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Abstract

Academic medicine as a practice model provides unique benefits to society. Clinical care remains an important part of the academic mission; however, equally important are the educational and research missions. More specifically, the sustainability of health care in the United States relies on an educated and expertly trained physician workforce directly provided by academic medicine models. Similarly, the research charge to deliver innovation and discovery to improve health care and to cure disease is key to academic missions. Therefore, to support and promote the growth and sustainability of academic medicine, attracting and engaging top talent from fellows in training and early career faculty is of vital importance. However, as the health care needs of the nation have risen, clinicians have experienced unprecedented demand, and individual wellness and burnout have been examined more closely. Here, we provide a close look at the unique drivers of burnout in academic cardiovascular medicine and propose system-level and personal interventions to support individual wellness in this model.
Support for the current and emerging cardiovascular academic workforce is critically important in the United States because future discovery and advancing science rely heavily on this group. The American Heart Association believes that the well-being of clinicians, researchers, and the entire health care workforce is paramount to achieving excellence in clinical care and academic pursuits.1,2 Burnout is an occupational hazard resulting from excessive workplace stress and is characterized by emotional exhaustion, depersonalization, and dissatisfaction with personal accomplishments.3 Compared with US working adults, burnout and reduced satisfaction with work-life integration are more prevalent among physicians; >25% of cardiologists and fellows in training (FITs) are affected, often disproportionally those in midcareer, women, individuals of underrepresented groups, and members of the LGBTQ+ (lesbian/gay/bisexual/transgender/queer/plus other identities) community.4,5 A hectic work environment, lack of control over workload, and insufficient time for medical documentation are independently associated with higher rates of burnout among cardiologists.6 A number of the topics discussed in this document are common in the academic setting and not necessarily unique to FITs or early career cardiologists. The goal is to make the facilitators and barriers to success in academia more clear and to minimize frustrations experienced in the early career stage.
The consequences of burnout are not insignificant and include lower-quality patient care, higher rates of medical error, decreased productivity, and reduced patient satisfaction. Disruptive behavior and loss of professionalism may manifest,7–11 and health care system cost escalates as a result of decreased clinical productivity and increased turnover.12–15 Personal ramifications of burnout include broken personal relationships, substance use, depression, and suicide.16–19 Clinician well-being is often described as having a feeling of satisfaction and engagement, along with a sense of professional fulfillment and meaning in work.20 It is important to acknowledge that burnout is not the antithesis of well-being but rather part of a continuum (optimal well-being, high stress, burnout) and represents a more severe form of breakdown in well-being. Improving professional fulfillment can be achieved by fostering a culture of wellness, promoting efficiency in practice, and cultivating personal resilience.21 The definition of individual wellness may vary depending on who is asked‚ but for many academicians‚ it includes having the opportunity to be creative, feeling challenged, and achieving success, both at home and professionally. It is true that some factors that drive well-being may not be under individual control. However, this document focuses on practical ideas and constructs such as career success and alignment of work assignments with personal goals that may lend to individual influence. Burnout among academic cardiovascular professionals is somewhat different from that in other practice models, resulting from the rapidly changing pace of health care and burgeoning workload requirement, the need for advanced expertise to treat increasingly sick patients, and the unique academic expectations such as promotion and scientific investigation. The immediate goals of this document are to outline the unique drivers of burnout in academic cardiovascular medicine and to propose both system-level and personal interventions to mitigate it and to support future physician-scientists, clinician-educators, and clinical academic physicians.

Current and Future Academic Physicians

What Defines the Academic Cardiovascular Physician?

In the past, academic physicians were expected to master an entire field of study, to independently conduct research, and to provide adequate care to cardiovascular patients. The traditional academic physician-scientist track is still common. However, with the adoption of more formalized teaching models, professional curriculum development, and educational scholarship, the physician-educator phenotype has emerged and become a common track for many academicians. Many universities no longer offer tenure to clinical faculty and now encourage promotion through a clinical track, in which excellence is measured by referrals, volume, expertise in a clinical niche, or the development of new clinical programs and service lines. The landscape for academic medicine is constantly changing, and available positions continue to vary depending on institutional and regional needs. Large universities are no longer the only market for academic jobs; satellite campuses have become increasingly common, as well as graduate training programs affiliated with community or corporate hospitals and medical groups.

