Physician Burnout and Patient-Physician Communication During Primary Care Encounters

  • Neda RatanawongsaEmail author
  • Debra Roter
  • Mary Catherine Beach
  • Shivonne L. Laird
  • Susan M. Larson
  • Kathryn A. Carson
  • Lisa A. Cooper
Original Article



Although previous studies suggest an association between provider burnout and suboptimal self-reported communication, no studies relate physician burnout to observed patient-physician communication behaviors.


To investigate the relationship between physician burnout and observed patient-physician communication outcomes in patient-physician encounters.


Longitudinal study of enrollment data from a trial of interventions to improve patient adherence to hypertension treatment.


Fifteen urban community-based clinics in Baltimore, MD.


Forty physicians and 235 of their adult hypertensive patients, with oversampling of ethnic minorities and poor persons. Fifty-three percent of physicians were women, and the average practice experience was 11.2 years. Among the 235 patients, 66% were women, 60% were African-American, and 90% were insured.


Audiotape analysis of communication during outpatient encounters (one per patient) using the Roter Interaction Analysis System and patients’ ratings of satisfaction with and trust and confidence in the physician.


The median time between the physician burnout assessment and the patient encounter was 15.1 months (range 5.6–30). Multivariate analyses revealed no significant differences in physician communication based on physician burnout. However, compared with patients of low-burnout physicians, patients of high-burnout physicians gave twice as many negative rapport-building statements (incident risk ratio 2.06, 95% CI 1.58 – 2.86, p < 0.001). Physician burnout was not significantly associated with physician or patient affect, patient-centeredness, verbal dominance, or length of the encounter. Physician burnout was also not significantly associated with patients’ ratings of their satisfaction, confidence, or trust.


Physician burnout was not associated with physician communication behaviors nor with most measures of patient-centered communication. However, patients engaged in more rapport-building behaviors. These findings suggest a complex relationship between physician burnout and patient-physician communication, which should be investigated and linked to patient outcomes in future research.


physician well-being physician burnout patient-provider relationship patient-provider communication 



These data have been presented in abstract form at the 2007 International Conference for Communication in Healthcare Research Forum in Charleston, SC. This study was conducted with funding from the National Heart, Lung, and Blood Institute grants nos. R01HL069403 and K24HL083113 (Dr. Cooper). The funding agency did not have a role in the design, conduct, or reporting of the study. Dr. Lisa Cooper had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Conflict of interest: None disclosed.

Author contributions:

Study concept and design: Ratanawongsa, Roter, Larson, Beach, Laird, Carson, Cooper

Acquisition of data: Roter, Larson, Carson, Cooper

Analysis and interpretation of data: Ratanawongsa, Roter, Larson, Beach, Laird, Cooper

Drafting of the manuscript: Ratanawongsa

Critical revision of the manuscript for important intellectual content: Ratanawongsa, Roter, Larson, Beach, Laird, Carson, Cooper

