Study participants included 27 primary care physicians and nurse practitioners from across the USA. Participants worked in a range of practice settings and rural-urban-suburban locations. Participant characteristics are listed in Table 1.

1.

Clinician Experiences with Burnout

Table 1 Participant Characteristics (N=27)

Clinicians shared their experiences over the last few years, with key themes centering on increased mental health challenges involving professional burnout, exposure to trauma, and moral injury. Key themes and corresponding quotes are provided in Table 2.

Table 2 Themes and Examples of Supporting Quotes

“Anxiety, COVID, burnout and now depression,” was how one physician described her experience. “It’s not a doctor’s natural inclination… [to say to yourself] ‘you’re burned out.’ I think it’s really the events over the last three years, since COVID that tipped me over the edge.” She then opened up about her mental health struggles, “I personally developed clinical depression about a year and a half ago, the first time in my life, and it sort of spiked again this summer, and that is the result of burnout” (MD55-64F#18). Another physician, who was in her second year of residency during the pandemic, explained, “I was right on the front lines doing ICU care and holding people’s hands at the end of life. It was horrible!” (MD25-34F#11). Other clinicians described pre-COVID-19 experiences with mental health challenges in which they had to “revisit” a counselor during the pandemic, because as one physician described, “the pain has just been so bad” (MD65+M#7), as a result of losing patients to COVID-19.

Other participants described experiencing moral distress or moral injury resulting from organizational policies or operating procedures that do not align with quality patient care or work-life balance. One physician from a healthcare system stated, “I have a ton of patients who I know exactly what they need, but I don’t have the resources or time to provide it” (MD35-44M#19). Others attributed emotional harm to system-level factors such as a disconnect between fee-for-service reimbursement models and quality patient care. One physician reflected on the system as “an industry that is treated like you’re buying clothes or groceries when you have to treat the patient or else they will die” (MD25-34F#11).

Despite the high number of clinicians in our study who described their struggle with burnout and other mental health challenges, most participants also displayed a sense of hopefulness and optimism. One physician stated, “I recognize now that I’m burned out and I’m trying to take steps because I still see myself practicing medicine for the next ten years, and I want to be happy doing that” (MD55-64F#18).

2.

Contributors of Burnout and Stress

Clinicians in our study shared their perspectives on the largest contributors to burnout, which included inefficiencies with electronic health record (EHR) systems, high levels of documentation, increased expectations for communicating with patients outside of visits, and increased workload due to staffing shortages and productivity requirements. These issues often required clinicians to work after clinic hours.

Many clinicians attributed the EHR as one of the main causes of burnout in primary care. One clinician explained, “It's been a very painful process over the last twenty years, and I absolutely think the electronic medical record leads to burnout” (MD55-64F#18). This viewpoint was shared by the majority of clinicians aged 55 years and older, while younger clinicians often described the EHRs as a “double edged sword” that has both good and bad characteristics. Most clinicians under the age of 55 described positive traits of EHRs and other digital technologies that help these clinicians treat patients. All participants, however, described the inefficiencies of their EHR systems and made comments such as “death by a thousand clicks” (MD55-64F#23) and “numerous hard stops” (MD55-64M#9). Most clinicians, regardless of age or provider type, described the need to work after clinic hours to complete medical record documentation. Many clinicians also shared their frustrations over the increasing volume of patient emails, texts, and telephone calls they receive.

Other commonly reported difficulties during the COVID-19 pandemic were increased workload and increased staffing issues as a result of shortages of providers, nurses, and administrative staff. Numerous participants described an increased demand from their healthcare delivery system for primary care clinicians to see more patients during the pandemic. As one physician stated, “[They’re] trying to fix some of the financial shortfall from the health system by telling clinicians to see more patients… And then they’re surprised. People burnout or leave” (MD45-54M#20).

There were also a number of issues discussed by clinicians in our study that were not widespread, yet deserve mention. Several clinicians described feeling undervalued by their health system because of the lack of inclusion in decision making, high workload, or low compensation.

3.

Recommended Strategies to Address Burnout and Stress

Clinicians in our study described a range of strategies with how to address burnout and mental health challenges experienced themselves or by other health professionals in their practice. The most commonly discussed strategies were at the organizational level and included enhancing the use of team-based care models, optimizing EHR functions, and increasing institutional awareness and recognition of the issues surrounding burnout. Many participants also identified the need for additional administrative time to complete medical record documentation.

Preventive strategies were discussed by one clinician in an independent practice. This physician described her efforts to create a culture of well-being and prevent burnout among clinicians, stating, “Wellness and anti-burnout measures have been a priority of my practice since the day we were founded. We’ve made a lot of decisions, which you know cost money and resources, but we feel it’s really important that we direct our funds in this way to prevent burnout of our providers” (MD55-64F#18). These strategies included hiring a national call system that uses telephone triage to address 90% of patient needs after hours. Practice scheduling policies allow 60 min for annual wellness visits and 30 min for regular exams to ensure clinicians have enough time to address patient concerns and provide quality patient care. The practice also has dedicated NPs that cover other clinicians’ patients during their days off. As a result of recent provider feedback, the practice now allows clinicians to work from home one day a week to conduct telehealth patient visits.

Many clinicians discussed the need for health system leaders to recognize issues with burnout and to make sincere efforts to enhance work-life balance and create a culture of health and well-being. This includes supportive leadership and accessible mental health services along with time away from work to access these services. One young physician noted that what helped her during the pandemic was to have colleagues check in and ask, “How are you feeling about this? If you need to take a mental health day or something… it is okay” (MD25-34F#21). Along with the notion of work-life balance, several clinicians mentioned a need for time off with someone covering their patients.

At a systems level, most clinicians discussed the need for reducing administrative burden associated with billing requirements and quality reporting. Several physician participants also described the long-standing professional culture in medicine that supports long-working hours and personal sacrifice, which they suggested needs to change to center on clinician health and well-being. One physician stated “I don’t think that American culture is very good at promoting work-life balance. Then, on top of that, the medical culture glorifies martyrdom” (MD45-54M#10).

Few participants in our study mentioned strategies at the individual level to address burnout. Several clinicians, however, indicated a high level of professional satisfaction in their role as a primary care provider and a deep connection between their work and the mission of the organization as conditions that help them overcome stressful situations. As one provider explained, “I really love our clinic… We’re all very unified in our mission, and who we’re serving, and that helps a ton” (NP35-44F#4). While no clinicians indicated an intention to leave their current practice, there were three female clinicians who explained their previous struggles with burnout and the difficult decision they made to leave their practice and start new positions that offered more autonomy, flexible working arrangements, and opportunities to provide better patient care.