Impact of Health Care System on Physicians' Discontent

Journal of Community Health, Vol. 26, No. 5, October 2001 ( 2001)

IMPACT OF HEALTH CARE SYSTEM ONPHYSICIANS’ DISCONTENT

Mike Magee, MD; Mohammadreza Hojat, PhD

ABSTRACT: This study was designed to investigate the impact of physi-cians’ perceptions of the health care system on their discontent withtheir profession. By using a random digit dialing technique, a structuredtelephone interview was conducted with 401 generalist physicians (343men, 56 women) who were practicing medicine at least for five years andwere younger than 65 years. Physicians’ willingness to choose medicineagain was correlated with their perceptions of different aspects of thehealth care system. Of the total participants, 288 (72 percent) indicatedthat they would choose medicine again, 91 (23 percent) would notchoose medicine, and 22 (5 percent) were not sure. Results of the step-wise logistic regression showed that after adjustment for physicians’ gen-der and age, those who would not choose medicine again were morethan twice as likely as other physicians who would choose medicine tobelieve that the health care environment will deteriorate more in thefuture (odds ratio = 2.1, p < .01), were less than half as likely to believethat physicians nowadays share more responsibilities with other healthcare professionals (odds ratio = .42, p < .01), and were less than half aslikely to confirm that patients understand their health insurance betterthan before (odds ratio = .46, p < .01). Findings suggest that physicians’discontent can be predicted by their negative perceptions of the healthcare environment. Findings have implications for improving the qualityof professional and personal life of the physician, thus improving thequality of care and satisfaction of the patient.

KEY WORDS: physician’s discontent; physician’s satisfaction; health care system;patient-physician relationships; quality care.

INTRODUCTION

Recent developments in the organization, financing and deliveryof health care, notably in the expansion of managed care, and in restric-tion of physician autonomy are posing enormous challenges to physicians.

Mike Magee is Senior Medical Advisor and Director of Pfizer Medical Humanities Initiative,Pfizer, Inc., New York, USA. Mohammadreza Hojat is Research Professor, Department of Psychiatryand Human Behavior, and Director of Jefferson Longitudinal Study of Medical Education at TheCenter for Research in Medical Education and Health Care, Jefferson Medical College of ThomasJefferson University, Philadelphia, Pennsylvania, USA.

Request for reprints should be addressed to Dr. Mike Magee, Pfizer Inc., Pfizer MedicalHumanities Initiative, 235 East 42nd Street, New York, NY 10017-5755 USA; e-mail: [email protected].

We would like to thank Paula Wheeler for her editorial assistance, and Yankelovich Partner,Inc. for conducting interviews and collecting data.

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0094-5145/01/1000-0357$19.50/0 2001 Human Sciences Press, Inc.

358 JOURNAL OF COMMUNITY HEALTH

While many view the glass half full by regarding these changes as a processthat ultimately leads to less expensive quality care in the future, others seethe glass half empty by perceiving a substantial dismay as a result of thechanges.1

Physicians’ views of the changes in the United States health caresystem are important factors in determining their personal satisfaction ordissatisfaction with their profession.2 Research findings indicate that somephysicians believe that their participation in the evolving health care sys-tem, such as the managed care health delivery, has profound and unpleas-ant overall effects on their satisfaction with their profession.3 Studying phy-sicians attitudes toward the health care system is important and timely,particularly in the light of research findings that link physicians attitudestoward changes to their perceived job stress and professional satisfaction.4

In a recent study only 18 percent of practicing physicians indicated thatthey held a positive view of the changes occurring in the health care sys-tem.2 Similar pattern of results was found in a study of the fourth yearmedical students.5 Consistent with these findings, results of other studiessuggest that a considerable number of physicians are dissatisfied with thechanges in the health care system.6–9

In a large scale study of young physicians in the United States pub-lished a decade ago, in response to the following question: “Given whatyou know about medicine as a career, if you were in college today, wouldyou go to medical school?”, only 60 percent of physicians would choose topursue a career in medicine, 31 percent would not choose medicine and9 percent were not sure.10 Another study showed that only 52 percent ofphysicians would definitely choose a medical career again.11 In a study byChuck and colleagues less than two-thirds (63 percent) of the surveyedphysicians indicated that their job was “fun.”9 In another study byScheckler and colleagues8 it was found that only 65 percent of surveyedphysicians reported that they were satisfied or very satisfied with theirpractice in a managed care health delivery environment (HMOs).

