healthcare worker burnout; whither primary care

 

 

 

A recent article assessed work overload and healthcare worker burnout (see health worker burnout JGIM2023 DOI: 10.1007/s11606-023-08153-z)

 

Details:

-- cross-sectional national survey of 206 large healthcare organizations from the AMA Coping with Covid Study survey, from 30 states with at least 100 physicians, between April and December 2020

-- healthcare worker work overload (by impact of Covid), burnout, and likelihood of leaving one's practice in the next 2 years (a good predictor of actual turnover), by questionnaire

-- 43,026 respondents were invited, mean response rate 44%

-- information was available for demographics and years in practice (categorized as  1-5, 6-10, 11-15, 16 -20, and >20)

-- 35% physicians (15,142), 26% nurses (11,040), 13% other clinical staff (5730 pharmacists, nursing assistants, respiratory therapists, physical therapists, occupational therapists, speech therapists, medical assistants, and social workers), and 26% nonclinical staff (11,114 housekeeping, administrative, receptions, lab/xray techs, finance, food service, IT, and nonclinical researchers)

-- race/ethnicity: white 60%/Black 2% MDs, rest about 8%

-- gender (F/M):  MDs 41%/51%, RNs 85%/7%,other clinical 78%/14%, nonclinical 73%/19%

-- years in practice: overall longer in physicians and nurses, with 35% more than 20 years

-- about 50% inpatient setting

-- main outcomes: assessing global healthcare worker burnout, intent to leave their jobs, and work overload; assessing the relationship between work overload and both worker burnout and intention to leave their jobs

 

Results:

-- proportion reporting burnout, intention to leave, and work overload:

    -- physicians:

        -- burnout: 47%

        -- intent to leave: 24%

        -- work overload: 37%

    -- nurses:

        -- burnout: 56%

        -- intent to leave: 41%

        -- work overload: 47%

    -- clinical staff:

        -- burnout: 54%

        -- intent to leave: 32%

        -- work overload: 47%

    -- nonclinical staff:

        -- burnout 46%

        -- intent to leave: 33%

        -- work overload: 45%

 

--Associations between work overload (using propensity-weighted associations, to statistically equalize the identified confounders associated with workers who report vs don’t report work overload):

    -- association of work overload with burnout, adjusted relative risks:

        -- physicians: aRR 2.42 (2.33-2.50)

        -- nurses: aRR 2.21 (2.12-2.30)

        -- clinical staff: aRR 2.29 (2.16-2.43)

        --nonclinical staff: aRR 2.90 (2.77-3.05)

    -- association of work overload with intention to leave:

        -- physicians: aRR 1.73 (1.61-1.87)

        -- nurses: aRR 1.87 (1.65-2.11)

        -- clinical staff: aRR 2.04 (1.74-2.38)

        --nonclinical staff: aRR 2.10 (1.82-2.43)

 

Commentary:

-- this study shows remarkably high levels of work overload, burnout, and intention to leave one’s job, pretty much throughout the whole array of healthcare workers (prior studies have noted work overload in physicians and nurses; this study reveals the problem to be prevalent across the spectrum of healthcare roles)

-- this study also confirmed the expected outcome: high work overload is strongly associated with burnout and intention to leave (2- to 3-fold). so this gives us a target: the importance of continuous assessment of work overload and devising mechanisms to counteract it that might well lead to happier healthcare workers who will continue in their jobs (and this is so important in our aging population, where there are decreasing numbers of people entering the workforce, yet the medical/social demands of the aging population are already increasing dramatically)

    -- one particular issue is the corporatization of health care, with its dramatic changes from public health officials who used to run hospitals and health care systems to MBA-trained officials, and with the medical directors being replaced by Chief Medical Officers, which (from my perspective) has led to more of an administratively-centered care vs a patient-centered approach.

    -- in particular, from an array of studies in different industries, it is really important to regularly assess worker job satisfaction as well as several indicators of work stress (how much control workers in the different jobs have over their work, the extent of teamwork, and the level of work chaos

-- the results of this study has profound implications for the future of our healthcare system

 

-- primary care burnout is particularly high in physicians, even in family physicians, a group with more orientation to and training in primary care: see https://www.aafp.org/about/policies/all/family-physician-burnout.html  and https://www.jabfm.org/content/33/3/378.abstract?etoc

-- many of us in primary care have noted a major decrease in new medical residents going into primary care, and this seems to be increasing over time and leading to widespread difficulty recruiting new primary care physicians

    -- primary care, which should be the bedrock of any healthcare system (and is in most countries with quite functional systems), is dramatically undercut in the US healthcare system

        -- primary care is in many ways the most demanding of specialties, given having the necessary knowledge of a wide array of medical and psychosocial issues that patients may have, and requiring significant amounts of time invested in speaking with patients, understanding their social conditions, interacting with them and family members as needed, and generally synthesizing a prioritized workplan for different patients (i.e. determining which problems need to be addressed and in what order; a situation very different from specialists who focus on the one problem that is their specialty without the context of the whole patient). I do not mean to demean specialists, just to highlight a major difference with primary care

       -- primary care also therefore requires extensive understandings of the current medical literature (continuous learning of the many aspects of medical care), given the very broad array of medical problems that patients have; this is a time-consuming process, but does promote the intellectually-stimulating aspects of primary care

       -- primary care also seems to be the recipient of much paperwork, forms, negotiating with insurance companies, calling and dealing with pharmacies, speaking with specialists to review plans as needed (including, perhaps, changing the priorities that the specialist suggests to those that best meet the overall patient care goals). by the way, this consideration supports the process where specialists in general make recommendations to primary care and do not simply begin a treatment regimen, or refer to other specialists without including primary care in the loop). As mentioned, I certainly do not want to negate the very important role of specialists; i just feel that we need to be a team working with patients but with primary care the true coordinator of the different inputs into patient management