Unique Drivers of Stress in Academic Cardiovascular Medicine and Training

Academic medicine offers the cardiovascular professional access to distinct clinical populations and the ability to pursue scientific research and to play a role in the education of future cardiovascular professionals, all of which are rewarding. However, academic positions can drive stress, and eventually burnout, in ways that are unique and include (1) productivity-driven compensation models that force competition for time between clinical care and academics,22–24 (2) the requirement for promotion in systems that have not evolved to consider combined clinical and academic expectations, and (3) distinct expectations based on faculty pathway (eg‚ grant funding, publications; Figure 1).
Figure 1. Unique drivers of burnout in academic cardiovascular medicine. There are unique drivers of burnout in academic cardiovascular medicine. Clinical and academic factors apply to all groups; however, the academic phenotype (clinical, education, or research) of the individual opens the door to additional stressors related to the path of promotion and academic work. RVU indicates relative value unit. Figure created with BioRender.com.
In this document, academic pathways are explored in detail because many of the known challenges can, at the very least, be mitigated if identified early and addressed effectively. However, linking physician compensation to productivity in the academic setting is worthy of discussion because it often erodes the support needed to successfully achieve academic missions while contributing to stress and burnout. Physicians in an equally efficient practice environment increase productivity or revenue primarily by shortening the amount of time with patients, ordering more tests/procedures, or working longer.12 The first 2 approaches may diminish the quality of care; the last approach increases the risk of burnout, particularly in physicians because they often have high educational debt and a strong desire to help, often with minimal resources, and may be subject to unhealthy role modeling by colleagues and the normalization of extreme work hours during the training process.25–27 Like productivity compensation models, the overall structure of health care delivery has affected the burden of stress on academic physicians, including growing health systems, community/academic partnerships/acquisitions, and the integration of different practice models under single academic umbrellas, yet often with disparate compensation models.
At the early career and FIT level, exhaustion is further affected by significant changes in personal and family life that often coincide in timing. Long hours and high clinical demand promote inflexibility for unexpected events such as family care issues or illness. Financial strain, particularly in the face of substantial educational debt and potential dependent care needs, may further increase stress in the early career years. FITs have fewer resources such as parental leave or the funds to pay for childcare, pressing them to make “either-or” decisions about families or career. These factors may affect career choice, especially if advanced training and subspecialization are required or additional research years and early career grant funding are needed to successfully pursue academics. Underrepresented racial groups, ethnic groups, and women likely experience additional obstacles in this respect. To that end, it is important to recognize that cardiovascular medicine has persistently been dominated by men, with women continuing to represent <20% of all cardiologists, despite their increased enrollment in medical school.28 This discrepancy is important to acknowledge because women in medicine are more likely to face the additional challenges of gender discrimination, gender bias, deferred personal life decisions, and barriers to professional advancement.29 These discrepancies are complicated further by family planning and considerations of the impact of radiation exposure during childbearing years.30 For underrepresented groups, the evaluation of stress and burnout is difficult, given the lack of validated assessment and understanding of cultural response bias, as well as the stigma that may be associated with responding. For this group, fundamentally identifying unique drivers of stress will require novel approaches.31

