Although physician assistants (PAs) report high levels of job satisfaction, studies suggest that about one-third of PAs have substantial symptoms of burnout, which is characterized by emotional exhaustion, depersonalization (cynicism), and reduced professional efficacy.1-12
Despite this notable prevalence, the implications of burnout among PAs are less well studied than among physicians. A substantial body of literature supports that burnout among physicians increases the risk of poor quality of care, job dissatisfaction, job turnover, and lower productivity.13 Although PAs frequently change specialties throughout their career and job stress contributes to turnover, little is known about the relationship between burnout and job satisfaction, intent to leave the current practice, or intent to reduce clinical work hours among PAs in the United States.3,4,10,14,15 Given the critical role of PAs in providing access to care and the projected physician workforce shortage, this study explored the relationship between burnout and job satisfaction and career plans among PAs.16,17
METHODS
In 2016, the authors obtained a random sample of 2,100 PAs from the 60,478 PAs with email and postal addresses listed in the Redi-Data database, a national agency that maintains information from state licensing boards on PAs. These PAs were sent an email with a description of the study and an invitation to participate with a link to the web-based survey. The PAs who did not respond after three separate emails were mailed a paper-based survey to complete and return. Contact information could not be verified for 69 PAs, resulting in a sample of 2,031 PAs. Participation was voluntary and anonymous. The study was reviewed by the Mayo Clinic institutional review board and deemed to be exempt.
Study measures
The survey consisted of questions about demographic characteristics (age, sex, relationships status, parental status), highest earned academic degree, and practice characteristics (current practice setting, current work area, years in current specialty), because these factors are associated with key outcomes in previous studies in healthcare professionals.7,18,19 For example, previous studies have found that physicians who are younger, female, mid-career, and work in private practice have a higher risk of burnout; physicians who are married have a lower risk of burnout.20,21 Large differences in the prevalence of burnout also have been found by specialty in studies of physicians.20 In a large national sample of nurses, demographics (age, relationship and parental status, work hours, and highest academic degree obtained related to nursing) were independent predictors of burnout.22 Additional items explored job satisfaction, intent to leave the current job within the next 2 years, intent to reduce clinical work hours within the next 12 months, burnout, and fatigue.
Job satisfaction and career plans
Consistent with previous studies of healthcare professionals, job satisfaction was measured using a 5-point Likert scale (very satisfied, satisfied, neither satisfied or dissatisfied, dissatisfied, and very dissatisfied), with those indicating they were dissatisfied or very dissatisfied considered dissatisfied with their current job.23
Items from previous national surveys of physicians were used to explore intent to leave the current job within the next 2 years (“What is the likelihood that you will leave your current job situation within 2 years”) and intent to reduce clinical work hours within the next 12 months (“What is the likelihood that you will reduce the number of hours you devote to clinical care over the next 12 months?”); response options were none, slight, moderate, likely, or definite.18,24,25 For those who indicated a moderate or higher chance (that is, moderate, likely, or definite response) that they would leave their current practice, a subsequent question, derived from previous publications, asked what they planned to do if they left. Response options were “Look for a different job opportunity and continue to work as a physician assistant,” “Look for a different job in medicine [such as administration] and no longer work directly with patients as a physician assistant,” “Leave medicine altogether to pursue a different career,” and “Retire.”18,26 Similarly, for those who indicated a moderate or higher intent to reduce their clinical work hours, a follow-up question, also derived from previous publications, asked them to indicate their primary reason for wanting to reduce their clinical work hours, with response options of “Frustration with Medicare and insurance reimbursement issues,” “To spend more time with family,” “Declining reimbursement for clinical care,” “Personal health problems,” “A family member's health problems,” “To pursue administrative/leadership opportunities,” “To pursue research or medical education opportunities,” and “Other.”18,26 PAs who indicated a moderate or higher intent to leave their current practice or reduce their work hours were considered as being at high risk for doing so, as research with physicians suggests self-reported intent to leave is correlated with actual departures.27-29
Burnout and fatigue
Burnout was measured using the 22-item Maslach Burnout Inventory (MBI) Human Services Survey (under license with Mind Garden, Inc.), the gold standard for burnout assessment.30 The MBI has emotional exhaustion, depersonalization, and personal accomplishment subscales. Consistent with other studies of healthcare professionals, PAs were considered to have overall burnout if they scored high on the emotional exhaustion (score of 27 or greater) and/or depersonalization (score of 10 or greater) subscale.13,20,30-32 Fatigue was measured using a linear analog scale (0 = “As bad as it can be” to 10 = “As good as it can be”), in which a lower score indicated a greater degree of fatigue.33
STATISTICAL ANALYSIS
Basic descriptive statistics were calculated and univariate comparisons were made using chi-square or Kruskal-Wallis tests, as appropriate. Multivariate analyses were conducted to identify factors independently associated with job dissatisfaction, moderate or higher intent to reduce clinical work hours within next year, and moderate or higher intent to leave the current job within the next 2 years. Each model included the following variables: age, sex, relationship status, parental status, highest academic degree, work hours in the past 7 days, years as a PA, practice setting, current specialty area, years in current specialty area, fatigue, and burnout. A 5% type I error rate and a two-sided alternative was used. All analysis was conducted using SAS version 9 (SAS Institute, Cary, N.C.).
