Mark D. Schwartz

Managed Care, Time Pressure, and Physician Job Satisfaction: Results from the Physician Worklife Study

AbstractOBJECTIVE: To assess the association between HMO practice, time pressure, and physician job satisfaction. DESIGN: National random stratified sample of 5,704 primary care and specialty physicians in the United States. Surveys contained 150 items reflecting 10 facets (components) of satisfaction in addition to global satisfaction with current job, one’s career and one’s specialty. Linear regression-modeled satisfaction (on 1–5 scale) as a function of specialty, practice setting (solo, small group, large group, academic, or HMO), gender, ethnicity, full-time versus part-time status, and time pressure during office visits. “HMO physicians” (9% of total) were those in group or staff model HMOs with >50% of patients capitated or in managed care. RESULTS: Of the 2,326 respondents, 735 (32%) were female, 607 (26%) were minority (adjusted response rate 52%). HMO physicians reported significantly higher satisfaction with autonomy and administrative issues when compared with other practice types (moderate to large effect sizes). However, physicians in many other practice settings averaged higher satisfaction than HMO physicians with resources and relationships with staff and community (small to moderate effect sizes). Small and large group practice and academic physicians had higher global job satisfaction scores than HMO physicians (P<.05), and private practice physicians had quarter to half the odds of HMO physicians of intending to leave their current practice within 2 years (P<.05). Time pressure detracted from satisfaction in 7 of 10 satisfaction facets (P<.05) and from job, career, and specialty satisfaction (P<.01). Time allotted for new patients in HMOs (31 min) was less than that allotted in solo (39 min) and academic practices (44 min), while 83% of family physicians in HMOs felt they needed more time than allotted for new patients versus 54% of family physicians in small group practices (P<.05 after Bonferroni’s correction). CONCLUSIONS: HMO physicians are generally less satisfied with their jobs and more likely to intend to leave their practices than physicians in many other practice settings. Our data suggest that HMO physicians’ satisfaction with staff, community, resources, and the duration of new patients visits should be assessed and optimized. Whether providing more time for patient encounters would improve job satisfaction in HMOs or other practice settings remains to be determined.

Working Conditions in Primary Care: Physician Reactions and Care Quality

BACKGROUND Adverse primary care work conditions could lead to a reduction in the primary care workforce and lower-quality patient care. OBJECTIVE To assess the relationship among adverse primary care work conditions, adverse physician reactions (stress, burnout, and intent to leave), and patient care. DESIGN Cross-sectional analysis. SETTING 119 ambulatory clinics in New York, New York, and in the upper Midwest. PARTICIPANTS 422 family practitioners and general internists and 1795 of their adult patients with diabetes, hypertension, or heart failure. MEASUREMENTS Physician perception of clinic workflow (time pressure and pace), work control, and organizational culture (assessed survey); physician satisfaction, stress, burnout, and intent to leave practice (assessed by survey); and health care quality and errors (assessed by chart audits). RESULTS More than one half of the physicians (53.1%) reported time pressure during office visits, 48.1% said their work pace was chaotic, 78.4% noted low control over their work, and 26.5% reported burnout. Adverse workflow (time pressure and chaotic environments), low work control, and unfavorable organizational culture were strongly associated with low physician satisfaction, high stress, burnout, and intent to leave. Some work conditions were associated with lower quality and more errors, but findings were inconsistent across work conditions and diagnoses. No association was found between adverse physician reactions, such as stress and burnout, and care quality or errors. LIMITATION The analyses were cross-sectional, the measures were self-reported, and the sample contained an average of 4 patients per physician. CONCLUSION Adverse work conditions are associated with adverse physician reactions, but no consistent associations were found between adverse work conditions and the quality of patient care, and no associations were seen between adverse physician reactions and the quality of patient care.

