The impact of organizational culture on professional fulfillment and burnout in an academic department of medicine.

Physician wellness is vital to career satisfaction, provision of high quality patient care, and the successful education of the next generation of physicians. Despite this, the number of physicians experience symptoms of burnout is rising. To assess the impact of organizational culture on physicians' professional fulfillment and burnout, we surveyed full-time Department of Medicine members at the University of Toronto. A cross-sectional survey assessed: physician factors (age, gender, minority status, disability, desire to reduce clinical workload); workplace culture (efforts to create a collegial environment, respectful/civil interactions, confidence to address unprofessionalism without reprisal, witnessed and/or personally experienced unprofessionalism); professional fulfillment and burnout using the Stanford Professional Fulfillment Index. We used multivariable linear regression to examine the relationship of measures of workplace culture on professional fulfillment and burnout (scores 0-10), controlling for physician factors. Of 419 respondents (52.0% response rate), we included 400 with complete professional fulfillment and burnout data in analyses (60% ≤ age 50, 45% female). Mean scores for professional fulfillment and burnout were 6.7±1.9 and 2.8±1.9, respectively. Controlling for physician factors, professional fulfillment was associated with satisfaction with efforts to create a collegial environment (adjusted beta 0.45, 95% CI 0.21 to 0.70) and agreement that colleagues were respectful/civil (adjusted beta 0.85, 95% CI 0.53 to 1.17). Lower professional fulfillment was associated with higher burnout scores. Controlling for professional fulfillment and physician factors, lower confidence in taking action to address unprofessionalism (adjusted beta -0.22, 95% CI -0.40 to -0.03) was associated with burnout. Organizational culture and physician factors had an impact on professional fulfillment and burnout. Professional fulfillment partially mediated the relationship between organizational culture and burnout. Strategies that promote inclusion, respect and civility, and safe ways to report workplace unprofessionalism are needed in academic medicine.

Introduction

Physician wellness is vital to career satisfaction, provision of high quality patient care, and the successful education of the next generation of physicians [1-11]. Despite this, research supports that almost half of all physicians experience burnout symptoms [12-14], characterized by work-related emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment [15]. Furthermore, the rates of burnout among physicians are rising [15].

Healthcare organizational factors, including excessive workloads, workflow inefficiencies, increased time spent in documentation, lack of input or control, and loss of meaning at work, contribute to physician burnout [16]. Among medical residents, unprofessional workplace behavior, and specifically intimidation, harassment and discrimination, have also been linked to lower work satisfaction and higher burnout [17]. A cross-sectional survey of 300 non-medical university faculty members found that both direct and indirect forms of harassment (gender, sexual, and academic) were higher in female than male faculty and associated with higher burnout, as measured by the Maslach Burnout Inventory (MBI) [18, 19]. Whether workplace unprofessionalism independently contributes to burnout among academic physicians is unknown.

We examined the relationship of organizational culture to professional fulfillment and burnout among full-time clinical faculty members in a large academic Department of Medicine (DOM). We hypothesized that, after controlling for factors linked to higher rates of physician burnout, organization culture would influence professional fulfillment and burnout.

Materials and methods

Study design and participants

We conducted a cross-sectional survey of full-time clinical faculty members in the DOM at the University of Toronto in 2019. Full-time clinical faculty members hold a primary clinical appointment at one of six university-affiliated hospitals; each hospital has a department of medicine and physician-in-chief. The study was approved by the Research Ethics Board of the University of Toronto. Participants provided informed consent.

Questionnaire design, testing and administration

Members of the DOM Mentorship, Equity and Diversity Committee designed, pilot-tested, and administered the questionnaire (S1 File) anonymously using SurveyMonkey (SVMK, San Mateo, USA) [20, 21]. A pre-notification e-mail was sent by the University DOM Chair prior to a second e-mail, bearing a unique survey link to each potential respondent. Reminder emails were sent at two-week intervals to maximize response rate. An honest broker (EL) collated responses to preserve respondent anonymity.

Assessments

We collected data to characterize respondents’ socio-demographic and professional characteristics. Socio-demographic variables included age (≤50, 51–60, 61–70, >70 years); gender (female/male); self-reported disability status (yes/no); under-represented minority (URM) membership (yes/no); socioeconomic status (SES) as a child/adolescent (lower/lower-middle/middle/upper-middle/upper); academic rank (lecturer/assistant professor/associate professor/professor), clinical specialty and academic position to determine protected time for scholarly work. Participants were asked whether they were interested in reducing their clinical workload to aid work-life integration (yes/no/not sure). To assess organizational culture, we asked participants to report their level of satisfaction with efforts made to create a collegial/supportive/inclusive environment (5-point Likert scale from ‘strongly satisfied’ to ‘strongly dissatisfied’); level of agreement that colleagues interact with them in a respectful/civil manner (5-point Likert from ‘strongly disagree’ to ‘strongly agree’); and level of confidence that they could take action to address unprofessionalism without reprisal (5-point Likert from ‘very doubtful’ to ‘strongly confident’) in each of the University DOM, University Division, Primary Hospital DOM, and Primary Hospital Division. Respondents were asked if they had witnessed unprofessionalism (e.g., disrespect, abuse, bullying, micro-aggression, or discrimination) by faculty members towards others in the last two years (yes/no) and whether they had personally experienced these behaviours (yes/no). We used the Stanford Professional Fulfillment Index (PFI) to assess professional fulfillment and burnout [22]. The Stanford PFI is composed of three subscales: 6-item professional fulfillment subscale; 4-item work exhaustion subscale; and 6-item interpersonal disengagement subscale. Subscales are scored from 0–10 with higher professional fulfillment and lower work exhaustion and interpersonal disengagement scores representing more favorable responses. Scores for work exhaustion and interpersonal disengagement were combined to assess burnout (score 0–10) with higher scores indicate more burnout symptoms and scores ≥ 3.3 indicating burnout [22].

