Evidence for the Quadruple Aim: A Systematic Review of the Literature on Physician Burnout and Patient Outcomes

Med Care. 2018 Dec;56(12):976-984. doi: 10.1097/MLR.0000000000000999.


Background: Experts express concern that attaining of the Triple Aim of reducing health care costs, improving patient experiences and ultimately population health, may be compromised by high levels of burnout among physicians. Some have called for a fourth aim of improving the work environment for care providers.

Objectives: Burnout has been linked to poor outcomes in many occupational settings. This study's aim was to investigate linkages between physician burnout and patient outcomes through a systematic review of the literature.

Research design: Systematic search of 3 databases using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. In total, 1201 articles were reviewed, and 28 were included in the final analysis. Studies needed to be empirical, measure physician burnout as a predictor, and include patient outcome measures.

Measures: The majority of studies were cross-sectional and measured patient outcomes via physician perception self-reports (n=14). Five studies reported clinical measures (quality, errors), and 9 included patient ratings of their care.

Results: Studies using self-reports of suboptimal quality and errors found that physicians higher in burnout consistently reported worse quality, yet studies linking burnout to independent clinical outcomes found no relationships. Similarly, burnout was related to lower patient ratings of care, but when specific behaviors were rated there was no relationship.

Conclusions: Although the interest in burnout's effects is strong, the lack of rigorous empirical studies examining patient outcomes is problematic. Future research should develop and test causal models to better understand which domains of patient care are influenced by physician burnout.

Publication types

  • Systematic Review

MeSH terms

  • Burnout, Professional / psychology*
  • Cross-Sectional Studies
  • Humans
  • Internationality
  • Outcome Assessment, Health Care*
  • Patient Safety
  • Physicians / psychology*
  • Quality of Health Care / standards
  • Workplace / psychology*