Zero-Burnout Practices Often Solo, Physician-Owned

Marcia Frellick

June 07, 2021

Primary care practices with zero burnout are more often solo practices owned by physicians and practices not involved in transformation initiatives, such as accountable care organizations (ACOs), according to an analysis published ntoday in Health Affairs.

The findings may have particular significance in an era when more physicians are being employed by hospitals and health systems, says lead author Samuel T. Edwards, MD, an assistant professor of medicine at Oregon Health and Science University, in Portland, Oregon.

"Market forces and various reform efforts have driven practices to consolidate, and we certainly see some signal here that burnout might be a potential negative consequence of that," said Edwards, who is also a staff physician in internal medicine at the Veterans Affairs Portland Health Care System.

30% of Practices Reported Zero Burnout

Edwards told Medscape Medical News he was surprised that 30% of the practices surveyed for this analysis reported zero burnout — meaning no member of the practice reported burnout — because reports of burnout are so pervasive in medicine.

For comparison, in 13% of practices surveyed, more than 40% of practice members reported burnout.

Burnout was assessed with a five-point measure that correlates with the emotional exhaustion scale of the Maslach Burnout Inventory.

It was also surprising, Edwards said, that practices with some of the heaviest workloads ― solo practitioners juggling large numbers of patients, insurance plans, and regulatory requirements ― were much more likely than larger practices to report zero burnout.

In this study, solo practices were 5.3 times as likely as practices with six to 10 clinicians to report zero burnout (95% CI, 1.25 – 22.6).

The researchers found no link between burnout and patient volume or the proportion of patients with Medicaid insurance.

"People assume that working harder is associated with more burnout, and there are lots of studies that say that's true. But in our study, it appears that people work really hard in some settings and are not burned out," Edwards said.

He says in small offices, there may be a stronger sense of agency, a sense that everyone is on the same team, and there may be stronger relationships with patients.

The study included survey data from 715 small- to medium-size primary care practices in the United States that participated in the Agency for Healthcare Research and Quality's EvidenceNOW quality improvement initiative between September 2015 and June 2017.

Zero-burnout practices shared several traits. They were more likely to have "a strong practice culture — one in which teamwork, communication, psychological safety, mindfulness of others, facilitative leadership, and understanding that people make and can learn from mistakes were among the key attributes," Edwards and colleagues write.

Burnout Higher With ACO Participation

Organizations that participated in ACOs and other external primary care transformation projects were more likely to have high burnout rates. Specifically, 29% of these practices reported zero burnout, vs 53% that reported high rates of burnout.

Edwards said the reasons for that are unclear in this cross-sectional study, but there seemed to be an indication that getting involved in too many demonstration projects might be associated with burnout. He noted that participants in this study were already involved in the EvidenceNOW initiative.

Factors regarding electronic health records (EHRs) were not tied to burnout in this study. Edwards said they surveyed for both satisfaction with EHRs and EHR features and whether they were linked to zero burnout.

He speculates that that may indicate that by now, practices have adapted to using EHRs, though they continue to be a source of frustration for individual clinicians.

Debora Goetz Goldberg, PhD, MHA, MBA, associate professor at George Mason University, in McLean, Virginia, told Medscape Medical News she has found similar results in her research of primary care practices and burnout. She found that health system–owned practices had higher levels of burnout.

"We thought that probably was related to less autonomy and decision-making authority," she said.

She pointed out that Edwards and colleagues found that physicians who had more "adaptive reserves" were more likely to have zero burnout. Her research found a similar association.

Such organizations, she explained, have a higher level of organizational development and a culture of innovation. They are more comfortable with change and adapt well.

"They are characterized by teamwork, strong communication, and a culture of learning," she said.

By contrast, burnout may be higher in health system–owned practices because clinicians may feel they have less control over their work environment and feel a loss of autonomy, according to Goldberg.

"Moral distress," which can happen when an individual's professional values don't line up with an organization's values, may also play a part, she said. Physicians may be required to see more patients than they feel they can serve well in a day, for instance.

Reducing burnout may take building a more collaborative leadership style, she said.

No Link Between Burnout and Patient Volume

The current research also highlighted leadership style as a potential driver of burnout.

Edwards and colleagues found that one of the strongest associations was between facilitative leadership and low burnout. Zero burnout is associated with participatory decision making.

"Interestingly, we saw that that kind of leadership could exist in multiple settings," he said. Healthcare professionals in smaller practices might know each other better and have a shared mission, but shared decision making can also exist in larger practices, he said.

Higher burnout was associated with traditional leadership models that are hierarchical and that operate with a command-and-control structure, according to the study.

The data may have implications for strategies regarding both the smallest and largest practices.

Initiatives that help small practices remain strong are valuable, especially for communities that depend on those practices, Edwards said.

The researchers give as an example the funding of primary care practice extension networks, which provide support similar to agricultural extension programs for farmers.

At the same time, "Having agency at the practice level about how things work is really important in reducing burnout. So in a large system, finding ways to promote agency at the most local level possible can really help with burnout," he said.

Edwards said his team controlled for the fact that mathematically, it's more likely zero burnout would be reported in a solo practice than in a larger practice.

Every practice in this study, he said, had to have at least three persons who responded to the survey, and responses had to represent three roles — a clinician, a nonclinician staff member, and a clinical staff member. The response rate also had to be 50% within the practice, he explained.

All authors are supported by the Agency for Healthcare Research and Quality. Edwards was also supported by the Department of Veterans Affairs Health Services Research and Development. Goldberg has disclosed no relevant financial relationships.

Health Affairs. Published online June 7, 2021.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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