How to reduce primary care physician burnout

Originally published in MedPage Today

by Todd Neale, MedPage Today Staff Writer

Primary care physicians who took part in a continuing medical education program emphasizing reflection about their clinical experiences reported improvements in burnout and mood, researchers found.

The participants also indicated positive changes in empathy and psychosocial beliefs, suggesting a more patient-centered approach to care, according to Michael Krasner, MD, of the University of Rochester in N.Y., and colleagues.

The program centered on improving physicians’ mindfulness, or the state of being fully attentive, when interacting with patients.

Krasner and his colleagues thought such a program would combat burnout, which they characterized as emotional exhaustion, depersonalization, and a feeling that work is not meaningful in the Sept. 23/30 issue of the Journal of the American Medical Association.

They said “the skills cultivated in the mindful communication program appeared to lower participants’ reactivity to stressful events and help them adopt greater resilience in the face of adversity.”

Still, they said in recognition of the nonrandomized nature of the intervention, “further study will be necessary to investigate the effects on practice efficiency, patients’ experience of care, and clinical outcomes.”

Burnout affects up to 60% of physicians, according to the researchers, and it has been associated with poorer quality of care, decreased patient satisfaction, increased medical errors and lawsuits, a reduced ability to express empathy, and a variety of personal problems.

Although the problem is well known, they said, few interventions for preventing it have been tested.

So the researchers tested an intervention designed to improve physician well-being through enhanced mindfulness.

The CME course involved an eight-week intensive phase comprising a weekly, 2.5-hour session followed by a seven-hour retreat. Physicians learned techniques of mindfulness meditation, narrative medicine, and appreciative inquiry aimed at increasing attention and awareness.

The initial phase was followed up with a 10-month maintenance phase consisting of a monthly 2.5-hour session.

Seventy physicians from the Rochester area participated and completed a mean of 33.6 out of a possible 52 hours.

Based on the results of self-administered surveys, there was overall improvement in several domains from baseline to the 15-month follow-up.

The largest effect sizes occurred for measures of mindfulness (P<0.001).

Improvements with medium effect sizes occurred for all three measures of burnout: emotional exhaustion, depersonalization, and personal accomplishment (P<0.001 for all).

In addition, there were significant gains made in empathy (P<0.001) and on the physician belief scale (P=0.001), "suggesting a shift toward greater value placed on understanding the patient's emotional and social life in addition to disease-related factors," the researchers said.

There was small to moderate improvement in several aspects of mood -- total score, depression, anger, fatigue, and vigor -- as well as two personality factors, conscientiousness and emotional stability (P<0.001 for all).

Several short-term improvements did not persist, including indicators of physician empathy, mood states and personality factors such as extraversion, agreeableness, and openness.

The positive changes in mindfulness were significantly correlated with gains in total mood disturbance, which combines six different mood elements(P<0.001 for all), suggesting a benefit from the intervention.

Even so, the researchers said, "because before-and-after designs limit inferences about intervention effects, these findings warrant randomized trials involving a variety of practicing physicians."

Aside from not being a randomized controlled trial, the study had several limitations, according to the researchers, including the use of physicians from a single location.

Also, the participants were more likely to be family physicians or to practice in rural areas compared with nonparticipants.

The investigators were unable to track how improvements over time affected clinical care, nor could they establish that the improvements were caused by intervention.

They also noted a potential lack of generalizability.

"We conducted the course in a single location, with experienced course facilitators. Even though this might appear to limit generalizability, instructors of mindfulness-based courses are becoming more available; fees for eight-week programs may range from $450 to $600."

Despite these limitations, Tait Shanafelt, MD, of the Mayo Clinic in Rochester, Minn., called the results "striking" in an accompanying editorial.

He said physicians will face new challenges as the healthcare system is reformed in the coming years, and with them will come an increasing risk of burnout.

"Although many physicians may be tempted to respond to this challenge by retreating from work ... the study by Krasner and colleagues demonstrates that training physicians in the art of mindful practice has the potential to promote physician health through work," he said.

"Helping [physicians] recognize and enhance the meaning they derive from the practice of medicine may help protect against burnout and promote patient-centered care for the benefit of both physicians and their patients."

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