Making evolutionary biology a basic science for medicine

New applications of evolutionary biology in medicine are being discovered at an accelerating rate, but few physicians have sufficient educational background to use them fully. This article summarizes suggestions from several groups that have considered how evolutionary biology can be useful in medicine, what physicians should learn about it, and when and how they should learn it. Our general conclusion is that evolutionary biology is a crucial basic science for medicine. In addition to looking at established evolutionary methods and topics, such as population genetics and pathogen evolution, we highlight questions about why natural selection leaves bodies vulnerable to disease. Knowledge about evolution provides physicians with an integrative framework that links otherwise disparate bits of knowledge. It replaces the prevalent view of bodies as machines with a biological view of bodies shaped by evolutionary processes. Like other basic sciences, evolutionary biology needs to be taught both before and during medical school. Most introductory biology courses are insufficient to establish competency in evolutionary biology. Premedical students need evolution courses, possibly ones that emphasize medically relevant aspects. In medical school, evolutionary biology should be taught as one of the basic medical sciences. This will require a course that reviews basic principles and specific medical applications, followed by an integrated presentation of evolutionary aspects that apply to each disease and organ system. Evolutionary biology is not just another topic vying for inclusion in the curriculum; it is an essential foundation for a biological understanding of health and disease.

Teaching communication in clinical clerkships: models from the Macy initiative in health communications

Medical educators have a responsibility to teach students to communicate effectively, yet ways to accomplish this are not well-defined. Sixty-five percent of medical schools teach communication skills, usually in the preclinical years; however, communication skills learned in the preclinical years may decline by graduation. To address these problems the New York University School of Medicine, Case Western Reserve University School of Medicine, and the University of Massachusetts Medical School collaborated to develop, establish, and evaluate a comprehensive communication skills curriculum. This work was funded by the Josiah P. Macy, Jr. Foundation and is therefore referred to as the Macy Initiative in Health Communication. The three schools use a variety of methods to teach third-year students in each school a set of effective clinical communication skills. In a controlled trial this cross-institutional curriculum project proved effective in improving communication skills of third-year students as measured by a comprehensive, multistation, objective structured clinical examination. In this paper the authors describe the development of this unique, collaborative initiative. Grounded in a three-school consensus on the core skills and critical components of a communication skills curriculum, this article illustrates how each school tailored the curriculum to its own needs. In addition, the authors discuss the lessons learned from conducting this collaborative project, which may provide guidance to others seeking to establish effective cross-disciplinary skills curricula.

Computers in the exam room : Differences in physician-patient interaction may be due to physician experience

BackgroundThe use of electronic medical records can improve the technical quality of care, but requires a computer in the exam room. This could adversely affect interpersonal aspects of care, particularly when physicians are inexperienced users of exam room computers.ObjectiveTo determine whether physician experience modifies the impact of exam room computers on the physician–patient interaction.DesignCross-sectional surveys of patients and physicians.Setting and ParticipantsOne hundred fifty five adults seen for scheduled visits by 11 faculty internists and 12 internal medicine residents in a VA primary care clinic.MeasurementsPhysician and patient assessment of the effect of the computer on the clinical encounter.Main ResultsPatients seeing residents, compared to those seeing faculty, were more likely to agree that the computer adversely affected the amount of time the physician spent talking to (34% vs 15%, P = 0.01), looking at (45% vs 24%, P = 0.02), and examining them (32% vs 13%, P = 0.009). Moreover, they were more likely to agree that the computer made the visit feel less personal (20% vs 5%, P = 0.017). Few patients thought the computer interfered with their relationship with their physicians (8% vs 8%). Residents were more likely than faculty to report these same adverse effects, but these differences were smaller and not statistically significant.ConclusionPatients seen by residents more often agreed that exam room computers decreased the amount of interpersonal contact. More research is needed to elucidate key tasks and behaviors that facilitate doctor–patient communication in such a setting.

Electronic medical records and physician stress in primary care: results from the MEMO Study.

