• Cost-effectiveness
• Ambulatory care
• Fatigue

Turnover is costly. When primary care physicians (PCPs) leave their practice for another location, leave medicine altogether for another career, partially leave by reducing clinical working time or retire early then relationships are broken, and patients and payors pay a price. Costs are higher and quality is lower.

In the USA we found that patients who had lost their PCP incurred additional healthcare expenditures: $61 more per year for non-Medicare patients (typically those under 65 years old) and $189 more per year for Medicare patients.1 This results in an estimated $86 000 additional spending per departing PCP, totalling $1 billion per year across the USA in excess healthcare expenditures due to disruption in relationships between patients and their PCP. Patients receive more and unnecessary testing, with the consequential risk of iatrogenic harm, when evaluated by a physician who does not know them well or at a site of service with higher costs and a more test-heavy approach, such as a single specialty clinic, urgent care or the emergency department.

Comprehensive primary care has long been shown to be associated with better cost and quality outcomes in comparisons by country or by region.2 Continuity with one’s personal physician has also been associated with reduced health service utilisation, complications and mortality.3

The study by Parisi et al 4 in the current issue of BMJ Quality and Safety adds to the literature by further demonstrating the value of continuity and the costs incurred by patients and payors when continuity is broken. Using administrative data for general practitioners (GPs) in England from 2007 to 2019 researchers determined that patients cared for in practices with persistently high levels of physician turnover, defined as more than 10% GP turnover in each of three consecutive years, had significantly worse outcomes: less access to same-day care, less continuity with one’s personal physician, more emergency department attendances and more emergency (ie, unplanned) hospitalisations.

Perhaps even more concerning are the trends in continuity and access across all GP practices over the decade of the current study. The likelihood of seeing one’s preferred GP dropped from 72.5% to 56.1%, while the odds of achieving a same-day appointment plummeted from 80.3% to 32.3% over the same interval.4 Continuity and access to care appear to be at risk in the UK as they are in the USA.

The study by Parisi et al 4 did not address the impact of increasing numbers of physicians working less than full time, yet this is a substantial contributor to the effective reduction in the size of the physician workforce and is thus also a threat to patient access to care, quality and cost. Burnout, dissatisfaction with work–life integration and dissatisfaction with the electronic health record (EHR) are each associated with intent to reduce hours providing clinical care.5 6 In one longitudinal study, for every 1 point increase in burnout on a 7-point scale there was a 43% increase in the odds of reducing clinical hours.5

Given the importance of continuity and access in primary care, it is critical to understand why physicians leave a profession they have invested so much of their lives preparing for and which is inherently meaningful. Parisi et al found that practices with high patient complexity and reduced financial support were more likely to have persistently high turnover.4 This suggests an imbalance between job demands (patient complexity) and job resources (financial and clinical staff support) is a risk factor for turnover.

We now turn to burnout as a key to understanding and addressing physician turnover and its negative consequences for patients and payers. Longitudinal studies in the USA document that physicians who experienced symptoms of burnout are twice as likely to have left their organisation 2 years later compared with those who did not experience burnout at baseline.7

The mismatch between job demands and job resources is a significant driver of burnout, which in turn is associated with physicians’ intention to leave their current practice and intention to reduce clinical work. Job demands have increased for PCPs over the past 20 years. In 2003, it was estimated to require 18 hours/day for PCPs to accomplish all of the recommended prevention and chronic illness care.8 9 By 2020, and still before pandemic, these estimates had risen to 26.7 hours/day.10 There is simply more work to be done than can be done in the ‘physician-acting-alone’ model of care commonly found in primary care in the UK and the USA. It should not be surprising, then, that burnout and intent to leave are higher when there are low levels of staff support (ie, fewer job resources)11 and greater dissatisfaction with the tool used to organise care, the EHR.6 Poor values alignment, low work control, poor teamwork and a chaotic workplace are each also associated with intention to leave one’s practice.12

The COVID-19 pandemic has exacerbated job demands. For example, patient medical advice requests via the patient portal increased abruptly by 57% across the entire US Epic user base at the onset of the pandemic and have remained at this higher level since, despite a return to baseline levels of in-person visits.13 The pandemic also exacerbated burnout and intentions to reduce clinical hours or leave clinical practice. Sixty-three per cent of US physicians now experience symptoms of burnout, reversing a 6-year downward trend in burnout rates and reflecting a marked rise from 38% just 1 year earlier.14 Whereas in the first year of the pandemic three-quarters of US physicians would choose to be doctors again, by the end of the second year of the pandemic that number had dropped to only half.

What can be done? We recommend two approaches: (1) prioritise enduring relationships with patients and within teams; (2) push more decision authority to the physicians closest to patients.