Considerations for FITs Exploring Academic Cardiovascular Medicine

Academia provides unique career options that allow physicians to engage in areas of focused interest, including clinical care, education, and research, each of which is addressed here. Although it is beyond the scope of this document, it is also important to recognize that academic models may offer distinct opportunities in quality improvement, data science, and technology, to name a few. In addition to the focused areas of interest, academic medicine provides a culture supportive for career growth and change over time, which may foster increasing personal and career-related satisfaction. These positive aspects of academic medicine, however, must be weighed against the unique drivers of stress, including both perceived and real barriers in academic medicine32–39 (Table 1). Dispelling misconceptions about perceived barriers requires in-depth exposure to and mentorship from experienced academicians and peer groups. Barriers such as nontransparent productivity goals, navigation of academic promotion, the pressure to take on increasing responsibilities, and difficulty in finding an appropriate mentor can be facilitated with a specific skill set, which includes the development of good communication skills, savvy negotiation techniques, clear goal planning, resilience and grit, effective mentorship, and networking and collaborating with others. However, other academic drivers of stress require broader involvement at the institution and societal levels.
Table 1. Considerations for an Academic Cardiovascular Medicine Career
Examples of barriers
Perceived
Academic careers not favorable: Historically, academic medical centers may not have highlighted the unique benefits of a career in academic medicine. The benefits are many: synergy in patient care, education, and research work; collaboration between specialists, scientists, and clinicians; and streamlined processes to translate scientific findings both from bench to bedside and from bedside to bench.
Career versatility: Many clinicians believe that once one leaves academia, return is not possible. However, with the broadening of education and research goals, many physicians cross between private, hybrid, and academic practice.
Real
Productivity expectations: Early career physicians are often unsure of clinical productivity metrics and individual expectations for productivity in early practice. As it pertains to contract negotiation and new independent roles, early career professionals may not appreciate how difficult it is to achieve specific targets. For example, how many echocardiograms, angiograms, or patient encounters are needed to meet an annual goal of 7000 RVUs?
Ambiguity in promotion and tenure: The promotion and tenure process is heterogeneous across institutions and therefore can be difficult to navigate. Common questions many early career faculty members have may include the following: How many manuscripts need to be submitted or accepted in a year? How much grant funding does one need to secure? How important are first authorships, citations, and journal impact factors?
Pressure to say “yes”: When making the transition from fellowship into early career, academicians are often asked to participate in activities that may not be aligned with their desired career paths. The pressure to say “yes” is substantial, and most early career academicians have difficulty understanding which endeavors to participate in, a fact often complicated if mentorship is lacking.
Finding a mentor: In contemporary academic practice, seasoned physicians often encourage team-based mentorship in which a variety of individuals make contributions.32 For example, one may require a research mentor, a career mentor, and other senior faculty members to provide additional advice and insights. Finding the right group of mentors may be challenging, depending on the individual’s unique needs.33–35 Possessing and developing good communication and interpersonal skills (for example, being affable, kind, and grateful) are critical to building successful and long-standing mentor-mentee relationships. Organizations such as the American Heart Association have developed mentorship programs and opportunities for research collaboration with senior scientists.
Real and perceived
Work-life integration: Physicians in academia consistently identify work-life balance/integration as a major challenge, a fact that is highly variable depending on career position, sex, and other life factors.36,37 The concept of integrating work and life outside of one’s work should be promoted in academia, with the realization that perhaps no perfect work-life balance exists but synergy between the two may be achievable.38,39Research support: Academic medical center budgets are under increasing strain, with many having eliminated startup packages that may have been offered to early career faculty in the past. However, many institutions have replaced these discretionary funding accounts with needs-based or merit-based pilot funding or general support for manuscript writing and statistics. These changes likely unnecessarily broaden competition when funding and resources are limited.
RVU indicates relative value unit.

The Academic Medicine Environment: Clinical

Description

The clinical academic physician maintains focus on clinical care and programmatic growth and development. This group often finds that their specialized clinical interests can be met only at a large tertiary teaching hospital. Many will build and grow highly specialized programs to meet the needs of increasingly complex patient populations, often requiring a geographically broad catch net for referrals. Yet for others, the mission may include multidisciplinary program development and leadership, with additional efforts dedicated to clinical research (including team science), education, and hospital administration. Here, we examine the unique challenges for those physicians who choose a career as an academic clinician.

Contributors to Exhaustion/Burnout

The drivers of clinical academic physician stress fall into 3 major domains: efficiency of practice and a culture of wellness, which are primarily organizational responsibilities, and maintaining personal resilience, which often falls on the individual physician.40 Growing data support that physicians are not deficient in resilience; burnout happens in even the most resilient doctors, which supports that future efforts should focus on system-based intervention to promote well-being.41
Numerous challenges are shared in both the community and academic clinical settings such as electronic health record struggles, regulatory compliance, ever-changing reimbursement policies, prior authorization programs, meaningful use requirements, and public reporting. These consistent challenges threaten physician wellness by compromising efficiency of practice. However, recent data suggest that younger physicians will drive advances in technology that may contribute to improved efficiency.42 Although this may not overcome the mismatch between physician and organization definitions of value-based care, greater work flexibility may promote increased resilience in younger generations.42
Many academic physicians who pursue new program building and growth are poorly prepared for managing the business of health care, and academic practices often lack the appropriate support structure for success. Health care is most effectively delivered by high-performance teams, a fact that is founded on 2 important principles: (1) Exponential advances in scientific discovery and evidence-based practice, increasingly specialized diagnostic strategies and therapeutic options, and continued subspecialization mandate diverse perspective and interdisciplinary care; and (2) teams, with their collective skill set, lived experiences, and judgment, are more effective than hierarchical or bureaucratic forms of health care delivery in terms of efficiency and quality of care for patients.43 Team-based care is a foundation of contemporary health care redesign models, and physicians must be proactive in assuming leadership positions.44
The academic clinician choosing to build a program requires an understanding of clinical integration and strategy, hospital operations, cost, and quality management, in addition to clinical expertise, leadership skills, and innovation. A diverse team can be leveraged to supplement any gaps in these domains but also to identify blind spots and offer alternative courses of action for planning and troubleshooting. Successful program leaders require ancillary and administrative support, protected time/effort for program building and goal setting, and potentially advanced leadership or business professional development to optimize skills and success (Figure 2).
Figure 2. Pillars of clinical program building. Clinical academic cardiovascular professionals often engage in new program development and building. The skill set required for new clinical program development is often not part of standard medical education curriculum. Therefore, those who take on new program development will need to rely on mentorship and both traditional and nontraditional acquisition of the pillars required for success in this pathway. Figure created with BioRender.com.

