Abstract
This study examines physician burnout using data from American Board of Family Medicine application questionaires.
Burnout is on the rise, with over half of US physicians reporting at least 1 symptom in 2014. Physician burnout has negative impacts on both physician well-being and patient care. Addressing burnout is imperative to improving the care of patients, promoting the health of physicians, and reducing health care costs. Practice features associated with burnout include clinic demands, paperwork, and maintaining work/life balance. Our purpose was to examine burnout in a national sample of board certified family physicians.
Methods
We used data from the family physicians seeking to continue their American Board of Family Medicine (ABFM) certification in 2016. All examinees completed an application questionnaire with core questions and 1 of 5 additional question sets. The strategy produces representative samples. One of these was the Mini Z survey. We assessed burnout with a single item that correlates with the emotional exhaustion subscale of the Maslach Burnout Inventory.
We used descriptive statistics and t tests or χ2 tests for bivariate analyses. Finally, a multivariable logistic regression determined independent associations between other Mini Z variables with burnout. An additional model with all Mini Z variables included was used to determine associations controlling for all other variables. All analyses were conducted in SAS statistical software (version 9.3, SAS Institute). This study was approved by the American Academy of Family Physicians institutional review board, and written informed consent was waived because the analysis was of secondary data that is routinely collected for business purposes.
Results
Of 9452 practicing family physicians, 1923 (20.3%) were administered the Mini Z. Physicians administered the Mini Z were demographically similar to those not receiving it and were mostly men (1122 [58.3%]) and held an MD degree (1746 [90.8%]). We excluded 141 owing to missing data, for a final sample of 1752. Twenty-five percent (441 of 1752) reported symptoms of burnout (Table 1). The presence of burnout was associated with many work-related factors including less control over workload (35.1% vs 82.8%, P < .001), lack of sufficient time for documentation (21.1% vs 61.0%, P < .001), stress owing to their job (91.4% vs 38.4%, P < .001), and more time spent on electronic medical records (EMRs) at home (62.1% vs 38.7%, P < .001).
Table 1. Presence of Burnout by Personal and Practice Characteristics and Mini Z Responses From Family Physicians Attempting to Continue the American Board of Family Medicine Certification in 2016a.
| Characteristic | No. (%) | P Value | ||
|---|---|---|---|---|
| Total Family Physicians (N = 1752) | Burned Out (N = 441) | Not Burned Out (N = 1311) | ||
| Overall, I am satisfied with my current job (agree/strongly agree) | 1308 (74.7) | 193 (43.8) | 1115 (85.0) | <.001 |
| I feel a great deal of stress because of my job (agree/strongly agree) | 907 (51.8) | 403 (91.4) | 504 (38.4) | <.001 |
| My control over my workload is (satisfactory/good/optimal) | 1240 (70.8) | 155 (35.1) | 1085 (82.8) | <.001 |
| Sufficiency of time for documentation is (satisfactory/good/optimal) | 893 (51.0) | 93 (21.1) | 800 (61.0) | <.001 |
| Which number best describes the atmosphere in your primary work area? (4 or 5 on 5 point scale with 5 being “hectic, chaotic”) | 599 (34.2) | 252 (57.1) | 347 (26.5) | <.001 |
| My professional values are well aligned with those of my department leaders (agree/strongly agree) | 1119 (63.9) | 184 (41.7) | 935 (71.3) | <.001 |
| The degree to which my care team works efficiently together is (satisfactory/good/optimal) | 1620 (92.5) | 365 (82.8) | 1255 (95.7) | <.001 |
| The amount of time I spend on the EMR at home is (excessive/moderately high) | 782 (44.6) | 274 (62.1) | 508 (38.7) | <.001 |
| My proficiency with EMR use is (satisfactory/good/optimal) | 1652 (94.3) | 404 (91.6) | 1248 (95.2) | .01 |
Abbreviation: EMR, electronic medical record.
