Physician Discontent: Title and subTitle BreakChallenges and Opportunities

Despite the substantial grumbling apparent among physicians, 8 of 10 physicians in national surveys report being satisfied overall with their careers in medicine.^{1 - 2} A closer look at changes in physician career satisfaction over the past 3 or 4 decades indicates more physicians qualifying their reports of satisfaction and a larger minority expressing some dissatisfaction than in earlier decades, but the magnitude of change hardly explains the anguish commonly expressed.^{3 - 4}

No comparable national data are available on other relevant professions because surveys use different questions and response categories, which can alter distributions. Surveys suggest, however, that nurses, dentists, and lawyers are no more satisfied, and perhaps are more dissatisfied, than physicians.^{5 - 7} Only two thirds of staff nurses in hospitals and two fifths in nursing homes report being satisfied.⁵ Physician satisfaction has been a source of special interest for decades perhaps because of the high status of the profession and the expense of training. Medical educators express more concern over attrition than do educators in other academic disciplines and many other professions where high attrition is the norm. There has been much commentary about physician discontent in the medical literature,^{8 - 10} in medical conferences concerned with this issue,¹¹ and in the media. Surveys, in contrast, continue to report relatively high satisfaction.

Like so much else, physician satisfaction depends on context, and aggregate summaries hide variability by geographic markets, practice environments, and specialty. An analysis of the proportion of physicians somewhat or very dissatisfied between 1997 and 2001 in 12 US markets revealed a range from 9% in Lansing, Mich, in 1999 to 34% in Miami, Fla, in 1997.² Important factors affecting such variations included perceived threats to autonomy and difficulties in managing patient interactions. Physicians in the specialties of otolaryngology, obstetrics-gynecology, ophthalmology, orthopedics, and internal medicine reported more dissatisfaction than those in other specialties in the 1996-1997 Tracking Physician Survey.¹²

Physicians remain privileged in many ways, not least in the respect that much of the public still has for them. But they must work in a health system that presents many uncertainties, a system in which large numbers of patients are uninsured or underinsured, public policies are complex and often contradictory, and financial, legal, organizational, and regulatory changes are common and often perplexing. The US health care system is a system in turmoil and many physicians believe that they no longer control their professional lives. This no doubt results in significant stress for physicians but it also presents opportunities. Adapting appropriately requires, first, a correct diagnosis of the problem.

Physicians' roles are defined by their own expectations and by those of their colleagues, health care managers, patients, and the general public. Earlier sociological studies of patients found low levels of knowledge, passiveness in seeking information, and high trust in physicians. In a 1957 study of ambulatory clinic patients, Pratt and colleagues¹³ found them to be poorly informed about their own illnesses and about 10 common diseases and noted that they showed little evidence of demanding information. By the mid-1980s, as many as two fifths of persons studied were behaving to some extent in a consumerist manner—seeking information, exercising some independent judgment, showing cost consciousness, and demonstrating a reasonable level of knowledge. Those who demonstrated a consumerist orientation were better educated and reported less faith in and dependence on physicians.¹⁴ Younger patients and those with chronic illness scored higher on this orientation. The most recent Community Tracking Study (2000-2001) found that 38% of those surveyed had "looked for or obtained information about a personal health concern" from a source other than their physician.¹⁵ Those with college education or higher were most likely to seek independent information and use the Internet.

Trends within medicine and medical care policy reinforce the idea that patients should be active partners in their treatment and exercise more control over their care. Applications of the idea of patient autonomy are reflected in the growth of report cards on the performance of health plans and hospitals, more stringent enforcement of ideas of consent and patient privacy, efforts to involve patients in treatment choices and decisions, increased attention to self-care and self-management of chronic disease, and efforts to enhance patient choice at the end of life. These trends are reinforced by the growth and increased advocacy of self-help organizations and disease advocacy groups. Many physicians welcome these and other changes in the provision of care, but they are probably most stressful for those well along in their careers who entered the profession and trained under different assumptions. Physicians in their late middle and older years are two thirds more likely to report being dissatisfied than physicians younger than 45 years.¹²

