Does Combatting Physician Burnout Improve Patient Care as Well?

Hi, everyone. I'm Dr Kenny Lin, a family physician at Georgetown University Medical Center in Washington, DC, and I blog at Common Sense Family Doctor.

In recent years, burnout in the medical profession has gone from being a relatively minor concern to an omnipresent topic in news stories, lectures, and conferences. A national survey performed in both 2011 and 2014 found that in the intervening years, the prevalence of burnout and dissatisfaction with work-life balance increased among all physician specialties.^[1] Not only can burnout lead to physicians prematurely leaving clinical practice, but it may also have other negative effects on patient care. A systematic review of 46 studies found consistent associations between poor well-being plus moderate to high levels of burnout in clinicians and higher numbers of self-reported medical errors.^[2]

Given the increasing scope of the problem and its potential impact on patient safety, there is surprisingly little research on interventions to prevent burnout in primary care clinicians. The most studied interventions are based on the concept of mindfulness, which Merriam-Webster defines as "the practice of maintaining a nonjudgmental state of heightened or complete awareness of one's thoughts, emotions, or experiences on a moment-to-moment basis." Pilot studies have found that mindfulness training reduces measures of burnout, depression, anxiety, and stress,^[3] and that higher clinician mindfulness is associated with greater patient-centered communication and patient satisfaction.^[4]

It isn't difficult to imagine how a burned-out family physician might deliver poorer-quality care than his or her colleagues. Just think about any of your most "difficult" clinical encounters with patients who miss appointments, don't adhere to instructions, come in with long lists of vague complaints, or seem perennially dissatisfied with their care. Managing these difficult encounters requires a different kind of expertise than simply biomedical-based decision-making^[5]; instead, we must negotiate patient expectations and demonstrate empathy, patience, and a positive attitude. Physicians who are unable to summon these skills on a regular basis run the risk of their patients minimizing or not disclosing critical information, leading to delayed or incorrect diagnoses.

The big question in my mind is, does improving work conditions and reducing burnout in primary care actually lead to fewer errors and better quality? The Agency for Healthcare Research and Quality supported the Healthy Work Place study,^[6] a cluster randomized trial of 34 primary care practices in the upper Midwest and New York City, to answer this question. In the intervention practices, clinic managers redesigned workflows, improved communication between providers and staff, and/or introduced targeted chronic disease management programs. Initial results seemed promising: After 12 months, clinicians at intervention sites reported significantly lower burnout and improved satisfaction compared with controls. Unfortunately, a subsequent analysis found that these interventions, collectively or individually, had no effect on medical errors or quality-of-care outcomes.^[7]

Although it is disappointing to learn that efforts to make family physicians' work conditions better did not have the secondary effect of improving patient safety and care quality, preventing burnout in primary care is a worthy goal in itself. As a family medicine educator, I am concerned not only about how to retain our best physicians, but also about attracting more medical students to primary care. As two leaders in general internal medicine have observed,^[8] optimal care of the patient requires care of the provider. Sustained efforts to increase joy and satisfaction in family practice will pay off by attracting the best and the brightest students to our specialty.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.

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