November 20, 2019, 02:21 p.m. Michael Devitt – Burnout can result from any number of systemic factors. For some physicians, it's administrative burden in its many forms. For others, it's an inability to connect patients with the resources they need beyond the exam room, such as adequate food and a safe place to stay.
Over time, not being able to address the social needs of patients can wear away at even the most resilient health care professional. A study published in the November/December issue of Annals of Family Medicine examined the relationship between burnout in primary care clinicians and the capacity of primary care clinics to address patients' social needs.
Whereas the study authors found clear associations between the inability to meet social needs and burnout levels, they also found that increasing services that address social needs in the clinic appeared to mitigate burnout symptoms and improved clinician morale.
The researchers interviewed 29 primary care clinicians -- physicians, nurse practitioners and physician assistants -- all of whom worked at outpatient clinics that served low-income populations. Thirteen clinicians specialized in family medicine, the rest in internal medicine or pediatrics.
During the interviews, clinicians discussed topics related to their workplace, burnout and experiences addressing the social needs of their patients. The participants also completed a two-item questionnaire that assessed emotional exhaustion and depersonalization and responded to a 10-point statement about whether their clinic had the tools and resources necessary to address patients' social needs.
The authors identified the following four general themes among the clinicians.
Burnout affects how clinicians perceive clinic resources and effectiveness. Clinicians with low emotional exhaustion and depersonalization scores were more likely to feel confident about their clinic's capacity to address social needs and maintain an individual sense of efficacy, while those with high scores expressed a low sense of efficacy. Regardless of burnout level, clinicians placed a high value on social needs interventions that were accessible, timely and tailored to individual patient situations and that took patient feedback into account.
Unmet social needs influence clinical practice. Although most clinicians thought that addressing social needs was crucial to providing high-quality care, they were concerned that doing so could negatively affect workflow. Many clinicians also recalled situations in which not meeting a patient's social needs unexpectedly caused a mental health crisis, which caused the clinician to fall behind, required staff to spend additional time and resources and often left the clinician feeling ineffective.
Some clinicians also noted a clash between meeting patients' social needs and otherwise routine treatment recommendations. At times, discussing social needs caused clinicians to feel frustrated and disconnected from patients. For example, one clinician reported being told by a patient that the patient was being evicted the next day, whereas the clinician had initially planned to talk with the patient about eating more fruits and vegetables.
"It plays on your sympathy to hear how difficult people's lives are, the frustration of being limited in what you can do, especially when (patients) are looking to you as the person who maybe can do something about it," said another clinician.
In-clinic resources offer some protection against burnout. Many clinicians reported that having social needs resources in or near the clinic served as a crucial buffer against burnout. Clinicians thought that having staff who specialized in behavioral health or social work allowed them to focus on providing and coordinating care and made them feel that they weren't the only person responsible for the patient, which mitigated some feelings of burnout. Most clinicians also thought that when patients' social needs were effectively met, their own morale improved.
Clinic-level resources are not a panacea. Most clinicians reported that even if resources to address social needs were maximized at the clinic level, some level of burnout would still occur. Many expressed a need for broader structural changes within and outside the health system. Several clinicians also considered external resources difficult to access and expressed concern about the roles of community caseworkers and social care professionals.
The authors noted that their findings could be interpreted in different ways. For example, although many clinicians wanted to increase the capacity of clinics to address the social needs of patients, adding more services could result in more burnout by increasing the time clinicians spend coordinating care.
In the interviews, however, the clinicians stressed the importance of team-based approaches that didn't depend solely on clinicians. By spreading social needs activities across more members of the care team, patients would still receive necessary services without further burdening the clinicians.
Citing a 2016 study that found many primary care residents were discouraged from seeking careers in primary care because of frustration about their inability to address patients' social needs, the study authors suggested their findings could serve as a starting point for additional research. "Given that research on burnout interventions has demonstrated only modest effects for those that do not consider patients' social needs," they wrote, "increasing clinics' capacity to address social needs may be a burnout prevention strategy worth testing."
Clif Knight, M.D., the AAFP's senior vice president for education, told AAFP News that the study findings were in line with other research on the topic that he has seen.
"This is consistent with the theory of control and support to offset work demands," Knight said. "When demands outweigh control and support, the risk of stress increases and may lead to burnout over time.
"Support can mean many things," Knight continued. "I often use the term resources rather than support. It encompasses adequate staffing (such as team documentation), effective processes and tools (such as a robust EHR and completing excellent EHR training), among other things. Certainly, having access to social support services for patients provides an important sense of support for the physician to be able to perform their professional role more effectively."
Danielle Jones, M.P.H., director of the Academy's Center for Diversity and Health Equity, highlighted AAFP resources such as The EveryONE Project, which assists family physicians in addressing their patients' social needs.
"In a survey conducted in 2017, 83% of members agreed that family physicians should identify and help address patients' social needs; however, many lack the time and proper staffing and/or resources to provide to patients," Jones told AAFP News.
To support members, the AAFP created The EveryONE Project Toolkit to help FPs and their practice teams screen patients for complex social needs such as food or housing insecurity, employment difficulties and transportation issues. The toolkit includes screening forms in several languages, a practice guide for developing an implementation plan and the Neighborhood Navigator, a nationwide resource directory that can be used to find patients local support using their ZIP code.
"In addition, the AAFP conducted focus groups with members at our 2018 Family Medicine Experience where members shared with us feedback similar to that found in the study, stating that there is an obvious connection between burnout and addressing patients' social needs," Jones said. "The AAFP urges its members to become more informed about the impact social needs have on health and health inequities and to identify tangible next steps they can take to address their patients' social needs and reduce health inequities within their scope."