• Family Physician Burnout, Well-Being, and Professional Satisfaction (Position Paper)

    Introduction

    The American Academy of Family Physicians (AAFP) is concerned about the high rates of professional burnout among physicians in the United States. This subject is important to the AAFP because family physicians suffer from significantly higher rates of burnout than physicians in most other specialties.1,2 Burnout can negatively affect quality of patient care and result in physicians leaving practice, thus contributing to the primary care workforce shortage.

    The State of Physician Burnout

    Physician burnout has been a significant area of concern and investigation for decades. A broad body of literature addresses both the causes of physician burnout and potential interventions to prevent or alleviate it. In addition, this issue has been covered in popular media.3,4 The literature shows that there is a high risk of physician burnout in the United States. A broad-based study that assessed U.S. physicians using the Maslach Burnout Inventory (MBI) showed that 54.4% of all physicians combined reported experiencing at least one symptom of burnout.1 The same study found a 63% burnout rate among U.S. family physicians. Further, the study found that only 35% of family physicians report being satisfied with their work-life balance. These striking findings bear out across medical specialties, career phases, and demographics.5

    Definition of Burnout

    The following is a classic definition of burnout:

    • “[Job burnout is] a psychological syndrome in response to chronic interpersonal stressors on the job. The three key dimensions of this response are an overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment."6

    Common Drivers of Burnout

    The importance of identifying and addressing the root causes of physician burnout cannot be overemphasized. Despite much research, definitive data on causes of physician burnout still may not exist.7 Studies indicate that common drivers of family physician burnout include the following: paperwork; feeling undervalued; frustrations with referral networks; difficult patients; medicolegal issues; and challenges in finding work-life balance.8,9 These factors have varying impact at different stages of a physician’s career. Inability to resolve work-life conflict has the greatest impact on physicians early in their careers.9 Long hours, frequent call, frustration with administrative burden, and reimbursement issues strongly affect physicians in the middle of their careers.9

    In 2013, the American Medical Association (AMA) commissioned a study by the Rand Corporation to identify high-priority determinants of physician professional satisfaction.10 The authors reported that two important factors influencing professional satisfaction are the use of electronic health records (EHRs) and physicians’ perceptions of their ability to provide high-quality care. Other factors that affect physician professional satisfaction include the following:

    • Autonomy and work control
    • Practice leadership
    • Collegiality, fairness, and respect
    • Work quantity and pace
    • Regulatory and professional liability concerns
    • Work content, allied health professionals, and support staff

    Effects of Burnout

    Understanding of how physician burnout directly affects patient health outcomes continues to increase. Research shows that symptoms of physician burnout can be connected with increased rates of medical errors, riskier prescribing patterns, and lower patient adherence to chronic disease management plans.11,12 Middle-career physicians report long hours and frequent call, resulting in greater burnout and dissatisfaction among these physicians compared with physicians in other career stages; middle-career physicians are also more likely to leave clinical practice.9 This is a notable concern because the middle of a physician’s career typically is the most productive phase in terms of providing patient care, serving as a leader and mentor, and assuming important administrative roles. The fact that burnout causes some physicians to leave practice early may explain why reported levels of satisfaction are highest among older physicians.

    Data from recent annual Medscape physician burnout studies reveal an increasing gender gap in rates of burnout.2 Across all specialties, the burnout rate among female physicians (55%) is 10% greater than the burnout rate of their male peers (45%). The reasons for this disparity are unclear and may require additional study.

    The U.S. health care system needs physicians to lead the transition to new methods of health care delivery and to sustain effective participation. However, the fact that more than half of U.S. physicians experience symptoms of burnout could compromise their ability to be effective in leading and sustaining change.7,12 Reducing physician burnout is critical to achieving the goals of redesigning the health care system and improving the health of patients, families, and communities in the United States.

    Definition of Well-being

    The Centers for Disease Control and Prevention (CDC) states the following definition:

    • "In simple terms, well-being can be described as judging life postively and feeling good."13

    Happiness at Work and Professional Satisfaction

    Well-being and professional satisfaction are not simply the absence of burnout, just as good health is not simply the absence of disease. The Medscape Lifestyle Report 2017 reveals that although 45% of family physicians report no symptoms of burnout, only 29% report being happy at work.2 In addition, although 77% of family physicians report that they would choose to be a physician again, only 67% of those physicians would choose family medicine as their specialty again.14

    The Family Physician Ecosystem

    Each individual family physician uniquely experiences his or her professional role within the context of many variables. These interacting variables form a family physician ecosystem (Figure 1). Potential solutions to improve personal well-being and professional satisfaction must be customized based on the family physician’s experience of this ecosystem.

