Burnout and job dissatisfaction are among the challenges the US healthcare system faces.1 More than half of US physicians report symptoms of burnout and, if given the option, only 45% would select their specialty again as a career.2,3 Burnout, which is characterized by emotional exhaustion, lack of enthusiasm for work, reduced sense of personal accomplishment, and cynicism, represents a long-term response to emotional and interpersonal stressors of a job.4-7 Burnout has been correlated with medical errors, job turnover, substance abuse, and suicidal ideation, and in recent years, rates of burnout among physicians have been increasing.2 Burnout is more prevalent in certain specialties, for example, family medicine and emergency medicine (both more than 60%), and is more common for female than male physicians.8 Studies of physician assistants (PAs) found that severe burnout is common among those working in emergency medicine, critical care, and oncology.9,10
Job satisfaction—the degree to which people harbor positive or negative feelings about their job—has been negatively correlated with burnout (lower burnout associated with higher job satisfaction).11,12 Dimensions of job satisfaction include attitudes toward one's work in general, promotion opportunities, pay, quality of supervision, and relationships with colleagues.12,13 Job satisfaction, burnout, stress, and other aspects of well-being, like happiness, can affect the quality of patient care. And job dissatisfaction, which is similar to burnout, is widespread among healthcare professionals.1,2,14
As healthcare practice shifts to meet the increasing demands of a growing and aging population, the healthcare workforce faces crucial issues.1,15 In fact, some physician leaders have proposed that a fourth aim, improving the work lives of healthcare professionals, be added to the Institute for Healthcare Improvement's Triple Aim for improving healthcare, which now consists of enhancing patient experience, improving population health, and reducing costs.1 Healthcare leaders have started to approach burnout and job satisfaction as systems issues, and workplace interventions are being designed to cultivate a sense of community and teamwork in order to promote engagement and enhance retention.16,17
The emergence of burnout as a healthcare systems issue is highlighted by a recent study of physicians across specialties; administrative burdens were positively correlated with symptoms of burnout and intent to leave clinical practice, and 47% felt that time spent on clerical tasks was unreasonable.18 The need to address administrative tasks is further demonstrated by a recent time motion study of physicians' workdays in four specialties.19 Researchers found that 49% of physicians' total time was spent on electronic health record and desk work; 27% was spent on direct clinical care.19 A small study focusing on PA burnout revealed that organizational factors, such as inadequate administrative support and little control over workload, contributed to burnout.17 Strong team culture, on the other hand, may protect against exhaustion, a significant burnout component.20
As vital members of healthcare teams, PAs contribute to organizational culture and processes as well as patient care. To date, few studies have investigated burnout and job satisfaction among PAs.21 Such research is needed if the PA profession is to have a voice in national discussions on workforce, organizational change, and policy.
PURPOSE
This study's primary objectives were to examine burnout, job satisfaction, stress, and other aspects of well-being among PAs; to identify any significant differences between female and male PAs; and to compare factors contributing to PA and physician job stress. The overall goal was to use available data to gain insight into the work lives of PAs.
METHODS
Data source
Data were collected from the 2016 American Academy of PAs (AAPA) salary survey. The survey included questions related to work environment as well as compensation and benefits and was sent to all PAs in the United States (AAPA members and nonmembers), excluding only those for whom AAPA had no e-mail address or did not have permission to contact. Other focused instruments serve as benchmarks for assessing burnout and job satisfaction; however, AAPA incorporated questions reflective of burnout, job satisfaction, and stress derived from the Medscape Physician Lifestyle Report 2016.13,22,23 Using the same questions allowed for direct comparison of PA and physician responses.
Analysis
Survey questions related to burnout, happiness, and stress were analyzed. Questions most closely aligned with the three dimensions of burnout (emotional exhaustion, sense of personal accomplishment, and cynicism) served as indicators of burnout. Responses to questions about happiness and factors that contribute to stress (including factors known to contribute to job satisfaction) provided insight into job satisfaction, stress, and well-being.