Statistical expertise: Carson

Obtained funding: Cooper

Administrative, technical, or material support: Carson, Cooper

Study supervision: Cooper


  1. 1.
    Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997 Feb 19;277(7):553–559.PubMedCrossRefGoogle Scholar
  2. 2.
    Roter DL, Stewart M, Putnam SM, Lipkin M Jr, Stiles W, Inui TS. Communication patterns of primary care physicians. JAMA. 1997 Jan 22–29;277(4):350–356.PubMedCrossRefGoogle Scholar
  3. 3.
    Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care. 1988 Jul;26(7):657–675.PubMedCrossRefGoogle Scholar
  4. 4.
    Stewart MA. Effective physician-patient communication and health outcomes: A review. CMAJ. 1995 May 1;152(9):1423–1433.PubMedGoogle Scholar
  5. 5.
    Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989 Mar;27(3 Suppl):S110–S127.PubMedCrossRefGoogle Scholar
  6. 6.
    Clever SL, Ford DE, Rubenstein LV, et al. Primary care patients’ involvement in decision-making is associated with improvement in depression. Med Care. 2006 May;44(5):398–405.PubMedCrossRefGoogle Scholar
  7. 7.
    Hall JA, Horgan TG, Stein TS, Roter DL. Liking in the physician–patient relationship. Patient Educ Couns. 2002 Sep;48(1):69–77.PubMedCrossRefGoogle Scholar
  8. 8.
    Hall JA, Roter DL. Do patients talk differently to male and female physicians? A meta-analytic review. Patient Educ Couns. 2002 Dec;48(3):217–224.PubMedCrossRefGoogle Scholar
  9. 9.
    Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999 Aug 11;282(6):583–589.PubMedCrossRefGoogle Scholar
  10. 10.
    Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003 Dec 2;139(11):907–915.PubMedGoogle Scholar
  11. 11.
    Beach MC, Roter DL, Wang NY, Duggan PS, Cooper LA. Are physicians’ attitudes of respect accurately perceived by patients and associated with more positive communication behaviors? Patient Educ Couns. 2006 Sep;62(3):347–354.PubMedCrossRefGoogle Scholar
  12. 12.
    Fernandez A, Schillinger D, Grumbach K, et al. Physician language ability and cultural competence. an exploratory study of communication with Spanish-speaking patients. J Gen Intern Med. 2004 Feb;19(2):167–174.PubMedCrossRefGoogle Scholar
  13. 13.
    Cvengros JA, Christensen AJ, Hillis SL, Rosenthal GE. Patient and physician attitudes in the health care context: Attitudinal symmetry predicts patient satisfaction and adherence. Ann Behav Med. 2007 May-Jun;33(3):262–268.PubMedCrossRefGoogle Scholar
  14. 14.
    Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory: Third edition. In: Zalaquett CP, Wood RJ, eds. Evaluating stress: A book of resources. Scarecrow Education; 1997:191–218.Google Scholar
  15. 15.
    Linzer M, Visser MR, Oort FJ, et al. Predicting and preventing physician burnout: Results from the United States and the Netherlands. Am J Med. 2001 Aug;111(2):170–175.PubMedCrossRefGoogle Scholar
  16. 16.
    Travado L, Grassi L, Gil F, Ventura C, Martins C, Southern European Psycho-Oncology Study Group. Physician-patient communication among southern European cancer physicians: The influence of psychosocial orientation and burnout. Psychooncology. 2005 Aug;14(8):661–670.PubMedCrossRefGoogle Scholar
  17. 17.
    Halbesleben JR. Patient reciprocity and physician burnout: What do patients bring to the patient-physician relationship? Health Serv Manag Res. 2006 Nov;19(4):215–222.CrossRefGoogle Scholar
  18. 18.
    Williams ES, Manwell LB, Konrad TR, Linzer M. The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: Results from the MEMO study. Health Care Manage Rev. 2007 Jul-Sep;32(3):203–212.PubMedGoogle Scholar
  19. 19.
    Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002 Mar 5;136(5):358–367.PubMedGoogle Scholar
  20. 20.
    Thomas MR, Dyrbye LN, Huntington JL, et al. How do distress and well-being relate to medical student empathy? A multicenter study. J Gen Intern Med. 2007 Feb;22(2):177–183.PubMedCrossRefGoogle Scholar
  21. 21.
