A Longitudinal Study of Trends in Burnout During Primary Care Transformation

The quadruple aim of primary care transformation includes promoting well-being among the primary care workforce. We longitudinally assessed burnout among clinicians and staff in 2 health delivery organizations engaged in primary care redesign guided by a shared transformation model.

We conducted a descriptive longitudinal study, using repeated cross-sectional measures from 6 waves of surveys of employed primary care clinicians (physicians, nurse practitioners, physician assistants) and staff conducted between 2012 to 2018 in the San Francisco Health Network and in UCSF Health. The 2018 wave had 613 respondents (response rate 88%). Outcome measures were scores on the Maslach Burnout Inventory emotional exhaustion and cynicism subscales. We used regression models to test for time trends in mean scores.

Trends in burnout differed by system and occupation. In one system, mean clinician scores steadily improved for emotional exhaustion (P = .04) and cynicism (P = .07). In the other system, clinician burnout scores initially worsened and then returned to baseline levels. In both systems, burnout trends among staff tended to move in the opposite direction from trends among clinicians.

The divergent trends of steady reduction in clinician burnout in one system and clinician burnout getting worse before getting better in the other system suggest that the effects of primary care transformation are influenced by the organizational context. Moreover, practice changes that reduce clinician burnout may not decrease-and may potentially even worsen-burnout among staff. Primary care transformation requires continuing efforts to promote meaningful work and sustainable workloads among all members of the primary care team.