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ORIGINAL RESEARCH |
From the Center for Health Services Research in Primary Care, Division of General Internal Medicine, and Departments of Epidemiology and Preventive Medicine and Obstetrics and Gynecology, University of California, Davis Medical Center, Sacramento, California.
Address reprint requests to: Richard L. Kravitz, MD, UC Davis Medical Center, Center for Health Services Research in Primary Care, Division of General Internal Medicine, 4150 V Street, Suite 2500, Sacramento, CA 95817; E-mail: Rlkravitz{at}ucdavis.edu.
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ABSTRACT |
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 ABSTRACT MATERIAL AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: We used data from the 1996–1997 (n =12,385; response rate, 65%) and 1998–1999 (n =12,280; response rate, 61%) waves of the nationally representative Community Tracking Study physicians’ survey. The principal outcome measures were one item related to overall career satisfaction, six items measuring physicians’ perceptions of their ability to provide high-quality care, and five items measuring physicians’ perceptions of their ability to obtain needed services for patients. All results were weighted and adjusted to reflect the complex survey design.
RESULTS: In 1996–1997, 34% of obstetrician–gynecologists (n =545) were very satisfied with their careers, and 24% were very or somewhat dissatisfied. Up to 45% perceived significant barriers to the delivery of high-quality care, and up to 58% were unable to "almost or almost always" obtain necessary services for patients. Results in 1998–1999 (n =484 obstetricians and gynecologists) were similar, except for a deterioration in perceived amount of time with patients and ability to obtain high-quality ancillary services. In comparison with primary care physicians, obstetrician–gynecologists were less satisfied (P = .001); in comparison with both primary care physicians and general surgeons, they had more problems delivering high-quality care (P < .001) and greater difficulties obtaining needed services for patients (P < .001). Controlling for selected demographic and professional characteristics, higher career satisfaction was associated with age greater than 65 years, practicing in small metropolitan areas and in academic settings, and having better perceptions of quality and ability to obtain services (P < .05).
CONCLUSION: Although most obstetricians and gynecologists are satisfied with their careers, many are experiencing significant professional distress.
The 40,000 obstetricians and gynecologists currently practicing in the United States play a critical role in the US health care system. However, the specialty is under pressure in several ways. Although obstetrics and gynecology training programs continue to fill to more than 90% capacity in the match, recent data suggest a decline in the percentage of offered positions filled by US medical graduates (from 82.5% in 1998 to 75.1% in 2002).1 Societal tolerance for poor birth outcomes is low, and malpractice premiums for obstetricians are among the highest in medicine.2,3 Finally, managed care has arguably threatened both physician autonomy and patient–physician trust.4
Physicians’ perceptions of the health care system are important because physician morale can affect patient care5 and because physicians’ experiences provide a unique window into system functioning.6 The career satisfaction and practice-related perceptions of obstetricians and gynecologists are especially important because access to obstetric care remains a problem in many areas7,8 and because the demand for women’s health care is increasing.9
Previous studies examining the work satisfaction of a variety of specialists have found that obstetricians and gynecologists often rank below the median.10–16 In 1995, the Robert Wood Johnson Foundation and the Center for Studying Health System Change launched the Community Tracking Study, a national longitudinal study of physicians and households. We used data from the 1996–1997 and 1998–1999 Community Tracking Study physicians’ surveys to address the following four research questions: 1) To what extent are US obstetricians and gynecologists satisfied with their chosen careers?; 2) Did these physicians perceive that they could deliver high-quality care to patients and obtain critical resources (such as specialty referrals, ancillary services, and hospital care) for their patients?; 3) How do levels of satisfaction and perceptions of quality among obstetrician–gynecologists compare with levels among primary care physicians (internists, family physicians, and general practitioners) and general surgeons?; and 4) How is the career satisfaction of obstetricians and gynecologists influenced by their personal and professional characteristics and perceptions of the practice environment? The results have implications for career choice, practice organization, and health care systems design.
