Thursday Review: “Physician Burnout and Patient-Physician Communication During Primary Care Encounters”

The Quiet Burnout Bombshell

One of the major ideas behind medical storytelling is that better physician-patient communication yields better results.¹ Writing in the Journal of General Internal Medicine, Dr. Neda Ratanawongsa, Dr. Debra Roter, Dr. Mary Catherine Beach, Shivonne L. Laird, Susan M. Larson, Kathryn A. Carson, and Dr. Lisa A. Cooper make a completely rational assumption:

[W]e hypothesized that professional burnout would diminish physicians’ inclination or ability to engage in rapport-building with their patients during routine medical visits. As secondary outcomes, we hypothesized that higher levels of burnout would be associated with less positive affect by physicians and patients, less patient-centeredness, shorter visit lengths, greater verbal dominance by physicians, and more negative patient ratings of satisfaction, trust, and confidence in their physicians.

It’s a kind of quiet bombshell, then, that after a survey of physician and patient interactions, no differences were evident in the rapport-building behaviors of physicians relative to their burnout scores.

What does this mean for how we talk about and deal with burnout?

Rethinking what burnout looks like

The big lesson from this particular study is that there is likely a more complex relationship between physician burnout and patient-physician communication than might have been thought.

The image Gail Gazelle et al. paint of a physician experiencing high levels of burnout is one who is short-tempered with staff, persistently late with paperwork, exhausted, and emotionally distant. It’s possible that this is a normal, even typical expression of burnout, but it’s also possible that there are much more subtle outward signs. This study specifically studies physician-patient communication. If there is such a thing as a “typical” manifestation of burnout, it appears not to be very obvious to patients… at least not always.

With regards to a patient relationship, it appears that physicians are still motivated to perform well, even in the midst of burnout. This is somewhat comforting to patients, that doctors want to build a relationship and treat patients well, even in the midst of their own suffering. It also speaks well of the character of the profession of physicians as a whole, that they prioritize being able to heal, even to a fault. Several articles we’ve looked at this month mention how medical education and medical practice often emphasizes the care of a patient at the expense of the well-being of the doctor.

Empathy for the patient at the expense of oneself is a thread the authors pick up. Ratanawongsa et al. briefly mention a facet of this I don’t remember being in any other of the studies we’ve examined: that women tend to experience slightly higher rates of burnout than men.

Huggard termed this phenomenon “compassion fatigue,” in which physicians who engage empathically with their patients experience secondary traumatic stress and develop burnout.² Gender effects may play a role in this as well. Shanafelt et al. found that women residents scored higher in empathy despite having lower well-being compared with men.³ This may suggest that — even early in their training — physicians are learning to put their patients’ well-being ahead of their own.⁴

Well-being at the expense of well-being

The authors’ discussion of why their findings are counter-intuitive centers around the personal experience of physicians and the idea that physicians are willing to sacrifice their own well-being. If a physician has high expectations of themselves as a healer and high expectations for the quality of their interactions and relationships with patients, they may never be able to meet their own expectations, let alone any institutional or organizational standards:

First, physicians with burnout may have unreasonably high expectations for themselves and may judge their performance more severely than other physicians or their patients. A prior study suggests that physicians significantly underestimate their patients’ positive attitudes towards them.⁵ …[P]hysicians with burnout may actually perform as well as or better than their counterparts in their observed encounters, despite rating themselves as worse on self-reported questionnaires.⁶

…

Alternatively, physicians reporting burnout may be more sensitive to high patient expectations that they feel they cannot meet. … Satisfaction with the patient-doctor relationship is associated with physicians’ global satisfaction,⁷ but physicians with high burnout may not perceive patient rapport-building as satisfying or successful.

The majority of the aspects which Ratanawongsa et al. surveyed, including length of patient encounter, trust and confidence in the physician, and patient-centered behavior, were uncorrelated with burnout. The two areas which the authors found were connected with burnout are

1. “negative” rapport-building statements and
2. statements of reassurance or optimism.

