Does Career Dissatisfaction Affect the Ability of Family Physicians to Deliver High-Quality Patient Care?

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Original Research

Does Career Dissatisfaction Affect the Ability of Family Physicians to Deliver High-Quality Patient Care?

J Fam Pract. 2002 March;51(3):223-228

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References

1. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract 1998;47:213-20.

2. Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary care: America’s health in a new era. Washington DC: National Academy Press; 1996.

3. Grumbach K, Selby JV, Damberg C, et al. Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists. JAMA 1999;282:261-6.

4. Mainous AG, Baker R, Love MM, Gray DP, Gill JM. Continuity of care and trust in one’s physician: evidence from primary care in the United States and the United Kingdom. Fam Med 2001;33:22-7.

5. Robert Graham Center for Policy Studies in Family Practice and Primary Care. The importance of having a usual source of health care. Am Fam Physician 2000;62:477.-

6. Haas JS, Cook EF, Puopolo AL, Burstin HR, Cleary PD, Brennan TA. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med 2000;15:122-8.

7. Patricelli RE. Providing universal and affordable health care to the American people. In: Providing universal and affordable health care. Washington DC: Institute of Medicine; 1989.

8. Linn LS, Yager J, Cope D, Leake B. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 1985;254:2775-82.

9. DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians’ characteristics influence patients’ adherence to medical treatment: results from the medical outcomes study. Health Psychol 1993;12:93-102.

10. Buchbinder SB, Wilson M, Melick CF, Powe NR. Estimates of costs of primary care physician turnover. Am J Managed Care 1999;5:1431-8.

11. Lewis CE, Prout DM, Chalmers EP. How satisfying is the practice of internal medicine? A national survey. Ann Intern Med 1991;114:1-5.

12. FP Report. Worrisome trend continues: specialty, primary care lose ground in 2001 match. FP Report 2001; 4:7.

13. Robert Graham Center for Policy Studies in Family Practice and Primary Care. The United States relies on family physicians unlike any other specialty. Am Fam Physician 2001;63:1669.-

14. Conte SJ, Imershein AW, Magill MK. Rural community and physician perspectives on resource factors affecting physician retention. J Rural Health 1992;8:185-96.

15. Donelan K, Blendon RJ, Lundberg GD, et al. The new medical marketplace: physicians’ views. Health Affairs 1997;16:139-48.

16. Schulz R, Scheckler WE, Moberg DP, Johnson PR. Changing nature of physician satisfaction with health maintenance organization and fee-for-service practices. J Fam Pract 1997;45:321-30.

17. Murray A, Montgomery JE, Chang H, Rogers WH, Inui T, Safran DG. Doctor discontent: a comparison of physician satisfaction in different delivery system settings, 1986 and 1997. J Gen Intern Med 2001;16:451-9.

18. Skolnik NS, Smith DR, Diamond J. Professional satisfaction and dissatisfaction of family physicians. J Fam Pract 1993;37:257-63.

19. Pathman DE, Williams ES, Konrad TR. Rural physician satisfaction: its sources and relationship to retention. J Rural Health 1996;12:366-77.

20. Kerr EA, Mittman BS, Hays RD, Zemencuk JK, Pitts J, Brook RH. Associations between primary care physician satisfaction and self-reported aspects of utilization management. Health Serv Res 2000;35(1 pt 2):333-49.

21. Petrozzi MC, Rosman HS, Nerenz DR, Young MJ. Clinical activities and satisfaction of general internists, cardiologists, and ophthalmologists. J Gen Intern Med 1992;7:363-7.

22. Kitai E, Kushnir T, Herz M, Melamed S, Vigiser D, Granek M. Correlation of work structure and job satisfaction among Israeli family physicians. Israeli Med J 1999;1:236-40.

23. Hueston WJ. Family physicians’ satisfaction with practice. Arch Fam Med 1998;7:242-7.

24. Hadley J, Mitchell JM, Sulmasy DP, Bloche MG. Perceived financial incentives, HMO market penetration, and physicians’ practice style and satisfaction. Health Serv Res 1999;34:307-21.

