When I wrote about the benefits of administrators shadowing frontline clinicians, I felt compelled to look for an opportunity to go to the front lines myself. After all, it has been 20 years since I donned a white coat and stethoscope. I’m firmly entrenched in the identity of writer but know that first hand research is invaluable.
I asked an internist in a hospital-based primary care clinic if I could follow her for an afternoon. She readily agreed and suggested I might bring a stethoscope. I decided to leave mine stored in the attic and assured her when I arrived that my focus was her and how she worked, not her patients.
The afternoon reminded me of what drew me to clinical medicine in the first place—the privileged connection with patients—and reaffirmed why the barriers and frustrations that get in the way of that connection and lead to burnout are such an important problem to solve.
I was thrilled to see that after 20 years away the basic components of clinical care—history-taking, diagnosis, treatment, and developing a caring relationship with a patient—have changed very little. Yes, the presence of the electronic health record (EHR) is a seismic change from when I trained and practiced, but the connection with the patient and the mystery-solving were the old friends I remembered.
The question burning in my mind as I watched her work was, “How did she do it? How, in the midst of a burnout epidemic, did she manage to remain unscathed and clearly joyful in her work?” During the afternoon I pondered what I’ve learned about the underlying causes of physician burnout to try to answer this question.
Christina Maslach and Michael Leiter, researchers on burnout, identified six areas in which misalignment or “mismatch” is predictive of professional burnout. 
These domains are:
- Work overload
- Lack of control
- Insufficient reward
- Breakdown of community
- Absence of fairness
- Conflicting values
I considered these domains as I tried to understand why this primary care provider was so upbeat and joyful in her work.
I saw that one of the protective factors in her clinic related to the work load domain. Her workload, during clinic hours at least, was far more reasonable than that demanded of many physicians today. She was afforded 20 minutes for returning patients and 40 for patients new to the practice. She left most of her charting to the hours after clinic ended, which meant long days there or evening work at home but translated into an easier pace while seeing patients.
In addition, she was facile with the EHR, which the hospital had launched many years before. She had found a way to insert the EHR into a streamlined workflow, rather than have it become a barrier and a frustration. The clinic also had an effective process for rooming patients and for care plans, prescription ordering, and lab draws, which helped to streamline her work.
Having a reasonable work load meant that she was able to spend quality time talking with her patients, connecting with them on a human level, without having her eyes on the monitor and hands on the keyboard. She was a pro at building a connection with her patients, even the ones new to her, and with inserting appropriate humor into the visit—a skill I so admire. To all appearances, regardless of the illness or concern that brought them to the clinic, her patients enjoyed the visits as well.
Later, when she finished seeing her scheduled patients, we sat in her office for a few minutes. I asked her why she appeared to be untouched by burnout. Her answer related to control not workload.
The internist told me that she had joined this practice just six months before—after 15 years as a hospitalist. She had chosen to leave her previous position when she found herself saddled with increasing administrative duties and frustrated by the lack of response by leadership when she raised concerns about the daily experience of frontline physicians. It was lack of control that led her to leave her field mid-career and start anew in ambulatory care.
Knowing that burnout affects at least half of physicians in this country and that its prevalence reflects systems issues, it was refreshing to find a primary care physician in a setting that allows her to experience the joy of patient care. So many clinicians in this country—and around the world—are working in chaotic work settings in which the workload is overwhelming and where they have little control over their work experience.
It is reassuring to know that it is still possible to enjoy clinical medicine. The shadowing experience inspired me to redouble my efforts to advocate for the changes that will allow more physicians to recapture that joy in practice.
1. Maslach C, Schaufeli WB, Leiter M. Job burnout. Annu. Rev. Psychol. 2001. 52:397–422.
Questions to consider:
- Is one domain more important than the others for clinical work settings?
- If you are dissatisfied or experiencing burnout, which of the six is most problematic in your work setting?
- If you are satisfied with your workplace, is one of the six domains especially protective of your job satisfaction?