Burnout Among Primary Care Clinicians

Author: Christine Zink, MD

It’s no secret that burnout has been plaguing professionals inside and outside of healthcare across the United States. Although, after navigating the trials of the COVID-19 pandemic, the volume has turned up significantly on burnout discussions involving healthcare professionals. Primary care clinicians have higher rates of burnout than most other clinicians, and the field is rated in the top five for burnout among all healthcare specialties.1,8

The amount of information that addresses burnout’s history, evolution, and solution is immense and challenging to weed through. To simplify some of the information, this article will touch on the overarching topic of burnout among primary care clinicians (physicians, physician assistants, and nurse practitioners). It will briefly discuss the epidemiology of burnout among different types of clinicians and the causes of burnout. Finally, it will delve into how individual clinicians and organizations can change to address burnout and instill long-lasting improvement in the healthcare system.

Here are the key takeaways:

  • The components of burnout include overwhelming exhaustion, depersonalization, and a sense of ineffectiveness.4
  • The burnout rate among primary care physicians is approximately 63%, 33% among physician assistants, and 25% among nurse practitioners.1-3
  • The two most important factors that contribute to clinician dissatisfaction are the use of electronic health records and clinicians’ perceptions of their lack of ability to provide high-quality care.1,4
  • Most experts attribute 80% of clinician burnout to the chaotic work environment and only 20% to personal factors.5
  • Burnout interventions that focus on organizational changes seem to be more successful than those that focus on changes in the individual clinician.6
  • One solution that seems to be successful in reducing clinician burnout is implementing a team-based care model that expands the role of medical assistants and incorporates a team of healthcare professionals that work alongside clinicians to address patient care needs.7

In 2014, the American Academy of Family Physicians (AAFP) developed a position paper on burnout because they were concerned about the high rates of professional burnout.1 The AAFP targeted burnout as a concern because of the negative effects it has on both the quality of patient care (clinicians leaving practice early, contributing to a shortage of primary care clinicians1 ) and on the clinicians themselves (increasing clinician risk for depression9).

Epidemiology

Research shows that across all specialties, approximately half of physicians (not including physician assistants and nurse practitioners) experience at least one symptom of burnout.1,5 In addition to decreased quality of care and clinicians leaving practice early, burnout is also associated with increased medical errors, riskier prescribing patterns, and lower patient adherence to chronic disease management plans.1 These ramifications have significant negative effects on all people.

Burnout in Primary Care Physicians:

  • In the AAFP’s 2014 position paper, the burnout rate among primary care physicians was 63%, and only 35% reported being satisfied with their work-life balance.1
  • These numbers did not include the evaluation of rates of burnout among physician assistants (PA) or nurse practitioners (NP). Since then, there have been reports of rising burnout among PAs and NPs.

Burnout in PAs:

  • Approximately 33% of PAs meet the criteria for burnout.2
  • 46% of PAs meet the criteria for work exhaustion and 30% for interpersonal disengagement.2
  • PAs are more likely than physicians to report professional fulfillment (over half of PAs).2

Burnout in NPs:

  • A recent study also evaluated the rates of burnout among NPs and found that 25% are burned out.3

Burnout in Early Medical Training:

  • A recent systematic review and meta-analysis found that nearly 30% of medical students screen positive for depression, and 10% report suicidal ideation during medical school.4
  • 30% of residents in training screen positive for depression and 60% are burned out.4

Definition

The classic definition of burnout is a psychological syndrome in response to chronic interpersonal stressors from the environment (on the job). The three critical elements of this response include1,4:

  • Overwhelming exhaustion (e.g., I don’t have time to determine why he has pain; just refer him to pain management.)
  • Depersonalization or feelings of cynicism and detachment from work (e.g., All I do is click on a computer screen all day to ensure I get paid.)
  • A sense of ineffectiveness and lack of accomplishment (e.g., This appointment will waste my day because no matter what I recommend, it never seems to help.)

