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Landon BE, Reschovsky J, Blumenthal D. Changes in Career Satisfaction Among Primary Care and Specialist Physicians, 1997-2001. JAMA. 2003;289(4):442–449. doi:10.1001/jama.289.4.442
Context A number of forces have changed the practice of medicine in the past
decade. Evidence suggests that physicians are becoming less satisfied in this
Objectives To describe changes in career satisfaction in a large, nationally representative
sample of physicians and to examine market and practice factors associated
with changes in physician satisfaction.
Design and Setting Data were collected from the first 3 rounds of the Community Tracking
Study (CTS) Physician Survey, a series of nationally representative telephone
surveys of physicians in 60 US sites conducted in 1996-1997 (round 1: 12 385
respondents; 65% response rate), 1998-1999 (round 2: 12 280 respondents;
61% response rate), and 2000-2001 (round 3: 12 389 respondents; 59% response
rate) for the Center for Studying Health System Change. The second and third
rounds of the survey included physicians sampled in the previous round, as
well as new physicians.
Participants Primary care and specialist physicians who spent at least 20 hours per
week in direct patient care activities.
Main Outcome Measures Changes in physicians' overall satisfaction with their career and the
proportion of dissatisfied physicians in particular sites.
Results Physician satisfaction levels declined marginally between 1997 and 2001,
with most of the decline occurring between 1997 and 1999. Among primary care
physicians, 42.4% were very satisfied in 1997, as were 43.3% of specialists,
compared with 38.5% and 41.4%, respectively, in 2001. There were nearly equal
increases in those who reported that they were somewhat satisfied. Overall
means mask significant differences across the 60 sites. Among 12 sites randomly
selected for more intensive study, the proportion of respondents who were
somewhat or very dissatisfied ranged from 8.8% of physicians in Lansing, Mich
(1999), to 34.2% in Miami, Fla (1997). Between 1997 and 1999, 25.6% of primary
care physicians reported decreased satisfaction and 18.1% reported improved
satisfaction, while approximately equal percentages reported increased (19.8%)
and decreased (20.4%) satisfaction between 1999-2001. Findings were similar
for specialist physicians. In multivariable models, the strongest and most
consistent predictors of change in satisfaction were changes in measures of
clinical autonomy, including increases in hours worked and physicians' ability
to obtain services for their patients. Changes in exposure to managed care
were weakly related to changes in satisfaction.
Conclusions Our findings demonstrate that overall physician satisfaction levels
over this time period did not change dramatically. In addition, satisfaction
and changes in satisfaction vary greatly among sites. Rather than declining
income, threats to physicians' autonomy, to their ability to manage their
day-to-day patient interactions and their time, and to their ability to provide
high-quality care are most strongly associated with changes in satisfaction.
A confluence of forces has changed the practice of medicine in unprecedented
ways during the past decade. There is increasing focus on, and concern about,
the quality of medical care,1,2 financial
constraints are being applied more frequently and stringently, and the practice
and management of medical care have become increasingly centralized and dominated
by managed care and physician organizations.3-5 Whereas
physicians once practiced primarily alone or in small autonomous groups, they
now are more likely to practice in large groups and are increasingly subjected
to profiling, administrative requirements, and preapproval for procedures
and treatments. Evidence suggests that some physicians are becoming unhappy
in this environment.6
Understanding trends in physician career satisfaction and how changes
in the practice environments of physicians affect their career satisfaction
is important for several reasons. First, physician satisfaction is associated
with quality of care, particularly as measured by patient satisfaction.7,8 Second, dissatisfied physicians are
more likely to leave the profession and discourage others from entering.9-11 This is disruptive
to patient-physician relationships, costly to physician practices, and could
ultimately diminish the overall quality of care if potentially outstanding
physicians are dissuaded from choosing this career.12 Finally,
career dissatisfaction might be one manifestation of physicians' perceptions
of problems in delivering high-quality care to their patients.13
To examine trends in career satisfaction, we administered surveys 2
years apart to a nationally representative sample of primary care physicians
(PCPs) and specialist physicians drawn from local health care markets throughout
the country.13,14 The 60 nationally
representative sites include both large and small metropolitan areas, rural
counties, and areas with both high and low penetration of managed care. In
addition, we also used a longitudinal approach that overcomes some inherent
limitations of cross-sectional studies. We had 3 primary questions. First,
is overall career satisfaction changing over time? Second, how do changes
in physician satisfaction vary by market and by specialty? Third, to what
extent are changes in physicians' practice environments and local markets
associated with changes in their satisfaction?
