System-Based Interventions to Address Physician Burnout: A Qualitative Study of Canadian Family Physicians’ Experiences During the COVID-19 Pandemic

Document Type : Original Article

Authors

1 Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada

2 Faculty of Nursing, Memorial University, St. John’s, NL, Canada

3 Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada

4 Department of Family Medicine Primary Care Research Unit, Dalhousie University, Halifax, NS, Canada

5 Doctors Nova Scotia, Dartmouth, NS, Canada

Abstract

Background 
Medical professionals experienced high rates of burnout and moral distress during the COVID-19 pandemic. In Canada, burnout has been linked to a growing number of family physicians (FPs) leaving the workforce, increasing the number of patients without access to a regular doctor. This study explores the different factors that impacted FPs’ experience with burnout and moral distress during the pandemic, with the goal of identifying systembased interventions aimed at supporting FP well-being and improving retention.
 
Methods 
We conducted semi-structured qualitative interviews with FPs across four health regions in Canada. Participants were asked about the roles they assumed during different stages of the pandemic, and they were also encouraged to describe their well-being, including relevant supports and barriers. We used thematic analysis to examine themes relating to FP mental health and well-being.
 
Results 
We interviewed 68 FPs across the four health regions. We identified two overarching themes related to moral distress and burnout: (1) inability to provide appropriate care, and (2) system-related stressors and buffers of burnout. FPs expressed concern about the quality of care their patients were able to receive during the pandemic, citing instances where pandemic restrictions limited their ability to access critical preventative and diagnostic services. Participants also described four factors that alleviated or exacerbated feelings of burnout, including: (1) workload, (2) payment model, (3) locum coverage, and (4) team and peer support.
 
Conclusion 
The COVID-19 pandemic limited FPs’ ability to provide quality care to patients, and contributed to increased moral distress and burnout. These findings highlight the importance of implementing system-wide interventions to improve FP well-being during public health emergencies. These could include the expansion of interprofessional team-based models of care, alternate remuneration models for primary care (ie, non-fee-for-service), organized locum programs, and the availability of short-term insurance programs to cover fixed practice operating costs.