*Remember: Burnout is not depression. Primary care clinicians who experience burnout do not always have depression, but burnout may increase the risk of depression.8 The lifetime rate of depression among clinicians is similar to that of the general population. However, the suicide rate is disproportionately higher among clinicians. Approximately 300 to 400 physicians are lost to suicide annually.4

Causes

It is challenging to nail down the causes of clinician burnout because they are multifactorial, and clinicians are impacted differently at different stages of their careers.1 Several changes in the healthcare system over the last decade, including the adoption of information technology, the institution of electronic health records, and the transition to new patient-centered accountable care models, have added complexity to practicing primary care, pulled clinicians away from patients, and contributed to dissatisfaction. Some studies have determined that the most important factors that influence clinician satisfaction are:1,4

  • The use of electronic health records
  • Clinicians’ perceptions of their ability to provide high-quality care
  • Autonomy and work control
  • Practice leadership
  • Collegiality, fairness, and respect
  • Work quantity and pace
  • Regulatory and professional liability concerns
  • Relationships with allied health professionals and support staff
  • Insufficient reward
  • A mismatch between the values of the employer and employee

Addressing these issues can help to combat the problem of burnout. However, it is extremely difficult to change the system that is driving clinician burnout since many clinicians leave their practice mid-career and do not take on leadership roles that could affect system change.1

Solutions

Resilience ≠ Lack of Burnout

Solutions to the burnout problem have also been difficult to nail down. Initially, the focus was on mindfulness and wellness for the individual clinician. To this end, promoters of clinician well-being evaluated resilience among US physicians and compared the results with the general US working population. They defined resilience as personality qualities that enable a person to adapt well and thrive in the face of adversity and stress.10 It is believed that the intensity and duration of medical training select resilient people who would be expected to navigate the demands of professional life effectively and thus, would be expected to overcome feelings of burnout. The study showed that physicians had higher resilience than the general population, even when the data was adjusted for sex, age, relationship status, hours worked per week, and burnout status.10 Also, physicians with greater resilience were less likely to experience burnout symptoms, yet burnout was still common among physicians, even those with the highest resilience scores.10 Researchers extrapolated from this information that although focusing on individual clinician wellness and encouraging resilience might affect small changes in burnout, addressing root causes in healthcare system practice environments is more likely to reduce burnout and promote overall well-being.10 In essence, many of the problems of burnout are institutional, not individual.

Now experts agree that combating burnout mainly requires a change in primary care clinicians’ practices, at the organizational level, and in the overall healthcare system.1 A recent meta-analysis of burnout solutions found that interventions that focused more on organizational changes were more successful than those that focused on changes in the individual clinician.6

Top 10 Interventions to Reduce Clinician Burnout

To determine the best avenues for change, the American College of Physicians (ACP) created a list of the top 10 interventions to reduce burnout and improve clinician well-being. To combat burnout, they suggest11:

  • Limiting work hours and offering flexible work arrangements
  • Investing in leadership development
  • Creating a wellness committee whose mission is to change the culture by promoting wellness
  • Establishing wellness as a quality indicator for the practice
  • Conducting facilitated clinician discussion groups that incorporate elements of mindfulness, reflection, shared experience, and small group learning
  • Establishing a culture in which teamwork and relationships take priority
  • Providing relationship-centered communication skills training for clinicians
  • Conducting workflow and quality improvement projects aimed at addressing clinician concerns
  • Implementing the Listen-Act-Develop model that is based on organizational psychology and social science and encourages integration with institutional efforts related to quality improvement, safety, burnout, and leadership development
  • Proactively working to reduce the stigma associated with mental illness so that clinicians seek help when they need it

Primary Care 2.0: Team-Based Model

It will take time and significant collaboration to instill changes at the institutional level. One example that has been underway is Stanford Medicine’s Primary Care 2.0. Stanford Medicine researchers offer a solution to clinician burnout with a team-based model for primary care.7 Primary Care 2.0 was launched in 2016 to reduce clinician burnout by changing healthcare delivery from a clinician-centric model to a team-centric model.7 This means that instead of clinicians carrying the patient workload, a team of healthcare professionals, including medical assistants, nurses, pharmacists, physical therapists, and dietitians, is given tasks.7 The key staffing component of Primary Care 2.0 seems to be the ratio of medical assistants to clinicians (2:1).7 In addition, the care model expands the role of medical assistants to include scribing, population health management, and between-visit care management.

