In this discussion, we first consider the results as well as the literature on specialties and control variables. Second, we consider the implications; third we consider limitations; and fourth, conclusions.
Geriatricians ranked at the top of the statistically significant specialties labeled "very satisfied" in both 2004-2005 and 1996-1997. Shah et al[22
] also find high levels of job satisfaction for geriatricians. In addition to the steady (non-erratic) hours, encounters with inspirational seniors, and enduring relationships this specialty is enjoying increasing demand as baby boomers retire[23
]. Geriatricians were also high on the list that did not adjust for any covariates (ranked second in Table ). But caution should be exercised in interpreting these findings. Evidence indicates that relatively poor Medicare reimbursements have lead to shortages of geriatricians nationwide[24
Pediatrics and pediatric sub-specialties rated high on satisfaction both the 2004-05 and 1996-1997 samples. There may be several reasons: 1) children tend to be more joyful than adults; 2) many health problems are easily resolved so that physicians feel effective; 3) adults who select to work with children may themselves be more joyful; 4) pediatricians encounter less "work stress" than other physicians [25
The 2004-2005 findings again demonstrate the high satisfaction levels and low dissatisfaction levels for dermatology found in the 1996-1997 data. High satisfaction levels for dermatology may be explained by 1) "prosperous employment opportunities[28
];" 2) opportunities for preserving business through patient self-referral of their own skin problems; 3) compared to other specialties, dermatologists have more stable work hours; 4) outcomes of treatment are frequently direct and obvious to patients thus enhancing patient-physician interactions[28
A change also occurred for ophthalmology. In 1996-1997, ophthalmology was statistically significant and high on the list for "dissatisfied" both before and after controlling for income and other covariates. In the 2004-2005 data, ophthalmology was statistically significant and positively associated with satisfaction prior to controlling for covariates (Table ) but not statistically significant after controlling for covariates (Table ). A literature search and discussions with local experts did not reveal any obvious reasons why changes in satisfaction would have occurred between 1996-1997 and 2004-2005
The low career satisfaction for neurological surgery and obstetrics and gynecology specialists may have several causes: irregular hours, medical malpractice lawsuits; loss of autonomy; and secular decline in pay compared to other specialties[4
]. This low career satisfaction might also be explained by the high expectations these physicians had when they entered these "top tier" specialties versus the current realities of practice. When career expectations are not met, when workers feel cheated, evidence of career dissatisfaction is widespread within most jobs, not just medical ones[31
]. Interestingly, these results might generalize to other countries. Lambert et al[32
] find evidence that younger physicians in England reject surgical specialties and obstetrics and gynecology for reasons relating to "quality of life" and work hours.
Our results on career satisfaction suggest some effect of lifestyle, especially "uncontrollable" lifestyle. (Bottom of Table and entire Table ). If the CTS had information on three key "controllable" specialties ---anesthesiology, diagnostic radiology, and pathology---- our multiple regression results for the "controllable " specialties may have been stronger. It is worth noting that two of the "uncontrollable" specialties, pediatrics and internal medicine and pediatrics (combined), rank very high on the satisfaction scale in Tables and . Nevertheless, overall, our results parallel those observed among medical students, for whom lifestyle controllability outranked income as an influence on career choice[8
The lack of statistical significance for age 75+ might be due to the small "n" within that age bracket(1.7% of sample). The positive and statistically significant results on the remaining age categories and relatively large coefficients in the lowest and highest ranges suggested a U-shaped curve, with physicians age<35 and 65-74 enjoying the highest levels of satisfaction. This might be due to the idealism of youth and the fact that most physicians in retirement age who choose not to retire must enjoy what they do.
Our statistically insignificant results on gender reflect the ambiguity in the literature. McMurray et al[33
] find women more dissatisfied than men. Keeton et al[29
], on the other hand, find among physicians practicing obstetrics and gynecology, females are more satisfied than males.
We found statistically insignificant results for non-Hispanic African-Americans. The social science literature on many other jobs, however, finds African-Americans more dissatisfied with their jobs[34
]. It could be that the medical profession may be one of the first to achieve racial parity for career satisfaction.
