This project, sponsored by the American Medical Association (AMA), aimed to characterize factors that influence physician professional satisfaction. In the context of recent health reform legislation and other delivery system changes, we sought to identify high-priority determinants of professional satisfaction that can be targeted within a variety of practice types, especially as smaller and independent practices are purchased by or become affiliated with hospitals and larger delivery systems. Based on project findings and input from other sources, including its membership and experts in physician practice design, the AMA plans to develop possible pathways for American physicians to practice in models...

A core strategic objective of the American Medical Association (AMA) is the advancement of health care delivery and payment models that enable high-quality, affordable care and restore and preserve physician satisfaction. The AMA has undertaken this commitment in the belief that such change can and should result in a more sustainable and effective health care system with a highly motivated physician workforce. At the same time, the AMA has noted challenges for physicians interested in payment and delivery reform, including existing variability in the degree of care integration, the need for new skills and resources, and the uncertainty created by...

To provide context for the current study, we sought to summarize existing literature on physician satisfaction. We identified several key studies that examined physician professional satisfaction by analyzing data from large, national surveys of physicians providing direct patient care, including the Robert Wood Johnson Young Physicians Study (Hadley and Mitchell, 1997), the Physician Worklife Study (Williams et al., 1999), the Women Physicians’ Health Study (Frank et al., 1999), and the Community Tracking Study/Health Tracking Physician Survey (Kemper et al., 1996). Although survey instruments differed from study to study, specific questions assessing professional satisfaction were similar enough to allow reasonable comparison...

The project employed a mixed methods design, incorporating a primary qualitative component (multiple case studies, with each of 30 physician practices constituting a “case”) and embedding a quantitative component to further investigate qualitative themes. We thus prioritized qualitative methods in the study design. While this prioritization required some sacrifices in quantitative design—for example, we conducted a physician survey within the study practices, rather than in a nationally representative sample—we preserved other aspects of quantitative rigor (e.g., achieving a high survey response rate, conducting appropriate statistical tests) to perform valid quantitative analyses within the study sample.

The project incorporated...

Like the initial conceptual model that guided data collection efforts, the final model that incorporated study findings represented possible relationships between three categories of conceptual inputs (health system context, practice organizational features, and physician individual characteristics), two products of interactions between these inputs (work characteristics and work perceptions), and three types of outcomes of these inputs and their interactions (physician outcomes, organizational outcomes, and patient outcomes).

In the final model (see Figure 4.1), the key physician outcomes were overall professional satisfaction, stress, burnout, intent to leave the practice or the profession, and physician health. The key organizational outcomes were practice...

During the course of the study, we distributed 656 physician experience surveys, receiving a total of 447 responses (68-percent response rate). Table 5.1 presents nonresponse analyses, based on data available for both survey respondents and nonrespondents. Respondents were statistically significantly more likely than nonrespondents to be from Massachusetts and Washington, to specialize in primary care, to be in small or medium-sized practices, and to practice in primary care practices. There were no statistically significant differences by gender, AMA membership status, age, or practice ownership.

It is important to note that the survey sample in this study isnotnationally representative....

In this report, we define “quality” expansively: Any activity that improves patients’ chances of having good health outcomes, avoiding harm, or having good experiences with the health care system is counted as improving the quality of care. “Quality care” thus occurs when a patient gets the services that he or she needs, without unnecessary risk, in a humane and respectful manner. Drawing distinctions between specific dimensions of quality (e.g., technical quality, safety, and patient experience) is beyond the scope of this report.

Using this expansive definition of quality, we found that, when physicians perceived themselves as providing high-quality care, they...

We found that EHRs had important effects on physician professional satisfaction, both positive and negative. In the practices we studied, physicians approved of EHRs in concept, describing better ability to remotely access patient information and improvements in quality of care. Physicians, practice leaders, and other staff also noted the potential of EHRs to further improve both patient care and professional satisfaction in the future, as EHR technology—especially user interfaces and health information exchange—improves.

However, for many physicians, the current state of EHR technology appeared to significantly worsen professional satisfaction in multiple ways. Poor EHR usability, time-consuming data entry,...

Greater physician autonomy and greater control over the pace and content of clinical work were both associated with better professional satisfaction. For some physicians, having a leadership or management role within the practice was a key way of achieving autonomy. However, practice ownership was not for everyone: Some physicians reported little taste for the business side of medicine, deriving satisfaction from employed positions that allowed them to focus more exclusively on clinical care.

