Burnout and Scope of Practice in New Family Physicians

Re: "Physician Burnout: Resilience Training is Only Part of the Solution" Card, 16:267-270doi:10.1370/afm.2223

Dr Card helpfully describes the distinction between 'avoidable' and 'unavoidable' suffering of physicians. This distinction originates in the patient safety literature, where the focus is currently directed in mitigating 'avoidable' patient harms. [1] Taking into consideration the avoidability of suffering in the medical profession which underlies burnout, interventions are more likely to be successful if they target sources of avoidable suffering.

The involvement of physicians in the co-design of interventions to mitigate burnout is a useful suggestion which has received less attention in the literature. Physicians are best placed to offer insights regarding the efficiency, acceptability and implementation potential of interventions. Success or failure to incorporate the perspectives of physicians may be as critical a determinant of the overall success of these strategies as their content.

Dr Card's emphasis on the principal role of healthcare organisations in promoting physician engagement is really important. Evidence shows that organisational interventions are the most effective approaches in mitigating physician burnout [2,3] and the need for reshaping the organisational culture of healthcare systems is unquestionable. With this fact in mind, we raise the following counter-argument.

We agree that resilience training is only a part of the solution for physician burnout but resilience approaches are unfairly downgraded if only recommended for physicians who lack resilience to unavoidable suffering. The consequences of this view can be harmful. First, there is reason to believe that most physicians can benefit from resilience-building interventions,[4] but this approach excludes physicians who are not experiencing current distress. In doing so it stigmatizes participation in these programmes, and discourages physicians from accessing this effective source of support. Second, it is hard to delineate between organisational and individual approaches, and multicomponent interventions which are time-protected and financially supported by healthcare organisations are particularly effective in reversing burnout.[2,3,5] Furthermore, it is important to note that organisations are made of individuals, and resilience training can complement attempts at organisational change by supporting a positive organisational culture. As such we recommend that resilience approaches are valuable and complementary to organisational improvement strategies.

Remarkable progress has been achieved in raising awareness of physician burnout internationally. The major challenge now is to draw 'agreed principles' which will convince decision makers of the need for larger investments in physician wellness. This target can be best achieved using an integrative approach.

Maria Panagioti, Senior Research Fellow, NIHR School for Primary Care Research, University of Manchester, UK
Judith Johnson, Lecturer of Clinical Psychology, University of Leeds and Bradford Institute for Health Research, UK
Aneez Esmail, Professor of General Practice, NIHR School for Primary Care Research, University of Manchester, UK

References
1. Pronovost PJ, Colantuoni E. Measuring preventable harm: helping science keep pace with policy. JAMA. 2009;301(12):1273-1275.
2. Panagioti M, Panagopoulou E, Bower P, et al. Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis. JAMA internal medicine. 2017;177(2):195-205.
3. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.
4. Cheshire A, Hughes J, Lewith G, et al. GPs' perceptions of resilience training: a qualitative study. The British journal of general practice : the journal of the Royal College of General Practitioners. 2017;67(663):e709-e715.
5. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA internal medicine. 2014;174(4):527-533.

Competing interests: None