RESULTS
Among the 2,031 PAs who were surveyed, 600 (29.5%) responded. The demographics and practice characteristics of responders were similar to the data on PAs provided by the National Commission on Certification of Physician Assistants (NCCPA) with respect to sex, although the PAs in this study were somewhat older (median age 44 versus 38 years) and less likely to be hospital-based (23.3% versus 44.8%) or work in pediatric or internal medicine subspecialties (9.2% versus 16.8%; Table 1).34 Overall, the average age of responding PAs was 45.6 years old, 68.5% of the respondents were female, 77.9% were married, 78.5% had children, and 58.9% worked in an outpatient setting. On average, PAs reported working 38.9 hours/week.
TABLE 1. -
Personal and professional characteristics, burnout, and work-life integration among 600 PAs vs. PAs nationally
|
Overall |
2016 NCCPA Statistical Profile of Certified PAs |
P value |
|
Age in years
|
|
|
∗ |
| Mean (SD) |
45.6 (11.1) |
|
|
| Median |
44 |
38 |
|
|
Sex, n (%)
|
|
|
.68 |
| Female |
409 (68.5%) |
78,247 (67.7%) |
|
| Male |
188 (31.5%) |
37,286 (32.3%) |
|
| Missing |
3 |
|
|
|
Current practice setting, n (%)∗∗
|
|
|
<.0001 |
| Hospital-based |
126 (23.3%) |
40,702 (44.8%) |
|
| Outpatient-based |
318 (58.9%) |
43,564 (47.9%) |
|
| Other |
96 (17.8%) |
6,647 (7.3%) |
|
| Missing |
60 |
|
|
|
Current work area, n (%)∗∗∗
|
|
|
<.0001 |
| Primary care |
144 (26%) |
25,781 (28.1%) |
|
| Pediatric or internal medicine subspecialty |
51 (9.2%) |
15,410 (16.8%) |
|
| Other direct care specialties |
50 (9%) |
7,272 (7.9%) |
|
| Emergency medicine |
70 (12.7%) |
12,152 (13.2%) |
|
| Surgical area |
135 (24.4%) |
23,143 (25.2%) |
|
| Other |
103 (18.6%) |
8,119 (8.8%) |
|
| Missing |
47 |
|
|
|
Hours worked per week, mean (SD) |
38.9 (10.6) |
40.6 |
∗ |
|
∗Unable to calculate P value because we did not have the NCCPA dataset.
∗∗Hospital-based includes medical and surgical inpatient, intensive care, and operating/recovery room. Outpatient-based includes ambulatory and outpatient clinic. Other includes hospice, home healthcare, nonclinical setting, and public health.
∗∗∗Based on specialty area that PA works in. Primary care includes family medicine, general internal medicine, and general pediatrics. Other direct care specialties include dermatology, neurology, physical medicine and rehabilitation, preventive or occupational or environmental medicine, radiation oncology, and psychiatry. Surgical area includes anesthesia and obstetrics and gynecology. Other includes radiology and pathology.
Overall, 487 (82.7%) PAs indicated they were satisfied or very satisfied with their job, 54 (9.2%) were neither satisfied nor dissatisfied, and 49 (8.3%) were dissatisfied or very dissatisfied with their job (Table 2). In regard to intent to reduce clinical hours, 115 (19.5%) reported a moderate or greater intent to reduce clinical hours in the next year. The most common reason for this was to “spend more time with family” (52.5%). With respect to leaving their current position, 192 (32.2%) indicated a moderate or greater intent to leave their current position within the next 2 years. The most common reason cited was to “look for a different job opportunity and continue to work as a physician assistant.” Fewer indicated a desire to pursue a different career or no longer work as a PA (15%), or to retire (20.3%).