New challenges affecting professional work, the erosion of public trust, reduced respect for expert authority, and increased regulatory activity are now evident in all sectors. They also are apparent throughout the developed world,¹⁶ suggesting that some of the stresses experienced by physicians and other professional groups reflect a global economy, the influence of mass and instant communication, the accessibility of information, and the growing legal and ethical complexity of new organizational arrangements and public transactions. While physicians commonly attribute their discontent to managed care, the cultural, ideological, technological, and economic changes apparent in modern societies are increasingly challenging traditional assumptions of medical practice and require rethinking of practice approaches.

Time has always been a core element of effective relationships between physicians and patients. Over the decades, both have consistently reported a preference for more time for each encounter, and the amount of time reported for each patient has consistently been a strong predictor of physician satisfaction, especially for those providing primary care.³ Although physicians complain of having less time to spend with each patient, a problem commonly attributed to managed care, average visit time has increased over the decades for both health maintenance organization and fee-for-service practice, for primary and specialty care, for new and continuing patients, for problems of varying severity, and for both young and old patients.¹⁷ Although similar time complaints abound in general practice in the English National Health Service, average consultation time has continued to increase and objective analysis of workload cannot account for these complaints in either the United States or in England.^{17 - 19}

Six cultural values help explain growing health demands. People in the United States have much faith in the market, and its ascendancy in medicine has received much hype in recent years. This has sharpened the focus on consumerism and the demands that go with it. People in the United States also value individualism and think of their own needs and wants and those of their loved ones with limited focus on collective responses and social solidarity. They are active in seeking out the best that may be available, and they value and demand choice, a major source of the backlash against restrictive forms of managed care. Finally, they believe strongly in technological progress and aggressively seek out what seems new and better.

These widely held values affect patient behavior and may add stresses to patient-physician encounters. Choices and the complexity of communication about them increase with improved treatments for a range of conditions and a large number of competing treatment alternatives and products. For example, while the advertising of prescription drugs directly to consumers comprises only a small proportion of promotional efforts, it is nevertheless an increasing trend²⁰ and contributes significantly to growth in pharmaceutical spending.²¹ The social value of such advertising is hotly debated but, regardless, it adds to the informational demands on physicians. A survey from the Kaiser Family Foundation of a national sample of adults found that 30% of respondents reported talking to a physician about a prescription medicine as a result of seeing an advertisement²² and that 44% received the requested drug. Physicians responded to such requests in a variety of ways that inevitably increased the time required during the consultation. Similarly, in a national survey of physicians in 2001, respondents reported that 63% of their patients talked to them very often or somewhat often about specific diseases or treatments that they had heard about from advertisements for prescription drugs, and similar reports were made about information patients obtained from the Internet.²³ Physicians reported that the general media and friends and family had an even larger influence on patients.²³

Patients are now more educated than ever, more active and consumer oriented,²⁴ more likely to seek information from sources other than the physician, and more likely to exercise independent judgment.^{14 ,24} Some are attentive to treatment possibilities that have not yet reached a stage of mature development, and increased media attention to medical research reinforces these inclinations. Thus the typical patient today has more information but also may be more confused by conflicting expert opinions and recommendations. Physicians have more to explain and face pressures to prescribe treatments they may not prefer.

The physicians' role is further complicated by continuing expansion of expectations, guidelines, and recommendations from varying professional societies and specialty groups, health plans, and advocacy organizations. Many of these recommendations are valuable, but their cumulative effect makes unrealistic demands. The list extending beyond more traditional care is extensive, from preventive concerns (obesity, nutrition, exercise, substance abuse, safe sex, etc) to recognition and treatment of psychiatric illnesses and risks. As new issues come to public awareness, such as child and spouse abuse, disparities in care, and the need for cultural competence, these areas also become new sources of expectations. Even achieving the most routine and accepted care expectations, such as immunization, prescription of β-blockers after myocardial infarction, and eye examinations for patients with diabetes, has been challenging. The recent estimate of 7.4 hours per working day required for primary care physicians to provide all services recommended by the US Preventive Services Task Force may be exaggerated, but it conveys the gap between expectations and reality.²⁵

