer extensive work–life policies, they go vastly underused because they are perceived to be at odds with success. Our research found that faculty were reluctant to use existing flexibility policies to avoid “signaling low commitment” and the resulting adverse career consequences reported in academic and other settings.12–14 Therefore, flexibility policies alone are insufficient; cultural transformation is necessary to gain acceptance of flexible work practices.
In academic medicine, the joint responsibilities of research, teaching, and clinical care, in addition to service and administration, represent competing demands that exacerbate time-related stress, a phenomenon we call work–work conflict. Additionally, our research demonstrated that faculty are deeply aware that if they use a flexibility policy, their work, especially clinical responsibilities, may fall on already-overworked colleagues.
The ABCC Framework
The Academic Biomedical Career Customization (ABCC) initiative was created to mitigate work–life and work–work conflicts via an integrated career–life planning process to create customized plans to meet career and life goals and to mainstream use of existing flexibility policies to meet those goals, and a time-banking system to recognize and promote behaviors benefiting team flexibility and success with support that “buys back” an individual’s time.
Intervention 1: Integrated career–life planning
The taskforce findings revealed that faculty widely perceive a single path to academic success. However, one-size-fits-all career tracks do not accommodate today’s variety of lifestyles and family situations. Therefore, we developed a process to reframe flexibility as integral to career success by incorporating it into regular career planning, and to legitimize the use of flexibility policies as commonplace, expected, and accepted events rather than one-off accommodations. The goal was to help each faculty member design a plan promoting both personal and professional goals, as well as goals of the institution, while also meeting other (e.g., financial) constraints.
Career–life plans were developed in three stages. First, participants completed a self-reflection guide focused on career and work–life goals, now and three to five years from now, using a modified version of the Mass Career Customization model from the consulting firm Deloitte (Supplemental Digital Appendix 1, available at http://links.lww.com/ACADMED/A520).15,16 Next, each faculty participant met with a coach from the ABCC program to identify trade-offs and potential solutions, using a technology application visually summarizing the faculty member’s current state and goals (Supplemental Digital Appendix 2, available at http://links.lww.com/ACADMED/A520).
Finally, participants engaged in career–life planning discussions with their team leaders (e.g., division chief). Team leaders were provided a guide and training on how to identify ways to balance the goals of the team and the goals of the individual faculty member (Supplemental Digital Appendix 3, available at http://links.lww.com/ACADMED/A520). Guides included a list of existing flexibility and career development policies, and concrete examples of how policy use could facilitate achievement of personal and professional goals, thus reframing policies as promoting individual success. ABCC’s self-reflection guide and accompanying career-planning tool kits are available on SSoM’s website (http://sm.stanford.edu/app/abcc).
Intervention 2: Time-banking system
The second component of ABCC is a time-banking system. This intervention was inspired by the practice, identified in our ethnographic research, of faculty “trading favors” with friends and colleagues to meet the time demands of work and home. These informal trades, although occasionally helpful, can be difficult to arrange; one-to-one reciprocation can be impractical; and, without a tracking mechanism, faculty felt that efforts were often unnoticed or forgotten, making it difficult to ask for favors in return. The banking system addressed these limitations by providing a mechanism for systematic and concrete recognition of faculty behaviors that support the flexibility needed by team members and the institution’s success. This incentive took the form of credits that participants could use for services that “buy back” their time, or otherwise support their own success.
A key advantage of the Stanford time-banking system is that it can be customized to each team’s needs by modifying the list of credit-earning activities. During an hourlong meeting moderated by ABCC representatives, faculty from a given team discussed and agreed on activities that would earn credit. The ABCC framework required that teams identify activities that were otherwise uncompensated or not adequately recognized by the existing incentive structure in their group and/or that benefited the team or an individual colleague. Examples included filling clinical service for a colleague on short notice; mentoring students, trainees, and junior faculty; service on institutional committees; and national service (e.g., National Institutes of Health study section); among others (Supplemental Digital Appendix 4, available at http://links.lww.com/ACADMED/A520). Most activities were assigned credit values proportional to faculty time invested, although some activities, such as covering a clinical shift on short notice, had to be assigned credits based on a more subjective assessment of the value to the team.
Faculty tracked participation in credit-earning activities by logging activities using a simple, free, online time-tracking tool, or having an administrative assistant log their activities. Each activity took less than a minute to enter, and logs could be viewed by all team members, fostering transparency to promote both accountability and a sense of recognition.