Research suggests that escalating disability claims for physicians arelinked to increasing levels of dissatisfaction.12–14 Physicians dissatisfactionwith career has also been found to predict physician burnout,15 higher jobdemand and lack of control.16 In addition, it has been reported that physi-cian discontent predicts lower patient compliance,17 poorer prescribing be-havior18 and patients’ dissatisfaction.19,20

These findings are alarming in that they suggest two things: First,a considerable number of physicians are disenchanted with practicingmedicine in the changing health care delivery environment characterizedby the expansion of managed care delivery system, restriction of physician

Mike Magee and Mohammadreza Hojat 359

autonomy, and patient care policies formulated by the giant health insur-ance companies.

Second, physicians discontent is correlated with their patients dis-satisfaction and noncompliance behavior. Therefore, given these influ-ences of the changes in the United States health care system on physicianssatisfaction and on their patients, it is timely and important to investigatefactors that are associated with the physicians’ discontent with medicineand medical practice.

Purpose of the Study

This study was designed to investigate the impact of physicians per-ceptions of aspects of the health care system on their satisfaction with theirmedical profession by using more recent data.

METHODS

Participants

Participants were 401 generalist physicians (343 men, 56women)who were practicing either internal medicine (n = 200), family medicine (n= 146), or general practice (n = 55). Only generalist physicians participatedin this study to control the confounding effects of medical specialties onthe findings. Participants were in practice at least for five years, wereyounger than 65 years, and had an office-based practice. These criteriawere used to select a sample with sufficient experience in practicing medi-cine, they were in practice from 5 to 21 years. The mean age was 46 years,ranging from 30 to 64 years.

Instrument

A structured interview was conducted based on 19 questions ad-dressing a variety of issues related to patient-physician relationships andphysicians views of the evolving changes in the United States health caresystem.

Procedures

Telephone interviews were conducted in December 1997 using arandom digit dialing technique. Telephone calls were made to the officesof physicians who met the study criteria prior to the interview in whichthe project was described, and arrangements were made for conducting


the interview at their convenience. Each interview took approximately 15minutes, and physicians were compensated for their interview time ($50incentive to participate).

The project had a broad purpose of identifying concerns, interests,and attitudes common to physicians and patients. Selected items used inthe present study were related to comparing present and past attitudestoward the patient-physician relationships, physicians’ perceptions of theirpatients’ understanding of health care policies, and physicians’ attitudestoward the future of health care system in the United States.

Physicians’ negative response to the following question: “If you hadthe opportunity to do things all over again, would you still choose to be-come a doctor?” was assumed to be an indication of their discontent withmedicine. Associations between responses to this question and those toother selected items were examined by employing chi-square and logisticregression analysis.

RESULTS

In response to the aforementioned question 288 physicians (72percent) indicated that they would choose medicine again, 91 (23 percent)would not choose to become a doctor (discontented physicians), and 22(5 percent) were not sure if they would choose to become a doctor if theyhad the opportunity to do things all over again. In all statistical analysesof this study, those who were not sure to choose medicine again wereexcluded, and data for two groups of physicians who would or would notchoose medicine again were used.

Bivariate Statistical Analyses

Statistically significant associations were found between responsesto the above-mentioned questions and seven other questions. Summaryresults are reported in Table 1.

