Thomas R. Konrad

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.

Understanding physicians' intentions to withdraw from practice: The role of job satisfaction, job stress, mental and physical health

Health care organizations may incur high costs due to a stressed, dissatisfied physician workforce. This study proposes and tests a model relating job stress to four intentions to withdraw from practice mediated by job satisfaction and perceptions of physical and mental health. The test used a sample of 1735 physicians and generally supported the model. Given the movement of physicians into increasingly bureaucratic structures, the clinical work environment must be effectively managed.

County-Level Estimates of Mental Health Professional Shortage in the United States

OBJECTIVE This study examined shortages of mental health professionals at the county level across the United States. A goal was to motivate discussion of the data improvements and practice standards required to develop an adequate mental health professional workforce. METHODS Shortage of mental health professionals was conceptualized as the percentage of need for mental health visits that is unmet within a county. County-level need was measured by estimating the prevalence of serious mental illness, then combining separate estimates of provider time needed by individuals with and without serious mental illness derived from National Comorbidity Survey Replication, U.S. Census, and Medical Panel Expenditure Survey data. County-level supply data were compiled from professional associations, state licensure boards, and national certification boards. Shortage was measured for prescribers, nonprescribers, and a combination of both groups in the nations 3,140 counties. Ordinary least-squares regression identified county characteristics associated with shortage. RESULTS Nearly one in five counties (18%) in the nation had unmet need for nonprescribers. Nearly every county (96%) had unmet need for prescribers and therefore some level of unmet need overall. Rural counties and those with low per capita income had higher levels of unmet need. CONCLUSIONS These findings identified widespread prescriber shortage and poor distribution of nonprescribers. A caveat is that these estimates of need were extrapolated from current provider treatment patterns rather than from a normative standard of how much care should be provided and by whom. Better data would improve these estimates, but future work needs to move beyond simply describing shortages to resolving them.

The Work Lives of Women Physicians

AbstractOBJECTIVE: To describe gender differences in job satisfaction, work life issues, and burnout of U.S. physicians. DESIGN/PARTICIPANTS: The Physician Work life Study, a nationally representative random stratified sample of 5,704 physicians in primary and specialty nonsurgical care (N=2,326 respondents; 32% female, adjusted response rate=52%). Survey contained 150 items assessing career satisfaction and multiple aspects of work life. MEASUREMENTS AND MAIN RESULTS: Odds of being satisfied with facets of work life and odds of reporting burnout were modeled with survey-weighted logistic regression controlling for demographic variables and practice characteristics. Multiple linear regression was performed to model dependent variables of global, career, and specialty satisfaction with independent variables of income, time pressure, and items measuring control over medical and workplace issues. Compared with male physicians, female physicians were more likely to report satisfaction with their specialty and with patient and colleague relationships (P<.05), but less likely to be satisfied with autonomy, relationships with community, pay, and resources (P<.05). Female physicians reported more female patients and more patients with complex psychosocial problems, but the same numbers of complex medical patients, compared with their male colleagues. Time pressure in ambulatory settings was greater for women, who on average reported needing 36% more time than allotted to provide quality care for new patients or consultations, compared with 21% more time needed by men (P<.01). Female physicians reported significantly less work control than male physicians regarding day-to-day aspects of practice including volume of patient load, selecting physicians for referrals, and details of office scheduling (P<.01). When controlling for multiple factors, mean income for women was approximately

The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study.

22,000 less than that of men. Women had 1.6 times the odds of reporting burnout compared with men (P<.05), with the odds of burnout by women increasing by 12% to 15% for each additional 5 hours worked per week over 40 hours (P<.05). Lack of workplace control predicted burnout in women but not in men. For those women with young children, odds of burnout were 40% less when support of colleagues, spouse, or significant other for balancing work and home issues was present. CONCLUSIONS: Gender differences exist in both the experience of and satisfaction with medical practice. Addressing these gender differences will optimize the participation of female physicians within the medical workforce.

The work lives of women physicians results from the physician work life study. The SGIM Career Satisfaction Study Group.

Background: A report by the Institute of Medicine suggests that changing the culture of health care organizations may improve patient safety. Research in this area, however, is modest and inconclusive. Because culture powerfully affects providers, and providers are a key determinant of care quality, the MEMO study (Minimizing Error, Maximizing Outcome) introduces a new model explaining how physician work attitudes may mediate the relationship between culture and patient safety. Research Questions: (1) Which cultural conditions affect physician stress, dissatisfaction, and burnout? and (2) Do stressed, dissatisfied, and burned out physicians deliver poorer quality care? Methods: A conceptual model incorporating the research questions was analyzed via structural equation modeling using a sample of 426 primary care physicians participating in MEMO. Findings: Culture, overall, played a lesser role than hypothesized. However, a cultural emphasis on quality played a key role in both quality outcomes. Further, we found that stressed, burned out, and dissatisfied physicians do report a greater likelihood of making errors and more frequent instance of suboptimal patient care. Practice Implications: Creating and sustaining a cultural emphasis on quality is not an easy task, but is worthwhile for patients, physicians, and health care organizations. Further, having clinicians who are satisfied and not burned out or stressed contributes substantially to the delivery of quality care.

A survey of smoking and quitting patterns among black Americans.