    Argentero P, Dell’Olivo B, Ferretti MS. Staff burnout and patient satisfaction with the quality of dialysis care. Am J Kidney Dis. 2008 Jan;51(1):80–92.PubMedCrossRefGoogle Scholar
  22. 22.
    Halbesleben JR, Rathert C. Linking physician burnout and patient outcomes: Exploring the dyadic relationship between physicians and patients. Health Care Manage Rev. 2008 Jan-Mar;33(1):29–39.PubMedGoogle Scholar
  23. 23.
    Patient-Physician Partnership to Improve High Blood Pressure Adherence Study. identifier: NCT00123045, Last updated January 18, 2008., U.S. National Institutes of Health. Available at = partnership+and+adherence&rank=3. Accessed June 5, 2008.
  24. 24.
    McManus IC, Keeling A, Paice E. Stress, burnout and doctors’ attitudes to work are determined by personality and learning style: A twelve year longitudinal study of UK medical graduates. BMC Med. 2004 Aug 18;2:29.PubMedCrossRefGoogle Scholar
  25. 25.
    Piedmont RL. A longitudinal analysis of burnout in the health care setting: The role of personal dispositions. J Pers Assess. 1993 Dec;61(3):457–473.PubMedCrossRefGoogle Scholar
  26. 26.
    Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory manual, 3rd edition. Mountain View, CA: CPP, Inc., 1996.Google Scholar
  27. 27.
    Ware J Jr, Kosinski M, Keller SD. A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Med Care. 1996 Mar;34(3):220–233.PubMedCrossRefGoogle Scholar
  28. 28.
    Roter DL, Stewart M, Putnam SM, Lipkin M Jr, Stiles W, Inui TS. Communication patterns of primary care physicians. JAMA. 1997 Jan 22–29;277(4):350–356.PubMedCrossRefGoogle Scholar
  29. 29.
    Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997 Feb 19;277(7):553–559.PubMedCrossRefGoogle Scholar
  30. 30.
    Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003 Dec 2;139(11):907–915.PubMedGoogle Scholar
  31. 31.
    Price EG, Windish DM, Magaziner J, Cooper LA. Assessing validity of standardized patient ratings of medical students’ communication behavior using the Roter Interaction Analysis System. Patient Educ Couns. 2008 Jan;70(1):3–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Roter D, Larson S. The Roter Interaction Analysis System (RIAS): Utility and flexibility for analysis of medical interactions. Patient Educ Couns. 2002 Apr;46(4):243–251.PubMedCrossRefGoogle Scholar
  33. 33.
    Roter D. The Roter method of interaction process analysis2007 March;21:55.Google Scholar
  34. 34.
    Ishikawa H, Hashimoto H, Roter DL, Yamazaki Y, Takayama T, Yano E. Patient contribution to the medical dialogue and perceived patient-centeredness. An observational study in Japanese geriatric consultations. J Gen Intern Med. 2005 Oct;20(10):906–910.PubMedCrossRefGoogle Scholar
  35. 35.
    Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract. 1991 Feb;32(2):175–181.PubMedGoogle Scholar
  36. 36.
    Ford S, Fallowfield L, Lewis S. Doctor-patient interactions in oncology. Soc Sci Med. 1996 Jun;42(11):1511–1519.PubMedCrossRefGoogle Scholar
  37. 37.
    Mead N, Bower P. Measuring patient-centredness: A comparison of three observation-based instruments. Patient Educ Couns. 2000 Jan;39(1):71–80.PubMedCrossRefGoogle Scholar
  38. 38.
    Paasche-Orlow M, Roter D. The communication patterns of internal medicine and family practice physicians. J Am Board Fam Pract. 2003 Nov-Dec;16(6):485–493.PubMedCrossRefGoogle Scholar
  39. 39.
    Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics 1986 Mar;42(1):121–130.Google Scholar
  40. 40.
    Byers AL, Allore H, Gill TM, Peduzzi PN. Application of negative binomial modeling for discrete outcomes: A case study in aging research. J Clin Epidemiol. 2003 Jun;56(6):559–564.PubMedCrossRefGoogle Scholar
  41. 41.
    Roter D, Hall JA. Doctors talking with patients. Patients talking with doctors: Improving communication in medical visits. 2nd ed. Westport, Conn.: Praeger; 2006.Google Scholar
  42. 42.