Underlying many care recommendations is the need to improve communication and the instructional process. Physicians are now taught the importance of involving patients in decision making. Doing this successfully requires at least 20 minutes.²⁶ Even physicians who internalize many of these new expectations and understand their importance often are at a loss to know realistically how to incorporate them into their practice. Organizations establishing recommendations and guidelines rarely consider the true time demands or how realistically their recommendations can be implemented.²⁵ A quarter of primary care physicians report that the expected scope of their practices is greater than it should be.²⁷

A number of regulatory factors also affect how physicians perceive their workload relative to the time available for each visit. Physicians increasingly understand the need for a more evidence-based approach, and health plans increasingly demand it. Two thirds to three quarters of physicians affected by management tools and patient satisfaction surveys reported the positive impact of these innovations on the quality and efficiency of their practice.²⁸ Physicians, however, may deal with different health plans with varying practice guidelines, disease management approaches, profiling practices, data systems, and reporting requirements. Although there is no evidence that the physician's overall administrative time has increased,^{17 - 19} the frustration from such external relations probably plays some role in perceived burden.

Sense of control over their own practice is a key intervening factor in how physicians view their changing environment. Williams and colleagues,²⁹ in analyzing responses from a national sample of more than 1400 primary care physicians, found that control over workplace issues was especially important in physicians' reports of job satisfaction and the extent of stress. A prospective analysis of young physicians first surveyed in 1991 and reinterviewed again in 1997 found that managed care reduced physicians' perceptions of their professional autonomy and that both perceived autonomy and income were independently associated with satisfaction.³⁰ Williams et al²⁹ found that those most valuing clinical autonomy had the lowest job satisfaction. Nevertheless, 86% of physicians interviewed in the Community Tracking Study in 2000-2001 agreed that they had the freedom to make clinical decisions that met their patients' needs, and 53% agreed strongly.³¹ These data suggest that there is little danger of significant loss of required clinical autonomy for most physicians. However, the 16% of physicians who perceived an overall financial incentive to reduce services to individual patients, an incentive linked to capitation and risk of deselection as a preferred provider, were more dissatisfied.³⁰

Studies of physician autonomy have been narrowly conceptualized. Perhaps more important from a historical perspective is the extent to which individual physicians and the profession as a whole have lost some control over the conditions of their work as government, corporations, other professions, managers, and even patients have gained greater influence.^{32 - 34} We remain in this transitional period, but return to the types of practice autonomy expressed in the nostalgic recollections of many older physicians is unlikely. Nevertheless, there are alternative futures and physicians can do a great deal to shape them.

Medicine has traditionally attracted talented young people who were individualistic and who greatly valued their independence. The traditional ideal of the majority of young physicians was to establish their own practices after a few years of experience, but this is decreasing. Traditional orientations spurred an entrepreneurial spirit and were a good fit for office-based fee-for-service practice organized by solo physicians and small groups. Medical care has increasingly become an activity dependent on team collaboration and well-organized systems of care. Many current deficiencies of medicine relate to poorly designed systems and inadequate communication and coordination.³⁵ More than ever, medicine needs physicians who can collaborate well with each other and with other professionals. It remains uncertain how best to attract such persons to medicine or how best to train medical students so they work effectively in teams.

Physician frustration about sufficient time for each patient must be understood in the context of the demands that can become evident within a patient encounter. While physicians may be spending as much or more time with each patient, they may increasingly fall behind in terms of meeting patient expectations and their own goals. Some adapt by implementing shortcuts, by ordering tests, or by extending the encounter through return visits. A small number may organize "boutique" practices for a limited list of patients who provide subsidy for the practice. Still others locate practice niches where they can be protected from unremitting demand. These may be stopgap solutions for some physicians under stress. They are not viable or desirable solutions for the future of medical care.

