Values of Family Physicians and Practice Outcomes

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Personal Values of Family Physicians, PracticeSatisfaction, and Service to the Underserved

B. Clair Eliason, MD; Clare Guse, MS; Mark S. Gottlieb, PhD

Background: Personal values are defined as desirablegoals varying in importance that serve as guiding prin-ciples in peoples lives, and have been shown to influ-ence specialty choice and relate to practice satisfaction.We wished to examine further the relationship of per-sonal values to practice satisfaction and also to a physi-cians willingness to care for the underserved. We alsowished to study associations that might exist among per-sonal values, practice satisfaction, and a variety of prac-tice characteristics.

Methodology:We randomly surveyed a stratified prob-ability sample of 1224 practicing family physicians abouttheir personal values (using the Schwartz values ques-tionnaire), practice satisfaction, practice location, breadthof practice, demographics, boardcertificationstatus,teach-ing involvement, and the payor mix of the practice.

Results: Family physicians rated the benevolence (moti-vation to help those close to you) value type highest, andthe ratings of the benevolence value type were positivelyassociated with practice satisfaction (correlation coeffi-

cient = 0.14, P = .002). Those involved in teaching medi-cal trainees were more satisfied than those who were notinvolved (P = .009). Some value-type ratings were foundto be positively associated with caring for the under-served. Those whose practicesconsisted of more than 40%underserved (underserveddefined as Medicare,Medicaid,and indigent populations) rated the tradition (motivationtomaintaincustomsoftraditionalcultureand religion)valuetype significantly higher (P = .02). Those whose practicesconsistedof more than 30% indigentcare rated theuniver-salism (motivation to enhance and protect the well-beingof all people) value type significantly higher (P = .03).

Conclusions: Family physicians who viewed benevo-lence as a guiding principlein their lives reported a higherlevel of professional satisfaction. Likewise, physicians in-volved in the teaching of medical trainees were more sat-isfied with their profession. Family physicians who ratethe universalism values highly are more likely to pro-vide care to the indigent.

Arch Fam Med. 2000;9:228-232

DISSATISFACTION andburn-out have been reported asserious problems for phy-sicians.1 Some reportshave stated that many

physicians would not choose to practicemedicine again if given a choice.2,3 The in-creased corporatization of medicine, pro-longed training, and high expectationsamong patients and organizations seemto be contributing to this dissatisfaction.However, surveys indicate that many phy-sicians remain quite satisfied with theirwork.4 Greater understanding of factorscontributing to practicesatisfactionshouldbe helpful to physicians who face many

challenges in their professional career.Personal values are defined as de-sirable goals varying in importance thatserve as guiding principles in peopleslives.5We previously reported on the per-sonal values of a group of exemplary fam-ily physicians and found a positive corre-lation between their ratings of benevolenceand practice satisfaction; ie, those whowere motivated to serve and help otherswere more satisfied with their work.6

In addition to practice satisfaction, itis probablethat the personal valuesof phy-sicians are associated with other impor-tant characteristics of practice. Limited ac-cess to medical care for the underinsuredhas been identified as a problem in ourhealth care system.7 This situation existsdespite an adequate physician work-force. Overspecialization, economic pres-sures of physicians, maldistribution of phy-sicians, insurance, and even public policyhave worked against many patients andhave limited their accessto medical care.7,8

Current market forces may be changingthis, but access to care for many remainslimited.9 There is a need to understand all

factorsthat maylimit accessto medical carefor patients, including the personal valuesof physicians. Arethere personal valuesthatare associated with physicians who ex-tend care to the underserved? If so, whatare these values?

In this study we examine the per-sonal values of practicing family physi-cians, their professional satisfaction,and other characteristics of the practice,including the physicians willingness to

ORIGINAL CONTRIBUTION

From the Department of Familyand Community Medicine,University of Illinois Collegeof Medicine at Rockford(Dr Eliason); and theDepartment of Family andCommunity Medicine, MedicalCollege of Wisconsin,Milwaukee (Ms Guse andDr Gottlieb).