Work hours variables measuring many hours (>60, 51-60 hours-per-week) were strongly and positively associated with dissatisfaction, similar to the 1996-97 findings. Work hours appeared to have become an even more important determinant of satisfaction in 2004-05 than 1996-97, consistent with the hypothesis that physicians are becoming increasingly concerned with work-life balance[29
Unlike the 1996-97 results, these 2004-05 results did not indicate that graduation from a foreign medical school was a statistically significant predictor of lower satisfaction. It may be that the shortage of American physicians has resulted in better career opportunities for international medical school graduates[35
Consistent with the 1996-97 results, higher income continued to be strongly and positively associated with satisfaction. Income, in fact, appeared to be among the most consistent of all covariates in both 1996-97 and 2004-05. This is consistent with economics literature suggesting that income is the most important predictor for most jobs[31
]. This is also one of the reasons we reported rankings unadjusted for any covariates in Table .
The finding that physicians currently employed in medical schools was unexpected. It could be due to the intrinsic rewards of intellectual stimulation, collaborative research, and creative expression associated with academic life[37
Consistent with the 1996-97 findings, these 2004-2005 findings also indicate a difference for percent of revenue from managed care. Whereas managed care may be having a waning influence on the public, it may continue to exert influence on physicians[38
As indicated in the earlier study,7 these results might be useful to medical students contemplating specialty choice. Presumably, medical students might select a specialty with high rather than low satisfaction, other things equal.. Specialty societies may also have interest in the results since they are concerned about the well-being of current members and the impression new medical students have of their specialty.
A free market for physicians would operate to improve the lowest ranking specialties since employers and payers would be forced to improve working conditions or wages to continue to attract high-quality personnel. But free market forces are weak in the regulated physician market. Medical group directors, HMO managers, insurance and Medicare executives, policy makers, and residency directors, may want to take direct action to improve career satisfaction among specialties that have especially low scores. Given the strong and consistent relations among income and work hours on the one hand and satisfaction, policy suggestions might include raising payments or reducing work hours for certain specialties. More research is needed to elucidate the reasons for low satisfaction within particular specialties in order to develop policy solutions.
These results may have implications for the future mix of specialists There may be fewer medical students entering obstetrics and gynecology or neurological surgery. Given the critical nature of these specialties, there may also be implications for public health.
First, the data are self-reported. However, only the physician knows his or her level of satisfaction. Secondly, even though a subset of the 2004-05 CTS respondents provided data in earlier survey rounds--with roughly 29% of these respondents providing data in all three earlier rounds--we did not perform a longitudinal data analysis on the subset of respondents who participated in earlier rounds, opting instead for a cross-sectional analysis of the full 2004-05 sample that provides the most contemporary and straightforward look at the broadest range of specialties. It is difficult to assign causal relations using cross-sectional data. But many of the results are consistent with causal relations asserted by other researchers. For example, Clark and Oswald[31
] assert that high income improves satisfaction and Becker et al[4
] assert that changes in the past 20 years have resulted in growing numbers of dissatisfied obstetrics and gynecology physicians. Third, whereas the response rates may differ across specialties, the CTS administrators believe these data are representative of physicians in the nation[17
Another limitation is our use of a single dependent variable that ranged from +1 to -1. This variable was not normally distributed and linear regression might result in predicted values outside the +1 and -1 range. However, the validity of our regression-based inferences using this dependent variable ultimately rests on the approximate normality of our regression coefficients. Although the quality of this approximation can only be assured by the Central Limit Theorem asymptotically, (i.e. for arbitrarily large sample sizes), we have followed standard practices to promote acceptably accurate approximations[39
]. In particular, our scoring of the response variable increased the symmetry of its distribution and we purposely restricted the categorical independent variables in our analyses to those with moderately large number of respondents in each category. A separate problem is that our dependent variable measured satisfaction and dissatisfaction along the same scale. It could be that satisfaction and dissatisfaction are different concepts and require different survey questions for measurement. Alternatively, if could be that this scaling masks the importance of independent variables that have strong but offsetting effects on both satisfaction and dissatisfaction
A final limitation involves some specialties with few incumbents. These include pediatric emergency medicine (n = 29), other medical subspecialties (n = 20), thoracic surgery (n = 21), critical care internal medicine (n = 29), hematology and oncology (n = 23), and neurological surgery (n = 24). Caution should be exercised when interpreting results for these specialties.
We are nevertheless confident in the overall results for several reasons. First, the CTS data are reliable, highly regarded, and used in numerous studies[15
]. Second, a number of specialties, e.g. pediatrics and obstetrics and gynecology, are well-known for their satisfaction and dissatisfaction and our results coincide with these widespread beliefs. Finally, results on many covariates (income, hours, managed care) are consistent with other studies inside and outside medicine[8