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Worklife and Satisfaction of General Internists
Tosha B. Wetterneck, MD;
Mark Linzer, MD;
Julia E. McMurray, MD;
Jeffrey Douglas, PhD;
Mark D. Schwartz, MD;
JudyAnn Bigby, MD;
Martha S. Gerrity, MD;
Donald E. Pathman, MD, MPH;
David Karlson, PhD;
Elnora Rhodes;
for the Society of General Internal Medicine Career Satisfaction Study
Group
Arch Intern Med. 2002;162:649-656.
ABSTRACT
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Background Prior studies have reported relatively low job satisfaction for general
internists. We used data from a large US physician survey to assess correlates
of satisfaction of general internists.
Methods The Physician Worklife Survey was mailed to a national random stratified
sample of 5704 US physicians. General internists were assessed for their satisfaction,
training, patient mix, work hours, the likelihood of recommending their specialty
to medical students, and job stability. We then compared them with a specialist
sample (internal medicine subspecialists [IMSSs]) and a primary care sample
(family physicians [FPs]). Logistic regression was used to model predictors
of satisfaction, stress, and medical student recruitment.
Results There were 2326 respondents (adjusted response rate, 52%): 450 (19%)
were general internists; 502 (22%), FPs; and 438 (19%), IMSSs. General internists
were less satisfied than were IMSSs with their relationships with colleagues
and with patient care issues (P<.01 for both)
and less satisfied than were FPs with community ties (P = .001). Global job, career, and specialty satisfaction were significantly
lower for general internists vs FPs and IMSSs (P<.05).
General internists spent proportionately more of their work week in the hospital
than did FPs (20% vs 13%; P<.001) and more time
providing outpatient care than did IMSSs (56% vs 42%; P<.001). General internists had more patients with complex medical
and psychosocial problems than did FPs (P<.01)
but fewer patients with complex medical problems than did IMSSs (P<.001). Higher satisfaction for general internists was associated
with older physician age, less time pressure during office visits, fewer work
hours, and fewer patients with complex psychosocial problems (P<.05 for all). General internists were less likely than were FPs
to recommend their specialty to medical students (P<.001).
Specialty satisfaction, female gender, and control of hassles predicted medical
student recruitment by general internists.
Conclusions General internists' role of caring for patients with complex problems
is associated with lower levels of satisfaction than for IMSSs and FPs. Adjusting
caseload for patient complexity, expanding time for office visits, and additional
training in the care of patients with psychosocially complex problems may
improve the job satisfaction of general internists and medical student recruitment
into the specialty.
INTRODUCTION
GENERAL INTERNISTS provide a large proportion of adult primary care
in the United States; therefore, the future of this specialty is vital to
the US health care system. Yet, job dissatisfaction among general internists
is prevalent.1-3
Prior studies2, 4-7
have revealed that general internists remain satisfied with their patient
and colleague relationships and the intellectual challenge of the profession.
However, they are dissatisfied with their income and the lack of control over
their practices, with more time spent on administrative and business aspects
and less time available to see patients.2, 4-7
A lack of general internist enthusiasm for their specialty and primary care
has also been documented.2-3,8
A national study2 of generalist and subspecialist
internists revealed that 40% would, if given the choice, select a career other
than internal medicine and 40% discouraged medical students from entering
their specialty. Zinn and colleagues8 found
similar career satisfaction between academic general internists and family
physicians (FPs). However, general internists were much less likely to encourage
medical students to enter primary care than were FPs (36% vs 86%), an action
known to affect student career choices.9
The advent of managed care brought irrevocable changes to the practice
of medicine, with a subsequent focus on physician satisfaction. Physician
satisfaction is an important determinant of patient adherence,10
patient satisfaction,11 and physician turnover.12 Meanwhile, the number of students choosing careers
in internal medicine has declined, with a corresponding increase in numbers
choosing internal medicine subspecialization and family practice. Many researchers
and the American College of Physicians–American Society of Internal
Medicine have called for a reaffirmation13
and a redefining of general internal medicine (GIM).14-15
Previous data published from the Physician Worklife Study (PWS) have
identified GIM as a specialty at risk. General internists had lower levels
of satisfaction and higher numbers of patients with complex psychosocial and
medical problems than did FPs and less time allotted for new patient and follow-up
appointments than did internal medicine subspecialists (IMSSs).16
To our knowledge, there are no other large, recent, national studies assessing
the satisfaction levels of general internists and worklife characteristics
associated with satisfaction. We, thus, performed this detailed analysis of
responses from the PWS to assess the satisfaction of general internists and
to compare their satisfaction with that of IMSSs and FPs. We also sought to
identify potentially modifiable factors negatively affecting the satisfaction
and work life of general internists.