TABLE 2. -
Job satisfaction and career plans of PAs
|
n (%) |
|
Job satisfaction
|
| Very satisfied |
206 (34.9%) |
| Satisfied |
281 (47.6%) |
| Neither satisfied nor dissatisfied |
54 (9.2%) |
| Dissatisfied |
26 (4.4%) |
| Very dissatisfied |
23 (3.9%) |
| Missing |
10 |
|
Career plans
|
|
|
Reducing clinical work hours
|
|
| Likelihood of reducing clinical work hours in next 12 months |
|
| None |
360 (60.7%) |
| Slight |
118 (19.9%) |
| Moderate |
36 (6.1%) |
| Likely |
46 (7.8%) |
| Definite |
33 (5.6%) |
| Missing |
7 |
|
Primary reason for considering reducing clinical work hours∗
|
|
| To spend more time with family or to address personal or family members health problems |
55 (54.5%) |
| To pursue administrative/leadership opportunities |
10 (9.9%) |
| Frustration with Medicare and insurance reimbursement issues or declining reimbursement for clinical care |
4 (4%) |
| Declining reimbursement for clinical care |
2 (2%) |
| Personal or family member's health problems |
2 (2%) |
| To pursue research or medical education opportunities |
1 (1%) |
| Other |
29 (28.7%) |
| Missing |
12 |
|
Leaving current practice
|
|
|
Likelihood of leaving current practice in next 2 years
|
|
| None |
202 (33.9%) |
| Slight |
201 (33.8%) |
| Moderate |
84 (14.1%) |
| Likely |
56 (9.4%) |
| Definite |
52 (8.7%) |
| Missing |
5 |
|
Plans if left current practice∗∗
|
|
| Look for a different job opportunity and continue to work as a PA |
114 (61%) |
| Look for a different job and no longer work directly with patients as a PA |
13 (7%) |
| Pursue a different career |
15 (8%) |
| Retire |
38 (20.3%) |
| Other |
7 (3.7%) |
| Missing |
5 |
∗Only asked of those who indicated a moderate or higher intent to reduce clinical work hours
∗∗Only asked of those who indicated a moderate or higher intent to leave the current practice
Job satisfaction
The unadjusted relationships between personal and professional characteristics and job dissatisfaction are shown in Table 3. PAs with high emotional exhaustion (41.7% versus 6.6%, P < .0001), high depersonalization (29.6% versus 13.6%, P < .0001), low personal accomplishment (34.7% versus 14.9%, P < .0001), and overall burnout (32.6% versus 6.7%, P < .0001) were more likely to be dissatisfied with their jobs. Higher fatigue was also more common among those who were dissatisfied with their job relative to those who were satisfied (mean [SD] 4.9 [2.13] versus 6.2 [2.20], P < .0001).
TABLE 3. -
Relationship between personal and professional characteristics and job dissatisfaction among PAs
|
Dissatisfied with job (n = 103) |
Satisfied with job (n = 487) |
P value |
|
Overall burnout, n (%)
|
|
|
<.0001 |
| Yes |
79 (32.6%) |
163 (67.4%) |
|
| No |
23 (6.7%) |
322 (93.3%) |
|
| Missing |
1 |
2 |
|
|
Fatigue, mean (SD)
|
4.9 (2.13) |
6.2 (2.2) |
<.0001 |
|
Hours worked per week, mean (SD)
|
40.8 (12.29) |
38.6 (10.18) |
.2 |
|
Years of experience working as a PA, mean (SD)
|
15.7 (9.17) |
16 (10.31) |
.94 |
|
Highest earned academic degree, n (%)
|
|
|
.55 |
| Baccalaureate |
34 (19.1%) |
144 (80.9%) |
|
| Masters |
67 (17.3%) |
321 (82.7%) |
|
| PhD/doctorate |
1 (7.7%) |
12 (92.3%) |
|
| Missing |
1 |
10 |
|
|
Current practice setting, n (%)∗
|
|
|
.43 |
| Hospital-based |
22 (17.9%) |
101 (82.1%) |
|
| Outpatient-based |
50 (15.8%) |
267 (84.2%) |
|
| Other |
20 (21.5%) |
73 (78.5%) |
|
| Missing |
11 |
46 |
|
|
Current work area, n (%)∗∗
|
|
|
.61 |
| Family medicine, general internal medicine, general pediatrics |
23 (16.1%) |
120 (83.9%) |
|
| Pediatric or internal medicine subspecialty |
6 (11.8%) |
45 (88.2%) |
|
| Other direct care specialties |
6 (12%) |
44 (88%) |
|
| Emergency medicine |
12 (17.4%) |
57 (82.6%) |
|
| Surgical area |
26 (19.4%) |
108 (80.6%) |
|
| Other |
21 (21%) |
79 (79%) |
|
| Missing |
9 |
34 |
|
|
Years in current specialty area, n (%)
|
|
|
.7 |
| 5 or fewer |
30 (19.2%) |
126 (80.8%) |
|
| 6 to 10 |
25 (15.5%) |
136 (84.5%) |
|
| 11 to 15 |
20 (20.2%) |
79 (79.8%) |
|
| More than 15 |
28 (16.3%) |
144 (83.7%) |
|
| Missing |
0 |
2 |
|
|
Age in years, mean (SD)
|
45.6 (11.05) |
45.6 (11.1) |
.91 |
|
Relationship status, n (%)
|
|
|
.05 |
| Single |
24 (24.2%) |
75 (75.8%) |
|
| Married |
71 (15.5%) |
387 (84.5%) |
|
| Partnered |
8 (28.6%) |
20 (71.4%) |
|
| Widowed |
0 (0%) |
4 (100%) |
|
| Missing |
0 |
1 |
|
|
Sex, n (%)
|
|
|
.03 |
| Male |
23 (12.4%) |
163 (87.6%) |
|
| Female |
80 (19.9%) |
323 (80.1%) |
|
| Missing |
0 |
1 |
|
|
Have children, n (%)
|
66 (14.3%) |
397 (85.7%) |
<.0001 |
∗Hospital-based includes medical and surgical inpatient, intensive care, and operating/recovery room. Outpatient-based includes ambulatory and outpatient clinic. Other includes hospice, home health, nonclinical setting, and public health.
