Keywords

Early in the process of co-writing this chapter, we made several (what turned out to be Sisyphean) attempts to meet up. Despite working at affiliated hospitals less than two miles apart and regularly converging in the same building at least once a week, we appeared unable to connect in person. Our attempts were thwarted by the usual suspects: sudden project deadlines, a gauntlet of conference calls and meetings, suicidal patients needing urgent attention (an occupational hazard of being psychiatrists), the illness of children requiring the use of precious sick leave, an imminent concern for a parent’s heart condition leading to a trip to the emergency room—to say nothing of the general everyday complexity of our clinical, teaching, and administrative schedules.

Such a scenario is no surprise to today’s women physicians. The early career years present unique risk factors for burnout, particularly for female physicians. This section focuses on the challenges and possible solutions relevant to this time period.

Challenges of the Early Career Phase

The early career phase is defined here as a timeframe spanning medical school, postgraduate training (internship, residency, and fellowship), and the first approximately 5 years of professional development. Transitioning out of the medical student role into residency and then out of the training role into one’s first post-training position represent important inflection points during the early career phase. These transitions are typically associated with changes both in the structure of workplace obligations and in subjective experiences of professional identity. Because trainees are under particular evaluative scrutiny but lack accumulated clinical experience and may be reluctant to ask for help or demonstrate uncertainty, this timeframe is particularly associated with high risk to experience aspects of medical culture that invoke shame [14, 66, 71]. This is compounded by the reality of shifting subjective standards, tendencies to compare one’s self to others, a fragile sense of belonging, and the experience of imposter syndrome which has been shown to be more relevant in women [97].

While the peri- versus post-training periods differ in notable ways, the early career phase is unified by a focus on establishing knowledge, clinical skills, and scope of practice and on developing a more confident, authoritative professional identity. On a practical level, the early career phase culminates in the establishment of a more stable occupational role after a protracted period of being in the student/learner role.

Women are likely to face four key areas of pressure or vulnerability in the early career phase which may impact their likelihood of experiencing burn-out:

  • Relationship and community building: For most women, the early career phase coincides with a time period from the mid- to late-twenties through the mid- to late-30s during which the establishment of romantic partnerships, community belonging, and a new sense of family often occurs. For sociocultural as well as other reasons, women often have unique and demanding roles in such processes.

  • Reproduction and family: Reproductive complexities may present themselves during this biological phase of life for women. This includes the experience of unwanted pregnancies, desired pregnancies, difficulty achieving pregnancy, complications in pregnancy and childbirth, and alternate routes to starting families (such as adoption). Beyond pregnancy and childbirth, early family life presents strenuous demands on the infant’s caretaker(s). Though adoption presents more opportunity for gender equality in terms of some burdens, women remain uniquely affected by all of these possibilities and experiences.

  • Expectations of productivity: Traditional expectations around workplace productivity during the early career phase may not align with the above-mentioned tasks related to partnership, family, and community building which predominantly affect women. Needs around flexibility, work hours, sick leave, and other forms of institutional support are particularly important.

  • Gendered expectations during role changes: Gendered expectations in the workplace that apply uniquely to the trainee period and early postgraduation career period must be confronted. During the trainee period, conformation to a subordinate trainee role may be reinforced particularly for women (and the opposite—criticism for stepping outside this role—may also occur) [41, 45, 74]. Yet the transition out of the trainee role demands occupying positions of authority and utilizing that authority effectively. Women may be at a disadvantage, for example, during various workplace negotiations (including contract negotiations) if they lack these skills to negotiate. Paradoxically, women who display such skills may also be penalized [8, 50]. Moving into attending-level roles requires greater use of authority and leadership.

Early Career Solutions

To date, there is a paucity of randomized controlled trials testing interventions to prevent, mitigate, or ameliorate burnout, which makes it difficult to propose evidence-based solutions or generalize findings. It is clear at this stage that wellness solutions are not “one size fits all” [103].

We use Stanford School of Medicine’s wellness framework [7] to group challenges and solutions into three major domains that are conceptualized as impacting wellness: Culture, Efficiency of Practice, and Resiliency. Each domain is explored with an opening vignette, followed by corresponding early career challenges and individual and institutional solutions. Some solutions not only are specific to academic environments but may also be useful in mid- to large-sized group practices or other institutional settings. Most recommendations have been identified in the literature, with the addition of some solutions that have arisen from personal experience or anecdote. Importantly, though both levels of strategies are needed and have shown to reduce physician burnout, it remains unclear which interventions are most effective in specific populations and how individual and organizational solutions might be combined to achieve the most impact on physician wellness [101].