BACKGROUND Little has been written about physician stress that may be associated with electronic medical records (EMR). OBJECTIVE We assessed relationships between the number of EMR functions, primary care work conditions, and physician satisfaction, stress and burnout. DESIGN AND PARTICIPANTS 379 primary care physicians and 92 managers at 92 clinics from New York City and the upper Midwest participating in the 2001-5 Minimizing Error, Maximizing Outcome (MEMO) Study. A latent class analysis identified clusters of physicians within clinics with low, medium and high EMR functions. MAIN MEASURES We assessed physician-reported stress, burnout, satisfaction, and intent to leave the practice, and predictors including time pressure during visits. We used a two-level regression model to estimate the mean response for each physician cluster to each outcome, adjusting for physician age, sex, specialty, work hours and years using the EMR. Effect sizes (ES) of these relationships were considered small (0.14), moderate (0.39), and large (0.61). KEY RESULTS Compared to the low EMR cluster, physicians in the moderate EMR cluster reported more stress (ES 0.35, p=0.03) and lower satisfaction (ES -0.45, p=0.006). Physicians in the high EMR cluster indicated lower satisfaction than low EMR cluster physicians (ES -0.39, p=0.01). Time pressure was associated with significantly more burnout, dissatisfaction and intent to leave only within the high EMR cluster. CONCLUSIONS Stress may rise for physicians with a moderate number of EMR functions. Time pressure was associated with poor physician outcomes mainly in the high EMR cluster. Work redesign may address these stressors.

Separate and Unequal: Clinics Where Minority and Nonminority Patients Receive Primary Care

BACKGROUND Few studies have examined the influence of physician workplace conditions on health care disparities. We compared 96 primary care clinics in New York, New York, and in the upper Midwest serving various proportions of minority patients to determine differences in workplace organizational characteristics. METHODS Cross-sectional data are from surveys of 96 clinic managers, 388 primary care physicians, and 1701 of their adult patients with hypertension, diabetes mellitus, or congestive heart failure participating in the Minimizing Error, Maximizing Outcome (MEMO) study. Data from 27 clinics with at least 30% minority patients were contrasted with data from 69 clinics with less than 30% minority patients. RESULTS Compared with clinics serving less than 30% minority patients, clinics serving at least 30% minority patients have less access to medical supplies (2.7 vs 3.4, P < .001), referral specialists (3.0 vs 3.5, P < .005) on a scale of 1 (none) to 4 (great), and examination rooms per physician (2.2 vs 2.7, P =.002) . Their patients are more frequently depressed (22.8% vs 12.1%), are more often covered by Medicaid (30.2% vs 11.4%), and report lower health literacy (3.7 vs 4.4) on a scale of 1 (low) to 5 (high) (P < .001 for all). Physicians from clinics serving higher proportions of minority populations perceive their patients as frequently speaking little or no English (27.1% vs 3.4%, P =.004), having more chronic pain (24.1% vs 12.9%, P < .001) and substance abuse problems (15.1% vs 10.1%, P =.005), and being more medically complex (53.1% vs 39.9%) and psychosocially complex (44.9% vs 28.2%) (P < .001 for both). In regression analyses, clinics with at least 30% minority patients are more likely to have chaotic work environments (odds ratio, 4.0; P =.003) and to have fewer physicians reporting high work control (0.2; P =.003) or high job satisfaction (0.4; P =.01). CONCLUSION Clinics serving higher proportions of minority patients have more challenging workplace and organizational characteristics.

Physician job satisfaction : Developing a model using qualitative data.

The purpose of this study was to develop a current and comprehensive model of physician job satisfaction. Information was gathered by [1] analysis of open-ended responses from a large group practice physician survey in 1988, and (2) analysis of focus group data of diverse physician subgroups from 1995. Participants were 302 physicians from large-group practices and 26 participants in six focus groups of HMO, women, minority, and inner-city physicians. Data were used to develop a comprehensive model of physician job satisfaction. The large group practice survey data supported the key importance of day-to-day practice environment and relationships with patients and physician peers. Future concerns focused on the effect of managed care on the physician-patient relationship and the ability of physicians to provide quality care. Focus groups provided contemporary data on physician job satisfaction, reinforcing the centrality of relationships as well as special issues for diverse physician subgroups of practicing physicians. New variables that relate to physician job satisfaction have emerged from economic and organizational changes in medicine and from increasing heterogeneity of physicians with respect to gender, ethnicity, and type of practice. A more comprehensive model of physician job satisfaction may enable individual physicians and health care organizations to better understand and improve physician work life.