Data for this study are from the first 3 rounds of the Community Tracking
Study (CTS) Physician Survey, a series of 3 nationally representative telephone
surveys of physicians conducted in 1996-1997 (round 1: 12 385 respondents;
65% response rate), 1998-1999 (round 2: 12 280 respondents; 61% response
rate), and 2000-2001 (round 3: 12 389 respondents; 59% response rate)
for the Center for Studying Health System Change.14 The
survey samples were designed to be representative of physicians directly providing
patient care in the continental United States, as well as in selected communities.
Each survey round used a complex sample clustered in 60 randomly selected
sites and a small, independently drawn, unclustered national sample comprising
about 10% of all interviews used to increase the precision of national estimates.15
In each site, we sampled physicians from the master files of the American
Medical Association and the American Osteopathic Association. The sample included
active nonfederal office- and hospital-based physicians who spent at least
20 hours per week in direct patient care, but excluded specialties such as
radiology, pathology, and anesthesiology. We oversampled PCPs, including those
in family practice, general practice, general internal medicine, internal
medicine/pediatrics, pediatrics, and geriatric medicine. The second and third
rounds of the survey included portions of physicians sampled in the previous
round, as well as new physicians. This approach created 2 panels of physicians,
the first interviewed in both rounds 1 and 2 and the other interviewed in
both rounds 2 and 3.
To create the first panel (round 1-round 2), 9353 of the 12 385
respondents (76%) to the first round were contacted in the second round. Of
these, a total of 915 had become ineligible because they had retired, worked
fewer than 20 hours per week, or were unlocatable. From the remaining 8438
we received 6569 responses, for a panel response rate of 78%. A further 650
were eliminated because they changed sites or PCP status between rounds or
were not practicing in the 60 sites, leaving a final sample of 5919 (3476
PCPs and 2443 specialists). To create the second panel (round 2-round 3),
11 394 of the 12 280 respondents to the second-round survey were
contacted in the third round. Of these, a total of 671 had become ineligible.
From the remaining 10 723 we received 7723 responses, for a panel response
rate of 72%. A further 976 were eliminated because they changed sites or PCP
status between rounds or were not practicing in the 60 sites, leaving a final
sample of 6747 (4257 PCPs and 2490 specialists). Some physicians were sampled
in both panels. Item nonresponse for both rounds of the survey was very low,
typically less than 3%, and less than 0.5% for the dependent variables. A
few independent variables were imputed using hot-deck procedures.16 Greater detail about the surveys is available elsewhere.14-17
In the first section of the survey, physicians were asked: "Thinking
very generally about your satisfaction with your overall career in medicine,
would you say that you are currently very satisfied, somewhat satisfied, somewhat
dissatisfied, very dissatisfied, or neither satisfied nor dissatisfied." These
responses were coded on a scale from 5 to 1 with "neither satisfied nor dissatisfied"
being coded as 3. In addition to reporting overall satisfaction levels, we
also report satisfaction levels by market for 12 of the markets that were
selected randomly for more intensive study. These sites had survey samples
large enough (approximately 500 physicians per round) to draw conclusions
about changes over time and were the subject of in-depth site visits that
were conducted concurrently with each round of the survey.
We determined changes in satisfaction for the panel respondents by calculating
the differences in reported satisfaction for participants in consecutive rounds
of the survey, with the resulting variable ranging from +4 to −4.
The literature suggests that changes in physician career satisfaction
may be influenced by 3 general factors: changes in the physician's practice
environment, including the income they derive from practice and hours worked;
changes in physicians' autonomy as measured by perceptions of their ability
to provide high-quality care to their patients and to obtain needed medical
services for them; and changes in the the local market.
