title: Is burnout associated with referral rates among primary care physicians in community clinics?
abstract: BACKGROUND
  There is little empirical research examining the effects of burnout on objective measures of primary care physicians' behaviour in the medical encounter.
  
  
  OBJECTIVE
  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.
authors.affiliation: Department of Public Health and.
authors.forename: Talma
authors.initials: T
authors.lastname: Kushnir
authors.forename: Dan
authors.initials: D
authors.lastname: Greenberg
authors.forename: Nir
authors.initials: N
authors.lastname: Madjar
authors.forename: Israel
authors.initials: I
authors.lastname: Hadari
authors.forename: Yuval
authors.initials: Y
authors.lastname: Yermiahu
authors.forename: Yaacov G
authors.initials: YG
authors.lastname: Bachner
mesh_terms: D000328:Adult; D000368:Aged; D002055:Burnout, Professional / Q000453:epidemiology*; D003151:Community Health Centers; D003430:Cross-Sectional Studies; D005163:Factor Analysis, Statistical; D005260:Female; D006279:Health Maintenance Organizations; D006801:Humans; D007557:Israel; D007588:Job Satisfaction; D008297:Male; D008875:Middle Aged; D010821:Physicians, Family / Q000523:psychology* / Q000706:statistics & numerical data; D058007:Physicians, Primary Care / Q000523:psychology* / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D016526:Workload
keywords: Burnout; community clinics; imaging tests; laboratory tests; primary care physicians; referrals; specialists