“We've Really Built Something”: Why Family Medicine Program Directors Stay in Their Positions—A Qualitative Study

Across medical specialties, a program director (PD) is essential to the excellence of each of the more than 12 000 residency and fellowship programs accredited in the United States.¹  Program success “all starts and ends with the program director,”²  although there is scant evidence on what makes a PD successful in the role.³  Short PD tenure (time in their position) may be a factor in overall program quality.^4,5  Median residency PD tenure across specialties is 4 to 6 years,⁶  and many PDs have been in their roles 2 years or less.⁷  In academic year 2020-2021, 1500 programs had a director change. Historically, 12% to 14% of programs, including all specialties, have a director change each year.⁶  Many PDs plan to step down in the next 1 to 2 years or have considered resigning.^4,5,8  In family medicine, 18% of PDs responding to national surveys between 2011 and 2017 had been in their position 12 years or more.⁷ 

Existing literature indicates multiple factors for why PDs leave the position—competing priorities, administrative burden, family obligations, managing the problems of others, teaching responsibilities, research demands, challenges with colleague relationships, burnout, institutional/departmental factors, availability of institutional resources, accreditation regulations, and perceiving the job as a stepping-stone.^2,5,9-13  Family medicine PDs may also move to other opportunities, feel they have accomplished their goals as PD, and are comfortable leaving a stable program, especially when they have a succession plan.¹⁴ 

Understanding why PDs stay in the position may lead to understanding factors that promote PD retention. A survey of internal medicine PDs found 4 positive attributes associated with PDs in their position for 10 years or longer: purpose, culture, nature of the work, and sense of achievement.¹⁵  In-depth interviews examining the experience of PDs with long tenures may reveal more detailed insights about what sustains physicians in the PD role.¹⁶  The purpose of this study was to explore important factors related to why some family medicine PDs have stayed in their positions long term (12 or more years).

In 2018, the Association of Family Medicine Residency Directors (AFMRD) engaged the American Academy of Family Physicians (AAFP) National Research Network (NRN) to conduct a 2-phase exploratory study using in-depth interviews with PDs. The first phase examined why PDs step away from the role.¹⁴  This second phase explored why PDs stay in their roles, using web conference or telephone interviews.

The AFMRD tracks data about PDs in US-based family medicine residency programs. Out of 710 programs, 83 PDs (12%) were identified who had a tenure of 12 or more years: 19 (23%) female and 64 (77%) male PDs. We reasoned that 12 or more years of PD tenure would provide both a sufficient pool of potential respondents and “intense manifestations” of PD experiences to yield information-rich interviews.¹⁶  The AFMRD staff sent a brief study description and invitation to an initial stratified random sample of 6 female and 20 male PDs. Sixteen (62%) PDs accepted the initial invitation. Contact information for those expressing interest in participating was forwarded to the AAFP NRN staff who then confirmed interest and scheduled a 1-hour interview. A second invitation was sent to 4 additional randomly selected female PDs to achieve proportions of male and female PDs similar to the population of family medicine PDs in the role 12 or more years. An interview was scheduled with the first invitee who accepted the second invitation. Participants were sent a study information sheet to review prior to the interview and were encouraged to ask questions before the interview and decline participation if desired.

The interviews included structured and in-depth semi-structured questions based on sparse existing literature, author experience as a PD (S.R.B.), and input from previous family medicine PDs not included in the study. Questions addressed the following: the circumstances and decisions around stepping into the PD role, the climate and surrounding support of the program, the most difficult competing demands and help they needed, the support and help they have, and what made it possible for them to stay in the role.

Structured questions were embedded, and answers were recorded on a Likert-type scale. Interviews were conducted by a single study team member (D.H.F.) and were audio recorded when permitted by the respondent, generating transcripts for analysis using ATLAS.ti data analysis software (version 8, Scientific Software Development GmbH).

Quantitative data analysis of structured interview questions included descriptive statistics only. Due to the small sample size, statistical tests comparing male and female respondents were not performed.

Qualitative data analysis of semi-structured questions proceeded through several phases using template coding and grounded hermeneutic editing styles of analysis and interpretation.^17,18  Memo forms were created by the interviewer (D.H.F.) following each interview and shared with study co-investigators for brief reflection and reaction.¹⁹  Memos reflected responses to key research questions, early interpretations, and commentary about the interview in the context of other interviews, including emergent questions for follow-up interviews.

The primary analyst (D.H.F.) used a coding template of a priori codes to segment data into broad conceptual categories created in an early phase of the study,¹⁴  plus additional conceptual categories new to this study.²⁰  The conceptual categories aligned with high-level interview guide domains to answer overall research questions and to facilitate focused analysis with subsequent coding cycles. Coding of segmented data used both template coding (using a priori codes from an early study phase with the same interview guide questions) and inductive coding of all segmented data across all cases. Cycles of coding were repeated across all cases until all data had been coded within the high-level conceptual categories.

To create a “pictorial whole” of the coded data, visual diagrams—networks of codes—were used to display, order, and describe connections between codes and to develop emergent themes within conceptual categories.^17-19  The visual diagrams and descriptive relationships among codes were refined iteratively with feedback from co-investigators and subsequent reviews of the underlying supporting data. A final network diagram of conceptual categories described the interrelated constructs that yielded an overall narrative about longer tenure among family medicine residency PDs in our sample. All analysis was done using ATLAS.ti.

