Primary care and non-primary care physicians: a longitudinal study of their similarities, differences, and correlates before, during, and after medical school

Association of Intrinsic Motivating Factors and Markers of Physician Well-Being: A National Physician Survey

BACKGROUND

Although intrinsic motivating factors play important roles in physician well-being and productivity, most studies have focused on extrinsic motivating factors such as salary and work environment.

OBJECTIVE

To examine the association of intrinsic motivators with physicians' career satisfaction, life satisfaction, and clinical commitment, while accounting for established extrinsic motivators as well.

DESIGN AND PARTICIPANTS

A nationally representative survey of 2000 US physicians, fielded October to December 2011.

MAIN MEASURES

Outcome variables were five measures of physician well-being: career satisfaction, life satisfaction, high life meaning, commitment to direct patient care, and commitment to clinical practice. Primary explanatory variables were sense of calling, personally rewarding hours per day, meaningful, long-term relationships with patients, and burnout. Multivariate logit models with survey design provided nationally representative individual-level estimates.

KEY RESULTS

Among 1289 respondents, 85.8% and 86.5% were satisfied with their career and life, respectively; 88.6% had high life meaning; 54.5% and 79.5% intended to retain time in direct patient care and continue clinical practice, respectively. Sense of calling was strongly positively associated with high life meaning (odds ratio [OR] 5.14, 95% confidence interval [95% CI] 2.87-9.19) and commitment to direct patient care (OR 2.50, 95% CI 1.53-4.07). Personally rewarding hours per day were most strongly associated with career satisfaction (OR 5.28, 95% CI 2.72-10.2), life satisfaction (OR 4.46, 95% CI 2.34-8.48), and commitment to clinical practice (OR 3.46, 95% CI 1.87-6.39). Long-term relationships with patients were positively associated with career and life satisfaction and high life meaning. Burnout was strongly negatively associated with all measures of physician well-being.

CONCLUSIONS

Intrinsic motivators (e.g., calling) were associated with each measure of physician well-being (satisfaction, meaning, and commitment), but extrinsic motivators (e.g., annual income) were not associated with meaning or commitment. Understanding the effects of intrinsic motivators may help inform efforts to support physician well-being.

Money, lifestyle, or values? Why medical students choose subspecialty versus general pediatric careers

Although there are many published studies on factors associated with medical student career choice, few are specific to pediatric careers, and even fewer address the choice between general and subspecialty pediatric training. Fourth-year medical students surveyed at 2 schools reported their demographics, anticipated future income, the factors influencing their career choice, and their anticipated career. This study included the subset of 337 students planning pediatric careers. Results indicated that marital status, anticipated income, and career values are associated with pediatric career plans. Specifically, married students were more likely than unmarried students to pursue general pediatric careers (P < .01). Compared with students planning subspecialties, those intending to pursue general pediatric careers anticipated lower incomes ($110,906 vs $135,984; P < .001) and rated lifestyle, comprehensive patient care, and working with the poor as more important (P < .05) when choosing a career. Students planning subspecialty pediatric careers placed more value (P < .05) on prestige, income, and research opportunities.

U.S. physician satisfaction: a systematic review

INTRODUCTION

There is concern in the US about the burden and potential ramifications of dissatisfaction among physicians. The purpose of this article is to systematically review the literature on US physician satisfaction.

METHODS

A MEDLINE search with the medical subject headings (MeSH) phrases: (physicians OR physician's role OR physician's women) AND (job satisfaction OR career satisfaction OR burnout), limited to humans and abstracts, with 1157 abstracts reviewed. After exclusions by 2 independent reviewers, 97 articles were included. Physician type sampled, sample size/response rate, satisfaction type, and satisfaction results were extracted for each study. Satisfaction trends were extracted from those studies with longitudinal or repeated cross sectional design. Variables associated with satisfaction were extracted from those studies that included multivariate analyses.

RESULTS

Physician satisfaction was relatively stable, with small decreases primarily among primary care physicians (PCPs). The major pertinent mediating factors of satisfaction for hospitalists include both physician factors (age and specialty), and job factors (job demands, job control, collegial support, income, and incentives).

CONCLUSIONS

The majority of factors associated with satisfaction are modifiable. Tangible recommendations for measuring and diminishing dissatisfaction are given.

Assessing physicians' orientation toward lifelong learning

BACKGROUND

Despite the importance of lifelong learning as an element of professionalism, no psychometrically sound instrument is available for its assessment among physicians.

OBJECTIVE

To assess the validity and reliability of an instrument developed to measure physicians' orientation toward lifelong learning.

DESIGN

Mail survey.

PARTICIPANTS

Seven hundred and twenty-one physicians, of whom 444 (62%) responded.

MEASUREMENT

The Jefferson Scale of Physician Lifelong Learning (JSPLL), which includes 19 items answered on a 4-point Likert scale, was used with additional questions about respondents' professional activities related to continuous learning.