Culture of Wellness

It’s 6:30 pm on a Thursday evening, usually dinnertime for all participants, but the only available time for three faculty women and their female supervisor to convene a weekly psychotherapy consultation group. The four women log on to a HIPAA-compliant platform for a 90-minute supervisory experience to engage in support, consultation and continuing education. During the session, one woman is seen through the online video lens with her infant crawling over her, desperately vying for her attention while her mother (the colleague) tries to attend to the case presentation. Another participant is seen crossing her living room where her school-aged children are seen studying as she lets the dog out, holding her laptop in front of her in order to continue contributing to the conversation. Near the end of the evening, the third faculty woman’s husband interrupts to ask where something is in the kitchen. Two of the women eat dinner as they participate while the third nurses a child. The productive and lively discussion is concluded at 8 pm.

A culture of wellness is defined as “a set of normative values, attitudes, and behaviors that promote self-care, personal and professional growth, and compassion for colleagues, patients, and self” [85]. In the above vignette, assuming that these four colleagues felt non-coerced to perform some of their professional duties outside of normal work hours, the group has created a culture of wellness among themselves by acknowledging that this supervisory work can occur in a flexible manner (during off-hours, via an online platform) and can accommodate the family lives of those involved. This includes recognition that each member may make valuable contributions and attend meaningfully to the session, despite occasional interruptions or coinciding role performances. To the extent that the institution in which these physicians are embedded sanctions this activity (by making the online platform available and easy to use, allowing the participants to time-bank afterhours work activity, reflecting positively on the ingenuity of such arrangements, etc.), the institution is facilitating a culture of wellness.

Six critical spheres impacting women at early stages in their career development where individuals and institutions can promote a culture of wellness include (1) the culture of medicine at large, (2) flexible career policies, (3) mentorship, (4) leadership/faculty development, (5) enhanced connectedness, and (6) promotion of self-care. Potential solutions targeting each area are explored below.

The Medical Culture

The culture of medicine comprises formal and informal practices. Informally, women often report many small (and some large) experiences of gender discrimination from superiors, colleagues, staff, and patients [46]. Formally, various policies, procedures, and administrative structures have adversely impacted women and led not only to their slower career advancement but also ultimately to leaving academic careers at early states [15, 20, 21, 63, 80]. An important background force is that of unconscious bias impacting evaluation, recruitment, promotion, and possibly compensation practices [15, 20, 21, 63, 80]. This bias is compounded by sexual harassment [64] and gender discrimination [16, 46]. Compounding these issues at this stage in training is the fact that early career physicians are particularly vulnerable to making mistakes and/or feeling uncertain about their nascent skills and knowledge in the context of overwhelming responsibilities. Experiences of shame and imposter syndrome may be experienced by women in ways that intersect with gender roles and norms [13, 49].

Institutional Solutions

  • Ensure new promotion and tenure policies that support women and minorities.

  • Require zero-tolerance policies for sexual harassment and review the National Academy of Sciences’ Interventions for Prevention Sexual Harassment [65]. Establish an Office of Diversity.

  • Appoint a diverse hiring committee and change search procedures to identify and reduce bias and identify females.

  • Seek alignment of rewards and incentives along culturally sensitive policies and missions.

  • Appoint women to leadership positions to enhance recruitment, mentorship, and/or advancement of women.

  • Improve data collection and management systems to track gender demographics of search committees and data on women and minority faculty in each department to identify barriers and solutions to women’s career advancement.

  • Review compensation data to identify any inequities and disparities.

  • Track wellness among all faculty through regular anonymous wellness surveys to identify hot spots and develop interventions.

  • Implement early and effective employee on-boarding orientations within departments to explore the relevant departmental policies, practices, and guiding cultural values. Include relevant organization charts and create a central online repository for standard operating procedures and other institutional policies, best practices to address staff wellness, and where to inquire about workplace flexibility or current initiatives to improve efficiency of practice. Consider maximal utilization of the organization website to achieve these goals.

  • Provide faculty development workshops associated with mentoring, clinical supervising, and teaching to address how to recognize shame in learners, more appropriately respond to medical errors or academic struggles, and help teachers recognize their role in potentially inflicting shame on others and prevent intentional shaming in the learning climate.

Flexible Career Policies

While women tend to prioritize a work-life balance [91], early career women experience more work-life conflicts than men [51]. These conflicts and the manner in which they are resolved have been shown to influence career decisions, career satisfaction, and burnout [20, 26, 27, 63]. One major solution to addressing this issue is the development of more family-friendly, flexible career policies as well as interventions that reduce barriers to accessing the use of such policies. Having the ability to adjust professional work effort allows women to tailor work hours to meet both personal and professional obligations. By allowing physicians to reduce their work hours, they are able to recover from burnout [84].