The Academic Medicine Environment: Education

Description

Academic educators are important for the future of medical care in the United States because they are responsible for training the next generation of physicians. Although education remains a central tenet in academic practice, the true physician-educator is someone who typically assumes a leadership role in medical student, resident, or fellowship education or may serve as a training program director or associate program director. Practically, the path to becoming an academic physician-educator includes exposure to faculty development opportunities during graduate medical education and the early career years. However, few physician-educators acquire formal training in medical education (ie, master’s degree in medical education). Although formal education tracks and degrees in medical education have become increasingly popular, the impact of these programs on the future academic clinician-educator remains unclear.

Contributors to Exhaustion/Burnout

To be successful, clinician-educators require time for developing curriculum, participating in direct education/instruction, observing and providing feedback and evaluation, and modifying education plans. This may require direct fiscal support, institutional sponsorship, and protected time for educational work. Administrative staff (ie, program coordinators and personnel committed to the fulfillment of the educational mission) are frequently not supported at the division or department level but remain critical to the success of educational programs and important to the well-being of physician-educators. Declining reimbursement coupled with the tie between clinician compensation and productivity has eroded the value in any time that does not generate revenue. As a result, the support structure for education has been negatively affected.

The Academic Medicine Environment: Research

Description

The foundation required for a career as a physician-scientist includes clinical care training coupled with (clinical or basic science) research training/experience. This background provides a unique skill set that allows the integration of research from bedside to bench and from bench to bedside.45 Translational and applied sciences can successfully be achieved within this context. However, it is worrisome that the number of physician-scientists in the United States is declining.45 The physician-scientist was deemed an endangered species as early as 197946 and has been the continual focus of the National Institutes of Health, including the more recent Physician-Scientist Workforce Working Group aimed at encouraging and retaining clinician-researchers. This effort is an expensive and highly demanding undertaking; it takes 13 to 17 years to successfully achieve independent investigator status.45

Contributors to Exhaustion/Burnout

The most unique risk factor for burnout in physician-scientists relates broadly to the research support infrastructure. The National Institutes of Health provides ≈82% of federally funded research in the United States, with a minority of funding coming from other sources (ie, foundational grants, private grant sources, industry).47 The number of investigators applying for funding has nearly doubled in the past 20 years, halving the likelihood of receiving National Institutes of Health funding from 30% to 35% down to 18% to 20% since the early 2000s.48 Funding opportunities appear to be even more competitive for women and individuals from underrepresented racial and ethnic groups, who make up a minority of successfully funded applications.49,50 The difficulty in securing research funding is compounded by the fact that research effort is split with clinical effort, and physician-scientists are often at a disadvantage when competing with investigators who can dedicate their full-time effort to research. The divide created by this time/effort chasm is propagated by incentives that favor clinical over research productivity. This push toward clinical effort is compounded even further as academic medical centers struggle to provide fair market value compensation to their clinical physician workforce.
For physician-scientists, additional drivers of academic stress include lack of access to appropriate senior-level mentorship; inequalities in the workplace; cuts in institutional support for research, requiring investigators to “do more with less”; extension of research or clinical duties to off-time such as weekends and vacations; and rising educational debt without commensurate rises in compensation.

