Health Workforce Brief Patient & Peer Relationships and Physician Burnout Debra Street & Jeralynn S. Cossman
This is the third in a series of four Mississippi Center for Health Workforce Research Briefs on physician burnout.
Data are from the Mississippi Workforce Study (2007/08 MSMD); over 1400 doctors licensed to practice in
Mississippi (2006-07) responded to the 2007/08 MSMD survey. Data from physicians in active practice involving
direct patient care who answered the questions on burnout (N=636) are analyzed in this brief.
INTRODUCTION AND BACKGROUND
Physician burnout is a syndrome characterized by depersonalization (of patients, family, and friends), emotional
exhaustion, and a reduced sense of accomplishment (Shanafelt, et al. 2002; Spickard 2002) that, if left unaddressed,
can lead to decreased work effectiveness and abandoned medical careers. One recent national study estimated that
around 22% of primary care physicians met at least some criteria for physician burnout (Linzer, et al., 2001). For
physicians practicing in particular specialties, such as oncology, rates can be even higher (Allegra, et al.2005). Similar
to the important influences of clients and peers in other professional realms (see, for example, Quinn, Anderson, and
Finkelstein, 1998), the quality of patient and peer relationships are contextual factors that shape Mississippi physicians’
daily experiences of their medical roles. The depersonalization associated with burnout may reduce the perceived
quality of peer and patient-provider relationships for physicians who experience burnout syndrome.
Pressures generated by patient relationships or practice burdens can contribute to depersonalization (the inability to
ful y empathize with patients and others) and emotional exhaustion (feeling and being overwhelmed). The
depersonalization that accompanies physicians’ negative perceptions of patient relationships may place the delivery of
high quality health care at risk. Conventional wisdom assumes that poorer quality relationships (peer and/or patient)
may contribute to burnout. However, burned out physicians’ negative perception of relationship quality may result
from their own harsh self-judgments. That may be a component of the occupational risk of setting unreasonably high
standards that physicians then sometimes fail to attain (in their own judgment, although not necessarily the judgment
of others), which contributes to burnout (Maslach and Leither, 1997). Feeling alienated from fellow professionals
poses additional risks for burnout, providing a platform by which already stressed physicians may compare themselves
unfavorably to their peers, magnifying tendencies towards a reduced sense of accomplishment—the sense that even
high quality performance somehow fal s short of the mark. Negatively perceived patient and peer relationships, when
unrelenting, can lead to higher levels of stress. This sets the stage for cascading risks of pressure towards
depersonalization, emotional exhaustion and the reduced sense of accomplishment that together characterize
physician burnout syndrome. This process of burnout may pose serious risks for a thriving Mississippi physician
workforce if the syndrome is widespread.
DATA AND METHODS
A validated single measure of burnout (Rohland, Kruse and Rohrer, 2004) on the 2007/8 MSMD survey asked the
“Please choose the single item that most closely represents how you feel: (1) I enjoy my work. I do
not feel burned out. (2) Occasional y I am under stress, and I don’t always have as much energy as I
once did. But, I don’t feel burned out. (3) I am definitely burning out and have one or more
symptoms of burnout, such as physical or emotional exhaustion. (4) The symptoms of burnout that
I’m experiencing won’t go away. I think about frustrations at work a lot. Or (5) I feel completely
burned out and often wonder if I can go on. I am at the point where I may need to make some
changes or may need to seek some sort of help.”
The two highest burnout scores (symptoms won’t go away and feeling completely burned out) were combined into a
single measure of persistent burnout. Respondents were then categorized by reported levels of burnout in their
professional lives, ranging from (1) no burnout to (2) stressed [no burnout],(3) occasional burnout,or(4) persistent burnout.
Among respondents to the MSMD 2007/08 survey, 19% of respondents reported occasional and 5% reported persistent
burnout. Fifty-five percent of Mississippi’s felt stressed; only 20% experienced no burnout at all.
We analyzed the association between burnout responses from the actively practicing physicians (N=633) who
responded to that section of the 2007 MSMD survey alongside items measuring different aspects of physicians’
professional relationships. The first set of items measured agreement with statements used to assess the perceived
quality of doctor-patient relationships:
• I am overwhelmed by the needs of my patients.
• My relationship with patients is more adversarial than it used to be.
• Time pressures prevent me from developing good patient relationships.
• I often feel like what I do for my patients is just a drop in the bucket.
• I feel a strong personal connection to my patients.
The second set of statements measured agreement with items designed to ascertain how Mississippi physicians with
different burnout levels perceived their relationships with peers (fel ow physicians and col eagues).
• My colleagues support my efforts to balance family and career responsibilities.
• Many of my col eagues do not share my life experiences.
• My physician colleagues are an important source of personal support.
• My physician colleagues are a source of professional stimulation.
• I wish there were more doctors like me in my practice.
The association between burnout level and patient/peer relationship quality are depicted in Figure 1 and Figure 2,
respectively. Higher average scores on the relationship items indicate higher levels of agreement with statements.
FINDINGS Relationships with patients. Physicians
Figure 1. Burnout and Patient Relationships
(occasional or persistent burnout) were
much more likely to agree that patients’
medical interventions were “just a drop
stressed physicians (no burnout or
stressed). Items characterizing patients as
developing good patient relationships.
more adversarial or perceiving a lack of
time to build good patient relationships
patients is just a drop in the bucket.
with physicians’ level of self-reported
lowest level of burnout (no burnout or
stressed) were most likely to disagree that
Strongly Disagree=1 Strongly Agree=5
good patient relationships, while physicians with the highest levels of burnout (oc asional or persistent) were much more
likely to agree with those statements. In contrast to these systematic differences in perceptions of patient relationships
by burnout level, most Mississippi physicians who responded to the 2007/08 MSMD survey felt personal y connected
to their patients, regardless of how much burnout they reported.