Our outcomes of interest were Stanford PFI scores for professional fulfillment and burnout. Exposures of interest were the 4 measures of organizational culture (collegial environment; respectful/civil interactions with colleagues; confidence in addressing unprofessionalism; and witnessed and experienced unprofessionalism). Covariates of interest were physician factors (age group, gender, URM status, disability, SES background, academic rank, specialty, and clinical workload).

Statistical analysis

We summarized binary and continuous data using proportions and means and medians, respectively. We assessed sample representativeness by comparing respondent characteristics to those of the sampling frame. We combined responses regarding organizational culture across the University and hospital DOMs and University and hospital Hospital Divisions into a single 10-point scale. We categorized protected time for scholarly work as ‘low/moderate/high’ for academic position descriptions with ≤30%, 31–69%, and 70%+ protected time, respectively. We report data elements with 6 or more responses.

We conducted multivariable linear regression analyses to examine associations between exposures of interest and each of professional fulfillment and burnout, before and after controlling for covariates [23]. To test the hypothesis that the relationship between organizational culture and burnout was mediated, part, by respondents’ professional fulfillment, we examined the effect on the relationship between measures of organizational culture and burnout after controlling for professional fulfillment. We assessed collinearity of independent variables using a Variance Inflation Factor of >4 [24]. We performed statistical analyses using SPSS 26.0 (IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp) and SAS Version 9.4 (SAS Institute Inc., Cary, NC). P-values <0.05 were considered significant.

Results

Respondent characteristics

Of 805 eligible faculty members, 419 (52.1%) completed the questionnaire. Of these, we included 400 questionnaires with complete Stanford PFI data. Respondents were similar to non-respondents with respect to age group and hospital affiliation but were significantly less likely to be a man (60.6% vs. 51.0%), assistant professor (43.6% vs. 38.2%) or cardiologist (14.4% vs. 9.2%), respectively. Of respondents, 192/320 (60.0%) were 50 years of age or younger, 153/340 (45.0%), female, 109/366 (29.8%), URM, 78/366 (21.3%), or from a lower/lower-middle SES background. Twelve respondents [12/352 (3.4%)] reported a disability (Table 1). Based on academic position descriptions, 96/337 (28.5%) had high protected time for scholarly work, while 117 (34.7%) and 124 (36.8%) had moderate or little protected time, respectively. Nearly half of respondents [174/380 (45.8%)] wanted to reduce their clinical workload.

Table 1

Characteristics of physician respondents (n = 400).

Respondent Characteristic	N (%)
Age group
≤50	192/320 (60.0)
51–60	73 (22.8)
61–70	45 (14.1)
>70 years	10 (3.1)
Gender
Woman	153 (45.0)
Man	187 (55.0)
Under-Represented Minority	109/366 (29.8%)
Socioeconomic Background
Low/Low-Middle	78/366 (22.5)
Middle	135 (39.0)
Upper middle/Upper	133 (38.4)
Self-reported disability	12/352 (3.4)
Medical Specialty
Cardiology	33/321 (10.3)
Critical Care	15 (4.7)
Emergency Medicine	26 (8.1)
Endocrinology	25 (7.8)
Gastroenterology	16 (5.0)
General Internal Medicine	41 (12.8)
Geriatrics	11 (3.4)
Hematology	26 (8.1)
Infectious Diseases	14 (4.4)
Medical Oncology	19 (5.9)
Nephrology	11 (3.4)
Neurology	22 (6.9)
Physiatry	11 (3.4)
Respirology	21 (6.5)
Rheumatology	20 (6.2)
Othera	10 (3.1)
Protected time for scholarly workb
70%+	96/337 (28.5)
40–50%	117 (34.7)
20–30%	124 (36.8)
Academic rank
Lecturer	12/335 (3.6)
Assistant Professor	139 (41.5)
Associate Professor	79 (23.6)
Full Professor	105 (31.3)

aIncludes Dermatology, Clinical Allergy & Immunology, Occupational Medicine, Palliative Medicine & Clinical Pharmacology & Toxicology.

bClinician scientists and administrators have ≥ 70% time protected for non-clinical work, Clinician investigators and Clinician educators have ~ 50% of their time protected for non-clinical work, and Clinician teachers and Clinicians in quality and innovation have 20–30% of their time protected for non-clinical work.

Perceptions of organizational culture

On average, mean agreement was high that colleagues treated them respectfully/civilly (mean score 8.4±1.9) (Table 2). Mean scores for level of satisfaction with efforts made by the institution to create a collegial environment and level of confidence in addressing unprofessional behavior by colleagues without fear of retaliation were lower (6.5±2.4 and 6.1±2.8, respectively) Several respondents indicated that they personally experienced unprofessionalism (41.0%) or witnessed unprofessional behaviours by faculty members towards others (without personally experiencing them) (18.8%) within the last 2 years. Unprofessional behaviours most frequently included disrespect (35.8%), micro-aggressions (20.5%), and bullying (17.3%).

Table 2

Physicians’ perceptions of the organizational culture.