∗∗Based on specialty area the PA works in. Other direct care specialties include dermatology, neurology, physical medicine and rehabilitation, preventive or occupational or environmental medicine, radiation oncology, and psychiatry. Surgical area includes anesthesia and obstetrics and gynecology. Other includes radiology and pathology.
On multivariate analysis adjusting for age, sex, relationship status, parental status, highest academic degree, work hours in the past 7 days, years as a PA, practice setting, current specialty area, years in current specialty area, and fatigue, burnout increased the odds of job dissatisfaction by over sixfold (OR 6.62, 95% CI 2.91-15.05, P < .0001; Table 4). Higher fatigue also remained independently associated with lower odds of job satisfaction (for each 1 point worse level of fatigue, OR 0.8, 95% CI 0.68, 0.94, P = .01). PAs with children had lower odds of being dissatisfied with their job (OR 0.32, 95% CI 0.14-0.72, P < .01).
TABLE 4. -
Relationship between personal and professional characteristics and job dissatisfaction among PAs
|
OR (95% CI)∗ |
P value |
Overall P value |
|
Overall burnout
|
|
|
|
| Yes |
6.62 (2.91, 15.05) |
|
<.0001 |
| No |
referent |
|
|
|
Fatigue (for each 1 point worse level of fatigue)
|
0.8 (0.68, 0.94) |
|
.01 |
|
Hours worked per week (for each additional hour)
|
0.98 (0.95, 1) |
|
.06 |
|
Years of experience working as a PA (for each additional year)
|
0.96 (0.9, 1.03) |
|
.25 |
|
Highest earned academic degree
|
|
|
.64 |
| Baccalaureate |
referent |
|
|
| Masters |
0.67 (0.29, 1.54) |
.34 |
|
| PhD/doctorate |
- |
- |
|
|
Current practice setting∗∗
|
|
|
.88 |
| Hospital-based |
referent |
|
|
| Outpatient-based |
1.01 (0.39, 2.62) |
.99 |
|
| Other |
1.24 (0.43, 3.57) |
.7 |
|
|
Current work area∗∗∗
|
|
|
.14 |
| Family medicine, general internal medicine, general pediatrics |
referent |
|
|
| Pediatric or internal medicine subspecialty |
1.47 (0.45, 4.84) |
.52 |
|
| Other direct care specialties |
0.09 (0.01, 0.83) |
.03 |
|
| Emergency medicine |
0.32 (0.08, 1.24) |
.1 |
|
| Surgical area |
0.64 (0.23, 1.79) |
.4 |
|
| Other |
0.87 (0.35, 2.19) |
.77 |
|
|
Years in current specialty area
|
|
|
.8 |
| 5 or fewer years |
referent |
|
|
| 6 to 10 years |
1.18 (0.46, 3.06) |
.73 |
|
| 11 to 15 years |
1.75 (0.57, 5.32) |
.32 |
|
| More than 15 years |
1.46 (0.43, 4.97) |
.54 |
|
|
Age (for each additional year)
|
1.05 (0.99, 1.1) |
|
.09 |
|
Relationship status
|
|
|
|
| Single |
referent |
|
.79 |
| Married |
1.02 (0.42, 2.48) |
.97 |
|
| Partnered |
2.01 (0.48, 8.44) |
.34 |
|
| Widowed |
-- |
- |
|
|
Sex
|
|
|
|
| Male |
referent |
|
.17 |
| Female |
1.87 (0.77, 4.57) |
|
|
|
Have children
|
0.32 (0.14, 0.72) |
|
.01 |
∗OR > 1 indicate increased risk of job dissatisfaction; OR < 1 indicate lower risk of job dissatisfaction.
∗∗Hospital-based includes medical and surgical inpatient, intensive care, and operating/recovery room. Outpatient-based includes ambulatory and outpatient clinic. Other includes hospice, home healthcare, nonclinical setting, public health, and other.