PARTICIPANTS AND METHODS
The development of the survey instrument, satisfaction facets, and global
measures have been described elsewhere.17-20
The Physician Worklife Survey is an 8-page 150-item mail survey that measures
physician practice characteristics and aspects and outcomes of job satisfaction.
The conceptual development of the satisfaction facets and global measures
included using items from existing satisfaction measurement instruments (mainly
the work of Stamps and Cruz21 and Lichtenstein22), 6 physician focus groups, and a content analysis
of physician open-ended data from a survey of large group practices.23 An item pool was constructed and subjected to expert
panel review for refinement. This measure was tested on a pilot group of 2000
physicians obtained from the American Medical Association's Masterfile (n
= 835; adjusted response rate, 55%). A 36-item 10-facet satisfaction measure
resulted after factor and reliability analysis. Reliabilities of the 10 facets
of satisfaction ranged from 0.65 to 0.77, and the global satisfaction measure
reliabilities ranged from 0.84 to 0.88. The satisfaction and global measures
are composed of 2 to 5 individual items each and are measured on 5-point Likert
scales. A modified global specialty satisfaction variable composed of 2 of
the 3 original items was used in a regression analysis of factors predicting
recommendation of specialty for general internists and had a reliability of
0.72. The facets include satisfaction with autonomy; relationships with patients,
relationships with colleagues, relationships with staff; patient care issues;
personal time; community; income; administration; and resources. Global satisfaction
measures evaluated job, career, and specialty satisfaction. The 10 facets
of satisfaction accounted for 58% of the variance seen in global job satisfaction.
A complete listing of the individual items and associated facets is included
in a prior publication from the PWS.16
The American Medical Association's Masterfile was then used to select
a national sample of physicians in primary care (family medicine, GIM, and
pediatrics) and subspecialties of internal medicine and pediatrics (n = 5704)
after stratification by race, ethnicity, practice specialty, and 2 levels
of regional participation in managed care (high and low). Four survey mailings
were sent in 1996 to 1997 with cover letters from investigators and local
and specialty medicine societies. Two hundred nonresponders were telephoned,
revealing an 18% inaccurate address rate. Sampling weights were constructed
from this information using the Lessler and Kalsbeek24
technique. Nonresponse bias was assessed, looking for trends between survey
instrument variables and return time of the survey, calculating Spearman rank
correlation coefficients. Few meaningful associations were found (only 4 of
140 variables with r>0.1).
All data analyses were weighted to adjust for response rates and sampling
probabilities using a software package (STATA, version 5.0; Stata Corp, College
Station, Tex). This adjusts for sampling design by using Taylor series linearization.
In all analyses involving the 3 specialties in which pairwise differences
in means or proportions were considered, P values
are given after adjusting for multiple comparisons. This was done by finding
the distribution of the maximum absolute test statistic for the 3 pairwise
comparisons under the null hypothesis of no differences and comparing the t statistics for the individual hypothesis tests with the
percentiles of this distribution.
