Abstract
Rates of burnout among clinicians have been exacerbated by the COVID-19 (COVID)pandemic. A survey of Missouri primary care professionals at federally qualified health centers was conducted during a COVID surge in August 2021 to assess burnout, stress, and job satisfaction as well as if respondents had sought assistance for burnout or attended resiliency training. Despite respondents reporting rates of burnout (56%) that exceed those reported nationally (48%), only 17% sought help for burnout. Most (81%) had not attended resiliency training; of those who did, 16% said sessions “make me feel less alone,” while an equivalent number found sessions not useful, identifying an absence of resources within their organization. Comments focused on the need for dedicated time to receive support, including time to seek assistance during working hours, time to take breaks, and time for self-care. The data suggest one path forward to remediate burnout: provide the workforce with time to access support.
Introduction
Rates of burnout are at an all-time high among clinicians,1 and especially concerning in primary care.2 We recently wrote about one strategy to reduce burnout across numerous health systems in Minnesota.3 In this article we share data from Missouri with challenging findings which may serve as a call to action in response to the crisis of burnout within medicine in general and primary care in particular.
Methods
Data were collected in partnership with the Missouri Primary Care Association (PCA) as a needs assessment for a grant application on improving burnout and mental health. We designed a brief survey, which included three Mini-Z items,4 three open-ended questions related to seeking assistance for burnout, and two questions on resiliency training.
A snowball sampling strategy was used: the survey was sent by the Missouri PCA to 56 federally qualified health center (FQHC) contacts in August 2021 during a COVID surge; contacts were asked to share the survey with primary care professionals within their FQHCs. Anonymous responses were received from 506 unique primary care professionals; the 2020 CMS Uniform Data System indicates approximately 5,200 FTEs in Missouri’s FQHCs, thus we estimate at least a 10% response rate.
Burnout measurement used the Mini-Z single item, validated against the MBI emotional exhaustion subscale;5 satisfaction and stress measurement used items from the Physician Worklife Survey.6 Open-ended comments were assessed via inductive coding to allow themes to emerge from participants’ responses about seeking help to address burnout; the emergent themes were then compared with existing literature to develop a conceptual model to guide remediation efforts. Statistics provided are mainly descriptive. The Harvard Institutional Review Board determined this was not human subjects research.
Results
Job satisfaction was present in 64% of respondents, low compared with national statistics of 72% in Internal Medicine4 while 64% of respondents reported high job stress and 56% reported burnout (ranging from having one or more symptoms to feeling completely burned out and needing help). Despite burnout rates that were higher than national numbers during the pandemic (48%),1 only 17% of survey respondents sought help for burnout, including counseling (44%), medication (23%), manager support (14%), and other strategies including exercise, meditation, and reducing work hours. In terms of resiliency training, a majority (81%) had not attended, and of those who did (n =86), 16% said sessions “make me feel less alone” and found solidarity with colleagues helpful. An equivalent number found sessions not useful, saying sessions were good, but there were no resources to implement in their organization. Open-ended comments regarding barriers to seeking assistance focused on needing dedicated time to receive support; comments highlighted other variables impacting organizations, burnout, and workers’ ability to seek assistance (Figure 1). Time was categorized by respondents as employer-paid time to seek assistance beyond or during working hours, time to take breaks during the day, time for self-care, and “worry-free” time off (Table 1).
Figure 1.
Variables that impact organizations, burnout, and healthcare workers’ ability to seek assistance. Variables in the model come from the Missouri survey respondents and were adapted from other studies: the Physician Worklife Survey,8,9 MEMO (Minimizing error maximizing outcomes) study,10 and the Reducing Burnout Driver Diagram.11
Table 1.
Time Categorizations by Respondents with Representative Quotes
| Time Categorization | Representative Quote |
|---|---|
| Employer-paid time to seek assistance | “Being able to use sick time instead of vacation time when scheduling an appointment with mental health provider.” “Available time off during work day/week to seek assistance.” “Provide paid time off specific to stress management services or counseling.” |
| Breaks during the work day | “It is often way too busy to step away to take a break or even a breath. Even regular breaks and lunch are often given up because of a busy schedule.” “Breaks! Take breaks when needed. Walk away if you have to. We are human, and not super humans.” “Provide frequent short mental breaks throughout the workday that allows the healthcare worker to actually walk away from the work and destress if needed. A designated stress-free room that is solely used to provide a relaxing environment even if for just 5–10 minutes.” |
| Time for self-care or wellness activities | “Remain committed to the investment in self-care and wellness. It’s easy to get busy and stay busy and think you don’t have time for wellness, but we have to do it… Carve out time in schedules for wellness - even if it’s 5, 15, 30, 45 minutes.” “Take care of yourself by exercising, saying no to some social obligations, and getting enough sleep.” “You cannot continuously pour from an empty cup. Find time for yourself and turn off all devices.” |
| Worry-free time off | “It would be nice if we were fully staffed and could take a mental health day without feeling guilty for leaving everyone else drowning.” “Time to get assistance with less worry about feeling guilty for taking the time to seek help.” “Hire more help to allow vacations to be taken without getting further behind in work.” |
Discussion/Implications
Primary care burnout is at troubling levels in Missouri and in other states summarized in recent web posts2. Addressing burnout within each state is one strategy to consider to mobilize the nation’s healthcare infrastructure to improve work conditions in primary care. These new data show troubling but remediable findings within a large rural state where many patients depend upon primary care by local safety net providers. Thematic analysis highlighted time as a primary barrier to accessing support needed to reduce burnout. Survey respondents proposed interventions that could be facilitated by workflow redesign including dedicated time to seek assistance; robust mental health support, including available counseling during or after work hours; mental health days or flexible use of sick time; and manager support in modulating workload.