The study team and authors include a current family medicine residency PD (S.R.B.), an experienced mixed-methods researcher in primary care (C.M.H.), and a qualitative researcher with more than 20 years of qualitative research in primary care (D.H.F.). Drawing on our professional experiences in primary care and reflecting on our previous experience studying why PDs leave the position provided valuable interpretive lenses for reviewing, iterating, and refining the emergent results in the present study. Staff at AFMRD had access to the initial database of potential interviewees. Only study research staff at the AAFP NRN and 2 authors (C.M.H., D.H.F.) had access to the names of respondents who ultimately completed interviews. To protect the identities of respondents, potentially identifiable information has been removed from quotations.

This study was approved by the AAFP Institutional Review Board.

Among 17 respondents, 4 (24%) were female and 13 (77%) were male, with a mean tenure of 17.4 years. Respondents were from 3 broad geographic regions of the United States—West, Midwest, and East. Thirteen (77%) completed the National Institute for Program Director Development training. Three interrelated constructs—developing the program, support systems, and job rewards—consistently emerged from across the interview data and are described in detail along with excerpts from the data to illustrate the findings.

Overall, PDs thought that they frequently “accomplished worthwhile things” and “had a positive influence on other people's lives” (Table 1). Participants had mixed perceptions around the challenges of being a PD.

Although details of their experiences may have differed, 3 interrelated constructs were described that supported the PDs' longer tenures in the role: (1) developing the program; (2) internal and external support systems; and (3) rewards of the job.

PDs described different ways they continually work to build the program, especially a supportive culture that develops faculty, staff, and residents to help shoulder the burden and train good physicians. Developing the program helps to reinforce support systems and enhances or enriches experiencing rewards of the job. Supporting this construct are 3 underlying subconstructs that explain the work these PDs do to develop and sustain a well-running program: (1) develop a supportive program culture; (2) work to sustain the program; and (3) develop people and shared leadership. PDs described strategies within these subconstructs that help develop programs (Table 2).

PDs with longer tenures in our data described the presence of support systems that they build or rely on to help run and sustain themselves and the program. Internal support systems include the residency program's faculty (core faculty and associate program directors), staff, and sometimes residents, who provide essential support, often fulfilling specific roles or duties delegated to them. External support systems include sustained supports from the sponsoring institution (especially system leaders—designated institutional officials, department chairs, chief executive officers, vice presidents) and a network including other PDs, mentors, trusted colleagues, and professional organizations. Support systems enable further program development and growth and rewarding job experiences. PDs detailed different types of supports that combined to enable their ability to develop the program and experience the rewards of the job (Table 3).

PDs consistently said they love the job or at least the significant parts of the job that bring them satisfaction, especially the rewards of developing good physicians and their enjoyment or love of teaching. Specific rewards of the job help sustain PDs in the role (Table 4).

Taken together, the PDs in this study described the ongoing work they do to build a program around them that supports their efforts and enables sustaining rewards. PDs noted that building a program is an ongoing effort, and results may not be immediate. Several PDs commented that it may be 4 or 5 years before a PD can build something that is lasting: “If…you think you're gonna change things dramatically in 3 years, and leave, or 5 years and leave, it's really not enough time to do anything long-lasting. It may be enough time to start something, but it's certainly not enough time to sustain anything in that period of time.”

This study on perspectives of family medicine PDs who have stayed long term in their positions provides new insights into the joys of the PD role and factors related to long-term tenure in the position. PDs continuously work to develop the program, need strong internal and external support systems, and describe many important rewards of the position. Developing the program consists of building a supportive culture, sustaining the program through innovation, keeping the purpose and big picture in mind, and developing people and shared leadership. A supportive culture includes faculty support, staff support, mentors, institution support, an active PD network, financial support, and the support of professional organizations. Rewards of the job are substantial, including love of teaching, program successes, and the ripple effect of producing good physicians to serve communities.

Despite persistent evidence of short tenure,^4,6,7,11  PDs are generally satisfied with their positions in multiple specialties.^9,10,21-25  Prior published factors related to satisfaction include mentor support, national meetings, advice from others, interaction with learners, a leadership and management skills fellowship, sharing in the lives of residents, social connectedness, feeling valued by colleagues, and staff support.^10,21-27  A study on why internal medicine PDs remain in the position highlighted similar results, including a sense of joy, achievement, and thriving.¹⁵  Our study adds to this literature by describing in more depth the factors related to satisfaction for long-term PDs, including strategies to develop support systems.

With this small sample of respondents, we cannot draw conclusions about the larger population of family medicine residency PDs of longer tenure. One interviewer conducted all interviews, which could be a source of bias; however, a single experienced interviewer using semi-structured and structured questions provides consistency of elicitation across respondents. While there was consistency across respondents in our sample, there may be additional substantive reasons why PDs stay in their roles, which may suggest additional support strategies for retaining PDs. We also do not know what the optimal PD tenure length is for sustaining residency program quality.

Further research could assess how consistent our findings are across specialties. Additionally, it would be beneficial to understand factors related to satisfaction for PDs in specific groups such as women and physicians underrepresented in medicine.²⁸ 

Family medicine PDs that stay long term in their positions describe many joys of the role. PDs need strong internal and external support systems and a supportive culture in their programs and institutions. Longer-term PDs cite both relying on and successfully cultivating these systems and cultures throughout their tenure as playing a role in why they stay in their positions.