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Journal of General Internal Medicine logoLink to Journal of General Internal Medicine
. 2021 May 28;36(12):3759–3765. doi: 10.1007/s11606-021-06883-6

Thriving among Primary Care Physicians: a Qualitative Study

Katherine Ann Gielissen 1,, Emily Pinto Taylor 2, David Vermette 1, Benjamin Doolittle 1
PMCID: PMC8642558  PMID: 34047922

Abstract

Background

Burnout is high in primary care physicians and negatively impacts the quality of patient care. While many studies have evaluated burnout, there have been few which investigate those physicians who are satisfied with their careers and life—a phenomenon we term “thriving.”

Objective

To identify factors contributing to both career and life satisfaction through qualitative interviews.

Participants

The subjects were primary care physicians.

Approach

Qualitative interviews were performed between July 2018 and March 2020. Physicians were identified by snowball sampling and were asked to complete validated instruments to identify job/life satisfaction and lack of burnout. Semi-structured interviews were conducted, focused on aspects of participants’ career and life which contributed to their thriving, including work environment, social networks, family life, institutional support, coping strategies, and extracurricular activities. Transcripts were analyzed using thematic content analysis using a grounded theory approach.

Main Measures

Personal, professional, and life factors that contributed to achieving career and life satisfaction in primary care physicians and potential solutions for burnout.

Results

Thirty-two physicians were interviewed (9.4% family physicians, 9.4% combined internists-pediatricians, 40.6% internists, and 40.6% pediatricians) with a mean age 54.7 years and 23.8 years in practice. No physicians included met the criteria for burnout. All met the criteria for career and life satisfaction. Five themes were identified as critical to thriving: an intrinsic love for the work, a rich social network, a fulfilling doctor-patient relationship, a value-oriented belief system, and agency in the work environment.

Conclusions

Several factors contribute to professional fulfillment and life satisfaction among primary care physicians, which we propose as a model for physicians thriving. Some factors were intrinsic, such as having value-oriented beliefs and inherent love for medicine, while others were extrinsic, such as having a fulfilling social network. Barriers and opportunities to apply these lessons for the wider physician community are discussed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-021-06883-6.

Key Words: burnout, thriving, primary care, qualitative research

INTRODUCTION

Physician well-being has been heralded as the fourth aim of quality care—in addition to improving patient outcomes, the patient experience, and reducing costs 1. Burnout, the inverse of well-being, is defined as a sense of emotional exhaustion, depersonalization, and reduced effectiveness, with an estimated prevalence in physician populations of 44–55% 24. Physicians who experience burnout are more likely to suffer depression, suicidality, substance use disorders, family strife, and difficult co-worker relationships5. They are also more likely to make medical errors and commit lapses in professionalism 4 ,6, 7. In addition, physician burnout has important financial impacts on the healthcare system: reduced physician hours and increased turnover, resulting in an estimated $4.6 billion in healthcare costs 8, 9. Burnout is as high as 60% among physicians in primary care–oriented specialties such as internal medicine (IM) and family medicine (FM) 4,10,11. These findings have raised concerns that ongoing burnout could worsen physician shortages and exacerbate poor access to care 12.

While physician burnout and its implications are well-described, physician well-being is not 13. Many studies propose quantitative measures of physician well-being, which emphasize wellness as a mental state rather than a complex process integrating the whole person 14. Brady et al. suggest physician wellness is “quality of life, which includes the absence of ill-being and the presence of positive physical, mental, social, and integrated well-being experienced in connection with activities and environments that allow physicians to develop their full potentials across personal and work-life domains,” and propose a “thriving model” to better elucidate the various domains of well-being 14. In 2003, Shanafelt and colleagues noted similarly “wellness goes beyond the absence of distress and includes being challenged, thriving, and achieving success in various aspects of personal and professional life” 15. Recent work by VanderWeele and colleagues conceptualized well-being as a construct of human flourishing, which encompasses the domains of happiness, life satisfaction, physical and mental health, meaning and purpose, character and virtue, and close social relationships. They suggest that endeavors to promote individual well-being ought to include such a holistic conceptualization of wellness 16.