Credits could be redeemed for support services at home (e.g., housecleaning, laundry, meal delivery, errand outsourcing, car service) or work (e.g., grantwriting, manuscript editing, speech coach, lab management services, website design, graphics for presentations, office organizing). Services were meant to benefit career and personal goals by providing mechanisms to alleviate time pressure and/or promote career success (Figure 1). Acknowledging previously unrecognized teaching, service, and clinical work with practical rewards turned this work into measurable accomplishments. Services were each assigned an initial price, in credits, but faculty were told in advance that the purchasing power of the credits might be adjusted during the program. Because credit-earning activities differed between teams, we adjusted the “value” of credits across teams, based on initial data on the rate of credit accrual, so that purchasing power was similar in terms of support services that could be obtained.
Recruitment and implementation
Team leaders were invited to join the pilot in fall 2012. Once a willing leader responded, faculty within that team were recruited via e-mail. The pilot group therefore consisted of team leaders and faculty who were not randomly selected but were generally receptive to the concept of faculty flexibility.
Sixty faculty participated, from four teams (three clinical divisions and a fourth “team” composed of faculty from five basic science departments). Women constituted 57% of participants (n = 34); 75% were clinical (n = 45); and academic rank was 10% (n = 6) clinical instructors, 29% (n = 17) assistant professors, 45% (n = 27) associate professors, and 17% (n = 10) professors. Faculty participated in the program for 1 to 27 months (median = 14).
The integrated career–life planning and time-banking system were designed to be complementary, and all participants received both interventions. The banking system was introduced to a team only after each team member had completed the career–life planning and, thus, had already reflected on their individual work–life and work–work challenges and how they might be mitigated. The banking system then provided a supportive infrastructure enabling faculty to adjust their time allocation in response to life events or changes in goals/values over time. The banking was designed to encourage faculty to take on more responsibility when able, thereby making it possible for colleagues to decrease workload when needed (e.g., grant deadline or family crisis), thus increasing flexibility throughout the team, and reframing flexibility as supporting both individual and team success. Because all participants received both interventions, we provide outcomes related to this two-pronged approach of career–life planning combined with a time-banking system rather than the two interventions separately.
Pilot outcomes were analyzed in fall 2014. Survey data of a pre–post matched sample served as the primary evaluation source. Upon enrollment, participants completed a presurvey, which was analyzed in comparison with an end-of-pilot postsurvey. A pulse survey was also conducted following career–life planning discussions to assess their immediate impact. A second data source included banking system credit accrual and usage. Finally, data on research productivity during the pilot were collected to understand career advancement because a major pilot goal was to alleviate work–life and work–work conflicts while promoting career development. Institutional review board approval for this study was waived by Stanford University’s Research Compliance Office.
Thirty-seven participants (62% response rate) completed the pulse survey after participation in career–life planning. Results demonstrated that 85% (29 of 34; 3 nonresponse) found self-reflection guides useful, 94% (32 of 34; 3 nonresponse) found discussing career and work–life plans with ABCC’s coach useful, and 58% (19 of 32; 5 nonresponse) found career–life planning discussions with team leaders useful. Notably, during career–life planning, faculty expressed interest in only small adjustments to work and life, rather than wholesale changes. This reflects an approach to change that is incremental and feasible rather than disrupting the academic model altogether.
All participants completed the presurvey (n = 60), a requirement to participate in the pilot. The postsurvey response rate was 70% (n = 42). Analyses include participants who completed both pre- and postsurveys (Table 1). Using factor analysis, we analyzed survey questions through the creation of six scales capturing multiple dimensions of program impact (see Supplemental Digital Appendix 5, available at http://links.lww.com/ACADMED/A520 for scale items). In paired t tests, four of the six scales showed significant increases in satisfaction from pre- to postintervention: support for a culture of flexibility (P = .020), wellness (P = .013), understanding professional development opportunities (P = .036), and institutional satisfaction (P = .020).
Among individual survey items, participants reported an increase in satisfaction with professional support needed to manage the fit between work, long-term career aspirations, and personal life (P = .009); a decrease in postponing or avoiding vacation (P < .001) and health habits (P =.043) because of lack of time; and an increase in agreement with the statements “SSoM supports the advancement of all faculty” (P =.011) and “SSoM supports my career development” (P =.026). In addition, there was an increase in understanding the time frame projected for promotion (P =.021), suggesting that the career-planning discussions were effective.
