Primary Care Research

How Small NYC Primary Care Practices Avoid Burnout Blues

July 31, 2018, 04:02 pm Sheri Porter –Physician burnout has long been a topic of concern in the United States, grabbing the medical community's attention in 2011 when a national survey reported that 45.5 percent of U.S. physicians had symptoms of burnout; by 2014, that prevalence had risen to 54.4 percent. 

"Although the number of SIPS (small independent primary care practices of five or fewer health care professionals) in the United States has been decreasing, they continue to serve a significant proportion of the population," wrote the authors. "Yet burnout among providers in these important sources of primary care is not well characterized."

Study Details

Corresponding author and internal medicine physician Donna Shelley, M.D., M.P.H., is an adjunct clinical associate professor at the New York University School of Medicine in New York City.

She told AAFP News the research team was immersed in the Agency for Healthcare Research and Quality's EvidenceNOW initiative associated with New York City's HealthyHearts NYC trial.

Shelley said researchers were focused on how practice facilitators could help small practices "make system and workflow changes necessary to adopt guidelines and improve quality of care for cardiovascular prevention and treatment."

As part of that process, researchers looked at burnout -- hypothesizing that those who reported more burnout could be less likely to effectively provide health care, which, in turn, could negatively affect patient outcomes.

Burnout was assessed by asking respondents to -- using their own definition of burnout -- choose one of several statements that "best describes how you feel about your situation at work."

Paraphrased answer options were:

• I enjoy work and have no symptoms of burnout;
  
• I occasionally feel stress and have less energy but do not feel burned out;
  
• I am definitely burning out and have one or more symptoms;
  
• My symptoms of burnout won't go away, and I have frequent thoughts about work frustrations; and
  
• I feel completely burned out, and I'm wondering about my ability to continue to practice.

Respondents were considered burned out if they picked one of the last three options.

Researchers also looked at various practice characteristics, including the number of health care professionals in the practice, patient panel size, patients' race/ethnicity and whether the practice was located in a medically underserved area and/or was designated as a patient-centered medical home (PCMH).

In addition, researchers used a tool called the Change Process Capacity Questionnaire as a measure of practices' strategies for quality improvement, as well as what is known as the "adaptive reserve measure," which helps assess characteristics such as leadership style, communication practices, trust, teamwork and culture of learning.

Regarding practice and respondent characteristics,

• 66.9 percent were solo practices,
  
• 46.5 percent were designated PCMHs,
  
• 204 respondents were M.D.-licensed physicians (a mix of internal medicine and family medicine), and
  
• 31 were nurse practitioners or physician assistants.

Additional Highlights

The researchers reported that a "higher adaptive reserve score was associated with lower odds of burnout. Other variables were not associated with burnout."

In addition, the authors noted the large percentage of solo practices that participated in the study and discussed the possibility that the 13.5 percent burnout rate could be related to the autonomy that solo-practice physicians enjoy.

"Studies have found an association between low work control or autonomy and higher levels of burnout," wrote the authors. "That autonomy varies by practice size, with smaller practices reporting greater logistic autonomy than larger practices."

Regarding the relationship between adaptive reserve and burnout, authors suggested that "interventions to reduce burnout in primary care practices should focus on strengthening factors that support organizational capacity for change," such as strong communication, leadership supports and innovation.

Author Insight

In further discussing the study's findings, Shelley pointed out the benefits that come with independent practice.

"These docs own their own businesses -- they are creating their own culture and climate, and they have complete autonomy," said Shelley.

"It is really stressful to be a small independent practice because of all the financial stresses. They don't have a big staff to do a lot of the administrative work they need done, and they don't have care coordinators. They might have a medical assistant or a practice administrator. Many didn't even have a nurse.

"And so, they have a lot of characteristics that you would think would be associated with higher burnout, but it may be that autonomy and control of your work environment actually trumped all of that."

During qualitative interviews with about 25 of the physicians, Shelley said they talked a lot about autonomy. "Many of them were immigrants, and owning their own practices was really important to them, as was their relationships with their patients.

"They talked about the real satisfaction they got out of treating multiple generations of one family and about serving the community," said Shelley.

She recalled one particular physician whose story stood out from the rest.

"One doctor, who is African and speaks four African languages, said half of his patient population are African immigrants. His patients receive language-concordant and culturally concordant care," she added.

Other doctors Shelley interviewed said if they closed their doors, they weren't sure their patients would ever seek primary care.

Of the small-practice physicians and other health care professionals who were part of the study, Shelley said, "We've been really impressed by the devotion to patients in a health care climate where everybody is talking about patient-centered care. These providers are offering that to their patients. They're happy doing it and they want to keep doing it.

"So the question is, how do we create some kind of shared resources that can help them continue to survive in a very challenging health care environment?"