    The following are the five influential elements of the family physician ecosystem:

    1. U.S. Health Care System Level – The U.S. health care system is heavily regulated and primarily based on fee-for-service payment. Reporting and documentation requirements place a significant burden on family physicians but do not yield a proportional improvement in quality of care.
    2. Organization Level – The majority of family physicians report that they are either employed or part of an organized medical staff.15 The values, requirements, and operational policies of an organization can influence professional satisfaction.
    3. Practice Level – The characteristics and efficiencies of the practice environment and the care team can affect the family physician’s well-being.
    4. Individual Level – Individual wellness habits and resilience capabilities can affect the family physician’s response to external stressors.
    5. Physician Culture Level – A culture that elevates self-sacrifice—or even self-neglect—in the service of others can contribute to feelings of shame and guilt when the family physician is unable to achieve superhuman performance levels. Peer-to-peer support is often unavailable.

    Interventions to Reduce Burnout and Increase Satisfaction

    Understanding the drivers of physician burnout informs the ongoing development of intervention models to prevent burnout and support services to help physicians cope with the symptoms. Historically, most programs to address burnout have focused on the treatment of individual physicians (e.g., counseling services). Studies have found that self-awareness and mindfulness training can reduce physician burnout and increase both physician well-being and patient-centered qualities.16 There is a growing trend among health care systems and other employers of physicians to adopt more system-level interventions, such as implementing institutional success metrics that include physician satisfaction and well-being, and developing practice models that preserve the decision-making autonomy of physicians.17

    Conclusion

    Though burnout affects physicians across all specialties, family physicians experience higher-than-average rates, especially when compared to the general U.S. working population. At the same time, satisfaction with work-life balance is decreasing. The AAFP believes that physician burnout is an important issue that must be dealt with openly and proactively because it affects both patient safety and physician well-being. In addition, burnout influences family physicians’ decisions about remaining in clinical practice, which affects patients’ access to high-quality care. Burnout also affects family physicians’ ability to lead changes at the practice and health care system levels.

    The AAFP strongly believes that physician burnout is a health system, organization, practice, and physician culture problem, not just an individual concern. Therefore, the AAFP takes a systems-based approach to identifying and combating root causes of physician burnout at all levels of the family physician ecosystem. As a trusted partner for members interested in developing their personal resilience skills, the AAFP is committed to providing resources to support members’ well-being and professional satisfaction. These resources are available to all AAFP members, including students, residents, active members, and life members.

    References

    1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613.
    2. Medscape Lifestyle Report 2017. Accessed June 22, 2017.
    3. Rabin RC, Kaiser Health News. A growing number of primary‐care doctors are burning out. How does this affect patients? Washington Post. March 31, 2014. Accessed June 22, 2017.
    4. Pearl R. Malcolm Gladwell: Tell people what it's really like to be a doctor. Forbes. March 13, 2014. Accessed June 22, 2017.
    5. Leiter MP, Frank E, Matheson TJ. Demands, values, and burnout: relevance for physicians. Can Fam Physician. 2009;55(12):1224‐1225, 1225.e1‐6.
    6. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422.
    7. Gabbard GO. Medicine and its discontents. Mayo Clin Proc. 2013;88(12):1347‐1349.
    8. Lee FJ, Stewart M, Brown JB. Stress, burnout, and strategies for reducing them: what's the situation among Canadian family physicians? Can Fam Physician. 2008;54:234‐235.
    9. Dyrbye LN, Varkey P, Boone SL, Satele DV, Sloan JA, Shanafelt TD. Physician satisfaction and burnout at different career stages. Mayo Clin Proc. 2013;88(12):1358‐1367.
    10. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Rand Health Q. 2014;3(4):1.
    11. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374(9702):1714‐1721.
    12. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995‐1000.
    13. Centers for Disease Control and Prevention. Well-being concepts. Accessed June 22, 2017.
    14. Medscape Physician Compensation Report 2017. Accessed June 22, 2017.
    15. American Academy of Family Physicians. AAFP Member Census, December 31, 2016. Table 4: Selected practice characteristics of active AAFP members. http://www.aafp.org/about/the-aafp/family-medicine-facts/table-4.html. Accessed June 22, 2017. 
    16. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284‐1293.
    17. Dunn PM, Arnetz BB, Christensen JF, Homer L. Meeting the imperative to improve physician well‐being: assessment of an innovative program. J Gen Intern Med. 2007;22(11):1544‐1552. Epub 2007 Sep 22.

    (2014 COD) (2017 COD)

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