Physicians Identify Professional Dissonance as a Cause of Burnout

Primary care providers (PCPs) may experience a high prevalence of burnout and low level of professional fulfillment. Recently, Sumit D. Agarwal, MD, a PCP at Brigham and Women’s Hospital, Boston, and colleagues sought to identify contributors to this burnout. Focus groups and interviews revealed a dissonance between professional values and the realities of primary care practice as the main contributor to burnout. Other causes of burnout included a mismatch between authority and responsibility, and a sense of undervaluation.

However, the focus groups went further, identifying institution-based solutions that may resolve the professional dissonance, reduce burnout rates and improve professional fulfillment. The findings of the qualitative study were published online Jan. 6 in JAMA Internal Medicine.¹

Although the study focused on PCPs, Dr. Agarwal believes the findings also apply to rheumatologists, because rheumatology—like primary care—is a cognitive-based specialty. In many ways, rheumatologists act as PCPs for their patients.

Focus Groups
The study included 26 PCPs (21 physicians, three nurse practitioners and two physician assistants) from a single urban academic medical center. The participants (81% women) came from 10 primary care clinics and attended at least one of the four focus group discussions or at least one of two interview sessions. They had a mean of 19.4 years of clinical experience.

The focus groups identified six qualitative themes that contributed to burnout, three of which were external factors and three of which were internal manifestations. The external factors were described as increasingly heavy workloads, days that involved less doctor work and more office work, and unreasonable expectations. The PCPs reported they found themselves increasingly doing more office work, such as charting for billing, fielding electronic messages and processing paperwork. The situation was made worse by the fact that the scope of their responsibilities in caring for patients also continued to grow. Additionally, participants felt they did not have authority over their work, meaning they lacked the resources to handle the increasing demands and lacked the ability to say no to those demands.

Internal manifestations of burnout included demoralization from working conditions, a sense of being undervalued by local institutions and the healthcare system, and a feeling of internal conflict in their daily work. The participants’ demoralization stemmed from the sense that the job was never actually completed at the end of the day. This feeling was made worse by their sense that their salaries did not accurately reflect their daily work. Reinforcing this feeling of being undervalued was the lack of boundaries around responsibilities, insufficient communication with leadership and specialists, and inadequate acknowledgement of the difficulties of primary care. The internal conflict presented itself as recurrent dilemmas between “doing what’s right for the patient” and “having to bill insurance or see X number of patients.”