This study investigates factors that promote thriving among community-based primary care physicians who have enjoyed satisfying, long-standing careers. Given the high prevalence of burnout among primary care physicians, the perspective of these thriving physicians is an important, untapped resource to better inform physician well-being, the “missing quality indicator” in the delivery of high-quality healthcare 6.

APPROACH

Setting, Participants, and Study Design

A qualitative methodology was chosen to provide insights into participants’ attitudes, reflections, and perspectives. Thematic analysis using a grounded theory-based approach was used because it would allow investigators to identify naturally occurring themes from the data 17, 18. Semi-structured interviews of primary care physicians were conducted from July 2018 to March 2020 in the area surrounding New Haven, CT. Physicians in primary care fields (pediatrics [P], combined medicine-pediatrics [MP], FM, and IM) were chosen given high rates of burnout and turnover in these fields, and multiple practice locations were represented (Table 1).

Table 1.

Characteristics of Study Participants (n = 32)

Characteristic Value*
Mean age (range), years 54.7 (36–78)
Female 16 (50.0%)
Mean years in practice (range) 23.8 (5–43)
Specialty
Internal medicine 13 (40.6%)
Pediatrics 13 (40.6%)
Combined internal medicine-pediatrics 3 (9.4%)
Family medicine 3 (9.4%)
Practice setting
Academic 1 (3.1%)
Federally qualified health center 2 (6.3%)
Private practice 22 (68.8%)
Mix academic and non-academic 7 (21.9%)
Ethnic group
Caucasian 13 (40.6%)
Asian/South Asian 11 (34.4%)
African American 6 (18.8%)
Latino 0 (0%)
Other 2 (6.3%)
Maslach Burnout Inventory, modified
“How often do you feel burned out from work?”
Never 5 (15.6%)
A few times a year or less 24 (75.0%)
Once a month or less 3 (9.4%)
A few times a month 0 (0%)
Once a week 0 (0%)
A few times a week 0 (0%)
Every day 0 (0%)
“How often do you feel you have become more callous to people since you took this job?
Never 13 (40.6%)
A few times a year or less 17 (53.1%)
Once a month or less 2 (6.3%)
A few times a month 0 (0%)
Once a week 0 (0%)
A few times a week 0 (0%)
Every day 0 (0%)
Satisfaction (“all things considered…”)†
“…how satisfied are you with your life?” mean (CI) 8.3 (± 0.3)
“…how satisfied are you with your career?” mean (CI) 8.4 (± 0.3)

*Data are expressed as number (%), unless otherwise noted. Percentages may not add to exactly 100% due to rounding

†Rated on a scale of 0–10, with 10 being the most satisfied

This study focused on those physicians who met the criteria for career and life satisfaction and who did not meet the criteria for burnout. Physicians were recruited using snowball sampling 19 by email, phone, and in person. On conclusion of the interviews, the participants were asked to identify peers they felt were thriving in their primary care practice, to be contacted for future interviews. Subjects who agreed to participate in the study completed a demographic questionnaire and the two single-item versions of the Maslach Burnout Inventory (MBI): “How often do you feel burned out from work?” and “How often do you feel you have become more callous to people since you took this job?” 20. Physicians who responded “once a week” or more frequently on either item were excluded from the study. Physician satisfaction with life and career was assessed using the questions, “All things considered, how satisfied are you with your life?” and “All things considered, how satisfied are you with your career?” Participants were asked to respond on an 11-point scale from 0 “totally dissatisfied” to 10 “totally satisfied.” This instrument has been used in multicultural settings among large population studies 21.