Two of the six scales showed no change from pre- to posttest: control over time and resources; and support from colleagues for flexibility (all P > .15). Nevertheless, there were indications that these were improved in some cases. For example, among the basic science faculty, satisfaction with time available to discuss science with colleagues increased significantly (P = .006), indicating increases in perceptions of available time and collegiality. Across clinical teams, the frequency with which faculty reported stepping in to fill clinical service on short notice to help a colleague increased significantly (P =.028). In follow-up commentary, this reflected an increased willingness for those needing flexibility to ask for help from their colleagues.
One of the most common concerns expressed before the pilot was that the “fee for service” banking model might adversely affect collegiality, by taking goodwill out of helping colleagues; however, we found no evidence for this in the survey or in the comments from participants. A second concern was that ABCC would be yet another underused flexibility initiative; however, only 8 of 60 participants “dropped out” of the pilot, neither following up with team leaders nor logging credits.
Banking system credit accrual and usage
Among basic science faculty, women accrued credits at a rate roughly double that of men because of higher accrual rates for women in the service and teaching categories, with similar accrual rates for mentoring (Figure 2, top). This gender disparity in service and teaching mirrors that reported previously for faculty outside of the medical school setting.17,18 In contrast, in clinical departments, male faculty accrued credits at a higher rate than female faculty, mainly because of a higher rate of accrual for service (Figure 2, bottom; values cannot be directly compared with basic science team because credit-earning activities were different). The opposite gender disparities for service in the basic science versus clinical departments may reflect a difference in other forms of recognition for service work in these two settings. Numbers of participants were too small to allow comparisons between type of appointment (clinical, research, or mixed) or rank.
In terms of credit usage, basic science faculty, especially male basic science faculty, preferred work support services: Women redeemed 52% and men redeemed 94% of their credits toward work support services (Figure 3, top). In contrast, clinical teams preferred home support services: Women redeemed 83% and men redeemed 84% of their credits toward home support services (Figure 3, bottom).
Because a major goal of ABCC was to enhance career advancement through mitigation of work–life and work–work conflicts, we assessed research productivity during the program. This impact was reflected in the comments of participants about the home and work support services. For example, one participant commented, “Instead of spending countless hours cleaning and cooking, I can actually accomplish work for Stanford in a timely manner.” Another participant, a female assistant professor, attributed her success in attaining a $1.5 million grant to her use of the work support services: “I used my credits to have [a speech coach] help me prepare for my [foundation] interview—which I ended up getting. She was incredibly helpful.”
The grantwriting/editing assistance also proved valuable. Of grants the participants submitted to the National Institutes of Health with the assistance of the grantwriting support service, 46% (6/13) were awarded. Because the broader ABCC framework was designed to increase a faculty member’s time for both home and work activities, we also measured overall grant success rates, including all participants active in research—not just those who had availed themselves of the grantwriting service. We compared the overall success of ABCC participants in obtaining private and federal grants with that of a closely matched control group of Stanford faculty nonparticipants, matched by gender, rank, time in rank, and type of division/department. This analysis included only faculty who participated in research activities, as assessed by having submitted at least one grant during the project period (27 ABCC participants and 27 matched controls). ABCC participants received, on average, 1.3 more awards over the two-year pilot compared with the matched sample, a funding difference of approximately $1.1 million per person.
The ABCC pilot demonstrated value in terms of participants’ perceptions of institutional support for flexibility, wellness, advancement, career satisfaction, and research productivity. In addition, three major findings inform future programmatic development. First, career planning can and should incorporate discussions of other life goals and how to use available policies to meet work and life goals. By incorporating work–life into career planning, institutions can increase awareness of existing work–life policies and reduce stigma associated with their use.
Second, faculty appreciate transparency and recognition for the “extracurricular” service work they perform (i.e., activities promoting the success of one’s colleagues and the team overall). The mere act of logging such work enables faculty to understand the proportion of their own time and their colleagues’ time devoted to these activities, and to feel recognized for supporting the team and institution. In addition, faculty reported reassurance from “having something in the bank”: knowing that their credits could be used to obtain support when needed (e.g., with the birth of a child or an upcoming grant deadline). Participants also commented that credits benefited not just the individual earning them but also his or her colleagues, by making it easier to ask for help.
