Burnout in primary care

Although occupational burnout can occur in any occupation, it is particularly common among healthcare professionals, whose work includes complex decision making, high expectations and a constant emotional element. In addition, healthcare professionals often have to perform their roles with inadequate resources. Ever-increasing responsibilities with decreasing autonomy over work in a challenging and sometimes unsupportive work environment often leads to a high prevalence of burnout among healthcare professionals working in primary care.¹

Burnout negatively affects physician health, productivity, and patient care. Its prevalence is high among physicians, especially those in primary care.¹

What is burnout?

Burnout is generally referred to as an inability to cope with chronic psychological stress at work because of insufficient resources to cope with job demands. GP burnout is a recognised healthcare problem that has become widespread over time and which has adverse effects for both clinicians and patients.²

Burnout is defined by the World Health Organization (WHO) in the 11th Revision of the International classification of diseases (ICD-11) as a syndrome resulting from chronic workplace stress that has not been successfully managed. In the ICD-11, burnout is classified as an occupational phenomenon and characterised as having three dimensions:³

• Emotional exhaustion: feelings of energy depletion or exhaustion.

• Cynicism/depersonalisation: increased mental distance from, or feelings of negativism or cynicism related to, one’s job.

• Personal accomplishment: sense of reduced professional efficacy and lack of accomplishment.

How common is burnout in primary care? (Epidemiology)

Burnout is particularly common among healthcare professionals working in primary care. Before the COVID-19 pandemic, the incidence of burnout and poor mental wellbeing was found to be higher among GPs than other Healthcare Professionals and higher than in the general population.¹

The results of a 2018 survey identified that one-third of the UK doctors surveyed (mostly working in emergency medicine or general practice) were exhibiting signs of burnout.[⁴

A systematic literature search and meta-analysis published in the British Journal of General Practice in 2022 found wide-ranging prevalence estimates (6% to 33%) across the different dimensions of burnout reported for 22,177 GPs across 29 countries for 60 studies. The mean burnout estimates were 16% for emotional exhaustion, 6% for depersonalisation, and 29% for personal accomplishment.²

Causes of burnout in primary care (aetiology)

Evidence suggests that an independent relationship exists between burnout and individual factors in clinicians as well as with work-related factors such as hours and administrative burden. The factors that contribute to burnout include:¹

• Work-related causes, eg, lack of control, overly demanding, high-pressure work environment, discrimination.

• Lifestyle causes, eg, poor sleep, poor work–life balance, or a lack of supportive relationships.

• Social and political causes, including society’s expectations of doctors, insufficient funding and pressure resulting from Government targets.

• Personality factors, eg, perfectionism, pessimism, or a need to be in control.

Occupational factors include:¹

• A challenging work environment, eg, chronic excessive workload, increased paperwork, long hours, poor work–life integration, and high patient demand.

• Insufficient control, eg, lack of skills, efficiency, and autonomy.

• Insufficient resources, eg, lack of peer and managerial support, or inadequate physical resources.

• A professional dissonance or psychological discomfort experienced while working in a system that does not align with their professional values, resulting in low professional fulfilment.

• Discrimination, eg, gender, racial.

A retrospective analysis of GP and nurse consultations of non-temporary patients registered at 398 English general practices between April 2007, and March 2014 found a substantial increase in practice consultation rates, average consultation duration, and total patient-facing clinical workload in English general practice. It was concluded that these results suggested that English primary care could be reaching saturation point. There is no doubt that workload has continued to increase since 2014 and many would consider that the situation is now well beyond saturation point.⁵

A cross-sectional survey in the UK between March 2016 and August 2017 found that a higher number of hours spent on administrative tasks, a higher number of patients seen per day, and feeling less supported were associated with higher burnout levels, which in turn was associated with worse perceptions of safety.⁶

Recent studies have shown that the COVID-19 pandemic has also played an important role in influencing physician burnout. For example, one study showed that infection or death from COVID-19 among colleagues or relatives showed significant association with higher emotional exhaustion and lower personal accomplishment.² A further factor has been the high demands and patient expectations during the recovery in the aftermath of the COVID-19 pandemic.

Although different health systems in different countries are a factor in causing burnout, there are many consistent issues relevant to primary healthcare professionals in all countries. One study of 26 primary care practitioners (PCPs) from 10 primary care clinics in the US found that participants described their workloads as excessively heavy, increasingly involving less "doctor" work and more "office" work, and reflecting unreasonable expectations. They felt demoralised by work conditions, undervalued by local institutions and the healthcare system, and conflicted in their daily work. Participants conveyed a sense of professional dissonance, or discomfort from working in a system that seems to hold values counter to their values as clinicians. They suggested potential solutions clustered around 8 themes: managing the workload, caring for PCPs as multidimensional human beings, disconnecting from work, recalibrating expectations and reimbursement levels, promoting PCPs' voice, supporting professionalism, fostering community, and advocating reforms beyond the health care team.¹

Workforce shortages in primary care

UK general practice faces a workforce crisis, with GP shortages (including inadequate recruitment and early retirement), organisational change, substantial pressures across the whole health-care system and an ageing population with increasingly complex health needs.⁷

Symptoms of burnout (presentation)

Burnout leads to a state of emotional, mental, and physical exhaustion. Healthcare professionals often ignore the signs of burnout and persevere with routine work. The symptoms may include tearfulness, depersonalisation, feelings of hopelessness, depression, and anxiety.

