In less than nine months millions of Americans will receive new health care coverage through provisions of the Affordable Care Act. Most observers believe that strong physician leadership can help heath care reform succeed, through the optimization of care quality and cost management. But, at the same time, too many American physicians are dissatisfied with current medical practice and unsure of what to do about it. Many would not recommend a career as a physician to their own children.
There are multiple causes for this dissatisfaction where it exists, including unpredictable reimbursement for services, excessive work burden and long hours, and excessive time devoted to non-clinical activities, including “paperwork”.
One possible reaction to physician dissatisfaction is a shrug of one’s shoulders. Most physicians are well paid, compared to most Americans, and are highly respected. We suggest, however, that improving physician practice satisfaction should be important for both patients and policymakers.
The Impact of Physician Dissatisfaction
As the country adapts to the opportunities accelerated by the Affordable Care Act, physician dissatisfaction threatens the success of care delivery and payment reforms. The Commonwealth Fund Commission on a High Performance Health System recently listed ten strategies to improve health care services and save $2 trillion over the next decade. At least seven of these strategies will require the close involvement of practicing physicians in order to succeed.
In addition to the ultimate success of needed delivery system changes, such as major improvements in care coordination and affordability, there are other reasons to improve physician satisfaction with their work. There is very little research on the relationship between physician satisfaction, the quality and cost of care, and patient experience. The limited research that does exist suggests that physician satisfaction is important for patients, not just for physicians.
Patients whose physicians report greater practice satisfaction report significantly greater satisfaction with their care. The Rand Medical Outcomes Study demonstrated a significant positive correlation between physician satisfaction and patient adherence to physician care recommendations among patients with major chronic conditions. The Community Tracking Study survey of over 16,000 practicing U.S physicians found that dissatisfied physicians were 2-3 times more likely to leave medical practice than their more satisfied colleagues. This is not what we need in the face of newly insured patients seeking care services after January 1, 2014.
Increasing Physician Satisfaction
Improving physician satisfaction with medical practice will require efforts from government, payers, and hospitals, in addition to physicians and physician organizations. This work should focus on two specific goals: first, increasing physicians’ sense of influence over their practice environment, so that physicians feel that they are able to “do right” by each of their patients; second, establishing reasonable financial stability for medical practice, while aligning physicians’ financial incentives more closely with broader societal goals.
Physicians’ sense of influence. Physicians who feel at the end of each working day that they have been able to deliver the quantity and quality of care that their patients’ require, are likely to be satisfied with their practice. Elements that interfere with that self-assessment can be either intrinsic or extrinsic to the practice. Major intrinsic elements include: too busy a schedule to allow for adequate patient care; inadequate or inefficient staff and technology support; administrative “paperwork” and other non-patient care activities that interfere with physician-patient contact; and lack of input into key decisions involving the practice.
Experience with practice redesign strategies in systems such as Kaiser Permanente, ThedaCare in Wisconsin and the Mount Auburn IPA in Massachusetts suggests that significant improvements in practice efficiency are possible through thoughtful use of technology and the better use of support personnel to relieve physicians of unproductive work. To accomplish these changes many physicians will need external expertise and support. Efficiency can be increased further if payment incentives foster the use of communications technologies in delivering care, such as substitution of phone and e-mail visits for some office visits and the use of email- or video-based physician-patient communication.
Experience in these and other organizations suggests that physicians are more satisfied if they have a sense of influence within the practice, whatever its size, input into key decisions, and the belief that they are working with their fellow physicians to improve the quality of care.
Two important extrinsic factors affecting physician satisfaction are interactions with public and private payers and physician-hospital relationships. Public/private payer standardization of formulary processes, prior authorization procedures, payment methodologies, and quality reporting requirements would have a significant positive impact on practice efficiency and physician satisfaction.
The current increase in physician practice acquisition by hospitals may call into question the future adequacy of the traditional hospital-organized medical staff management model. New models of co-management between hospitals and physician partner organizations, through which a practicing physician has a more expansive role in the policies and management of the institution, are needed not just to improve employed physician satisfaction but to foster an institutional culture that promotes common success.
Financial stability. “Reasonable financial stability” for medical practice is of course quite subjective, but there are at least two points to consider. First, there must be a reasonable expectation that young physicians can pay off the costs of medical education in a reasonable time, ideally without having to choose a specialty based on income rather than interest; and second, physicians must have the capital available to pay for improvements in practice, such as electronic medical records and modern practice management systems. Financial concerns are leading to undesirable consequences, including physicians avoiding less remunerative specialties such as internal medicine and family practice; the “squeezing out” of lower income applicants to medical schools; and regional shortages of physicians based upon the wealth or lack thereof of the community served. Serious efforts must be made to try to reduce the cost of medical education.
Secondly, efforts directed at physician payment reform, involving both public and private payers, must be ramped up dramatically. It seems unlikely for the foreseeable future that unit payment rates for physician services will increase much beyond the annual change in per capita GDP. However, there is a clear opportunity for physicians to stabilize and even improve income stability by participation in new payment mechanisms designed to involve physicians in the management of the total cost of care for patients, and to share in the success of doing so. Achieving this goal will be easier for most physicians if they band together to create the needed infrastructure for managing total health care costs. There are many such practice models, including models that incorporate and foster small practices.
A half-century ago, Kenneth Arrow, the Nobel Prize winning economist, and Talcott Parsons, a leading sociologist, independently developed arguments that physician professionalism is vital to patients and to society. Professionalism means many things, but above all, they argued, it means putting the patient first. We believe that satisfaction with medical practice enhances the physician-patient bond. Taking physician satisfaction seriously does not mean giving physicians anything they want. But it should mean creating an environment where physicians are always able to put patients first. More research is needed to understand the most effective interventions to create that environment.