Mean differences between specialties were examined for the 10 facets
of satisfaction, 3 areas of global satisfaction, and intermediate outcomes
of job stability, stress, burnout, and specialty recommendation to medical
students. Burnout was assessed with a single-item measure of the degree of
burnout. Job stability was assessed by asking intention to leave the job or
practice of medicine. For general internists, satisfaction and recommendation
analyses were also performed comparing gender and age groups (<45 years
and  45 years). Mean differences between specialties were evaluated for
clinical training, patient case mix, work hours, and percentage of time spent
in different activities. Time pressure was a variable representing respondents'
needing more time in an office visit than allotted. Worklife control was measured
with 13 single-item questions asking about control over multiple work-related
issues. Factor analysis determined 3 work control factors: control of workplace,
medical decisions, and hassles. Health maintenance organization physicians
were defined as those practicing in staff- or group-model health maintenance
organizations with greater than 50% capitation or managed care patients. Full-time
physicians were defined as those practicing more than 40 hours per week. Logistic
regression analyses were used to model predictors of general internist satisfaction
for the facets and global scales, controlling for age, gender, health maintenance
organization practice setting, percentage of patients with complex psychosocial
problems, income, work hours, and the time pressure factor. Logistic regression
was also used to model predictors of general internists' desire to recommend
their specialty to medical students, controlling for global specialty satisfaction,
age, gender, and variables specifying control of medical decision making,
hassles, and workplace control.25
RESULTS
DEMOGRAPHICS
After accounting for inaccurate addresses, ineligible physicians, and
returned envelopes, the adjusted response rate was 52% (n = 2326). Adjusted
response rates by specialty were 45% for general internists, 52% for FPs,
and 48% for IMSSs (pediatricians had substantially higher return rates). Of
the 2326 respondents, 19% were general internists; 22%, FPs; and 19%, IMSSs
(Table 1). Respondents were mostly
men, white, and married; their average age was 47 years. There were few differences
in demographics or practice settings (Table
1).
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Table 1. Demographic Characteristics of Sample Physician Respondents
From the Physician Worklife Study*
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SATISFACTION
For the 10 satisfaction facets, general internists were most satisfied
with relationships with patients and least satisfied with income, personal
time, and administrative duties (Table 2). When compared with other specialties, general internists were
less satisfied than were IMSSs in their relationships with colleagues and
in patient care issues (P<.01 for both) and less
satisfied than were FPs with community ties and income (P = .001 and P<.05, respectively). For
global satisfaction measurements, general internists were the least satisfied
with their job, career, and specialty (Table 2). Most of these differences in the global satisfaction measures
(0.2-0.5 on a 5-point Likert scale) were believed to be clinically and statistically
meaningful. There were no gender differences in global satisfaction for general
internists. However, analysis by gender and age showed that older male general
internists were more satisfied than younger male general internists with their
jobs and career (Table 3). Interestingly,
the opposite was seen for women: younger female general internists were more
satisfied with their jobs than older female general internists.
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Table 2. General Internist Satisfaction Compared With That of FPs and
IMSSs*
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Table 3. General Internists' Global Satisfaction and Recommendation
of Their Specialty by Sex and Age*
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PHYSICIAN AND PRACTICE CHARACTERISTICS
General internists reported significantly less training in primary care,
psychosocial care, and practice management than did FPs (P<.001 for all) (Table 4).
Exposure to utilization review and managed care training was minimal for all
3 specialties. Remarkably, general internists reported significantly (P = .001) less training in psychosocial care than did IMSSs.
An analysis of case mix by specialty (Table
5) showed that general internists reported that 46% of their patients
were elderly persons, nearly double that reported by FPs. General internists
also reported significantly more patients with medically and psychosocially
complex problems than FPs. For general internists working full time, just
more than half of their time (56%) was spent in outpatient practice, 20% in
hospital care of patients, and 25% on patient and other work-related activities
(percentages do not total 100 because of rounding) (Table 5). General internists spent proportionately more time in
the hospital than did FPs and more time in the office than did IMSSs (P<.001 for both).