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MATERIAL AND METHODS |
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ABSTRACTMATERIAL AND METHODSRESULTSDISCUSSIONREFERENCES |
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Each of the first two physician survey waves included two samples. In the "site sample," 60 communities (sites) were selected, and physicians were sampled from within each site. This sample was supplemented by a sample of individual US physicians in the continental United States. In the site sample, nine sites were selected with certainty; the other 51 were selected from ten geographic and size strata. The physician sampling frame for both waves was obtained from databases maintained by the American Medical Association and the American Osteopathic Association, which include all practicing US physicians, not just members of the societies. There was overlap between each wave, such that 7092 of 12,304 respondents (57.6%) in the second wave were also surveyed in the first wave. Physicians were included if they were actively practicing office-based or hospital-based medicine, were not employed by the federal government, and spent at least 20 hours per week in direct patient care. Residents, fellows, and physicians practicing hospital-based specialties without longitudinal responsibility for patient care (radiology, anesthesiology, pathology) were excluded. Primary care physicians as defined by the Community Tracking Study (family or general practice, general internal medicine, general pediatrics) were oversampled at a ratio of 2.5 to 1.17
There were 12,385 responding physicians in the first wave (overall response rate, 65%) and 12,280 in the second (response rate, 61%). These response rates were obtained after vigorous recruitment efforts, including use of advance mailings, specialty-society endorsements, a $25 incentive or honorarium, tracing of noncontacts, and conversion of "soft refusers."18 By comparison, response rates in two recent meta-analyses of physician surveys averaged less than 60%.19,20 The current analysis focuses on physicians who indicated that they practice obstetrics, gynecology, or a subspecialty thereof. There were 545 such physicians in the 1996–1997 sample and 484 in 1998–1999, an 11% decline ascribed to sampling error (personal communication, Hoangmai Pham, MD, MPH, Center for Studying Health Systems Change; April 1, 2003).
For comparative purposes, we also analyzed data from primary care physicians (general internists, family physicians, and general practitioners) and general surgeons. Our rationale was that primary care physicians (narrowly defined to exclude obstetrics and gynecology) deliver general health services (including gynecologic preventive care) to women; general surgeons provide an overlapping spectrum of operative care in a neighboring anatomic region. Item nonresponse rates rarely exceeded 3%.
Career satisfaction was measured with a single item: "Thinking very generally about your satisfaction with your overall career in medicine, would you say that you are currently (very satisfied, somewhat satisfied, somewhat dissatisfied, very dissatisfied, or neither satisfied nor dissatisfied)?" Ability to provide care was assessed with six items, each scored along a five-point scale (from strongly agree to strongly disagree): 1) I have adequate time to spend with patients during their office visits, 2) I have the freedom to make clinical decisions that meet my patients’ needs, 3) It is possible to provide high-quality care to all of my patients, 4) I can make clinical decisions in the best interests of my patients without the possibility of reducing my income, 5) The level of communication I have with other physicians about the patients I refer to them is sufficient to ensure the delivery of high-quality care, and 6) It is possible to maintain the kind of continuing relationships with patients over time that promote the delivery of high-quality care. Ability to obtain services was assessed with five items, each scored along a six-point scale (always, almost always, frequently, sometimes, rarely, or never able to obtain specific services when needed): 1) referrals to other specialists of high quality, 2) high-quality ancillary services, such as physical therapy, home health care, nutritional counseling, and so forth, 3) nonemergency hospital admissions, 4) adequate number of inpatient days for the respondent’s hospitalized patients, and 5) high-quality diagnostic imaging services.
In addition to item means, frequencies, and percentages, we calculated values for two summary measures. A scale of perceptions of ability to provide quality care was calculated as the mean of the six relevant items (1 = strongly disagree to 5 = strongly agree) and then transformed to a 0–100 scale, according to the following formula:
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where S is the transformed (0–100) score, 
is the mean scale score for that subject, min is the scale minimum (1.0), and max is the scale maximum (in this case, 5.0). This scale had an internal consistency (Cronbach 
coefficient)21 of 0.76 among obstetricians in our study, compared with 0.82 among all physicians evaluated in the study of Landon et al.22
Similarly, a scale of ability to obtain needed services was constructed as the mean of the five relevant items (1= never to 6 = always) and transformed as above. Internal consistency reliability was 0.83, which is excellent for group comparisons. Scale means were calculated based on available data only for subjects with nonmissing values for at least 50% of scale items.
Physicians participating in the Community Tracking Study also answered questions about their personal, professional, and practice characteristics. Age, gender, practice setting, hours of direct patient care, and income were assessed in standard fashion. These variables were selected for attention, based on previous studies relating them to physician satisfaction and on a general conceptual model positing physician satisfaction as a product of individual characteristics, conditions of practice, and the rewards of practice.23 As a measure of the impact of managed care on their practices, physicians were also asked, "Approximately what percentage of practice revenue from patient care would you say comes from managed care?"
