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Faculty Vitality—Surviving the Challenges Facing Academic Health Centers

A National Survey of Medical Faculty

Pololi, Linda H. MBBS; Evans, Arthur T. MD, MPH; Civian, Janet T. EdD; Gibbs, Brian K. PhD; Coplit, Lisa D. MD; Gillum, Linda H. PhD; Brennan, Robert T. EdD

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doi: 10.1097/ACM.0000000000000674
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Nothing great was ever achieved without enthusiasm.

—Ralph Waldo Emerson, Circles, 1841

Caring for people, educating physicians, making discoveries, improving health care—the missions of all academic health centers (AHCs)—require a dedicated, vibrant, creative faculty. Despite the importance of these missions, there is surprisingly little known about how best to measure or enhance faculty vitality, which we consider the most important quality of an AHC. Although faculty satisfaction, faculty burnout, and attrition might be easier to measure,1–10 they are clearly insufficient as measures of vitality and ignore essential aspirational characteristics. Although there is some overlap among the meanings of faculty satisfaction, engagement, and vitality, we posit that the distinction is critically important to the leaders of AHCs, and we further propose that leaders are more interested in enhancing the energy, creativity, and resourcefulness—the vitality—of their faculty than in promoting faculty satisfaction or the connection with the institution that characterizes faculty engagement.


Why is vitality a useful concept? Professional fulfillment, motivation, and commitment to ongoing intellectual and personal growth, full professional engagement, enthusiasm, positive feelings of aliveness and energy, and excitement about work are the characteristics of vitality.11 Although the concepts of “vitality” and “satisfaction” have some similarities, they operate in different dimensions. For example, along the continuum from faculty lethargy or enervation to optimal vitality, it is possible for faculty to feel either satisfied or dissatisfied with their jobs. Just as politeness and compassion are both positive, and are often coexisting physician attributes, it is clear that a culture of excellence and peak performance depend most on compassion and vitality rather than satisfaction and politeness. One might even argue that the most vital faculty are often dissatisfied with the status quo, driving them to constantly seek improvements. The concept of “engagement” refers to an employee’s willingness and ability to contribute to organizational success.

Vitality has been studied in other settings. Among nonmedical university faculty, for example, investigators compared the characteristics of “star performers” with those of their “stagnant” colleagues.12–15 Vital faculty were defined as highly active and productive employees who continually publish, teach, and perform administrative and professional services,13 but it was noted that focus on just performance and productivity was a narrow operational definition even though both individual success and institutional reputation depend on these qualities.15 In contrast to vitality, burnout is a deficit model or a syndrome of emotional exhaustion, depersonalization, and a sense of low personal accomplishment16,17 that leads to decreased effectiveness at work. Of particular relevance to AHCs, one study demonstrated that emotional exhaustion—the absence of vitality—was most strongly associated with lower work performance.18

Given the dramatic changes in health care delivery and its funding, and deteriorating research support, several scholars, including the president of the Institute of Medicine, suggest that AHCs face an uncertain future that threatens the integrity of their missions.19,20 AHCs are straining under demands for increased productivity, quality improvement, and competing fiscal pressures that can erode their values and faculty vitality. We propose that if AHCs are to successfully preserve their missions in research, education, and health care delivery, they must adapt to change by enhancing faculty vitality and productivity.

A number of questions are therefore paramount: What is the vitality of faculty currently? What enables high levels of faculty vitality? What predictors of vitality are mutable and amenable to intervention? With these questions in mind, we analyzed a database that measured detailed faculty perceptions of their professional experiences and their institution’s culture at 26 representative AHCs in the United States.


The C – Change Faculty Survey was developed in 2007 by the National Initiative on Gender, Culture, and Leadership in Medicine. Familiarly known as C – Change for culture change, the action–research initiative seeks to facilitate change in the culture of academic medicine, so as to maximize the contributions of all faculty and trainees, and increase diversity in leadership. The validated C – Change survey has been used in numerous U.S. and Canadian medical schools and has been adapted for use with medical students and residents to assess the learning environment and professionalism. Detailed descriptions of our survey study methods have been previously published.3


Selecting AHCs.

