Primary care physicians in small, independent practices are substantially less likely than their peers in hospital settings or large primary care practices to experience symptoms of burnout, new data show. Among 235 providers practicing in 174 small, independent practices in New York City, just 13.5% reported symptoms of burnout. By contrast, the rate of burnout among physicians nationally is estimated to be 54.4%, Batel Blechter, a PhD student at New York University School of Medicine, and colleagues report in the July-August issue of the Journal of the American Board of Family Medicine. Smaller practice settings afford providers more independence and autonomy, which may partially explain the improved psychological well-being of these professionals, according to senior author Donna Shelley, MD, MPH, an associate professor of medicine and population health, vice chair for research, and codirector of the Section on Tobacco, Alcohol and Drug Use in the Department of Population Health at New York University School of Medicine. Although solo practitioners and small group practices face significant challenges in view of mounting operating costs, diminishing reimbursements, and expanding legislative mandates, "these providers have more control over their work environment, which we know is associated with job satisfaction, productivity and quality of care," Shelley said in an interview with Medscape Medical News. Additionally, Shelley continued, practicing in these smaller settings may promote the type of professional culture and camaraderie that enhances physician resilience, which has been shown to offer protection against burnout. Because burnout among physicians working in small independent practices has not been well characterized, Blechter and colleagues sought to assess burnout levels in this population, as well as practice and provider characteristics that might influence burnout. Using baseline physician survey data from an ongoing trial designed to evaluate external factors that contribute the adoption of clinical practice guidelines in small, independent primary care practices in New York City, the investigators assessed provider burnout with a single-item measure that has been validated against the Maslach Burnout Inventory. Providers who chose one or more of these responses met the study criteria for burnout: "I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion," "The symptoms of burnout that I'm experiencing won't go away. I think about frustrations at work a lot," and "I feel completely burned out and often wonder if I can go on practicing. I am at the point where I may need some changes." ''Of the small practices represented in the study, 66.9% were solo provider practices and 46.5% were recognized as patient-centered medical homes. The study sample included 204 physicians and 31 nurse practitioners or physician assistants. Across the study population, 13.5% of the providers responded affirmatively to one of the burnout indicator statements — a "remarkably low" rate compared with the physician burnout rate reported in previous studies, the authors write. In bivariate analyses looking at associations between burnout and practice and provider characteristics, only a higher adaptive reserve score, which assesses providers' perception of practice leadership, communication practices, trust, teamwork, collective efficacy, and culture of learning, was associated with lower odds of burnout (odds ratio, 0.12; 95% confidence interval, 0.02 - 0.85; P = .034). Other practice-related variables considered that were not associated with burnout included the number of providers, medically underserved area designation, patient-centered Medical Home status, and performance on the Change Process Capacity Questionnaire, which is a measure of practices' quality improvement strategies. In addition, neither the number of years a provider worked in the participating practice nor the hours worked per week was associated with burnout. Considering that nearly 70% of the providers in the study were solo practitioners, a possible explanation for the relatively low burnout rate could be the autonomy associated with owning one's own practice, the authors hypothesize. Providers working in larger, integrated health systems and Federally Qualified Health Centers are subject to greater administrative regulations and have less control of their work environment. This hypothesis is consistent with previous studies linking low levels of autonomy to an increased risk for burnout and indicating that smaller practices offer more provider autonomy, the authors explain. The association in the current study between higher adaptive reserve and lower levels of burnout is also consistent with previous studies and may have important practice implications. "The relationship between adaptive reserve and provider burnout suggests that interventions to reduce burnout in primary care practices should focus on strengthening factors that support organizational capacity for change (i.e., strong communication, leadership supports innovation)," the authors write. "These factors may manifest differently in [small independent practices (SIPs)] as compared to larger systems but may be just as important in influencing provider burnout." Although subject to some limitations, including the reliance on data collected from practices in New York City, which may limit the generalizability of the findings to small practices in other regions, and the exclusion of provider demographic information that may have influenced outcomes, "this study adds new information about factors that may impact burnout among providers practicing in SIPs," the authors write. "Future research is needed to better define the complex relationships between individual and organizational factors, including adaptive reserve, and provider burnout and how these factors impact patient outcomes in SIPs." Source