Burnout identified by Mini Z item “Using your own definition of burnout, please select one of the answers” and the responses “I am definitely burning out and have one or more symptoms of burnout, eg emotional exhaustion.” “The symptoms of burnout that I’m experiencing won’t go away. I think about work frustrations a lot.” “I feel completely burned out. I am at the point where I may need to seek help.” indicating burnout.
In adjusted analyses, we found positive independent associations between job stress (OR, 16.38; 95% CI, 11.49-23.37) and excessive time spent on EMRs at home (OR, 2.67; 95% CI, 2.12-3.38) with burnout (Table 2). Controlling for all variables in the Mini Z simultaneously attenuated the strength of the associations for all variables and resulted in efficient team work, excessive time spent on EMRs at home, and EMR proficiency losing statistical significance.
Table 2. Adjusted Associations Between Practice Characteristics With Burnout Among 1752 Family Physicians Seeking to Continue Their Certification With the American Board of Family Medicine in 2016a.
| Characteristic | Odds Ratio (95% CI) | |
|---|---|---|
| For Each Variable Independently Controlling for Demographic and Practice Characteristics | With All Other Variables Included in the Model | |
| Overall, I am satisfied with my current job (agree/strongly agree) | 0.13 (0.10-0.16) | 0.29 (0.21-0.39) |
| I feel a great deal of stress because of my job (agree/strongly agree) | 16.38 (11.49-23.37) | 9.06 (6.13-13.38) |
| My control over my workload is (satisfactory/good/optimal) | 0.11 (0.08-0.14) | 0.32 (0.23-0.44) |
| Sufficiency of time for documentation is (satisfactory/good/optimal) | 0.17 (0.13-0.22) | 0.57 (0.40-0.81) |
| Which number best describes the atmosphere in your primary work area? (4 or 5 on 5 point scale with 5 being “hectic, chaotic”) | 3.61 (2.86-4.55) | 1.42 (1.06-1.91) |
| My professional values are well aligned with those of my department leaders (agree/strongly agree) | 0.28 (0.22-0.35) | 0.64 (0.47-0.87) |
| The degree to which my care team works efficiently together is (satisfactory/good/optimal) | 0.21 (0.15-0.31) | 0.88 (0.53-1.44) |
| The amount of time I spend on the EMR at home is (excessive/moderately high) | 2.67 (2.12-3.38) | 1.12 (0.81-1.55) |
| My proficiency with EMR use is (satisfactory/good/optimal) | 0.46 (0.30-0.72) | 0.72 (0.40-1.29) |
Abbreviation: EMR, electronic medical record.
Variables controlled for in both regression models include previous certification examination result, sex, age, degree type, international medical graduate status, race and ethnicity, percent time in direct patient care, practice size, organization and ownership status, patient-centered medical home status, and scope of practice.
Discussion
In a national sample of family physicians, 25% reported symptoms of burnout, which is substantially lower than estimates using the Maslach Burnout Inventory (63%) but is closer to estimates of academic general internists (38%) using the Mini Z. Burnout was associated with multiple workplace-related factors, with the strongest associations being stress and hectic/chaotic work area.
Electronic medical record-related variables were not significant when controlling for other workplace factors, whereas insufficiency of time for documentation remained significant. With recent findings that physicians spend half as much time on direct clinical contact as on EMRs and desk work, our findings concur with others that the tasks required for EMR use are associated with burnout, not the EMR itself. This disproportionate time documenting may decrease the potentially protective benefits of patient contact.
Our study has several limitations. First, although the sample was national, early career physicians are under-sampled because recertification occurs at least 7 years after residency. Furthermore, because the Mini Z only correlates with 1 domain of burnout, the difference in prevalence with other studies may be owing to the use of different assessments.
Conclusions
Our findings suggest that burnout among family physicians is not uncommon. Future interventions to reduce burnout and improve patient care and physician satisfaction can be targeted toward addressing workplace factors.
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