AbstractOBJECTIVE: To describe gender differences in job satisfaction, work life issues, and burnout of U.S. physicians. DESIGN/PARTICIPANTS: The Physician Work life Study, a nationally representative random stratified sample of 5,704 physicians in primary and specialty nonsurgical care (N=2,326 respondents; 32% female, adjusted response rate=52%). Survey contained 150 items assessing career satisfaction and multiple aspects of work life. MEASUREMENTS AND MAIN RESULTS: Odds of being satisfied with facets of work life and odds of reporting burnout were modeled with survey-weighted logistic regression controlling for demographic variables and practice characteristics. Multiple linear regression was performed to model dependent variables of global, career, and specialty satisfaction with independent variables of income, time pressure, and items measuring control over medical and workplace issues. Compared with male physicians, female physicians were more likely to report satisfaction with their specialty and with patient and colleague relationships (P<.05), but less likely to be satisfied with autonomy, relationships with community, pay, and resources (P<.05). Female physicians reported more female patients and more patients with complex psychosocial problems, but the same numbers of complex medical patients, compared with their male colleagues. Time pressure in ambulatory settings was greater for women, who on average reported needing 36% more time than allotted to provide quality care for new patients or consultations, compared with 21% more time needed by men (P<.01). Female physicians reported significantly less work control than male physicians regarding day-to-day aspects of practice including volume of patient load, selecting physicians for referrals, and details of office scheduling (P<.01). When controlling for multiple factors, mean income for women was approximately

Outcomes of states' scholarship, loan repayment, and related programs for physicians.

22,000 less than that of men. Women had 1.6 times the odds of reporting burnout compared with men (P<.05), with the odds of burnout by women increasing by 12% to 15% for each additional 5 hours worked per week over 40 hours (P<.05). Lack of workplace control predicted burnout in women but not in men. For those women with young children, odds of burnout were 40% less when support of colleagues, spouse, or significant other for balancing work and home issues was present. CONCLUSIONS: Gender differences exist in both the experience of and satisfaction with medical practice. Addressing these gender differences will optimize the participation of female physicians within the medical workforce.

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

A sample of adult Black policyholders of the nations largest Black-owned life insurance company was surveyed in 1986 to add to limited data on smoking and quitting patterns among Black Americans, and to provide direction for cessation initiatives targeted to Black smokers. Forty per cent of 2,958 age-eligible policyholders for whom current addresses were available returned a completed questionnaire. Population estimates for smoking status agree closely with national estimates for Blacks age 21-60 years: 50 per cent never-smokers; 36 per cent current smokers; 14 per cent ex-smokers. Current and ex-smokers reported a modal low-rate/high nicotine menthol smoking pattern. Current smokers reported a mean of 3.8 serious quit attempts, a strong desire and intention to quit smoking, and limited past use of effective quit smoking treatments and self-help resources. Correlates of motivation to quit smoking were similar to those found among smokers in the general population, including smoking-related illnesses and medical advice to quit smoking, previous quit attempts, beliefs in smoking-related health harms/quitting benefits, and expected social support for quitting. Methodological limitations and implications for the design of needed Black-focused quit smoking initiatives are discussed.

Effect of vaccination by community pharmacists among adult prescription recipients.

Context:Many states attempt to entice young generalist physicians into rural and medically underserved areas with financial support-for-service programs—scholarships, service-option loans, loan repayment, direct financial incentives, and resident support programs—with little documentation of their effectiveness. Objective:The objective of this study was to assess outcomes of states’ support-for-service programs as a group and to compare outcomes of the 5 program types. Design:We conducted a cross-sectional, primarily descriptive study. Participants:We studied all 69 state programs operating in 1996 that provided financial support to medical students, residents, and practicing physicians in exchange for a period of service in underserved areas; federally funded initiatives were excluded. We also surveyed 434 generalist physicians who served in 29 of these state programs and a matched comparison group of 723 nonobligated young generalist physicians. Data Collection:Information on eligible programs was collected by telephone, mail questionnaires, and from secondary sources. Obligated and nonobligated physicians were surveyed, with 80.3% and 72.8% response rates, respectively. Main Outcome Measures:Levels of socioeconomic need of communities and patients served by physicians, programs’ participant service completion and retention rates, and physicians’ satisfaction levels. Results:Compared with young nonobligated generalists, physicians serving obligations to state programs practiced in demonstrably needier areas and cared for more patients insured under Medicaid and uninsured (48.5% vs. 28.5%, P <0.001). Service completion rates were uniformly high for loan repayment, direct incentive, and resident-support programs (93% combined) but lower for student-targeting service-option loan (mean, 44.7%) and scholarship (mean, 66.5%) programs. State-obligated physicians were more satisfied than nonobligated physicians, and 9 of 10 indicated that they would enroll in their programs again. Obligated physicians also remained longer in their practices than nonobligated physicians (P = 0.03), with respective group retention rates of 71% versus 61% at 4 years and 55% versus 52% at 8 years. Retention rates were highest for loan repayment, direct incentive, and loan programs. Conclusions:States’ support-for-service programs bring physicians to needy communities where a strong majority work happily and with at-risk patient populations; half stay over 8 years. Loan repayment and direct financial incentive programs demonstrate the broadest successes.