From the Association of American Medical Colleges (AAMC) list of all AHCs, we created a stratified random sample of 26 AHCs that reflected the national population of AHCs by geographic region and public/private sector. Institutions where the majority of the faculty were from underrepresented in medicine minority (URMM) groups (American Indian or Alaska Native, black or African American, Hispanic/Latino, Native Hawaiian or other Pacific Islander) were termed “high URMM faculty institutions” (HUFI) as compared with “traditional” schools.

Sampling faculty within AHCs.

Using data from the AAMC and the AHC deans, we stratified faculty by sex, age (under 39 years of age, 39–47 years, and 48 years and older), URMM status, and surgical specialty. We selected 25 faculty members from each of six sex-by-age categories for a base sample of 150 faculty per AHC. We then oversampled URMM faculty and female surgeons to ensure adequate numbers for analysis. Weights were employed in the analyses to adjust for oversampling. This resulted in a list of 4,578 full-time faculty who received the electronic survey with reminders at two- to three-week intervals and a phone follow-up and a hard-copy mailing for nonresponders. We excluded from the analytic sample faculty who reported their rank as anything other than assistant, associate, or full professor. The survey was distributed in waves from 2007 through early 2009.


We derived the domains and items of our survey questions in large part from themes identified in previous C – Change qualitative studies,21–26 in conjunction with a literature search and reviews of relevant instruments.1,27–31 The 74-item survey related to advancement, vitality, relationships, feelings about the workplace, diversity and equity, leadership, institutional values and practices, mentoring, and work–life integration. Items used five-point Likert scales (range: 1 = strongly disagree to 5 = strongly agree). We obtained human subjects institutional approvals from Brandeis University, Boston University, and the AAMC.

We used factor analysis and semantic review of items to identify 12 dimensions of institutional culture.3,32 After negatively stated individual items were reverse coded, the mean response for all items in the scale provided a summary score on the original five-point Likert scale. Table 1 describes the scales used in the current analysis, with their reliability coefficients and descriptive statistics.

Table 1
Table 1:
Dimensions of AHC Culture Used As Outcome Variable or As Predictor Variables: Definitions and Univariate Statistics, From a Study of Faculty Vitality at 26 AHCs, 2007–2009a

One of the scales was previously labeled “engagement” during factor analysis. We abandoned the term engagement because, although one item measures an element of emotional attachment to the institution, the five items collectively capture the key elements of faculty vitality: “I feel energized by my work,” “I look forward to coming to work,” “I am proud to work here,” “I find my work to be personally satisfying,” and “I feel burnt out (reverse coded). The other dimensions of the AHC culture were considered potential predictors of vitality, although we excluded perceptions of institutional change and self-efficacy in career advancement because, on the basis of our conceptual model, they were more likely consequences of vitality rather than predictors.

Several personal and professional demographic items were also included as predictors: sex; URMM status; age; rank; and primary role of clinician, researcher, administrator, or educator. AHC-level variables included National Institutes of Health (NIH) funding rank, whether the AHC was a HUFI or traditional institution, whether the AHC was a public or private school, region, school size, and percentage of faculty who were women.

Analytic overview

We used sampling weights based on sex, age, and URMM characteristics to generalize our findings to the national population of AHC faculty. To address missing values, 10 multiply imputed data sets were estimated using IVEware 2002 statistical software (Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, Michigan).33 Multiple imputation yields point estimates and confidence intervals that are less biased than a complete case analysis (ignoring missing values).34

We used a two-level (individual and AHC) linear regression model to estimate predictors of faculty vitality using HLM 7 for Windows statistical software, 2011 (Scientific Software International, Inc., Lincolnwood, Illinois). The models were constructed by testing progressive blocks of variables, starting with personal demographics, followed by dimensions of the culture, and by conducting joint significance tests for each group of variables using the multiple general linear hypothesis testing available in HLM 7.


Of the 4,578 faculty invited to participate, 2,381 responded (52% response rate), and 2,218 were eligible for analysis (assistant, associate, or full professor). Table 2 describes the sample characteristics. The distribution of faculty vitality scores is depicted in Figure 1. Half of the faculty had scores of 4.0 or higher, which would result if all five items representing vitality were given a positive response. However, 25% of the weighted sample had scores less than 3.5, indicating that, on average, fewer than half the items representing vitality were given a positive response.

