Leadership Health Care (LHC), a Nashville Health Care Council program for emerging leaders, Cohorts provide the participants an opportunity to engage in a peer mentoring program facilitated by an experienced healthcare executive. Throughout six cohort sessions, participants discuss substantive topics around a common focus area to enhance their knowledge and leadership skills.
At a recent Nashville Health Care Council LHC Operations Cohort session, Dr. Gregory Guldner—Vice President of Academic Affairs at HCA Healthcare Graduate Medical Education (GME) —shared a compelling vision for how health systems can tackle one of the most urgent issues facing healthcare today: physician burnout and retention. With more than 20 years of experience in physician well-being and a background in clinical psychology, Dr. Guldner, who practiced as an emergency physician for 28 years, is leading a movement to redesign training environments around a simple but transformative idea: support team members' basic psychological needs at work.
The Scale and Stakes of GME at HCA
HCA Healthcare operates one of the largest GME programs in the country—spanning 79 teaching hospitals, more than 340 programs, and training over 5,400 residents and fellows across 16 states. With 6,200+ faculty members, the scale presents both a significant opportunity and a substantial challenge.
Retention is no longer just a talent strategy—it’s a survival strategy. Dr. Guldner put it plainly: “Try getting an anesthesiologist right now—good luck.” Specialties like emergency medicine and hospital-based radiology are feeling the pinch acutely, and the financial toll of turnover is immense. The key to retention, he argues, isn’t compensation alone. “Beyond a certain point, it’s not about money anymore. It’s about the experience.”
Rethinking Burnout: Why Wellness Interventions May Be Missing the Mark
In healthcare, the conversation around workplace burnout often centers on stress management workshops, mindfulness apps, and meditation sessions. But Dr. Gregory Guldner, speaking at a recent LHC Cohort session, shared compelling evidence that these well-intentioned solutions may not be the answer.
"Burnout is primarily a workplace environment problem," Dr. Guldner explained. “It’s not just emotional exhaustion or a bad day—it’s when exhaustion, depersonalization, and low sense of achievement start to impact performance.” And yet, much of the literature on burnout leans heavily on interventions that place the burden back on the individual—expecting them to build resilience or cope more effectively with the demands of an unchanged environment.
"Burnout is primarily a workplace environment problem," Dr. Guldner explained. “It’s not just emotional exhaustion or a bad day—it’s when exhaustion, depersonalization, and low sense of achievement start to impact performance.” - Dr. Gregory Guldner, Vice President of Academic Affairs at HCA Healthcare Graduate Medical Education.
Dr. Guldner referenced the work of clinical psychologist Dr. Maria Panagioti, who analyzed 20 wellness interventions for physicians. Only five showed any statistically significant effect—and most of those targeted organizational changes, not individual self-care strategies. “Wellness initiatives can actually do harm,” Guldner cautioned. “Especially when they’re mandatory and added to an already full plate.”
System Change vs. Self-Care: What Actually Works
The data Dr. Guldner shared paints a clear picture: organizational-level interventions tend to produce far greater impact than individual ones. When hospitals adjusted workflows, improved staffing ratios, or shortened rotations, burnout indicators improved. But when physicians were enrolled in time-intensive self-care programs—ranging from yoga workshops to 24-hour wellness curriculums—the outcomes were underwhelming.
Even interventions that were statistically significant often showed marginal improvements, like a two-point drop in depersonalization on a 30-point scale after five hours of guided meditation. “You might get a statistically significant result,” Guldner noted, “but practically speaking, the benefit is tiny.”
More importantly, few studies accounted for biases like effort justification—when participants report positive outcomes simply because they invested significant time or energy. “The research quality just isn’t there,” he said. “We need better data. And we need to stop asking individuals to adapt to broken systems.”
The takeaway? Burnout isn't something to be “managed” with an app or a yoga mat. It’s a structural issue—and until the system changes, no amount of mindfulness will meaningfully move the needle.
A Theory-Driven Framework: Self-Determination Theory
Dr. Guldner also shared a compelling perspective on Self-Determination Theory (SDT), emphasizing its relevance to workplace culture and leadership. At its core, SDT outlines three fundamental psychological needs: autonomy, belonging, and competence. Autonomy, he explains, is often misinterpreted as the absence of oversight. Instead, it’s about psychological freedom—the sense that we are the authors of our actions and that we willingly endorse the work we do, even if we don’t always enjoy it. The opposite of this is control, which is easier for organizations to default to but often undermines motivation. Policies that feel transactional or overly directive can inadvertently erode this sense of autonomy, even when intentions are good.