Survey responses were solicited using Likert scales (1-7 and 1-5) in accordance with how responses to questions were collected in previous surveys. Descriptive statistics consisted of frequencies, medians, means, standard deviations, and significance tests for comparisons of PA responses by sex. In addition, because small differences in large data sets may be statistically significant but not substantial, the effect size (for example, magnitude of difference) helps determine whether statistically significant differences are meaningful. Therefore, Cohen's d (a measure of effect size), which is the difference between two means divided by the standard deviation for the data, also is reported. Differences that are statistically significant but have very small to small effect sizes (for example, d < 0.2) may not be important; significant differences with larger effect sizes (for example, d = 0.2 considered small, d = 0.5 considered medium, d = 0.8 considered large, and d = 1.2 considered very large) are more likely to be meaningful.24,25 Finally, given that Likert scales may be considered ordinal rather than interval in nature, nonparametric tests may be more appropriate, particularly given the assumption of normality that t-tests require.26,27 Therefore, Mann-Whitney U tests, which are not bound by an assumption of normally distributed data, were used to compare male and female response distributions in Table 1.27 For every comparison, the Mann-Whitney U test and parametric t-test produced concordant results.
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TABLE 1.: PA burnout, job stress, and happiness by sex
RESULTS
Responses were received from 15,999 PAs for an overall response rate of 16.4%. The total responses received accounted for an estimated 15% of all PAs in the United States. Questions related to burnout, happiness, and stress were identified as optional; the number of respondents to these questions varied between 6,111 and 7,857 for individual question response rates of 6.3% to 8.1% (Table 1). Although the response rate was low, because the survey was sent to nearly all PAs in the United States (that is, the entire population of PAs was surveyed as opposed to a random sample of PAs), the sample size was large and margin of error was very low, ±0.72%. In addition, respondent demographics were similar to those published by the National Commission on Certification of Physician Assistants (NCCPA), which provided a measure of external validity.28
Table 1 displays overall median and mean responses, as well as median and mean responses by sex to each measure on its original scale. Collapsed frequency distributions, whether or not responses from women and men differed significantly, and effect sizes also are reported. Regarding indicators of burnout, median scores reveal that overall, PAs experienced moderate to high enthusiasm for work and relatively little cynicism or feelings of low sense of personal accomplishment (Table 1). In fact, 27% reported high or extreme enthusiasm for work and 21.4% reported some degree of cynicism (moderate 13.9%, high 5.3%, extreme 2.2%). Only 10.4% reported experiencing low sense of personal accomplishment, with 6.2% reporting a moderately low sense of personal accomplishment, 2.8% reporting high, and 1.5% reporting an extremely low sense of personal accomplishment. Median scores for happiness showed that PAs were generally happy in and outside of the workplace and that they felt satisfied with their lives in general (Table 1). More than 75% agreed or strongly agreed that they were happy at work. Median responses related to stressor importance revealed that PAs rated some factors known to be associated with job dissatisfaction (for example, difficult colleagues, staff, or employers) as having slight or neutral importance (Table 1). Among all the stressors, income not high enough and spending too many hours at work were rated highest (median = 5 on a 1-7 scale); 25.5% rated spending too many hours at work as extremely important, 13% rated it very important, and 17.1% rated it moderately important.
Although responses to several questions differed slightly between men and women, the only differences that had meaningful effect sizes were related to factors contributing to stress (Table 1). With the exception of too many bureaucratic tasks and increasing computerization of practice, women rated all factors contributing to stress as having slightly higher importance; however, differences with effect sizes of d > 0.2 were limited to five factors, including too many difficult patients and difficult colleagues or staff (Table 1). Notably, compared with male PAs, a higher percentage of female PAs had quit a job due to stress at least once during their careers (32.2% versus 25.6%, P < .05) and a higher percentage were considering quitting their job for the first time due to stress (14.2% versus 10.2%, P < .05) (Table 2).