∗∗∗Based on specialty area that the PA works in. Other direct care specialties include dermatology, neurology, physical medicine and rehabilitation, preventive or occupational or environmental medicine, radiation oncology, and psychiatry. Surgical area includes anesthesia and obstetrics and gynecology. Other includes radiology and pathology.
Career plans
Differences in intent to reduce clinical work hours by demographic and practice characteristics are shown in Tables 5 and 6. PAs with overall burnout (59.6% versus 36.8%, P < .0001), high emotional exhaustion (47.4% versus 26.1%, P < .0001), and high depersonalization (36.8% versus 21.5%, P = .001) were more likely to have a moderate or higher intent to reduce their clinical work hours within the next year. No association was found between fatigue and intent to reduce clinical work hours.
TABLE 5. -
Relationship between personal and professional characteristics and moderate or higher intent to reduce work hours among PAs
|
Yes (n = 115) |
No (n = 478) |
P value |
|
Overall burnout, n (%)
|
|
|
<.0001 |
| Yes |
68 (28%) |
175 (72%) |
|
| No |
46 (13.3%) |
301 (86.7%) |
|
| Missing |
1 |
2 |
|
|
Fatigue, mean (SD)
|
5.7 (2.29) |
6 (2.23) |
.17 |
|
Hours worked per week, mean (SD)
|
37.8 (11.51) |
39.1 (10.21) |
.44 |
|
Years of experience working as a PA, mean (SD)
|
17.4 (10.57) |
15.6 (9.93) |
.15 |
|
Highest earned academic degree, n (%)
|
|
|
.23 |
| Baccalaureate |
34 (30.4%) |
143 (30.5%) |
|
| Masters |
78 (69.6%) |
314 (67%) |
|
| PhD/doctorate |
0 (0%) |
12 (2.6%) |
|
| Missing |
3 |
9 |
|
|
Current practice setting, n (%)
|
|
|
.11 |
| Hospital-based |
17 (16.3%) |
109 (25.2%) |
|
| Outpatient-based |
64 (61.5%) |
253 (58.4%) |
|
| Other |
23 (22.1%) |
71 (16.4%) |
|
| Missing |
11 |
45 |
|
|
Current work area, n (%)
|
|
|
.49 |
| Family medicine, general internal medicine, general pediatrics |
26 (26%) |
118 (26.3%) |
|
| Pediatric or internal medicine subspecialty |
12 (12%) |
39 (8.7%) |
|
| Other direct care specialties |
7 (7%) |
43 (9.6%) |
|
| Emergency medicine |
16 (16%) |
54 (12.1%) |
|
| Surgical area |
19 (19%) |
116 (25.9%) |
|
| Other |
20 (20%) |
78 (17.4%) |
|
| Missing |
15 |
30 |
|
|
Years in current specialty area, n (%)
|
|
|
.33 |
| 5 or fewer |
27 (23.9%) |
131 (27.4%) |
|
| 6 to 10 |
29 (25.7%) |
133 (27.8%) |
|
| 11 to 15 |
16 (14.2%) |
82 (17.2%) |
|
| More than 15 |
41 (36.3%) |
132 (27.6%) |
|
| Missing |
2 |
0 |
|
|
Age in years, mean (SD)
|
47.1 (12.76) |
45.2 (10.61) |
.18 |
|
Relationship status, n (%)
|
|
|
.02 |
| Single |
22 (19.1%) |
76 (16%) |
|
| Married |
83 (72.2%) |
378 (79.4%) |
|
| Partnered |
7 (6.1%) |
21 (4.4%) |
|
| Widowed |
3 (2.6%) |
1 (0.2%) |
|
| Missing |
0 |
2 |
|
|
Sex, n (%)
|
|
|
.21 |
| Male |
31 (27%) |
157 (33%) |
|
| Female |
84 (73%) |
319 (67%) |
|
| Missing |
0 |
2 |
|
|
Have children, n (%)
|
91 (79.1%) |
373 (78%) |
.8 |
TABLE 6. -
Relationship between personal and professional characteristics and moderate or higher intent to leave current practice among PAs
|
Yes (n = 192) |
No (n = 403) |
P value |
|
Overall burnout, n (%)
|
|
|
|
| Yes |
115 (60.5%) |
130 (32.3%) |
<.0001 |
| No |
75 (21.6%) |
272 (78.4%) |
|
| Missing |
2 |
1 |
|
|
Fatigue, mean (SD)
|
5.7 (2.24) |
6.1 (2.23) |
.02 |
|
Hours worked per week, mean (SD)
|
38.8 (12.25) |
39.1 (9.76) |
.54 |
|
Years of experience working as a PA, mean (SD)
|
15.9 (10.7) |
16.1 (9.88) |
.28 |
|
Highest earned academic degree, n (%)
|
|
|
.42 |
| Baccalaureate |
57 (30.5%) |
121 (30.6%) |
|
| Masters |
128 (68.4%) |
264 (66.7%) |
|
| PhD/doctorate |
2 (1.1%) |
11 (2.8%) |
|
| Missing |
5 |
7 |
|
|
Current practice setting, n (%)
|
|
|
.54 |
| Hospital-based |
36 (20.8%) |
90 (24.6%) |