Keywords

Main Subjects

References

  1. Leiter MP, Maslach C. Latent burnout profiles: a new approach to understanding the burnout experience. Burn Res. 2016;3(4):89-100. doi:1016/j.burn.2016.09.001
  2. Jameton A. Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ: Prentice-Hall; 1984.
  3. Patterson JE, Edwards TM, Griffith JL, Wright S. Moral distress of medical family therapists and their physician colleagues during the transition to COVID-19. J Marital Fam Ther. 2021;47(2):289-303. doi:1111/jmft.12504
  4. Canadian Medical Association. Burnout 101: Signs and Strategies. https://www.cma.ca/burnout-101-signs-and-strategies. Updated July 24, 2020. Accessed May 23, 2023.
  5. Neumann JL, Mau LW, Virani S, et al. Burnout, moral distress, work-life balance, and career satisfaction among hematopoietic cell transplantation professionals. Biol Blood Marrow Transplant. 2018;24(4):849-860. doi:1016/j.bbmt.2017.11.015
  6. Rosen A, Cahill JM, Dugdale LS. Moral injury in health care: identification and repair in the COVID-19 era. J Gen Intern Med. 2022;37(14):3739-3743. doi:1007/s11606-022-07761-5
  7. Bourne DW, Epstein E. The experience of moral distress in an academic family medicine clinic. HEC Forum. 2023;35(1):37-54. doi:1007/s10730-021-09453-9
  8. Epstein EG, Whitehead PB, Prompahakul C, Thacker LR, Hamric AB. Enhancing understanding of moral distress: the measure of moral distress for health care professionals. AJOB Empir Bioeth. 2019;10(2):113-124. doi:1080/23294515.2019.1586008
  9. Abraham CM, Zheng K, Poghosyan L. Predictors and outcomes of burnout among primary care providers in the United States: a systematic review. Med Care Res Rev. 2020;77(5):387-401. doi:1177/1077558719888427
  10. British Columbia College of Family Physicians. CMA Reports Family Physicians Have Highest Rate of Burnout Among Physicians. 2022. https://bccfp.bc.ca/about-us/news/cma-reports-family-physicians-have-highest-rate-of-burnout-among-physicians/. Accessed June 13, 2023.
  11. The College of Family Physicians Canada. Position Statement on Physician Burnout in Canada. 2022. https://www.cfpc.ca/en/policy-innovation/health-policy-goverment-relations/cfpc-policy-papers-position-statements/position-statement-on-physician-burnout-in-canada. Accessed June 13, 2023.
  12. Canadian Medical Association. CMA 2021 National Physician Health Survey. 2022. https://www.cma.ca/sites/default/files/2022-08/NPHS_final_report_EN.pdf. Accessed May 23, 2023.
  13. Kiran T, Green ME, Wu CF, et al. Family physicians stopping practice during the COVID-19 pandemic in Ontario, Canada. Ann Fam Med. 2022;20(5):460-463. doi:1370/afm.2865
  14. Hedden L, Banihosseini S, Strydom N, McCracken R. Family physician perspectives on primary care reform priorities: a cross-sectional survey. CMAJ Open. 2021;9(2):E466-E473. doi:9778/cmajo.20200102
  15. Jensen PM, Trollope-Kumar K, Waters H, Everson J. Building physician resilience. Can Fam Physician. 2008;54(5):722-729.
  16. Lee FJ, Stewart M, Brown JB. Stress, burnout, and strategies for reducing them: what's the situation among Canadian family physicians? Can Fam Physician. 2008;54(2):234-235.
  17. Ofei-Dodoo S, Loo-Gross C, Kellerman R. Burnout, depression, anxiety, and stress among family physicians in Kansas responding to the COVID-19 pandemic. J Am Board Fam Med. 2021;34(3):522-530. doi:3122/jabfm.2021.03.200523
  18. Dai M, Willard-Grace R, Knox M, et al. Team configurations, efficiency, and family physician burnout. J Am Board Fam Med. 2020;33(3):368-377. doi:3122/jabfm.2020.03.190336
  19. Hiefner AR, Constable P, Ross K, Sepdham D, Ventimiglia JB. Protecting family physicians from burnout: meaningful patient-physician relationships are "more than just medicine.” J Am Board Fam Med. 2022;35(4):716-723. doi:3122/jabfm.2022.04.210441
  20. Buck K, Williamson M, Ogbeide S, Norberg B. Family physician burnout and resilience: a cross-sectional analysis. Fam Med. 2019;51(8):657-663. doi:22454/FamMed.2019.424025
  21. Puffer JC, Knight HC, O'Neill TR, et al. Prevalence of burnout in board certified family physicians. J Am Board Fam Med. 2017;30(2):125-126. doi:3122/jabfm.2017.02.160295
  22. Rassolian M, Peterson LE, Fang B, et al. Workplace factors associated with burnout of family physicians. JAMA Intern Med. 2017;177(7):1036-1038. doi:1001/jamainternmed.2017.1391
  23. Dominic C, Gopal DP, Sidhu A. 'It's like juggling fire daily': well-being, workload and burnout in the British NHS - a survey of 721 physicians. Work. 2021;70(2):395-403. doi:3233/wor-205337
  24. Pérula-de Torres LA, Atalaya JCV, García-Campayo J, et al. Controlled clinical trial comparing the effectiveness of a mindfulness and self-compassion 4-session programme versus an 8-session programme to reduce work stress and burnout in family and community medicine physicians and nurses: MINDUUDD study protocol. BMC Fam Pract. 2019;20(1):24. doi:1186/s12875-019-0913-z