Relationships with peers. There was little
difference across burnout levels in whether,
Figure 2. Burnout and Col eague Relationships
on average, physicians felt a need for “more
doctors like me” in their practices (most
agreed they would like more doctors like
them), nor in whether they felt supported
physicians with oc asional or persistent burnout
were only slightly less likely than physicians
experiencing no burnout at all or who were
important source of personal support. stressed to regard other physicians as
(Figure 2). However, differences in other
peer relationship items followed distinctive
stressed or experiencing no burnout, physicians
with persistent or occasional burnout were less
Strongly Disagree=1 Strongly Agree=5
likely to say that peers supported their
efforts to balance family and career responsibilities, shared similar life experiences, or to regard their physician
col eagues as sources of professional stimulation.
IMPLICATIONS Doctor-patient relationships have inevitable hierarchical qualities, while relationships with other physicians and
professional colleagues are more likely to be lateral peer relationships. This descriptive analysis of the MSMD
2008/08 data suggests that the hierarchical character of patient relationships may render them more vulnerable than
peer relationships to the depersonalization component of physician burnout. The range of variation (from lowest
levels of agreement to highest) by burnout category was greater across the patient measures than for the professional
ones. Recent research has underscored ways that traditional doctor-patient relationships are evolving (Schneider,
1998), including the propensity for contemporary patients to be more demanding, informed consumers of health care
than ever before (Rothman 2001). The temporal reality of rapid changes in healthcare relationships (Warren, Weitz,
and Kulis 1998) suggests the need for “anti-burnout” strategies that are attentive to career stage of the physicians at
risk, a potential direction for future research.
Regardless of burnout level, Mississippi physicians in the study recognized that, while other doctors are not necessarily
their mirror images, peers are nonetheless important sources of personal support. From this general vantage point,
peer relationships differed little by burnout level. However, more specific components of peer relationships (support
for work/life balance, professional stimulation, shared life experience) varied by burnout level, as physicians with
persistent or occasional burnout differed substantially from their less beleaguered counterparts. Other research
demonstrates that work and family imbalance are also associated with high rates of burnout (see Cossman and Street
2009). Consequently, to the extent that peers can help fel ow professionals to re-calibrate critical aspects of the
personal/professional interface, that kind of support likely mitigates stress that could otherwise contribute to higher
burnout risks. As for perceiving professional stimulation and shared life experiences in peer relationships, those are
more common stances for the least burned out physicians (stressed, no burnout) in the study. Unmet expectations about
patient or peer relationships, plus other medical practice pressures, are a recipe for physician burnout.
What could be done to ameliorate the burnout risks associated with negative perceptions of peer relationship quality?
A first step is better and ongoing education starting with early medical training and spanning lifelong learning about
the importance of intra-professional support and patient relationship management for successful medical practices
and careers. More training and professional society attention to the changing generational expectations and
experiences of physicians is in order. It could help minimize some peer-related burnout risks by reinforcing respect
and support both for what experienced physicians in more traditional roles bring to the table, and by understanding
the changing pace of medical care and professional expectations for newly trained physicians. Future healthcare
provision, even in rural areas, is evolving towards more inter and intra-professional collaboration and less solo
practice. This requires further adaptations both to the doctor-patient role in a multi-professional practice
environment and to finding mechanisms that identify and support physicians considered “at risk” for burnout.
We cannot establish directionality for peer relationships and burnout—it may be that physicians who report higher
levels of stress perceive peer relationships more negatively because they do not receive adequate work-life balance
support or professional stimulation from them, or their life experiences are very different, or patient needs real y are
unmanageable and overwhelming. Alternatively, physicians who experience high levels of burnout and who have the
least positive patient and peer relationships may view those relationships through a negative lens because they are
already burned out and, consequently, are less likely to notice or focus on more positive aspects of their professional
relationships. In many ways the quality of relationships and degrees of burnout seem to be components in a virtuous
(when positive) or vicious (when negative) circle. Devising interventions to interrupt the negative aspects of
relationships and/or burnout cycles, or to reinforce the continuation of positive ones, seem an urgent requirement for
a workforce that deals with manageable amounts of pressure and stress.
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ABOUT THE AUTHORS
Jeralynn S. Cossman, Clinton Wallace Dean’s Eminent Scholar and Associate Professor of Sociology at Mississippi State University, is the Director of the Mississippi Center for Health Workforce. Debra Street, an Associate Professor of Sociology at the State University of New York at Buffalo, is an alumna of the Robert Wood Johnson Scholars in Health Policy Research Program and a member of the National Academy of Social Insurance. The North East Mississippi Area Health Education Center (NE MS AHEC,
is hosted by the Social Science Research Center at Mississippi State
University and is an affiliate of the Mississippi Area Health Education Center Program (MS
AHEC) at the University of Mississippi Medical Center. The MS AHEC Program is partially
funded by a grant from the Health Resources and Services Administration (HRSA). The
Mississippi State Medical Association, the Mississippi Academy of Family Physicians, the
American Academy of Family Physicians, and the Social Science Research Center at Mississippi
State University provided resources for the Mississippi Workforce Study (2007/08 MSMD).
The material in this brief reflects the authors’ perspective, but not necessarily those of affiliated
organizations and funding organizations or funding agencies.
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