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Original Investigation
Physician Work Environment and Well-Being
January 6, 2020

Professional Dissonance and Burnout in Primary Care: A Qualitative Study

Author Affiliations
  • 1Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
  • 2Harvard Medical School, Boston, Massachusetts
  • 3Humana Edge, Humana, Boston, Massachusetts
JAMA Intern Med. Published online January 6, 2020. doi:10.1001/jamainternmed.2019.6326
Key Points

Question  What are the contributors to high burnout and low professional fulfillment among primary care practitioners?

Findings  In this qualitative study of burnout involving 26 participants, frontline primary care practitioners expressed a sense of professional dissonance, or discomfort from working in a system that seems to hold values counter to their own as clinicians. Factors they mentioned that may be more specific to primary care practitioners included an authority-responsibility mismatch and feeling undervalued.

Meaning  In this study, primary care practitioners identified many contributors to burnout and low professional fulfillment but also suggested possible solutions in which institutions may want to invest to resolve dissonance, reduce burnout rates, and improve professional fulfillment in primary care.


Importance  Burnout negatively affects physician health, productivity, and patient care. Its prevalence is high among physicians, especially those in primary care, yet few qualitative studies of burnout have been performed that engage frontline primary care practitioners (PCPs) for their perspectives.

Objective  To identify factors contributing to burnout and low professional fulfillment, as well as potential solutions, by eliciting the views of PCPs.

Design, Setting, and Participants  For this qualitative study, focus group discussions and interviews were conducted between February 1 and April 30, 2018, among 26 PCPs (physicians, nurse practitioners, and physician assistants) at a US academic medical center with a network of 15 primary care clinics. Participants were asked about factors contributing to burnout and barriers to professional fulfillment as well as potential solutions related to workplace culture and efficiency, work-life balance, and resilience.

Main Outcomes and Measures  Perceptions of the factors contributing to burnout and low professional fulfillment as well as potential solutions.

Results  A total of 26 PCPs (21 physicians, 3 nurse practitioners, and 2 physician assistants; 21 [81%] women) from 10 primary care clinics participated. They had a mean (SD) of 19.4 (9.5) years of clinical experience. Six common themes emerged from PCPs’ experiences with burnout: 3 external contributing factors and 3 internal manifestations. Participants described their workloads as excessively heavy, increasingly involving less “doctor” work and more “office” work, and reflecting unreasonable expectations. They felt demoralized by work conditions, undervalued by local institutions and the health care system, and conflicted in their daily work. Participants conveyed a sense of professional dissonance, or discomfort from working in a system that seems to hold values counter to their values as clinicians. They suggested potential solutions clustered around 8 themes: managing the workload, caring for PCPs as multidimensional human beings, disconnecting from work, recalibrating expectations and reimbursement levels, promoting PCPs’ voice, supporting professionalism, fostering community, and advocating reforms beyond the institution.

Conclusions and Relevance  In sharing their perspectives on factors contributing to burnout, frontline PCPs interviewed during this study described dissonance between their professional values and the realities of primary care practice, an authority-responsibility mismatch, and a sense of undervaluation. Practitioners also identified possible solutions institutions might consider investing in to resolve professional dissonance, reduce burnout rates, and improve professional fulfillment.

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