  25. Soler JK, Yaman H, Esteva M, et al. Burnout in European family doctors: the EGPRN study. Fam Pract. 2008;25(4):245-265. doi:1093/fampra/cmn038
  26. Xiao Y, Chen J. Job burnout facing Chinese general practitioners in the context of COVID-19. Int J Qual Health Care. 2022;34(2):mzac023. doi:1093/intqhc/mzac023
  27. Lange M, Joo S, Couette PA, Le Bas F, Humbert X. Impact on mental health of the COVID-19 outbreak among general practitioners during the sanitary lockdown period. Ir J Med Sci. 2022;191(1):93-96. doi:1007/s11845-021-02513-6
  28. Gelmez Taş B, Özceylan G, Zeren Öztürk G G, Toprak D. Evaluation of job strain of family physicians in COVID-19 pandemic period- an example from Turkey. J Community Health. 2021;46(4):777-785. doi:1007/s10900-020-00950-5
  29. Rochfort A, Collins C, Burgers J. Emotional distress, occupational stress and burnout among family doctors in Europe: monitoring and testing of interventions is required. Eur J Gen Pract. 2021;27(1):271-273. doi:1080/13814788.2021.1985998
  30. Marchildon GP, Hutchison B. Primary care in Ontario, Canada: new proposals after 15 years of reform. Health Policy. 2016;120(7):732-738. doi:1016/j.healthpol.2016.04.010
  31. Hutchison B, Glazier R. Ontario's primary care reforms have transformed the local care landscape, but a plan is needed for ongoing improvement. Health Aff (Millwood). 2013;32(4):695-703. doi:1377/hlthaff.2012.1087
  32. Aggarwal M, Williams AP. Tinkering at the margins: evaluating the pace and direction of primary care reform in Ontario, Canada. BMC Fam Pract. 2019;20(1):128. doi:1186/s12875-019-1014-8
  33. Mathews M, Spencer S, Hedden L, et al. Development of a primary care pandemic plan informed by in-depth policy analysis and interviews with family physicians across Canada during COVID-19: a qualitative case study protocol. BMJ Open. 2021;11(7):e048209. doi:1136/bmjopen-2020-048209
  34. Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 4th ed. Thousand Oaks: SAGE Publications; 2014.
  35. Berg BL. Qualitative Research Methods for the Social Sciences. 2nd ed. Boston: Allyn & Bacon; 1995.
  36. Guest G, MacQueen KM, Namey EE. Applied Thematic Analysis. Thousand Oaks: SAGE Publications; 2012.
  37. Yin RK. Case Study Research Design and Methods. 5th ed. Thousand Oaks: SAGE Publications; 2014.
  38. Spencer S, Hedden L, Vaughan C, et al. "It was horrible for that community, but not for the way we had imagined": a qualitative study of family physicians' experiences of caring for communities experiencing marginalisation during COVID-19. SSM Qual Res Health. 2022;2:100176. doi:1016/j.ssmqr.2022.100176
  39. Vaughan C, Lukewich J, Mathews M, et al. Family physicians' perspectives on the impact of COVID-19 on preventative care in primary care: findings from a qualitative study. Fam Pract. 2022. doi:1093/fampra/cmac113
  40. Eggertson L. Canadian primary care doctors face shortage of protective equipment. CMAJ. 2020;192(14):E380-E381. doi:1503/cmaj.1095856
  41. Mathews M, Ryan D, Hedden L, et al. Family physicians' responses to personal protective equipment shortages in four regions in Canada: a qualitative study. BMC Prim Care. 2023;24(1):56. doi:1186/s12875-022-01958-7
  42. Canadian Institute for Health Information. Virtual Care: A Major Shift for Physicians in Canada. 2022. https://www.cihi.ca/en/virtual-care-a-major-shift-for-physicians-in-canada. Accessed April 12, 2023.
  43. Hedden L, Spencer S, Mathews M, et al. "There's nothing like a good crisis for innovation": a qualitative study of family physicians' experiences with virtual care during the COVID-19 pandemic. BMC Health Serv Res. 2023;23(1):338. doi:1186/s12913-023-09256-3
  44. Ryan BL, Brown JB, Freeman TR, et al. Virtual family physician care during COVID-19: a mixed methods study using health administrative data and qualitative interviews. BMC Prim Care. 2022;23(1):300. doi:1186/s12875-022-01902-9
  45. Ouellet V, Newman K, Dubinsky Z, McNair M. Most Doctors Took Financial Hit in 1st Year of COVID, But Top Earners Did Just Fine. CBC News; 2022. https://www.cbc.ca/news/investigates/doctors-payment-data-covid-cews-1.6568343. Accessed April 12, 2023.
  46. Çevik H, Ungan M. The impacts of the COVID-19 pandemic on the mental health and residency training of family medicine residents: findings from a nationwide cross-sectional survey in Turkey. BMC Fam Pract. 2021;22(1):226. doi:1186/s12875-021-01576-9
  47. Galbraith N, Boyda D, McFeeters D, Hassan T. The mental health of doctors during the COVID-19 pandemic. BJPsych Bull. 2021;45(2):93-97. doi:1192/bjb.2020.44
  48. Myran DT, Cantor N, Rhodes E, et al. Physician health care visits for mental health and substance use during the COVID-19 pandemic in Ontario, Canada. JAMA Netw Open. 2022;5(1):e2143160. doi:1001/jamanetworkopen.2021.43160
