Physicians at small practices have considerably lower levels of burnout

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Physicians who work in small, independent primary care practices – also known as SIPs – report dramatically lower levels of burnout than the US national average (13.5% versus 54.4%), according to a study led by researchers at NYU School of Medicine. The findings indicate that the independence and sense of autonomy that providers have in these small practices may provide some protection against symptoms of burnout.

Physician burnout is a major concern for the healthcare industry. It is associated with low job satisfaction, reduced productivity among physicians, and may negatively impact quality of care. Multiple national surveys suggest that more than half of all physicians report symptoms of burnout.

Research on physician burnout has focused primarily on hospital settings or large primary care practices. The researchers say that this is the first study that examines the prevalence of burnout among physicians in small independent primary practices – practices with five or fewer physicians. Despite declines in the number of small practices in the US, primarily due to market forces driving consolidation, close to 70% of all primary care office visits occur in small practice settings, according to the American Medical Association.

Researchers examined data collected from 235 physicians practicing in 174 SIPs in New York City. The rate of provider reported burnout was 13.5%, compared to the 2014 national rate of 54.4%. A 2013 meta-analysis of physician surveys conducted in the US and Europe found that lower burnout rates were associated with greater perceived autonomy, a quality and safety culture at work, effective coping skills, and less work-life conflict.

“Burnout is about the practice culture and infrastructure in which primary care doctors work. So, the obvious question is: what is it about the work environment that results in low burnout rates in small practices?” said Dr Donna Shelley, professor of population health and medicine at NYU School of Medicine, and the study’s senior author. “It’s important to study the group that’s NOT showing high burnout to help us create environments that foster lower burnout rates. The good news is that a culture and systems can be changed to support primary care doctors in a way that would reduce the factors that are leading to burnout.”

Researchers analysed data as part of the HealthyHearts NYC (HHNYC) trial, which is funded by the Agency for Healthcare Research and Quality’s (AHRQ) EvidenceNOW national initiative. AHRQ is a division of the US Department of Health and Human Services. The HHNYC trial evaluates how practice coaching or facilitation helps SIPs adopt clinical guidelines for the treatment and prevention of cardiovascular disease.

Each physician answered a multiple-choice question with response options indicating various levels of burnout. Options ranged from no symptoms of burnout, to feeling completely burned out and questioning whether or not to continue practicing medicine. The question was validated against the Maslach Burnout Inventory, a nationally recognised measure that identifies occupational burnout. Physician respondents were categorized as burned out if they checked one of the last three options in the multiple-choice question.

As part of the HHNYC trial, physician respondents were also asked a number of questions about the culture of their practices. The tool used specifically measures “adaptive reserve,” or a culture where individuals have opportunities for growth, and the ability to learn from mistakes by talking and listening to each. Physicians that described this kind of culture in their practice reported lower levels of burnout. According to Shelley, practices where employees feel that they are included in decisions and have control over their work environment are referred to as having ‘high adaptive reserve.”

Shelley is careful not to minimise the challenges that physicians working in solo practices or SIPs face. She cites that even though burnout rates are lower, many of these practices are struggling financially, and many of these physicians are on call all of the time.

“The more we can understand what drives low rates of burnout, the more likely it is that we’ll find solutions to this problem,” said Shelley. “The hope is that our research can inform ways for larger systems to foster autonomy within practices so that there is space to carve out a work environment that is aligned with doctors’ needs, values and competencies.”

Shelley lists a number of the study’s limitations. Since the findings are representative of physicians working in small practices in New York City, the study does not capture burnout rates in other cities across the country. It is also possible that the researchers underestimated the number of hours worked by physicians, since hours worked is associated with burnout. Shelley also cited the lack of data linking physician burnout to patient outcomes.

In addition to Shelley, study co-authors include Nan Jiang, Chuck Cleland, Carolyn Berry, Gbenga Ogedegbe, NYU School of Medicine; and Batel Blechter, Johns Hopkins University.

The research was supported by the Agency for Healthcare Research and Quality.

Abstract
Background: Little is known about the prevalence and correlates of burnout among providers who work in small independent primary care practices (<5 providers).
Methods: We conducted a cross-sectional analysis by using data collected from 235 providers practicing in 174 small independent primary care practices in New York City.
Results: The rate of provider-reported burnout was 13.5%. Using bivariate logistic regression, we found higher adaptive reserve scores were associated with lower odds of burnout (odds ratio, 0.12; 95% CI, 0.02–0.85; P = .034).
Conclusion: The burnout rate was relatively low among our sample of providers compared with previous surveys that focused primarily on larger practices. The independence and autonomy providers have in these small practices may provide some protection against symptoms of burnout. In addition, the relationship between adaptive reserve and lower rates of burnout point toward potential interventions for reducing burnout that include strengthening primary care practices’ learning and development capacity.

Authors
Batel Blechter, Nan Jiang, Charles Cleland, Carolyn Berry, Olugbenga Ogedegbe, Donna Shelley

NYU Langone Health material
Journal of the American Board of Family Medicine abstract


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