ARCH FAM MED/ VOL 9, MAR 2000 WWW.ARCHFAMMED.COM228

2000 American Medical Association. All rights reserved.

at STANFORD Univ Med Center, on November 8, 2009www.archfammed.comDownloaded from
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care for the medically underserved. We hypothesizedthat there would be a positive association between theratings of benevolence and practice satisfaction ratingsamong family physicians. We also hypothesized thatfamily physicians who care for the underserved wouldhave higher ratings of the self-transcendent valuesbecause self-transcendent values emphasize enhancingthe welfare of others and oppose self-enhancing val-ues. Furthermore, we wished to examine associationsthat might exist among the value-type ratings of familyphysicians, practice satisfaction, and a variety of prac-tice characteristics such as location of practice (ruralvs nonrural), type of practice, board certification, sex,and the age of the family physician.

RESULTS

Seven hundred twelve usable surveys were returned (58%response rate). Response rates were not significantly dif-ferent among the 12 sampling strata. Table 2 gives thedemographics and practice patterns. The mean value-type ratingsfrom highest to lowestandthecorrelation withpractice satisfaction ratings are presentedinTable 3. Thebenevolence value type wasratedthehighest andthe powervalue type was the lowest. The association of the ratings

of the benevolence value type with the ratings of practicesatisfaction was statistically significant (P = .002, correla-tion coefficient = 0.14). Both the self-determination valuetype and the hedonism value type had a negative or in-verse association with the practice satisfaction ratingsthat reached statistical significance (P = .04, correlationcoefficient = 0.008 and P = .05, correlation coeffi-cient = 0.01, respectively). The power value-type ratingswere also negatively associated with practice satisfaction,but the association was not statistically significant.

About half (52%) of the family physicians surveyedprovided 40% or more care to the underserved (Medi-care, Medicaid, and indigent patients). After controllingfor age and sex, rural practices (P = .005) and solo prac-

tices (P = .04) were significantly more likely to provide40% or more care to the underserved. Tradition was theonly value type to be significantly associated with ser-vice to the underserved (P = .02) when age, sex, solopractice, and rural practice were controlled. However,family physicians whose practice consisted of 30% ormore indigent patients rated the universalism value typesignificantly higher than other family physicians(P = .03).

A variety of associations were found between value-type ratings, demographics, and practice patterns (see

MATERIALS AND METHODS

INSTRUMENT

The Schwartz values questionnaire and instrument has beenvalidated in multiple cultures and has been described pre-viously.5,6,10,11 The respondent rates the importance of 56personal values from 1 (opposed to my values) to 7 (ofsupreme personal importance). The value types are de-

fined by their principal motivation and by the specific rep-resented values. Using value types rather than single val-ues has increased the reliability of the instrument.5 A briefdefinition of eachvalue type and its dimension is includedin Table 1. The value types have been organized into a2-dimensional structure, with the self-transcendent val-ues dimension opposing the self-enhancement values di-mension, and the conservation values dimension oppos-ingthe opennessto change valuesdimension. Schwartzhasshown a dynamic relationship between the value types.5,6

Actions taken in pursuit of some values may be compat-ible or incompatible with other value types.10,12

The practice satisfaction portion of the survey con-sists of 3 questions on a semantic differential scale from 1to 7. The stem ofthe 3 questions is For me the practice of

medicine is . . . with available responses anchored by thefollowing word pairs: bad-good, unfulfilling-fulfilling, andunenjoyable-enjoyable. In addition, we asked a series ofquestions about demographics, the respondents involve-ment with teaching, the scope of their practice, organiza-tional type of practice, payor sources of the practice, anddate of last recertification.

SURVEY

We obt ain ed fro m the Ame ric an Aca demy of Fam ilyPhysicians (Leawood, Kan) 1224 physician names and

addresses that had been randomly drawn from 12 groupsaccording to age group (25-39 years, 40-54 years, or 55-70years), rural and nonrural status, and access to the under-served (high and low access, 102 physicians in eachstratum). In the high-access group, 40% to 70% of the pa-tientsin the practice were represented by Medicare or Med-icaid or were indigent, comparedwith the low-access group,in which 0% to 30% of the patients were represented byMedicare or Medicaid or were indigent. The confidential

survey,along with a returnenvelope, wasmailed to the phy-sicians 3 times, about 6 weeks apart, in the summer of 1996.The second and third mailings were only to those who hadnot responded previously.