Flexible career policies are seen as important for recruitment, retention, and career satisfaction [61, 96]. Though faculty women tend to use these policies more than men, several barriers have prevented women, in particular, from using such policies [96]. Barriers have included lack of reliable information about program eligibility and benefits; workplace norms and cultures that stigmatize participation; influence of uninformed or unsupportive department leaders; and worries about burdening coworkers through participation, damaging collegial relationships, or unfavorably affecting workflow and grant funding. Furthermore, one academic center reported that use of family-friendly policies was significantly lower within the school of medicine compared to other schools within the academic center [96]. A study of resident use and perceptions of barriers of work-life policies also report that barriers affecting the use of work-life policies include policy awareness and perception of negative attitudes from leadership [104]. Not surprisingly, the potential impact on co-resident relationships was identified as among the most commonly identified barriers. Furthermore, those residents perceiving the highest barriers endorsed higher burnout. Conversely, those residents who perceived that leadership supported the use of such policies were more likely to be aware of and actually use work-life policies.

The American Association of Medical Colleges (AAMC) has identified a “good work-life policy” as one that includes (1) paid leave offered to both full and part-time faculty, (2) no required length of prior service in order to qualify for leave, (3) 12 weeks of paid leave (longest cited), (4) 6 months (longest cited) total leave (paid and unpaid), and (4) shared leave when both parents are on faculty [4]. However, even with strong policies, women have had difficulty identifying and/or accessing an institution’s work-life policies, despite the fact the AAMC reported that over three-quarters of medical schools had policies allowing for the tenure clock to stop [4] and one-third had a policy allowing faculty to work less than full-time while remaining on a tenure-eligible track [12].

Underutilization of such policies is most commonly due to faculty not requesting their use. Reasons for this include (1) a lack of information and/or misinformation about the programs (faculty are either unaware of benefits or misinformed about their eligibility and how to access the benefits); (2) unsupportive workplace norms and cultures characterized by discouraging use of work-family benefits, a culture of overwork, pressure to publish and write grants, or fear of being perceived as not a “good faculty” member); (3) failure of the administration to plan for flexibility within interdependent teams (clinical, research, teaching) where a faculty member may feel obligated to fellow colleagues, in addition to the administration burdening faculty to plan for accommodations; and (4) lack of support of supervisors and managers [86].

Institutional Solutions

  • Implement policies that allow flexible work arrangements for faculty.

    • Ensure that flexible policies are clear and easily accessible (e.g. include on department website, in new faculty/trainee orientations, and/or in faculty manuals).

    • Identify and address barriers to policy awareness and utilization.

    • Educate department chairs and key supervisors about the policies and ensure they facilitate participation and advocate for work-life integration.

    • Consider broadening leave policies to include leaves for family members with serious illness and catastrophic events (fire, divorce, custody disputes).

    • Make childcare leave and stop-the-clock policies as opt-out vs opt-in.

    • Track program utilization to ensure it is applied equitably.

    • Ensure that university leaders reinforce support of such policies.

  • Consider programs that reduce on-the-job stress (e.g., emergency sick-child care programs, on-site child care, elder care, day care hours in line with physician schedules, remote access to EMR, telecommuting)

  • Ensure that promotion and tenure are the same for all faculty regardless of leave use.

  • Offer part-time tenure tracks for those institutions offering tenure.

  • Develop a time-banking intervention to augment flexible career policies [30]. Faculty can “buy back” time spent on otherwise uncompensated or not adequately recognized activities that benefit teams and/or individual colleagues and are allowed to redeem credits for services that would free up time to meet other demands at work or home (e.g., housecleaning, laundry, meal delivery, car service, grant writing, manuscript editing, and speech coach).

  • Align hospitals and school of medicine holidays to minimize child care issues.

  • Schedule meetings within “official” work hours.

  • Provide food services, laundry, dry cleaning, and other domestic conveniences on site to facilitate work-life integration.

  • Clarify leadership/training program attitudes toward use of work-life policies.

  • Consider solutions to build in greater flexibility to the workforce, such as hiring moonlighting physicians or shifting trainee rotation schedules to accommodate major life changes.

Individual Solutions

  • Identify and understand your institution’s flexible policies. Meet with your supervisor, human resources administrator, Office of Faculty, Diversity Office, or Office for Women.

  • Be clear about your legal protections including the Pregnancy Discrimination Act of 1978 (protects women in pregnancy against discrimination based on pregnancy), Family and Medical Leave Act (FMLA) (unpaid or paid if earned or accrued, job-protected leave up to 12 weeks a year for eligible women), and the Fair Labor Standards Act (FLSA) (provides nursing mothers the right to express milk in the workplace for up to 1 year postpartum). For more information, review AAMC Toolkit [4]

  • Negotiate your salary before you are hired! Remember, a man’s starting salary tends to be higher than that of a woman’s and taking leave or working part-time for more than 2 months can lead to smaller increases in salary [31]. Consider resources around negotiation skill-building prior to engaging in negotiation (for examples, see resources on www.leanin.org/education/negotiation).

  • When flexible policies are not being appropriately followed by your institution, consult the faculty affairs dean, equity, diversity and inclusion dean, ombudsman, or other resource centers to help negotiate a solution.

  • Consult the AAMC Toolkit [4] for further details of what and how to manage a leave of absence.