Preparing The Next Generation of Academic Cardiovascular Physicians: a Call to Action

It is easy to identify how the unique drivers detailed here contribute to exhaustion, yet many are external and beyond the control of a single individual. Therefore, if the goal is to support and promote the continued contributions of academic physicians (education, scientific advance, specialty programs) to health care and the US population overall, the proposed solutions must be largely at the level of organizations, institutions, and government. Academic medicine provides unique career options that allow physicians to pursue focused areas of interest in medical content and career design. It offers the opportunity to grow under continuing guidance and mentorship of experts in the field and to shift interests over time, leading to increased engagement, career versatility, and satisfaction. Academic physicians are critically important to the future of medicine and are accountable to train the next generation of physicians, to care for the sickest patients, and to participate in new discovery to treat and cure disease. In this document, we have reviewed both common and unique drivers of burnout in the most common academic physician phenotypes. Here, we focus on potential solutions for FITs and early career faculty members who embark on pursuing a career in academic medicine, understanding that the support for well-being includes global recommendations for the health care workforce1 but also specific support depending on the type of academic practice/role that one chooses (Figure 3).
Figure 3. Tools to mitigate burnout risk in cardiovascular medicine academicians. To help reduce burnout, all cardiovascular academic physicians require support for clinical and academic expectations. However, unique support structures and systems are required for each of the academic phenotypes: clinical, education, and research. The specific pathway support needs provide the foundation for early success and continued development for an individual’s unique academic pathway. Resources to support these needs should be explored and expanded to include both academic and nonacademic sources, given that the product of academic medicine benefits all health systems: educated and trained physician workforce, complex patient care clinics/programs, and scientific advancement for understanding disease and treatment. EHR indicates electronic health record; and GME, graduate medical education. Figure created with BioRender.com.
At the outset, the unique needs of trainees in some specialties are worthy of mention. Trainees in areas such as cardiothoracic surgery, interventional cardiology, clinical electrophysiology, advanced imaging, and interventional radiology are uniquely challenged because of their need to accrue high-volume clinical experience and technical expertise to be certified as competent. At the same time, these FITs may require training and mentorship in other areas such as leadership, research, and education. Combining clinical and research (or education) interests is recommended to enhance efficiency while allowing the FIT to develop an academic reputation that can be built on as academic promotion is pursued. Given the time needed to develop procedural competency, it should be recognized that FITs in procedural subspecialties may take longer to achieve excellence in all academic areas.
Equally important is the experience of trainees and early career faculty from underrepresented groups such as members of the LGBTQ+ community, women, and individuals of historically underrepresented races and ethnicities in cardiovascular medicine. A single solution cannot address all of the barriers for special populations of medical professionals, but overarching principles should be applied and provide a good start for supporting change. Diversifying the workforce in academic cardiovascular medicine will require partnerships with institutions and dedicated funding to tailor academic and psychosocial support structures to maximize the potential of underrepresented groups. This may include, for example, access to on-the-job training and skill set development through specialized learning programs or dedicated research or educational funding. More broadly, stakeholder involvement and support through philanthropic, advocacy, and governmental agencies will be required to advocate for academic medical environments that embrace diversity to improve health care for all.51

