Loneliness, Burnout, and Other Types of Emotional Distress Among Family Medicine Physicians

Results From a National Survey

Samuel Ofei-Dodoo, PhD, MPA, MA; Rebecca Mullen, MD, MPH; Andrew Pasternak, MD, MS; Christina M. Hester, PhD, MPH; Elisabeth Callen, PhD, GStat; Edward James Bujold, MD; Jennifer K. Carroll, MD, MPH; Kim S. Kimminau, PhD

Disclosures

J Am Board Fam Med. 2021;34(3):531-541. 

In This Article

Discussion

While previous research has investigated physician burnout and physician depression, this cross-sectional survey is one of the first studies to also look at physician loneliness and its associations with other forms of emotional distress. In this study, 44.9% of a national sample of family medicine physicians identified as lonely. The prevalence of depression and burnout was 44.3% and 45.1%, respectively. Physicians who experienced a greater feeling of loneliness were more likely to report at least 1 manifestation of burnout, screen positive for depression, and experience a higher degree of fatigue than those who experienced a lesser feeling of loneliness. The associations between loneliness and depression in addition to loneliness and exhaustion remained significant after adjusting for the respondents' age, gender, employment status, practice location, and membership.

The high prevalence of loneliness in this national sample of family medicine physicians and the association with both depression and burnout mirrors results from a prior study assessing Kansas family physicians.[18] In addition, our high depression and burnout prevalence rates are in line with findings of previous studies.[18,34,39,46] Family medicine physicians typically spend their days interacting with other health care professionals, staff, and patients; however, our results demonstrate that loneliness and emotional distress can occur even in clinical environments. Family medicine physicians often have to cope with substantial administrative and regulatory burdens.[47] Such tasks may be adversely affecting their ability to interact with colleagues in meaningful ways and could potentially be leading to loneliness.[19,48] Instead of focusing on developing meaningful clinical relationships with patients, physicians may be becoming more focused on "clicking the boxes," and documentation due to increased government regulation, malpractice suits, and health system demands. Further exploration of the factors influencing the loneliness and emotional distress among family medicine physicians may reveal additional or different contributing factors and thus inform interventions. Although we captured perceived social isolation in this study, other authors have suggested that there are also structural and professional components to isolation, illustrating the potential multi-factorial effect of the workplace environment.[19,49]

Loneliness and depression are known to be associated in the general population,[50] though loneliness and burnout are correlated in certain populations, such as medical residents.[21,22] To our knowledge, this is the first study illustrating a relationship of loneliness to both depression and burnout in a national sample of physicians. Although loneliness, burnout (overwhelming exhaustion), and depression are overlapping constructs of helplessness, these states of emotional distress seem to be distinct phenomena,[51] where loneliness is due to unmet social needs, burnout is a negative work-related state of mind, and depression is a sadness that may impact all areas of someone's life. There is a paucity of research on the temporal relation between loneliness and burnout, although other authors have suggested that loneliness may increase vulnerability to environmental stressors leading to burnout and that social networks and relationships may help mitigate the negative impacts of burnout.[21,22] In support of this, one study illustrated that lower levels of social capital were associated with decreased academic performance in minority medical students,[52] highlighting the importance of social ties in a health care context.

Physician loneliness was not associated with practice location or employment status. Our results corroborate other studies that have not documented a significant difference in loneliness between respondents in rural and urban settings.[53–55] Generalizability of our findings may be somewhat limited, as 85% of the respondents practiced in urban settings. While social and professional isolation may be more common in rural practice settings, structural isolation can occur in any practice setting.[49]

While age was not associated with loneliness scores, physicians with additional years of practice were less likely to consider themselves lonely. Previous literature on other forms of physician emotional distress suggests that burnout and depression begin early in the medical career and increase throughout training;[34,56] our results illustrate that this may also be the case for loneliness. The reasons for this are not clear, but we hypothesize that physicians who are more established in their clinical settings have had more time to develop meaningful relationships within physician groups and in their community. It may also be that younger physicians, accustomed to working in groups during the training, are assigned into practice settings where there are fewer professional interactions, which in turn contributes to isolation.[57] Notably, this trend of younger persons suffering more loneliness is also illustrated in the general population, which suggests the potential contribution of external factors such as increased societal fragmentation, concerns with self-identity, and significant life transitions.[1,58,59]

Overall, our data highlight the urgent need to examine the underlying causes and components of physician loneliness to inform interventions that elevate physician wellbeing. Although there is significant attention on physician burnout, our results illustrate that the current narrative on physician unhappiness must expand to include loneliness.[60] As other authors have noted, there are likely 3 types of isolation contributing to physician distress: professional, structural, and social isolation.[49] The increasing fragmentation of medicine and "disconnected workplace" for family medicine physicians may result in structural and professional isolation, while difficulty making and sustaining meaningful relationships with patients and colleagues may contribute to social isolation.[19,48] These multi-level factors must all be considered in future organizational and individual strategies to reduce loneliness among physicians. In addition, our results endorse the need to better understand loneliness in younger family medicine physicians, potentially involving solutions such as curricular changes that mitigate emotional distress in training physicians.[61]

Study Limitations

There were some limitations to the study given the cross-sectional nature and low response rate. Response rates were typical of surveys[8,9,18,39,46] but were lower in the AAFP NRN members. The lower response rate for AAFP NRN members may have been because compensation was not provided for this survey; when compensated, the response rates tend to be in the more typical range for AAFP NRN members.[62,63] The low participation rate likely contributes to some non-responder bias that could affect the interpretation of the results. Emotionally distressed physicians may be less motivated to respond to the survey, or more likely to participate because the topic may be relevant to them. Given the anonymous nature of the survey that was emailed to members of the AAFP NRN and AAFP Member Insight Exchange, which are not necessarily mutually exclusive groups, we are unable to account for any double-counting of responses. In addition, while we found correlations among loneliness, depression, and physician burnout, we are unable to determine which of these factors if any, leads to the other two. However, prior literature has shown that loneliness predicts depressive symptomatology, even after controlling for objective social isolation, stress, and social support.[50] While this study was unable to ascertain the reasons for physician loneliness, further research should explore these root causes, which could help drive practice changes and inform interventions focused on physician wellbeing. In addition, future research should focus on longitudinal monitoring of younger physicians to determine which factor represents a tipping point for the others or if they co-occur.

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