Physician Burnout Tied to Higher Referral Rates (Will Boggs)

Disponível em: http://www.medscape.com/viewarticle/813989?src=emailthis

By Will Boggs, MD

NEW YORK (Reuters Health) Nov 07 - Burnout among primary care physicians is associated with increased referral rates for diagnostic tests and specialists, researchers from Israel report.

"I was not at all surprised by the results, because they are related to my previous findings," Dr. Talma Kushnir from Ben-Gurion University of the Negev in Beer-Sheva told Reuters Health. "In that study that was based on self-reports, we found that family physicians with high burnout tended to talk less with their patients and refer them more to laboratory and diagnostic tests and to consultations with specialists, compared with family physicians with low levels of burnout."

"The strength of the present study is that it is based on objective data regarding referrals," said Dr. Kushnir, whose findings were published online October 22 in Family Practice.

Dr. Kushnir and colleagues interviewed 136 primary care physicians, assessed burnout using the Maslach Burnout Inventory (MBI), quantified their workload, and used data from their HMO to calculate referral rates. For referrals, they counted expensive/high-cost diagnostic imaging tests, inexpensive imaging tests, nurse treatments, and specialist referrals.

Sixty (44.5%) physicians reported high levels of emotional exhaustion, 49 (36%) had high levels of depersonalization, and 43 (31.6%) reported low levels of personal accomplishment.

Just over half (76, 56%) of the physicians reported high burnout levels (defined as emotional exhaustion scores of at least 27 and/or average depersonalization score of 10 or more).

There were significant positive associations between overall burnout score and referrals for diagnostic tests and specialist clinics. Moreover, the higher the objective workload, the higher the rate of referrals.

Board-certified specialists made more referrals than non-board-certified specialists.

In multivariate analyses, the final model explained 18.1% of the referral rate variance, with board-certified specialist mostly strongly associated, followed by burnout and objective workload. Path analysis confirmed the independent influence of these three factors on referral rates.

"While we did not study expenditure directly, clearly, any excess referrals, especially those to expensive imaging tests, would be translated to increased costs to the health care system, which makes the subject of burnout a highly important issue," the researchers say.

"Physician should be aware that burnout and associated negative moods may significantly affect one's behavior, decision making, and work performance," Dr. Kushnir said. "This means that the quality of patient care may also be affected by burnout. Given findings in recent studies that burnout also affects health (e.g., risk factors for cardiovascular disease) and may even become a chronic condition, then it is important, for the sake of both the physician and patients, to prevent rather than ignore it."

"My experience in research on burnout has led me to conclude that the absence of positive job features (e.g., absence of control, lack of recognition for one's work, inability to utilize your skills) is probably more important in causing burnout than the presence of negative characteristics such as work over-load and over-demanding patients," Dr. Kushnir said. "This means that that in order to prevent undue stress and burnout, it may be more productive to capitalize on increasing the positive features of the job than to attempt to reduce the negative one."

Dr. Jerry Stein, who was not involved in the new research, has studied burnout in pediatric oncologists. "We have been sweeping this problem under the rug for too many years, and I hope that our efforts will stimulate others to find creative solutions to the problem of staff burnout," he told Reuters Health by email.

"If you are feeling burned out, your colleagues and coworkers probably feel the same way," said Dr. Stein, from Schneider Children's Medical Center of Israel in Petach Tikva. "Use them as your support system, and encourage your division leaders to help develop programs to heighten awareness of this problem."

Dr. Alan H. Rosenstein, medical director of Physician Wellness Services in San Francisco, California, offered some suggestions for curbing burnout: "First is the recognition that it's a serious issue that involves a large percentage of physicians. Second is to get through the barriers of (1) admitting that they are under stress and it shows ('I'm not stressed'), (2) they won't be able to take care of it themselves ('I've been under stress throughout my entire academic career and I can handle it'), (3) Accepting outside help (concerns about confidentiality, threats to their competency, or punitive ramifications), (4) Making it a priority ('Yes, I think I need to have a better work-life balance'), and (5) Doing it."

"Most physicians can't or won't act on their own," Dr. Rosenstein said. "They're too busy. The organizations they work for need to take a pro-active approach in helping. They can help by addressing issues related to improving organization stress (culture/ scheduling/ work loads/ productivity demands), behavioral stress (time management/ stress management/ conflict management, diversity management), and emotional stress (counseling), and do what they can to promote 'wellness' through education, facility support, Wellness Committees, or a Physician Employee Assistance Program."

SOURCE: http://bit.ly/1hmjvOh

Fam Pract 2013.