  49. Pathman DE, Sonis J, Rauner TE, Alton K, Headlee AS, Harrison JN. Moral distress among clinicians working in US safety net practices during the COVID-19 pandemic: a mixed methods study. BMJ Open. 2022;12(8):e061369. doi:1136/bmjopen-2022-061369
  50. Peck JA, Porter TH. Pandemics and the impact on physician mental health: a systematic review. Med Care Res Rev. 2022;79(6):772-788. doi:1177/10775587221091772
  51. Rimmer A. COVID-19: eight in 10 doctors have experienced moral distress during pandemic, BMA survey finds. BMJ. 2021;373:n1543. doi:1136/bmj.n1543
  52. Crawley M. How Ontario’s New Health-Care Deal Could Change the Way Your Family Doctor Works. CBC News; 2023. https://www.cbc.ca/news/canada/toronto/ontario-canada-doctors-family-health-teams-1.6764329. Accessed May 24, 2023.
  53. Health Canada. The Government of Canada and Ontario Reach Agreement in Principle to Improve Health Services for Canadians. Ottawa, Ontario: Health Canada; 2023. https://www.canada.ca/en/health-canada/news/2023/02/the-government-of-canada-and-ontario-reach-agreement-in-principle-to-improve-health-services-for-canadians.html. Accessed May 24, 2023.
  54. Ontario Medical Association. OMA insurance. 2023. https://www.omainsurance.com/?gclid=Cj0KCQjw2v-gBhC1ARIsAOQdKY2sbufvafni2VCnRggtZQIFXGns6lIiAhDleKBuyl_gloZA8xE6jJUaAk3PEALw_wcB. Accessed April 12, 2023.
  55. Ontario Ministry of Health. INFOBulletin: COVID-19 Advance Payment Program (Bulletin No. 4754). Government of Ontario; 2020. https://www.health.gov.on.ca/en/pro/programs/ohip/bulletins/4000/bul4754.pdf. Accessed April 30, 2023.
  56. Doctors Nova Scotia. COVID-19 Roster Agreement. Doctors Nova Scotia; 2020. https://doctorsns.com/sites/default/files/2020-04/COVID-19-roster-agreement.pdf. Accessed April 30, 2023.
  57. ewfoundland and Labrador Medical Association (NLMA). FFS Physician Work Disruption Policy for Pandemic Event. NLMA; 2020.
  58. Whitehead IO, Moffatt S, Jagger C, Hanratty B. A national study of burnout and spiritual health in UK general practitioners during the COVID-19 pandemic. PLoS One. 2022;17(11):e0276739. doi:1371/journal.pone.0276739
  59. Lemire F. Combating physician burnout. Can Fam Physician. 2018;64(6):480.
  60. Ontario College of Family Physicians. Urgent Need to Cut Red Tape and Admin Burden to Support Ontario’s Family Doctors and Patients. 2023. https://www.ontariofamilyphysicians.ca/news-features/news/~309-Urgent-Need-to-Cut-Red-Tape-and-Admin-Burden-to-Support-Ontario-s-Family-Doctors-and-Patients. Accessed June 13, 2023.
  61. Ontario College of Family Physicians. New Survey Shows Full-Blown Crisis in Family Medicine. 2023. https://www.ontariofamilyphysicians.ca/news-features/news/~310-New-Survey-Shows-Full-Blown-Crisis-in-Family-Medicine. Accessed June 13, 2023.
  62. Ontario College of Family Physicians. Solutions for Today: Ensuring Every Ontarian Has Access to a Family Physician. 2023. https://www.ontariofamilyphysicians.ca/advocacy/positions-discussions-reports/access-to-physicians. Accessed June 13, 2023.
  63. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281. doi:1016/s0140-6736(16)31279-x
  64. Kalani SD, Azadfallah P, Oreyzi H, Adibi P. Interventions for physician burnout: a systematic review of systematic reviews. Int J Prev Med. 2018;9:81. doi:4103/ijpvm.IJPVM_255_18
  65. Wiederhold BK, Cipresso P, Pizzioli D, Wiederhold M, Riva G. Intervention for physician burnout: a systematic review. Open Med (Wars). 2018;13:253-263. doi:1515/med-2018-0039
  66. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146. doi:1016/j.mayocp.2016.10.004
  67. Mathews M, Meredith L, Ryan D, et al. The roles of family physicians during a pandemic. Healthc Manage Forum. 2023;36(1):30-35. doi:1177/08404704221112311
  68. Mathews M, Ryan D, Hedden L, et al. Family physician leadership during the COVID-19 pandemic: roles, functions and key supports. Leadersh Health Serv (Bradf Engl). 2022;35(4):559-575. doi:1108/lhs-03-2022-0030
  69. Mathews M, Liu T, Ryan D, et al. Practice- and system-based interventions to reduce COVID-19 transmission in primary care settings: a qualitative study. Healthc Policy. 2023;19(2):63-78. doi:12927/hcpol.2023.27232
  70. Moritz LR, Buote R, McKay M, et al. Family physicians’ perspectives on collaboration challenges between primary care and specialist care during the COVID-19 pandemic in Canada: a qualitative study. SSM Qual Res Health. 2023;4:100338. doi:1016/j.ssmqr.2023.100338
  71. Young G, Mathews M, Hedden L, et al. “Swamped with information”: a qualitative study of family physicians' experiences of managing and applying pandemic-related information. Front Commun. 2023;8. doi:3389/fcomm.2023.1186678

Files

History

  • Receive Date: 14 June 2023
  • Revise Date: 01 March 2024
  • Accept Date: 29 May 2024
  • First Publish Date: 01 June 2024

Share

How to cite

Statistics