Q&A: Professional dissonance drives burnout in PCPs
A recent survey of PCPs revealed that dissonance between their professional values and the realities of primary care practice was a major contributor to burnout. Results from the survey were recently published in JAMA Internal Medicine.
Along with identifying factors that contributed to burnout, physicians who were surveyed also made suggestions for potential solutions specific to PCPs, including restructuring PCP reimbursement to account for time spent working outside of patient visits and efforts to promote communication between PCPs and specialists.
Although the survey only included PCPs from one institution — Brigham Health — “the themes and suggested strategies will resonate across different practice settings,” Richard W. Grant, MD, MPH, a research scientist at Kaiser Permanente, and Lara Goitein, MD, a pulmonologist at Christus St. Vincent Regional Hospital, wrote in an editorial published alongside the findings.
Karen Sherritt, MD, an assistant professor of medicine at Harvard Medical School, and one of the study’s researchers, spoke with Healio Primary Care about the themes of burnout identified in the survey, professional dissonance and potential solutions for PCP burnout. – by Erin Michael
Q: What are the main factors PCPs identified as contributors to burnout?
A: PCPs identified six themes of contributors to burnout. They also described professional dissonance as a broader unifying theme that is reflected in each of the six themes. The themes include workload, content of work, authority/responsibility mismatch, a sense of demoralization, feeling undervalued, and feeling conflicted. Authority/responsibility mismatch is something that we think may be particular to PCPs. Participants felt many tasks seem to be funneling down to them. Oftentimes, these are poorly functioning system issue or undesirable tasks that they do not feel they have the resources to handle or the authority to say “no” or draw boundaries on. A lot of them described how specialists are sending refills and prior authorizations to the PCPs to take care of. They described how staff and other departments tell them “PCPs must do that,” and they describe many patients calling them to problem-solve when they do not get responses from the specialist’s office or if they are unable to get appointments in a timely fashion. They described how patients are using the email system 24/7, and some use it very frequently and expect instant responses. Many felt “dumped on” by the system. Despite these increasing responsibilities, they felt their authority over their work life was decreasing.
Under the sense of demoralization, [PCPs] felt that issues like inadequate electronic record support and sensing that the business side of things has become more important than the medicine side of things are demoralizing to them. Some also mentioned that punitive rules, like rules for closing notes or meeting population health metrics, are also contributing to feeling demoralized by the working conditions.
Feeling undervalued, they described that they are doing more work that is unacknowledged and uncompensated, and if it is not compensated, then it is not valued. They brought up discrepancies between compensation for procedural vs. cognitive specialties, and some of them mentioned the issue of lack of boundaries between PCPs and specialists as all contributing to why they feel undervalued by the system.
Finally, PCPs are feeling conflicted throughout the day. No one actually told us “I’m conflicted,” but we heard story after story of conflict. Some of these conflicts were “I want to connect with my patient, but I have to look at the computers so that I don’t get behind in my notes;” or “I just want to take a lunch break, but I don’t have time to do it.” Some also raised conflicts about work and home life, saying that when they get home, they want to spend time with their family, but they feel that they need to get back on the computer to finish important tasks. After stepping back and looking at all the data, there was a unifying theme of professional dissonance, which was reflected in all the stories that we heard.
Q: What is professional dissonance, and how does it lead to burnout in PCPs?
A: This can be defined as a condition when the values that brought PCPs into the profession are in conflict with the values of the larger health care delivery system they are working in. Professional dissonance has its foundation in social psychology. Leon Festinger, PhD, developed the cognitive dissonance theory in 1957, and later contributions were added by his student Elliot Aronson, PhD. The theory states that when a human has two conflicting thoughts, or conflicting thought and behavior, it creates a stress and what they call a negative drive state — like thirst or hunger — which motivates the person to do something to lessen the conflict or stress. This could be happening consciously or subconsciously. Professional dissonance can be described as occurring when the values and cultural norms of a profession are in conflict with the values or required tasks of the system the professionals are working in. It was first described in social workers by Melissa Floyd-Pickard, PhD, in 2005 and 2007. Our practitioners and clinicians gave many examples of these value-conflicts. For instance, while clinicians highly value caring for patients, they find themselves needing to address productivity demands instead, which are often times in competition with taking care of patients due to short appointment times. While they value autonomy, they find that they are being managed by others. While they see medicine as an art and science, they are experiencing medicine as a business.
