Family medicine residency (FMR) managers are crucial to the success of family medicine residency programs. Historically, the role of the residency manager has been administrative and clerical; however, since the Accreditation Council for Graduate Medical Education’s (ACGME) Next Accreditation System (NAS) began in 2013 in the United States of America, managers’ roles have expanded to include more managerial and liaison responsibilities. In addition to a significant increase in data management and accreditation validation documentation responsibilities, managers now commonly oversee communications between program directors and faculty members, residents, applicants, staff and representatives of hospitals, medical schools, and multiple external organizations.^1-3 Residency program managers insofar are responsible for the administrative duties in medical residency programs within a teaching hospital or medical facility. A wide variety of job titles are used for FMR managers, including program coordinator, academic coordinator, program administrator, residency manager, and program manager. This study uses the title of “family medicine residency manager” to encompass all the various job titles of FMR administrators.

Work engagement, defined as “a positive, fulfilling work-related state of mind that is characterized by vigor, dedication, and absorption,”⁴ has been validated as one of the most important factors in the success of any work environment.⁵ Work engagement is associated with positive work outcomes such as low turnover intentions,⁶ reduced absenteeism,⁷ increased productivity,⁸ and job satisfaction in diverse groups including hospitality workers,^8,9 telecommunication workers,⁶ and medical residents.^10,11 We were unable to identify any published work engagement studies involving FMR managers.

Job satisfaction defined as “the pleasure people derive from their work, including their ability to positively affect the lives of people through work”² has been studied using  nine  general domains (satisfaction with pay, opportunities for promotion, fringe benefits, contingent rewards, nature of supervision, relationships with co-workers, nature of work, communications, and working conditions).¹²

Attitudinal work outcomes, job satisfaction and turnover intentions have predominantly been studied in relation to the negative outcome of burnout,^13-16 but not to the positive outcome of enhanced work engagement, experientially among FMR managers. Job turnover intention is defined as “a conscious and deliberate willingness to leave an organization.”¹⁷ Although no standard framework has been developed to understand why employees leave voluntarily, factors such as poor workplace communication, hostile work environment, unexplained work task, inequitable salary and benefits packages, have been implicated.^18,19 A 2018 study reported that 51% of 307 FMR managers had been employed in their current organization for less than five years, suggesting a high turnover rate.² There is currently no published data on FMR managers’ turnover intentions. Studies in diverse industries have found turnover intentions to be an accurate predictor of actual turnover.^20,21 Studies have also consistently shown a strong and inverse association between job satisfaction and employee turnover intentions.^21-25

Given the increased volume and significance of job responsibilities and duties expected of FMR managers after the adaptation of NAS, they could be vulnerable to experiencing increased job-related stress and the negative outcomes of decreased work engagement, job satisfaction and increased turnover. We studied job satisfaction and turnover intentions among FMR managers and examined the associations between work engagement, job satisfaction, turnover intentions, and self-reported demographic characteristics. Our specific hypotheses based on the described conceptual framework were:

     1.FMR manager work engagement, job satisfaction, and turnover intentions are related.

     2.Job satisfaction domains (pay, promotion, supervision, fringe benefits, contingent rewards, operating procedures, co-workers, nature of work, and communication) are predictors of work engagement.

     3.FMR manager characteristics (sex, employment status, tenure [length of service in current organization], annual salary, and educational status), job satisfaction domains (pay, promotion, supervision, fringe benefits, contingent rewards, operating procedures, co-workers, nature of work, and communication), and work engagement are predictors of turnover intentions.