Measure
Level of satisfaction with efforts to create a collegial environment–mean (SD)	6.5 (2.4)
Level of agreement that colleagues are respectful & civil–mean (SD)	8.4 (1.9)
Level of confidence addressing unprofessionalism without retaliation–mean (SD)	6.1 (2.8)
Unprofessionalism–n (%)
Witnessed but not experienced	73 (18.8)
Personally experienced	159 (41.0)
Stanford Index–mean (SD)
Professional Fulfillment	6.7 (1.9)
Work Exhaustion	3.6 (2.2)
Interpersonal Disengagement	2.2 (1.9)
Burnout	2.8 (1.9)
Interest in reducing clinical workload to improve work-life balance–n (%)
Yes	174/380 (45.8)
No	133 (35.0)
Uncertain	73 (19.2)

Self-reported professional fulfillment and burnout

Most respondents (85.4%) found their work meaningful. Approximately two-thirds felt worthwhile at work (64.3%), found their work satisfying (71.2%), and felt they were contributing professionally in ways they valued (70.8%). Although half (52.8%) affirmed that they felt happy at work, only 37.1% felt in control when dealing with difficult problems at work. About half of respondents reported feeling physically exhausted at work (56.3%), a sense of dread when they thought about the work they had to do (49.5%) and emotionally exhausted at work (46.0%). Some (30.5%) respondents reported lacking enthusiasm at work, while 18.1% reported feeling at least moderately less interested in talking to patients and 20.4% reported being at least moderately less sensitive to the feelings of others. Over a quarter of physicians affirmed feeling less empathetic and connected with colleagues (28.5% and 33.1%, respectively) and 16.3% and 18.3% of physicians affirmed feeling less empathetic and connected with patients, respectively. Mean scores for professional fulfillment, emotional exhaustion and interpersonal disengagement were 6.7±1.9, 3.6±2.2, and 2.2±1.9, respectively. The mean score for burnout was 2.8±1.9 with 31.8% of respondents meeting burnout criteria.

The relationship of organizational culture to professional fulfillment

In univariate analyses, positive perceptions of the organizational culture and higher academic rank were associated with greater professional fulfillment. Conversely, having personally experienced unprofessionalism at work, female gender, self-reported disability, low or moderate protected time for scholarly work, and a desire to reduce clinical workload were associated with lower scores (Table 3). In multivariable modeling, professional fulfillment was significantly higher among those with greater satisfaction with efforts to encourage a supportive/collegial workplace (adjusted beta per level of satisfaction 0.45, 95% CI 0.21 to 0.70) and greater agreement that colleagues were respectful/civil (adjusted beta per level of agreement 0.85, 95% CI 0.53 to 1.17) and significantly lower among respondents with self-reported disability (adjusted beta -1.33, 95% CI -2.22 to -0.44), but unrelated to confidence in taking action regarding unprofessional behavior without fear of retaliation or unprofessional behaviors.

Table 3

Relationship of physician and organization factors to professional fulfillment–results of linear regression modeling.

Independent Variable	Dependent Variable: Stanford Professional Fulfillment Score
	Unadjusted Parameter Estimate	95% Confidence Limits		Adjusted Parameter Estimate	95% Confidence Limits
Physician Factors
Age (ref ≤ 50 years)
51–60	0.49	-0.02	1.01	0.19	-0.30	0.69
61–70	0.57	-0.05	1.19	0.68	-0.02	1.37
71 +	1.13	-0.04	2.30	0.83	-0.25	1.90
Female gender (ref = male)	-0.51	-0.92	-0.10	-0.13	-0.51	0.24
URMa (ref = no)	-0.38	-0.81	0.06	0.10	-0.30	0.49
SES background (ref = lower/middle)
Middle/Upper-middle	0.36	-0.14	0.85	0.07	-0.36	0.50
Upper	0.23	-0.88	1.35	-0.24	-1.16	0.68
Self-reported disability (ref = no)	-1.65	-2.72	-0.57	-1.33	-2.22	-0.44
Current academic rank (ref = Lecturer/Assistant Professor)
Associate Professor	0.70	0.19	1.20	0.32	-0.17	0.81
Professor	1.14	0.68	1.60	0.27	-0.34	0.87
Protected time for scholarly work (ref = a lot)
Little (low)	-0.86	-1.36	-0.35	-0.04	-0.53	0.45
Some (moderate)	-0.55	-1.07	-0.04	0.08	-0.38	0.53
Workplace Culture Factors
Collegial & Supportive–per unit increase	0.45	0.20	0.70	0.45	0.21	0.70
Respectful & Civil–per unit increase	0.69	0.39	0.99	0.85	0.53	1.17
Confidence take action–per unit increase	0.41	0.23	0.59	0.20	0.00	0.41
Unprofessional behavior in workplace (ref = none)
Witnessed but not personally experienced	-0.36	-0.92	0.19	-0.20	-0.69	0.29
Personally experienced	-1.06	-1.50	-0.63	-0.05	-0.49	0.38
Desires reduction in clinical workload (ref = no)	-1.01	-1.45	-0.57	-0.42	-0.85	0.00

aURM = under-represented minority.

The relationship of organizational culture to correlates of burnout

In univariate analyses, greater burnout symptoms were associated with less positive perceptions of organizational culture and personal experiences with unprofessionalism at work in addition to younger age, female gender, URM status, self-reported disability, lower rank, less protected time for scholarly work, and a desire to reduce clinical workload (Table 4). In multivariable modeling, greater burnout symptoms were associated with younger age, self-reported disability (parameter estimate 1.55, 95% CI 0.49 to 2.61), interest in reducing clinical workload (parameter estimate 1.20, 95% CI 0.77 to 1.63), lower satisfaction with efforts to encourage a supportive/collegial workplace (adjusted beta per unit increase in satisfaction -0.32, 95% CI -0.57 to -0.07), lower agreement that colleagues were respectful/ civil (adjusted beta per unit increase in agreement -0.49, 95% CI -0.81 to -0.16), and lower confidence in taking action regarding unprofessional behavior without fear of retaliation (adjusted beta per unit increase in confidence -0.31, 95% CI -0.51 to -0.10). When professional fulfillment was added to the multivariable model, fulfillment was inversely associated with burnout (adjusted beta per point increase in Stanford PFI score -0.45, 95% CI -0.56 to -0.33). Although, the effects of satisfaction with efforts to encourage a supportive/collegial workplace and agreement that colleagues were respectful/civil on burnout were attenuated and became non-significant, declining confidence in taking action regarding unprofessional behavior remained significantly associated with greater burnout symptoms (adjusted beta per unit increase in confidence -0.22, 95% CI -0.40 to -0.03) (Table 5).