Regarding ways that professional dissonance can lead to burnout, I believe there are at least two mechanisms, and more study is needed on this. The first is that dissonance represents a conflict and stressor that can lead to anxiety and burnout, and the literature supports cognitive dissonance in its various forms as contributing to burnout. The second potential way suggested by the PCPs in the study, as they described, is extending great effort to uphold professional values and excellence in care. This was mainly by personal sacrifice — they describe giving up vacation time, evenings and weekends. One participant stated that they felt like a salmon swimming upstream constantly. I suspect that this kind of unrelenting effort adds to the burnout. So the values conflict and create stress, and the great effort needed to uphold their professional value may also eventually contribute to burnout. In addition, there is some evidence in the literature that if there is no relief or response from the system, some professionals will resort to leaving the position as their only alternative. We cannot prove this in our study, but I suspect that prolonged, unresolved professional dissonance is one of the reasons why so many clinicians are leaving clinical medicine for alternative positions or deciding to retire early. But obviously, more work needs to be done in this area.
Q: What can institutions do to help PCPs manage their workload?
Institutions can advocate for national reforms regarding documentation and electronic record regulations, paperwork and other cumbersome regulations. At the local level, PCPs desire adequate numbers of well-trained support staff who are empowered to work without constant supervision from clinicians. They also desire efforts to improve staff retention and efforts to create efficient electronic record workflows that make work and chart review easier and address the constant flow of incoming information and requests.
Q: What are some examples of how institutions can care for PCPs as multidimensional human beings?
A: Institutions can enhance family-friendly policies that acknowledge clinicians are family members who have responsibilities for children or elderly parents. Ones that recognize that clinicians are humans who need sick days, care options and flexibility to access appointments, either for themselves personally or for family emergencies. Based on what our physicians are saying, institutions should re-evaluate their safety policies because PCPs have safety concerns, especially when dealing with sometimes angry or threatening patients. Some of them also mentioned concerns about policies during severe weather alerts — they feel that outpatient clinics should be given the option to close for the safety of both staff and patients. That was a smaller proportion of people, but there were concerns about those things.
Q: How can institutions increase reimbursement for work that PCPs do outside of patient visits?
A: Institutions can advocate for improved payments for primary care services, because these practitioners have stated that they want to be compensated for all the time required to do their job, not just face-to-face time. They explained that the nonface-to-face time is currently demanding the majority of their time — which is supported by a paper from Christine A. Sinsky, MD, and colleagues in 2016 that said every hour a clinician spends face to face, they spend 2 hours doing desk work and computer work. The other thing that institutions can do is assist in designing a more realistic, reasonable job description for primary care, because right now, a full time job requires about 80 hours or more a week.
Q: How can institutions improve physician professionalism? Why is this important?
A: Institutions can help create protected time and space for clinicians to do what they feel is essential for their job, including reading, learning and doing case reviews with colleagues during the work day in order to provide and maintain excellence in care. Institutions can also acknowledge and support the doctor-patient relationship, because PCPs want to preserve and protect the time that they spend with patients. This is really important because these are key issues contributing to professional dissonance. Clinicians highly value the study of medicine, keeping up on the literature, and honoring the trust that patients place in them. Right now, the reality is that there is no time in the workday to read or stay up to date and there is less and less time in the evenings because more and more of that paperwork and charting is overflowing to the evenings.
Q: What is the take-home message of your study?
A: PCPs express the sense of professional dissonance as a contributor to burnout because the values of their profession conflict with the values of the health care delivery system. In addition to the added stress of dissonance, PCPs described working tremendously hard to uphold their professional values and maintain excellent care, even at their own personal expense. They identified many potential solutions for the syndrome of burnout that threatens both the long-term health of the profession and patient care. To reduce high burnout rates in primary care, frontline PCPs should be actively engaged in development and implementation of solutions. More attention and study should be given to the issue of professional dissonance, which may be affecting PCPs’ career decisions.
Festinger L (1957). A theory of cognitive dissonance. California: Stanford University Press.
Disclosure: Sherritt reports no relevant financial disclosures.