One Thousand Cuts: Insights From a Qualitative Study Exploring Emergency Medicine Program Director Attrition and Career Experiences.

Background: Duration of tenure of emergency medicine (EM) program directors (PD) has decreased in recent decades. We sought to explore the perspectives of EM PDs on their job experiences to identify causes and strategies to promote longevity in the role. Methods: Using a constructivist paradigm, we conducted semi-structured interviews of EM PDs who had recently (within 24 months) transitioned out of the PD role or were contemplating a transition. We used purposive sampling to seek diversity of participants with regard to gender, region of practice, and program training format. We collected data from January to August 2024. Three researchers independently performed a thematic analysis of interview transcripts. We resolved discrepancies through in-depth discussion and negotiated consensus. Results: 12 PDs participated. Our analysis revealed that PDs came into their roles with idealism and a desire to meaningfully impact their trainees, programs, and patients. They experienced fulfillment from having an impact on their trainees and the field of EM, performing an intellectually challenging job, solving problems, and leading their teams to success. They struggled with the high administrative burden, lack of support and resources, challenging interpersonal interactions, and a substantial burden of responsibility oftentimes coupled with limited power to enact change. The misalignment between their ideals and goals and the realities of their job contributed to emotional exhaustion, burnout, and a desire to leave the role. Participants had recommendations at the individual, institutional, and organizational levels to support PDs in their careers. Conclusion: This study illuminates the positive and negative experiences of PDs in their roles and provides insight into how PD longevity can be supported.