Independent variables used to assess changes in physician satisfaction
for the panel respondents were generally constructed either as changes in
a continuous variable or as sets of categorical variables. For continuous
variables, the preceding value (from either round 1 or round 2) was subtracted
from the later value (from either round 2 or round 3). For categorical variables,
dummy variables were constructed indicating an increase or decrease in the
variable, with those physicians with no (or small) change serving as the reference
We measured changes in several attributes of physicians' practice environments,
including practice size, ownership, and involvement with managed care. The
survey assessed size (dichotomized to <10 or ≥10 physicians) and type
of practice (physician group, staff/group model health maintenance organization
[HMO], medical school–based practice, hospital-owned practice, or another
setting). After exploring alternative specifications, we created dummy variables
indicating whether physicians changed from a larger to smaller practice setting
or vice versa.
Changes in ownership were captured by 2 dummy variables indicating whether
the physician was a full or partial owner who became a nonowner or vice versa.
A dichotomous variable indicated whether the physician's practice had been
acquired in the preceeding 2 years.
Changes in the physicians' patient population were assessed with 2 continuous
variables measuring changes in the percentage of practice revenue from Medicaid
Changes in the practice's overall exposure to financial influences of
managed care were examined using continuous variables measuring changes in
the proportion of total practice revenue derived from managed care and changes
in the proportion of managed care revenues received in the form of capitation.
To measure effects of various administrative care management strategies,
physicians were asked, on a 6-point scale ranging from "very large" to "no
effect," the extent to which practice profiling, patient satisfaction surveys,
and guidelines affected their practice of medicine. Because responses to these
questions varied little over time, and because these variables were not significant
in preliminary analyses, they were not included in the final analysis.
Changes in work effort were assessed by categorical variables, indicating
whether the number of hours worked the previous week changed from fewer than
60 hours to more than 60 hours, or vice versa. Change in income was included
as a categorical variable indicating that income increased or decreased by
at least 5% after accounting for inflation. A measure of income per work effort
based on hours worked in the prior week was correlated with the income measure,
and was therefore not included in final analyses.
Professional autonomy refers to individuals' ability to control the
terms and content of their work. Based on the work of the Society of General
Internal Medicine Task Force on Physician Satisfaction, we identified 2 general
influences on clinical autonomy: control over work and ability to provide
needed services.13,18,19 To
measure clinical autonomy, we created a summary score based on responses to
a set of 5 questions assessing these factors. Respondents first were asked
their level of agreement with a general statement regarding the ability to
provide high-quality care and with 3 statements related to aspects of the
process of care delivery: whether they had adequate time with patients, freedom
to make clinical decisions, and the ability to form continuing relationships
with patients over time that promote the delivery of high-quality care. Response
categories included agree strongly, agree somewhat, neither agree nor disagree,
disagree somewhat, and disagree strongly. An exploratory factor analysis indicated
that there was a single underlying construct to the questions. Since the factor
loadings were almost equal, we created the index by summing up the responses.
The resulting index was highly internally consistent (Cronbach α, .82).
Primary care physicians and specialists were also asked to rate the
appropriateness of the level of patient complexity that they were expected
to address prior to or at the time of referral, respectively.20 We
constructed categorical variables indicating increases or decreases in each
of these variables between the 2 rounds of the survey.
We measured ability to provide needed services with a series of 5-point
questions that were combined to construct 3 indices by averaging component
variables: ability to obtain outpatient services ("index 1," including 3 items
related to obtaining referrals to specialists, ancillary services, and diagnostic
imaging), ability to obtain hospitalizations ("index 2," including 2 items
related to obtaining hospitalizations and length of stay), and ability to
obtain mental health services ("index 3," including 2 items related to obtaining
outpatient mental health treatment and inpatient mental health hospitalizations).
The mental health questions were only asked of PCPs, psychiatrists, and obstetricians/gynecologists.
Change scores were then calculated for each index. A dummy variable was created
to account for physicians who did not routinely need the applicable services
(eg, some specialists rarely hospitalize patients).
To assess changes in measures of managed care penetration, we created
variables by subtracting site-level averages of the percentage of physician
revenue from managed care, and also the percentage of physician revenue that
For descriptive analyses, we used t tests to
examine changes in continuous variables and the χ2 test for
dichotomous and categorical variables. We computed descriptive information
on overall satisfaction using the cross-sectional information from the 3 rounds
of the survey. Because the characteristics of the sample changed somewhat
over time, we computed regression-adjusted mean satisfaction levels for rounds
2 and 3 based on the composition of the first round of the survey.