General Recommendations for the Early Career Academic Physician

Creating efficiency in the workplace is a key intervention that can help build a manageable schedule, reduce the likelihood of burnout, and support the goal of creating a fulfilling academic career. Although efficiency in work is not the same for everyone, some key tenets may be helpful for the majority of physicians (Table 2).
Table 2. Key Tenets to Creating Workplace Efficiency
Key tenetExamples
Time managementLimit meetings to the minimum necessary
Consider using digital project-sharing tools
Learn when to say “no” to focus your energy
Minimize distraction
Track your time and schedule
Delegate mindfully and collaborate
Consider avoiding unnecessary commutes; work from home some days; obtain the necessary social and family support (ie, aids at home, childcare support)
Incorporate flexibility into work hours
Identify and reduce duplicative efforts
Be mindful of (and avoid) perfection; perfection≠productivity and busy≠productive
Negotiate protected time for research, education, or administrative tasks when feasible
Manage communicationLimit the number of types of communication (ie‚ minimize unnecessary nonbusiness emails)
Reply succinctly to emails
Practice effective communication strategies (ie‚ sometimes a phone call or text message may mitigate a series of emails)
Plan and stick to a time of day for cutoff from email/messages
Provide clear communication (ie, SMART: specific, measurable, attainable, relevant, time bound)
Meet efficientlyMake sure all meetings have a clear (circulated) agenda
Ensure that relevant people/stakeholders are invited
Encourage participants to be prepared and to provide undivided attention
Record notes that indicate plan of action and dates due
Provide clarity for roles/duties/tasks
Respect the meeting time
Manage projectsAssemble the right team (including a project manager or administrative assistant when feasible/needed)
Be direct; set specific and attainable goals; measure progress; and provide timely feedback
Enhance your efficiency (ie‚ finalize important tasks at the beginning of the day, when fresh and energized; delete unimportant tasks; begin the day early when feasible)
Break large projects down into smaller tasks
Get help and delegate low-priority tasks; do not micromanage
Train employees and provide appropriate supervision and mentorship to enhance commitment (better than enforcing compliance)
Monitor (and address) bottlenecks
Complete tasks according to priority and importance (eg‚ [1] urgent/important, [2] not urgent/important, [3] urgent/less important, [4] not urgent/less important)
Organize your workspace (digital and physical); use automation when possible
Establish realistic end dates and manage them; do not procrastinate
Consider ultradian rhythms; work uninterrupted on a task or group of (related) tasks in 90-min intervals
Minimize multitasking (usually decreases efficiency and may prolong the time of the initial task by 25%)
Take planned brain breaks (including daily breaks to think creatively) and time off to recharge and get adequate sleep
Reward team members, including yourself
Think about the big picture (strategically)
Time protection is one of the most important tenets to consider when building an academic career. Often, early career professionals are excited to “jump in”; however, they often find themselves overcommitted and may be undersupported. Early career academicians should strive to protect their time, to enhance efficiency, and to focus on top-priority tasks that are aligned with their career goals. Declining low-priority tasks is important but needs to be done tactfully, with awareness of the departmental mission. The creation of a 5-year plan is reasonable to lay out short-term goals. Securing harmony between clinical and research content may require savvy negotiation skills that highlight the ability to recruit for prospective studies, to generate research, and to create a local registry of patients. In the absence of an existing clinical program aligned with one’s research interests, volunteering to develop a new needed service might be appropriate and appreciated, yet it must be recognized that this may require development of a business plan and guidance from administrators and physicians with similar experience. Last, when a new program is being developed or a highly specialized area that grants authority on a specific topic is being pursued, the upside niche of expertise must be balanced with the downside that there is likely a shallow pool of practitioners competent in this area of expertise. Thus, when the clinical need arises, time may be taken from other academic pursuits for care of patients. To further support the protection of time such that it aligns with goals, early career faculty should consider the exploration of flexibility in work duties. Some clinical duties such as interpretation of ECGs, echocardiograms, or other noninvasive tests provide flexibility that may allow shifting between responsibilities such that when grants or other deadlines are looming, clinical duties may be shifted. Although these recommendations are important for the early career cardiologist, they may not be within an individual’s control. Therefore, it is important to have strong mentors and leaders who advocate for early career faculty development.
To enhance academic career success, it is highly advisable that early career cardiovascular professionals build individualized strategies to combat fatigue and to promote wellness, focusing on self-care and healthy habits (adequate sleep, healthy nutrition, exercise, outside interests, meaningful social relationships). Resilience and grit are important attributes and can be learned but remain only a small piece of wellness. Although the main focus of the early career is to grow technical skills, one should also work on nontechnical skills such as leadership, communication, strategic thinking, project management, and professionalism, particularly with career advancement. To the extent that wellness is attributable to systemic issues, the early career cardiologist should leverage support from mentors and local leadership.
Last, an important premise of early career success and burnout mitigation is choosing the right position, particularly with respect to organizational culture and alignment with individual values. Those who find themselves working in a toxic environment (ie, lack of trust/support, unhealthy rivalry, no mentorship, existence of in-groups/out-groups) should attempt to improve their environment. However, if the work environment is not conducive to achieving individual goals or if growth potential stalls, alternative opportunities may need to be considered. This is especially important before irreversible exhaustion and eventual burnout ensue and derail career aspirations.

Specific Recommendations for the Clinical Academic Physician

We must recognize that professional satisfaction should be a shared responsibility between the clinician and the institution. Each must adapt their values to find a middle ground that meets the needs of both, recognizing that health care is both personal and a business. Interventions to support efficiency of practice and a culture of wellness span normalizing and supporting flexible work environments to enhancing clinical support. It is important to note that physicians working in flexible clinical environments will maintain some control over their schedules. To enhance flexible clinical environments, the following should be considered: (1) float pools (float teams provide care to bridge gaps when a physician is not available), (2) job sharing, (3) flexible hours (shifting to less traditional clinic hours may benefit physicians and patients), and (4) telemedicine. Technology may help reduce physician documentation burdens and automate repetitive tasks such as using dictation to reduce note writing time and leveraging automated tasks within the electronic health record such as order sets, note templates, or scribes. Early career cardiologists may wish to consider negotiating for scribe support as part of their hiring process. In addition, for clinical academic physicians, education in business management, coding/billing, program development, and marketing may be required to provide the tools needed to be successful. Special attention to faculty development is required for this group as they navigate the changing landscape of promotion and tenure while providing predominantly clinical service. Many institutions and societies offer leadership development programs that address these skills, and these programs should be considered by early career cardiologists as part of their hiring package. Last, a focus on process improvement, leadership, and project management skills, as well as teaching and curriculum development, in health care will be needed for success in an academic clinical role.