This is the first study to provide information regarding job satisfaction, work engagement, and turnover intentions among FMR managers. The findings show that less than 40% are satisfied with their positions and nearly half have thought about resigning within the past month. These findings in crucial members of the residency team are particularly worrying as turnover intentions are predictors of actual turnover.^20-22  In addition, about 55% of the managers have held that position for less than five years, confirming other reports that showed similar or greater rates of short tenure among medical residency program managers.^2,13,29 The underlying causes for short tenure and high turnover intentions among medical residency managers are not well defined, but may be related to the combined effects of the expanded job role and responsibilities,^1-3 increased job stress without adequate support,² and job dissatisfaction.^21,23,24

Work engagement is positively associated with job satisfaction and negatively associated with turnover intentions.^6,8 These findings support and enhance work engagement studies of other employees in diverse industries.^6,8,30 Our findings are in line with studies showing that when employees are satisfied, they are less likely to seek other jobs.^21,23,24,31 In our study, dissatisfied managers were four times more likely to report turnover intentions.

Of the nine domains of job satisfaction, nature of work, fringe benefits, communication, and promotion significantly predicted FMR manager work engagement. This finding indicates that medical residency managers are more emotionally and cognitively engaged when their job responsibilities are clearly communicated, they have the resources necessary to accomplish their work, perceive their work as meaningful, are compensated fairly and equitably, and have opportunities to be promoted. These findings correlate with engagement findings from studies in other work environments and studies of medical residents that associated job satisfaction positively with work engagement.^10,11,31,32 Overall, employees are more engaged when they work in an environment that provides practical and psychologically meaningful support as well as advancement and promotion opportunities.³³ To be effective, support, development and advancement opportunities must be clearly communicated to FMR managers.

Our results show that the prospect of promotion is a predictor of work engagement among managers, but opportunities to advance in medical residency programs are often limited. Currently, many organizational structures do not provide opportunities or a clear pathway for managers to undertake professional development or achieve promotion. In a survey of 400,000 U.S. workers, engagement and employment stability were very high when employees perceived promotion to be fair and managed effectively.³⁴ To reduce or minimize turnover intentions and promote greater emotional investment among FMR managers, the accrediting bodies (Graduate Medical Education-International [ACGME-I], ACGME, AAFP [American Academy of Family Physicians], ABFM [American Board of Family Medicine]), AFMA and individual medical residency programs internationally should advance on strategies to support and develop medical residency managers. These strategies could include professional development training and opportunities for lateral movement to develop new skills and expand professional knowledge and collegial support networks.

Finally, in studying the impact of personal characteristics on turnover intentions, level of education significantly predicted turnover intention while, five of the nine job satisfaction domains (pay, supervision, contingent rewards, nature of work, and communication) as well as work engagement significantly predicted turnover intentions with negative coefficients. These findings indicate that FMR managers are more likely to resign when they are highly educated, perceive their pay to be small and unfair, perceive supervisors to be unfair and unsupportive, feel their work is meaningless, job responsibilities are unclear, and perceive they are underappreciated, or are emotionally and cognitively disengaged from work. These findings correlate with multiple studies of employees in diverse work environments.^6,8,18,19 Clearly, when medical residency managers are emotionally and cognitively engaged at work, they tend to remain in the organization, validating and rewarding organizations that foster employee engagement.^31,35

Our study has several limitations. The results are limited to those FMR managers who were members of AFMA at the time of the study and chose to respond to the survey. Although the majority of FMR managers are members of AFMA, responses of non-members could have changed the results of the study. The survey also presents a snapshot of the managers’ subjective responses. As this is a cross-sectional study, we could not establish causal relationship between work engagement, job satisfaction, and turnover intentions; nor can we know whether one preceded the other. Additional research is warranted. Finally, the study was conducted at a time of the year when workload was unusually heavy due to medical residency graduations, orientation of interns, and advancement of resident classes.

Our study reports high prevalence of job dissatisfaction and turnover intentions among FMR managers and confirms the associations between work engagement, job satisfaction, and turnover intentions. Recognizing the high turnover rates and low job satisfaction among FMR managers should stimulate development of increased opportunities for creative and sustainable solutions. Given the role and level of importance of FMR managers within graduate medical education, our study highlights the importance of developing conversations to improve job satisfaction and work engagement among the managers. Accrediting bodies such as ACGME, AAFP, ABFM, and ACGME-I as well as AFMA need to work with graduate medical education programs to prioritize understanding the needs of FMR managers and implement appropriate programs to support these essential colleagues.