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.”

Professional Dissonance
Dr. Agarwal says, these factors can be described as professional dissonance, which he defines as the “psychological discomfort or stress when your values as a physician conflict with the values of the setting in which you work.”

The term fits Dr. Agarwal’s own experience as a PCP. But he was originally surprised when he realized the focus group discussions were crystalizing around the idea that the healthcare system is built on misaligned values. Essentially, the focus groups told the researchers their burnout results from being on the frontline of absorbing that dissonance.

Unfortunately, according to Dr. Agarwal, many healthcare providers experience professional dissonance, and he feels the conflict between the values of the profession and the values of the system “should raise some alarm, and not just in primary care physicians.”

One example he cited was that physicians value staying up to date with medical literature. “We need to align the system better with our professional values,” he adds. “We need to increase reimbursement for cognitive-based care.”

Solutions
The authors suggest that institutions actively engage PCPs in the development and implementation of solutions to burnout. In the focus groups, the PCPs suggested eight solutions: managing workload, caring for PCPs as multidimensional human beings, disconnecting from work, recalibrating expectations and reimbursement levels, promoting PCPs’ voices, supporting professionalism, fostering community and advocating reforms beyond the institution.

Of these solutions, workload reduction was the primary recommendation made by participants. According to the participants, workload reduction solutions could include reevaluating the relative value unit targets that place unreasonable productivity demands on healthcare providers and hiring more nursing support, especially registered nurses. However, they emphasized that any decision to hire more staff should not hinge on the expectation that PCPs pay for the expense by increasing the number of patients seen. Efforts should be made to free up time for physicians and provide physicians with support for professional development, such as stipends.

The focus groups also identified a desire for flexible work schedules and family-friendly policies to facilitate a healthier work-life balance. These modifications could be supplemented by initiatives that enable PCPs to disconnect from work after hours, during vacation and on sick days.

Lara C. Pullen, PhD, is a medical writer based in the Chicago area.

Reference

1. Agarwal SD, Pabo E, Rozenblum R, et al. Professional dissonance and burnout in primary care: A qualitative study. JAMA Intern Med. 2020 Jan 6. [Epub ahead of print]