Do smaller, independent practices have happier doctors?

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This article is sponsored by Careers by KevinMD.com.

Physician burnout is not a novel topic within the health care industry. Numerous studies have been done on the increasing prevalence of its symptoms — from emotional exhaustion and loss of empathy to doubt that one’s work even makes a difference — among today’s practitioners. In fact, a recent survey polled more than 15,000 physicians from 29 specialties and found that 42 percent reported feelings of burnout.

Several of the specialties reporting the highest levels of burnout were within the realm of primary care and included family medicine (47 percent), obstetrics and gynecology (46 percent) and internal medicine (46 percent). Does this mean choosing to practice primary care unavoidably increases your likelihood of eventual burnout? Not exactly — especially if you work within a small, independent practice.

Study author suggests autonomy may be the key to lower burnout rates

study led by researchers at the NYU School of Medicine and published in the online Journal of the American Board of Family Medicine examined levels of burnout among 235 physicians practicing in 174 small, independent primary care practices in New York City.

Among these physicians, the study authors found an astonishingly low level of burnout: a mere 13.5 percent compared to 54.4 percent (the national average in 2014). But why?

“We had to go back to the qualitative data to figure this out,” says Donna Shelley, M.D., senior study author, and professor in the Departments of Population Health and Medicine at NYU Langone Health. “That’s always where the answers really are.”

When the researchers sat down with their subjects, they discovered that a lot of them actually had the same complaints as non-independent doctors who work within health care systems.

“They had complaints about electronic health records and reimbursement rates,” Shelley continues. “And because they’re actually running their own business, you would think that would lead to some serious stress and subsequent burnout. But somehow whatever control they had over their practice as a result of remaining independent seemed to be related to that low burnout rate.”

Shelley says that the physicians who participated in the study valued the autonomy they had as independents and the ability it gave them to practice medicine the way they wanted and where they wanted.

“Many of these doctors were immigrants and practiced within the communities in which they lived,” Shelley explains. “Many spoke more than one language and attracted a lot of bilingual and non-English-speaking immigrants. They were really committed to their communities and were the kind of old-fashioned docs who see a patient from cradle to grave. Many had taken care of generations of the same family. That is very fulfilling. Doctors mostly go into medicine to take care of people. That’s their mission.”

Shelley says that it’s important to note that the small, independent primary care practices included in the study were well-supported by the city health department. “Their burnout rate could potentially be lower because the city health department identified them years ago as serving a large number of Medicaid and underserved populations and has been helping them with electronic health records and quality improvement,” she adds.

So, what can the health care industry do to improve burnout rates among physicians in general?

Shelley says, “We should look into sites that are actually happier and try to understand the secret sauce. What is it about these small, independent practices that create a lower level of burnout even though they are under tremendous stress to deal with this challenging environment regarding reimbursements and financial security and sophisticated use of the electronic health record to document quality improvements? Despite all of that, they seem to be happier.”

She suggests health care systems start by finding ways to give their physicians a greater sense of autonomy. “We have a project here at NYU where we provide small amounts of money to individual clinicians or teams of clinicians so that they can innovate in an area where they see a need for change,” Shelley explains. “Theoretically, it should improve burnout rates. These physicians are being given funds and space to act autonomously and make changes.”

Shelley adds that she’s looking forward to further research into factors that drive lower burnout rates. “I’ve been moved by the doctors I’ve met,” she says. “It has given me a lot of hope for the future of medicine.”

AID suggests restoring the doctor-patient relationship may also help reduce burnout

As Shelley noted earlier, practicing as an independent physician is not without its stresses — and not all independent doctors have a well-funded city health department providing them with support. But that doesn’t mean you’re totally on your own if you’d rather not work within a health care system. Independent practice associations, like the Association of Independent Doctors (AID), are working to educate patients, insurance providers and the government about the importance of independent physicians as well as looking out for their best interests.

“The Association of Independent Doctors was founded in 2013 to give independent doctors a collective voice,” explains executive director Marni Carey. “While hospitals are fantastic at marketing their physicians, independent doctors were sort of dying on the vine because they didn’t have the time, resources, clout or skills to do that sort of PR work for themselves. We stood up to speak out on behalf of independent doctors and explain to businesses, lawmakers, and consumers why it’s so important that they remain so.”

Carey says AID has five mission statements including promoting transparency in pricing, stopping the consolidation of hospitals and medical groups, working with insurance companies on payments, educating patients and helping doctors remain independent. “We’ve had over 1,000 doctors become members of AID, and we’re in 33 states,” she adds.

Carey agrees with Shelley’s hypothesis that greater autonomy could reduce physician burnout rates among doctors in general.

“It’s certainly one of the biggest benefits of practicing as an independent doctor,” she says. “Being able to make decisions that are strictly about the patient and what you think is best for the patient without having to try to make your employer happy as well. When hospitals employ doctors, I think that allegiance shifts from the patient to the employer who is measuring productivity, even though doctors don’t want it to.”

“Doctors who work autonomously in small practices have a say in how things are run,” Carey continues. “They can be decision makers. After all, doctors are naturally gifted people. Most of them are pretty sharp. They want a say in how their day goes and how the practice is run. If that means they can only see 15 patients a day and do a great job, rather than see 35, they get to make that decision.”

She also notes that she regularly hears that doctors would be happier if they could restore the integrity of the patient-doctor relationship.

“They want it to be about the two people who care most about the patient, which is the patient and the doctor,” Carey says. “The hospital doesn’t care. The government doesn’t care. They’re just trying to make the money work out. Doctors don’t want to be exploited. They don’t want everybody making money off of their backs, which is unfortunately what is happening.”

Angela Rose is a writer, Careers by KevinMD.com.

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