Physician Job Satisfaction

The purpose of this study was to develop a current and comprehensive model of physician job satisfaction. Information was gathered by [1] analysis of open-ended responses from a large group practice physician survey in 1988, and (2) analysis of focus group data of diverse physician subgroups from 1995. Participants were 302 physicians from large-group practices and 26 participants in six focus groups of HMO, women, minority, and inner-city physicians. Data were used to develop a comprehensive model of physician job satisfaction. The large group practice survey data supported the key importance of day-to-day practice environment and relationships with patients and physician peers. Future concerns focused on the effect of managed care on the physician-patient relationship and the ability of physicians to provide quality care. Focus groups provided contemporary data on physician job satisfaction, reinforcing the centrality of relationships as well as special issues for diverse physician subgroups of practicing physicians. New variables that relate to physician job satisfaction have emerged from economic and organizational changes in medicine and from increasing heterogeneity of physicians with respect to gender, ethnicity, and type of practice. A more comprehensive model of physician job satisfaction may enable individual physicians and health care organizations to better understand and improve physician work life.

Rekindling Student Interest in Generalist Careers

Rekindle: from Old Norse, kynda, to start (a fire) burning; to stir up, arouse, to cause to glow, or illuminate; and from Middle English, to bring forth young (1). Despite changes to the structure of the U.S. health care system in the past 30 years, most Americans continue to seek regular health care from primary care physicians (2). In our increasingly complex, fragmented, and consumerist health care system, patients still desire a continuous healing relationship with my doctor, who provides accessible, competent, comprehensive, whole-person care (3). Leading health economists argue that the supply of generalist physicians is not keeping up with demand, as driven by growth of the population and per capita gross domestic product (4). A deficit of 200000 generalist physicians is projected to occur by 2020 (5). Although experts may quibble about the numbers, most would agree that with fewer than 40% of current graduates from U.S. medical schools expected to enter generalist practice, the projected physician workforce will be out of balance (6). We must act now to rekindle student and resident interest in generalist careers or face a shortage of primary care physicians who are trained to care for the complex medical needs of an aging population. It will require a broad view and coordinated effort to ensure that an adequate number of potential generalists emerges from the education pipeline. Selection of Generalist Careers by Medical Students In a classic study of influences on the career choices of Harvard medical students from the 1940s through the 1970s, Funkenstein concluded that economic incentives and the prevalent ideology are more compelling for most students than are their personal characteristics and original career plans (7). In the post-war golden age of medicine (1945 to 1980), medical expenditures grew faster than the number of physicians, exerting market forces on career options (8, 9). By the late 1980s, generalist residency programs experienced a 30% decrease in applicants, and for the first time, a majority of programs did not fill their positions (6). Students were turned off by what they saw as overworked and dissatisfied generalist physicians and residents, and 40% of internists discouraged students from considering careers in internal medicine (10, 11). In 1985, Schroeder proposed that we promote generalism by 5 mechanisms: 1) narrowing the reimbursement gap between generalists and subspecialists; 2) selecting medical students with broader biosocial interests and backgrounds, who are more likely to choose primary care careers; 3) increasing the number of generalist faculty role models; 4) shifting the focus of education away from National Board Medical Examination knowledge toward clinical process and skills; and 5) regulating residency positions by specialty boards to redress the ratio of generalists to subspecialists (12). Although these recommendations were only partially heeded, internal medicine, pediatrics, and family medicine experienced a resurgence in popularity among medical school graduates in the early 1990s. The growth of health maintenance organizations and the institution of the resource-based relative value scale in Medicare reimbursement increased need and opportunities for primary care (13). Policy leaders set a goal that 50% of medical school graduates would choose to enter primary care careers; this target was attained by 1998 (14, 15). The primary care bubble burst in the late 1990s as the economy entered a recession and reimbursement for cognitive services provided by generalists did not keep pace with increases in procedurally oriented disciplines (16). Patients and physicians alike rebelled against the gatekeeper model of the health maintenance organization (17). The number of senior medical students in the United States who matched into generalist residency positions has been decreasing since the late 1990s (Figure 1) (6). Since the peak in 1998, the proportion of all U.S. graduates who choose residencies in primary care has decreased from 50% to 40% (Figure 2). In the 2004 match, the proportions of positions filled by U.S. graduates were 71% for pediatrics, 55% for internal medicine, and 41% for family practice. The