Table 4

Relationship of physician and organization factors to symptoms of burnout–results of linear regression modeling.

Independent Variable	Dependent Variable: Stanford Burnout Score
	Unadjusted Parameter Estimate	95% Confidence Limits		Adjusted Parameter Estimate	95% Confidence Limits
Physician Factors
Age (ref = <50 years)
51–60	-0.57	-1.07	-0.06	-0.14	-0.65	0.36
61–70	-1.2	-1.83	-0.63	-0.97	-1.68	-0.27
71+	-1.4	-2.60	-0.32	-0.91	-2.00	0.17
Female gender (ref = male)	0.85	0.45	1.24	0.24	-0.14	0.61
URMa (ref = no)	0.60	0.17	1.03	-0.105	-0.55	0.26
SES background (ref = lower/middle)
Middle/Upper-middle	-0.32	-0.81	0.17	-0.07	-0.50	0.37
Upper	0.08	-1.02	1.17	0.40	-0.53	1.34
Self-reported disability (ref = no)	1.55	0.49	2.61	1.29	0.39	2.19
Current academic rank (ref = Lecturer or Assistant Professor)
Associate Professor	-0.52	-1.01	-0.02	-0.29	-0.79	0.20
Professor	-1.35	-1.80	-0.90	-0.21	-0.83	0.40
Protected time for scholarly work (ref = a lot)
Little (low)	0.91	0.41	1.41	0.12	-0.38	0.62
Some (moderate)	0.42	-0.08	0.93	-0.10	-0.56	0.36
Workplace Culture Factors
Collegial & Supportive–per unit increase	-0.31	-0.57	-0.06	-0.32	-0.57	-0.07
Respectful & Civil–per unit increase	-0.34	-0.66	-0.03	-0.49	-0.81	-0.16
Confidence take action–per unit increase	-0.60	-0.79	-0.42	-0.31	-0.51	-0.10
Unprofessional behavior in workplace (ref = none)
Witnessed but not personally experienced	0.51	-0.02	1.04	0.30	-0.20	0.79
Personally experienced	1.41	0.99	1.82	0.36	-0.08	0.80
Desires reduction in clinical workload (ref = no)	1.20	0.77	1.63	0.62	0.19	1.05

aURM = under-represented minority.

Table 5

Correlates of burnout–professional fulfillment added to the multivariable model.

Independent Variable	Dependent Variable: Stanford Burnout Score
	Adjusted Parameter Estimate	95% Confidence Limits		Adjusted Parameter Estimate	95% Confidence Limits
Physician Factors
Age (ref = <50 years)
51–60	-0.14	-0.65	0.36	-0.055	-0.51	0.40
61–70	-0.97	-1.68	-0.27	-0.67	-1.31	-0.03
71+	-0.91	-2.00	0.17	-0.545	-1.53	0.44
Self-reported disability (ref = no)	1.29	0.39	2.19	0.69	-0.13	1.52
Workplace Culture Factors
Collegial & Supportive–per unit increase	-0.32	-0.57	-0.07	-0.12	-0.35	0.115
Respectful & Civil–per unit increase	-0.49	-0.81	-0.16	-0.11	-0.41	0.20
Confidence take action–per unit increase	-0.31	-0.51	-0.10	-0.22	-0.40	-0.03
Desires reduction in clinical workload (ref = no)	0.62	0.19	1.05	0.43	0.04	0.82
Professional Fulfillment–per unit increase in score				-0.45	-0.56	-0.33
Adjusted R2	0.378			0.497

aControlling additionally for gender, under-represented minority (URM) status, socioeconomic status (SES) background, rank, protected time, witnessed and personally experienced unprofessional behavior.

Discussion

We examined the relationship between measures of the organizational culture and professional fulfillment and burnout. Controlling for identified risk factors for burnout, including gender, career stage, and clinical workload, we found that physicians’ satisfaction with efforts made to encourage a supportive/collegial workplace and level of agreement that colleagues were respectful/civil were significant contributors to professional fulfillment. Greater professional fulfillment and confidence in taking action to address unprofessional behavior without fear of retaliation were associated with fewer burnout symptoms. Controlling for these factors, we found no relationship between having witnessed or personally experienced unprofessional behavior with either professional fulfillment or burnout. These findings suggest a need to develop and implement strategies that promote inclusion, respect and civility, and safe ways to identify and act upon workplace unprofessionalism in academic medicine.

This is the first study to examine the relationship between organizational culture and both professional fulfillment and burnout. Both fulfillment and burnout were associated with physicians’ perceptions regarding efforts made by our DOM to promote a diverse and inclusive workplace and the level of workplace respect/civility, while confidence in addressing unprofessional behavior without fear of retaliation was correlated with a lower risk of burnout. Controlling for these factors, physicians’ reported experiences of workplace unprofessionalism by colleagues were unrelated to both professional fulfillment and burnout. This suggests that an organization’s expectations for professional behavior and response to unprofessionalism, is an important buffer against the negative effects of microaggressions and unprofessional behaviours/discourse. These findings suggest a need for interventions to enhance workplace professionalism and enable safe reporting of incivility [25].

Physician burnout has been linked to female gender, URM status, earlier career stage (age/rank), excessive clerical and regulatory workload, and lack of control at work [5, 16, 26–30]. In a study comparing the predilection for burnout in physicians vs. individuals with a graduate or professional degree, burnout symptoms were significantly more common in physicians and persisted despite adjustment for age, sex, relationship status, and hours worked/week in multivariable analysis [31]. Although each of these factors was associated with greater burnout symptoms in our univariate analyses, these relationships were attenuated after controlling for measures of organizational culture [32-34]. One interpretation of these findings is that younger, female, and URM status faculty may be more likely to experience burnout due to differences in their perceptions or experiences of workplace culture.