|
| Outpatient-based |
103 (59.5%) |
214 (58.5%) |
|
| Other |
34 (19.7%) |
62 (16.9%) |
|
| Missing |
19 |
37 |
|
|
Current work area, n (%)
|
|
|
|
| Family medicine, general internal medicine, general pediatrics |
45 (25.4%) |
99 (26.5%) |
.29 |
| Pediatric or internal medicine subspecialty |
12 (6.8%) |
39 (10.4%) |
|
| Other direct care specialties |
16 (9%) |
34 (9.1%) |
|
| Emergency medicine |
26 (14.7%) |
44 (11.8%) |
|
| Surgical area |
38 (21.5%) |
97 (25.9%) |
|
| Other |
40 (22.6%) |
61 (16.3%) |
|
| Missing |
15 |
29 |
|
|
Years in current specialty area, n (%)
|
|
|
.24 |
| 5 or fewer |
61 (31.9%) |
97 (24.1%) |
|
| 6 to 10 |
49 (25.7%) |
113 (28.1%) |
|
| 11 to 15 |
30 (15.7%) |
67 (16.7%) |
|
| More than 15 |
51 (26.7%) |
125 (31.1%) |
|
| Missing |
1 |
1 |
|
|
Age in years, mean (SD)
|
45.9 (12.72) |
45.5 (10.26) |
.82 |
|
Relationship status, n (%)
|
|
|
.16 |
| Single |
34 (17.7%) |
66 (16.5%) |
|
| Married |
143 (74.5%) |
318 (79.3%) |
|
| Partnered |
12 (6.3%) |
16 (4%) |
|
| Widowed |
3 (1.6%) |
1 (0.2%) |
|
| Missing |
0 |
2 |
|
|
Sex, n (%)
|
|
|
.36 |
| Male |
56 (29.2%) |
132 (32.9%) |
|
| Female |
136 (70.8%) |
269 (67.1%) |
|
| Missing |
0 |
2 |
|
|
Have children, n (%)
|
140 (72.9%) |
326 (80.9%) |
.03 |
On multivariate analysis adjusting for age, sex, relationship status, parental status, highest academic degree related to being a PA, work hours in the past 7 days, years as a PA, practice setting, current specialty area, years in current specialty area, and fatigue, burnout increased the odds of a moderate or higher intent to reduce clinical work hours within the next year (OR 3.4, 95% CI 2.07-5.58, P < .0001; Table 7). No other variable was an independent predictor of moderate or higher intent to reduce their clinical work hours within the next year.
TABLE 7. -
Relationship between personal and professional characteristics and moderate or higher intent to reduce work hours among PAs
|
OR (95% CI)∗ |
P value |
Overall P value |
|
Overall burnout
|
|
|
|
| Yes |
3.4 (2.07, 5.58) |
|
< .0001 |
| No |
referent |
|
|
|
Fatigue (for each 1 point worse level of fatigue)
|
1 (0.89, 1.11) |
|
.94 |
|
Hours worked per week (for each additional hour)
|
1 (0.99, 1.02) |
|
.89 |
|
Years of experience working as a physician assistant (for each additional year)
|
1.02 (0.98, 1.06) |
|
.41 |
|
Highest earned academic degree
|
|
|
.49 |
| Baccalaureate |
referent |
|
|
| Masters |
1.42 (0.8, 2.52) |
.24 |
|
| PhD/doctorate |
∗∗ |
|
|
|
Current practice setting
|
|
|
.5 |
| Hospital-based |
referent |
|
|
| Outpatient-based |
1.45 (0.74, 2.83) |
.27 |
|
| Other |
1.48 (0.71, 3.09) |
.29 |
|
|
Current work area
|
|
|
.32 |
| Family medicine, general internal medicine, general pediatrics |
referent |
|
|
| Pediatric or internal medicine subspecialty |
1.75 (0.73, 4.17) |
.21 |
|
| Other direct care specialties |
0.71 (0.26, 1.96) |
.51 |
|
| Emergency medicine |
1.23 (0.54, 2.84) |
.62 |
|
| Surgical area |
0.98 (0.47, 2.04) |
.96 |
|
| Other |
1.71 (0.89, 3.28) |
.1 |
|
|
Years in current specialty area
|
|
|
.32 |
| 5 or fewer |
referent |
|
|
| 6 to 10 |
1.12 (0.6, 2.12) |
.72 |
|
| 11 to 15 |
0.94 (0.44, 2.01) |
.86 |
|
| More than 15 |
1.4 (0.65, 3) |
.38 |
|
|
Age (for each additional year)
|
1 (0.97, 1.04) |
|
.82 |
|
Relationship status
|
|
|
|
| Single |
referent |
|
.11 |
| Married |
0.71 (0.37, 1.39) |
.32 |
|
| Partnered |
1.29 (0.43, 3.87) |
.65 |
|
| Widowed |
∗∗ |
|
|
|
Sex
|
|
|
.43 |
| Male |
referent |
|
|
| Female |
1.24 (0.73, 2.1) |
|
|
|
Have children
|
1.69 (0.88, 3.24) |
|
.11 |
∗OR > 1 indicate increased risk of intent to reduce clinical work hours; OR < 1 indicate lower risk of intent to reduce clinical work hours.