Longitudinal Analyses. We investigated determinants of career satisfaction by evaluating changes
in satisfaction for the longitudinal panels of physicians. Cross-sectional
studies of physician career satisfaction can be biased because unobserved
physician preferences may affect their practice choices (eg, involvement with
managed care, size of practice) as well as their career satisfaction. In a
longitudinal first-differences model, in which the dependent and independent
variables are mostly expressed in terms of their changes over time, unobserved
physician preferences, as well as observable physician characteristics, are
held constant because we are only looking at changes affecting a given physician
over time. The inclusion of baseline career satisfaction in the regression
models also allows us to control for possible bias due to floor and ceiling
effects as well as for the tendency of individual physicians to rate their
satisfaction more or less highly.
We used ordinary least-squares regressions to investigate multivariable
relationships. For these models, we combined both panels into a single data
set because our model suggests that the determinants of satisfaction would
not change appreciably over time. We estimated separate models for PCPs and
specialist physicians because we thought that changes in the practice environment
and autonomy might be expected to affect generalists and specialists differently.
We first examined bivariate relationships. Variables that were not significantly
related to changes in satisfaction at P<.10 in
either bivariate or multivariable models were eliminated from the models.
This did not result in significant changes for any of the remaining coefficients.
Because they were a primary interest of this study, variables related to exposure
to managed care at both the individual and market level were also included
in the final model. All analyses were done using SUDAAN v8.01 (RTI International,
Research Triangle Park, NC) to control for the complex sample design and use
weights created for the panel.14 The SUDAAN
software also accounts for the nonindependence of observations when the same
physician is included in both panels.
Each category of characteristics (for instance, changes in practice
environment or changes in physician autonomy) was entered individually and
then in combination to examine both direct and indirect effects. For instance,
we speculated that changes in satisfaction related to managed care exposure
might be mediated by changes in professional autonomy, so we examined these
groups of variables individually and in combination. For each subgroup, variables
were first examined for collinearity. Correlations were below levels at which
multicollinearity would be considered likely (r<0.30).
We report results from the model including all categories of independent variables
because individual coefficients remained robust when alternative specifications
We also performed additional exploratory multivariable analyses at the
site level, using the combined panel data sets. For these analyses, we created
site-level means of physician satisfaction as well as independent variables
related to managed care exposure and distribution of patients across public
and private payers. We also used information from Interstudy21 and
the Bureau of Health Professions Area Resource File22 to
examine physician, hospital, and health plan concentration.
The characteristics of the respondents across the 3 rounds of the survey
are presented in Table 1. Among
primary care physicians, 23.6% were women in 1997 and this increased to almost
31% in 2001 (P<.01). Fourteen percent of specialists
were women in 1997, as were 18.7% in 2001 (P<.01).
A slightly higher proportion of PCPs were international medical graduates
(21.3%-24.9% [1997 and 2001, respectively], compared with 18.5%-18.8% for
specialists). Among PCPs in 1997, 33.1% were internists, 21.0% were pediatricians,
and the remainder were either family physicians or general practitioners.
By 2001, the proportion that were internists had increased to 37.3%, with
an accompanying decrease in the proportion of family physicians to general
practitioners. Among specialists, the share of medical specialties increased
from 40.3% in round 1 to 47.6% in round 3, while the surgical specialties
decreased from 36.7% to 31.3% (P<.01).
Physician career satisfaction levels declined marginally between 1997
and 2001 (Table 2), although there
did not appear to be a clear trend over that time period. In addition, modest
declines noted between 1997 and 1999 appeared to moderate by 2001. There were
no significant differences between levels in 1999 and 2001. For instance,
42.4% of PCPs and 43.3% of specialists were very satisfied in 1997, compared
with 38.5% and 41.4%, respectively, in 1999 (P<.001
for PCPs and P<.01 for specialists). For PCPs,
however, this was accompanied by an offsetting increase in the percentage
of physicians who were somewhat satisfied (P<.001).
The proportion of specialists who were somewhat dissatisfied also increased
between 1997 and 1999, from 12.9% to 14.8% (P<.05).