Interview Guide

A semi-structured interview was developed by two of the study authors (B.D., K.A.G.) (Appendix A). The questions were derived from a review of the literature on dimensions of physician wellness, the authors’ conceptual framework of physician well-being, and focused on aspects of each participants’ career and life which contributed to their thriving, including work environment, social networks, family life, institutional support, emotional coping strategies, and extracurricular activities. B.D. is an expert on physician wellness and has published widely on the topic 2226. K.A.G. has specific expertise in qualitative research and developing semi-structured interview templates 27, 28. Interviews were conducted in person or over the phone and were audio-recorded by one of three of the study authors, who all had prior experience with qualitative interviewing (B.D., K.G., and E.P.T.). This study was approved by the Yale University Institutional Review Board.

Qualitative Analysis

Audio-recorded interviews were transcribed and anonymized (©Rev.com, San Francisco, CA). Each transcription was verified for accuracy to the audio recording by the first author (K.A.G.). One interviewee was not audiotaped due to technical challenges; this interview was analyzed from contemporaneous notes. All other interviews were analyzed directly from transcriptions.

We employed thematic content analysis using a grounded theory-based approach. This allowed investigators to identify naturally occurring themes from the data in an ongoing, iterative process that co-occurred with data collection 17. Thematic summaries and conceptual memos were individually documented by each study member, who met multiple times to discuss themes and generate an initial codebook. The group then underwent an iterative process of interview template analysis and revision, definition, and identification of new codes as new interviews were transcribed, following an open coding method until consensus was reached on the final codes and their definitions. Thematic saturation was reached at 16 participants but all participants not meeting burnout criteria were included in the analysis. Final codes were related to each other through axial coding, in which categories and subcategories were linked to form concepts that were “dense, well-developed, and related” with discrepancies discussed between the study authors until consensus was attained 17. Each interview was coded by at least one study author, with eight interviews cross-coded by the first author to ensure consistent applications of codes. All transcripts were coded using the Dedoose software (Los Angeles, CA).

RESULTS

We individually interviewed 33 primary care physicians (13 IM, 14 pediatrics, 3 combined internal medicine-pediatrics, 3 FM); approximately half of which self-identified as female (Table 1). One participant invited to the study met screening criteria for burnout and was excluded from the analysis. The average duration for each interview was 32.48 minutes (range 23.30–61.30). All participants included in the study met criteria (≥ 7 on 11-point scale) for satisfaction with life (mean 8.3, CI 8.0–8.6) and career (mean 8.4, CI 8.1–8.7). Through the analysis of these conversations, we identified five key factors related to thriving among primary care physicians (Fig. 1). Quotes are annotated with randomly assigned continuous numbers for each participant in that specialty (Supplemental Table 1).

Figure 1.

Figure 1

Conceptual model of a thriving physician. Thriving physicians establish lasting relationships with patients, maintain love for their work, find mechanisms to stay grounded and connected, have agency to work in the best interests of their patients, and practice medicine in ways that align with their values.

Love of the Work

Uniformly, primary care providers reported a genuine love for the daily work of being a physician. Whether this was rooted in fascination with science, a commitment to teaching and learning, or gratitude for the privilege of caring for others, all participants drew purpose and drive from their profession. Many physicians referred to their role as a physician as a “calling” or “vocation” indicating they found their role as a primary driver for their ongoing practice and enjoyment of the work:

There are much more profitable ways to earn a living than being a physician, but there’s nothing that’s more satisfying than being a physician, that you have to go into it as a career and a calling. (IM3)

The vocational nature of the work also imparted pride and a sense of duty in times of difficulty, such as receiving calls from concerned patients or performing clinical tasks during nights and weekends.

Developing Relationships with Patients

All participants noted the importance of longitudinal, trusting relationships with patients as a central component of thriving in primary care, as it provided both a driver for job satisfaction and ongoing practice. Participants reported feeling invested in patients, referencing the gratifying impact of caring for generations of families:

I have a bunch of people who I've taken care of them, and now I take care of their children. And that’s really special, because then I get to see them as a patient and then as a parent, and it’s just so much fun. (P2)

In addition, providers noted that knowing their patients allowed them to find meaning in their relationships. Most cited their enjoyment of how ongoing relationships added variety to otherwise common medical presentations.

