In this national survey of 2,326 physicians, job satisfaction in group and staff-model HMOs was a trade-off: more satisfaction with autonomy and administrative issues versus less satisfaction with resources and relationships with nonphysician staff and community. Time allotted for new patients in HMOs was significantly less than in 2 other practice settings (solo and academic), and 83% of family physicians practicing in HMOs felt stressed for time during new patient visits. HMO doctors had significantly less global job satisfaction and a higher intent to leave their current practice within 2 years when compared with physicians in most other settings. Finally, we found that time pressure, independent of practice setting, significantly detracted from 7 of 10 satisfaction components and from satisfaction with current job, career and specialty.
Why study physician satisfaction? Crucial medical outcomes have been linked to physician satisfaction, including prescribing behavior, patient adherence to medications, patient satisfaction and quality of care.12–16
Burnout of physicians is an expensive and unfortunate outcome,3
and the career choices of medical students and residents may be influenced by stressed and dissatisfied teachers.17
HMOs were less satisfying globally than many other practice types. HMO physicians, more satisfied with their overall autonomy and freedom from administrative issues, appear to feel unencumbered but still relatively dissatisfied. Their lower satisfaction with resources and with staff and community relationships provide areas for assessment and intervention. The impact of the relatively smaller amount of time allotted for patient visits requires further investigation, as time stress had a broad and negative impact on job satisfaction.
The potential impact of shortened patient visits has been studied by Levinson et al., who described physician-patient encounters and the risk of a malpractice suit.18
Primary care physicians who had been sued spent an average of 15 minutes with each patient while physicians who had not been sued spent 18.6 minutes, a difference of 3.6 minutes. Researchers from Cleveland and Cincinnati have likewise shown that patient satisfaction is strongly associated with visit time, especially for visits over 15 minutes,19
and several other recent articles20–23
and an editorial24
have echoed the importance of adequate time for patient visits. The amount of additional time that respondent physicians said they would need to provide quality care ranged from 1 to 6 minutes (). What remains to be tested is whether providing physicians with these small increments of time would increase job satisfaction and the quality of care.
It may be that HMOs allot less time for patient visits because they provide other resources (e.g., nonphysician staff) to oversee disease management programs for chronic illnesses. However, the HMO physicians in our study reported relatively lower satisfaction with resources and with their relationships with nonphysician staff than did many other respondents. A less complex patient mix would be another potential explanation for less time availability in HMOs, but according to the respondents, case mix in HMOs was comparable to that seen in nonacademic settings.
Doctors felt time pressure in all settings, not just in HMOs, and acknowledged needing up to 41% more time than allotted to provide quality care during new patient visits. Our data do not make clear who is allotting less than adequate time for doctors and patients to spend together. While it could be organizations attempting to streamline care, another plausible explanation is that it is physicians themselves who have shortened the duration of patient visits to maintain panel sizes and access to care.
The odds of intending to leave the practice were high among HMO physicians and is a troublesome finding, particularly since it is correlated with job and career dissatisfaction. Prior research25,26
shows a strong correlation between intent to leave and actually leaving a practice. This high intent to leave, coupled with the low odds of global satisfaction, suggests that group and staff-model HMO physicians may be a relatively unstable group. Periodic surveying of HMO physicians concerning sources of satisfaction and dissatisfaction could allow timely interventions that would maintain continuity and preserve the quality of care.
Our data also show some interesting findings outside the HMO setting. That is, time pressure in patient visits is a source of dissatisfaction in many domains and requires attention. General internal medicine has low specialty satisfaction and, at least by self-report, a complex patient mix among primary care specialties. Finally, our study provides “normative” data on time allotted and time needed in patient visits by specialty and practice setting. These data can be used by physicians and health care organizations to assess their own visit times.
There are several strengths and weaknesses to our study. We surveyed a large representative national random sample of physicians emphasizing diversity within our respondents. We had an extensive developmental process resulting in a highly validated survey instrument10
that is available for use by other researchers and health care organizations. The weaknesses include the less than optimal 52% response rate, although this is comparable to the reported response rate average of 54% in national physician surveys.27
Interestingly, our “wave analysis” of late versus early responders showed that fourth (last) wave respondents had higher time pressure than all others, with a gradual increase with each successive wave. Thus, our study may actually have underestimated the impact of time pressure on physicians. Another weakness was the difficulty we encountered in defining an “HMO physician.” Many physicians practice in settings which accommodate multiple types of managed care plans, and group and staff-model HMO physicians vary in the number of their patients that are capitated or under managed care contracts. (Our HMO physician respondents ranged from a few who noted that none of their patients were capitated or in managed care to many who noted>75%.) By defining HMO physicians as those who practice in a group or staff-model HMO and have the majority of their patients in capitated or other managed care arrangements, we believe we have identified a clearly defined and homogeneous group. Indeed, a recent article showed substantial heterogeneity between group or staff-model HMO physicians and other office-based physicians with 1 or more contracts with an HMO or Independent Practice Association.14
Thus, we have chosen to limit our analysis to the former group. Finally, despite sampling only generalists with no secondary AMA specialty classification, some physicians sampled as generalists still claimed to be practicing as specialists. We chose to analyze physicians based upon the category (specialty) in which they were sampled and acknowledge some uncertainty in specialty classification.
In summary, while some aspects of daily practice are viewed positively by physicians practicing in group or staff-model HMOs, the balance is tipped in the direction of less global satisfaction and a significantly higher intent to leave the practice within 2 years when compared with physicians in many other practice settings. Potential explanatory factors include resource availability, staff and community relationships, and insufficient time allotted for new patient visits. To improve satisfaction and stability in HMO physicians, all of these factors require attention and further investigation.