Table 2
Table 2:
Characteristics of 2,218 Participating Faculty Members, From a Study of Faculty Vitality at 26 AHCs, 2007–2009a
Figure 1
Figure 1:
The distribution of faculty vitality scores of 2,218 faculty at 26 representative U.S. medical schools, 2007–2009. The authors surveyed 4,578 full-time faculty at 26 representative U.S. medical schools about their organizational culture; 2,218 responses were used for this analysis. Vitality was assessed using responses (on a five-point Likert scale) to five items capturing the key elements of faculty vitality. A vitality score of 5 represents the highest vitality.

In a multivariable model that included both individual- and AHC-level factors, the strongest predictors of vitality were the faculty members’ perceptions of four dimensions of AHC culture: Relationships/inclusion, Values alignment, Work–life integration, and Institutional support (Table 3). Holding other factors constant, a one-point increase on each of these four dimensions (slightly more than one standard deviation) would predict a combined effect of increasing the vitality score by 0.7 points (slightly less than one standard deviation)—that is, a very large effect size. Representative items for the four dimensions include the following: “I feel ignored or invisible here” (Relationships/inclusion); “My values are well aligned with the values exhibited by my institution” and “My institution rewards excellence in clinical care” (Values alignment); “It’s difficult to succeed here without sacrificing personal and/or family commitments” (Work–life integration); and “I get the help I need with how to advance in my career” (Institutional support). Age was the only other individual-level characteristic that had a significant independent relationship with the vitality score. Age demonstrated a nonlinear relationship with vitality (P = .01 for combined linear/quadratic term; Figure 2); faculty over the age of 60 years had the highest vitality scores, and faculty in the midcareer range (ages 35–50 years) had the lowest. Holding perceptions of culture constant, neither female faculty nor URMM faculty had vitality scores that were different on average from male or nonminority faculty.

Table 3
Table 3:
Factors Associated With Faculty Vitality, From a Study of Faculty Vitality at 26 AHCs, 2007–2009a
Figure 2
Figure 2:
Display of the nonlinear relationship between faculty age and vitality score of 2,218 faculty at 26 representative U.S. medical schools, 2007–2009. The authors surveyed 4,578 full-time faculty at 26 representative U.S. medical schools about their organizational culture; 2,218 responses were used for this analysis. Vitality was assessed using responses (on a five-point Likert scale) to five items capturing the key elements of faculty vitality. A vitality score of 5 represents the highest vitality.

Among the AHC-level characteristics, two variables independently predicted the vitality score, although the effects were weaker than the individual-level perceptions of culture (Table 3). Faculty at private medical schools had a vitality score that was 0.08 points higher, on average, than faculty at public medical schools. And faculty at AHCs with more NIH funding had higher vitality scores. For example, faculty at an AHC ranked 20th in the country in NIH funding would be expected to have a vitality score 0.08 points higher, on average, than faculty at an AHC ranked 50th (a difference in rank of 30 points). The model accounts for 45% of all variance in vitality scores at the faculty level, whereas AHC characteristics explained less than 1% of the total variance.

Discussion and Conclusions

A quarter of the faculty of U.S. AHCs participating in this study lack optimal vitality. The most powerful predictors of faculty vitality were positive professional relationships, and feeling included and belonging in the organization. Alignment of individual and institutional values, work–life integration, and institutional support were other strong predictors. Much weaker predictors were whether it was a public or private institution, and the AHC’s national rank in NIH funding. There was no independent association between vitality and either the sex of the faculty member or minority status, a finding supported by other studies.35 The relationship between vitality and age should be of interest to AHCs. Whereas young faculty have reasonably high vitality, vitality scores quickly dip and reach the lowest point during the years when faculty should be most productive in their careers. At this point, AHCs have made a large investment in the training and development of their faculty, yet these midcareer faculty members are at highest risk of burnout and attrition. It is heartening, however, that the most senior faculty—over the age of 55—who lead their institutions and serve as role models have the highest vitality.

Faculty vitality is essential for AHCs to respond constructively to the momentous changes they face in health care funding, research support, and medical education.19,20,36 Yet the national discourse on these challenges has been relatively silent, thus far, on the role of faculty vitality or the aspects of the institutional culture that appear to predict vitality—especially relationships and values alignment. Achieving optimal contributions from motivated faculty will require a better understanding by institutional leaders of their institution’s culture and the determinants amenable to intervention. Similar requirements are necessary for ensuring excellence in training the next generation of leaders of American health care.