Similarly, physicians found that relationships with patients provided purpose to their day. Some explained that deeply connected relationships with patients were personally meaningful:

You get to really… know a lot of people, the hugs, the kisses, the cookies, the thanks that you get are priceless, truthfully. (IM9)

Long-standing, trusting relationships also provided affirmation of the choice to become a physician and validation that patients appreciated the ongoing effort to help and support them:

One of the most important factors in physician happiness and well-being… is the positive validation and reinforcement from your patients that you are making a difference in their lives and overall health. The overwhelming appreciation from the patients has a positive impact. (IM7)

Maintaining Agency in the Workplace

Agency, or the ability to affect change in the workplace, was a recurring theme, especially given the significant administrative burden of modern medicine. One provider summarized the problem:

The economics of primary care are very difficult in the community. The solution is to give up a certain amount of autonomy, joining with others into larger groups. (IM2)

As such, participants described agency as an important factor for thriving. Agency could include a physician’s ability to control their schedule, pursue further training within and outside the scope of medicine, and their overall sense of how much they could positively affect the system in which they worked. As one stated, “It’s paramount that no one can tell me when to work, who to see, who not to see” (FM2). Participants discussed the importance of impacting hiring decisions to establish the culture of a practice.

Agency included how freely participants felt they were able to advocate for their patients, allowing them to care for patients in the “manner in which they deserved” (P4). This theme manifested in participants’ perceptions of autonomy, in which they felt empowered to provide the level of care they believed was best for their patients:

I think the reason which I think it worked was because I have independence… So, basically, everything is patient focused, it's not career-focused. It's basically what the patient needs, I can give that patient. (IM1)

Remaining Grounded and Connected

Thriving physicians described lives in which they were deeply connected with their colleagues, staff, families, and communities. At work, physicians were positively impacted by building trust longitudinally with other physicians—both consultants and partners—and through the joy of friendship with staff:

What helps me thrive… is my staff. I'm blessed with a great staff. We get along. We're like a big family, and that’s what makes me happy to come to work (IM4)

This connectedness through relationships with coworkers and colleagues was important to ensure shared values in caring for patients, as well as an overall sense of community in the workplace.

Participants also conveyed the importance of meaningful relationships outside their work. This was represented in many contexts, including marriage, children, extended family, and deep friendships:

I see my friends several times a week, and I surround myself by people who care about other people… Every single one of them is benevolent, giving of their money, generous, kind, work in non-profits, have professions that I respect, and are wonderful friends who would be there in a drop of a hat (P4)

The care and understanding of partners, family, and friends was an important outlet and support network during challenging times for physicians.

Lastly, physicians were grounded in the community with others, bonded by a variety of hobbies, religious beliefs, cultural heritages, or advocacy causes:

People recognize me in town. They know who I am, and that’s actually helped my work-life balance because I can feel like I'm part of a community, and that gives me great satisfaction. (IM8)

Practicing Value-Oriented Medicine

The final theme was the importance of providing care that aligned with personal values. Participants worked and conducted their lives, intrinsically motivated by a sense of moral duty, justice, spiritual conviction, or other values to serve their patients. For some, this was manifested by participation in organized religion:

Having a faith of some sort I think is important for patients as you try to counsel them through some of the hard times in their life, but [it’s] also important for us… I think if we, as physicians, thought more about what we do as a calling as opposed to a job it would be a lot easier. (FM1)

Not all participants identified a specific faith community, but instead referred to an overall “human spirit” or to non-faith-based values as important for ongoing care. There was a common theme of looking beyond oneself toward pursuing the support and care of others. Values espoused by participants as being helpful included gratitude, selflessness, and a sense of purpose. Others cited the importance of justice, equity, and their ability to play an active role in enacting these values:

I just think at that point I decided my life was gonna be about helping people. That I saw suffering that I could actually do something for. And that, I think, has informed my whole life. (P5)

Threats to Thriving

All physicians described aspects of their work that negatively impacted their ability to thrive; specifically, issues around administrative duties:

When I think about some of the negative things, it always involves the bureaucratic—the administrative—side of things, and how I feel invisible to higher ups. (MP1)

Other physicians commented on challenges surrounding electronic medical records:

How one figures out with the electronic records how to become increasingly efficient, even though it's never as efficient as prior to having the electronic record, at the same time to maintain the relationship with the patient and to maintain the quality that you want to maintain in terms of giving patient care, that can be difficult. (IM3)

Regardless of the source, threats to thriving affected four of the five themes: they interfered with patient relationships, inhibited agency, detached providers from community, and/or prevented physicians from practicing value-oriented medicine.

DISCUSSION

This project offers insights into the thriving primary care physician. While many studies focus on burnout, we strove to better characterize the “positive deviants”—those physicians with a satisfying and successful career and personal life. Recent literature has encouraged physicians to consider whole, thriving lives for their patients, but have not extended this consideration to physicians themselves 16, 29. While burnout is endemic in physician communities, we found thriving is not simply the absence of burnout, nor is it finding the proper work-life balance. We instead re-introduce a concept described by Aristotle in his Nicomachean Ethics: eudaimonia30. Eudaimonia comes from the Greek words “eu” meaning good, “daimon” meaning spirit, and has been variably translated to “human flourishing” and “living well” 31. Eudaimonia describes a way of living rather than a mental state, which these physicians fulfilled. They pursued work they found intrinsically meaningful, which in turn enhanced their feeling of satisfaction and purpose.

We propose that eudaimonia is applicable to physician thriving, described by the five themes elucidated in this study. Instead of focusing on initiatives that impose external notions of wellness, our findings suggest thriving is—in part—an internal process by which an individual finds interconnectedness and significance in their life and work. It is unclear, however, if our findings represent an intrinsic personality trait, the environment in which our primary care physicians worked, or specific actions they took to seek fulfillment. We posit it is likely a combination of the three.

Much of the literature on burnout and wellness focuses on work-life balance4. Indeed, prior conceptual frameworks on wellness often depict a sharp divide between personal and professional life32. Interestingly, our physicians did not consistently describe a goal of working towards a perfect equilibrium between work and home life. They found it challenging to discern where their role as physicians ended and their personal lives began. Rather, they described a love for the work itself and sought patient-focused roles driven by relationships with people in alignment with their intrinsic, value-oriented beliefs. Their practice was therefore part of a continuum; their lives were fully enmeshed with their community, patients, and family. In a qualitative study, Schwartz et al. describe wellness initiatives from non-medical disciplines, such as protective services, business, and education33. Fostering bidirectional relationships and connecting with the community was an important domain for wellness in these professions. To our knowledge, this enmeshing of life and work has not previously been described among physicians. We propose that striving towards work-life balance may not necessarily be the goal of physicians who wish to thrive, but rather it is to seek a life that is full of meaningful relationships that add to a sense of community and interconnectedness. In short, the goal of a physician who wishes to thrive is to seek eudaimonia.

Additionally, we found predominant themes related to agency, which constitute external factors in physician thriving. Our physicians described the loss of agency in their workplace and as one of the most important threats to thriving. Primary care physicians valued the ability to affect their work through continued learning, advocacy, and control over systems and workflows. Themes of agency have previously been described in the literature; there is increasing recognition that burnout should not simply be addressed at an individual level, but instead needs to be the concern of organizations and society8, 32. Prior work with primary care physicians has shown that dissonance between one’s values and those of the health system can contribute to burnout34. This study referred to such dissonance as “responsibility-authority mismatch,” where responsibility for patient care increased, but agency over the work they performed did not34. Our data suggest preserving agency in the workplace may guard against professional dissonance. In our findings, primary care physicians valued not only the ability to control work schedule and environment, but also the power to practice medicine in a way that aligned with their intrinsic values, which provided meaning and drive to their daily work.