In general, analyses of survey results were concordant with interviewee reports; physicians reporting greater degrees of control over their clinical work were more likely to also report...

Among the practices we studied, practice leadership affected physician professional satisfaction in two main ways.

First, professional satisfaction was higher when physicians and their clinical colleagues reported that their values were well aligned with those of their leaders. Values alignment was especially important concerning approaches to clinical care. Some physicians reported that having leaders with clinical experience (either as physicians or other types of front-line clinical staff) enhanced the sense of values alignment between practice leaders and practicing physicians.

Second, physicians reported better professional satisfaction when practice leadership took a balanced approach to new practicewide initiatives, maintaining physician professional autonomy...

Physicians’ perceptions of collegiality, fairness, and respect were important determinants of professional satisfaction. In interviews, respondents reported four main areas in which these constructs operated: relationships with colleagues in the practice (including practice leadership), relationships with providers outside the practice, relationships with patients, and relationships with payers. Within the practice, frequent meetings with other physicians and allied health professionals (such as business meetings in physician partnerships) fostered greater collegiality. Some physicians who no longer co-owned their practices observed a decrease in interpersonal familiarity with their former partners when business meetings ceased, leading to lower overall morale.

Physicians reported limited but...

Physicians, clinical staff, and practice leaders commonly reported challenges stemming from the quantity and pace of physician work. Especially in primary care specialties, physicians described how pressure to provide greater quantities of services effectively limited the time and attention they could spend with each individual patient, detracting from the quality of care in some cases.

Some of the physicians we interviewed had joined practices in which payment did not rely on the number of patients seen, but in doing so, they reported accepting lower incomes. Others reported that improvement strategies adapted from other industries (e.g., lean improvement techniques) had improved...

In general, physicians described better satisfaction when their work content matched their training and dissatisfaction when they were required to perform work that other staff could perform—especially when they sensed that the content of their work was being dictated to them. Specific types of satisfying work varied by specialty and by individual, but some patterns emerged. For example, many primary care physicians appreciated providing care that was continuous, including inpatient care. Some of these physicians missed caring for hospitalized patients, expressing concern about losing their skills in inpatient medicine when hospitalists cared for their inpatients. Among surgeons, some expressed...

Although few physicians reported dissatisfaction with their current levels of income, physician income was an important contributor to satisfaction in the following ways:

Income stability. Physicians reported that having a stable income was an important contributor to overall professional satisfaction, and some described taking steps to preserve their incomes when pay rates decreased (or other changes threatened to reduce income).

Income fairness. Payment arrangements that were perceived as fair, transparent, and aligned with good patient care enhanced professional satisfaction. When practices changed their internal payment arrangements, clear and logical explanations for these changes were described as being important to preserving...

Physicians and practice managers described externally imposed rules and regulations under which they operated as having predominantly negative effects on professional satisfaction. Among these, meaningful-use rules stood out as having the greatest effect on professional satisfaction at the time of this study. While physicians agreed generally with the intent of meaningful-use rules, they expressed frustration with the time and documentation burdens these rules imposed—especially when they believed they were being asked to generate new documentation of activities that they had already performed.

The prominence of meaningful-use regulations in our interviews may reflect the particular timing of this study, which...

Our study did not identify health reform as a prominent contributor to overall physician professional satisfaction, either positively or negatively. In general, physicians and administrators expressed uncertainty about how various aspects of health reform (including but not limited to those contained in the Affordable Care Act) would affect physician satisfaction and practice financial sustainability. In response to this uncertainty, several practices sought economic security by increasing in size or becoming affiliated with hospitals and large delivery systems. Leaders of smaller, independent practices that did not initiate such growth or affiliation described feeling pressure to join larger systems, sensing that it...

Most physicians included in this study were generally satisfied with their medical practices, similar to prior studies of overall physician professional satisfaction. However, a substantial minority of physicians report low professional satisfaction, and even those who are generally satisfied with their careers describe a range of specific factors that substantially frustrate, stress, or otherwise dissatisfy them. Many of these sources of dissatisfaction are remediable, and, importantly, many seem likely to detract from the quality and efficiency of patient care. Therefore, interventions to remediate the most troubling of these sources of dissatisfaction seem necessary and timely.

Our study found that physicians...