Third, faculty programs are not one-size-fits-all. The effectiveness of the ABCC pilot program was enhanced by designing it to allow customization to the microcultures of individual teams. This customization was provided by having each team determine which activities should accrue credits to encourage the specific faculty behaviors that best support the flexibility of that team. Such customization should make it possible to readily adapt the Stanford ABCC program, not only to other medical schools but also to nonacademic medical programs, plus a variety of other work environments.
The cost of the program ($2,500–$3,000 per active participant per year) represents a small fraction of average salaries; nevertheless, it is significant enough to require serious consideration. It should be noted that all employers distribute resources, and what the ABCC approach requires is a commitment to distribute some of those resources in a way that incentivizes individuals to support each other’s flexibility. In less well-resourced environments, the purchasing power of credits may need to be reduced to stay within the available budget, or the credits used for time saving or career support that is less costly to the institution, such as a preferred parking spot, preference in teaching or clinical schedule, a larger share of an existing administrative assistant’s time, or lunch with the dean or department chair. It will be important to assess whether the ABCC approach can yield similar results with these less costly forms of support.
On first blush, providing meals and housecleaning with university funds might seem extravagant. However, such support services can be a cost-effective way to buy additional hours of faculty time; by reducing time spent on things like housework, faculty can allocate more hours to their highest priorities at work or home. Buying time has been shown to promote happiness for individuals across the income spectrum.19 For some faculty, the grantwriting assistance had the biggest impact on productivity and freeing up time to meet other demands at work or home, whereas other faculty found it more effective to spend their credits on meal delivery to free up their time to meet a grant deadline or address a family crisis. By allowing faculty to choose when and how to spend credits, the time-banking system creates an efficient way for institutions to deliver the customized support needed to help each faculty member meet her or his specific work and life challenges.
One potential critique is why not, instead, convert credits into salary supplements? One reason is that faculty participants reported that the credit system made feelings of recognition and institutional support more salient and concrete. Indeed, research on “perceived organizational support,” the degree to which employees believe that an organization cares about their well-being and values their contributions, has been shown to positively affect employee commitment and performance and to reduce turnover.20 Because of the pilot’s size and short time frame, effects on retention could not be adequately measured. The survey questions, as a proxy for such measures, provided evidence for increased faculty satisfaction, which suggests that there may be substantial return on investment in faculty retention. Indeed, one participant commented that “sometimes when I’m very busy or disillusioned, the services are the only thing keeping me here.” The cost of a single faculty turnover in clinical departments is estimated at over $1 million,21 which, if not spent on faculty replacement, is enough to instead fund the banking system for over 300 faculty annually.
Thus, the ABCC program has the potential to pay for itself by enabling faculty to spend more time on high-value, revenue-generating activities, such as grantwriting and seeing additional patients, and to be more successful in those endeavors; and also by reducing the high cost of faculty turnover, recruitment, and retention. Given the documented program benefits, one team decided to continue ABCC beyond the end of the pilot by taking over funding and administration within their own department. This department has continued to make changes and improvements to the program. For example, all faculty now receive a baseline number of credits, with the most allotted to junior faculty, who have less control over their schedules. Also, faculty have the option to donate some of their credits to staff who assist with projects and tasks on short notice. A version of the program also has been extended to the department’s residents.
The traditional and human-centered design research methodologies used to design this pilot led to innovative interventions that addressed actual faculty experiences. Our experience suggests that institutions can mitigate effects of extreme time pressure at academic medical centers while also supporting the productivity and excellence of their faculty.
Acknowledgments: The authors wish to thank Dr. Bonnie Maldonado, senior associate dean for faculty development and diversity at Stanford Medicine, for support in program dissemination; Philip Pizzo, former dean of Stanford School of Medicine, for creating and supporting the taskforce on faculty flexibility, and for his charge to think boldly and creatively in addressing the issue; John Etchemendy, former provost of Stanford University, for instigating the many studies on Stanford faculty quality of life that laid the groundwork for the School of Medicine’s focus on uncovering data-driven solutions to the problem; Udaya Patnaik and his colleagues at Jump Associates for their major contributions to the design of ABCC using their “hybrid thinking” approach; members of the taskforce convened by the Dean’s Office; Deloitte consulting for providing advice on the framework; and all participants in the ABCC pilot program.