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Satisfaction Challenge

From: The Hospitalist, May 2010

by Nasim Afsarmanesh, MD

In 1973, a survey was conducted to evaluate physician satisfaction. Less than 15% of physicians reported any doubt that they had made the right career choice, with 3.7% stating that they were “not happy.”¹ Twenty years later, surveys revealed a different story: Forty percent of physicians stated that they would not choose the medical profession if they had to choose a career again.²

Dissatisfaction in medicine has been reported in diverse age groups, different areas of the country, and various medical specialties.³ When dissatisfied, physicians often leave their jobs and, consequently, the patient-physician relationship is disrupted. This turnover is quite costly to the healthcare system. In primary care, the cost of replacing a physician is estimated at $250,000.⁴

Here are some of the factors that contribute to burnout, as well as solutions for ensuring job satisfaction.

Challenges Ahead

Burnout is an interesting phenomenon in the medical profession. Unlike many other professionals, physicians often experience extreme fatigue and emotional exhaustion at an early stage in their careers—during medical school and residency. By midcareer, the momentum is maintained as colleagues recognize their hard work, and they continue to place service to others before themselves. Physicians who encounter burnout often experience emotional exhaustion, impaired job performance, relationship difficulties, and poor health, including irritability, sleep disturbances, headaches, depression, and drug addictions.

Increased rates of burnout have been linked to several internal and external factors. Internal factors—management style in a workplace, multiple demands at work, social support from colleagues, lack of control over the work environment—have been illustrated to correlate with higher rates of burnout. The ever-increasing demand on physicians’ time leads to higher rates of dissatisfaction. There are an exponentially increasing number of medications, tests, and procedures to discuss with patients and families. This is complicated by the rise of e-mail and the Internet, as some patients expect immediate responses to their concerns.

Some studies have shown that personality factors can lead to burnout. Compulsiveness, a trait often seen in physicians, is an adaptive behavior for the demands of medical education and practice. However, it can lead to chronic feelings of inadequacy, an exaggerated sense of responsibility, and difficulty setting limits. Furthermore, physicians often are conditioned in the psychology of postponement. It takes root in the early years of medical education and leads to habitually delaying various sources of renewal, such as vacations and relationships.

External factors include payment reductions, managing various insurers, and increasing malpractice cases.^1,2,5 Evaluating the changing landscape of managed-care organizations reveals that while a small fraction of physicians are employed by them, more than 90% contract with them. Commonly cited reasons for dissatisfaction with managed care include “trafficking” of patients in and out of care, administrative paperwork, limitations on referring patients to specialists, financial incentives to curb medical workups, and pressure to evaluate increasing numbers of patients.⁶

Malpractice cases have increased in the past 30 years. The American Medical Association (AMA) has identified 18 states where providers are finding it challenging to purchase affordable insurance.⁷ An additional 26 states have been placed on “orange alert,” indicating a worsening situation in availability and affordability of insurance. Physicians who are not personally burdened by malpractice suits feel its repercussions. They practice “defensive medicine” by ordering increasing numbers of tests and procedures to avoid potential litigation. Physicians involved in lawsuits, regardless of the outcome, describe feeling shame, self-doubt, and disillusionment with medical practice.

What Makes You Happy?

In the December 2006 issue of The Hospitalist (see “Are You Satisfied?” p. 4), Mary Jo Gorman, MD, MBA, FHM, then president of SHM, pointed out five factors that contribute to physician satisfaction:

1. Stimulation and challenge at work. It’s critical to have a job that requires technically difficult tasks, procedures, or intellectual challenges. The ability to interact and collaborate with other physicians further adds depth and richness to hospitalists’ clinical practice. However, it’s important to realize that overstimulation can lead to discomfort and unhappiness.
2. Feeling appreciated. Recog-nition for your performance leads to feeling valued at work and has a strong correlation with overall job satisfaction. It keeps hospitalists interested and motivated. However, recognition should be personalized; otherwise, it can have a detrimental effect.
3. Control over work. Auto-nomy and control over work is important to ensuring job satisfaction. This includes actively participating in the design of your work schedule and other work-related matters. When decisions are imposed on physicians, it creates tension and stress.
4. Work environment. This includes the type of work, support, and opportunities for growth and development, as well as interactions with colleagues and staff.
5. Income. Compensation is often fourth or fifth on the list of priorities for physicians. While all of us seek fair compensation for our work, it often is not the main reason we choose an employment.

Solutions

Burnout prevention is the responsibility of all healthcare professionals. It’s critical to promote well-being on all levels: physical, emotional, psychological, and spiritual. The following recommendations are based on various interventions established nationally to address physician burnout:

Establish realistic goals. Identify realistic goals for your professional and personal life, and actively work on balancing the two. Emphasize these goals throughout your professional career, avoiding the natural tendency for postponement.

Improve your work environment. Involve physicians in the design and management of the practice; build flexible schedules that allow coverage during important life events (i.e., graduations, births, weddings); minimize paperwork and improve efficiency; and establish a committee for open discussion of physician wellness issues.

Take care of yourself. Mentorship programs support junior members in their career development and help them balance the challenges of their personal and professional lives. Mentors can detect dissatisfaction and help physicians re-evaluate their interests and career paths. Require physicians to have their own primary-care physician (PCP) to ensure their physical and mental well-being. Offer memberships to fitness centers.

Provide opportunities to grow. Seek opportunities for medical education; address personal goals and aspirations, such as hobbies and interests; and establish sabbatical programs to gain perspective and broaden your horizons.

Fortunately, medicine has an enthusiastic applicant pool. There is hope that highly motivated and qualified students will continue to apply and enter the medical profession. However, there is concern that the dissatisfaction in medicine might influence the caliber of applicants who apply.

Medical education and training needs to address the challenges of practicing medicine. Students should be taught about the challenges of delivering high-quality care, risk management, cost containment, and utilization review. During the clinical years in medical school and residency, trainees need to experience the fast pace of medicine, the realities of payment dilemmas, and increased paperwork. It ultimately is the responsibility of educators in the medical profession to encourage students and residents to establish more accurate expectations of the practice of medicine. TH

Dr. Afsarmanesh is director of hospital medicine quality initiatives at Ronald Reagan UCLA Medical Center in Los Angeles.

References

1. Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. N Engl J Med. 2003;348(23):2281-2284.
2. Hadley J, Cantor JC, Willke RJ, Feder J, Cohen AB. Young physicians most and least likely to have second thoughts about a career in medicine. Acad Med. 1992;67:180-190.
3. Harvey LK, Shubat SC. AMA Public Opinion on Healthcare Issues. Chicago: American Medical Association Press; 1988.
4. Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Serv Res. 2009;9:166.
5. Buchbinder SB, Wilson M, Melick CF, Powe NR. Estimates of costs of primary care physician turnover. Am J Manag Care. 1999;5(11):1431-1438.
6. Reams HR, Dunstone DC. Professional satisfaction of physicians. Arch Intern Med. 1989;149:1951-1956.
7. McMurray JE, Williams E, Schwartz MD, et al. Developing a model using qualitative data. J Gen Intern Med. 1997;12(11):711–714.