ANALYSIS

The 10 value types were computed by averaging the rat-ings for the associated specific values. Value-type ratingswere adjusted to account for generally high or generallylow rating tendencies according to the method describedby Schwartz.5 A measure of satisfaction was constructed byaveraging the responses to the 3 job satisfaction ques-tions. These measures were combined, having previouslyshown a reliability of of .84 as determined by Cronbach.6

For the analyses, physicians providing care to the under-served were defined as those whose sum of the percentagemidpoints of the response categories for Medicare, Med-icaid, and indigent patients was 40% or higher. Partial cor-relationswere used to examine theassociationbetween valuetypes and job satisfaction while controlling for rating ten-dency andconfounding variables such as sexand age. Analy-sis of variance and regression were used to find the rela-tionship between demographic and practice patterns andvalue-type ratings, as well as job satisfaction and care tothe underserved. Statistical analyses were donewiththe StataStatistical Software package.13





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Table 4). Practice satisfaction was found to be associ-ated with teaching medical trainees (P = .009). Thoseteachingmedicaltraineesalsorated the security (P = .004)and hedonism value types lower (P = .004) than thosenot involved in teaching.

We found significant value-type associations withboth sex and age, although this was not the focus of ourstudy. Men rated the conformity value type and the tra-dition value type higher than women (both P.001).Women rated the universalism value typehigher thanmen(P.001). Older physicians rated the security value typehigher (P.001) and the stimulation value type lower(P = .002).

COMMENT

PRACTICE SATISFACTION

The positive association of the benevolence value typeand practice satisfaction (P.001, correlation coeffi-cient = 0.14) is consistent with other research involvingphysician satisfaction and confirms our previous find-ings in exemplary physicians.6 In a work satisfaction sur-vey of physicians and dentists, Lewis et al14 found thattheir service to humanity and direct patient care werehighly satisfying elements of their professional life. Ri-chardson and Burke15 studied stress and job satisfactionamong physicians and found the major source of satis-

faction to be their relationship with their patients andcolleagues. Mawardi16 found highsatisfactionamong phy-sicians associated with helping patients solve problemsand developing relationships withpatients and their fami-lies. Reams and Dunstone17 found in a qualitative studythat physicians who focused mainly on patient care andless on the business aspect of medicine were more highlysatisfied. Findings by Pastor et al18 were similar in a studyof satisfaction among rural physicians, who derived mostof their job satisfaction from patient care, while incomewas not a source of satisfaction.

The 67% of the respondents in our survey who par-ticipated in some teaching were as a group more highlysatisfied (P = .009) than those who did not teach. Teach-ing of medical trainees is a helping activity that is con-sistent with the benevolence value type, although we didnot find that those involved in teaching rated benevo-lence higher than those not involved in teaching. Hall etal19 found higher satisfaction among emergency room phy-sicianswho were involved with teaching residents. Lloydet al,20 however, reported increased depression among

Canadian emergency room physicians who were in-volved with medical education. Whether this wasbecause they were overextended because of increasedresponsibilities is unclear.

The self-direction value type wasthe secondhighest-rated value type in our study, indicating that physiciansvalue their ability to choose and be independent. Thosefamily physicians who rated the values of self-directionhighest were somewhat less satisfied (P = .04) with theirpractice of medicine. Many outside forces have imposedlimitations on physicians decision making. Those phy-

Table 1. Value Dimensions, Value Types, and Definitions

Value Dimension Value Type Definition

Self-enhancement Power A desire for social status andcontrol over people andresources

Achievement Personal success bydemonstrating competence

Hedonism Pleasure or sensuousgratification for oneself

Openness tochange

Stimulation Excitement and challenge in lifeSelf-direction Able to choose independent