As shown in the table, physicians who would not choose medicineagain were less likely than others to believe that compared to 10–15 yearsago, patients understand their health insurance better (18 percent versus35 percent, χ2 = 10.3, p < .01). Consistent with this finding, these discon-tented physicians were less likely than others to indicate that the majorityof their current patients understand the rules and policies of their healthinsurance plans (46 percent versus 61 percent, χ2 = 6.3, p < .05). Thesephysicians were also less likely than others to agree that the majority of


TABLE 1

Percent Distributions1 of Physicians’ Responses that wereSignificantly Associated with the Following Question

Would WouldChoose Not

If You had the Opportunity to Do Things Again ChooseAll Over Again, Would You Still Choose to (n = 288) (n = 91)Become a Doctor? % % χ2(1)

Compared to 10–15 years ago, patientsunderstand their health insurance bet-ter now. 35 18 10.3**By the year 2000, the health care envi-ronment will deteriorate more fromwhere it is now. 47 66 10.1**Compared to 10–15 years ago, doctorsnow share more of the responsibilityfor a patient’s health with a team ofother health care professionals. 85 70 9.9**The majority of patients you currentlysee understand the outside forces thatlimit doctors. 67 52 7.4**The majority of patients you currentlysee understand the rules and policies oftheir health insurance plans. 61 46 6.3*Patients in general are satisfied in theirdoctors’ accessibility 87 95 4.1*The best possible doctor-patient rela-tionship of the future is described interms of modern medicine with oldfashioned values. 84 75 4.0*

1Percentages show proportions of physicians who endorsed the indicated statements among

those who would or would not choose to become a doctor.**p < .01.*p < .05.


their patients understand the outside forces that limit their doctors (52percent versus 67 perfcent, χ2 = 7.4, p < .01).

Those who would not choose medicine again were less likely tobelieve that compared to the past, physicians nowadays share more of theresponsibility for a patient’s health with a team of other health care profes-sionals (70 percent versus 85 percent, χ2 = 9.9, p < .01).

While these discontented physicians believe more than others thatpatients are satisfied with their doctors’ accessibility (95 percent versus 87percent, χ2 = 4.1, p < .05), they were less likely to describe a desirable pa-tient-physician relationship in terms of modern medicine with old-fash-ioned values (75 percent versus 84 percent, χ2 = 4.0, p < .05).

The discontented physicians expressed a more pessimistic view ofthe health care environment than others by expecting that by the year2000, the health care environment will deteriorate more (66 percent ver-sus 47 percent, χ2 = 10.1, p < .01).

Multivariate Statistical Analyses

All of the aforementioned variables, plus gender (male = 0, female= 1) and age (younger than the median of the age distribution (45 years =0, else = 1) were included in a stepwise logistic regression model to exam-ine the unique contribution of those variables in predicting physicians’discontent. Inclusion of gender and age would make statistical adjustmentfor these demographic variables so that the final outcomes would not beconfounded by gender and age. Results of logistic regression analysis arepresented in Table 2.

As shown in the table only three of the variables showed a uniqueand statistically significant contribution in the logistic algorithm. Thosewho would not choose to become a doctor again were more than twice aslikely (odd ratio = 2.1, p < .01) as those who would choose again to becomea doctor to believe that the health care environment will deteriorate moreby the year 2000. These discontented physicians were about half as likelyas their counterparts to agree that doctors nowadays, as compared to10–15 years ago, share more responsibility with health care team (oddsratio = .42, p < .01), and less than half as likely as the other physicians toconfirm that patients understand their health insurance better than before(odds ratio = .46, p < .01).

DISCUSSION

The results of the present study suggest that while the majority ofphysicians would choose medicine as a career again, at least one in every


TABLE 2

Summary Results of the Stepwise Logistic Regression Analysis

OddsWould You Choose Medicine Again? Ratio + SE6

Sex1 1.8 .38Age2 1.1 .27The health care environment will deterioratemore by the year 2000.3 2.1** .26Doctors share more responsibility with healthcare team than before.4 .42** .31Patients understand their health insurance betterthan before.5 .46** .29

1male = 0, female = 1.

2<45 years = 0, ≥45 years = 1.To control for the possible confounding effests of sex and age, we included them in the statisticalmodel.

3yes = 1, else = 0.

4yes = 1, else = 0.