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Table 4. Clinical Training of General Internists, FPs, and IMSSs in
the Physician Worklife Study*
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Table 5. Practice Characteristics of General Internists, FPs, and IMSSs*
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MULTIVARIATE REGRESSION ANALYSIS FOR CORRELATES OF SATISFACTION IN
GIM
After controlling for age, gender, practice setting, work hours, income,
time pressure, and percentage of patients with complex psychosocial problems,
older general internists were more likely to be satisfied than were younger
general internists in 7 of 10 facets of satisfaction and 2 global satisfaction
scales (Table 6). Women had higher
job and career satisfaction compared with men. More weekly work hours were
associated with decreased satisfaction in multiple areas, including autonomy,
relationships with patients, patient care issues, personal time, and administrative
duties. Increased time pressure during office visits was associated with decreased
satisfaction in many areas, including autonomy, patient care, and global job
satisfaction. More weekly work hours were also associated with increased stress
levels among general internists. Interestingly, stress also increased for
general internists who had more patients with psychosocially complex problems.
A separate regression analysis found no relation between the 5 training areas
and the facets of satisfaction or global satisfaction (data not shown).
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Table 6. Regression Analysis of General Internists' Satisfaction and
Stress*
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JOB STABILITY MEASURES AND RECOMMENDATION OF THE SPECIALTY
Despite the lower satisfaction among general internists, there were
no differences between the 3 specialties in stress, burnout, or intent to
leave the job (data not shown). However, general internists were substantially
less likely to recommend their specialty as a career to students compared
with FPs (3.26 vs 3.85 on a 5-point Likert scale; P<.001).
Women general internists were more likely to recommend their specialty than
were men (Table 3), with younger
women internists the most likely to recommend the specialty. Regression analysis
of factors predicting recommendation of specialty for general internists revealed
that global specialty satisfaction ( = .84, P<.001),
female gender ( = .26, P=.01), and control
of hassles ( = .13, P=.04) were significant
predictors and explained 70% of the variance.
COMMENT
In this sample of 1390 physicians from the PWS, we have shown that general
internists are less satisfied with their jobs, careers, and specialty than
are FPs and IMSSs. General internists are also less satisfied with their relationships
with colleagues and with patient care issues than are IMSSs and less satisfied
with community ties than are FPs. We found that general internists have less
training in primary care, psychosocial care, and managed care and that they
have more patients with psychosocially complex problems (which were also a
source of increasing job stress) and more patients with medically complex
problems than FPs. More than half of a general internist's 59-hour work week
is spent in outpatient care, while 20% is spent in the hospital. General internists'
satisfaction was associated with older age, female gender, fewer weekly work
hours, and less time pressure during office visits. While general internists
were substantially less likely than FPs to recommend their specialty to medical
students, young women in GIM displayed higher enthusiasm for recommending
the specialty than other general internists.
SATISFACTION
Our results show that general internists' satisfaction continues to
be of concern. Our findings of specific areas of satisfaction and dissatisfaction
are consistent with and amplify those of prior studies.2, 6
Lower satisfaction with relationships with colleagues and patient care issues
than IMSSs is a new finding and may reflect dissatisfaction with "second-class
citizenship" compared with procedurally oriented colleagues and the increasing
challenges of the gatekeeper role found by Wahls et al.6
Factors addressed in the patient care issue questions included the gatekeeper
role (which may increase adversarial relationships with physicians) and increasing
time pressure (which may overwhelm primary care physicians). In this regard,
FPs had comparable low levels of satisfaction with patient care issues. General
internists in our study were somewhat less satisfied with income than were
FPs. Because income has been shown to be important to medical students who
do not choose GIM but less so for those who enter,9, 26
fair compensation across the specialties may increase general internist satisfaction
and attractiveness.
TRAINING
The Robert Wood Johnson Foundation's Survey of Young Physicians in 199127 found low levels of training in the business aspects
of medicine. However, those trained in family medicine reported better preparedness
over internal medicine–trained physicians in preventive care, psychosocial
care, and practice management. Merkel et al28
surveyed internal medicine residency programs in 1985; less than half had
mandatory training in psychosocial care. Our findings confirm low levels of
training among the specialties in the business aspects of medicine and show
that general internists have less training in primary care and psychosocial
care than do FPs. Training did not relate to satisfaction, although this lack
of association may be due to the consistently low degree of preparedness in
these areas.
