One in Four Physicians Rethinking Clinical Practice

Diana Phillips

November 02, 2017

Struggling to find joy in the practice of medicine, many physicians are planning to reduce their clinical work hours or leave their clinical practice, a study has shown.

In a national survey of physicians across all specialties in the United States in 2014, nearly one in five respondents indicated their plan to reduce practice hours within 12 months, and one in four said they would likely leave their current practice within 2 years, Christine A. Sinsky, MD, from the American Medical Association, Chicago, Illinois, and colleagues report in an article published in the November issue of the Mayo Clinic Proceedings.

The leading driver of physicians' intent to reduce clinical work hours or leave their current practice was professional burnout, the authors write.

The survey population comprised 6695 practicing physicians sampled from and similar to the 835,451 physicians in the American Medical Association Physician Master file.

Of the survey respondents, 19.8% planned to switch to a part-time clinical schedule within 1 year, and 26.6% planned to leave their current practice within the next 2 years through retirement (37.4%), pursuit of a different practice opportunity (35.2%), movement to an administrative position in healthcare (9.7%), or switch to a different career entirely (7.4%). Physicians aged 50 to 59 years were most likely to indicate their intention to leave medicine altogether in the next 24 months, the authors report.

After adjustment for potential confounding variables, the analysis showed that burnout, dissatisfaction with work-life integration, and dissatisfaction with the electronic health record (EHR) burden were the strongest correlates of likelihood to reduce clinical work hours, with respective odds ratios of 1.81 (95% confidence interval [CI], 1.49 - 2.19; P < .001), 1.65 (95% CI, 1.27 - 2.14; P < .001), and 1.44 (95% CI, 1.16 - 1.80; P < .001).

Similarly, after adjustment for potential confounders, the strongest predictor of physicians' likelihood to leave their current practice within 2 years was burnout (OR, 2.16; 95% CI, 1.81 - 2.59; P < .001). Additional drivers were dissatisfaction with work-life integration (OR, 1.49; 95% CI, 1.17 - 1.89; P = .001) and dissatisfaction with the EHR (OR, 1.57; 95% CI, 1.27 - 1.93; P < .001).

Notably, in the subpopulation of physicians who planned to leave the practice of medicine to pursue a different career, the association with burnout was even stronger (OR, 5.79; 95% CI, 2.47 - 13.56; P < .001).

The prevalence of physician burnout and its association with the increasing administrative burden introduced by EHRs in particular has been well established. In a previous study reported by Medscape Medical News, the clerical burden of EHRs, computerized physician order entry, and communication via patient portals was linked to burnout risk and job dissatisfaction among clinicians.

The findings of the current study have "potentially profound implications" for the adequacy of the physician workforce in the United States and for the financial viability of healthcare organizations, Dr Sinsky and colleagues stress.

"Reduction of clinical work hours results in reduced access to care for patients and thus has a direct effect on the adequacy of physician supply," they write. "Leaving current practice, even for another practice, erodes continuity of care and results in reduced access during the transitions, as the physician is either ramping down capacity in their old practice or ramping up in their new practice."

The price of physicians leaving medical practice altogether is even higher. "Replacing physicians is costly to institutions, with one recent analysis suggesting costs of $800,000 or more per physician," the authors report. "In addition, turnover is disruptive to patients, staff, and organizational culture. A physician workforce that has one eye on the door may not be optimally engaged and aligned with advancing the institution's goals."

In an accompanying editorial, Kristine D. Olson, MD, from the Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, notes that if even just one third of these physicians follow through with their stated plan to move out of clinical practice within 2 years, "the United States stands to lose 4762 physicians (equivalent to eliminating the graduating class from 19 medical schools for 2 years, assuming 125 students per class)." In addition to the losses potentially outpacing the workforce gains associated with the addition of 11 medical schools built in the United States between 2001 and 2011, the potential exodus of clinicians "would exacerbate the physician shortfall of 45,000 to 90,000 expected by 2025, and impede patients' access to care," she writes.

To stem the potential tide of physician attrition, the underlying drivers of that attrition must be considered, Dr Sinsky and colleagues write. "A comprehensive approach by national policymakers and health care delivery institutions will be necessary to address this challenge. Given the magnitude of the problem, the investment in such efforts should be equal to or greater than efforts to increase the size of the pipeline."

Given the strong association between physician burnout and intent to leave, healthcare leaders should employ strategies for detecting instigators and drivers of the burnout phenomenon, Dr Olsen writes in her editorial. "Monitoring physician well-being is especially important now that most physicians are employed in large organizations and may lack authority to act independently," she adds.

Funding for this study was provided by the Mayo Clinic Department of Medicine Program on Physician Well-being. The study authors have disclosed no relevant financial relationships. Dr Olson received partial reimbursement for airfare and hotel to attend a summit on Physicians Professional Satisfaction and Practice Sustainability, Joy in Medicine.

Mayo Clin Proc. 2017;92:1608-1611, 1625-1635. Article full text, Editorial full text

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