25. Bates AS, Harris LE, Tierney WM, Wolinsky FD. Dimensions and correlates of physician work satisfaction in a midwestern city. Med Care 1998;36:610-7.

26. Grumbach K, Osmond D, Vranizan K, Jaffe D, Bindman AB. Primary care physicians’ experience of financial incentives in managed-care systems. N Engl J Med 1998;339:1516-21.

27. Kerr EA, Hays RD, Mittman BS, Siu AL, Leake B, Brook RH. Primary care physicians’ satisfaction with quality of care in California capitated medical groups. JAMA 1997;278:308-12.

28. Kemper P, Blumenthal D, Corrigan JM, et al. The design of the Community Tracking Study: a longitudinal study of health system change and its effects on people. Inquiry 1996;33:195-206.

29. Metcalf CE, Kemper P, Kohn LT, Pickreign JD. Site definition and sample design for the Community Tracking Study (technical publication no.1). Washington, DC: Center for Studying Health System Change; 1996.

30. Keil L, Chattopadhyay M, Potter F, Reed MC. Community Tracking Study Physician Survey round 1 survey methodology report (Technical Publication No.9). Washington, DC: Center for Studying Health System Change; 1998.

31. Reschovsky JD, Edson D, Sewall A, et al. Community Tracking Study physician survey public use file: user’s guide, round 1, release 1. Technical publication no 10. Washington, DC: Center for Studying Health System Change; 1998.

Analytical strategy

Two sets of logistic regression were performed. In the first, adjusted odds ratios were derived to measure the association of personal, professional, and practice characteristics with dissatisfaction (Table 2). Next, the relationship of dissatisfaction with each of the indicators of quality of care was assessed with 6 separate multivariate logistic regression procedures (Table 1). The adjusted odds ratios in Table 1 are the products of that analysis and represent the association of perceived ability to deliver quality of care after controlling for the effects of personal, professional, and practice variables. SUDAAN software, version 7.5.3 (Research Triangle Institute, Research Triangle Park, NC), was used to conduct statistical tests and make national estimates with variance adjustment for the complex survey sample design and physician nonresponse.

TABLE 2
PERSONAL, PROFESSIONAL, AND PRACTICE-RELATED FACTORS ASSOCIATED WITH FP/GP DISSATISFACTION (N = 3166)

PERSONAL/PROFESSIONAL CHARACTERISTICS	Multivariate Odds Ratio (95% CI)
Age in years (n = 2965)
<35	1.0
35–44	1.43 (0.94-2.16)
45–54	1.89 (1.20-2.98)
55–64	2.46 (1.56-3.88)
64	2.30 (1.40-3.80)
Sex (n = 3106)
Women	1.0
Men	1.28 (0.92-1.78)
Type of medical training (n = 3106)
Allopathic	1.0
Osteopathic	1.74 (1.34-2.25)
Graduate of foreign medical school (n = 3106)
Puerto Rico	1.0
Other	1.33 (1.03-1.73)
Board certification (n = 3063)
Board certified	1.0
Board eligible	1.15 (0.82-1.63)
Neither	0.93 (0.69-1.25)
Net income in 1995 ($) (n = 3103)
0–49,000	2.31 (1.29-4.14)
50,000–99,999	1.83 (1.20-2.79)
100,000–149,999	1.45 (0.98-2.14)
150,000–199,999	1.41 (0.91-2.16)
200,000–249,999	1.0
250,000–299,999	1.82 (0.98-3.38)
300,000 +	1.93 (0.98-3.81)
PRACTICE CHARACTERISTICS
Practice type (n = 3106)
1 or 2 physicians	1.19 (0.74-1.93)
3+ physicians	1.14 (0.70-1.85)
HMO	1.35 (0.82-2.22)
Medical school	1.01 (0.52-1.93)
Hospital based	1.0
Other	1.16 (0.74-1.83)
Community size (n = 3106)
Large metropolitan area (>200,000)	1.42 (0.81-2.49)
Small metropolitan area (< 200,000)	1.0
Nonmetropolitan area	1.07 (0.55-2.08)
Ownership (n = 3106)
Full owners	1.57 (1.11-2.21)
Part owners	1.0
Not an owner	1.01 (0.72-1.43)
Percentage of patients for whom you serve as gatekeeper (n = 3106)
0	2.20(1.44-3.37)
1–9	1.59 (1.06-2.40)
10–19	1.0
20–29	1.47 (0.98-2.20)
30–59	1.83 (1.29-2.60)
60–89	2.31 (1.62-3.28)
90–100	2.29 (1.44-3.64)
NOTE: Ns vary because not all physicians answered every item on the survey.
FP/GP denotes family physician/general practitioner; HMO, health maintenance organization.