CASE MIX
Case mix has become an area of increasing interest, especially considering
the relationship between time allotted for appointments and physician job
satisfaction.16 Our study reinforces the findings
of Kravitz et al,29 with general internists
reporting twice as many elderly patients and patients with complex medical
problems than FPs. In addition, we found that general internists have more
patients with complex psychosocial problems than FPs. Zinn et al8
found that academic general internists experienced less satisfaction from
taking care of patients with psychosocially complex problems than did FPs.
Our study showed low levels of general internist training in psychosocial
aspects of care and general internists had an association between patients
with complex psychosocial problems and decreased resource satisfaction and
higher stress. This suggests an important but remediable deficiency in internal
medicine residency program training.
WORK HOURS AND LOCATION
More work hours per week for general internists were associated with
less satisfaction with autonomy, patient care, administration, and personal
time and with higher stress levels. Full-time general internists in our study
worked 59-hour work weeks and spent proportionately more hours per week in
the hospital than did FPs, attesting to the role of general internists in
dealing with patients with complex medical problems. This difference becomes
important given the evolution of the hospitalist movement in internal medicine.30 The full impact of this new field on the practice
of GIM is not yet known.31 Designated hospitalists
incorporated into a group practice's call schedule may better define inpatient
and outpatient roles, decrease work hours, and increase personal time and
satisfaction.
TIME PRESSURE
For general internists, time pressure during office visits was related
to lower satisfaction with autonomy and patient care and to lower global job
satisfaction. A previous study16 from the PWS
showed that IMSSs reported having more time for new consultations and physical
examinations (51 minutes) than did general internists (39 minutes) and FPs
(34 minutes). Discrepancies in visit length between general internists and
FPs may be explained by differences in case mix, because general internists
have more elderly patients and patients with complex problems. However, when
compared with IMSSs, generalists typically need to provide routine preventive
care and screening and coordinate all of a patient's medical issues in 39
minutes, while IMSSs often focus on problems within one organ system and are
allotted 51 minutes. Research has shown that time pressure may also have an
adverse effect on patients because the physician has less time to address
psychosocial concerns32 and alcohol use,33 and this may lead to inappropriate34
or increased35 medication prescribing. Generalist
satisfaction may increase in systems that take into account case mix and perceived
time pressure when creating physician schedules and panel size.
RECOMMENDING ONE'S CAREER TO MEDICAL STUDENTS AND JOB STABILITY
The future of GIM relies on medical students choosing this specialty
as a career. It is, therefore, disturbing that general internists reported
lower rates of encouraging students to select their specialty than did FPs,
confirming and expanding on an earlier study8
of academic general internists and FPs. We did find that young women general
internists were the most enthusiastic about recommending GIM as a career and
that satisfaction with internal medicine and female gender predicted general
internists' recommendation of their specialty. Our findings will hopefully
trigger additional research to detect why general internists are dissatisfied
and not recruiting medical students.
GENERATIONAL AND GENDER ISSUES
The higher satisfaction levels of older general internists in our study
echoes previous research. Haas et al,1 in a
study of academically affiliated general internists in Boston, found that
younger physicians (those aged <50 years) had lower overall satisfaction
than did older physicians. This may represent selection bias because unhappy
internists may have left the specialty or practice of medicine, leaving mainly
satisfied physicians. We found a potential gender difference in older general
internist satisfaction, however, with older women having lower global job
satisfaction than younger women. Our overall finding, then, of older general
internist satisfaction compared with young physicians may be more reflective
of the male preponderance in medicine. Interestingly, female gender predicted
higher job and career satisfaction, findings not seen in a study in 1990.1 The gender and age satisfaction differences, along
with young women internists' enthusiasm about student recruitment, may impact
favorably on the future of GIM because the percentage of women in this specialty
is expected to reach 32% by 2010.36 Further
research should be directed at identifying factors important in young physician
work life and satisfaction—especially addressing gender differences,
personal time, community ties, patient care issues, resources, and relationships
with patients and colleagues.