5yes = 1, else = 0.

6The standard error of the obtained odds ratios.**p < .01.

five physicians surveyed (23 percent) would not choose to become a doc-tor if they had the opportunity to do all things all over again. Althoughthis figure is lower than 31 percent reported by Cohen and colleagues,10 itstill shows that a significant number of physicians are dissatisfied with theirprofession by indicating that they would not choose medicine again astheir profession. One reason for lower dissatisfaction rate among physi-cians in this study as compared to Cohen and colleagues study could bethe specialty areas of the participating physicians. Participants in our studyincluded only generalist physicians while Cohen and colleagues sampleconsisted of both generalist and specialist physicians. Research findingsshow that specialist physicians are more likely than their generalist coun-terparts to express discontent as a result of changes in the health caresystem.2,21

Other findings of this study support the notion that physicians’percentions of the changes in the United Sates health care system suchas patient’s lack of understanding of their health care insurance policies,graduate deterioration of health care system, diffusion of responsibilitieswith other health professionals, limitation on physician autonomy, andfading of traditional values in modern medicine contribute to physicians


uncertainty about the future of health care. These findings are consistentwith the reports that the changes in the health care system not only haveinfluenced physicians satisfaction with their profession,1,2,4,8,22–25 but havealso influenced patient-physician communication.26

Findings of the present showed that more than half of the surveydphysicians believe that health care environment would deteriorate more inthe future. These outcomes are consistent with the findings that physiciansatisfaction, and trust in health care system are declining.27 In a study byDonelan and colleagues, 55 percent of physicians expressed a negativeview of the recent changes in the health care system.28 Physicians percep-tions that their patients nowadays do not understand their health insur-ance and that physicians do not share responsibilities with others are re-flections of their negative views of the evolving health care system in theUnited States. Our results indicate that these factors have a negative im-pact on physicians satisfaction with their professions.

Findings of this study deserve close attention for two reasons: First,physicians satisfaction with their profession is considered as an indicatorof quality of the practice plan in which physicians render care.29 Second,and more importantly research findings suggest physician discontent hasan impact on patient care, and that the patients of those physicians whoare more satisfied with their profession were themselves more satisfiedwith the care rendered to them.20

The underlying reasons for the link between satisfaction of physi-cians and their patients deserve further empirical scrutiny. Do the physi-cians who perceive that the health care system is deteriorating practicea more defensive medicine? Do they communicate differently with theirpatients? To what extent can physicians’ perceptions of practice environ-ment influence the quality of care rendered to their patients? Research onthe impact of changes in the health care system on physicians satisfaction,such as the present study, can provide a context for studying the afore-mentioned issues in the world of practice. In addition, understanding fac-tors that have impact on physicians satisfaction or dissatisfaction can notonly be beneficial in improving the quality of professional and personallife of the physician, but can also improve the quality of care rendered tothe patients, and therefore, increase patients’ satisfaction and their compli-ance behavior.

REFERENCES

1. Kassirer JP. Doctor discontent. N Engl J Med 1998;339:1543–1645.2. Hojat M, Gonnella JS, Erdmann JB, Veloski JJ, Louis DZ, Nasca TJ, Rattner SL. Physicians’ per-


ceptions of the changing health care system: Comparisons by Gender and Specialties. J CommunityHealth 2000; 25:455–471.

3. Warren MG, Weiz R, Kulis S. The impact of managed care on physicians. Health Care Mangt Rev.1999;24:44–56.

4. Richardsen AM, Burke RJ. Occupational stress and work satisfaction among Canadian womenphysicians. Psychol Rep 1993;72:811–821.

5. Hojat M, Veloski JJ, Louis DZ, Xu G, Ibarra D, Gottlieb JE, Erdmann JB. Perceptions of medicalstudents of the current changes in the United States health care system. Eval Hlth Prof 1999;22:169–183.