Belonging and competence are more intuitive but equally critical. Belonging refers to warm, reciprocal relationships and a sense of being valued within a community. Competence involves opportunities for growth, mastery, and feeling effective in one’s work. Guldner also noted that while not formally part of the original SDT framework, his team includes “deep meaning” as a fourth element due to its strong influence in their research. Across a large-scale structural equation model of 34,000 employees, the evidence was clear: when leaders support these needs—through interpersonal relationships, polices and procedures, and the built environment—employees are far more likely to experience healthy, internal motivation.
Creating Environments That Prevent Burnout
When it comes to tackling clinician burnout, Guldner believes the solution isn’t more pizza parties or resilience training—it's about transforming the environment.
In a cohort session focused on the well-being of residents, Dr. Guldner shared findings from a survey of nearly 2,000 residents using the AMA's Mini Z burnout assessment. His team found that 70% of burnout variation could be predicted by workplace factors, not personal resilience. The top predictors? Hindrance job demands and the presence—or absence—of autonomy, belonging, competence, and meaning.
Of these, autonomy emerged as the strongest predictor of whether residents would endorse their program. But Dr. Guldner emphasized a crucial point: “Autonomy is not about freedom or doing whatever you want. It’s about feeling heard and having meaningful input in your work.”
He shared four deceptively simple survey questions that signal autonomy in action—none of which mention freedom from supervision. Instead, they measure whether a person had input, could share their ideas, and felt their feelings were acknowledged. According to Dr. Guldner, when leaders demonstrate they understand their team’s perspectives and take those feelings into account, people are far more likely to stay engaged and committed—even when the job is hard.
So how do leaders create this kind of environment? Start small.
In what Dr. Guldner calls “engagement rounds,” leaders ask individuals directly: What’s bugging you? What can we change to make your day better? From fixing a broken otoscope to redirecting an air vent blowing cold air on a workstation—these quick, high-feasibility changes have outsized impact.
“We’re not teaching resilience,” he said. “We’re teaching leaders how to build systems where people can thrive.”
And it’s working. Residents who trained in programs where leaders attended Dr. Guldner’s workshops were twice as likely to say they’d prefer to work at an HCA Healthcare facility compared to non-HCA Healthcare organizations.
Reframing Leadership More On Autonomy, Belonging, Competence, and Meaning
The cohort also explored how leadership communication—down to the tone of an email—can either support or sabotage team dynamics. Dr. Guldner challenged leaders to recognize where team members may feel coerced or undervalued, encouraging more autonomy-supportive practices. “Where do you feel forced to do things you otherwise wouldn’t?” he asked. “Let me figure that out, because I want to align with you.”
Guldner also emphasized the growing role of technology in supporting leadership. AI tools are emerging to flag overly controlling language in workplace emails, offering more empathetic alternatives.
The conversation expanded beyond communication into the core psychological needs that drive engagement: belonging, competence, and meaning as mentioned earlier. Leaders were urged to consider whether any experiences, spaces, or even team traditions make individuals feel excluded. From overlooked roles like front desk or janitorial staff, to inaccessible social activities, the call was clear—intentionally build inclusive culture.
On the topic of competence, he encouraged leaders to reflect on tasks, tools, or workflows that may consistently undermine team confidence. And when it comes to meaning, Dr. Guldner didn’t hold back: “It’s amazing how few organizations do anything at all on this,” he said. “Amplifying meaning is your job as a leader.”
This framework—autonomy, belonging, competence, and meaning—offers a powerful lens for building stronger, more connected teams. It asks leaders to pause and ask: Are we creating the kind of environment where people can thrive?
The Future of Physician Retention Starts with Belonging
Dr. Guldner’s message to healthcare leaders is clear: solving burnout and retention requires more than surface-level fixes—it demands a fundamental redesign of the systems we train and work in. By grounding HCA Healthcare’s GME strategy in psychological science and prioritizing autonomy, belonging, competence, and meaning, Dr. Guldner is charting a path toward more humane, effective medical training. The takeaway for all health systems? Belonging isn’t a soft concept—it’s a strategic imperative. And when leaders invest in the environments their people work in, they don’t just reduce burnout—they build the kind of culture people want to stay in.
The research presented was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
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