Factors Associated with Physician Tolerance of Uncertainty: an Observational Study.

BACKGROUND: Physicians need to learn and work amidst a plethora of uncertainties, which may drive burnout. Understanding differences in tolerance of uncertainty is an important research area. OBJECTIVE: To examine factors associated with tolerance of uncertainty, including well-being metrics such as burnout. DESIGN: Online confidential survey. SETTING: The Massachusetts General Physicians Organization (MGPO). PARTICIPANTS: All 2172 clinically active faculty in the MGPO. MAIN MEASURES: We examined associations for tolerance of uncertainty with demographic information, personal and professional characteristics, and physician well-being metrics. KEY RESULTS: Two thousand twenty (93%) physicians responded. Multivariable analyses identified significant associations of lower tolerance of uncertainty with female gender (OR, 1.23; 95% CI, 1.03-1.48); primary care practice (OR, 1.56; 95% CI, 1.22-2.00); years since training (OR, 0.99; 95% CI, 0.98-0.995); and lacking a trusted advisor (OR, 1.25; 95% CI, 1.03-1.53). Adjusting for demographic and professional characteristics, physicians with low tolerance of uncertainty had higher likelihood of being burned-out (OR, 3.06; 95% CI, 2.41-3.88), were less likely to be satisfied with career (OR, 0.37; 95% CI, 0.26-0.52), and less likely to be engaged at work (RR, 0.87; 95% CI, 0.84-0.90). CONCLUSION: At a time when concern about physician well-being is high, with much speculation about causes of burnout, we found a strong relationship between tolerance of uncertainty and physician well-being, across specialties. Particular attention likely needs to be paid to those with less experience, those in specialties with high rates of undifferentiated illness and uncertainty, such as primary care, and ensuring all physicians have access to a trusted advisor. These results generate the potential hypothesis that efforts focused in understanding and embracing uncertainty could be potentially effective for reducing burnout. This concept should be tested in prospective trials.

Understanding Physician Work and Well-being Through Social Network Modeling Using Electronic Health Record Data: a Cohort Study.

BACKGROUND: Understanding association between factors related to clinical work environment and well-being can inform strategies to improve physicians' work experience. OBJECTIVE: To model and quantify what drivers of work composition, team structure, and dynamics are associated with well-being. DESIGN: Utilizing social network modeling, this cohort study of physicians in an academic health center examined inbasket messaging data from 2018 to 2019 to identify work composition, team structure, and dynamics features. Indicators from a survey in 2019 were used as dependent variables to identify factors predictive of well-being. PARTICIPANTS: EHR data available for 188 physicians and their care teams from 18 primary care practices; survey data available for 163/188 physicians. MAIN MEASURES: Area under the receiver operating characteristic curve (AUC) of logistic regression models to predict well-being dependent variables was assessed out-of-sample. KEY RESULTS: The mean AUC of the model for the dependent variables of emotional exhaustion, vigor, and professional fulfillment was, respectively, 0.665 (SD 0.085), 0.700 (SD 0.082), and 0.669 (SD 0.082). Predictors associated with decreased well-being included physician centrality within support team (OR 3.90, 95% CI 1.28-11.97, P=0.01) and share of messages related to scheduling (OR 1.10, 95% CI 1.03-1.17, P=0.003). Predictors associated with increased well-being included higher number of medical assistants within close support team (OR 0.91, 95% CI 0.83-0.99, P=0.05), nurse-centered message writing practices (OR 0.89, 95% CI 0.83-0.95, P=0.001), and share of messages related to ambiguous diagnosis (OR 0.92, 95% CI 0.87-0.98, P=0.01). CONCLUSIONS: Through integration of EHR data with social network modeling, the analysis highlights new characteristics of care team structure and dynamics that are associated with physician well-being. This quantitative methodology can be utilized to assess in a refined data-driven way the impact of organizational changes to improve well-being through optimizing team dynamics and work composition.

Physician Burnout, Engagement and Career Satisfaction in a Large Academic Medical Practice.