thought and action

Self-transcendent Universalism Motivation to enhance andprotect all people

Benevolence Motivation to help those closeto you

Conservation Tradition Desire to maintain customs ofculture and religion

Conformity Restraint of actions likely toviolate social norms

Security Desire for order and stability forself and society

Table 2. Demographics of Family Physicians Surveyed

CharacteristicResponseRate,* %

Rural practice 52

Organizational arrangement of practice

Solo practice 29

Primary care group practice 41

2-Person practice 9

Multispeciality group practice 19

Unknown 3Member of medical school faculty 32

Par ticipate in t eaching of medi cal trainees 67

Routinely perform the following services

Routine obstetric deliveries 27

High-risk obstetric deliveriesincluding cesarean delivery

8

Any obstetric service 27

Inpatient pediatrics 61

Outpatient surgery 58

Inpatient adult medicine 78

Inpatient surgery 31

Staff hospital intensive care 51

Any inpatient car e unit or crit ical care unit 79

None of the above 15

30% Covered by indigent or charity care 4

40% Covered by Medicare, Medicaid, or indigent care 52Male sex 83

Age group, y

25-39 31

40-54 35

55-70 34

Board certification within last 7 y 74

Year graduated from medical school

Median 1978

Range 1949-1994

Year of board certification

Median 1992

Range 1950-1996

*The population was 712 for a 58% response rate.Sex missing in 4 cases.

Year graduated missing in 14 cases; year of board certfication missingin 24 cases.





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sicians who are able to accept many of these limitationsand work within existing frameworks will likely bemore satisfied. Previous studies indicate that too manyregulations and restrictions lead to dissatisfactionamong physicians.21,22

ACCESS TO CARE

The relationship between the personal values of physi-cians and access to care has been little explored in themedical literature. We hypothesized thatphysicians wouldprovide more care to the underserved if they empha-sized the self-transcendent value types compared withthe self-enhancement value types depictedin the Schwartzvalues dimensions.5,6 In this values dimension struc-ture, self-enhancing values oppose the self-transcen-dent value types.

The analysis of our data did show an association offamily physicians whose patients were made up of morethan 40% Medicare or Medicaid recipients or recipientsand/or indigent patients and the traditional value type(P = .02).The traditional value type is represented by per-sonalvalues, including the following categories:humble,accepting my portion in life, devout, respect for tra-dition, and moderate. In the values dimension it is ad-jacent to the benevolence value type. A small group offamily physicians in our survey whose practices con-sisted of more than 30% indigent patients rated the uni-versalism valuetype higher (P = .03)compared withotherfamily physicians. These findings provide general sup-port to our hypothesis that self-transcendent value typeswill be rated higher by physicians who extend care to theindigent.

LIMITATIONS AND OTHER ASSOCIATIONS

The correlationsbetween the value types and practice sat-isfaction are low and provide little explanation for thevariation in practice satisfaction. Nevertheless, the asso-ciations found between practice satisfactionand the valuetypes of benevolence, self-determination, and hedo-nism are consistent with other research and were statis-tically significant.

The value type and practice pattern associationsfound in Table 4 are interesting and possibly meaning-

ful, but should be interpreted cautiously. About 5% ofstatistical association (P = .05) will occur by chance. Be-cause we did not make prior hypotheses about specificassociations in this part of the study, these associationsmust be interpreted more cautiously. Those associa-tions with a lower P value (P.005) are more likely tobe significant. The negative associationsbetween the highratings of the value types of security and hedonism withthe teaching of medical trainees is statistically signifi-cant (P = .004 and P = .006, respectively) and is consis-tent with the Schwartz values dimension.5,6 Teaching isgenerally an activity for which there is less personal eco-nomic gain and that involves actions that assist others.Thus, one might expect a negative association with thevalue types of hedonism and security.

A possible limitation in this study is the potentialfor self-reporting bias. A written score on a question-naire does not necessarily translate to actual deeds. Theconfidentiality of the questions would weigh against this

because the family physicians had no apparent personalgain. Schmitt et al11 have also demonstrated 6-week test/retest reliability of the value type indices, ranging from0.70 to 0.90.

The definition of providing care to the under-served in this study resulted in an underserved group thatincluded Medicare patients. The literature demon-strates that Medicare patients who are white, educated,upper class, and have supplemental insurance are not un-derserved.23 There is evidence, however, that signficantsegments of the Medicare population are underserved.

Table 3. Mean Ranking of Value Types (Highest to Lowest)and Correlation With Practice Satisfaction

Value type n Mean Correlation* P

Benevolence 706 5.3 0.14 .002

Self-direction 698 4.7 0.08 .04

Conformity 704 4.7 0.06 .11

Achievement 703 4.5 0.05 .18

Security 700 4.5 0.02 .61

Universalism 701 4.5 0.02 .67

Hedonism 704 4.0 0.07 .05Tradition 695 3.7 0.03 .50

Stimulation 699 3.6 0.04 .25

Power 703 2.3 0.06 .12

*Partial correlation.