TABLE 2.: PA frequency of quitting due to stress
Table 3 displays a comparison of mean PA to mean physician responses to questions about factors contributing to job stress (physician responses obtained from the 2016 Medscape Physician Lifestyle Report). Median responses from physicians were not available for comparison. PAs rated most factors as more important than physicians did. Factors that physicians rated as more important included too many bureaucratic tasks (M = 4.74 versus 3.94) and increasing computerization of practice (M = 4.02 versus 3.4). Overall, like PAs, physicians generally rated these factors as having little to neutral importance.
TABLE 3.: Factors contributing to stress: PA comparison to physicians
18DISCUSSION
This brief report is the first national study of trends related to burnout and job stress among practicing PAs. Although widespread job dissatisfaction among healthcare professionals has been reported, consistent with previous works, we found that a significant majority of PAs are generally satisfied with many aspects of work life.29 However, these findings should be viewed with caution. Fewer than half (45%) of PAs reported never having quit their job due to stress and almost 13% were considering leaving their job for this reason. On a national level, this suggests that more than 15,000 PAs may leave their current positions due to stress, which has significant implications for the provision of high-quality, timely, accessible, and cost-effective patient care.18
Studies of PAs in particular specialties highlight the complex relationship between burnout and job satisfaction. For example, a study of PAs in oncology revealed that although 30% reported symptoms of burnout, 86% reported satisfaction with their careers in general and 88% reported satisfaction with their choice in specialty.9 Taken together, data on PA satisfaction suggest that further research is needed to examine factors that contribute PA well-being in various specialty settings and to explore the relationship between stress, burnout, job satisfaction, and intent to leave.21
PA practice setting varies by sex; for instance, female PAs are more likely than male PAs to work in primary care, an area of practice associated with high levels of physician burnout.8,30 Thus, although the few meaningful differences between female and male PA responses may be partly attributable to differences in specialty, the fact that a higher percentage of female PAs had quit or were considering quitting due to stress suggests that, like female physicians, female PAs may have less-satisfying work lives than their male counterparts. Overall, compared with PAs, physicians rank bureaucratic tasks and increasing computerization of practice as more significant stressors. PAs rank difficult colleagues, staff, and employers as more significant, which may be due in part to the collaborative, team-based model of PA practice. Although study findings indicate that in general a relatively low percentage of PAs experience symptoms associated with burnout, direct comparisons of physician and PA burnout were not possible.
LIMITATIONS
This brief report has several limitations. Because raw response data from studies related to physician satisfaction could not be obtained, we were unable to determine whether differences between PA and physician responses were statistically significant. In addition, although the survey included a large number of PAs, the low overall response rate and self-report nature of survey data introduce the potential for nonresponse bias. In other words, those who chose to respond to the survey may differ from those who chose not to respond; for example, responders may have been more likely to feel strongly about the questions being asked. The potential for nonresponse limits the study's generalizability to the overall population of PAs. Survey questions were reflective of those used in previous works; however, use of standard instruments such as the Maslach Burnout Inventory was not feasible. Using such instruments to examine issues related to PA work lives would likely strengthen future studies. Finally, an analysis of factors known to contribute to work life, such as specialty setting and number of years in practice, was beyond the scope of this report.
CONCLUSIONS
Despite these limitations, this study provides a glimpse into the work lives of PAs and a basis for further research. Current endeavors to reduce burnout and improve the work lives of healthcare professionals include developing interventions that streamline workflows, strengthen teamwork, and promote flexibility and work-life balance.1,16 Through further examination of the PA profession and engagement in healthcare organizations, PAs can help facilitate these and other changes needed to improve the health of the healthcare workforce and thereby improve patient care.
REFERENCES
1. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider.
Ann Fam Med. 2014;12(6):573–576.
2. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
Mayo Clin Proc. 2015;90(12):1600–1613.
3. Peckham C. Medscape physician compensation report 2016.
www.medscape.com/features/slideshow/compensation/2016/public/overview#page=30. Accessed June 12, 2018.
4. Freudenberger HJ. Staff burn-out.
J Soc Issues. 1974;30(1):159–165.