The authors define negative rapport-building statements, according to the Roter Interaction Analysis System (RIAS), as a statement by the patient or physician characterized by criticism or disagreement, not just with one another, but with anyone outside the patient-physician encounter. Although defined as “negative”, these kinds of statements build rapport by allowing honest expressions of differences in opinion or concerns about outside situations.

Ratanawongsa et al. suggest that there is a causal link between negative rapport-building statements and burnout, that because physicians tend to empathize with their patients, they feel that these negative statements reflect something about their care: The higher-burnout physicians in our sample may tend to perceive patient rapport-building statements as placing demands on them.

They also suggest a link between burnout and statements of reassurance or optimism. Although the interactions studied were audio-only recordings, there may have been non-verbal cues from doctors which elicited an empathetic response from patients: Patients’ overtures of rapport-building — such as reassurance/optimism statements — could represent patients’ efforts to demonstrate empathy or support for their physicians.

By examining the connection between rapport and physician-patient communication (there appears to be very little of it), Ratanawongsa et al. end up pointing us towards the measure of a physician’s own experience. Their discussion of the study’s results mostly points towards physicians falling short in no measure but their own.

Just like Dr. Deborah Lathrop pointed to the importance of physicians telling stories of expectations and loss in their career, Ratanawongsa et al. point us toward the importance of helping physicians realize that their biggest critic can be themselves. Narrative reflection and public storytelling can help break the vicious cycle where burnout leads to faulty perceptions of suboptimal performance, which then predisposes to worsening burnout.

Sources

The article reviewed: Ratanawongsa, Neda, Debra Roter, Mary Catherine Beach, Shivonne L. Laird, Susan M. Larson, Kathryn A. Carson, and Lisa A. Cooper. “Physician Burnout and Patient-Physician Communication during Primary Care Encounters.” Journal of General Internal Medicine 23, no. 10 (2008): 1581–88. https://doi.org/10.1007/s11606-008-0702-1.

¹ For example, Ratanawongsa et al. cite: Stewart, M. A. “Effective Physician-Patient Communication and Health Outcomes: A Review.” CMAJ: Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne 152, no. 9 (1995): 1423–33. ↑

² Huggard, Peter. “Compassion Fatigue: How Much Can I Give?” Medical Education 37, no. 2 (February 1, 2003): 163–64. https://doi.org/10.1046/j.1365-2923.2003.01414.x. ↑

³ Shanafelt, Tait D., Colin West, Xinghua Zhao, Paul Novotny, Joseph Kolars, Thomas Habermann, and Jeff Sloan. “Relationship between Increased Personal Well-Being and Enhanced Empathy among Internal Medicine Residents.” Journal of General Internal Medicine 20, no. 7 (July 2005): 559–64. ↑

⁴ Ratanawongsa, Neda, Scott M. Wright, and Rachel B. Levine. “Association between Higher Mental Well-Being and Residents’ Capacity for Empathy.” Journal of General Internal Medicine 21, no. 4 (April 2006): 401–2. https://doi.org/10.1111/j.1525-1497.2006.00286.x. ↑

⁵ Hall, Judith A., Terry S. Stein, Debra L. Roter, and Nancy Rieser. “Inaccuracies in Physicians’ Perceptions of Their Patients.” Medical Care 37, no. 11 (November 1, 1999): 1164–68. ↑

⁶ Shanafelt, Tait D., Katharine A. Bradley, Joyce E. Wipf, and Anthony L. Back. “Burnout and Self-Reported Patient Care in an Internal Medicine Residency Program.” Annals of Internal Medicine 136, no. 5 (March 5, 2002): 358–67. ↑

⁷ Suchman, A. L., D. Roter, M. Green, and M. Lipkin. “Physician Satisfaction with Primary Care Office Visits. Collaborative Study Group of the American Academy on Physician and Patient.” Medical Care 31, no. 12 (December 1993): 1083–92. ↑

Featured Image: Robert Thom’s illustration of Benjamin Rush.