Mentorship

Mentorship has been shown to be helpful to the well-being of early career women and under-represented minority women mentees [1, 2, 98] and is a key strategy for faculty success [48]. Having a mentor and role models who are successful at integrating work and life may help foster academic advancement and prevent burnout [42, 69]. In fact, a lack of adequate mentorship and role models were some of the reasons for women’s premature departure from academic medicine [20, 55]. Though these findings reflect an academic setting, they are likely to extrapolate to other settings in which professionals are embedded in an institution or other hierarchical occupational structure.

Despite the importance of mentorship, women compared to men have more difficulty finding mentors—particularly clinician educators [76]. This is notable given that women make up nearly 50% of current medical school classes with an increasing number of women entering early faculty positions. Still, women represent only 38% of academic medical center faculty [52, 63] and far fewer are in senior faculty or leadership positions [94].

Although mentoring comes in a variety of modalities (dyadic, peer, group, etc), a mentoring network can be particularly useful to women. DeCastro et al. [23] found that multiple mentors including peers and women helped mitigate challenges related to gender in mentoring and also provided varying skill sets to meet the diverse needs of female mentees. For example, negotiations required in the early career phase represent a point of vulnerability for women who have been shown in studies to be disadvantaged by gender bias, framing of negotiations, and lack of exposure to relevant skill building [8, 88]. Appraising employment contracts is a complex task that may fall outside a woman’s expertise, and the process often involves negotiation around compensation, work hours, productivity expectations, terms of occupational flexibility, and amount of leave. Some institutions offer no negotiation around contract offerings, an experience which can echo the insubordination experienced in training. Mentorship can be invaluable to helping early career women navigate these complex issues.

One issue for women is whether it is important to have women mentors. Female mentors can be particularly useful given their differences in communication and language styles [72] and emphasis on support and collaboration over independence and competition [58]. They can serve as role models of success for mentees in areas such as workplace communication, boundary setting, negotiation, and work-life balance, particularly within the context of a male-dominated workplace environment [3, 23, 24]. However, mentoring across gender lines can produce excellent mentorship as well. Because of few underrepresented minorities in leadership including sexual and gender minority faculty, it is important for “allied” role models to serve as mentors [87]. After all, it is the lack of mentorship that has kept women from advancing—not who is doing the mentoring [23].

Institutional Solutions

  • Develop an institutionally sponsored or organized mentorship program.

  • Protect time for mentorship and/or provide credit for successful mentoring.

  • Acknowledge and reward mentors.

  • Train mentors, team leaders, and/or division chiefs in coaching skills and career development mentoring. Include topics with particular emphasis on unconscious bias; acknowledgment of complex challenges faced by early career women faculty including experiences of isolation, discrimination, and stereotyping; as well as information on how to access and use flexible career development policies to achieve personal and professional goals.

  • Address barriers to mentoring.

  • Facilitate support networks for early career women.

  • Develop peer mentorship opportunities.

Individual Solutions

  • Find a mentor. If no formal mentorship program is available, start meeting faculty. Go to social events hosted by your department and women’s networking events in the institution, or attend national organizations where networking is encouraged. Set up informational meetings with interested faculty and ask about their interests. Consider identifying a scholarly project advisor or clinical supervisor with whom to work. This is a safe way to see if the advisor or supervisor shares your interests, values, and characteristics of a good mentor (consistent, listens actively, creates a safe environment where you can share your thoughts and feelings, able to strike a balance between autonomy and guidance, and treats you and your goals with respect) [44].

  • Develop a personal mentor network. Identify and include peers and/or faculty within and outside your institution who have expertise in a number of diverse skills, given the range of one’s career tasks (i.e., teaching, administration, and leadership). One mentor is often not enough! Ensure that at least one mentor is a woman and of high standing.

  • Be proactive. Once a potential mentor(s) is identified, ask if they might have time to regularly mentor you. Take responsibility for the relationship: develop clear, specific goals and strategies to achieve goals, and set a meeting schedule and agenda. Engage in critical self-assessment, track your progress on goals, and ask for and integrate feedback. Use an Independent Development Plan (see Appendix 1) as a template to help self-reflect and guide mentoring discussions.

  • Identify important topics to explore. Topics of particular interest to early career faculty might include how to access and effectively utilize flexible career policies and benefits; how to balance divergent commitments of clinical service, research, teaching, administration, and family; when to consider having a child and how to address this with administration and colleagues; how to manage sexual harassment, stereotype threats, and implicit bias; how to develop negotiation skills—particularly as they apply to compensation and resource acquisition; and how to diplomatically say “no” when opportunities are not aligned with values or career goals. Other topics might include how to transition from training to practice, identifying core values that will enhance meaning and joy in your life, guidance around career choices, how to maintain a healthy lifestyle, and ways to think about promotion, scholarship, service involvement, and time management.

