Burdensome EHRs, insurance snafus, ever-changing rules and regulations, less quality time with patients, and a lack of autonomy are just some of the systemic factors(www.ncbi.nlm.nih.gov) reported to contribute to physician burnout. These factors also help explain why the Academy has devoted so much time and effort in the past few years to reducing burnout and improving well-being among family physicians.
One aspect that has not been studied as extensively is the relationship between burnout and practice location. Although a 2018 Annals of Family Medicine study indicated that early-career FPs who practiced a broader scope of medicine and those who practiced in more than one setting had significantly lower self-reported burnout rates than their peers who practiced in fewer settings and provided fewer services, that study did not analyze practice settings geographically.
Now, a small pilot study(www.researchgate.net) published in the July issue of South Dakota Medicine has found that FPs who practice in rural areas have significantly lower burnout rates than those who practice in medium-sized or larger metropolitan areas and suggested that some aspects of rural practice may confer a protective effect against burnout.
- Results of a small pilot study suggest that family physicians who practice in rural areas have significantly lower burnout rates than those who practice in medium-sized or metropolitan areas.
- The burnout rate among FPs who practiced in rural areas was less than half that of FPs who practiced in a metropolitan setting.
- The study authors suggested that some elements of practicing in a rural setting may provide a protective effect on physician well-being.
The authors emailed an online survey to 302 graduates of the Sioux Falls Family Medicine Residency Program. Responses were collected in November and December 2017. Recipients were told not to complete the survey if they were retired or not currently in a clinical practice.
The survey requested demographic information that included practice scope and the population size of the FP's practice location. Locations were categorized as rural (10,000 people or less), medium-sized (between 10,000 and 50,000 people) or metropolitan (greater than 50,000 people).
In addition, participants were asked to rate their level of burnout using a single-item question from the Physician Work-Life Study.(nam.edu) A total of 99 FPs completed the survey.
Compared with FPs in metropolitan settings, rural FPs tended to be male, older and to practice obstetrics, including deliveries. Half of all male FPs who completed the survey practiced in a rural setting, and just over two-thirds of female FPs practiced in metropolitan areas.
FPs practicing in rural areas had the lowest burnout rates of any group. Twenty-five percent of rural FPs reported burnout, compared to 37.5% of those in medium-sized towns and 51.4% in metropolitan areas, a finding the authors called statistically significant.
The authors also calculated burnout rates based on other factors and reported several notable though not statistically significant trends that could warrant further study:
- Burnout rates were considerably higher among female FPs than male FPs regardless of practice area (47% vs. 27%).
- Female FPs who practiced in rural areas had a 31% burnout rate, while those who practiced in medium-sized or metropolitan areas had a 54% burnout rate.
- Male FPs who practiced in rural or medium-sized areas had a 21% burnout rate, while those who practiced in metropolitan areas had a 43% burnout rate.
- Overall, 30% of FPs 45 and younger reported burnout, while 48% of FPs older than 45 reported burnout.
- The lowest burnout rate, 16%, was reported in FPs 45 and younger who practiced in rural areas.
- The highest burnout rate, 75%, was seen in FPs older than 45 who practiced in metropolitan areas.
- In total, FPs who practiced obstetrics with deliveries had slightly higher burnout rates than those who did not (41% vs. 34%).
- FPs who practiced obstetrics with deliveries had lower burnout rates when practicing in rural areas (20% vs. 30%), but higher rates when practicing in medium-sized (50% vs. 25%) and metropolitan areas (73% vs. 42%).
It's important to note that the single-item question focused only on the emotional exhaustion component of burnout and did not address other aspects, such as depersonalization and personal achievement. It's also important to note that the residency program's mission statement(siouxfallsfpr.org) emphasizes training physicians to practice in the rural upper Midwest; as such, the study results may not be applicable to other parts of the country.
Despite these limitations, the authors suggested that practicing in a rural area could positively affect physician well-being and be used as a recruiting tool to draw more FPs to those settings.
"Resident physicians who are considering rural practice -- but are worried about burnout -- can be assured that rural practice may in fact be protective against burnout. This will hopefully encourage family physicians to pursue rural practice, where there may be more professional fulfillment and a higher quality of life," they wrote.
Authors Provide Additional Insight
Study authors Amy Hogue, M.D., and Mark Huntington, M.D., Ph.D., serve as the associate program director and director, respectively, at the Sioux Falls Family Medicine Residency Program. They also serve as assistant professor and professor, respectively, in the Department of Family Medicine at the University of South Dakota Sanford School of Medicine in Vermillion. In the following Q&A with AAFP News, they provided additional comment about the research.
AAFP News: How did you become interested in this type of research, and which of the study's findings surprised you the most?
Hogue: There has been an abundance of published research on physician burnout lately, but none that addressed this particular issue. Rural doctors may have fewer resources and increased work hours. Also, when you get asked to examine your patient's rash at the grocery store, it may be harder to maintain a good work-life balance. For these reasons, we felt rural doctors may be at higher risk for burnout. We were surprised to see that the opposite was true.
AAFP News: What do you think led to the lower burnout rate among FPs who practiced in rural areas?
Hogue: We need more research to address this. However, we suspect that rural physicians may have more autonomy and respect from their communities. Also, rural America is just a great place to live.
AAFP News: What is the take-home message for family physicians?
Hogue: Our country desperately needs more rural family physicians. Hopefully, the results of this study will encourage family physicians to take a closer look at rural practice settings.
AAFP News: What would you say to younger family physicians who are just starting out and considering where they'd like to practice?
Hogue: Talk to other physicians in the practice you are joining. Do they feel fulfilled by their work? Do they feel valued? Really try to get a sense if they are happy. These factors may matter more than money, though the pay in rural areas is usually pretty good, too.
AAFP News: How would older FPs benefit from practicing in a rural setting?
Huntington: It was interesting that the most burned out subgroup was physicians over 45 in metropolitan areas. It would be helpful to see if this would be reproduced in a larger study. This may be a subgroup that rural recruiters should consider targeting. While it is also possible that those who (felt) burned out in rural areas moved to metropolitan areas, skewing the data, we think this is less likely but certainly should be part of future investigations on this topic.
AAFP News: Any final thoughts?
Hogue: A burnout rate of 25%, while lower than the more populated areas, is still significant. Burnout has been associated with an intent to leave practice location within one year. While it is always hard for a practice to lose a physician, this can be especially devastating in underserved rural areas. We need to continue to consider how to best support rural physicians.
Related AAFP News Coverage
Leader Voices Blog: New AAFP Initiative Addresses Rural Health Care Crisis
More From AAFP
In the Trenches: Reclaiming Family Medicine's Broad Scope Benefits Everyone