Our study’s focus on faculty vitality complements and extends findings from related research on faculty dissatisfaction,1,2,7,37–44 faculty burnout,2,7,8,45,46 attrition,3–5 and engagement.10,47 Several studies of practicing physicians have similarly linked physician–peer relationships40,42 and relationships between physicians and their patients43 with physician satisfaction scores. One of the few studies reporting on medical faculty vitality, albeit in a single institution,35 found that leadership, workplace climate, and management of career–life choices affected faculty vitality. However, other dimensions of institutional culture, such as relationships and values alignment, were not considered.

Notably, our findings among AHC faculty are corroborated by research findings reported primarily in the psychology literature that support a conceptual model linking vitality and performance with “self-determination,” “authenticity,” and “flow.”48–54 For example, self-determination theory (SDT), validated in educational and clinical settings, posits that the social context of work can either support or thwart the natural tendencies toward active engagement and psychological growth.48,49 Researchers of SDT refer to the concept of vitality as the energy that is available to the self—that is, the energy that is exhilarating and empowering, that allows people to act more autonomously and persist more at important activities. SDT studies suggest that vitality and energy are enhanced by activities that satisfy basic psychological needs for relatedness, competence, and autonomy.49

Our finding that vitality is dependent on good relationships and a sense of trust and belonging in the organization is consistent with studies on “authenticity,” which exists when people act in accordance with their values, preferences, and needs, as opposed to acting merely to please others, attain rewards, or avoid punishments.50 In practice, this means that individuals who can authentically express their own feelings and beliefs in their workplace can bring more of their selves to their roles and are more deeply engaged in what they are doing.51,52 The importance of this is that under these circumstances, people, including medical faculty, are best able to form trusting relationships with one another that can bridge differences such as gender, race, and ethnicity.55 And it is within these relationships that they can work through difficulties, resulting in growth and learning.56

Our finding that values alignment predicts faculty vitality also recalls Csikszentmihalyi’s53,54 studies on “flow,” a term he uses to refer to the state of operating at the peak of one’s abilities, experiencing total concentration, deep enjoyment, and meaningfulness in work. Ideally, we would like medical faculty to be functioning in a flow state. According to the principles of flow, when faculty apply their work to what they value most deeply, they can be most successful and fulfilled. Meaningfulness of work is more likely to be felt when one’s values are aligned with institutional values because working in accordance with one’s core values facilitates accessing sources of meaning in work. Csikszentmihalyi’s explanation of the association between meaningfulness of work and peak performance helps explain the finding that vitality is linked to values alignment in AHCs.

Our findings are also consistent with a study at a single AHC that asked faculty to rank the factors necessary to foster continued learning and professional growth. The top three factors were “maintaining my academic vitality,” “retaining my own values,” and “balancing personal and professional demands.” “Time management” was rated fourth, and “finding meaning in my work” was ranked fifth.57

The strengths of the study include the national, representative sample of 26 AHCs, a large cross-disciplinary representative faculty sample, and the theoretical grounding of the conceptual model and instrument development. Limitations include an incomplete response rate and the possibility that the statistical associations we found might not reflect causal relationships because of the cross-sectional design and possible residual or unmeasured confounding. We do not have enough information about nonresponders to adequately assess for response bias. However, the large sample, the diversity of the participating institutions, and the consistency of findings with existing literature support generalizability of our findings.

To achieve optimal vitality, faculty need trusting relationships with colleagues and need to feel authentic at work, believing that their personal values align with those of the AHC. These human factors are the building blocks of vitality. Although we need research that prospectively measures whether changes in vitality contribute to increases in faculty productivity, leaders seeking to support and enhance the vitality, professional fulfillment, and productivity of their faculty should invest in activities that foster relationship formation and inclusion, and should explore faculty and institutional values and address any misalignment. Work–life integration for both men and women faculty is an additional area for attention.

Acknowledgments: The authors thank all the members of the C – Change research team who participated in developing items for the survey and supporting the process of C – Change work. The authors thank the Association of American Medical Colleges for assisting in the initial phase of the project, and Ms. Vasilia Vasiliou for research assistance. The authors are indebted to the medical faculty who generously shared their perspectives in the survey.