We also examined changes in career satisfaction for physicians included
in the 2 panel samples (Table 3).
Overall, 25.7% of physicians reported decreased satisfaction between 1997
and 1999, and this proportion was similar for both PCPs and specialists. Only
17.9% reported increased satisfaction. In contrast, between 1999-2001, approximately
equal numbers of physicians in the panel reported decreased (21.4%) and increased
These overall means mask significant site-level variation. Across the
12 high-intensity sites, the percentage of physicians who were somewhat or
very dissatisfied ranged from a low of 8.8% of physicians in Lansing, Mich,
in round 2 to a high of 34.2% of physicians in Miami, Fla, in round 1 (Figure 1), and these were reflective of the
range of variation seen across the full sample of 60 sites. More physicians
in 7 of these 12 markets were dissatisfied in 2001 vs 1997, with the biggest
change occurring in Syracuse, NY, where the percentage of somewhat or very
dissatisfied physicians increased from 14% to 21% during the time period of
the study. Among the markets with the highest proportion of dissatisfied physicians
in 1997 (including Newark, NJ [24%], Orange County, Calif [27%], and Miami,
Fla [34%]), dissatisfaction levels appeared to moderate by 2001. Multivariable
analyses to understand further changes in satisfaction at the market level
revealed only a single significant predictor. Increasing proportion of capitated
managed care revenue in a market was associated with decreased satisfaction
(P = .01) among physicians in that market.
Changes in Practice Environment. Multivariable linear regression results for the 7733 PCPs and 4933 specialists
included in the panel analyses are presented in Table 4. Of note, there were few significant interactions between
the individual predictors and a dummy variable indicating the panel the physician
belonged to, suggesting it was reasonable to combine them into a single regression.
Primary care physicians and specialists who became owners of their practices
were more likely to report increased satisfaction (P<.01
and P<.001, respectively) while PCPs who reported
increases in the number of hours they worked, from less than 60 to more than
60 hours per week, reported decreased satisfaction (P<.01).
Income was not related to changes in specialist satisfaction, but changes
in satisfaction among PCPs were significantly related to income (P<.01). Changes in exposure to managed care were generally not related
to changes in satisfaction.
Changes in Professional Autonomy. The most consistent predictors of changes in both PCP and specialist
career satisfaction were changes in measures related to clinical autonomy.
Primary care physicians who reported increases in the level of patient complexity
that they were expected to address without referral were more likely to report
decreased satisfaction (P<.01). Similarly, both
PCPs and specialists who reported more difficulty obtaining high-quality outpatient
services (P<.01) and inpatient services (P<.05) were also more likely to be report decreased
satisfaction with their careers. Finally, changes in the clinical autonomy
scale, which measures physicians' ability to provide high-quality care, maintain
continuing patient relationships, adequacy of time with patients, and freedom
to make clinical decisions, were strongly related to changes in satisfaction
for both PCPs and specialists (P<.001 for both).
Changes in Market-Level Characteristics. Primary care physicians in markets with increased proportions of managed
care revenue in the form of capitation were significantly less satisfied (P<.01), while specialists' satisfaction was not related
to changes in the market-level measures of managed care. Lastly, we also examined
predictors of changes in satisfaction at the market level. Both increased
market-level managed care penetration and higher proportions of capitated
managed care revenue were associated with decreases in market-level physician
Despite a lack of systematic data, many observers perceived a decline
in physician career satisfaction. As physician practice continues to evolve,
it becomes increasingly important to understand how satisfaction is changing
and whether managers and policy makers at the local or national level can
influence these changes.
In this national study of satisfaction among a large representative
sample of physicians, we find several notable results. First, our findings
demonstrate that overall levels of career satisfaction among physicians over
this time period did not change dramatically, although there appeared to be
a slight decline between 1997 and 1999. Second, national-level data mask significant
variation in local markets. These findings suggest that changes in physician
satisfaction may be significantly influenced by local phenomena. Third, we
found that changes in physicians' clinical autonomy, including their ability
to obtain needed outpatient and inpatient services, were the most consistent
and powerful predictors of changes in their levels of satisfaction over time.
Change in income was a significant predictor only for PCPs, and change in
practice ownership was significant for both PCPs and specialists. A number
of other possible influences, such as managed care penetration within physicians'
practices, had little apparent effect.