RESULTS

Factor analysis of the JSPLL yielded 4 subscales entitled: "professional learning beliefs and motivation,""scholarly activities,""attention to learning opportunities," and "technical skills in seeking information," which are consistent with widely recognized features of lifelong learning. The validity of the scale and its subscales was supported by significant correlations with a set of criterion measures that presumably require continuous learning. The internal consistency reliability (coefficient alpha) of the JSPLL was 0.89, and the test-retest reliability was 0.91.

CONCLUSIONS

Empirical evidence supports the validity and reliability of the JSPLL.

Assessment of Knowledge of Primary Care Activities in a Sample of Medical and Chiropractic Students

OBJECTIVE

To examine the influence of chiropractic education on knowledge of primary care tasks. Scores received on a test of knowledge of primary care tasks were compared between 3 samples of chiropractic students and 1 small sample of medical students.

DATA SOURCES

The taxonomy of primary care tasks that was previously published provided the basis for test items used in this study. A team of test writers prepared an evaluation instrument that was administered to final-term chiropractic students at 3 colleges and to a small sample of medical students as they were entering their residency programs.

RESULTS

The chiropractic students scored below the medical students on the primary care examination in every area except musculoskeletal conditions. Chiropractic students scored higher than medical students on the musculoskeletal portion of the examination.

CONCLUSIONS

In this sample, chiropractic students performed almost as well as medical students on a test that was designed to measure knowledge of primary care tasks. If the premise is accepted that medical school is the gold standard of primary care instruction, that chiropractic students fared almost as well as medical students is noteworthy.

Interim evaluation of the Rural Health Scholars Program

BACKGROUND

The imperative to address physician maldistribution has been directed in part at medical schools.

DESCRIPTION

The Rural Health Scholars Program (RHSP) is an enrichment initiative that has been implemented at 2 medical schools to increase the number of students likely to practice primary care in rural, underserved areas. It is a longitudinal program that includes a skill-building workshop; a 5-week summer preceptorship with community-based preceptors in rural, underserved areas; and opportunities to return to preceptorship sites during 3rd- and 4th-year rotations. Students also attend community-based and teleconference seminars and workshops, as well as informal social gatherings.

EVALUATION

A static-group comparison design was used to compare program participants with nonparticipants regarding residency program types and locations.

CONCLUSIONS

The RHSP is meeting some interim objectives conducive to its long-term goal of developing physicians who will practice primary care medicine in rural, underserved areas of North Carolina.

Who is a generalist? An analysis of whether physicians trained as generalists practice as generalists

Accurate data on the number of generalist physicians are needed to monitor the physician workforce and to plan for future requirements in the changing health care system. This study assessed the relationship between two frequently used definitions of a generalist physician: completion of graduate medical education (GME) in only a generalist discipline and physician's self-report of practicing as a generalist. Data for 4,808 physician graduates from six Pennsylvania medical schools from 1986 to 1991 were analyzed using information from the GME tracking census of the Association of American Medical Colleges and the Physician Masterfile of the American Medical Association. Of 1,291 physicians trained in a generalist discipline, 1,205 (93%) reported practicing as generalists. Conversely, of the 3,517 not trained in a generalist discipline, 3,358 (95%) were not practicing as generalists. These results indicate GME training is a valid predictor of self-reported practice and provide baseline data to monitor future changes.

Perceptions of medical school seniors of the current changes in the U.S. health care system

Perceptions of medical school seniors about changes occurring in the health care environment were investigated. A survey was completed by 196 Jefferson Medical College seniors in the class of 1997. Of the respondents, 79% believed that cost reduction rather than quality of care is the primary consideration behind recent changes, 78% felt that managed care organizations hamper physicians' abilities to render optimal care, 83% maintained that the control of health care by insurance companies would lead to lower quality of care, 69% agreed that patients should have the freedom to seek a specialist's care without being referred by a primary care physician, 82% recommended that mentally ill patients should be referred to a mental health professional, and 82% believed that learning to work in a managed care environment should be an essential component of medical education. Assessment of student perceptions can assist in the development and implementation of appropriate curricular changes.

Gender comparisons of medical students' psychosocial profiles

OBJECTIVES

This study was designed to compare male and female medical students on selected personality attributes that could influence their academic attainment and personal success.

DESIGN

Participants were 1157 medical students (743 men, 414 women) who completed a set of psychosocial questionnaires measuring intensity and chronicity of loneliness, general anxiety, test anxiety, neuroticism, depression, extraversion, self-esteem, locus of control, perceptions of parents, general health and appraisals of stressful life events. Data were analysed by employing multivariate and univariate analysis of variance and chi-square analysis.

SETTING

Jefferson Medical College.

SUBJECTS

Medical students.