Although limited to 12 respondents, we found a relationship between having a disability and both lower professional fulfillment and higher burnout scores. To our knowledge no prior study has reported these relationships. Unlike gender and URM status, the relationships between disability and both professional fulfillment and burnout were not attenuated by factors related to organizational culture suggesting that the effect of disability on both metrics may be through different mechanisms related to environmental barriers [35] or the effort required by disabled physicians to complete work-related tasks. Additional research is needed to confirm these findings in disabled physicians and if true to ascertain how more inclusive work environments can be created for disabled physicians.

Large-scale surveys in the United States have reported physician burnout rates ranging from 43.9%-54.4% [15, 36, 37]. Conversely, only 31.8% of our physicians met criteria for burnout. This may reflect respondent bias as a lower response rate among assistant professors would bias towards a lower burnout rate. Conversely, a lower response rate among male faculty would bias towards a higher burnout rate. Lower burnout rates may also reflect different practice contexts (Canadian Universities and hospitals, socialized medicine, favorable medicolegal climate) or the instruments used to assess burnout. A study that compared the performance characteristics of the Stanford PFI to the MBI, found a moderate correlation between the Stanford PFI burnout measures with their closest related MBI equivalents (r≥0.50) [22].

Our study has several strengths. First, it is the largest survey conducted to date using the Stanford PFI, which was specifically designed to assess work-related well-being among physicians. The Stanford PFI [22] has three key advantages compared to the MBI [19]. It concurrently assesses professional fulfillment and burnout, assesses interpersonal disengagement and burnout in interactions with patients and colleagues, and evaluates metrics over a two-week time horizon—reducing the potential for recall bias. Second, we sampled academic physicians across multiple hospitals, specialties, academic foci, and stages of academic career development. Third, our study is novel in assessing the impact of features of organizational culture, as opposed to organizational factors (workflow, workload, time spent in documentation, lack of control, and loss of meaning), on professional fulfillment and burnout. Finally, our response rate aligns with those of prior multi-disciplinary, cross-sectional surveys of physicians [38, 39]. Our study also has limitations. Gender was evaluated as binary. Survey respondents differed marginally from the DOM membership with respect to gender and specialty [40]. Notwithstanding, the relationships that we identified are valid within our sample but require confirmation in other cohorts and contexts. To this end, our findings may not be generalizable to non-respondents, other universities/departments, and settings.

Given the implications of burnout for physicians, patients, and healthcare systems [41-44], our findings indicate that there is a need for greater emphasis on culture in academic medicine, specifically with respect to promoting inclusion, respect and civility, and safe ways to report workplace unprofessionalism. They also highlight the importance of an institutional commitment to creating a positive work environment and the need for a fair and transparent reporting process to address workplace unprofessionalism. To this end, our DOM developed and implemented strategies to address organizational culture at the University of Toronto including education (cultural sensitivity, allyship, and implicit bias); changes in organizational structure, policies, and processes (fairness and transparency of appointments, addressing workplace incivility) and mentorship [45]. The extent to which physician wellbeing may be improved by efforts to address equity, diversity, inclusion, and organizational culture (professionalism, and mechanisms to report and address unprofessional behaviours) remains to be fully elucidated.

Physicians’ perceptions of the organizational culture at work were strongly related to their self-reported professional fulfillment and burnout. Strategies that promote inclusion, respect and civility, and safe ways to report workplace unprofessionalism are needed in academic medicine.

Department of medicine faculty survey 2019.

(PDF)

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15 Feb 2021

PONE-D-20-32481

The impact of organizational culture on professional fulfillment and burnout in an academic Department of Medicine

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b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

4. Thank you for stating the following financial disclosure:

'The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.'

At this time, please address the following queries:

Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

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'Gillian Hawker receives salary support as the Sir John and Lady Eaton Professor and Chair of Medicine, Department of Medicine, University of Toronto. Sharon Straus holds a Tier 1 Canada Research Chair from the Canadian Institutes of Health. Karen Burns holds a Physician Services Incorporated Mid-Career Clinical Research Award. No other competing interests are declared.'

a. Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to  PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests).  If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

b. Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: It was a pleasure reviewing the manuscript “The impact of organizational culture on professional fulfilment and burnout in an academic Department of Medicine”

The topic is relevant and the idea innovative. Burnout is frequent in the ICU setting and it is largely undiagnosed. The mortality rate of adult ICU patients depends on the severity of illness and patient population; it ranges between 6.4% and 80% during the COVID-19 Pandemic. Interdisciplinary work between many medical professions is essential in an ICU to deliver high quality patient care. Members of the ICU team include physicians, nurses, technicians, therapists, nutritionists, pharmacists, and other support staff making effective management an important element of a highly functioning ICU. Currently, health care delivery has far lower levels of reliability than that achieved in other industries (e.g., aviation) and staff are not supported efficiently. Successful improvement of Critical Care requires a perspective that treats the ICU as a complex, socio-technical system and prevents staff to suffer burnout. ICU healthcare workers who provide aggressive care to critical patients have moral distress and are at risk for burnout, which in turn can lead to poor quality patient care and higher job turnover rates (Meltzer et al. Am J Crit Care 2004, Corley et al. J Adv Nurs 2000, Appropricus ESICM Abstract).