declining interest has been greatest for family medicine, which has seen a 41% relative reduction in the number of positions filled by U.S. graduates. The corresponding reductions for internal medicine and pediatrics have been 9% and 8%, respectively. Because these data include students who go on to subspecialize in internal medicine and pediatrics, the number of students who eventually practice primary care will be even fewer. Moreover, the number of students who choose residencies in primary care internal medicine decreased by 46%, and 24% fewer students chose programs in primary care pediatrics. Figure 1. Number of U.S. medical school graduates who matched in primary care specialties, 1999 to 2004. Figure 2. Proportion of all graduating medical students in the United States who matched to generalist residency programs, 1991 to 2004. Twenty years later, few of Schroeders recommendations have been implemented, and Funkenstein may still be right. Unless we can substantially reshape market forces, the practice environment, and reimbursement, we will be fighting an uphill battle for the hearts and minds of our students and residents (18). We present recommendations, some familiar and others newer (and perhaps bolder), to address this critically important dilemma (Table). Table. Strategies To Increase Choice of Generalist Careers Recommendations 1. Improve Satisfaction and Enthusiasm among Generalist Physicians Who Are Role Models In a national survey of 460 students and residents, having a positive role model was a strong predictor of choice of a generalist career among senior students (odds ratio, 6.5 [95% CI, 4.2 to 10.2]) (19). However, students and residents are likely to encounter generalist physicians who are poor role models because they are unhappy and stressed, are under tremendous time pressure, feel burned out, and are considering leaving their practices (20). The Community Tracking Study of more than 12000 U.S. physicians from 1996 to 2001 found that the strongest predictors of dissatisfaction were threats to clinical autonomy, increasing time pressure, and the challenge of maintaining high-quality care (21). Dissatisfaction among practicing generalists trickles down through housestaff to medical students. In a national survey, student perceptions of resident and attending satisfaction was a strong predictor of generalist career choice (odds ratio, 3.9 [95% CI, 2.7 to 5.6]) (10). Most students interact with resident and attending physician role models before choosing a career path, and in a systematic review, generalist role models were linked to choice of a career in primary care (22, 23). Peer support for primary care from residents was also a strong predictor (odds ratio, 5.7 [95% CI, 1.6 to 20.1]) (19). Unless generalist physicians and residents convey joy in and commitment to their careers, it will remain difficult to recruit students to generalist specialties. We suggest some strategies to improve satisfaction and enthusiasm among current practicing generalists. First, narrow the reimbursement gap between cognitive and procedural services. From 1998 to 2000, inflation-adjusted income increased 9% for medical subspecialists and radiologists but decreased 2.1% for generalist physicians (24). Although physicians tend to underplay the importance of money in their career choice, the Community Tracking Study noted a doseresponse relationship between annual income and job satisfaction (25). In addition, medical students have increasingly chosen specialties with higher income potential from 1996 to 2002 (26). The resource-based relative value system of Medicare reimbursement, which is to be updated in 2006, should create financial incentives for what primary care physicians do well. Working together, leaders from the 3 primary care disciplines could develop a schedule of care management fees that would pay generalists for the currently nonreimbursable care, such as e-mails, telephone calls, and case management, that they provide as part of managing patients with chronic diseases (27, 28). Some Medicaid programs already pay a case management fee, which provides incentive to improve quality and efficiency of ongoing care (29). Generalists must study budget-neutral models for case-based reimbursement that will promote improved care for patients who require complex care for chronic disease (30, 31). Second, decrease clinical time pressure with more flexible and controllable schedules. A preference for a controllable lifestyle was the strongest predictor of career choice, accounting for 55% of the variability in specialty choices of graduating medical students in the United States. Generalist specialties were perceived as noncontrollable (26). From 1989 to 1998, the average duration of a visit to a physicians office in the United States increased from 18.4 to 19.9 minutes (32). Nevertheless, most generalist physicians still felt they needed more time per visit to provide quality care. In 1997, physicians said they needed an average of 23% more time than they were allotted for a visit with a new patient (20). Physicians who reported that they needed more time than allotted for patient visits scored lower on 7 of 10 domains of job satisfaction. Innovations are needed to help physicians work smarter, not just faster. The bewildering array of new expectations and demands by patients, insurers, and regulators causes physicians to rush through visits to provide recommended care. When the associated paperwork is added in, is there still time for healing on our lengthening to-do lists? Research into medical errors in ambulatory care is beginning to link time pressure and physician stress with lower quality in managing chronic diseases (33). Physicians may f