Specific Recommendations for the Physician-Educator

Despite the challenges associated with pursuing an academic clinician-educator path, significant rewards remain. This career path offers physicians a meaningful role in the transfer of knowledge from one generation to the next. In addition to providing instruction to learners at the undergraduate and graduate medical education levels, the physician educator provides education to members of the cardiovascular team and to patients. Fostering academic clinician-educators is important to all members of the health care system and to society overall. Interested FITs should be exposed to mentorship opportunities aimed at developing their skills as clinician-educators early during training. This should include exposure to fundamental principles of educational theory and competency-based training. Institutional support is critical to the continued success of educating top medical talent (Figure 2).
Educator support is traditionally derived from departmental budgets, but efforts should be made to pursue support from other groups who derive benefit from physician education: private payers, government, and industry. Last, equitable compensation to clinical-based peers, perhaps exploring alternative sources of compensation to provide stipends by sectors that rely on US–trained physicians, is important to attract and retain top talent. Only with this type of proposed support can the clinician-educator pathway be sustained while fostering those who are passionate about this cause and can remain fully committed to continue to educate the next generation of US–trained physicians.

Specific Recommendations for the Physician-Scientist

The benefits that result from fostering physician-scientists are easily understandable: Medical innovation, discovery, and novel therapeutics are among the top potential rewards. These benefits are potentially realized by the population at large, so the fundamental question is, “Whose responsibility is it to support this group?” In the past, this has largely fallen on academic universities, the National Institutes of Health, the American Heart Association, and other typically not-for-profit funding organizations. However, many of these groups have declining profit margins, lower budgets, and fewer personnel to accommodate increasing work requirements. In current compensation models, physician-scientists are disadvantaged because revenue production is weighted against research, resulting in an economic misalignment of incentives. A detailed exploration of individual funding opportunities is beyond the scope of this document. Early career physician-scientists are encouraged to think with their institution about how to secure funding for (1) direct research support at a duration demonstrated to allow early career development grant awardees to successfully attain independent investigator funding (at least 5 and likely up to 10 years),52 (2) indirect research support, and (3) equitable compensation (Figure 2). More globally, this discrepancy will likely require a shift in the current paradigm wherein alternative funding streams and support will require careful thought and likely the integration of government and private incentive-based structures.
From an individual standpoint, the first step in garnering adequate research support often involves showing scientific promise. This can be demonstrated in different ways, including a history of scientific presentations and publications, a record of previous funding, known relationships with successful investigators, contribution to the scientific community, and preparation of a detailed research plan that includes individual career goals and scientific research goals. Well–laid-out career and research program goals create the foundation to negotiate required direct and indirect research support. This may vary considerably among investigators; some may approach their first position with funding in place, whereas others may require institution- or organization-sponsored bridge funding. The career and research plan document may outline direct research support required to accomplish the goals, as well as indirect support such as access to biostatistics faculty, support for publication, meeting travel assistance, and access to shared equipment. In summary, the physician-scientist has the added requirement of producing not only a well–thought-out individual career plan but also a reasonable research plan. These documents should be reviewed with at least 1 or more trusted mentors, reviewed and revised if applicable‚ and ultimately used to negotiate the support system required to be successful.

Conclusions

The future cardiovascular health of Americans relies on a well-trained and experienced physician workforce created by rigorous academic medical training. Cardiovascular physicians pursuing careers in academic medicine are critical to continuing this mission, which includes providing clinical care for common and increasingly complex disease, educating and training the next generation of physicians/health care workers, and pursuing scientific discovery and innovation to treat and cure disease. Exhaustion and burnout uniquely threaten future and early career academic physicians. However, with appropriate mentorship, goal planning, strategic practice efficiency skill sets, and negotiation for specific tools related to the academic phenotype (clinical, education, research), young academicians can look forward to a fulfilling and long career in academic cardiovascular medicine.