In another survey 70% of ICU workers perceived conflicts, (Azoulay E, Timsit JF, Sprung CL, et al. Prevalence and Factors of Intensive Care Unit Conflicts: The Conflicus Study. Am J Respir Crit Care Med. 2009 Jul 30m). These were usually considered harmful and were significantly associated with job strain. Workload, communication, and end-of-life care emerged as potential targets for improvement. Hamric and colleagues evaluated moral distress in both nurses and doctors. They found that ICU nurses experienced moral distress more often than physicians; however, similar situations provoked moral distress in both groups (Hamric et al. Crit Care Med 2007). Studies related to moral distress and futile or inappropriate care in the ICU do not provide patient-linked data. Consequently, the real extent of the problem of perceived inappropriate care at the end-of-life in the ICU is unknown and the magnitude of situations causing feelings of moral distress may be underestimated. Feelings like frustration, stress, guiltiness, lack of motivation, lack of communication, isolation and finally burn out are common. There is evidence in the medical and non-medical literature suggesting that the burn out leads to low performance and concentration. The performance of all Critical Care workers is prone to error and is often associated with monitoring and daily care tasks like ordering of medication or execution of patient treatment. ERRORS cause distress and can lead to more burnout. A blaming culture can lead to more mistakes and so on. The organisational culture is as complex to measure as is the incidence or severity of burnout. There are few validated tools and these are limited. This study is looking at a relevant element and it is using one those few tools that can provide reliable information. The Stanford Professional Fulfilment Index (PFI) reports on professional fulfilment, work exhaustion, interpersonal disengagement.

Major concerns:

The limit of most surveys is the response rate which in this occasion is just above 50%.

The target people for this survey are the faculty members, in reality the entire staff could be included. The ICU is a complex system and isolating one part of the staff can have benefits and disadvantages such as reporting only on one component or one side of the problem.

The percentage of people happy with their condition was high. Results presented in this manuscript would be more valuable if a benchmark was available.

This model could be used in several institutions and compared in future.

Minor concerns:

-small error in the text and the title page : “The impact of organizational culture on professional fulfillment and burnout in an academic…”

Please change fulfilment

Reviewer #2: Thank you for the opportunity to review this paper by Dr. Burns and colleagues on the impact of organizational culture on professional fulfillment and burnout in an academic department of medicine. This well-written paper reports the results of a cross-sectional survey of 400 full-time physicians. I have a few comments/queries for the authors to consider:

Abstract:

1) Please provide the score range for the SPFI so the mean scores presented in the results are interpretable

2) Are the "physician factors" referred to on line 40 the same as the "physician characteristic" defined on line 34? if so perhaps change one of the terms for consistency.

Introduction

4) The introduction is concise and lays out both the problem and gap well.

Methods

5) For the assessments, more detail on some of the definitions would be helpful. For example, for self-reported disability status, how was this question asked? Does it include physical, mental, or cognitive disabilities? For participant age, why were those grouping selected? 60% of respondents are in the <50 are group.

Results

6) The sentence starting on line 138 is confusing and it is difficult to tell which numbers apply to which groups given the placement of comas.

Discussion

7) The paragraph (starting line 251) discussing the novel findings related to disability should be tempered slightly. With only 12 people in this group the results should be interpreted with caution.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Francesca Rubulotta

Reviewer #2: No

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27 Apr 2021

ONE-D-20-32481

The impact of organizational culture on professional fulfillment and burnout in an academic Department of Medicine

Submitted by Dr. Karen E. A. Burns

Date: Feb 23, 2021

____________________________________________________________________

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

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Done. Thank you.

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses.For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

We have appended the questionnaire as Appendix 1. Thank you for this suggestion.

3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

Although, we have no difficulty sharing our database, we (Department of Medicine, under the leadership (Chair) of Dr. Gillian Hawker) did not advise our full time faculty respondents that we would make their de-identified responses, including their demographic data and responses to open ended questions, accessible through an open access policy.

We do not have the opportunity to revisit this issue at this point in time as the questionnaire was administered in 2019. Since we told respondents that all data would be confidential, we feel that it would be unethical to provide the study database at this time. However, for individuals who are interested, we would be willing to consider providing access to the data on an individual basis with a written request stating the purpose and how the data would be used.

Individuals interesting in accessing the database may contact Mr. Ed Lorens, 6 Queen’s Park Crescent West, 3rd Floor, Toronto, Ontario, Canada M5S 3H2; E-mail: ed.lorens@utoronto.ca

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

Not applicable. Please see above.

4. Thank you for stating the following financial disclosure:

'The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.'

At this time, please address the following queries:

a. Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

b. State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

c. If any authors received a salary from any of your funders, please state which authors and which funders.

d. If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

Included in our cover letter. Thank you.

This study was unfunded. The authors received no specific funding for this work.

5. Thank you for stating the following in the Competing Interests section:

'Gillian Hawker receives salary support as the Sir John and Lady Eaton Professor and Chair of Medicine, Department of Medicine, University of Toronto. Sharon Straus holds a Tier 1 Canada Research Chair from the Canadian Institutes of Health. Karen Burns holds a Physician Services Incorporated Mid-Career Clinical Research Award. No other competing interests are declared.'

a. Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

We confirm that this does not alter our adherence to PLOS ONE policies on data sharing and materials. We have added the following,

Gillian Hawker receives salary support as the Sir John and Lady Eaton Professor and Chair of Medicine, Department of Medicine, University of Toronto. Sharon Straus holds a Tier 1 Canada Research Chair from the Canadian Institutes of Health. Karen Burns holds a Physician Services Incorporated Mid-Career Clinical Research Award. No other competing interests are declared. We confirm that salary support and personnel awards did not impact our ability to adhere to PLOS ONE policies on data sharing and materials.

b. Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf.

Done.

Please know it is PLOS ONE policy for corresponding authors to declare, on behalf of all authors, all potential competing interests for the purposes of transparency. PLOS defines a competing interest as anything that interferes with, or could reasonably be perceived as interfering with, the full and objective presentation, peer review, editorial decision-making, or publication of research or non-research articles submitted to one of the journals. Competing interests can be financial or non-financial, professional, or personal. Competing interests can arise in relationship to an organization or another person. Please follow this link to our website for more details on competing interests: http://journals.plos.org/plosone/s/competing-interests

The above text regarding potential COIs has been added to the manuscript.

6. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ.