    Shanafelt TD, West C, Zhao X, et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med. 2005 Jul;20(7):559–564.PubMedCrossRefGoogle Scholar
  43. 43.
    Stewart DE, Ahmad F, Cheung AM, Bergman B, Dell DL. Women physicians and stress. J Womens Health Gend Based Med. 2000 Mar;9(2):185–190.PubMedCrossRefGoogle Scholar
  44. 44.
    Goehring C, Bouvier Gallacchi M, Kunzi B, Bovier P. Psychosocial and professional characteristics of burnout in Swiss primary care practitioners: A cross-sectional survey. Swiss Med Wkly. 2005 Feb 19;135(7–8):101–108.PubMedGoogle Scholar
  45. 45.
    Piette JD, Schillinger D, Potter MB, Heisler M. Dimensions of patient-provider communication and diabetes self-care in an ethnically diverse population. J Gen Intern Med. 2003 Aug;18(8):624–633.PubMedCrossRefGoogle Scholar
  46. 46.
    Morris AL, Phillips RL, Fryer GE Jr, Green LA, Mullan F. International medical graduates in family medicine in the United States of America: An exploration of professional characteristics and attitudes. Hum Resour Health. 2006 Jul 18;4:17.PubMedCrossRefGoogle Scholar
  47. 47.
    Laird SL, Beach MC, Cooper LA. International medical graduates report more difficulties delivering patient-centered care than U. S. medical graduates. Journal of General Internal Medicine. 2006;21(4):76.Google Scholar
  48. 48.
    Hall JA, Stein TS, Roter DL, Rieser N. Inaccuracies in physicians’ perceptions of their patients. Med Care. 1999 Nov;37(11):1164–1168.PubMedCrossRefGoogle Scholar
  49. 49.
    West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: A prospective longitudinal study. JAMA. 2006 Sep 6;296(9):1071–1078.PubMedCrossRefGoogle Scholar
  50. 50.
    Suchman AL, Roter D, Green M, Lipkin M Jr. Physician satisfaction with primary care office visits. Collaborative study group of the American Academy on Physician and Patient. Med Care. 1993 Dec;31(12):1083–1092.PubMedCrossRefGoogle Scholar
  51. 51.
    An PG, Rabatin JS, Brown RL, Manwell LB, Linzer M, Schwartz MD. Effects of caring for difficult patients: Data from the MEMO (Minimizing Error, Maximizing Outcome) study. Journal of General Internal Medicine. 2007 Apr;22:125.Google Scholar
  52. 52.
    Halbesleben JR. Patient reciprocity and physician burnout: What do patients bring to the patient-physician relationship? Health Serv Manage Res. 2006 Nov;19(4):215–222.PubMedCrossRefGoogle Scholar
  53. 53.
    Huggard P. Compassion fatigue: How much can I give? Med Educ. 2003 Feb;37(2):163–164.PubMedCrossRefGoogle Scholar
  54. 54.
    Ratanawongsa N, Wright SM, Levine RB. Association between higher mental well-being and residents’ capacity for empathy. J Gen Intern Med. 2006 Apr;21(4):401,2; author reply 402.Google Scholar
  55. 55.
    Center for Health Program Development and Management. The Maryland study on physician experience with managed care. 2001.Google Scholar
  56. 56.
    Deary IJ, Watson R, Hogston R. A longitudinal cohort study of burnout and attrition in nursing students. J Adv Nurs. 2003 Jul;43(1):71–81.PubMedCrossRefGoogle Scholar
  57. 57.
    Jackson SE, Schwab RL, Schuler RS. Toward an understanding of the burnout phenomenon. J Appl Psychol. 1986 11;71(4):630–640.PubMedCrossRefGoogle Scholar
  58. 58.
    Leiter MP, Durup MJ. Work, home, and in-between: A longitudinal study of spillover. J Appl Behav Sci. 1996 03;32(1):29–47.CrossRefGoogle Scholar
  59. 59.
    Richardsen AM, Martinussen M. Factorial validity and consistency of the MBI-GS across occupational groups in Norway. Int J Stress Manag. 2005 08;12(3):289–297.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Neda Ratanawongsa
    • 1
    • 2
    Email author
  • Debra Roter
    • 1
  • Mary Catherine Beach
    • 1
  • Shivonne L. Laird
    • 1
  • Susan M. Larson
    • 1
  • Kathryn A. Carson
    • 1
  • Lisa A. Cooper
    • 1
  1. 1.Johns Hopkins UniversityBaltimoreUSA
  2. 2.Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical CenterBaltimoreUSA

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