All results were weighted to be representative of non-federal, patient care physicians practicing in the continental United States, adjusting for survey nonresponse and for the complex sampling design. We used Stata 6.0 (Stata Corp., College Station, TX) to generate the design-corrected results. Differences in mean satisfaction, perceptions of ability to provide quality care, and perceptions of ability to obtain services were compared among specialties and in relation to pertinent personal and professional characteristics with the Wald test, as implemented in the Stata svytest procedure, to yield P values adjusted for stratification and clustering. Differences in perceptions of the ability to deliver high-quality care between Round 1 and Round 2 were compared with the use of similar methods that also adjusted for the fact that some physicians participated in both rounds. Because many of the items and scales used in this analysis were not normally distributed, we reexamined the major results with nonparametric tests; we do not report them here because 1) they consistently confirmed the parametric results, and 2) available software packages do not correct nonparametric results for complex survey sampling. Independent associations between physician characteristics and our measures of physician satisfaction and perceptions of quality were evaluated with design-corrected multiple logistic regression (svylogit in Stata 6.0). In this analysis, we dichotomized the dependent variables, so a positive outcome was defined as a career satisfaction scale score of 5 or more ("very satisfied"), a "Provide Quality Care Scale" score of 4.0 or more ("somewhat agree"), and an "Obtain Needed Services Scale" score of 5.0 or more ("almost always"). These breakpoints were selected on the basis of distribution (for satisfaction) and clinical judgment (for perceptions of quality and ability to obtain needed services). Models were constructed based on the a priori hypothesis that physician satisfaction and perceptions of quality and resource availability would be related to 1) physician characteristics (age, gender, subspecialization), 2) practice characteristics (practice size and setting, practice income), and 3) managed care exposure (percentage of practice revenue that is derived from managed care). To achieve the most precise parameter estimates, data from both rounds were pooled, and a round "indicator variable" (1 = subject present in Round 2, 0 = subject present in Round 1 only) was included in each model to control for differences in satisfaction between rounds of data. Additionally, models were run that included interactions between all covariates and the round indicator, to identify subtle changes between rounds in the relationship between the covariates and satisfaction. These models revealed no significant changes between rounds and are not reported further.
Physicians constituted the primary sampling units for the nine sites selected with certainty and for the supplemental physician sample; for physicians from the 51 other sites, "site" was the primary sampling unit. These definitions automatically adjust the standard errors for clustering by site and for the correlation of responses in physicians who took part in both survey waves.
This study was approved by the University of California at Davis Human Subjects Committee on March 9, 2001.
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RESULTS |
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). In 1996–1997, 34.3% of the 545 responding obstetrician–gynecologists were very satisfied with their careers in medicine, 40.0% were somewhat satisfied, 1.4% were neutral, 16.9% were somewhat dissatisfied, and 7.1% were very dissatisfied. These results place obstetrics and gynecology near the bottom of the major medical specialties in terms of career satisfaction (30th among 31 specialties; data not shown).12
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After weighting and adjusting for the complex survey design, mean satisfaction among male and female obstetricians and gynecologists in the combined cohort was similar (3.75 versus 3.82, P =.58). However, career satisfaction was significantly higher in small metropolitan communities (population less than 200,000: mean satisfaction score, 4.14) than in large metropolitan communities (population greater than 200,000; mean satisfaction score 3.72) (P <.001). Satisfaction in nonurban communities (3.80) was statistically indistinguishable from satisfaction in small and large metropolitan areas.
Tables 2 and 3 display physician’s perceptions of their ability to provide quality care and to obtain needed services for patients. In both tables, national estimates are presented for 1996–1997, for 1998–1999, and for the two survey waves combined.
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). However, only 55% agreed that they could maintain the kind of longitudinal relationships with patients that promote high-quality care.
Results from 1998–1999 were largely consistent with those from 1996–1997. The only significant change was a sharp decline in the proportion of obstetrician–gynecologists who perceived adequate time with patients (71% in 1996–1997 falling to 60% in 1998–1999, Table 2).
In 1996–1997, 73% of obstetricians and gynecologists reported that they could always or almost always obtain high-quality diagnostic imaging services, 66% that they could obtain referrals to other specialists of high quality, and 61% that they could obtain high-quality ancillary services (Table 3). Fifty-four percent could always or almost always arrange for nonemergency hospital admissions, and 42% could obtain an adequate number of inpatient days for hospitalized patients (Table 3). Except for a decline in ability to obtain ancillary services (from 61% in 1996–1997 to 53% in 1998–1999) there were no significant changes over time (Table 3).
Using the combined (1996–1997 and 1998–1999) data set, we compared the perceptions of obstetricians and gynecologists with those of primary care physicians and general surgeons. Career satisfaction, ability to provide quality care, and ability to obtain needed services were each measured with separate 100-point scales, as described in the Methods section. Obstetricians and gynecologists had significantly lower career satisfaction than primary care physicians; the difference between obstetrician–gynecologist physicians and general surgeons was similar in magnitude but not statistically significant (Figure 1). Compared with both primary care physicians and general surgeons, obstetrician–gynecologists also had significantly lower perceptions of 1) ability to deliver high-quality care, and 2) ability to obtain needed services (P <.001 in both cases, Figure 1). There were no significant differences along any of the three measures between primary care physicians and general surgeons.
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). Physicians practicing in health maintenance organizations were less likely to be very satisfied (Table 4). Among the most powerful predictors of satisfaction, however, were obstetricians’ and gynecologists’ perceptions of being able to provide high-quality care (odds ratio, 1.76; P < .05) and being able to obtain needed services for patients (odds ratio, 1.33; P < .01). These odds ratios can be interpreted as implying a 76% increase in the odds of being very satisfied for each 1-point increase in the "Provide Quality Care Scale" and a 33% increase in the odds of being very satisfied for each 1-point increase in the "Obtain Needed Services Scale."
