Two sets of logistic regression were performed. In the first, adjusted odds ratios were derived to measure the association of personal, professional, and practice characteristics with dissatisfaction (Table 2). Next, the relationship of dissatisfaction with each of the indicators of quality of care was assessed with 6 separate multivariate logistic regression procedures (Table 1). The adjusted odds ratios in Table 1 are the products of that analysis and represent the association of perceived ability to deliver quality of care after controlling for the effects of personal, professional, and practice variables. SUDAAN software, version 7.5.3 (Research Triangle Institute, Research Triangle Park, NC), was used to conduct statistical tests and make national estimates with variance adjustment for the complex survey sample design and physician nonresponse.
PERSONAL, PROFESSIONAL, AND PRACTICE-RELATED FACTORS ASSOCIATED WITH FP/GP DISSATISFACTION (N = 3166)
|PERSONAL/PROFESSIONAL CHARACTERISTICS||Multivariate Odds Ratio (95% CI)|
|Age in years (n = 2965)|
|Sex (n = 3106)|
|Type of medical training (n = 3106)|
|Graduate of foreign medical school (n = 3106)|
|Board certification (n = 3063)|
|Board eligible||1.15 (0.82-1.63)|
|Net income in 1995 ($) (n = 3103)|
|300,000 +||1.93 (0.98-3.81)|
|Practice type (n = 3106)|
|1 or 2 physicians||1.19 (0.74-1.93)|
|3+ physicians||1.14 (0.70-1.85)|
|Medical school||1.01 (0.52-1.93)|
|Community size (n = 3106)|
|Large metropolitan area (>200,000)||1.42 (0.81-2.49)|
|Small metropolitan area (< 200,000)||1.0|
|Nonmetropolitan area||1.07 (0.55-2.08)|
|Ownership (n = 3106)|
|Full owners||1.57 (1.11-2.21)|
|Not an owner||1.01 (0.72-1.43)|
|Percentage of patients for whom you serve as gatekeeper (n = 3106)|
|NOTE: Ns vary because not all physicians answered every item on the survey.|
|FP/GP denotes family physician/general practitioner; HMO, health maintenance organization.|
Nearly 18% of physicians report being dissatisfied with a career in medicine. The rate of dissatisfaction among FP/GPs is similar to that for all physicians, specialists, and primary care physicians as a group. However, there is some variability among primary care specialties, with internists reporting more dissatisfaction (chi-square = 14.8, P < .01) and pediatricians (chi-square = 25.9, P < .01) reporting less dissatisfaction than FP/GPs (Table 3).
EXTENT OF PHYSICIAN DISSATISFACTION
|Type of Physician||Satisfied or Very Satisfied n (%)*||Dissatisfied or Very Dissatisfied n (%)*||Neither Satisfied nor Dissatisfied n (%)*|
|Total physicians||10,093 (80.7)||2198 (17.7)||212 (1.6)|
|Specialists||4316 (80.5)||953 (18.0)||87 (1.6)|
|Total primary care||5777 (81.0)||1245 (17.4)||125 (1.6)|
|FP/GPs||2537 (81.9)||569 (17.3)||60 (1.7)|
|Pediatricians||1403 (86.2)||206 (12.6)||17 (1.3)|
|Internists||1837 (77.5)||470 (20.6)||48 (1.9)|
|*Unweighted number of survey respondents and weighted percent of US FP/GPs.|
|FP/GPs denotes family physicians/general practitioners.|
Factors associated with FP/GP dissatisfaction
Many characteristics were associated with the dissatisfaction reported by 17.6% of FP/GPs. The associated characteristics are included in 3 domains. The first 2 domains, personal/professional and practice characteristics, reveal significant factors associated with dissatisfaction (Table 2). The data in the third domain, patient care characteristics, represent results after we had statistically controlled for all factors in the first 2 (Table 1).
Personal/Professional Characteristics. A higher level of dissatisfaction was related to being older; only 10.1% of physicians younger than 35 years of age reported dissatisfaction versus 25.1% of physicians aged 55 to 64 years (odds ratio [OR] 2.46; 95% confidence interval [CI], 1.56-3.88). FP/GPs more likely to be dissatisfied were those who had osteopathic training and those who had been graduated from foreign medical schools. Levels of dissatisfaction were also higher among FP/GPs earning less than $100,000 per year.
Practice Characteristics. Physicians who fully owned their practice were more likely to express dissatisfaction with their careers than were physicians who either shared ownership or did not own their practice (OR 1.57; 95% CI, 1.11-2.21). The pattern of dissatisfaction related to gatekeeping (ie, providing permission for their patients to seek specialty care) was similar to that related to income. FP/GPs serving as gatekeepers for less than 10% or more than 30% of their patients were the most dissatisfied.
Patient Care Characteristics. After we had controlled for the effects of personal, professional, and practice characteristics, we found that FP/GP career dissatisfaction was, without exception, consistently and strongly associated with a perceived inability to provide high-quality care as assessed by physician responses to each of 6 statements (Table 1). Dissatisfied physicians were much more likely to “disagree strongly” than. to “agree strongly” with the statements about clinical freedom (OR 7.89; 95% CI, 4.86-12.83), continuity of care (OR 7.11; 95% CI, 4.90-10.33), clinical decisions free of financial penalties (OR 4.44; 95% CI, 3.13-6.31), adequacy of time with patients (OR 4.42; 95% CI, 2.84-6.87), ability to provide high-quality care (OR 4.26; 95% CI, 2.88-6.31) and sufficient communication with specialists (OR 3.57; 95% CI, 2.20-5.80). The most notable differences found between dissatisfied and satisfied FP/GPs were related to a lack of clinical freedom and difficulty maintaining continuing relationships with patients.