RESULTS

Men scored significantly higher on the intensity of loneliness, and women scored higher on general anxiety, test anxiety and neuroticism scales, but the magnitudes of the effect size estimates were not large. No significant gender difference was observed on measures of chronicity of loneliness, depression, extraversion, self-esteem, external locus of control, perception of general health and perceptions of the mother and the father. Women who experienced stressful life events, such as death in the family or personal illness, appraised these events more negatively than did their male counterparts.

CONCLUSIONS

Implications of the findings for medical education and practice are discussed.

What influences career choices among graduates of a primary care training program?

OBJECTIVE

To identify factors that influence primary care residents to become generalists or specialists.

DESIGN

Structured survey and interview.

SETTING

A large university-based, internal medicine residency program in primary care.

PARTICIPANTS

Of 92 residency graduates who completed training between 1979 and 1993, 88 (96%) participated.

MAIN RESULTS

Although 82% of the participating graduates reported themselves very committed to primary care at the beginning of residency, only 68% pursued generalist careers. Factors influencing career choice that were more important to generalists than specialists included breadth of knowledge used in primary care practice (p = .04), breadth of clinical problems in practice (p = .001), and opportunity for continuity of care (p = .01). Although salary was rated "not important," 50% of generalists and specialists advocated increased salaries for generalists as a way to increase interest in primary care. Other promoting factors included mentors, increased prestige for generalists, community-based training, lifestyle changes, and decreased paperwork. Seventy-three percent of participants felt it was easier to be a specialist than a generalist.

CONCLUSIONS

A substantial minority of primary care residents pursue specialty careers. To produce more generalists, graduates recommend addressing income inequities, providing generalist role models, increasing community-based teaching, and increasing prestige for generalists.

Practice and career satisfaction among physiatrists. A national survey

To evaluate physiatrist career satisfaction and current practice patterns, a 15-page survey was mailed randomly to 400 fellow members of the American Academy of Physical Medicine and Rehabilitation. The 208 questionnaires (52%) returned revealed respondents' level of satisfaction with career choice, current practice, relationships with other physicians, their own residency training, and problems experienced that impede their practice. Factor analysis identified six areas of satisfaction: time demands, organizational support, current practice, current specialty, profession, and training. Problems with work consisted of four factors: external intrusions into practice, having to deal with non-rehabilitation problems, dealing with PM&R problems, and insufficient time for patients. Results showed that 75% of physiatrists were satisfied with their practice/profession. Satisfaction with current practice was greater with fewer external intrusions into practice, a larger percentage of income from traditional non-managed payment sources (including Medicaid), and less competition. Changes in health care, such as managed care, competition, and increased external regulations, appear to interfere with current practice. Variation in satisfaction was not significantly correlated with size of community, variation in rates of payment denials, workloads of greater than 50 hours per week, and a number of other factors that one might expect to affect satisfaction. Physiatrists had made many changes in their practice in response to the changes in the health care environment but had not cut care for indigent patients. Needs for greater residency training in outpatient clinics, physicians' offices, managed care, and long-term care settings were expressed. This is the first comprehensive published report on physiatric satisfaction in a changing health care environment. Further research in some of the areas will be required.

Medical students' specialty choice and the need for primary care. Our future

Recent changes in the health care environment have directed increasing attention to the recognized oversupply of specialists and relative lack of primary care physicians. Despite this imbalance and the need for more primary care physicians, US medical schools are not producing them in adequate numbers. To effect change in the production of primary care physicians, a comprehensive approach that addresses key factors in medical student specialty choice is needed. This article discusses such factors and how they affect medical students during the course of their training. Issues concerning primary care specialty choice and the physician work force are important to the development of the future US health care system.

The impact of early career specialization on licensing requirements and related educational implications

PURPOSE

It was hypothesized that physicians who pursue early career specialization in their first year of graduate medical education after medical school are likely to experience a decline in their scores on the medical licensing examination.

METHOD

A longitudinal prospective design was used in which 1,927 physicians who graduated from Jefferson Medical College between 1980 and 1991 were studied. Type of first-year graduate training program was the independent variable, and performance on a medical licensing examination (Part III examination of the National Board of Medical Examiners [NBME]) was the dependent variable. Scores on Parts I and II of the NBME taken in medical school, medical school class rank, and gender were the control variables.

RESULTS

Findings showed significant differences on Part III scores among physicians in 12 different graduate programs despite statistical adjustments for baseline differences. Physicians in family medicine and emergency medicine programs obtained the highest adjusted Part III scores, followed by physicians in internal medicine and transitional programs. The next group consisted of physicians in pediatrics, obstetrics-gynecology, anesthesiology, and general surgery programs. The group with the lowest Part III scores included physicians in pathology, radiology, and psychiatry.

IMPLICATIONS

These findings suggest that students who meet only the minimal standards in medical school should be advised to pursue a broad training program in the first year of graduate medical education to strengthen their general clinical competence as a means to increase their chances of passing licensing examinations.