Across the country, federally qualified health centers provide a critical safety net, delivering needed medical care regardless of a person’s ability to pay. And so it’s worrisome when researchers document a sharp increase in dissatisfaction among the clinicians and staff who make those centers run.

“We’re not sure why we saw things getting worse in the centers,” said Mark Friedberg, a senior natural scientist at Rand Corporation and director of their Boston office. “The best takeaway from this study is we need to track this. We need to get to the bottom of it because it is alarming.”

Friedberg and his colleagues surveyed FQHC staff in 2013 and 2014 as part of a larger evaluation of the FQHC Advanced Primary Care Practice Demonstration at the Centers for Medicare & Medicaid Services (CMS), which focused on patient-centered medical homes. To conduct the study, researchers sampled all 503 FQHC sites participating in the demonstration project, ultimately receiving survey responses from more than 1,200 clinicians and staff in 2013, representing 440 FQHC sites. A follow-up survey in 2014 gained responses from more than 500 clinicians and staff who had also participated in the baseline survey and represented nearly 300 FQHC sites. The results were published in the August issue of Health Affairs.

Researchers found that even though the survey took place only about 15 months apart, responses “worsened significantly over time.” Between surveys, overall satisfaction rates declined from 84.2 percent to 74.4 percent, while rates of burnout increased from 23 percent to 31.5 percent. The proportion of survey respondents who said they were likely to leave their practices within two years rose from about 29 percent to more than 38 percent.

Also, 12 of 13 practice culture measures worsened over the two-survey period, with the greatest declines related to teamwork and facilitative leadership. Other workplace environment measures that worsened over time included work control as well as working in a hectic or chaotic practice atmosphere.

While the surveys didn’t tease out the specific reasons for increasing dissatisfaction, the researchers did offer some guesses. Friedberg and co-authors Rachel Reid, Justin Timbie, Claude Setodji, Aaron Kofner, Beverly Weidmer and Katherine Kahn write:

For example, rapid adoption of new electronic health records (which can disrupt practice workflow and distract from face-to-face care), expansion of coverage under the Affordable Care Act (which may have caused a demand surge for many clinics), and medical home transformation (whether spurred by the CMS FQHC Advanced Primary Care Practice Demonstration or other initiatives) all could have stressed FQHC clinicians and staff members.

“I was surprised to see that big of a change in such a short period of time,” Friedberg told me. “If you look at measures of physician satisfaction over time, by and large across the country, it’s remarkably stable. So with that as a prior finding, this was a surprise.”

On the other hand, Friedberg said FQHCs, which typically care for patients with complicated health, behavioral and social needs, often do experience staff turnovers every few years. With that in mind, he said the survey results could also simply be reflecting the challenging environments inside FQHCs — or as Friedberg said, “it could be all we’re seeing is two points in time in their natural histories.” Still, he said neither explanation is very reassuring, especially considering the critical importance of FQHCs in caring for the nation’s most vulnerable populations.

“I hope that more work is done to confirm, update and better understand the causes of what we reported,” Friedberg said. “The best possible thing would be that someone fails to confirm what we found. I’d love to be not correct on this because I do worry that this is a leading indicator of the sustainability of our safety net. …How long can you run a system in which things are getting worse for the workforce?”

To request a copy of the study, visit Health Affairs.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for 15 years. Follow me on Twitter — @kkrisberg.