In 2021, the group reported the new model’s results and found that it was beneficial for patients and primary care clinicians, but only if the model was sustained.7 The team model was significantly and inversely associated with burnout. The researchers also found that quality of care and patient satisfaction remained similar to sites utilizing traditional care models.7 Furthermore, the cost of care at the Primary Care 2.0 site was lower than at other clinics.7 However, the gains in clinician satisfaction were not sustained after 24 months. The researchers suspect this is because of staffing cuts (the medical assistant to clinician ratio changed from 2:1 to 1.5:1) that occurred at 16 months, placing administrative tasks back into the hands of the clinicians.7

The ideas and solutions presented in this article are not completely comprehensive but offer clinicians a starting point for instilling change in their practice and institution. Burnout is a concerning issue that requires leadership and action now to improve overall care for Americans.

We encourage you to visit the sites mentioned in this article to learn more about the solutions to burnout. In addition, listen to this podcast on self-care methods to help healthcare workers combat burnout, and tune into this webcast that discusses ways to improve healthcare provider distress at multiple levels.

 

References

  1. 1. American Academy of Family Physicians. Family physician burnout, well-being, and professional satisfaction (position paper). Published 2014. Accessed July 31, 2022. https://www.aafp.org/about/policies/all/family-physician-burnout.html

2. Blackstone SR, Johnson AK, Smith NE, McCall TC, Simmons WR, Skelly AW. Depression, burnout, and professional outcomes among PAs. JAAPA. 2021;34(9):35-41. https://journals.lww.com/jaapa/Fulltext/2021/09000/Depression,_burnout,_and_professional_outcomes.7.aspx

3. Abraham CM, Zheng K, Norful AA, Ghaffari A, Liu J, Poghosyan L. Primary care practice environment and burnout among nurse practitioners. J Nurse Pract. 2021;17(2):157-162. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920210/

4. Carrau D, Janis JE. Physician burnout: solutions for individuals and organizations. Plast Reconstr Surg Glob Open. 2021;9(2):e3418. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7929696/

5. Brown MT. Practical ways to address physician burnout and improve joy in practice. Fam Pract Manag. 2019;26(6):7-10. https://www.aafp.org/pubs/fpm/issues/2019/1100/p7.html

6. Nelson K, Stewart G. Primary care transformation and physician burnout. J Gen Intern Med. 2019;34(1):7-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6318192/

7. Shaw JG, Winget M, Brown-Johnson C, et al. Primary Care 2.0: a prospective evaluation of a novel model of advanced team care with expanded medical assistant support. Ann Fam Med. 2021;19(5):411-418. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8437557/

8. American Academy of Family Physicians. Is that me? Dealing with family physician burnout and depression. Accessed July 31, 2022. https://www.aafp.org/family-physician/patient-care/current-hot-topics/recent-outbreaks/covid-19/covid-19-physician-wellbeing/is-that-me-family-physician-burnout-depression.html

9. Agarwal SD, Pabo E, Rozenblum R, Sherritt KM. Professional dissonance and burnout in primary care: a qualitative study. JAMA Intern Med. 2020;180(3):395-401. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990959/

10. West CP, Dyrbye LN, Sinsky C, et al. Resilience and burnout among physicians and the general us working population. JAMA Netw Open. 2020;3(7):e209385. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7333021/

11. American College of Physicians. Top 10 culture change interventions to reduce burnout and improve physician well-being. Accessed July 31, 2022. https://www.acponline.org/practice-resources/physician-well-being-and-professional-fulfillment/top-10-culture-change-interventions-to-reduce-burnout-and-improve-physician-well-being