Is burnout associated with referral rates among primary care physicians in community clinics?

Fam Pract. 2014 Feb;31(1):44-50. doi: 10.1093/fampra/cmt060. Epub 2013 Oct 22.


Background: There is little empirical research examining the effects of burnout on objective measures of primary care physicians' behaviour in the medical encounter.

Objectives: We studied possible associations between primary care physicians' burnout and the rates of referrals. We conceptualized referral rate as a negative outcome of burnout because high and unnecessary referral rates incur extra costs to health care systems.

Methods: In this cross-sectional study, 136 primary care physicians in one district of one Israeli health maintenance organization (HMO) completed the Maslach Burnout Inventory in the presence of an interviewer. Data on each physician's objective workload and number of referrals for high- and low-cost imaging tests, specialist clinics and treatments by nurses were collected from the HMO's databases.

Results: Due to high correlations between referral rate indicators, a Confirmatory Factor Analysis revealed one factor: 'referrals for diagnostic tests and specialist clinics'. Path Analysis using Structural Equation Modelling explained a total of 18.1% of referral rate variance, with board-certified specialist mostly associated (β = 0.31, P < 0.01), followed by burnout (β = 0.20, P < 0.05) and objective workload (β = 0.18, P < 0.05).

Conclusions: In this preliminary investigation, we found that referral rates for diagnostic tests and specialist clinics increased independently for board-certified specialists (compared with GPs), for those with higher burnout levels and when objective workload increases. These findings support the conceptualization of referrals rates as objectively measured negative outcomes of burnout. Further replications with other objective outcomes, additional HMOs and bigger samples are warranted.

Keywords: Burnout; community clinics; imaging tests; laboratory tests; primary care physicians; referrals; specialists.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Burnout, Professional / epidemiology*
  • Community Health Centers*
  • Cross-Sectional Studies
  • Factor Analysis, Statistical
  • Female
  • Health Maintenance Organizations
  • Humans
  • Israel
  • Job Satisfaction
  • Male
  • Middle Aged
  • Physicians, Family / psychology*
  • Physicians, Family / statistics & numerical data
  • Physicians, Primary Care / psychology*
  • Physicians, Primary Care / statistics & numerical data
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Referral and Consultation / statistics & numerical data*
  • Workload