TABLE 2
Physician characteristics across frequency clusters (n=422)1
| Physician characteristic | Frequency-of-difficult-encounter cluster | ||
|---|---|---|---|
| High, % (n=113) | Medium, % (n=268) | Low, % (n=41) | |
| Family physicians (vs general internists) | 41.6 | 49.6 | 58.5 |
| Age, mean (SD) | 40.8 (9.0)*† | 43.3 (9.0) | 46.1 (13.4) |
| Female sex | 50.4† | 44.6‡ | 26.8 |
| Racial/ethnic minority | |||
| • Black or African American | 8.0 | 4.1‡ | 14.6 |
| • Asian | 13.3 | 11.9 | 9.8 |
| • Hispanic or Latino | 6.6 | 3.1 | 0 |
| • Other | 6.2 | 3.4 | 0 |
| Full-time work status | 83.8 | 83.5 | 80.5 |
| Exact probability tests were used to contrast proportional differences. *P<.05 for high vs medium frequency of difficult encounter clusters. †P<.05 for high vs low frequency of difficult encounter clusters. ‡P<.05 for medium vs low frequency of difficult encounter clusters. | |||
We examined the relationship between perceived frequency of difficult encounters and patient outcomes using a double-mediation model with physician burnout and satisfaction as mediators. We found that the greater the perceived number of difficult encounters, the greater the burnout and job dissatisfaction. For example, on a 5-point Likert scale measuring burnout where 1 = no burnout and 5 = significant and persistent burnout, medium-cluster physicians scored 0.48 points higher than the low-cluster physician cohort. High-cluster physicians scored 0.84 points higher than their low-cluster colleagues (both P<.05). Similarly, high-cluster physicians were less satisfied with their jobs; on a 5-point scale where 1 = low satisfaction and 5 = high satisfaction, high-cluster physicians scored 0.60 points lower than low-cluster physicians (P<.05).
Yet, there was no clear association between perceived frequency of difficult encounters and patient outcomes. High-cluster physicians had a 5.57% lower overall error rate compared with low-cluster physicians (P<.05), although this was not true for specific errors, such as those in hypertension or diabetes management, where rates were similar. High-cluster physicians also had a 7.68% lower overall quality rate (P<.05), although, again, this was not true for management of specific conditions such as hypertension and diabetes, where rates were similar. In sum, in our double-mediation model, there was no consistent influence of a physician’s difficult-encounter cluster on patient outcomes, even when including physician burnout and level of satisfaction as mediators.
DISCUSSION
Our principal finding is that the perception of frequent difficult encounters—while associated with significant physician burnout and dissatisfaction—was not associated with worse quality of patient care or higher rates of error. Physicians with a high volume of difficult encounters and burnout maintained standards of care for their patients comparable to those of their peers who experienced less frequent difficult encounters. We propose several hypotheses to explain this observation.
First, the Conservation of Resources (COR) Theory suggests that when resources are depleted or stressed by work demands (difficult encounters), burnout will result.17 In response, burned-out individuals will reduce their resource expenditure (attention, time) and focus their resources on the most important aspects of their work—in our case, measured quality of care. In the physician-patient communication literature, Williams et al suggest that burned-out physicians use a strictly biomedical style of communication,18 which is less resource intensive than more patient-centered forms of communication.19 Thus, while a physician may be burned out and dissatisfied, she or he will focus communication on key clinical aspects of the encounter (the presenting complaint, necessary preventive care) while de-emphasizing the psychosocial aspects of care. Consequently, a physician may be burned out by difficult encounters, but may continue to provide adequate patient care.
Second, these results may reflect (in part) the professional socialization of physicians. The rigors of medical school and residency training provide physicians with a high level of personal hardiness. The nursing literature defines hardiness as the interrelatedness of 3 factors controlled by the individual through lifestyle: control of the environment, commitment to self-fulfilling goals, and reasonable levels of challenge in daily life. Thomsens et al found that these traits serve as buffers to protect individuals from the psychological repercussions of stress.20
Nikou designed a study to investigate the relationships among hardiness, stress, and health-promoting behaviors in students attending a nursing student conference.21 The results indicated that hardiness was inversely related to stress and positively related to health-promoting behaviors. Thus, while physicians face challenging and difficult encounters and become burned out and dissatisfied, they are able to deliver acceptable patient care due to the buffering effect of their professional socialization.
Third, physicians’ responses to performance measurement pressures—ubiquitous in the culture of primary care medicine today—may also contribute to our findings. Physicians are called on to meet both national and local standards of care, and are expected to keep patients satisfied. Such objectives may be tied to financial incentives.22 In this environment, many doctors are likely to respond so that quality measures are met, even when faced with a challenging patient encounter. Higashi et al found that the quality of care delivered to patients was better as the number of chronic conditions increased.23 Others have argued that current clinical practice guidelines, which have driven quality measurement, have led to unintended consequences—for example, polypharmacy with inadequate consideration of adverse drug-drug interactions.22,24,25