Bianca Frogner is the Director of the Center for Health Workforce Studies, Deputy Director of the Primary Care Innovation Lab and Professor of Family Medicine at the University of Washington School of Medicine. As a health economist, she studies issues at the intersection of health workforce, technology and reimbursement.

Burnout among primary care providers (PCPs) has long been a concern in medicine. PCPs are often paid less than other specialists, have to deal with enormous amounts of administrative tasks that take away from patient time, and often (though increasingly rarely) own their own practices, adding the burdens and stresses of a small business owner. COVID-19 unsurprisingly exacerbated these stressors, and even as cases decrease, an ongoing survey of PCPs finds high levels of stress and burnout combined with workforce and workload challenges well over a year into the pandemic. There may be long-term consequences for clinician recruitment and retention and ultimately patient care if we do not have a robust health workforce.

A recent study in Health Affairs brings a new perspective on clinician burnout in primary care. A multi-institutional team of researchers led by Samuel Edwards examined the concept of “zero-burnout practices” in an effort to shift the narrative away from burnout being an individual clinician’s problem to a structural problem experienced by an organization. The researchers looked at survey data collected between 2015 and 2017 that used standardized tests to measure clinician and staff burnout and workplace culture at 1,495 small-to-medium-sized primary care practices. Practices were divided into two groups based their survey responses: 1) “zero-burnout practices” where no clinical and non-clinical staff reported burnout (30%) and 2) “high-burnout practices” where 40% or more of surveyed practice members reported burnout (13%); those in the middle were excluded. 

While they can’t demonstrate any causal links, Edwards and colleagues found several significant differences between zero-burnout and high-burnout practices. Zero-burnout practices were more likely to be solo or clinician-owned practices as opposed to larger and/or hospital-owned practices. They also had significantly higher odds (2.5 to 6 higher) of scoring well on the workplace culture test, which measures practice characteristics that support resilience, also referred to as adaptive reserve. Staff at zero-burnout practices were much more likely to say their workplaces were places of joy and hope where people seem to enjoy their work, and that their leaders promote an enjoyable work environment and a sense of accomplishment. Perhaps surprisingly, characteristics often associated with burnout (such as large patient volume, greater Medicaid patient load, and EHR capabilities) were not significant predictors in this study. 

These findings by Edwards and colleagues suggest that burnout is a structural issue that can and should be addressed at the organizational level. To prevent burnout, the authors argue we need to move away from the “victim blaming” that expects clinicians to resolve burnout on their own. Instead, we should consider supporting practice-level interventions — like investments that would give practices the flexibility to develop the leadership and culture of change the authors found to be associated with zero-burnout practices and supported by a recent National Academies of Medicine report — and then evaluate how these investments translate to patient care. Doing so may help us emerge from the pandemic with a stronger and more resilient primary care system.