Contrary to our hypothesis, physician burnout was not associated with differences in their own communication behaviors during medical visits. However, physician burnout was related to patient communication. Patients demonstrated more rapport-building of certain types in interactions with high burnout physicians.
Rapport-building exchanges serve an important function within the patient-physician encounter. Even disagreements with the physician or criticism directed toward others (the most frequent elements included in the negative rapport composite) may be seen as reflecting openness in the medical dialogue and solidarity with the physician. Higher patient engagement and participation in the medical encounter, including both positive and negative exchanges, are associated with patient’s experience of care as patient-centered34
and patient satisfaction.35
By other measures, higher burnout was not associated with lower quality physician communication. We found no evidence of poorer affective tone, less patient-centeredness, verbal dominance, shorter visits, or lower patient ratings. Our findings differ from previous studies, which have suggested that high burnout physicians have lower confidence in their communication skills, lower capacities for empathy, and suboptimal self-reported communication behaviors with patients.16,19,20
Several explanations may account for the difference between our findings and others. 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.48
Because of their reduced sense of personal accomplishment, physicians with burnout may be more likely to perceive suboptimal interactions with patients. As a result, physicians 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.19
A concerning implication of this explanation is the risk that excellent physicians could enter a vicious cycle where burnout leads to faulty perceptions of suboptimal performance, which then predisposes to worsening burnout. In a longitudinal study of physicians-in-training, West et al. found that physicians with self-perceived medical errors had increased odds of subsequent burnout and depression.49
Alternatively, physicians reporting burnout may be more sensitive to high patient expectations that they feel they cannot meet. Although our physicians completed the burnout scale prior to the specific patient encounter analyzed, these findings may suggest that high-burnout physicians have patient panels characterized by high patient engagement. Satisfaction with the patient-doctor relationship is associated with physicians’ global satisfaction,50
but physicians with high burnout may not perceive patient rapport-building as satisfying or successful. The higher-burnout physicians in our sample may tend to perceive patient rapport-building statements as placing demands on them. An et al. found that providers who perceive they have a higher proportion of “difficult” relationships are more likely to have symptoms of burnout.51
The “social exchange model of burnout” suggests that patients bring both demands and resources that may affect physician well-being and that physicians who perceive a lack of reciprocity in the patient-doctor relationship may be susceptible to burnout.52
Thus, although we measured burnout before assessing communication behaviors, the relationship could extend in the other direction, with patient-provider relationships affecting physician well-being.
Our findings may also relate to the balance between empathy and boundary-setting in the patient-provider encounter. Huggard termed this phenomenon “compassion fatigue,” in which physicians who engage empathically with their patients experience secondary traumatic stress and develop burnout.53
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.42
This may suggest that – even early in their training – physicians are learning to put their patients’ well-being ahead of their own.54
Finally, patients may perceive unmeasured nonverbal cues from physicians with burnout that elicit an empathic response to these physicians. Patients’ overtures of rapport-building – such as reassurance/optimism statements – could represent patients’ efforts to demonstrate empathy or support for their physicians. We did not find any significant differences in the emotional tone of physicians relative to burnout; however, these cues may have been communicated through facial expressions or body language — a channel not rated by the coders.
The limitations of this study should be considered. First, we did not administer the complete MBI or include items from all three domains of burnout, and so our scale and categories may not represent clinically meaningful differences in the level of burnout among physicians. However, our questions demonstrated high internal consistency. Second, our sample included only a subset of patients from each physician’s panel, and we may have obtained different results with a larger or a randomly selected sample. Third, our sample of physicians and patients may not be representative of primary care encounters in other settings, particularly outside of urban, minority community clinics. Compared with a 2001 statewide random sample of Maryland physicians, our study physicians were younger, more likely to be women, and more likely to be an ethnic minority.55
Fourth, our communication analyses were limited to data from audiotaped encounters, and we were unable to assess the role of other cues – such as body language – in the interactions. Fifth, with only one visit recorded for each patient, our study cannot assess the directionality or causality in the relationship between burnout and communication outcomes. Finally, during the interval between the measurement of physician burnout and the measurement of communication behaviors in the patient encounters, burnout may have changed for some physicians. The MBI has demonstrated stability for up to 1 year, capturing the enduring state of burnout in diverse populations – including nurses.14,26,56–59
However, if burnout did change over time, we may have underestimated or overestimated the associations between burnout and communication behaviors. For example, we may have found a stronger relationship with patient rapport-building or ratings had we measured burnout closer to the time of the encounters.
More research is needed to understand the potential strength and mechanisms of a relationship between physician well-being and patient-physician communication. Our study focused on only one aspect of physician well-being: burnout. This analysis did not address other aspects of physician well-being – such as career satisfaction, coping strategies, or acute stressors – which could mediate or modify the relationship between burnout and communication.
In conclusion, our study found that higher physician burnout may be associated with more patient rapport-building behaviors and patients’ experiences of confidence and trust in their physicians. Future studies should investigate the complex links among clinician well-being, quality of medical visit communication, and patient outcomes.