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Bruce E. Landon, MD, MBA
Harvard Medical School, Boston, Mass

JAMA. 2004;291:634.

Despite reports of dissatisfaction among practicing physicians¹ and a 22% decrease in applications to US medical schools since 1997,² recent data suggest that the majority of physicians remain satisfied with their careers,³ although there may be substantial variability across geographical areas.³ In a nationally representative telephone survey of physicians from 1997 to 2001, we found that more than 80% of physicians with direct patient care responsibilities were somewhat or very satisfied with their careers.

Physician career satisfaction appears to be a complex function of a number of variables. Overall career satisfaction among physicians may remain high despite decreases in some of these domains. The Society of General Internal Medicine (SGIM) Career Satisfaction Study Group defined 10 domains of professional satisfaction.⁴ Among the highest predictors of global job satisfaction were patient care issues and relationships with patients and colleagues.

The SGIM study group⁴ defined autonomy as "independence of action," including the ability to treat patients according to the best clinical judgment. We found that both primary care physicians and specialists who rated their autonomy lower and those that reported more difficulty obtaining high-quality outpatient services and inpatient services were more likely to report decreased satisfaction with their careers over the 4-year period.³ Similarly, in a cross-sectional study, Stoddard et al⁵ found clinical autonomy to be significantly related to career satisfaction.

Conversely, while physicians may be largely satisfied with their careers in medicine, they may be less satisfied with particular aspects of practice, including income, control over personal time, and the administrative aspects of practice. In a 1999 study in Massachusetts, more than 60% of physicians reported dissatisfaction with managed care.⁶ Many of these physicians also rated the fee schedules or capitation rates they received from managed care companies as "fair" or "poor."

Similarly, the study by Stoddard et al⁵ found that the level of income was associated with satisfaction. Another study⁶ from the SGIM study group found that physicians' dissatisfaction with pay was associated with an increased likelihood of leaving their jobs within 2 years. Rates of increases in physician income have barely kept pace with inflation. In addition, within medicine, primary care specialties have been particularly affected because of continued increases in practice expenses accompanied by relatively flat reimbursement rates. In our national longitudinal study,³ we found that primary care physicians who reported lower income were significantly more likely to become less satisfied, although primary care physicians with increases in income did not become more satisfied over time. Among specialists, neither increases nor decreases in income were related to changes in satisfaction.

Another aspect of practice that has changed in the recent past is control over work. Whereas physicians once practiced primarily alone or in small autonomous groups, they now are more likely to be employed in large groups and are increasingly subjected to profiling, administrative requirements, and preapproval for procedures and treatments.⁷ Financial constraints are also prevalent. Patients report less trust in physicians, and physicians are no longer respected as highly as they once were.⁸ Among the most important changes related to this area of practice are control over work and personal time. Linzer et al⁹ reported that physicians in health maintenance organizations were less satisfied with their careers and that the adequacy of time with patients was an important predictor.

The data on physician satisfaction cannot be fully understood without examining the principal domains determining physician career satisfaction. Although physicians have traditionally derived career satisfaction from their services to patients, other aspects of satisfaction including income and personal time are also important and appear to be more subject to change over time. If the balance between these factors continues to shift, this could potentially lead to increasing levels of dissatisfaction among physicians.

Funding/Support: This work was supported in part by The Robert Wood Johnson Foundation through their sole funding of the Center for Studying Health System Change and by US Agency for Healthcare Research and Quality grant PO-1–HS-10803.

REFERENCES
1. Barnard A, Tong K. The doctor is out—more and more physicians, frustrated with managed care, are trying new professions and finding life less stressful. Boston Globe. July 9, 2000:A1. 2. Barzansky B, Etzel SI. Educational programs in US medical schools, 2002-2003. JAMA. 2003;290:1190-1196. FREE FULL TEXT 3. Landon BE, Reschovsky J, Blumenthal D. Changes in career satisfaction among primary care and specialist physicians, 1997-2001. JAMA. 2003;289:442-449. FREE FULL TEXT 4. Konrad TR, Williams ES, Linzer M, et al, for the Society of General Internal Medicine Career Satisfaction Study Group. Measuring physician job satisfaction in a changing workplace and a challenging environment. Med Care. 1999;37:1174-1182. FULL TEXT | ISI | PUBMED 5. Stoddard JJ, Hargraves JL, Reed M, Vratil A. Managed care, professional autonomy, and income. J Gen Intern Med. 2001;16:675-684. FULL TEXT | ISI | PUBMED 6. Landon BE, Aseltine R Jr, Shaul JA, Miller Y, Auerbach BA, Cleary PD. Evolving dissatisfaction among primary care physicians. Am J Manag Care. 2002;8:890-901. ISI | PUBMED 7. Casalino L, Gillies RR, Shortell SM, et al. External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. JAMA. 2003;289:434-441. FREE FULL TEXT 8. Pescosolido BA, Tuch SA, Martin JK. The profession of medicine and the public. J Health Soc Behav. 2001;42:1-16. FULL TEXT | ISI | PUBMED 9. Linzer M, Konrad TR, et al. Managed care, time pressure, and physician job satisfaction. J Gen Intern Med. 2000:15:441-450. FULL TEXT | ISI | PUBMED