  • Create peer mentorship groups. If not offered through the organization, find peers with whom you can meet on a regular basis to discuss issues that affect early career women or who share interest in specific research topics. You may want to bring in speakers to address particular relevant issues to the group. Such groups might also serve as writing groups where members can gain writing skills and publish while advancing their careers. Writing groups can commit to rotating first authorship and key tasks in article development to ensure that the entire group progresses academically.

  • Consider sponsorship of group meetings through national organizations (i.e., AMWA).

Leadership and Faculty Development

Historically, women have been abandoning careers in academia at early career stages partly due to dissatisfaction based on few opportunities for professional development and difficulty networking because of a paucity of senior female mentors and poor access to those in positions of power [20]. As such, faculty development (FD) must focus not only on developing and practicing nascent skills of early faculty women starting out in their careers but also on skills of faculty in leadership positions who have significant impact on early career women. For women in non-academic settings, FD may be analogous to leadership development. Whether or not women desire to seek leadership roles, such skills may contribute to important role functions (e.g., greater sense of self-efficacy, institutional engagement, and experience of influence on workplace culture). Aside from leadership or other work-based skills, FD might also include ways to manage work -life challenges and promote well-being [10].

Leadership styles significantly impact the well-being of those they lead [83, 106]. As part of improving the skills of leaders, leaders need to understand that some early career faculty may base career success more on intrinsic factors such as a respect and passion for and recognition of work rather than on other conventional definitions of success including promotion, publications, and compensation [22]. By addressing those factors that are important for a women’s meaningful career, leaders may be able to mitigate burnout and improve retention.

Unfortunately, since few women serve in leadership positions within schools of medicine [94], early career women have few female role models and senior mentors. Without an identifiable pathway to leadership, women’s career opportunities may seem limited. As the number of women in leadership positions increases, a cultural transformation may lead to a more inclusive, collaborative, and less hierarchical environment [70], and, therefore, lessen burnout and enhance professional fulfillment.

Institutional Solutions

  • Survey early career faculty regarding their FD needs and address barriers to engaging in FD.

  • Task the Office of FD and/or Women and Diversity, and/or create a task force to review the current state of FD in the institution and make recommendations.

  • Develop FD programs for early career women on key faculty skills (e.g., management, work-life balance, negotiation, career development, promotion/tenure, and wellness strategies) and workshops on transitioning from training to practice. When scheduling such programs, it is important to accommodate early physician’s clinical demands and less-flexible schedules [36].

  • Identify resources and funding for junior faculty to make use of faculty development opportunities and advertise them more effectively.

  • Select leaders thoughtfully based on their ability to listen, engage, develop and lead physicians and assess them regularly [83].

  • Implement leadership development programs for current leaders and/or workshops on leadership skills, communication, unconscious bias, and gender and diversity issues, including how to motivate early career women based on their values and meaning for success.

  • Develop sponsorship programs to advocate and facilitate advancement of talented women [95].

Individual Solutions

  • Identify and take advantage of FD offerings through your department, institution, and/or national organizations.

  • Review benefits to determine whether there are funds to support going to FD opportunities outside the department/institution.

  • Find out about leadership programs whether within your organization or external to your organization (AAMC, AMWA, AMA, specialty organizations).

  • Ask your mentor to help you develop leadership and other important skills and/or advocate for your nomination to a leadership program.

  • Seek positions on committees that help hone leadership and administrative skills and create visibility, as well as enhance regional or national reputations important for promotion. However, be careful to guard against those commitments that take up time without enhancing promotion. It is important to keep an eye on balancing service to oneself against service to the institution. Women may be more vulnerable to enlistment in “emotional labor” activities (for example, office caretaking or organizing office social activities) that are not as salient to promotion criteria.

  • Seek out sponsors in positions of power to facilitate career development [6, 68].

Enhance Connectedness

Research has shown that support in the workplace can serve as a buffer against burnout [99]. Taylor et al. [93] proposed that women (among other species) respond to stress often through a “tend-and-befriend” approach instead of the often-described fight-or-flight response. As a biologically derived and adaptive response, “tending” or nurturing each other and “befriending” or creating social groups can serve to reduce stress. Facilitated engagement groups sponsored by a department or institution have been shown to enhance personal and professional growth and decrease stress and depression. A randomized, controlled study offering a protected-time, 12-weekly, 1-hr sessions mother’s group mitigated burnout and distress for physician mothers and reduced cortisol levels, depression, and parenting stress [56]. Other strategies that have enhanced connectedness include wellness workshops [10], dinner events with early career faculty to explore wellness issues [102], social writing events [25], as well as reflection groups for medical students [33].

Institutional Solutions

  • Offer facilitated early career female physician engagement groups with protected time.

  • Sponsor informal social get-togethers with residents and families, such as happy hours and outdoor activities to promote healthy engagement among residents. Salles, Liebert, and Greco [77] described a surgery department that assigned one to two residents per year to serve as social event planners.