Changes in autonomy cannot be attributed simply to the spread of managed
care, since managed care variables generally were not important predictors
of change in satisfaction, even in models that did not include the change
in autonomy measures.23 Instead, more subtle
factors seem to be at work. These may be related to unmeasured differences
in managed care organizations in different communities, or in how physicians'
organizations respond to managed care. In addition, it could also reflect
changes in the intensity of managed care practices over the time period, such
as those related to increasing use of certain types of capitation, which we
were unable to measure.
Previous studies of the trends in and determinants of physician satisfaction
relied on cross-sectional data,13,24,25 focused
on selected markets or specialties,26,27 or
failed to identify the full range of influences on satisfaction. The few existing
longitudinal studies of career satisfaction use old data, have low response
rates, or rely on sequential cross-sectional data, thus failing to fully control
for personal characteristics of the physicians.6,26,28 Furthermore,
previous research has not examined whether changes in satisfaction vary across
local health care markets. If differences do exist across markets, this might
present opportunities for managers and policy makers to understand and target
factors important to physician satisfaction in particular markets. This study
addresses many of these methodological limitations and takes advantage of
the ability to use representative cross-sectional data as well as longitudinal
information to analyze the determinants of changes in satisfaction.
Our findings related to variation in local markets merit attention because
cross-sectional satisfaction levels across markets and changes in satisfaction
levels both varied substantially across markets. To our knowledge, no previous
study has documented these marked differences in satisfaction across markets.
Many have observed that "all health care is local" and these findings appear
consistent with this view.29 We attempted to
explain changes in satisfaction at the site level through multivariable models.
However, the small number of sites, the small number of respondents in some
sites, and resulting limits in statistical power precluded meaningful analysis
using the market as the level of analysis. We did find, however, that increased
levels of capitation within managed care were associated with decreased satisfaction
at the site level, despite there being no relationship at the individual level.
The latter finding suggests that increasing capitation at the market level
may be a marker for more aggressive managed care practices that can lead to
subtle changes in practice norms and that may limit physicians' opportunities
to escape these managed care influences by moving to different practices in
the same market. This effect may operate through market-level influences on
physicians' professional autonomy.
Other measures of market characteristics, such as hospital concentration
and physician density, did not prove to be important predictors of changes
in physician satisfaction. This might be because local markets differ substantially
in ways that are difficult to measure. These range from subtle variations
in practice norms and patient expectations to more basic differences in the
structure and organization of medical groups and local contracting practices
and the rate at which these factors are changing.30,31 Findings
from recent site visits, however, do suggest some possible explanations for
some of the more dramatic changes between 1999-2001. For example, in Syracuse,
NY, which experienced a significant increase in dissatisfaction, increased
health plans leverage that resulted from the merger of the 2 largest health
plans in the market might have had deleterious effects on physician payment
and autonomy. In contrast, in Newark, NJ, which experienced a significant
decline in dissatisfaction, the state moved aggressively to adopt new more
stringent oversight of HMOs and to mandate prompt payment requirements following
the high-profile collapses of 2 health plans in 1998.32-34
Our data are subject to several limitations. First, we used only a single
measure of general satisfaction. Our measure, however, is robust and similar
questions have been used in numerous other studies in the past. Second, while
to our knowledge our sample is the largest nationally representative longitudinal
study of physicians, the sample sizes for many individual markets were relatively
small. Consequently, with the exception of the 12 high-intensity sites, we
were unable to make precise estimates of changes at the individual market
level and lacked statistical power to identify actionable influences. This
is, however, the first study to document these important differences across
markets and this area should be a high priority for future research.
In summary, our data suggest that declining physician career satisfaction
is real but variable in both time and space. Physician satisfaction seems
to have declined from 1997 to 1999, but not appreciably between 1999 and 2001.
However, this was not true for all markets. Constraints on physicians' clinical
autonomy seem to have been the most important influences on changes in career
satisfaction among physicians, but other factors, such as increases in hours
worked and changes in practice ownership status, have also played a role.
Future research needs to explore the determinants of physician satisfaction
in different markets and should highlight local interventions that might be
pursued to maintain or improve physician satisfaction.
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