∗∗Cannot be determined due to small sample size.
PAs with overall burnout (60.5% versus 32.3%, P < .0001), high emotional exhaustion (52.1% versus 20.1%, P < .0001), and high depersonalization (31.6% versus 21.3%, P = .01) were more likely to have a moderate or higher intent to leave the current practice in the next 2 years. PAs with higher fatigue also were more likely to have a moderate or higher intent to leave the current practice in the next 2 years (mean 5.7 [2.24] versus 6.1 [2.23], P = .02; Table 6).
On multivariate analysis adjusting for age, sex, relationship status, parental status, highest academic degree related to being a PA, work hours in the past 7 days, years as a PA, practice setting, current specialty area, years in current specialty area, and fatigue, burnout increased the odds of having a moderate or higher intent to leave the current practice in the next 2 years (OR 3.41, 95% CI 2.26-5.16; P < .0001; Table 8). No other variable was an independent predictor of moderate or higher intent to leave the current practice in the next 2 years.
TABLE 8. -
Relationship between personal and professional characteristics and moderate or higher intent to leave current practice among PAs
|
OR (95% CI)∗ |
P value |
Overall P value |
|
Overall burnout
|
|
|
|
| Yes |
3.41 (2.26, 5.16) |
|
<.0001 |
| No |
Referent |
|
|
|
Fatigue (for each 1 point worse level of fatigue)
|
0.97 (0.88, 1.06) |
|
.46 |
|
Hours worked per week (for each additional hour)
|
0.99 (0.97, 1) |
|
.11 |
|
Years of experience working as a physician assistant (for each additional year)
|
1 (0.97, 1.03) |
|
.97 |
|
Highest earned academic degree
|
|
|
.24 |
| Baccalaureate |
referent |
|
|
| Masters |
0.93 (0.57, 1.51) |
.77 |
|
| PhD/Doctorate |
0.16 (0.02, 1.33) |
.09 |
|
|
Current practice setting
|
|
|
.97 |
| Hospital-based |
referent |
|
|
| Outpatient-based |
1.03 (0.6, 1.77) |
.91 |
|
| Other |
1.08 (0.59, 1.96) |
.81 |
|
|
Current work area
|
|
|
.68 |
| Family medicine, general internal medicine, general pediatrics |
referent |
|
|
| Pediatric or internal medicine subspecialty |
0.61 (0.27, 1.39) |
.24 |
|
| Other direct care specialties |
0.65 (0.29, 1.46) |
.3 |
|
| Emergency medicine |
0.97 (0.47, 1.99) |
.94 |
|
| Surgical area |
0.91 (0.5, 1.66) |
.76 |
|
| Other |
1.08 (0.62, 1.90) |
0.78 |
|
|
Years in current specialty area
|
|
|
0.14 |
| 5 or fewer |
referent |
|
|
| 6 to 10 |
0.69 (0.41, 1.16) |
0.16 |
|
| 11 to 15 |
0.72 (0.39, 1.32) |
0.29 |
|
| More than 15 |
0.47 (0.24, 0.9) |
0.02 |
|
|
Age (for each additional year older)
|
1.02 (0.99, 1.05) |
|
0.13 |
|
Relationship status
|
|
|
0.11 |
| Single |
referent |
|
|
| Married |
1.26 (0.71, 2.26) |
.43 |
|
| Partnered |
2.18 (0.83, 5.73) |
.11 |
|
| Widowed |
∗∗ |
|
|
|
Sex
|
|
|
.68 |
| Male |
referent |
|
|
| Female |
1.1 (0.7, 1.72) |
|
|
|
Have children
|
0.7 (0.41, 1.17) |
|
.17 |
∗OR > 1 indicate increased risk of intent to leave current practice; OR < 1 indicate lower risk of intent to leave current practice.
∗∗Sample size too small to be determined.