  • Sponsor dinners among early career women faculty and other outside work activities to enhance informal engagements and build meaningful relationships between colleagues.

  • Provide social writing groups where early career faculty can develop meaningful relationships among colleagues while developing important professional skills that contribute toward promotion.

  • Implement wellness workshops for early and/or new faculty which might explore cost benefits of a successful academic career, challenges of maintaining a work-life integration, where to locate resources and develop strategies to maintain wellness, and how to map out a plan to reassess work-life balance at regular intervals.

  • Implement a compassion cultivation program such as gratitude cards to be filled out by an individual for a valued colleague, or start meetings by asking each member to identify for what they have been grateful.

  • Sponsor wellness workshops targeting early faculty women.

Individual Solutions

  • Participate in available engagement groups for women—particularly around work-life integration, mother’s group, or other early career women’s issues.

  • If such a group doesn’t exist, consider starting one. Find a group of like-minded women who might be interested in forming a group. Meet during lunch hour or lobby for protected time.

Promote Self-Care

Higher rates of burnout, emotional exhaustion, self-blame [89], suicide [19], and inadequate sleep and excessive sleepiness [32] have been reported in female physicians. Female physicians are also more likely to report sickness presenteeism [38]. These all highlight the importance for institutions to support self-care and provide easy access to health services among this particular cohort. This is compounded by the fact that lack of time in one’s schedule, stigma, denial of illness, and concerns of confidentiality result in barriers to seeking care [11, 18]. Institutional solutions need to not only decrease barriers but also support opportunities to seek self-care.

Institutional Solutions

  • Review internal practices that might impede self-care seeking.

  • Lobby to eliminate requirement to report mental health treatment if required by the state medical board [34].

  • Provide self-assessment tools to compare to peers nationwide [28, 82] and web-based prevention tools (e.g., [37]).

  • Encourage senior staff, including program directors and chiefs to model wellness.

  • Disseminate information regarding wellness opportunities, including peer-assistance programs, so physicians are aware of them [78].

  • Enhance accessibility to wellness programs and health care by offering more practical time slots and/or protected time, proximal locations.

  • Implement systems to protect from overburdening residents who cover absences and to avoid low-morale consequences [17].

  • Encourage importance of self-care when sick; discourage sick presenteeism [77].

  • Provide trainee support groups and/or allow small group discussions to help trainees develop tools to manage stress [77].

  • Provide structured wellness programs [29, 53, 79] and educate about risk factors and workplace stressors particularly associated with early women physicians; encourage healthy behaviors including an emphasis on positivity, maintaining balance, and promoting self-compassion to improve resilience and sleep quality.

  • Provide healthy snacks and drinks for trainees.

  • Provide a dedicated lactation room for postpartum colleagues and provide policies that allow for lactation breaks.

  • Implement non-gender-associated, early career, evidence-based strategies including facilitating mental health treatment [40, 62]; incentivizing exercise and physical activity programs [100, 105], stress reduction [39, 60], mindfulness [35, 57, 73, 105], meditation [67], and coping skills programs [75]; and offering communication skills training [5, 9] and reflection groups for medical students [33].

Efficiency of Practice

A clinical instructor at a hospital affiliated with an academic center has worked for 3 years teaching students, supervising residents, and furthering various academic projects, at which point she begins to wonder when she can apply for promotion to assistant professor. After reaching out to a senior professor in the department leadership team for clarification on the appropriate timeline, she receives several vague replies related to some ambiguities in the process. The administrative assistant who coordinates appointments and promotions is new, adding to the slowdown. Finally, after several months, the original professor intercedes by email, making a clear declaration of support that the clinical instructor be allowed to apply for promotion now, as indicated by her scholarly activities and his support. Immediately after this email, the necessary materials are sent to the clinical instructor.

Efficiency of practice can be conceptualized as a ratio of “value-added clinical work accomplished” divided by time and energy spent [7]. Improving efficiency of practice usually boils down to maximizing the elements of clinical care that feel valuable and rewarding while minimizing the elements that feel inefficient, unnecessary to the central tasks of clinical caretaking, or clerical in nature. A common breakdown in efficiency of practice involves the growing burden of charting and management of tasks generated by the electronic health record (EHR), often leading to spillover of work outside normal working hours; a vignette portraying a woman physician completing chart tasks remotely after putting her children to bed paints a familiar scene. However, this opening vignette highlights several additional themes. First, efficiency of practice may refer not only to clinical work but also to any system that gets bogged down and impacts the wellness of physicians. In this vignette, the initial period of inquiry about advancement shows a breakdown of systems that could be better streamlined to anticipate the kinds of questions that early faculty may pose. It also demonstrates how an institutional leader can help facilitate efficiency of practice by interceding in a supportive and, importantly, effective manner. The delayed process has only created a demoralizing and aggravating experience to the vulnerable early faculty member seeking promotion. This illuminates the fact that enabling more efficient practice is also a way of conveying support and appreciation—on an individual level as well as an institutional one.