1. Schindler BA, Novack DH, Cohen DG, et al. The impact of the changing health care environment on the health and well-being of faculty at four medical schools. Acad Med. 2006;81:27–34
2. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250:463–471
3. Pololi LH, Krupat E, Civian JT, Ash AS, Brennan RT. Why are a quarter of faculty considering leaving academic medicine? A study of their perceptions of institutional culture and intentions to leave at 26 representative U.S. medical schools. Acad Med. 2012;87:859–869
4. Alexander H, Lang J. The long-term retention and attrition of U.S. medical school faculty AAMC Analysis in Brief. 2008;8:1–2
5. Corrice AM, Fox S, Bunton SA. Retention of full-time clinical MD faculty at U.S. medical schools AAMC Analysis in Brief. 2011;11:1–2
6. Demmy TL, Kivlahan C, Stone TT, Teague L, Sapienza P. Physicians’ perceptions of institutional and leadership factors influencing their job satisfaction at one academic medical center. Acad Med. 2002;77(12 pt 1):1235–1240
7. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work–life balance among U.S. physicians relative to the general U.S. population. Arch Intern Med. 2012;172:1377–1385
8. Dyrbye LN, Shanafelt TD. Physician burnout: A potential threat to successful health care reform. JAMA. 2011;305:2009–2010
9. Linn LS, Yager J, Cope D, Leake B. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA. 1985;254:2775–2782
10. Bunton SA, Corrice AM, Pollart SM, et al. Predictors of workplace satisfaction for U.S. medical school faculty in an era of change and challenge. Acad Med. 2012;87:574–581
11. Ryan RM, Frederick CM. On energy, personality and health: Subjective vitality as a dynamic reflection of well-being. J Pers. 1997;65:529–565
12. Baldwin RJ. Faculty vitality beyond the research university: Extending a contextual concept. J Higher Educ. 1990;61:160–180
13. Clark SM, Corcoran M, Lewis DR. The case for an institutional perspective on faculty development. J Higher Educ. 1986;57:176–195
14. Clark SM, Lewis DR Faculty Vitality and Institutional Productivity: Critical Perspectives for Higher Education. 1985 New York, NY Teachers College Press
15. Huston TA, Norman M, Ambrose SA. Expanding the discussion of faculty vitality to include productive but disengaged senior faculty. J Higher Educ. 2007;78:493–522
16. Maslach C Burnout: The Cost of Caring. 1982 Englewood Cliffs, NJ Prentice-Hall
17. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397–422
18. Wright TA, Bonett DG. The contribution of burnout to work performance. J Org Behav. 1997;18:491–499
19. Becker BN, Formisano RA, Getto CJ. Commentary: Dinosaurs fated for extinction? Health care delivery at academic health centers. Acad Med. 2010;85:759–762
20. Dzau VJ, Cho A, Ellaissi W, et al. Transforming academic health centers for an uncertain future. N Engl J Med. 2013;369:991–993
21. Pololi L, Cooper LA, Carr P. Race, disadvantage and faculty experiences in academic medicine. J Gen Intern Med. 2010;25:1363–1369
22. Pololi L, Conrad P, Knight S, Carr P. A study of the relational aspects of the culture of academic medicine. Acad Med. 2009;84:106–114
23. Carr PL, Pololi L, Knight S, Conrad P. Collaboration in academic medicine: Reflections on gender and advancement. Acad Med. 2009;84:1447–1453
24. Pololi L, Kern DE, Carr P, Conrad P, Knight S. The culture of academic medicine: Faculty perceptions of the lack of alignment between individual and institutional values. J Gen Intern Med. 2009;24:1289–1295
25. Conrad P, Carr P, Knight S, Renfrew MR, Dunn MB, Pololi L. Hierarchy as a barrier to advancement for women in academic medicine. J Womens Health (Larchmt). 2010;19:799–805
26. Pololi LH, Jones SJ. Women faculty: An analysis of their experiences in academic medicine and their coping strategies. Gend Med. 2010;7:438–450
27. Butler JK. Toward understanding and measuring conditions of trust: Evolution of a conditions of trust inventory. J Manage. 1991;17:643–663
28. Pololi L, Price J. Validation and use of an instrument to measure the learning environment as perceived by medical students. Teach Learn Med. 2000;12:201–207
