Health care system leaders and policymakers may need to make some structural changes to help prevent mental health problems and job turnover among physicians.

A recent study published in the Proceedings of the National Academy of Sciences suggests that a commonly used behavioral intervention of informing physicians about how their performance compares to that of their peers appears to have backfired. Investigators found it had no statistically significant impact on performance and instead decreased physicians’ job satisfaction and increased burnout.

The team conducted a 5-month field experiment involving 199 primary care physicians and 46,631 patients. The study examined the impact of a peer comparison intervention on physicians’ job performance, job satisfaction, and burnout. The findings suggest that a lack of leadership support may be the key mechanism causing this backfiring effect.

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Study investigator Justin Zhang, MD, a resident physician in internal medicine at the University of California, San Francisco, said it is the health system leadership’s responsibility to promote physician buy-in to quality improvement efforts. Leadership also needs to provide physician clinics the tools they need to implement preventive care measures as seamlessly as possible.

It is common for policymakers and business leaders to use peer comparison information to motivate a range of behaviors. The potential impact of peer comparison interventions on recipients’ well-being is largely unknown, however. The current study revealed that implementation of peer comparison did not significantly improve physicians’ preventive care performance and significantly decreased job satisfaction and increased burnout. The effect on job satisfaction persisted for at least 4 months after the intervention had been discontinued.

The quantitative and qualitative evidence on the mechanisms underlying the unanticipated negative effects in this study highlights the importance of evaluating the psychological costs of behavioral interventions, according to the investigators.

Burnout Pervasive

When policymakers and organizational leaders implement seemingly innocuous behavioral interventions, they need to know how it affects burnout, Dr Zhang said. “Despite many health systems’ transition towards pay-for-performance models, there remain significant opportunities for improvement,” he said. “This is particularly true in primary care where there are large proportions of our patient population who are overdue for lifesaving preventive screenings.”

Burnout among physicians is a pervasive problem that became worse throughout the COVID-19 pandemic. “While our study was conducted specifically within the context of primary care, it is quite possible that these results and implications translate over to medical subspecialties. Healthcare delivery is becoming increasingly complex,” Dr Zhang said. “As such, it takes a team-based approach with leadership support to be able to deliver excellent patient care, achieve quality measure goals, while also optimizing physician well-being.”

And physician burnout appears to translate into increased health care expenditures. A cross-sectional study published earlier this year in Mayo Clinic Proceedings showed that primary care physician turnover resulted in approximately $979 million in excess health care expenditures for public and private payers annually. Of this, $260 million was attributable to physician burnout-related turnover.

‘Top-Down Approach’ Needed

“Tackling physician burnout requires a top-down approach,” Dr Zhang said. “Health system leaders need to listen to their staff physicians and other medical professionals, understand the areas that they feel like they need more support in, and ultimately implement structural changes to address those identified challenges and/or provide their health care workers the tools to empower themselves to navigate those challenges.”

Current trends suggest that organizational leaders need to engage employees in the design phase of an intervention, probe their feelings, and revise the design if needed. David A. Rogers, MD, the UAB (University of Alabama at Birmingham) Medicine Chief Wellness Officer, said the continuing pandemic is exacerbating many previously existing problems. “Physician burnout was already occurring at alarming rates and the magnitude of the problem has grown as we navigate through all of the on-going stresses caused by the pandemic in the social environment of marked polarization,” Dr Rogers said.

A growing body of research continues to show that leadership development is essential and much more nuanced and careful tested interventions are warranted. “Even a seemingly innocent organizational effort like providing performance feedback can be a cause of distress for physicians unless it is accompanied by enlightened leadership,” Dr Rogers said.

According to a review published in 2018 in Behavioral Sciences, systematic application of evidence-based interventions is urgently needed and may include but is not limited to group interventions, mindfulness training, assertiveness training, and facilitated discussion groups.

Work Overload the Main Contributor

The lead author of the review, Rikinkumar S. Patel, MD, MPH, a child and adolescent psychiatry fellow at Duke University in Durham, North Carolina, said work overload is the main contributor to physician burnout, but it is reversible and preventable. “Burnout has adverse outcomes on physician well-being, patient care, and the health care system,” Dr. Patel said. “Physicians experiencing signs of burnout are more likely to have decreased work productivity, exhaustion, and poor quality of care when compared to their earlier careers.”

Physician burnout can increase the economic burden of training and recruiting new staff members when efficient physicians quit because of burnout. “There is a need for management to keep a check on doctors’ physical and behavioral well-being,” Dr Patel said. “Self-awareness among physicians can enhance the ability to recognize their vulnerability to burnout, and immediate measures should be taken to overcome and manage fatigue, stress, and accentuate resiliency.”


Reiff JS, Zhang JC, Gallus J, et al. When peer comparison information harms physician well-being. Proc Natl Acad Sci U S A. Published online July 14, 2022. doi:10.1073/pnas.2121730119   

Sinsky CA, Shanafelt TD, Dyrbye LN, et al. Health care expenditures attributable to primary care physician overall and burnout-related turnover: A cross-sectional analysis. Mayo Clin Proc. 2022:97:693-702. doi:10.1016/j.mayocp.2021.09.013

Patel RS, Bachu R, Adikey A, et al. Factors related to physician burnout and its consequences: A review. Behavioral Sci. 2018;8(11):98. doi:10.3390/bs8110098