Efficiency of practice is attained not only through individual work practices but also through workplace systems including policies, technologies, and well thought-out staffing. As many of these inefficiencies vary according to specialty and local work environments, the challenges and solutions are largely local. We did not identify any studies targeting early career women and efficiency of care interventions per se; however, research clearly indicates that inefficient practice (e.g., necessitating hours spent at home on work-related tasks) increases odds of burnout [103]. Below we present some general individual and workplace solutions and highlight a few recommendations specific to the early career phase.

Institutional Solutions

  • Integrate aspects of efficiency of practice into effective employee on-boarding orientations, including provision of organization charts, where to find standard operating procedures and other institutional policies, and information about current initiatives to improve efficiency of practice.

  • Consider how the EHR can support the use of templates, and how best it is to distribute templates to trainees and new faculty.

  • Enhance easy and fast access to IT support services and EHR support services. The latter is particularly important for the early career phase when the learning curve around the specific EHR used is steep.

  • Consider a wide range of efficient practice ideas including use of scribes, use of technologies (such as dictation or voice-to-text), and number and quality of support staff to perform clerical tasks.

  • Develop a mechanism where physicians come together, ideally within small work units, to identify local factors that, if modified, could improve system’s issues. Through this participatory management and collaborative action planning, physicians feel engaged and empowered, working constructively with leaders to shape their own future [92]. Within a training program or academic department, this mechanism might be a committee or breakout session at the Annual Program Review targeting specific areas and brainstorming solutions for identified inefficiencies.

Individual Solutions

  • Consider alternate avenues for crowdsourcing efficiency practices (both individual and institutional). For example, Facebook groups for women physicians may provide a shared national platform for deriving solutions to efficient practices and institutional support measures implemented throughout the country. (Regarding Facebook groups, there are also downsides to participating in such groups; confidentiality and professionalism concerns should be considered.)

  • Seek out documentation templates from peers and superiors. Consider the role for documentation strategies involving dictation, voice-to-text technologies, or medical scribes.

  • Consider how you might approach your supervisor or institution with requests about systems-practices, technologies, or support staff. Consider opportunities to bring these requests into negotiation.

  • Ask around about EHR task management strategies with a particular eye toward understanding how to prioritize which tasks are most impactful regarding productivity measures, promotion, hospital accreditation, and patient outcomes. Women may be more likely to internalize a desire to “please” the institution via completion of these tasks, while the reality may be that few physicians are achieving them perfectly while still maintaining good standing at their institution. Furthermore, cogent arguments about the inefficiency of certain tasks may be taken up by your leadership if you communicate with them about your clinical experience and rationale.

  • As you transition from early to advanced trainee and early attending-type roles, begin to pay back/forward efforts to enhance the efficiency of practice for those working under you. Consider developing an orientation guide for trainees that explains practices specific to the institution or service rotation. Or provide high-quality documentation templates in order to model good documentation practices and make note writing more efficient for trainees.

Personal Resiliency

Six months after the birth of her first child, a second-year resident discovered that she was unexpectedly pregnant. The thought of having two infants during residency so close to together was emotionally overwhelming, yet the idea of ending the pregnancy was also laden. She decided to continue the pregnancy but struggled with fatigue and often fell asleep shortly after returning home. Following the birth, her milk production ceased early on (not uncommon in the setting of long work hours and difficulties arranging pumping), yet her child was doing well with the bottle, which allowed her partner to do the night feedings. During the day, the baby was in a hospital-affiliated daycare that had extended hours. Every morning of her inpatient rotations, the resident met up with a good friend and co-resident an hour earlier than usual to have breakfast together at a special café on campus. On mornings she was running late, this friend would bring her breakfast to the work room instead. The simple pleasures of a shared meal and supportive company buoyed her spirits during a stressful time. Several years later, she was able to reflect the support back in a similar manner during a time of her friend’s need.

Personal resilience is defined as “the set of individual skills, behaviors, and attitudes that contribute to physical, emotional, and social well-being,” thus enabling the prevention of burnout [7]. The opening vignette illustrates a scenario in which a supportive friend/colleague has volunteered and been accepted into a critical helping role in establishing some self-care during a high-risk burnout period. It demonstrates the reality that meeting self-care needs takes support and teamwork and cannot be done alone sometimes. It also demonstrates that institutional solutions such as on-site daycare with extended hours and access to good, healthy food can facilitate greater self-care, but the decision around specific needs/wants (in this case, the routine of a special breakfast with a supportive friend) and the commitment to engage must ultimately be made by the individual.