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DISCUSSION |
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The average obstetrician–gynecologist in our study was just shy of being "somewhat satisfied" with his or her career in general. Obstetricians and gynecologists had significantly lower overall career satisfaction than did primary care physicians, although the absolute difference was modest. Few prior studies of physician job satisfaction have had large enough sample sizes to permit comparisons among specialties, but one large 1989 survey from Massachusetts ranked obstetrician–gynecologists seventh of nine specialties in terms of overall satisfaction with medicine.10 Twenty-three percent of obstetrician–gynecologists in the 1996–1997 wave of the Community Tracking Study were somewhat or very dissatisfied with their careers, compared with 20% of internists, 17% of family physicians, 14% of medical subspecialists, and 12% of pediatricians.12 Prior studies have shown that physician dissatisfaction is an important predictor of job turnover,24 patient dissatisfaction,25 and patient nonadherence to treatment.26 Therefore, high levels of dissatisfaction within obstetrics and gynecology may bode poorly for doctors, patients, and medical organizations.
Beyond general career satisfaction, our findings shed light on specific sources of professional distress and provide a perspective on trends in quality of care. In both survey years, between 25% and 45% of obstetricians and gynecologists perceived significant barriers to the delivery of high-quality care, including insufficient time with patients, lack of clinical autonomy, and inability to make appropriate clinical decisions without an adverse effect on income. Most strikingly, nearly half of respondents were distressed by their inability to "maintain the kind of continuing relationships with patients over time that promote the delivery of high quality care." There is scattered evidence that continuity of care is associated with improved patient-centered outcomes in obstetrics.27,28 Continuity-of-care is threatened by health care system changes at several levels, as well as by physician mobility.29,30
Another potential cause of physician distress is inability to obtain services that are necessary for patient care. Difficulties gaining hospital admission and securing adequate number of bed days topped physicians concerns. The number of inpatient days allowed for routine obstetric deliveries hit a nadir (of 1.5 days) around the time of the 1996–1997 survey.31 Since then, legislation enacted at the state level has forced managed care organizations to ease rules mandating ultrashort stay ("drive-through") deliveries, which might explain the small (nonsignificant) improvement between survey waves.
Higher career satisfaction was positively associated with older age and academic practice but negatively associated with practicing in a health maintenance organization. Surprisingly, there was no significant association with income, perhaps because the majority of respondents had incomes over $200,000. Older physicians might be more satisfied than those in midcareer either because they will soon be in a position to retire or because they have consciously chosen not to do so. Academic physicians might derive a number of intangible rewards from teaching and performing research. The issue of health maintenance organizations in relation to physician satisfaction is more complex. In one recent study, physicians in group and staff-model health maintenance organizations were more satisfied with autonomy and administrative issues but less satisfied with material resources and relationships with nonphysician staff.32
Not surprisingly, our results suggest that career satisfaction is related not only to obstetricians’ and gynecologists’ personal and professional characteristics but also to their perceptions of ability to deliver quality care and to obtain needed resources for patients. These associations emphasize physician satisfaction as a statistical "miner’s canary" that may be a sensitive indicator of important structural problems in the health care delivery system.
Interpretation of these results is limited by the possibility of response bias, reliance on self-reported measures, and the study design itself. In particular, we cannot make causal inferences with any confidence. The overall response rate is suboptimal; physicians facing greater practice demands might have been less likely to respond, leading to underestimates of dissatisfaction and distress. Another potential limitation of this study is that the most recent results available to support this analysis were obtained in 1998–1999. Reassuringly, however, we observed little change between the two study waves.
In summary, the results of this large national study suggest problems with conditions of practice for obstetricians and gynecologists in the United States. Policymakers should take note, because respondents’ perceptions might reflect physician demoralization, erosion of clinical quality in the area of women’s health care, or both. At the same time, we found evidence of considerable resilience within the specialty. Despite rapid change in the US health system and the impression that some parts of the system are fraying at the edges, most obstetricians and gynecologists continue to feel that they can provide good quality care and derive considerable satisfaction from their work.
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Footnotes |
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doi:10.1016/S0029-7844(03)00666-5
Received February 10, 2003. Received in revised form May 22, 2003. Accepted June 5, 2003.
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REFERENCES |
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10. Stamps PL, Cruz NTB. Issues in physician satisfaction: New perspectives. Ann Arbor: Health Administration Press, 1994:197.
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22. Landon BE, Reschovsky J, Blumenthal D. Changes in career satisfaction among primary care and specialist physicians, 1997–2001. JAMA 2003;442–9.
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