DISCUSSION
In this national study, more than 80% of PAs were satisfied or very satisfied with their jobs, consistent with other research on PAs reporting that more than 80% are satisfied, a higher rate than among other groups of healthcare professionals.5,23,35 Despite the overall high prevalence of job satisfaction, about one in five PAs indicated a moderate or higher intent to reduce clinical hours within the next year, and one in three indicated a moderate or higher intent to leave their current clinical practice within the next 2 years. Among those who reported a moderate or higher intent to leave their current practice within the next 2 years, 15% intended to no longer work directly with patients or as a PA. In a 2016 study of more than 6,200 PAs, 6.4% indicated they planned to leave their current position in the next 12 months, with nearly two-thirds seeking another clinical position.34 Data suggest PAs use the flexibility their profession affords by changing specialties, settings, and roles; however, 16% of those who plan to leave do so in order to obtain a position outside of healthcare, or a nonclinical health-related position, or in order to pursue additional education.34 In this cohort, burnout was the single strongest predictor of PAs being dissatisfied with their job, having a moderate or higher intent on reducing their clinical work hours within the next year, or moderate or higher intent to leave their current practice within the next 2 years.
A similar relationship between burnout and intent to reduce clinical work hours and leave their current practice has been reported in studies of physicians.18,24,27-29,36 For example, in a study of more than 7,000 US surgeons, physicians with burnout had twice the likelihood of intending to leave their current practice within the next 2 years than physicians without burnout, after adjusting for multiple personal and professional characteristics.24 In a separate study of 6,880 US physicians (all specialties), burnout also was an independent predictor of intent to leave the current practice and intent to reduce clinical work hours.18 Longitudinal studies support that not only do physicians with burnout say they are going to leave their current practice and reduce their clinical work hours, they actually do so.27-29,36 A substantial proportion of these physicians leave medicine altogether, with burnout being one of the main contributing factors in the decision to pursue another career.18 The cost to society is substantial.37 In the United States, physician turnover and reduced clinical hours attributable to burnout every year costs the US healthcare system about $4.6 billion every year.38 For an organization, the cost is about $7,600 per employed physician annually.38
The available data suggest that burnout doubles the odds of physicians leaving their current job.27-29,36 If PAs follow similar patterns, and even if only 10% of the 32% of PAs who indicated a moderate or higher intent to leave were to leave clinical practice, this could result in a reduction of about 3,697 clinicians.34 About 923 would be leaving due to burnout.37 These findings suggest burnout is a serious threat to the adequacy of the PA workforce in the United States. Additionally, reduction in clinical hours and turnover impedes access to care, erodes continuity of care, and disrupts optimal team practice.
Among PAs in this study, burnout was associated with a sixfold higher odds of job dissatisfaction after controlling for other personal and professional factors. Work hours, practice setting, and current work area (specialty) were not independent predictors of job dissatisfaction. Other studies have found longer work hours to be associated with lower job satisfaction among PAs and high workload to be a common reason for leaving a current job.34,39,40 These studies, however, did not control for burnout (as measured by the MBI) or include PAs practicing in multiple specialties. Our findings build on previous work demonstrating salary, autonomy, job resources, advancement opportunities, and quality of relationships with collaborating physicians and other team members are associated with job satisfaction among PAs.1,8,39,41
LIMITATIONS
Although our study is the first of its kind to examine burnout and its relationship to job satisfaction and career plans among PAs, the study has a number of limitations. First, our response rate was 29.5%, which is similar or better than national surveys of other healthcare professionals.20,22 It is not known if PAs who were dissatisfied with their jobs or felt burned out were more or less likely to complete a survey on job satisfaction. Respondents to this study were similar to PAs nationally with respect to sex, although they were older and more likely to work in an outpatient setting.34
Second, our study is cross-sectional and therefore cause and effect cannot be determined. Finally, although some existing data establish a relationship between intent and following through on leaving current practice, there is no data on the PA profession in this regard.27-29,36
CONCLUSIONS
One in five PAs in this cohort reported a moderate or higher intent to reduce clinical hours within the next year, and one in three indicated a moderate or higher intent to leave their current clinical practice within the next 2 years. If a subset of these PAs actually do so, the effect on the adequacy of the healthcare professional workforce could be substantial. Burnout was the primary contributing factor to intent to reduce clinical hours or leave the current practice. Turning the tide will require concerted efforts at the organizational and national level to address system-level factors contributing to burnout among PAs. Interventions to prevent and reduce burnout among physicians recently have been published, and the recent consensus study published by the National Academies of Sciences, Engineering, and Medicine provides a framework for how to approach the design and evaluation of system-level interventions for all healthcare professionals.42,43 Rigorous studies are needed to identify specific useful interventions for PAs. Given the scope of this problem, this will require a substantial and coordinated effort.
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