OBJECTIVE: To determine (1) if engagement among physicians impacted plans to stay in current role and job satisfaction, (2) what factors impact engagement and burnout, and (3) the relationship between engagement and burnout. Burnout has been described as a syndrome characterized by depersonalization, emotional exhaustion, and a sense of low personal accomplishment resulting in decreased effectiveness at work. Engagement may be regarded as the antonym to burnout and has been described as a connection to one's work characterized by dedication, vigor, and absorption. DESIGN: We extracted data from an academic practice-wide survey conducted at two time-points and evaluated physician burnout and engagement. We used the Maslach Burnout Inventory and the Utrecht Work Engagement Scale to evaluate the association between burnout and engagement and the impact of engagement on mitigating the effect of burnout in a large physician academic faculty practice. SETTING: Large academic practice PARTICIPANTS: Academic physicians METHODS: The authors conducted a hospital-wide physician practice survey in 2014 and 2017 assessing physician burnout and engagement. RESULTS: Of eligible physicians (n=1882), 92.0% completed a survey. High levels of engagement and burnout were shown in 59.5% and 45.6%, respectively. Compared to physicians with high levels of engagement and low levels of burnout, physicians with low engagement and low burnout were less satisfied with their career (OR=0.20, 95% CI=0.11-0.35) and less likely to stay in their current role (OR=0.52, 95% CI= 0.37-0.73). Among physicians with high levels of burnout, highly engaged physicians were more satisfied (OR=0.21; 95% CI=0.12-0.36 vs OR=0.08; 95% CI=0.05-0.12) and more likely to stay in their career (OR=0.34; 95% CI=0.25-0.45 vs OR=0.27; 95% CI=0.21-0.34) than non-engaged physicians. CONCLUSION: Engaged physicians have higher career satisfaction. There are many actionable ways to improve engagement.

Patterns in Physician Burnout in a Stable-Linked Cohort.

Importance: Physician burnout is widely reported to be an increasing problem in the US. Although prior analyses suggest physician burnout is rising nationally, these analyses have substantial limitations, including different physicians joining and leaving clinical practice. Objective: To examine the prevalence of burnout among physicians in a large multispecialty group over a 5-year period. Design, Setting, and Participants: This survey study was conducted in 2017, 2019, and 2021 and involved physician faculty members of the Massachusetts General Physicians Organization. Participants represented different clinical specialties and a full range of career stages. The online survey instrument had 4 domains: physician career and compensation satisfaction, physician well-being, administrative workload on physicians, and leadership and diversity. Exposure: Time. Main Outcomes and Measures: Physician burnout, which was assessed with the Maslach Burnout Inventory. A binary burnout measure was used, which defined burnout as a high score in 2 of the 3 burnout subscales: Exhaustion, Cynicism, and Reduced Personal Efficacy. Results: A total of 1373 physicians (72.9% of the original 2017 cohort) participated in all 3 surveys. The cohort included 690 (50.3%) male, 921 (67.1%) White, and 1189 (86.6%) non-Hispanic individuals. The response rates were 93.0% in 2017, 93.0% in 2019, and 92.0% in 2021. Concerning years of experience, the cohort was relatively well distributed, with the highest number and proportion of physicians (478 [34.8%]) reporting between 11 and 20 years of experience. Within this group, burnout declined from 44.4% (610 physicians) in 2017 to 41.9% (575) in 2019 (P = .18) before increasing to 50.4% (692) in 2021 (P < .001). Conclusions and Relevance: Findings of this survey study suggest that the physician burnout rate in the US is increasing. This pattern represents a potential threat to the ability of the US health care system to care for patients and needs urgent solutions.

Association of Self-reported Primary Care Physician Tolerance for Uncertainty With Variations in Resource Use and Patient Experience.

Importance: Inappropriate variations in clinical practice are a known cause of poor quality and safety, with variations often associated with nonclinical factors, such as individual differences in cognitive processing. The differential response of physicians to uncertainty may explain some of the variations in resource use and patient experience. Objective: To examine the association of physician tolerance for uncertainty with variations in resource use and patient experience. Design, Setting, and Participants: This survey study linked physician survey data (May to June 2019), patient experience survey data (January 2016 to December 2019), and billing data (January 2019 to December 2019) among primary care physicians (PCPs) at Massachusetts General Hospital with at least 10 visits in 2019. The statistical analysis was performed in 2021. Main Outcomes and Measures: The analysis examined associations of PCP tolerance for uncertainty with the tendency to order diagnostic tests, the frequency of outpatient visits, hospital admissions, emergency department visits, and patient experience data (focused on physician communication and overall rating). A 2-stage hierarchical framework was used to account for clustering of patients under PCPs. Binary outcomes were modeled using a hierarchical logistic model, and count outcomes were modeled using hierarchical Poisson or negative binomial models. The analysis was adjusted for patient demographic variables (age, sex, and race and ethnicity), socioeconomic factors (payer and neighborhood income), and clinical comorbidities. Results: Of 217 included physicians, 137 (63.1%) were women, and 174 (80.2%) were adult PCPs. A total of 62 physicians (28.6%) reported low tolerance, 59 (27.2%) reported medium tolerance, and 96 (44.2%) reported high tolerance for uncertainty. Physicians with a low tolerance for uncertainty were less likely to order complete blood cell counts (odds ratio [OR], 0.66; 95% CI, 0.50-0.88), thyroid tests (OR, 0.67; 95% CI, 0.52-0.88), a basic metabolic profile (OR, 0.78; 95% CI, 0.60-1.00), and liver function tests (OR, 0.72; 95% CI, 0.53-0.99) than physicians with a high tolerance for uncertainty. Physicians who reported higher tolerance for uncertainty were more likely to receive higher patient experience scores for listening to patients carefully (OR, 0.65; 95% CI, 0.50-0.83) and higher overall ratings (OR, 0.80; 95% CI, 0.66-0.98) than physicians with medium tolerance. Conversely, no association was found between physician tolerance for uncertainty and patient outpatient visits, hospital admissions, or emergency department visits. Conclusions and Relevance: In clinical practice, identifying and effectively managing inappropriate variations and improving patient experience have proven to be difficult, despite increased attention to these issues. This study supports the hypothesis that physicians' tolerance for uncertainty is associated with differences in resource use and patient experience. Whether enhancing physicians' tolerance for uncertainty could help reduce unwarranted practice variations, improve quality and patient safety, and improve patient's experience remains to be established.