6. Lewis LE, Prout DM, Chalmers ED. How satisfying is the practice of internal medicine? AnnIntern Med 1991;114:1–5.

7. Nadler ES, Sims S, Tyurance PH, Fairchild DG, Brennan TA, Bates DW. Does a year make adifference? Changes in physician satisfaction and perception in an increasingly capitated environ-ment. Am J Med 1999;107:38–44.

8. Scheckler WE, Schultz R, Moberg P. Physician satisfaction with the development of HMOs inDane County. Wisconcin Medical Journal 1994;93:444–446.

9. Chuck JM, Nesbitt TS, Kwan J, Kam SM. Is being a doctor still fun? Western J Med 1993;159:665–669.

10. Cohen AB, Cantor JC, Barker DC, Hughes RG. Data watch: Young physicians and the Future ofthe medical profession. Hlth Aff 1990 Winter issue:138–148.

11. Lemkau J, Rafferty J, Gordon R Jr. Burnout and career-choice regret among family practicephysicians in early practice. Fam Prac Res J 1994;14:213–222.

12. Altman LK, Rosenthal E. Changes in medicine bring pain to healing profession. New York Times1998;1:1.

13. Hall CT. Young doctors disheartened. San Francisco Chronicle November 18, 1995; B, 1:1.14. Hilzenrath DS. Disability claims rise for doctors. Washington Post February 16, 1998, A1.15. Goldberg R, Boss RW, Chan L, Goldberg J, Mallon WK, Moradzadeh D, Goodman EA, McCon-

kie ML. Burnout and its correlates in emergency physicians: Four years experience with a well-ness booth. Acad. Emerg. Med. 1996;3: 1156–1165.

16. Johnson JV, Hall EM, Ford DE, Meal LA, Levine DM, Wang NY, Klag MJ. The psychosocialwork environment of physicians: The impact of demands and resources on job satisfaction andpsychiatric distress in a longitudinal study of Johns Hopkins medical school graduates. J. Occup. &Environ. Med. 1995; 37:1151–1159.

17. DiMatteo MR, Sherbourne CD, Hays RD, Ordway L, Kravitz RL, McGlynn EA, Kaplan S, RogersWH. Physicians’ chartacteristics influence patients’ adherence to medical treatment: results fromthe medical outcomes study. Hlth Psychol 1993;12: 93–102.

18. Melville A. Job satisfaction in general practice: Implications for prescribing. Social Science & Medi-cine 1980;14:496–499.

19. Linn LS, Yager J, Cope D, Leake B. Health status, job satisfaction, job stress, and life satisfactionamong academic and clinical faculty. JAMA 1985; 254:2775–2782.

20. Hass JS, Cook EF, Puopolo AL, Burstin HR, Cleary PD, Brennan TA. Is the professional satisfac-tion of general internists associated with patient satisfaction? J Gen Int Med 2000;15:122–128.

21. Schultz R, Scheckler WE, Moberg DP, Johnson PR. Changing nature of physician satisfactionwith health maintanance organization and fee-for-service practices. J Fam Pract 1997;45:321–330.

22. Dean VC. Physician satisfaction reflects changes in the health care landscape. J Fam Pract 1997;45:319–320.

23. Nash DB (ed.). Future Practice Alternative in Medicine (2nd Edition). New York: Igaku-Shoin, 1993.24. Rice B. What’s a doctor doing selling Amway? Med. Econ 1997;74:79.25. Gray BH. Trust and trustworhy care in managed care era. Hlth Aff. 1997;16:34–49.26. DiMatteo MR. The role of the physician in the emerging health care environment. Western J Med

1998;168:323–333.27. Kenagy JW, Berwick DM, Shore MF. Service quality in health care. JAMA 1999;281:661–665.28. Donelan K, Blendon RJ, Lundberg GD, Calkins DR, Newhouse JP, Leape IL, et al. The new

medical market place: physicians’ views. Hlth Aff 1997;16:139–148.29. Gazewood JD, Longo DR, Madsen R. Physician satisfaction with Medicaid managed care: The

Missouri experience. J Fam Pract 2000;49:20–26.

Impact of Health Care System on Physicians' Discontent

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