This study critically assesses the impact of a reproducible organizational intervention program with the aim of promoting physician well-being at a multisite urban primary care group. Interventions were designed to increase physician control over their work environment, improve order in clinic functioning, and deepen the meaning physicians find in their work. Assessments reveal a significant decrease in emotional and work-related exhaustion.
The significant decrease in exhaustion, as measured by the MBI and QWC subscales, indicates an improvement in physician self-perceived capacity for empathy and emotional connection. This is a pivotal change that over time could lead to a decrease in depersonalization and increase in personal accomplishment and satisfaction. The capacity for emotional connection with patients and coworkers gives clinicians access to sources of energy renewal in the workplace, otherwise lost on one who is emotionally depleted and unable to connect. Finding renewal not only on weekends and vacations, but also at work, is vital to a sustainable career.
It is likely that strategic efforts to increase physicians’ control over their work environment (Table ), particularly soliciting their input on the scheduling template and making adjustments to length of visits and case-mix, contributed to decreasing their emotional exhaustion. In a study of well-being among Kaiser Permanente physicians, 58% in 2 staff model HMO’s reported high emotional exhaustion.31
That study indicated that physicians’ sense of control over their practice environment was the greatest predictor of satisfaction, commitment to the organization, and personal/professional well-being. Low well-being, low work satisfaction, and practice-related concerns have also been reported in a large number of other studies.15,26–46
Despite the obvious need to assist physicians in enhancing their well-being at the same time as organizational processes are improved, there is little published data focusing on the evaluation of organizational-based interventions aimed at physician and organizational well-being. Most interventions target the individual physician with little connection to the organizational and social context within which that physician is practicing.
The QWC measures of organizational health indicated that 3 domains—efficacy, mental energy, and work-related exhaustion—showed steady improvement since 2002. Of those, improvement in work-related exhaustion was statistically significant, even when multivariate statistics were applied to control for the possible influence from other domains assessed simultaneously. Efficacy indicates satisfaction with work planning, orientation toward a common goal, an effective decision-making process, and optimization of resource allocation and use. Mental energy is a marker for a relative absence of restlessness, irritation, moodiness, anxiety, and impaired concentration among those responding to the survey. Work-related exhaustion refers to feeling emotionally drained and tired after work. Taken together, the positive trends on these dimensions suggest that physicians perceived and appreciated increased order in their work environment and that subjectively they felt less distressed after the implementation of the intervention.
The improvement noted in physicians’ perceived capacity for emotional connection and their sense of reduced distress and burnout occurred against a backdrop of decreased satisfaction among Oregon and U.S. physicians.1,2,33
Thus, programs such as the one presented in this study might be an important mitigator, at least partially, of the continuous slide in physician well-being and job satisfaction. The organization will also benefit. Physicians who are more satisfied with their work tend to be more productive.8,22,30,31
Work satisfaction also enhances efforts in recruitment and retention of physicians.20,47,48,49
Estimates indicate that replacing 1 primary care physician can result in $20,000 to $26,000 in recruitment costs, loss of $300,000 to $400,000 in annual gross billings, loss of $300,000 to $500,000 in inpatient revenue, plus additional losses of specialty referral revenue.47
Rates of yearly physician turnover range from 10% to 15% nationally,47
comparable to the current study. Furthermore, distressed physicians have higher medical error rates, increasing malpractice risk, and associated costs to the organization.3,25,50
An effective well-being program can help mitigate these losses.
Implementing this program provided key lessons to the organization. First, establishing physician well-being as an essential value of the organization helps create the intended culture. Second, a regular iterative process of inquiry and feedback from physicians can identify issues that negatively affect well-being and barriers to improvement. Third, assessment of well-being using reliable and valid instruments further establishes the value and creates a common language that can help physicians and the organization address well-being issues.
There are several limitations to this study. The program was applied to a relatively small, newly formed employed physician group that experienced substantial change over the 4-year study. The small number of physicians limits the statistical power to detect changes in outcome measures over time. Also, as expected for a young growing organization, physician turnover was significant, although similar to groups nationally. Improvements in well-being measures might be attributable to dissatisfied physicians leaving the organization, replaced by more positive colleagues. A substantially larger and more stable cohort would be needed to detect smaller changes in physician and organizational well-being. From prior experiences using QWC, observed changes in the current study are fewer than expected. This may indicate a limited ability for Legacy Clinic to sustain improvement processes. Future studies need to better describe in more detail the ingredients of interventions, intensity of their use, and degree of adoption by the organization.
Although the program showed a number of positive trends, based on the years of dedicated leadership and physician efforts, results show needed improvements. The key elements of this program, however, and the principle of applying data-guided interventions are applicable to health care organizations that face the challenge of increasing productivity in times of increasing physician discontent.
Caring for others in an ever more constrained world of regulation and productivity demands, physicians increasingly sense an erosion of control. The tide of physician distress and burnout over the last several years is rising. Given the negative consequences to patients, physicians, and their organizations, it is imperative that leadership gives well-being the prominence it deserves.51,52
Only by applying robust measures of well-being, engaging physicians in reflection and conversation about promoting it in the workplace, tracking it as a meaningful outcome, and making changes to enhance its realization, will physicians and their organizations thrive in their service to patients.