Chronic illness is treated inadequately. Bodenheimer and colleagues³⁶ identify 6 elements of needed change, including linkage with community-based resources, priority on chronic care and organizational arrangements and incentives to support it, support for patient self-management, an appropriate design of practice teams to provide chronic care, evidence-based decision support, and computerized clinical information systems. Some of these elements have been studied in a variety of ways over many years in particular practice situations with promising indications that they can improve quality. In many instances team treatment of patients with such common chronic diseases as diabetes, depression, congestive heart failure, and asthma with an organized evidence-based approach has been found to improve quality.^{37 - 38} However, it has been difficult to systematically demonstrate cost savings and to make the business case for broad changes. Nevertheless, many large health plans are implementing and assessing these approaches.

Initiatives to reduce the burden of practice among primary care physicians by increasing the use and scope of practice of nonphysican clincians have been studied for decades.^{39 - 40} An experimental study of pediatric nurse practitioners in 1967 demonstrated their value in managing chronic disease in children and in acceptability and satisfaction.⁴¹ Subsequently, many studies have been done and as one knowledgeable observer noted, "No professional role has been more thoroughly discussed, described, studied, and reported."³⁹ Randomized trials in major medical journals continue to report that nurse practitioners can provide care and management of chronic disease comparable to that provided by physicians in primary care.^{42 - 43} This seems to be accepted by large health plans and group practices that make good use of such professionals.

The rapid advance of information technology provides potential to avoid errors, use time efficiently, and enhance quality.⁴⁴ New approaches to mining administrative data to identify patients appropriate for disease management facilitates effective use of resources. Projects demonstrating improvements in quality of care for chronic illness are proceeding in large health care systems,³⁷ and increasing evidence exists for the value of focusing such efforts on patients at risk of disease exacerbation and disability.^{36 - 37} The new technology also provides sophisticated systems of guidance, alerts, and reminders that can reduce medical error.⁴⁴ Furthermore, the opportunities to communicate with patients via e-mail, to develop personalized Web sites that provide additional reliable health information and instruction, and to direct patients to useful links and support groups relevant to their needs make the expansion of practice scope more viable.¹⁹ A number of vendors now offer sophisticated assistance to health plans and medical groups for implementation.⁴⁵ Still other ideas, such as group visits for patients under chronic care, are being tried with reports of good results but they need more appraisal. A recent field study of drop-in group medical appointments found that, while participants believed such visits contributed to psychosocial care, the approach did not attract sufficient patient participation and could not demonstrate financial viability in a noncapitated practice environment.⁴⁶

The failures of medical care in the United States have not been due to lack of innovation. The challenge is implementation and overcoming resistance to change. It is ironic that computerization of general practice patient records is almost universal in England despite its limited resource base,⁴⁷ while computerization of primary care records in the United States has been slow and difficult to achieve. New and sophisticated uses of information technology are no panacea and must be implemented within careful guidelines and controls, but when done well they can help maintain the structure of the practice's organizational system, close communication gaps, help maintain a sound evidence base, and help understand the epidemiology of one's own practice. Concerns about remuneration, such as might arise when e-mail is used to correspond with patients, are among the barriers to expansions of information technology.

A preliminary report of the Relay Health WebVisit study⁴⁸ suggests the potential of such expansion. Working with various health plans and 10 self-insured employers, the project reimbursed participating physicians $25 for each Web visit with patient co-payments varying from $0 to $10. A study of claims filed between June 2000 and February 2002 found a reduction in cost compared with matched controls, as well as high patient and physician satisfaction; furthermore, e-mail was found to be a preferred approach for nonurgent visits by both physicians and patients. A study of patients reported less work absenteeism due to illness and fewer visits and telephone calls to physicians. This is still an early development that requires more study, but should these results be sustained it opens new possibilities.

Many physicians and medical leaders are distressed about various aspects of contemporary medical care, including disparities in access and quality, fairness of remuneration, perceived erosions of autonomy, ethical challenges, public criticism of the profession, and a sense that public trust is being lost.⁴⁹ The context of medical practice, including rapid changes in discovery and technology, media attention, financial and legal complexities, and the increased role of private managers and government, challenges the traditional paradigm. Nevertheless, physicians as clinicians retain much trust and loyalty from their patients, which can be a sound foundation for developing new understandings and partnerships.