I have entered my ORCID ID previously. Verified.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

Although, we have no difficulty sharing our database, we did not advise respondents that we would make their de-identified responses, including their demographic data, accessible through an open access policy. We do not have the opportunity to revisit this issue at this point in time. Since we told respondents that all data would be confidential, we feel that it would be unethical to provide the database at this time. However, for individuals who are interested, I would be willing to consider providing access to the data on an individual written request basis.

Please see our response below

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: It was a pleasure reviewing the manuscript “The impact of organizational culture on professional fulfilment and burnout in an academic Department of Medicine”

The topic is relevant and the idea innovative. Burnout is frequent in the ICU setting and it is largely undiagnosed. The mortality rate of adult ICU patients depends on the severity of illness and patient population; it ranges between 6.4% and 80% during the COVID-19 Pandemic. Interdisciplinary work between many medical professions is essential in an ICU to deliver high quality patient care. Members of the ICU team include physicians, nurses, technicians, therapists, nutritionists, pharmacists, and other support staff making effective management an important element of a highly functioning ICU. Currently, health care delivery has far lower levels of reliability than that achieved in other industries (e.g., aviation) and staff are not supported efficiently.

Successful improvement of Critical Care requires a perspective that treats the ICU as a complex, socio-technical system and prevents staff to suffer burnout. ICU healthcare workers who provide aggressive care to critical patients have moral distress and are at risk for burnout, which in turn can lead to poor quality patient care and higher job turnover rates (Meltzer et al. Am J Crit Care 2004, Corley et al. J Adv Nurs 2000, Appropricus ESICM Abstract).In another survey 70% of ICU workers perceived conflicts, (Azoulay E, Timsit JF, Sprung CL, et al. Prevalence and Factors of Intensive Care Unit Conflicts: The Conflicus Study. Am J Respir Crit Care Med. 2009 Jul 30m). These were usually considered harmful and were significantly associated with job strain. Workload, communication, and end-of-life care emerged as potential targets for improvement.

Hamric and colleagues evaluated moral distress in both nurses and doctors. They found that ICU nurses experienced moral distress more often than physicians; however, similar situations provoked moral distress in both groups (Hamric et al. Crit Care Med 2007). Studies related to moral distress and futile or inappropriate care in the ICU do not provide patient-linked data. Consequently, the real extent of the problem of perceived inappropriate care at the end-of-life in the ICU is unknown and the magnitude of situations causing feelings of moral distress may be underestimated. Feelings like frustration, stress, guiltiness, lack of motivation, lack of communication, isolation and finally burn out are common. There is evidence in the medical and non-medical literature suggesting that the burn out leads to low performance and concentration. The performance of all Critical Care workers is prone to error and is often associated with monitoring and daily care tasks like ordering of medication or execution of patient treatment. ERRORS cause distress and can lead to more burnout. A blaming culture can lead to more mistakes and so on. The organisational culture is as complex to measure as is the incidence or severity of burnout. There are few validated tools and these are limited.

This study is looking at a relevant element and it is using one those few tools that can provide reliable information. The Stanford Professional Fulfilment Index (PFI) reports on professional fulfilment, work exhaustion, interpersonal disengagement.

Major concerns:

The limit of most surveys is the response rate which in this occasion is just above 50%.

The target people for this survey are the faculty members, in reality the entire staff could be included. The ICU is a complex system and isolating one part of the staff can have benefits and disadvantages such as reporting only on one component or one side of the problem.

The percentage of people happy with their condition was high. Results presented in this manuscript would be more valuable if a benchmark was available. This model could be used in several institutions and compared in future.

Thanks for your kind review.

Although higher response rates are achieved in single discipline surveys, a response rate of 50% is considered acceptable for multidisciplinary cross-sectional surveys. Mean response rates of 54% [1] to 61% [2] for physicians and 68%32 for nonphysicians have been reported in recent systematic reviews of postal questionnaires.

References

Asch DA, Jedrzwieski MK, Christakis NA. Response rates to mail surveys published

in medical journals. J Clin Epidemiol 1997;50:1129-36.

Cummings SM, Savitz LA, Konrad TR. Reported response rates to mailed physician

questionnaires. Health Serv Res 2001;35:1347-55.

We agree that all member of individual hospitals or ICUs could be surveyed with our questionnaire. This may represent an area of inquiry for future research.

Our study presents the findings of a biennial survey administered to physicians that are full time faculty members within our DOM. The DOM at the University is the largest DOM in Canada with over 600 full time members including physicians from a wide range of specialties. Most surveys have focused on burnout in multidisciplinary members (nurses, physicians, allied health care providers). Conversely our goal was to examine career satisfaction, professional fulfillment, burnout and the impact of organizational culture on these metrics among physicians from various specialties within our large academic DOM. As such this represents the largest survey ever conducted using the Stanford PFI to measure both professional fulfillment and burnout. This tool was specifically designed to assess these wellness measures in physicians. Selection of this tool, aligned well with our objective which was to examine career satisfaction, professional fulfillment, burnout and the impact of organizational culture on these metrics in physicians.

Although our findings many not be generalizable to other disciplines, we believe that our findings are generalizable to academic physicians and aligns with our intended goals.

Minor concerns:

-small error in the text and the title page : “The impact of organizational culture on professional fulfillment and burnout in an academic…”

Please change fulfilment

Fulfillment is spelled with two letter l’s throughout.

We checked the Merriam-webster dictionary to verify that this is the correct spelling.

https://www.merriam-webster.com/dictionary/fulfillment?src=search-dict-box

Definition of fulfillment

1: the act or process of fulfillingthe fulfillment of a promisethe fulfillment of all the requirements

2: the act or process of delivering a product (such as a publication) to a customerthe fulfillment of a book order

Thank you for taking the time to review our manuscript and for your thoughtful input and review.

