Influence of patient multimorbidity on GP burnout: a survey and register-based study in Danish general practice

Anette Fischer Pedersen; Karen Busk Nørøxe; Peter Vedsted

doi:10.3399/bjgp20X707837

Published eLetters

eLetter submission guidelines

Submit a Response to This Article

Compose eLetter

Title *

Author Information

Contributors

First Name and Middle Initial *

First or given name, e.g. 'Peter'.

Last Name *

Your last, or family, name, e.g. 'MacMoody'.

Email Address *

Your email address, e.g. higgs-boson{at}gmail.com. PLEASE NOTE: your email address will be published.

Occupation *

Your role and/or occupation, e.g. 'Orthopedic Surgeon'.

Affiliation *

Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.

Statement of Competing Interests

Competing interests? *

Yes

Please describe the competing interests

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

Jump to comment:

Multimorbidity and GP burn out
Anette F. Pedersen, Karen B. Nørøxe and Peter Vedsted

Published on: 05 March 2020
Multimorbidity and GP burn out
Stewart W. Mercer, Graham CM. Watt, Johanna Reilly and Anne Mullin

Published on: 28 January 2020

Published on: (5 March 2020)
Page navigation anchor for Multimorbidity and GP burn out
Multimorbidity and GP burn out
Anette F. Pedersen, Senior researcher, Research Unit for General Practice
Other Contributors:
Karen B. Nørøxe, Physician, Aarhus University Hospital

Peter Vedsted, Professor, Research Unit for General Practice
We thank Dr Mercer and co-authors for their letter about our paper providing evidence of a relationship between patient multimorbidity and GP burnout in primary care in Denmark. We know from the literature that burnout among GPs is a complex area influenced by a number of personal and situational factors. That makes it difficult to pinpoint the specific characteristics of a practice population that may lead to burnout in GPs.

In our analysis, multimorbidity was...
Show More

We thank Dr Mercer and co-authors for their letter about our paper providing evidence of a relationship between patient multimorbidity and GP burnout in primary care in Denmark. We know from the literature that burnout among GPs is a complex area influenced by a number of personal and situational factors. That makes it difficult to pinpoint the specific characteristics of a practice population that may lead to burnout in GPs.

In our analysis, multimorbidity was operationalised as two or more physical conditions and not as two or more mental and/or physical conditions. We agree with Mercer and co-authors that such a definition would likely have underestimated the true prevalence of multimorbidity in primary care. Meanwhile, although we probably underestimated the level of multimorbidity, we provided evidence of an association between physical multimorbidity and GP burnout. Our study supports that physical multimorbidity among patients is an important contributor to GP well-being. This does not rule out that the workload from caring for mentally ill persons is also an important contributor.

Physical multimorbidity was highly associated with age and we had to exclude age from the adjusted statistical model owing to multicollinearity. When we alternatively used the age and sex-standardised multimorbidity rate, the association between physical multimorbidity and GP burnout disappeared. We discussed that adjusting for a variable so closely related to the exposure variable is troublesome. For instance, the oldest age strata with the highest levels of multimorbidity were given least weight. We follow Mercer and co-authors and agree that this problem might not have been the case if we had included mental conditions, which would probably have decreased the close relationship between age and multimorbidity.

In our discussion, we hopefully made it clear that the non-existing relationship between the age and sex-standardised multimorbidity rate and GP burnout should not overshadow the revealed association between the crude multimorbidity rate and GP burnout since adjusting for age in a construct so closely related to age will induce interpretative challenges. We have shown that the amount of physical multimorbidity is just another brick in the whole GP burnout wall.
Show Less

Competing Interests: None declared.
Published on: (28 January 2020)
Page navigation anchor for Multimorbidity and GP burn out
Multimorbidity and GP burn out
Stewart W. Mercer, Professor of Primary Care and Multimorbidity, Usher Institute, University of Edinburgh
Other Contributors:
Graham CM. Watt, Emeritus Professor of General Practice, University of Glasgow

Johanna Reilly, Clinical Academic Fellow in General Practice, University of Edinburgh

Anne Mullin, GP and Chair of the GPs at the Deep End Steering Group, Govan Health Centre, Glasgow
This important paper by Pederson and colleagues provides evidence of a relationship between GP burnout and patient multimorbidity in practices in Denmark. This relationship was significant in unadjusted analysis, but disappeared when adjusted for patient age and gender, leading the authors to conclude that the burden of multimorbidity of older patients added to ‘actual work pressure’. This conclusion, if correct, means that practices with elderly patients have greater work pressure and GPs in such practices will be at greater risk of burnout.

Before...
Show More

This important paper by Pederson and colleagues provides evidence of a relationship between GP burnout and patient multimorbidity in practices in Denmark. This relationship was significant in unadjusted analysis, but disappeared when adjusted for patient age and gender, leading the authors to conclude that the burden of multimorbidity of older patients added to ‘actual work pressure’. This conclusion, if correct, means that practices with elderly patients have greater work pressure and GPs in such practices will be at greater risk of burnout.

Before such a conclusion can be reached, there are critical points to consider. It is established that multimorbidity is more common and occurs at an earlier age in deprived areas in high income countries,^1,2 including Denmark.³ A previous study by the same group showed higher burnout in GPs working in deprived areas.⁴ These studies seem incompatible with the current findings.

The answer is likely to lie in how multimorbidity was defined and measured in this study. Multimorbidity was operationalised as two or more physical chronic conditions, as recorded in secondary care data. Such a definition will have two effects; to underestimate the true prevalence of multimorbidity in primary care and to exclude the contribution mental health conditions make to multimorbidity (usually defined as 2 or more mental and/or physical conditions).

Our conjecture is that the management of mental-physical multimorbidity is more challenging than physical multimorbidity, especially if physical conditions are concordant. In our previous work, the common physical conditions in those with multimorbidity aged over 75 years were all concordant; hypertension, coronary heart disease, chronic kidney disease, diabetes, and stroke.⁵ In deprived areas, where patients are younger, the common physical morbidities are discordant (chronic pain, asthma, hypertension).⁵ The combination of discordant physical conditions, a range of mental illnesses (e.g. addiction, depression)⁵ and the social problems that patients present in deprived areas⁶ demands a holistic generalist response and has been shown to lead to increased GP stress.⁶. It is essential this is fully taken into account before reaching conclusions around the relationship of GP burn out to multimorbidity.

[On behalf of the Deep End Steering Group]

References

1. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: A cross-sectional study. Lancet. 2012; 380(9836):37–43.

2. Violan C, Foguet-Boreu Q, Flores-Mateo G, et al. Prevalence, determinants and patterns of multimorbidity in primary care: A systematic review of observational studies. PLoS One 2014; 21;9(7).

3. Willadsen T, Siersma V, Nicolaisdó ttir D, et al. Multimorbidity and mortality: A 15-year longitudinal registry-based nationwide Danish population study. [cited 2020 Jan 22]; Available from: https://us.sagepub.com/en-us/nam/open-access-at-sage.

4. Pedersen AF, Vedsted P. Understanding the inverse care law: A register and survey-based study of patient deprivation and burnout in general practice. Int J Equity Health 2014;13(1).

5. McLean G, Guthrie B, Mercer SW, Watt GCM. General practice funding underpins the persistence of the inverse care law: Cross-sectional study in Scotland. Br J Gen Pract 2015; 1;65(641):e799–805.

6. Mercer SW, Watt GCM. The inverse care law: Clinical primary care encounters in deprived and affluent areas of Scotland. Ann Fam Med 2007; 5(6):503–10.

Show Less

Competing Interests: None declared.