Family Physicians’ Observations of Their Practice, Well Being, and Health Care in the United States
Discussion
The optimism and career satisfaction reported among the majority of family physicians during the mid-1990s may have eroded in subsequent years. In this national survey in 1999, 63% would again choose to go to medical school, and 66% would again choose family practice. Only 55% were satisfied that they are receiving appropriate financial compensation, and 31% stated that they were “tired of being a doctor” and worried that they were “burning out.”
Although it is unlikely that financial incentives are a primary motivator for the decision to choose family practice, satisfaction with financial compensation was significantly associated with greater career satisfaction and lower work stress.
Nearly half of these family physicians reported that they had personally experienced a recent increase in stress-related symptoms. Many did not feel in control of the stressors they faced in daily practice, and most were overwhelmed by the paperwork and administrative requirements. It is no surprise that career satisfaction and workload stress are inversely related. However, it is less clear whether escalating work stress usually erodes career satisfaction or whether those who are less enamored with their career choice are more likely to experience practice demands as stressful.
Higher reported work hours were associated with greater career satisfaction as well as with higher perceived workload stress and less satisfaction with personal life. Although family physicians working the most hours may be doing so because they love what they are doing, long hours take their toll. Forty-four percent of respondents said they were working so many hours that their health or relationships were adversely affected. Several respondents wrote in the margins that they had opted for 50% to 80% of full time, because it was the only way to make practice tolerable. However, such a work arrangement often constitutes a full-time job by most standards, but for reduced pay.
Only 12% of the respondents felt that residency training had provided good training in practice administration. Despite recent efforts to create more relevant practice management curricula, ratings of this item did not vary significantly by years in practice, suggesting that most new graduates still do not feel prepared for the business of medicine.
Previous research has clearly shown that increased demands coupled with loss of control and a lack of safe outlets for frustration can lead to increased stress.14 This is the situation in which many of today’s family physicians find themselves. Residency training programs and state professional associations can play a significant role by speaking with candor about physician stress; integrating programs on stress management, career goals, and values clarification; and encouraging advocacy for constructive change of the health care system. Training programs must contemplate which changes are likely to maximize the number of graduates who become successful, satisfied practitioners in the current health care environment.
This sample of family physicians was sharply critical of a health care system driven by corporate managed care. Only 7% of family physicians agreed that corporate managed care is the best way to provide the health care America needs at a cost society can afford. Only 20% believed that managed care had accomplished improvements in both accountability and quality of care. Forty-two percent of these family physicians reported bad patient outcomes they perceived as attributable to managed care business processes. Despite the improved access touted by behavioral health carve-outs, 76% of family physicians report that obtaining good-quality behavioral or mental health treatment for their patients has gotten more difficult as such corporate entities have dominated that market.
There was virtual consensus for specific reforms. More than 85% of these family physicians agreed that all Americans should have access to redress for damages when managed care agents inappropriately delay or deny treatment and that managed care medical directors should be accountable to state boards of physician quality assurance for their decisions about patient care. Only 36% unequivocally supported a government-administered universal national health plan; however, an additional 21% who were equivocal suggested that growing discontent with the status quo could shift the balance to a majority in support.
Limitations
The numerous limitations inherent to our study include the use of a newly constructed questionnaire with design flaws, a modest response rate, the likelihood that respondents were different than nonrespondents, and poor representation of minority respondents. Comparison with data from other studies is limited by differences in study design and sample. These cross-sectional regression analyses allow only statistical prediction of associations, not cause-and-effect conclusions. This survey cannot be generalized to other physician specialties, and it is not appropriate to assume that family physicians are more discontent than other physicians, other professionals, or other workers.