Results

Nearly 18% of physicians report being dissatisfied with a career in medicine. The rate of dissatisfaction among FP/GPs is similar to that for all physicians, specialists, and primary care physicians as a group. However, there is some variability among primary care specialties, with internists reporting more dissatisfaction (chi-square = 14.8, P < .01) and pediatricians (chi-square = 25.9, P < .01) reporting less dissatisfaction than FP/GPs (Table 3).

TABLE 3
EXTENT OF PHYSICIAN DISSATISFACTION

Type of Physician	Satisfied or Very Satisfied n (%)*	Dissatisfied or Very Dissatisfied n (%)*	Neither Satisfied nor Dissatisfied n (%)*
Total physicians	10,093 (80.7)	2198 (17.7)	212 (1.6)
Specialists	4316 (80.5)	953 (18.0)	87 (1.6)
Total primary care	5777 (81.0)	1245 (17.4)	125 (1.6)
FP/GPs	2537 (81.9)	569 (17.3)	60 (1.7)
Pediatricians	1403 (86.2)	206 (12.6)	17 (1.3)
Internists	1837 (77.5)	470 (20.6)	48 (1.9)
*Unweighted number of survey respondents and weighted percent of US FP/GPs.
FP/GPs denotes family physicians/general practitioners.

Factors associated with FP/GP dissatisfaction

Many characteristics were associated with the dissatisfaction reported by 17.6% of FP/GPs. The associated characteristics are included in 3 domains. The first 2 domains, personal/professional and practice characteristics, reveal significant factors associated with dissatisfaction (Table 2). The data in the third domain, patient care characteristics, represent results after we had statistically controlled for all factors in the first 2 (Table 1).

Personal/Professional Characteristics. A higher level of dissatisfaction was related to being older; only 10.1% of physicians younger than 35 years of age reported dissatisfaction versus 25.1% of physicians aged 55 to 64 years (odds ratio [OR] 2.46; 95% confidence interval [CI], 1.56-3.88). FP/GPs more likely to be dissatisfied were those who had osteopathic training and those who had been graduated from foreign medical schools. Levels of dissatisfaction were also higher among FP/GPs earning less than $100,000 per year.

Practice Characteristics. Physicians who fully owned their practice were more likely to express dissatisfaction with their careers than were physicians who either shared ownership or did not own their practice (OR 1.57; 95% CI, 1.11-2.21). The pattern of dissatisfaction related to gatekeeping (ie, providing permission for their patients to seek specialty care) was similar to that related to income. FP/GPs serving as gatekeepers for less than 10% or more than 30% of their patients were the most dissatisfied.

Patient Care Characteristics. After we had controlled for the effects of personal, professional, and practice characteristics, we found that FP/GP career dissatisfaction was, without exception, consistently and strongly associated with a perceived inability to provide high-quality care as assessed by physician responses to each of 6 statements (Table 1). Dissatisfied physicians were much more likely to “disagree strongly” than. to “agree strongly” with the statements about clinical freedom (OR 7.89; 95% CI, 4.86-12.83), continuity of care (OR 7.11; 95% CI, 4.90-10.33), clinical decisions free of financial penalties (OR 4.44; 95% CI, 3.13-6.31), adequacy of time with patients (OR 4.42; 95% CI, 2.84-6.87), ability to provide high-quality care (OR 4.26; 95% CI, 2.88-6.31) and sufficient communication with specialists (OR 3.57; 95% CI, 2.20-5.80). The most notable differences found between dissatisfied and satisfied FP/GPs were related to a lack of clinical freedom and difficulty maintaining continuing relationships with patients.