Combating Burnout: Back to Medicine as a Calling

• physician burnout
• physicians
• family
• physicians
• primary care
• burnout
• psychological
• occupational stress

For several years, the medical literature has exploded with headlines decrying an epidemic of physician burnout. Burnout rates are reportedly highest among those on the front lines of patient care, including primary care physicians (PCPs).¹ While there is still no consensus on how to define burnout and its measurement is complicated by numerous methodological challenges,^2,3 burnout is finally being recognized as a consequence of dysfunctional health environments rather than a personal failing of physicians. With this evolution, health systems are shifting from a focus on physician coping through mindfulness and meditation to more appropriate attention to the work environments in which physicians provide care. Three studies in this issue of Annals of Family Medicine investigate structural work and practice factors and their impact on physician burnout.

In the first study, Creager et al reviewed data from 1,437 family medicine physicians to evaluate whether practice type (solo vs employed) affected burnout.⁴ While the researchers hypothesized that employed physicians would feel less control and more burnout, they found instead that practice type itself did not predict outcomes. In any practice environment, it was physician satisfaction with hours, control over workload, time for documentation, and alignment of values with leadership that were most protective from burnout.

In a second study, Cohidon et al analyzed survey data from PCPs across 11 high-income countries to compare practice characteristics with physician satisfaction and found that 8% to 37% of physicians reported high levels of dissatisfaction.⁵ Heavier workloads, long hours, fewer home visits, and limited options for same-day appointments—all indicators of low job control—were linked to worse satisfaction.

In professions outside of medicine, a strong sense of personal control and autonomy in the job clearly protects against emotional exhaustion.^6–8 Many have assumed that the shift from solo practice to physicians as employees is a major contributor to burnout, but the reality may be more nuanced. A solo practitioner might be stressed knowing she is the only person responsible for a full panel of patients, while an employed physician might feel high levels of autonomy at being able to share his workload and choose his hours. Increasing one’s sense of control at work may be more related to individual employment choices than the type of practice in which one works.

Newer research suggests that physicians who identify their profession as “a calling” experience less burnout. This raises interesting questions about how to make work environments more congruent with that sense of calling.⁹ A broader scope of practice has been associated with lower burnout rates among early-career family physicians.¹⁰ If full-spectrum care matches the physician’s sense of calling, their identity as a doctor, and their training, it might protect against other job factors which can worsen burnout. In the third article about physician experience, Kung et al interviewed 29 PCPs working in low-income communities.¹¹ Those physicians with limited access to social services needed to devote more time to get help for their patients and felt more burnout and emotional exhaustion. The inability to provide key services for patients creates a strong conflict between the internal calling of a physician and the reality of what can be offered to patients. Health systems that support high-quality and well-resourced care will not only improve patient health outcomes but may better support the care physicians feel called to provide and reduce the risk for burnout.

Corporate business research has focused on financial motivators that improve employee satisfaction, but the non-monetary incentives described in nonprofit organization research actually may be more relevant for physicians. Such incentives include the draw of interesting work, matching of leadership values with one’s own professional values, and strong relationships with colleagues.^{6, 12–14} Modern medicine devalues these potential incentives, replacing them with hours documenting in front of a computer screen and poorly designed electronic health systems which can take up to 61 clicks to order acetaminophen.¹⁵ But the research is clear: medicine must return to prioritizing care and relationships.

Burnout is a poorly understood problem that will require complex solutions. There are no easy solutions—a certain practice type, electronic medical record, or payment method—to eradicate burnout from the current health care environment. The solutions must recognize the importance of medicine as a calling and test interventions that promote consistency between the calling and its actual practice, that promote collegiality and teamwork, and that focus on building autonomy and control over the daily work lives of physicians.

• Received for publication October 7, 2019.
• Accepted for publication October 8, 2019.

• © 2019 Annals of Family Medicine, Inc.