Conclusion
A statewide approach to reduce burnout, as taken by the Minnesota Hospital Association3 in 93 heath systems throughout the state, may be an effective mechanism to address worklife and wellness in clinicians in Missouri. Given the emphasis on time pressure noted in this survey and in prior national studies,7 a statewide approach to time (time for self-care, time for documentation, and time to listen to patients’ concerns) is, we believe, a focus which could quickly build loyalty and trust among Missouri physicians. This approach has been supported by the American College of Physicians and the American Medical Association, among other large national organizations. Support by the federal government and insurance companies for sufficient time to carry out the important work of caring for patients will further support this effort.
Footnotes
Erin E. Sullivan, PhD, is with the Sawyer School of Business, Suffolk University, Boston, Massachusetts, and Harvard Medical School, Center for Primary Care, Harvard University, Boston, Massachusetts. Danielle McKinstry, MHA, is with the Sawyer School of Business, Suffolk University, Boston, Massachusetts. Joni Adamson, MBA, is with Missouri Primary Care Association, Jefferson City, Missouri. Lindsay Hunt, MEd, is with Harvard Medical School, Center for Primary Care, Harvard University, Boston, Massachusetts. Russell S. Phillips, MD, is with is with Harvard Medical School, Center for Primary Care, Harvard University, Boston, Massachusetts and the Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts. Mark Linzer, MD, is in the Department of Medicine and Institute for Professional Worklife, Hennepin Healthcare System, Minneapolis, Minnesota.
Disclosure
ML is supported by CRICO (Harvard Risk Management Foundation) for diagnostic safety work as a consultant, and also through his place of employment (Hennepin Healthcare) by the American Medical Association, American College of Physicians, the Optum Office for Provider Advancement (OPA), Essentia Health Systems, Gillette Children’s Hospital, the Institute for Healthcare Improvement, and the American Board of Internal Medicine Foundation for burnout prevention research and training. Dr. Phillips is supported by grants from the Agency for Healthcare Research and Quality and the Health Resources and Services Administration.
References
- 1.Prasad K, McLoughlin C, Stillman M, et al. Prevalence and correlates of stress and burnout among US healthcare workers during the COVID-19 pandemic: A national cross-sectional survey study. EClinicalMedicine. 2021;35:100879. doi: 10.1016/j.eclinm.2021.100879. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.The Larry A Green Center. Quick COVID 19 Survey. [Accessed May 17, 2022]. Available at: https://www.green-center.org/covid-survey.
- 3.Koranne R, Williams ES, Poplau S, et al. Reducing burnout and enhancing work engagement among clinicians: The Minnesota experience. Health Care Manage Rev. 2022;47(1):49–57. doi: 10.1097/HMR.0000000000000298. [DOI] [PubMed] [Google Scholar]
- 4.Linzer M, Smith CD, Hingle S, et al. Evaluation of work satisfaction, stress, and burnout among US internal medicine physicians and trainees. JAMA Netw Open. 2020;3(10):e2018758. doi: 10.1001/jamanetworkopen.2020.18758. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Rohland BM, Kruse GR, Rohrer JE. Validation of a single-item measure of burnout against the Maslach Burnout Inventory among physicians. Stress Health. 2004;20(2):75–79. [Google Scholar]
- 6.Linzer M, McLoughlin C, Poplau S, et al. The Mini Z Worklife and Burnout Reduction Instrument: Psychometrics and Clinical Implications [published online ahead of print, 2022 Jan 19] J Gen Intern Med. 2022 doi: 10.1007/s11606-021-0727-8-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Prasad K, Poplau S, Brown R, et al. Time pressure during primary care office visits: A prospective evaluation of data from the healthy work place study. J Gen Intern Med. 2020;35(2):465–72. doi: 10.1007/s11606-019-05343-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Konrad TR, Williams ES, Linzer M, et al. Measuring physician job satisfaction in a changing workplace and a challenging environment. Med Care. 1999:1174–82. doi: 10.1097/00005650-199911000-00010. [DOI] [PubMed] [Google Scholar]
- 9.Linzer M, Konrad TR, Douglas J, et al. Managed care, time pressure, and physician job satisfaction: Results from the physician worklife study. J Gen Intern Med. 2000;15(7):441–50. doi: 10.1046/j.1525-1497.2000.05239.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Linzer M, Manwell LB, Williams ES, et al. Working conditions in primary care: Physician reactions and care quality. Ann Intern Med. 2009;151(1):28–36. doi: 10.7326/0003-4819-151-1-200907070-00006. [DOI] [PubMed] [Google Scholar]
- 11.Sullivan EE, Dwiel K, Hunt LS, Conroy K, Barnett KG. Moving the needle on primary care burnout: Using a driver diagram to accelerate impact. Healthc. 2021;9(4):100595. doi: 10.1016/j.hjdsi.2021.100595. [DOI] [PMC free article] [PubMed] [Google Scholar]