This study has several limitations. First, the response rate of 52%
was suboptimal but typical of physician survey responses of 54%37;
fortunately, our assessment of late or nonresponse bias suggests that little
such bias existed. Second, the self-report nature of the survey could lead
to inaccuracy. Third, some physicians claimed to be practicing another specialty
other than the specialty in which they were sampled from the American Medical
Association's Masterfile. These discrepancies may result from physician preference
for categorizing their limited practice38 or
physician switching of their practice from GIM to a medicine subspecialty
or vice versa.39 Last, none of the factors
we explored predicted the relatively low specialty satisfaction among general
internists.
Our study clarifies the role of general internists as providers of primary
care to adults with complex medical and psychosocial problems in inpatient
and outpatient settings. However, general internists' satisfaction with their
job and specialty is moderate and lower than that of their 2 closest related
specialties. Also, many general internists are not recommending their specialty
to medical students with the vigor of physicians in other specialties. Fortunately,
many factors that predict general internist dissatisfaction are modifiable.
Attention to such factors as training in primary care and psychosocial care,
long work hours, case mix adjustment (including psychosocial patient complexity)
when devising panel sizes, and monitoring and minimizing time pressure during
office visits may serve to increase the satisfaction of general internists
and reaffirm the future of this primary care specialty. Higher levels of satisfaction
among young women general internists and their willingness to recruit medical
students may also strengthen the future of GIM.
AUTHOR INFORMATION
Accepted for publication July 30, 2001.
Dr Douglas is now with the Department of Statistics, University of Illinois
at Champaign-Urbana.
This study was supported by grant 27069 from the Robert Wood Johnson
Foundation, Princeton, NJ.
This study was presented in part at the Midwest regional meeting of
the Society of General Internal Medicine, Chicago, Ill, September 11, 1999;
and the annual meeting of the Society of General Internal Medicine, San Diego,
Calif, May 5, 2001.
| Study Group
Society of General Internal Medicine Career Satisfaction
Study Group
University of Wisconsin, Madison: Mark Linzer,
MD; Julia E. McMurray, MD; Jeffrey Douglas, PhD; John Frey, MD; William E.
Sheckler, MD. University of Alabama, Tuscaloosa:
Eric S. Williams, PhD. University of North Carolina at Chapel
Hill: Donald E. Pathman, MD, MPH; Thomas R. Konrad, PhD. University of Alabama, Birmingham: Kathleen Nelson, MD. University of Washington, Seattle: Richard Shugerman, MD. New York University, New York: Mark D. Schwartz, MD. Brigham and Women's Hospital and Harvard Medical School, Boston, Mass:
JudyAnn Bigby, MD. Oregon Health Sciences University, Portland: Martha S. Gerrity, MD. Society of General Internal
Medicine, Washington, DC: David Karlson, PhD; Elnora Rhodes.
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Corresponding author and reprints: Tosha B. Wetterneck, MD, Department
of Medicine, University of Wisconsin Hospital and Clinics, 600 W Highland
Ave, J5/214 Clinical Science Center, MC 2454, Madison, WI 53792-2454 (e-mail: tbw{at}medicine.wisc.edu).
From the Departments of Medicine (Drs Wetterneck, Linzer, and McMurray)
and Biostatistics and Epidemiology (Dr Douglas), University of Wisconsin,
Madison; the Department of Primary Care and Internal Medicine, New York University,
New York (Dr Schwartz); the Department of Medicine, Brigham and Women's Hospital
and Harvard Medical School, Boston, Mass (Dr Bigby); the Department of Internal
Medicine, Oregon Health Sciences University, Portland (Dr Gerrity); the Department
of Family Medicine, University of North Carolina at Chapel Hill (Dr Pathman);
and the Society of General Internal Medicine, Washington, DC (Dr Karlson and
Ms Rhodes).
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