29. Pololi LH, Dennis K, Winn GM, Mitchell J. A needs assessment of medical school faculty: Caring for the caretakers. J Contin Educ Health Prof. 2003;23:21–29
30. . Women in Science and Engineering Leadership Institute (WISELI). University of Wisconsin–Madison. WISELI Reports and Publications. Accessed January 3, 2015
31. University of Michigan: Survey of Academic Climate and Activities, Fall 2001. Accessed January 3, 2015
32. Hatcher L A Step-by-Step Approach to Using the SAS System for Factor Analysis and Structural Equation Modeling. 1994 Cary, NC SAS Institute
33. Raghunathan TE, Lepkowski JM, Van Hoewyk J, Solenberger PW. A multivariate technique for multiply imputing missing values using a sequence of regression models. Surv Methodol. 2001;27:85–95
34. Rubin DB Multiple Imputation for Nonresponse in Surveys. 1987 New York, NY Wiley
35. Dankoski ME, Palmer MM, Nelson Laird TF, Ribera AK, Bogdewic SP. An expanded model of faculty vitality in academic medicine. Adv Health Sci Educ Theory Pract. 2012;17:633–649
36. Bloom SW. Structure and ideology in medical education: An analysis of resistance to change. J Health Soc Behav. 1988;29:294–306
37. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114:513–519
38. Rhoads JM. Overwork. JAMA. 1977;237:2615–2618
39. Pincus CR. Have doctors lost their work ethic? Physicians’ disability claims increase. Med Econ. 1995;72:24–30
40. McMurray JE, Williams E, Schwartz MD, et al. Physician job satisfaction: Developing a model using qualitative data. J Gen Intern Med. 1997;12:711–714
41. Buchbinder SB, Wilson M, Melick CF, Powe NR. Primary care physician job satisfaction and turnover. Am J Manag Care. 2001;7:701–713
42. Wahls TL, Olson KA, Turney SL. Practice satisfaction and dissatisfaction in general internal medicine departments of large multispecialty clinics. J Gen Intern Med. 1993;8:578–579
43. Bates AS, Harris LE, Tierney WM, Wolinsky FD. Dimensions and correlates of physician work satisfaction in a midwestern city. Med Care. 1998;36:610–617
44. Leigh JP, Kravitz RL, Schembri M, Samuels SJ, Mobley S. Physician career satisfaction across specialties. Arch Intern Med. 2002;162:1577–1584
45. Spickard A, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians: Definitions, risk factors, and prevention. JAMA. 2002;288:1447–1450
46. Ramirez AJ, Graham J, Rishards MA, et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer. 1995;71:1263–1269
47. Harter JK, Schmidt FL, Killham EA, Agrawal S Q12 Meta-analysis: The Relationship Between Engagement at Work and Organizational Outcomes. 2009 Washington, DC Gallup Organization
48. Deci EL, Ryan RM. The “what” and “why” of goal pursuits: Human needs and the self determination of behavior. Psychol Inq. 2000;11:227–268
49. Deci EL, Ryan RM Self-determination theory: A macrotheory of human motivation, development, and health. Can Psychol. 2008;49(3):182–185
50. Goldman BM, Kernis MH. The role of authenticity in healthy psychological functioning and subjective well-being. Ann Am Psychother Assoc. 2002;5:18–20
51. Kahn WA. Psychological conditions of personal engagement and disengagement at work. Acad Manage J. 1990;33:692–724
52. Kahn WA. To be fully there: Psychological presence at work. Hum Relat. 1992;45:321–349
53. Csikszentmihalyi M Beyond Boredom and Anxiety: Experiencing Flow in Work and Play. 2000 San Francisco, Calif Jossey-Bass
54. Csikszentmihalyi M Flow: The Psychology of Optimal Experience. 1990 New York, NY Harper & Row
55. Alderfer CPLorsch JW. An intergroup perspective on group dynamics. In: Handbook of Organizational Behavior. 1987 Englewood Cliffs, NJ Prentice-Hall:190–222
56. Smith KK, Berg DN Paradoxes of Group Life: Understanding Conflict, Paralysis, and Movement in Group Dynamic. 1987 San Francisco, Calif Jossey-Bass
57. Pololi LH, Dennis K, Winn GM, Mitchell J. A needs assessment of medical school faculty: Caring for the caretakers. J Contin Educ Health Prof. 2003;23:21–29
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