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

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 boardcertified
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.