Finally, our physicians described their work as a calling, a vocation, and found purpose in the work itself. This is consistent with prior literature across multiple disciplines which demonstrates that calling is linked with increased levels of career maturity, endurance, and satisfaction with life and career35. In physicians specifically, a prior study of primary care physicians and psychiatrists showed that a high sense of calling may be protective and was associated with less burnout and less regret in choosing medicine as a career36. These findings also coincide with prior descriptions of eudaimonia, which defines the importance of intrinsic goals of personal growth, intimacy, and making meaningful contributions to one’s community.

Limitations

While we reached thematic saturation at 16 participants, it is possible that we failed to uncover other relevant factors germane to physician thriving. Our study was conducted in physicians practicing primarily in urban and suburban areas in Connecticut. Findings may not be generalizable to physicians in other geographic regions or to those physicians who practice in an academic setting, where publishing and teaching demands create different job pressures. Since this study evaluated primary care physicians, these findings may not be generalizable to other specialties. Additionally, practice locations were in a Medicaid-expansion state, and primary care physicians in non-expansion states may have different stressors related to limited access to care. While our study participants were diverse, there may have been unique themes from minority communities or women that were not explicitly explored. Furthermore, while this study employed open-ended non-judgmental questions, there is always the possibility of implicit bias, leading questions, and inaccurate interpretation by the interviewer or the coding team. We sought to mitigate this possibility through a rigorous qualitative approach.

CONCLUSIONS

Using our framework, we have extrapolated recommendations to encourage thriving in physicians (Table 2). Intrinsically, physicians should seek out joy in their work and find those aspects of medicine that inspire a love of the work, grounded in personal values. Extrinsically, we believe that a healthcare system that enhances the doctor-patient relationship, encourages physician agency, and emphasizes a connected culture would foster improved physician well-being. With an improved internal culture, other elements might improve, such as “love for the work.” We recognize that an intrinsic value-oriented drive may be a trait unique to this cohort, though we feel it can be encouraged throughout training with additional community involvement. Future studies that explore fostering a rich, supportive culture rather than a specific program would be appropriate next steps. Randomized controlled trials may be impractical, but physician well-being can be tracked over time, even beginning at the level of undergraduate and graduate medical education. At an institutional level, we believe that well-being and burnout should be a core quality metric, like catheter-based line infections or readmission rates, that are closely monitored and acted upon to improve the clinical workplace. Focused support for practices of thriving can then follow in those areas of higher burnout.

Table 2.

Practical Steps toward Thriving. While Not Exhaustive, These Suggestions Were Derived from the Interview Participant Data and Review of the Literature on Evidence-Based Interventions to Improve Well-being37

Aspect of thriving Practical examples
Support love of the work

• Foster a sense of calling

• Encourage clinical investigation, reading, and passion for ongoing learning

• Promote reflection on the “role of the physician” during and after training

Facilitate relationships with patients

• Encourage sharing of positive affirmations from patients in the workplace, such as bulletin boards with cards and sharing at staff meetings

• Maintain continuity between patients and providers to allow for long-term relationship-building

Remain grounded and connected

• Convene timely meetings with staff to allow for building of camaraderie

• Provide safe spaces for physicians and staff to gather

• Support involvement in community organizations, family life, celebration of personal successes

Practice value-oriented medicine

• Encourage providers’ spiritual or religious practices

• Create space to discuss “calling,” “meaning,” and “purpose”

• Remove barriers to practice, promoting physicians’ ability to care for patients “as they deserve”

Create agency in the workplace

• Allow for job flexibility

• Involve physicians on hospital leadership and decision-making committees

• Engage physicians in hiring decisions

• Provide opportunities and space for physicians to advocate locally, regionally, and nationally for patient care

Supplementary Information

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Declarations

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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