        -- primary care is sorely underpaid compared to other specialties, markedly undervaluing the cognitive components of patient care versus the interventional ones (perhaps related to the fact that the mechanism for physician reimbursement is largely dominated by surgeons and interventional specialists...). This reinforces primary care clinicians feeling undervalued by the health care system/local institutions/etc (see https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2758330 ), and is a source of job dissatisfaction

        -- training in outpatient primary care is in general significantly less robust than in inpatient medicine, except in family medicine. For internal medicine, 90+ percent of training is inpatient, and outpatient medicine requires a very different medical knowledge database and approach than inpatient medicine; and in my extensive experience teaching, even the brightest medical residents who have an interest in primary care and working in the community, typically feel much less prepared for working in an outpatient primary care setting (though, there is a very steep learning curve, and most are really very comfortable within a few months)

            -- recruitment into primary care has been further undercut by the development of hospitalist medicine, which I believe is because hospitalists do have a generalist-type practice (albeit hospital-based), the actual work of hospitalists is more bounded (outpatient primary care tends to be more boundless, with patient concerns and needs exceeding the usual workday), hospitalists have very clear times on and off (perhaps 7-10 days on, working specific hours, then 7-10 days off….), hospitalists are paid more (a huge issue in Boston where the cost-of-living is so high), and medical residents de facto have had 3 years of “hospitalist” training since they functioned in-patient for the vast majority of their 3-year residency. [this is not to say that hospitalists are “bad”: they certainly provide very important care; it is just that our system and its incentives are out of balance]

        -- the burden and burnout of primary care is most evident in younger primary care physicians (https://revcycleintelligence.com/news/younger-primary-care-physicians-seeing-high-levels-of-burnout-stress ), perhaps because they have different expectations for the life of a doctor, but also perhaps because the excessive workload in primary care is evident right away (the preponderance of office-centered/paperwork work over patient-centered interactions), but the truly huge benefits of primary care (developing profound relationships with patients and families) takes a much longer time to be evident. and, these patient relationships are the real reason that some of us in primary care for decades still love it, despite all of the above.

            -- and personally, I do really love primary care (an unabashed advocate), given the combination of intense relationships with patients and families, along with the continuous intellectual stimulation of combining the always evolving new medical literature with the patient in front of me, taking into account their medical condition in the context of their values, support systems, cultural issues, level of medical understanding, etc, etc

-- of course, covid has exacerbated many of the above issues. But these issues have been increasingly evident in community health centers in Boston over the past 2-3 decades, well before covid: now, it is much harder to recruit healthcare workers at all levels, and there has been more frequent turnover than in the past.  This is leading to much more system-wide staffing shortages, including in hospitals (despite their profoundly more adequate salaries and benefits than in the community)

 

Limitations:

-- the “other clinical staff” and “nonclinical staff” in the above study cover many different job categories, and there could well be very large differences in job satisfaction and stress within these categories. For example, nursing assistants may have much more job stress than the average of the category, and speech therapists less???

-- no granular data on the specialties of the clinical staff (primary care vs specialty)

-- this study had a mean response rate of 44%, in the ballpark of other survey studies, though there is likely a large selection bias: those workers who feel most negatively about their job situation are more likely to respond

-- no data on the baseline functioning of the sites of care: are people working in supportive environments? Are there collegial relationships? Is there a fair distribution of the workload, with everyone participating to their levels of training?

-- the data were collected during Covid, which was a particularly stressful time in the healthcare system, made worse by its politicization. Many healthcare workers worked exceedingly hard and long hours (work overload), yet a sizable number of patients in the current political polarization of healthcare did not even acknowledge that Covid existed (ie, as opposed to the prior reality that healthcare workers felt appreciated and validated in the jobs, during covid overworked and tired workers were at times actually confronted by patients when told their medical condition was a result of covid… and refused vaccines that would have likely kept them out of the hospital in the first place)

    -- and we are inheriting the legacy of covid: so many healthcare workers have left the field that the base for recruiting people into healthcare settings is relatively depleted

 

So, a few points related to my likely-way-too-long rant above:

-- the US healthcare system is in real trouble.  We seem to be evolving into one that is less and less able to meet the needs of our population (and, it was never great: we have always needed a public system that provided care to everyone, independent of one’s financial situation, and one that is coordinated, patient-focused and patient-centered. And one that is more seamless/holistic, as found in many countries with one-payer public systems, where there is much less focus on paper-work and non-patient tasks for all healthcare workers. our system really should pivot to incorporate social issues (access to good housing, food, exercise venues, social support systems, income inequality, public health concerns, etc) as well as the current focus on the medical issues (inpatient and outpatient clinical care)

-- we also need to redirect the health care system to promote primary care as its foundation, with systems that reinforce and validate primary care and that deal with the financial and workload issues mentioned above, have medical schools and training programs that promote primary care, validate the importance of primary care within the medical hierarchy, etc

-- and, as with climate change abatement initiatives, these changes are urgent right away: the more we wait, the worse it will be and correction is less attainable. In both cases, the situation worsens slowly, and many people adapt to (or rationalize) what they see as a gradual new-normal, and do not devote their full attention to the predictable long-term devastation of these two existential outcomes (of course, climate change is number 1, but healthcare system devolution is certainly a real issue)

 

-- and, the bottom line of the study above: we need to have systems in inpatient and outpatient care that validate, support and compensate all healthcare workers appropriately, that routinely assess worker job satisfaction and involve the healthcare workers in improving these systems, and specifically to make sure they minimize overwork and allow for gratifying and long-term jobs......

 

geoff

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