Some medical organizations see the need for reasserting medical professionalism, and in 2002 a number of medical organizations around the world simultaneously published a charter on medical professionalism⁵⁰ enunciating as fundamental principles the primacy of patients' welfare, patients' autonomy, and social justice followed by a statement of 9 professional responsibilities such as competence, honesty, confidentiality, and improving quality of care. The statement includes important common values and concerns, but one can reasonably be skeptical of its generality and the conflicts it embodies. As with much in life the devil is in the details.

It is useful to restate the governing values of the profession and to maintain their visibility, but the solutions to the types of problems discussed here will have to be solved closer to the level of service. Such efforts must take place under conditions in which practitioners lack the desired control over practice, and solutions have to be iterative and responsive to changing conditions. Two widely disseminated Institute of Medicine reports^{35 ,51} have initiated a useful discussion of promoting quality and have engaged many physicians, managers, and policy makers in the private and public sectors. Documenting deficiencies in acute, chronic, and preventive care and preventable errors^{51 - 52} has not achieved the "tipping point" that advocates hope for, and some have responded with frustration.⁵³ Nevertheless, there is increasing understanding that quality of care is embodied in systems as well as in the efforts of conscientious and well-motivated individuals and that improving quality is a collective challenge requiring collaboration.

Significant impediments to improving quality and to designing effective and efficient patterns of care exist, even when physicians and managers work collectively to reduce errors. Financial incentives often distort practice and divert physicians from important safety and disease-management objectives.⁵⁴ Nevertheless, physicians have welcomed the emergence of care management tools and incentives that reward quality²⁸ ; medical leadership can help encourage this development and promote diffusion of these valuable tools.

Given the many interests in the practice of medicine it is not surprising that managers make efforts to maintain their positions as financial, regulatory, and other changes occur. Normative statements abound about our health care system and how physicians should practice, but no convincing roadmap exists for achieving these aspirations in our pluralistic political system. Many professionals of good will and a range of medical and other health-related organizations are struggling to identify areas of consensus and useful initiatives, but clinicians and their organizations also are defensive and fear losing ground on what has been a rapidly shifting terrain.

The proliferation of information and adequate knowledge of all new technologies is beyond the capacities of most individual clinicians, and there are many commercial and patient pressures to adopt unproven interventions. Most agree that the large and confusing array of new management and informational tools—some developed to advance the interests of pharmaceutical companies, manufacturers of medical products, subspecialty groups, and advocacy organizations—need validation, refinement, and simplification. The very significant competing interests call for a respected adjudicator who can convene participants from both the private and the public sectors and work toward a consensus based on the best evidence. Given the stakes involved, this is an extraordinarily challenging assignment requiring much trust. The appropriate venues are likely to be contested. Organizations such as the Institute of Medicine might provide the needed credibility, or new structures tailored more specifically to the purposes at hand may be needed.

The proliferation of efforts to improve safety, enhance quality, and reduce disparities contributes to the sense of overload experienced by many physicians. With good leadership and a clear sense of direction, the uncertainty that now prevails can lead to informational systems and organizational collaborations that empower physicians, provide them with extraordinary access to expanded knowledge and expert systems, and relieve some of their burdens. Realizing this potential will require sacrifice of some of the traditional independence and personal autonomy that physicians so much value.

These tensions and potentials occur in an imperfect—many would say dysfunctional—context. The public wishes to have perfection in physician practice in a health system that has gross failures, substantial inequities, bureaucratic impediments, and distorted and conflicting incentives. Aspirations such as optimizing technical proficiency while enhancing humane care, developing effective partnerships with patients, maintaining continuity and effective coordination of care, and seriously addressing the expanded expectations of medical practice may seem utopian in this context. Good organizational strategies reinforced by strong professional leadership can help medicine advance from rhetoric to reality.