Chronic stress associated with emotionally intense work demands for which resources are inadequate can result in burnout. Burnout is distinct from job dissatisfaction, fatigue, occupational stress and depression. Although burnout correlates with these problems, it may be present in their absence or absent in their presence. As a work-related phenomenon, burnout is further distinguished from depression. In particular, the emotional exhaustion domain of burnout has been suggested to map more closely to depression, but the depersonalisation and low personal accomplishment domains of burnout do not correlate well with depression or any other psychological issues.⁸

Burnout may also cause a wide range of physical and psychological effects often associated with stress.

• Physical symptoms may include headaches or dizziness, muscle tension or pain, dyspepsia, chest pain or palpitations, sexual problems.

• Psychological symptoms may include difficulty concentrating, struggling to make decisions, feeling overwhelmed, constantly worrying, being forgetful, increasing alcohol intake.

• Changes in behaviour may include being irritable and snappy, sleeping too much or too little, eating too much or too little, avoiding certain places or people.

See also the article on Acute Stress Reaction.

There are some early warning signs to help recognise burnout, which include:⁹

• The ‘disappearing act’: not answering calls, unexplained absences during the day; lateness; frequent sick leave.

• Low work rate: slowness in performing procedures, clerking patients, dictating letters, and making decisions; arriving early and leaving late, but still not managing to get through a reasonable workload.

• ‘Clinic rage’: bursts of temper; shouting matches; reacting badly to real or imagined slights.

• Rigidity: poor tolerance of ambiguity; inability to compromise; difficulty prioritising; inappropriate ‘whistle blowing’.

• ‘Bypass syndrome’: junior colleagues or nurses find ways to avoid seeking the doctor’s opinion or help.

• Career problems: difficulty with exams; uncertainty about career choice; disillusionment with medicine.

• Insight failure: rejection of constructive criticism; defensiveness; counter-challenge.

Complications of burnout in primary care

Persistent burnout is a cause of reduced quality of life and is associated with increased risk of sleep impairment and with several medical disorders including mild cognitive impairment, diabetes, and cardiovascular disease.¹⁰

Burnout is associated with negative consequences on patient care, the healthcare workforce and healthcare system costs, and individual practitioner's own care and safety:⁸

• Cross-sectional studies have linked burnout with suboptimal patient care practices, as well as with a doubled risk of medical error and a 17% increased odds of being named in a medical malpractice suit. Higher levels of burnout are associated with increased odds of reporting a major medical error. Self-perceived major medical errors were also associated with worsening burnout, depressive symptoms and decrease in quality of life.

• Cross-sectional studies have also reported significant correlations between burnout and both job satisfaction and patients’ satisfaction with their care, and between physician job satisfaction and patient-reported adherence to medical advice. These associations suggest a potential impact on healthcare outcomes.

• Cross-sectional studies have associated physician burnout with decreased productivity, job dissatisfaction and more than doubled self-reported intent to leave one's current practice for reasons other than retirement. Increasing emotional exhaustion or decreasing job satisfaction are associated with a greater likelihood of reduction in professional effort and work hours, resulting in lost productivity. In addition to the obvious effects on practitioners’ lives, these practice changes may reduce patient access to care and further strain healthcare systems already struggling to meet the needs of the populations they serve.

• Physician turnover also has financial implications for healthcare organisations, with increased costs. Burnout may also increase healthcare expenditures indirectly via higher rates of medical errors and malpractice claims, absenteeism and lower job productivity.

Consequences to physician health

Burnout may have long-term physical and mental health consequences such as substance misuse and addiction, depression and anxiety, and even suicide. They may also have a knock-on effect on the wellbeing of co-workers, family members, and close friends of an individual suffering from burnout. Along with the previously noted correlations with depression, physician burnout is associated with physician impairment more broadly, including a 25% increased odds of alcohol abuse/dependence and a doubled risk of suicidal ideation. Physician burnout is also associated with increased risk of motor vehicle crashes and near-miss events, even after adjusting for fatigue.⁸

The impacts of burnout on the health system

Burnout among primary care practitioners has potentially very harmful consequences for both individual patients and the healthcare system. The GMC report Caring for doctors, caring for patients states that staff wellbeing significantly improves productivity, care quality, patient safety, patient satisfaction, financial performance and the sustainability of our health services.¹¹

Burnout correlates with an increased risk of medical errors, poor patient outcomes, and patient dissatisfaction and complaints, affecting the overall performance of healthcare organisations.(¹² )