Institutions that promote wellness programming and/or allow individuals to take advantage of activities that support personal resilience have contributed to a culture of wellness. However, the domain of Personal Resiliency focuses on those actions of the individual who engages in resiliency behaviors. These behaviors are particularly critical in a field in which self-denial of basic needs has been indoctrinated in training and when meeting those needs has at times been labeled selfish. It is also particularly important for women who are often called upon to care for others in our sociocultural systems, frequently shortchanging their ability to meet their own needs. Such expectations around other-caregiving at the detriment of self-care are likely to be reified in medical culture. Under Culture of Wellness, we identifed various institutional solutions that may facilitate personal resilience in early career women. Here we will focus on individual solutions associated with Personal Resilience.

Increase Connectedness

As mentioned under Culture of Wellness, being connected with others – whether colleagues, family and/or friends – is a crucial part of enhancing and maintaining personal resilience, particularly among women.

  • Participate in available engagement groups for women, particularly peer-oriented groups which may address challenges of work-life integration, parenthood, or other early career women’s issues. Check if your institution runs a program similar to Lean In (at Stanford, these were named “Voice and Influence” groups).

  • If such a group doesn’t exist, consider starting one. Find a group of like-minded women who might be interested in meeting together. Meet during lunch hour, for breakfast before work (lobby for protected time or time-banking). This type of group might also be developed outside of the work environment to include women peers who face similar challenges, even outside of the medical profession.

  • Even in the absence of “formalized” groups, reach out to other women in your department or across the department to see if they are interested in having lunch. Formal mentorship is not the only reason to network and get together; generating informal connections with fellow women physicians is also rewarding.

  • If getting together whether at work or outside of work presents a challenge, consider developing or joining a virtual journal or book club, connect through social media, or join a Facebook group which can bring women together.

Enhancing Self- Care and Compassion

In order to better manage the multiplicity of factors that impact early career women’s wellness, engaging in personal self-care is critical. With the help of our institutions promoting easier access to needed services or providing a more supportive environment to facilitate our self- care (see Culture of Wellness), women will be more able to take advantage of such opportunities.

  • Seek counseling and/or medical appointments as needed.

  • Prioritize adequate sleep, healthy nutrition, and regular exercise [54]. Consider having walking meetings.

  • Sign-up for support groups, mindfulness or meditation-based practices, time for reflection, and other evidence-based interventions that support wellness.

  • Implement positive psychology exercises such as 3 Good Things before going to bed by writing down three good things that happen to you during the day. This practice has shown to increase happiness and decrease depressive symptoms [81].

  • Be thoughtful about which hobbies you want to prioritize and consider those that are maximally replenishing. Recognize that without intentional planning, these activities may erode. Approach time management like financial management: with intention, goals, and a positive attitude.

  • Learn to set compassionate limits and boundaries with work-related tasks and activities. Decline requests (ideally by expressing gratitude and responding quickly) that are unmanageable or not in line with career goals. Though in the early career this can feel presumptuous at times, learning to say “no” and to avoid becoming over-committed is a central task that any leader or later-phase physician will emphasize as important.

Meaning in Work

Becoming a doctor is a respected career path leading to a position of societal authority. For these reasons, the decision to become a physician is often reinforced by those around us and perhaps only rarely questioned. But what does it mean to become a physician today and how has the career of a physician changed over the last 50 years as women have entered the workforce? The early career phase is an important stage to consider what this occupational role means to you, and what you desire out of a “career.” Taking some time to deconstruct what meaning and functions we get out of our work lives will lead to more clarity in pursuing work goals. Consider the following:

  • What roles do you want your work to play? These might include financial goals, the acquisition of power or influence, scientific inquiry-related goals, a sense of service, providing specific community caretaking, teaching, community outreach, having a voice and platform, connecting with individuals on a day-to-day basis, having a flexible job, experiencing engagement and excitement, experiencing intellectual stimulation, etc.

  • What are your own core values? Consider completing a value card sort at important junctures [59] to align your work life with your broader values (see Table 15.1).

  • Think of your career as a journey, not an arc. The metaphor of “rising to the top” is rarely as simple as that directionality presumes. When connecting with potential mentors, pay attention to the ways that their careers may have fortuitously veered in unforeseen directions, often related to connections that came about organically.

  • Consider the roles that failures played in career trajectories. Consider writing a “failure resume” as a means to explore the generative and learning role that failure can play [90].

  • Consider a wide range of settings and employment opportunities. As women have entered the medical workforce, the positions that doctors can occupy has broadened.

  • Consider the ways that academic institutions have traditionally been organized and how tenure-track pathways have been shaped by an era in which men often had partners working at home. Challenge your institution to rethink how women might have a slightly different trajectory, and reflect on how to inhabit a strong and assertive vision for that trajectory. Research indicates that women demonstrate more productivity later in their careers [43, 47].

Table 15.1 Card sort example (arrange values according to the importance in your life)
Full size table

As institutions strengthen their culture of wellness and reduce the inefficiencies of practice for early career women, these women will be able to invest more time in personal resilience activities and will be better prepared to move through subsequent career and life stages with more meaning and joy.