Trends and Factors Associated With Physician Burnout at a Multispecialty Academic Faculty Practice Organization.

Importance: Physician burnout is common, and prevalence may differ throughout a clinician's career. Burnout has negative consequences for physician wellness, patient care, and the health care system. Identifying factors associated with burnout is critical in designing and implementing initiatives to reduce burnout. Objective: To measure trends and identify factors associated with physician burnout. Design, Setting, and Participants: Survey study conducted from May 16 to June 15, 2014, and again from May 16 to June 15, 2017, measuring rates of physician burnout in a large academic medical practice. Factors associated with burnout out were evaluated. In 2014, 1774 of 1850 eligible physicians (95.9%) completed the survey. In 2017, 1882 of 2031 (92.7%) completed the survey. Exposures: Medical specialty, demographic characteristics, years in practice, and reported rates of burnout. Main Outcomes and Measures: Burnout rates measured at 2 points and risk factors associated with burnout. Results: Respondents included 1027 men (57.9%) and 747 women (42.1%) in 2014 and 962 men (51.1%) and 759 women (40.3%) in 2017. The mean (SD) number of years since training completion was 15.3 (11.3) in the 2014 survey data and 15.1 (11.3) in the 2017 data. Burnout increased from 40.6% to 45.6% between the 2 points. The increased rate was associated with an increase in exhaustion (from 52.9% in 2014 to 57.7% in 2017; difference, 4.8%; 95% CI, 1.6%-8.0%; P = .004) and cynicism (from 44.8% in 2014 to 51.1% in 2017; difference, 6.3%; 95% CI, 3.1%-9.6%; P < .001). Compared with midcareer physicians (11-20 years since training), early-career physicians (≤10 years since training) were more susceptible to burnout (odds ratio, 1.36; 95% CI, 1.05-1.77), while physicians in their late career (>30 years since training) were less vulnerable (odds ratio, 0.59; 95% CI, 0.40-0.88). Conclusions and Relevance: Efforts to alleviate physician burnout and administrative burden require a combination of a shared commitment from physicians and organizations and central and locally implemented programs. Continued research is necessary to establish the most effective initiatives to decrease physician burnout at the individual and organizational level.

The Impact of Administrative Burden on Academic Physicians: Results of a Hospital-Wide Physician Survey.

PURPOSE: To determine the characteristics of clinically active academic physicians most affected by administrative burden; the correlation between administrative burden, burnout, and career satisfaction among academic physicians; and the relative value and burden of specific administrative tasks. METHOD: The authors analyzed data from the 2014 Massachusetts General Physicians Organization Survey. Respondents reported the percentage of time they spent on patient-related administrative duties and rated the value and burden associated with specific administrative tasks. A five-point Likert scale and multivariate regression identified predictors of administrative burden and assessed the impact of administrative burden on perceived quality of care, career satisfaction, and burnout. RESULTS: Of the eligible workforce, 1,774 physicians (96%) responded to the survey. On average, 24% of working hours were spent on administrative duties. Primary care physicians and women reported spending more time on administrative duties compared with other physicians. Two-thirds of respondents reported that administrative duties negatively affect their ability to deliver high-quality care. Physicians who reported higher percentages of time spent on administrative duties had lower levels of career satisfaction, higher levels of burnout, and were more likely to be considering seeing fewer patients in the future. Prior authorizations, clinical documentation, and medication reconciliation were rated the most burdensome tasks. CONCLUSIONS: Administrative duties required substantial physician time and affected physicians' perceptions of being able to deliver high-quality care, career satisfaction, burnout, and likelihood to continue clinical practice. There is variation in administrative burden across specialties, and multiple areas of work contribute to overall administrative workload.