______________________________________________________________________

Reviewer #2: Thank you for the opportunity to review this paper by Dr. Burns and colleagues on the impact of organizational culture on professional fulfillment and burnout in an academic department of medicine. This well-written paper reports the results of a cross-sectional survey of 400 full-time physicians. I have a few comments/queries for the authors to consider:

Abstract:

1) Please provide the score range for the SPFI so the mean scores presented in the results are interpretable

Thank you for this suggestion. The score range has now been added to the abstract.

We used multivariable linear regression to examine the relationship of measures of workplace culture on professional fulfillment and burnout (scores 0-10), controlling for physician factors.

2) Are the "physician factors" referred to on line 40 the same as the "physician characteristic" defined on line 34? if so perhaps change one of the terms for consistency.

These terms represent different facets.

Physician characteristics included age (≤50, 51-60, 61-70, >70 years); gender (female/male); self-reported disability status (yes/no); under-represented minority (URM) membership (yes/no); socioeconomic status (SES) as a child/adolescent (lower/lower-middle/middle/upper-middle/upper); academic rank (lecturer/assistant professor/associate professor/professor), clinical specialty and academic position to determine protected time for scholarly work.

Physician factors include the above physician characteristics and whether respondents were interested in reducing their clinical workload to aid work-life integration (yes/no/not sure).

We have changed physician characteristics to physician factors where appropriate throughout the manuscript. Thank you for noting this.

Introduction

4) The introduction is concise and lays out both the problem and gap well.

Thanks kindly for this comment.

Methods

5) For the assessments, more detail on some of the definitions would be helpful. For example, for self-reported disability status, how was this question asked? Does it include physical, mental, or cognitive disabilities? For participant age, why were those grouping selected? 60% of respondents are in the <50 are group.

Thank you for this suggestion. We have appended the questionnaire as an electronic appendix. (see Appendix 1)

We asked whether individuals perceived that they had a disability.

Whether or not it affects your day-to-day life, are you a person with a disability?

Please check ONE only.

Response options included Yes, No, Not sure, and Prefer not to answer

We defined disability in the hyperlink as follows:

Disability / Disabilities. A person with a disability is someone who has a long-term or recurring physical, mental, sensory, psychiatric or learning disability and considers oneself to be disadvantaged by reason of that disability, or believes that society is likely to consider them to be disadvantaged by reason of that disability. A person with a disability may also be someone whose functional limitations owing to their disability have been accommodated in their environment. Examples of disabilities include, but are not limited to:

· Addiction to alcohol or drugs

· Chronic illness (e.g. epilepsy, cystic fibrosis, cancer, diabetes)

· Developmental disability (e.g. autism, down syndrome, brain injury)

· Learning disability (e.g. dyslexia, attention deficit hyperactivity disorder (ADHD))

· Mental illness (e.g. schizophrenia, depression)

· Physical disability (e.g. cerebral palsy, spinal cord injury, amputation)

· Sensory disability (i.e. hearing or vision loss)

Regarding age, we included 4 age categories age (≤50, 51-60, 61-70, >70 years). WE collapsed the lowest three age categories due to small numbers (no one less than 30 years of age, very few between ages 31 and 40, more individuals between 41 and 50 into one category < 50 years. A similar phenomenon occurred at the higher end with only a few physicians >80 years of age. Consequently, we collapsed these individuals with physicians who were > 70 years of age. Looking at he distribution of the data, we felt that the best way to collapse the data was using the aforementioned cut offs as most respondents were between 51 and 70. Thank you for the opportunity to clarify.

Results

6) The sentence starting on line 138 is confusing and it is difficult to tell which numbers apply to which groups given the placement of comas.

Thank you for the opportunity to clarify and remove a comma.

Respondents were similar to non-respondents with respect to age group and hospital affiliation, but were significantly less likely to be a man (60.6% vs. 51.0%), assistant professor (43.6% vs. 38.2%) or cardiologist (14.4% vs. 9.2%).

The revised text reads as follows:

Respondents were similar to non-respondents with respect to age group and hospital affiliation but were significantly less likely to be a man (60.6% vs. 51.0%), assistant professor (43.6% vs. 38.2%) or cardiologist (14.4% vs. 9.2%), respectively.

Discussion

7) The paragraph (starting line 251) discussing the novel findings related to disability should be tempered slightly. With only 12 people in this group the results should be interpreted with caution.

We have changed the wording to acknowledge that this finding should be regarded as hypothesis generating. Thank you for this suggestion.

First sentence: We found a relationship between having a disability and both lower professional fulfillment and higher burnout scores.

Current sentence:

Although limited to 12 respondents, we found a relationship between having a disability and both lower professional fulfillment and higher burnout scores.

We believe that the remaining text tempers our findings and is aligned with the reviewer’s comments. Thank you.

To our knowledge no prior study has reported these relationships. Unlike gender and URM status, the relationships between disability and both professional fulfillment and burnout were not attenuated by factors related to organizational culture suggesting that the effect of disability on both metrics may be through different mechanisms related to environmental barriers [35] or the effort required by disabled physicians to complete work-related tasks.

We have also edited the last sentence in this paragraph.

Additional research is needed to confirm these findings in disabled physicians and if true to ascertain how more inclusive work environments can be created for disabled physicians.

________________________________________

Thank you Dr. Rubulotta and Reviewer #2. We sincerely appreciate you taking the time to review our manuscript.

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Not applicable.

Submitted filename: Response to reviewer comments R1.docx

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24 May 2021

The Impact of Organizational Culture on Professional Fulfillment and Burnout in an Academic Department of Medicine

PONE-D-20-32481R1

Dear Dr. Burns,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Gerard Hutchinson, MD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: The manuscript is improved. I am pleased with the current form and I think this is worth publication.

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Reviewer #1: Yes: Francesca Rubulotta

Reviewer #2: No

28 May 2021

PONE-D-20-32481R1

The Impact of Organizational Culture on Professional Fulfillment and Burnout in an Academic Department of Medicine

Dear Dr. Burns:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

Dr. Gerard Hutchinson

Academic Editor

PLOS ONE