Burnout Singeing All Levels of Medicine: Physicians, Nurses, Office Staff

Marcia Frellick

March 28, 2017

Burnout is prevalent among not only physicians and nurses but also clinical associates and office staff, and new data quantify the working conditions that are associated with the high rates.

Overall, 41% of primary care team members working in a Veterans Affairs  (VA) patient-centered medical home report burnout, report Christian D. Helfrich, PhD, MPH, from the Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care at the VA Puget Sound Health Care System in Washington, and colleagues.

Rates of burnout by role were as follows: physicians, 49.25%; nurse care managers, 41.5%; clinical associates (licensed practical nurses), 32%; and administrative clerks, 35.7%.

"An important finding from this paper is that, while the overall prevalence of burnout was lower for nurse care managers, clinical associates, and administrative clerks relative to PCPs [primary care physicians], the associations with workload and staffing variables did not differ significantly by occupation," the authors write.

The biggest differences in burnout rates among teams were found in three areas: fully staffed vs not fully staffed teams (35.2% vs 52.3%, respectively) (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.47 - 0.65); turnover vs no turnover in the last year (45.7% vs 33.2%) (OR,  1.67; 95% CI, 1.43 -  1.94); and overcapacity on patient panels vs no overcapacity (43.9% vs 39.9%) (OR, 1.19; 95% CI, 1.01 - 1.40).

"Working on multiple teams, average panel comorbidity, and working extended hours were not associated with burnout," the authors add.

The findings were published online February 23 in the Journal of General Internal Medicine.  Previous studies have rarely looked at burnout on a team level that included clinical associates or clerks, the authors note.

Team Stability, Staffing Key

However, under improved circumstances — a fully staffed team with no turnover and a patient panel within capacity — the burnout rate was 30.1 percentage points lower (28.5% vs 58.6%) than when teams are understaffed and have turnover and heavy patient loads.

"Overall, our findings confirm the importance of team stability and the completeness of team staffing as critical factors in predicting burnout levels among primary care physicians, nurses, and administrative staff," the researchers conclude.

In an accompanying editorial, Michael Hochman, MD, MPH, from the Gehr Family Center for Implementation Science at Keck School of Medicine at the University of Southern California in Los Angeles, says policymakers have been right to focus on medicine's "triple aim" of improving patient experience, expanding population health, and cutting costs.

But this study adds support for additional focus on the "quadruple aim," which includes improving clinician work life.

"Perhaps in no specialty is this more important than primary care, which requires constant vigilance and frequent interpersonal interaction," he writes.

Dr Hochman says future studies should test interventions that address factors in this study to see whether they not only decrease the burnout rate but also  improve clinical outcomes.

In addition, the interventions should address frustrations with electronic health records, a factor pinpointed in other studies, he says.

"Ironically, it may prove that the best strategy for achieving the Triple Aim will involve strategies for addressing the last of the Quadruple Aims," he writes.

Cross-Sectional Analysis

For the current study, Dr Helfrich and colleagues used a validated measure from the Physician Worklife Study that asks respondents to rate their level of burnout by using a 5-point scale.

The results come from a cross-sectional analysis of 4610 (estimated response rate, 20.9%) respondents to a national VA primary care personnel survey administered to members of patient-aligned care teams, as well as administrative data on primary care team workload. Previous studies have relied on self-reported workload, not that measured per team, the authors note.

The low response rate is included as a limitation of the study. Researchers found lower response rates for administrative clerks, those who had been at the VA longer, and those at medical center–based clinics (as opposed to community-based clinics), so they adjusted for those factors.

Generalizability is hard to gauge given the VA structure, which includes "lower average panel sizes, higher patient comorbidities, longer visit times, and a salaried structure with a quality metric-based performance system," the authors note.

This work was supported by the Patient Centered Medical Home Demonstration Laboratory Coordination Center (XVA-61-041) of the U.S. Department of Veterans Affairs. The study authors and editorialist have disclosed no relevant financial relationships.

J Gen Intern Med. Published online February 23, 2017.  Abstract, Editorial

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