Table 4. Practice Pattern Association* With Value Typeand Practice Satisfaction Ratings

Practice PatternValue Type

(P)

Rural practice None

Solo practice + Conformity, .03 Universalism, .01

Primary care group practice None

2-Person group practice None

Multispeciality group practice NoneRoutinely include in practice

Obstetrics Hedonism, .02+ Universalism, .02 Conformity, .05

Inpatient care + Power, .01

Intensive care unit or critical care unit None

30% of patients covered by indigent orcharity care

+ Universalism, .03

40% of patients covered by Medicare,Medicaid, or indigent care

+ Tradition, .02

Managed care 50% or more vs 20% or less None

Member of medi cal school f acul ty None

Participate to some extent in teachingmedical trainees

Security, .004 Hedonism, .006

Board cert if ied within last 7 y Self-direction, .03

+ Benevolence, .04

*Adjusted for age and sex.Practice satisfaction was not significant for all except those who

participate in teaching medical trainees (P = .009).Analysis of variance and regression analysis are used to find significant

relationships between practice patterns and value types and/or practicesatisfaction, but not between value type and practice satisfaction.

+ indicates a positive association; indicates a negative association.





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This includes the following: (1) those without supple-mental insurance,23,24 (2) those from core urban andrural areas,23,25,26 (3)minority elders such as African Ameri-cans,23,25,26 (4) low-income, and sometimes middle-income Medicare recipients,23,26,27 (5) elders whosemobility is impaired,28 and (6) those who are less welleducated.23 Because we were not able to further identifythese subgroups of Medicare patients, the access to carefor this group may range from poor to good. For thesereasons, our ability to find a significant relationship be-

tween the self-transcendent values and providing care tothe underserved may have been reduced.

CONCLUSION

This study found associations between practice satisfac-tion and teaching medical trainees, as well as betweenpractice satisfaction andranking of the benevolence valuetype or the self-direction value type. Two valuetypes werefound to be associated with providing care to the under-served, universalismand tradition. Theseassociationsraiseinteresting questions as to cause and effect that cannotbe answered definitively by a cross-sectional study suchas this one. Does the involvement in teaching contrib-ute to practice satisfactionor do satisfiedphysicians gravi-tate towardteaching?Arevaluesmutable and, if so,wouldchanges toward increased benevolence or self-directionincrease professional satisfaction? Or could the prob-lem of underserved populations be addressed by a shiftin physician values toward universalism and tradition?These questions will challenge future researchers.

At this juncture, practicing physicians who are dis-satisfiedwith their work may benefit by identifying valuesthat are important to them and looking for positions thatwill allow them to follow those values. It might also be-hoove them to become more involved in providing lead-ership at all levels within health care organizations andthereby have a hand in shaping the environment in whichthey work.

Most wouldagree that we need more physicians whoare satisfied with their work and who have motivationto be of service to their patients and to help provide careto the underserved of our society. This study suggeststhat such physicians would give high ratings to the self-transcendent values. Practicing physicians who are dis-satisfied with their work may benefit by focusing onactivities that involve helping and serving their pa-tients, not on business and financial issues.

The current medical climate, in which practiceguide-lines, nonphysician case managers, and regulatoryefforts are prevalent, will likely lead to increased dissat-

isfaction among physicians who rate the self-directionvalue type high. Medical organizations that employ phy-sicians may find that their physician employees are moresatisfied if they are not overregulated. Family physi-cians in turn need to be more assertive in providing lead-ership in health care organizations at all levels or theymay find themselves increasingly dissatisfied as they losetheir autonomy.

We have previously recommended6 and recom-mend again consideration of personal values in the se-lection of medical students, because practice satisfac-

tion and the benevolence value-type rating haveconsistently shown a positive association at least in pri-mary care specialties.

Finally, additional research would be helpful to fur-ther clarify the relationships that might exist among per-sonal values, practice satisfaction, and the provision ofmedical care to the underserved.

Accepted for publication July 16, 1999.Reprints: B. Clair Eliason, MD, Department of Fam-

ily and Community Medicine, University of Illinois Col-lege of Medicine at Rockford, 1601 Parkview Ave, Rock-ford, IL 61107-1897.

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