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Actions Reported by Physicians With Large Improvements in Burnout and Professional Fulfillment

Author/s: 
Tait D. Shanafelt, MD, Maryam S. Makowski, PhD, Brook Hale, et al.

Importance Occupational distress among physicians is a highly prevalent problem that limits the effectiveness of the health care delivery system. While system change is necessary, individual physicians must also consider personal actions to mitigate occupational distress.

Objective To identify physician actions associated with large-effect-size improvements in burnout and/or professional fulfillment over a 6-month interval.

Design, Setting, and Participants This qualitative study using a mixed-methods approach recruited US physicians from the American Medical Association Physician Data file. The study used 2 quantitative online surveys that were administered 6 months apart (October 2 to November 13, 2024, and April 2 to May 16, 2025) to identify physicians with large-effect-size (≥0.8 SD) improvement in burnout and/or professional fulfillment. These physicians were subsequently recruited to participate in a qualitative study using structured interviews to identify changes they believed contributed to this improvement.

Main Outcomes and Measures Burnout and professional fulfillment were assessed using the Stanford Professional Fulfillment Index.

Results A total of 359 practicing physicians responded to both the baseline and follow-up surveys, among whom 87 (24.3%) had an effect size improvement of 0.8 SD or greater in burnout and/or professional fulfillment and were invited to participate in qualitative interviews. Thirty physicians (20 participants [66.7%] aged 30-49 years and 10 [33.3%] aged ≥50 years; 22 [73.3%] female) completed interviews. Thematically, these physicians reported changes in 4 categories: active (ie, intentional) work changes, passive work changes, active personal changes, and passive personal changes. A majority of participants (26 [86.7%]) reported active work and/or personal changes. Active work changes included changes to workload and work schedule, developing new skills or changing the focus of work, changing job or position, taking on or giving up a leadership position, improving efficiency, and advocating for personal needs. Active personal changes included deliberate changes in mindset, contemplative practices, taking time away, working with a therapist or coach, and prioritizing self-care. Passive work changes occurred independent of action by the individual physician and included new leadership, staffing changes, system-initiated workflow changes, and advances in technology. Passive personal changes were infrequently reported.

Conclusions and Relevance Physicians with large improvements in burnout and professional fulfillment reported specific actions at work or in their personal life that they believed led to this improvement. These findings suggest that both individual- and system-level changes may be necessary to optimize occupational well-being among physicians.

Keywords 
burnout, professional Occupational Distress Qualitative Study Mixed-Methods Approach U.S. Health Study

Human Papillomavirus Immunization in Rural Primary Care

Author/s: 
Ferrara, Laura, K., Gunn, Rose, Dickinson, Caitlin, Stock, Isabel, Griffith-Weprin, Jennifer, Wiser, Amy, Hatch, Brigit, Fagnan, L.J., Carney, P.A., Davis, M.M.

Abstract

Introduction: Despite the safety and efficacy of the human papillomavirus vaccine, thousands are impacted by human papillomavirus and its related cancers. Rural regions have disproportionately low rates of human papillomavirus vaccination. Primary care clinics play an important role in delivering the human papillomavirus vaccine. A positive deviance approach is used to identify workflows, organizational factors, and communication strategies in rural clinics with higher human papillomavirus vaccine up-to-date rates. Positive deviance is a process by which exceptional behaviors and strategies are identified to understand factors that enable success.

Methods: Rural primary care clinics were rank ordered by human papillomavirus vaccine up-to-date rates using 2018 Oregon Immunization Program data, then recruited via purposive sampling of clinics in the top and bottom quartiles. Two study team members conducted previsit interviews, intake surveys, and 2-day observation visits with 12 clinics and prepared detailed field notes. Data were collected October-December 2018 and analyzed using a thematic approach January-April 2019.

Results: Four themes distinguished rural clinics with higher human papillomavirus vaccine up-to-date rates from those with lower rates. First, they implemented standardized workflows to identify patients due for the vaccine and had vaccine administration protocols. Second, they designated and supported a vaccine champion. Third, clinical staff in higher performing sites were comfortable providing immunizations regardless of visit type. Finally, they used clear, persuasive language to recommend or educate parents and patients about the vaccine's importance.

Conclusions: Positive deviance identified characteristics associated with higher human papillomavirus vaccine up-to-date rates in rural primary care clinics. These findings provide guidance for rural clinics to inform human papillomavirus vaccination quality improvement interventions.

Copyright © 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

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