5. Maslach C, Schaufeli WB, Leiter MP. Job burnout.
Annu Rev Psychol. 2001;52(1):397–422.
6. van Dierendonck D, Schaufeli WB, Sixma HJ. Burnout among general practitioners: a perspective from equity theory.
J Soc Clin Psychol. 1994;13(1):86–100.
7. 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.
8. Peckham C. Physician burnout: it just keeps getting worse.
www.medscape.com/viewarticle/838437_1. Accessed June 13, 2018.
9. Tetzlaff ED, Hylton HM, DeMora L, et al. National study of burnout and career satisfaction among physician assistants in oncology: implications for team-based care.
J Oncol Pract. 2018;14(1):e11–e22.
10. Bell RB, Davison M, Sefcik D. A first survey. Measuring burnout in emergency medicine physician assistants.
JAAPA. 2002;15(3):40–52.
11. Schermerhorn JR.
Organizational Behavior. 7th ed. New York, NY: Wiley; 2000.
12. Bhatnagar K, Srivastava K. Job satisfaction in health-care organizations.
Ind Psychiatry J. 2012;21(1):75–78.
13. Bowling Green State University College of Arts and Sciences. Job descriptive index.
www.bgsu.edu/arts-and-sciences/psychology/services/job-descriptive-index.html. Accessed June 13, 2018.
14. McHugh MD, Kutney-Lee A, Cimiotti JP, et al. Nurses' widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care.
Health Aff (Millwood). 2011;30(2):202–210.
15. Dall TM, Gallo PD, Chakrabarti R, et al. An aging population and growing disease burden will require a large and specialized health care workforce by 2025.
Health Aff (Millwood). 2013;32(11):2013–2020.
16. 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.
17. Benson MA, Peterson T, Salazar L, et al. Burnout in rural physician assistants: an initial study.
J Physician Assist Educ. 2016;27(2):81–83.
18. Sinsky CA, Dyrbye LN, West CP, et al. Professional satisfaction and the career plans of US physicians.
Mayo Clin Proc. 2017;92(11):1625–1635.
19. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties.
Ann Intern Med. 2016;165(11):753–760.
20. Willard-Grace R, Hessler D, Rogers E, et al. Team structure and culture are associated with lower burnout in primary care.
J Am Board Fam Med. 2014;27(2):229–238.
21. Hoff T, Carabetta S, Collinson GE. Satisfaction, burnout, and turnover among nurse practitioners and physician assistants: a review of the empirical literature.
Med Care Res Rev. [e-pub Sep. 1, 2017].
22. West CP, Dyrbye LN, Satele DV, et al. Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment.
J Gen Intern Med. 2012;27(11):1445–1452.
23. Peckham C. Medscape physician lifestyle report 2016.
www.medscape.com/slideshow/lifestyle-2016-overview-6007335#5. Accessed January 30, 2018.
24. Cohen J.
Statistical Power Analysis for the Behavioral Sciences. 2nd ed. New York, NY: Lawrence Erlbaum Associates; 1977.
25. Sawilowsky S. New effect size rules of thumb.
J Mod Appl Methods. 2009;8(2):467–474.
26. Sullivan GM, Artino AR Jr. Analyzing and interpreting data from Likert-type scales.
J Grad Med Educ. 2013;5(4):541–542.
27. Norman G. Likert scales, levels of measurement and the “laws” of statistics.
Adv Health Sci Educ Theory Pract. 2010;15(5):625–632.
28. National Commission on Certification of Physician Assistants. 2016 statistical profile of certified physician assistants.
www.nccpa.net/Uploads/docs/2016StatisticalProfileofCertifiedPhysicianAssistants.pdf. Accessed June 13, 2018.
29. Hooker RS, Kuilman L, Everett CM. Physician assistant job satisfaction: a narrative review of empirical research.
J Physician Assist Educ. 2015;26(4):176–186.
30. Coplan B, Cawley J, Stoehr J. Physician assistants in primary care: trends and characteristics.
Ann Fam Med. 2013;11(1):75–79.
