Workplace Factors Associated With Burnout of Family Physicians

Burnout is on the rise, with over half of US physicians reporting at least 1 symptom in 2014.¹ Physician burnout has negative impacts on both physician well-being and patient care.¹ 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.² Our purpose was to examine burnout in a national sample of board certified family physicians.

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.³ One of these was the Mini Z survey.² We assessed burnout with a single item that correlates with the emotional exhaustion subscale of the Maslach Burnout Inventory.²

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.

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).

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.

In a national sample of family physicians, 25% reported symptoms of burnout, which is substantially lower than estimates using the Maslach Burnout Inventory (63%)¹ but is closer to estimates of academic general internists (38%) using the Mini Z.² 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,⁴ our findings concur with others that the tasks required for EMR use are associated with burnout, not the EMR itself.⁵ This disproportionate time documenting may decrease the potentially protective benefits of patient contact.⁶

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.

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.

Corresponding Author: Monee Rassolian, MD, North Park Medical Center, 2355 Keele St, Toronto, ON M6M 4A2, Canada (mrassolian@hotmail.com).

Accepted for Publication: February 17, 2017.

Published Online: May 8, 2017. doi:10.1001/jamainternmed.2017.1391

Author Contributions: Dr Peterson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Rassolian, Peterson, Mainous.

Acquisition, analysis, or interpretation of data: Rassolian, Peterson, Baxley, Knight, Peabody, Fang.

Drafting of the manuscript: Rassolian, Peterson, Mainous.

Critical revision of the manuscript for important intellectual content: Rassolian, Peterson, Baxley, Knight, Peabody, Fang.

Statistical analysis: Rassolian, Peterson, Peabody, Fang.

Administrative, technical, or material support: Peterson, Baxley, Knight.

Study supervision: Rassolian, Peterson, Mainous.

Conflict of Interest Disclosures: Drs Peabody and Peterson are employees of the American Board of Family Medicine Foundation. No other disclosures are reported.

Additional Contributions: Thomas R. O’Neill, PhD, and James C. Puffer, MD, from the American Board of Family Medicine and Andrew W. Bazemore, MD, MPH, from the Robert Graham Center, contributed to the conception of this project. They were not compensated.