Management of burnout in primary care

As well as help and support for individual practitioners and the primary healthcare team, burnout must be addressed with systematic solutions. Tackling the problem requires organisational, primary health care team and individual measures.¹³

Measures aimed at the individual include active coping strategies promoting mental resilience and adaptive behaviour, stress-reducing activities, improving work conditions, and reducing exposure to work stressors, which together may alleviate the distress of burnout and should be introduced early in the clinical course of burnout syndrome.¹⁰

The best form of treatment is always prevention (see below) and recognising and addressing any early warning signs of burnout. However, the symptoms of burnout often become severe as a result. A number of strategies have been used, including cognitive behavioural therapy, mindfulness, meditation and stress management coaching with generally favourable but variable outcomes:¹⁰

• Further studies are needed to determine the efficacy of mindfulness, CBT, and other stress-coping interventions in reducing the extent and severity of burnout.

• CBT has been found to be relatively beneficial in improving work-directed behaviour, overall work performance, and in reducing mental strain.

• Mindfulness-mediated positive reappraisal of work stressors and of the cognitive-affective responses to these stressors (emotional exhaustion and cognitive weariness), through mentally assigning them a more benign connotation, may promote self-understanding of the burnout experience, thus enhancing mental resilience and restoring a sense of meaning despite the adversarial circumstances that caused burnout.

• Meditation has been used to combat burnout symptoms and mindfulness training may be modestly beneficial in decreasing anxiety and perceived work stress.¹³

• Individualised professional coaching for stress management over a 6-month pilot trial was also effective.¹³

However, there is little data to suggest long-term benefit of any particular stress management intervention in the management of burnout symptoms, reinforcing the necessity of system-based interventions in addition to those targeted for affected individuals.¹³

Preventing burnout in primary care

The GMC report Caring for doctors, caring for patients includes an ABC of doctors’ core needs, which provides recommendations to improve the working lives of doctors and minimise workplace stress. To ensure wellbeing and motivation at work, and to minimise workplace stress, people have three core needs, and all three must be met.¹¹

• Autonomy/control: the need to have control over our work lives, and to act consistently with our work and life values.

• Belonging: the need to be connected to, cared for, and caring of others around us in the workplace, and to feel valued, respected, and supported.

• Competence: the need to experience effectiveness and deliver valued outcomes, such as high-quality care.

Preventing burnout has to include addressing all causes as outlined above and therefore must include individual, team and organisational strategies. At an organisational level, the risk of burnout may be reduced by addressing workplace pressures, ensuring adequate resources (time, people, and funding), and increasing opportunities for team working.

The NICE guideline 'Mental wellbeing at work' recommends the creation of a supportive and inclusive work environment to improve mental wellbeing in the workplace, including training and support for managers.¹⁴

Individual strategies

Work-life balance: stress levels can be reduced by adopting simple measures including taking time off, going on holiday, spending time with family and friends, and taking up hobbies. Time should be set aside to do something relaxing that is totally unrelated to work. Setting boundaries between work and home life is essential.

Self-reflection and vigilance for signs of burnout: self-care (eg, healthy diet, regular exercise, and good sleep hygiene), and incorporating stress-reduction strategies (eg, deep breathing exercises, yoga, and meditation).

Understanding our limitations and seeking help early. Building resilience, practising mindfulness, and participating in cognitive behavioural therapy, mentoring, and coaching may help to respond better to stress and improve wellbeing.

Primary health care team strategies

The following approaches are only effective and sustainable if viewed as the responsibility of all practice staff:¹⁴

• Consider staff wellbeing to be at the centre of the work culture. Promote work–life balance and make health and wellbeing a core priority.

• Create a safe and healthy work environment. Ensure a good-quality lighting and ventilation, reduce noise pollution, and ensure that premises are well maintained, comfortable, and clean.

• Create a room or space where staff can go to relax or sit in silence.

• Encourage communication and generate trust, with an open-door policy, and allowing staff to articulate ways of reducing their stress. Hold regular formal and informal meetings, with all staff having a voice, and making time to listen and be compassionate for each other.

• Recognise staff concerns also by doing regular surveys or creating a platform for any concerns to be voiced and addressed.

• Encourage reflection and learning from any mistakes with a 'no blame' culture.

• Acknowledge hard work and provide positive feedback. Highlight and share good practice and successful outcomes.

• Raise awareness of mental wellbeing, and offer access to early intervention at every opportunity.

• Signpost access to internal and external mental health support.

• Follow policies such as anti-bullying and anti-discrimination initiatives, and conduct staff risk and wellbeing assessments.

• Facilitate social interaction and organise activities.

• Provide peer support and allow people time to chat and engage with one another.

• Implement supportive mentoring schemes to help manage stress or issues related to home or work.

See also the articles Tips on Managing Wellbeing in Primary Care and Resources for Healthcare Professionals in Managing Burnout.