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Circulation
Pages: e229 - e241
PubMed: 36120864

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Published online: 19 September 2022
Published in print: 18 October 2022

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Keywords

  1. AHA Scientific Statements
  2. academic medicine
  3. burnout
  4. physician wellness

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Elisa A. Bradley, MD, Chair
David Winchester, MD, MS, Vice Chair
Andrea J. Carpenter, MD, PhD
Meryl S. Cohen, MD, MS Ed, FAHA
Laxmi S. Mehta, MD, FAHA
Chittur A. Sivaram, MD
on behalf of the American Heart Association Fellows in Training and Early Career Committee of the Council on Clinical Cardiology; Council on Cardiovascular Surgery and Anesthesia; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; and Stroke Council

Notes

Dr Winchester is employed by the Malcom Randall VAMC, North Florida/South Georgia Veterans Health System, which supported him in the effort while writing this article. The views expressed in this article do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on May 12, 2022, and the American Heart Association Executive Committee on June 20, 2022. A copy of the document is available at https://professional.heart.org/statements by using either “Search for Guidelines & Statements” or the “Browse by Topic” area. To purchase additional reprints, call 215-356-2721 or email [email protected].
The American Heart Association requests that this document be cited as follows: Bradley EA, Winchester D, Alfonso CE, Carpenter AJ, Cohen MS, Coleman DM, Jacob M, Jneid H, Leal MA, Mahmoud Z, Mehta LS, Sivaram CA; on behalf of the American Heart Association Fellows in Training and Early Career Committee of the Council on Clinical Cardiology; Council on Cardiovascular Surgery and Anesthesia; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; and Stroke Council. Physician wellness in academic cardiovascular medicine: a scientific statement from the American Heart Association. Circulation. 2022;146:e229–e241. doi: 10.1161/CIR.0000000000001093
The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit https://professional.heart.org/statements. Select the “Guidelines & Statements” drop-down menu, then click “Publication Development.”
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at https://www.heart.org/permissions. A link to the “Copyright Permissions Request Form” appears in the second paragraph (https://www.heart.org/en/about-us/statements-and-policies/copyright-request-form).
Circulation is available at www.ahajournals.org/journal/circ

Disclosures

Writing Group Disclosures
Writing group memberEmploymentResearch grantOther research supportSpeakers’ bureau/honorariaExpert witnessOwnership interestConsultant/advisory boardOther
Elisa A. BradleyPenn State Health Heart and Vascular InstituteNoneNoneNoneNoneNoneNoneNone
David WinchesterUniversity of Florida College of Medicine; Malcom Randall VAMCNoneNoneNoneNoneNoneNoneNone
Carlos E. AlfonsoUniversity of Miami Miller School of MedicineNoneNoneNoneNoneNoneNoneNone
Andrea J. CarpenterUniversity of Texas, San AntonioNoneNoneNoneNoneNoneNoneNone
Meryl S. CohenChildren’s Hospital of PhiladelphiaNoneNoneNoneNoneNoneNoneNone
Dawn M. ColemanUniversity of MichiganNoneNoneNoneNoneNoneNoneNone
Miriam JacobCleveland Clinic Foundation Heart and Vascular InstituteNoneNoneNoneNoneNoneNoneNone
Hani JneidUTMB; Baylor College of MedicineNoneNoneNoneNoneNoneNoneNone
Miguel A. LealUniversity of WisconsinNoneNoneNoneNoneNoneNoneNone
Zainab MahmoudWashington University of St. LouisNoneNoneNoneNoneNoneNoneNone
Laxmi S. MehtaThe Ohio State UniversityNoneNoneNoneNoneNoneNoneNone
Chittur A. SivaramUniversity of OklahomaNoneNoneNoneNoneNoneNoneNone
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
Reviewer Disclosures
ReviewerEmploymentResearch grantOther research supportSpeakers’ bureau/honorariaExpert witnessOwnership interestConsultant/advisory boardOther
David W. BrownBoston Children’s HospitalNoneNoneNoneNoneNoneNoneNone
Julie DampVanderbilt UniversityNoneNoneNoneNoneNoneNoneNone
Ersilia M. DeFilippisColumbia University College of Physicians and SurgeonsNoneNoneNoneNoneNoneNoneNone
Akshay KhandelwalHenry Ford Health SystemNoneNoneNoneNoneNoneNoneNone
Gaby WeissmanMedStar Washington Hospital Center, Georgetown UniversityNoneNoneNoneNoneNoneNoneNone
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.

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Physician Wellness in Academic Cardiovascular Medicine: A Scientific Statement From the American Heart Association
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