A multiyear physician survey on career fulfillment showed significant variation in satisfaction levels across local health-care markets, and it found that, nationally, 18 percent of physicians were somewhat or very dissatisfied, according to a study by researchers at Harvard Medical School and the Center for Studying Health System Change (HSC) that appears in the Jan. 22 Journal of the American Medical Association. Overall, the study shows that physician career satisfaction levels were relatively consistent from year to year, and a clear majority of physicians nationally are satisfied with their careers.
“Physician career satisfaction is one indicator of the overall health of our health-care delivery system,” says lead author Bruce Landon, assistant professor of health care policy and medicine at the Medical School Department of Health Care Policy and Beth Israel Deaconess Medical Center. “For example, excellent, but dissatisfied physicians could decide to leave the practice of medicine early, and highly talented students might opt for different career paths if the perception exists that medicine is not a fulfilling career. Both of these outcomes would clearly weaken patient care and the health-care system in general.”
The study surveyed more than 12,000 primary care and specialist physicians in 1997, 1999, and again in 2001. For each of the three years, roughly 80 percent of primary care and specialist physicians were somewhat or very satisfied with their careers, and nearly 18 percent were somewhat or very dissatisfied with their careers. The study also investigated physician career satisfaction in 12 randomly selected local markets to determine some of the root causes of satisfaction and dissatisfaction. These market regions included Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Phoenix, Ariz.; Orange County, Calif.; Seattle; and Syracuse, N.Y.
“This is the first study to identify wide variation in physician satisfaction across local markets,” said co-author James Reschovsky of HSC, a nonpartisan policy research organization funded exclusively by the Robert Wood Johnson Foundation. “It’s difficult to pin down exactly what market forces are driving the variation, but market-level changes such as new state regulations, health plan mergers, and changes in hospital competition likely play a role.”
For example, Phoenix physicians were more than twice as likely to be dissatisfied with their careers in 2001 as doctors in Lansing. Nearly one in four Phoenix physicians reported being somewhat or very dissatisfied with their careers in medicine, compared with about one in 10 Lansing physicians in 2001.
Researchers did link variation in market-level physician satisfaction with the degree of capitated contracting – in which health plans pay physicians a fixed monthly amount for each patient – in local markets. Higher proportions of capitated managed care revenue were associated with decreases in market-level physician satisfaction.
Across the local markets, the biggest change over time occurred in Syracuse, where the percentage of physicians who were somewhat or very dissatisfied with their careers increased from 14 to 20 percent between 1997 and 2001. In northern New Jersey, however, the opposite occurred, with the percentage of somewhat or very dissatisfied physicians declining from 24 percent in 1997 to 17 percent in 2001.
Findings from recent HSC site visits may explain some of the more dramatic local changes. For example, the merger of two large health plans in the Syracuse market may have increased plans’ leverage over physicians. In northern New Jersey, the state adopted more stringent oversight of managed care plans, including requirements for prompt payment – changes that may have resulted in increased physician autonomy.
In contrast to the wide variation in physician satisfaction across the 12 local markets, national levels of physician satisfaction changed little between 1997 and 2001, with a slight dip in satisfaction between 1997 and 1999, but holding steady between 1999 and 2001.
The trend in physician satisfaction may reflect changes in managed care plan practices, which often have tried to limit physicians’ clinical autonomy. Many physicians dislike these restrictions, prompting a backlash against managed care. Many health plans now offer broader provider networks and have eased restrictions on care by eliminating prior approvals for specialty referrals and certain tests and procedures.
Consistent with these trends, the study also found that physician autonomy – including freedom to make clinical decisions in the best interest of patients, having enough time with patients, and maintaining continuing relationships with patients – was more important than income in influencing changes in physician satisfaction.
The study was based on HSC’s Community Tracking Study Physician Survey, a nationally representative survey of physicians, with response rates ranging from 59 to 65 percent. The Physician Survey includes a group of physicians – known as a panel – who were interviewed in multiple years, allowing researchers to determine what factors over time influenced changes in physician satisfaction.