Steven Shearer, PhD

The 1990s were a time of remarkable upheaval in US health care. The input of physicians and consumers was marginalized in a market-driven system guided by insurers, employers, and government. Well-intentioned managed care concepts that many physicians would endorse were less evident than managed care business practices that sparked rancor and frustration, as well as creating time and income pressures.

Although 80% of physicians believe that the current health care system requires fundamental change,^1,2 there is little agreement about what form that change should take. For example, 25%³ to 40%⁴ of physicians in statewide surveys and 66% of students entering one medical school system⁵ endorse a single-payer national health plan. Despite the lack of consensus about what direction reform should take, there is growing skepticism about the current model. For example, only 21% of surveyed internal medicine residents believe that corporate managed care is the best model for our health care system.⁶ Among students, residents, faculty members, and deans of medical schools, 52% favor a single-payer system, while 22% favor a corporate managed care system.⁷

Coincident with marked changes in American health care, the popular press have reported deteriorating morale and career satisfaction among physicians.^8,9 For family physicians there are mixed but generally positive data about career satisfaction. Survey data report that only 52% of young family physicians would definitely again choose to become a physician,10 yet from 70%10 to 74%¹¹ would again choose family practice as a specialty. In a 1996 survey⁴ (at a time when both family practice residency applicants and salaries for new graduates peaked), 82% of family physicians reported satisfaction with their careers; 75% stated that they would again select family practice as a specialty; and 65% reported satisfaction with their compensation.⁴

Since 1996, annual surveys of the family practice residents in our own training program have shown a steady decline in the number who would go to medical school again (from 73% to 50% between 1996 and 1999). We suspected that our residents were reacting to changes and uncertainties similar to those faced by all family physicians. This prompted us to survey practicing family physicians about their experiences with and attitudes toward their practice and the US health care system.

Methods

We designed a 41-item questionnaire that focused on family physicians’ observations related to corporate managed health care and personal perception of their own well-being and career. Family physicians were asked to rate each item on a 5-point scale (where 1=strongly disagree, and 5=strongly agree). Additional items focused on demographic information, nature of practice, presence of a primary relationship, presence of children in the home, political inclination, extent of managed care participation, and both the nature and perceived adequacy of compensation. The final questionnaire was the product of pretesting and feedback by 6 of the family practice faculty members from our residency training program and consultation with researchers.

We selected a random national sample of 800 practicing members of the American Academy of Family Physicians (AAFP) in June 1999. A 6-page survey was mailed to each family physician, accompanied by a cover letter requesting participation and a postcard by which a summary of the final survey results could be requested. We sent a second mailing 5 weeks later to those who had not yet responded.

We examined the data from all 41 items that were rated on a Likert scale using principal component factor analysis and varimax rotation with Kaiser normalization.¹² The 4 factors of highest reliability (a >0.650) and highest eigenvalue were chosen post hoc as dependent variables (ie, attitudes about managed care, satisfaction with career, workload stress, and satisfaction with personal life) and analyzed by stepwise regression using all remaining factors and personal and practice variables as independent variables.

Results

A total of 361 completed surveys were returned; 16 surveys were returned as undeliverable (response rate=46%). The mean physician age was 46 years (range=27-77 years); 74% were men, 26% were women. Most were white/non-Hispanic; only 1.1% were Hispanic, 1.7%, African-American, and 4.8%, Asian-American. Practice characteristics are shown in Table 1. The characteristics of these respondents were very similar to those reported for the AAFP membership in December 2000.¹³ The exceptions were that minority family physicians were underrepresented among respondents to our survey and that respondents averaged nearly 5 more years in practice than the AAFP membership mean.

Among this sample of family physicians, 51% received all of their income by salary. Only 10% reported that more than half their income was capitated; 72% still received no income through capitation. The respondents reported working a mean of 51 hours per week; however, 33% reported averaging more than 60 hours, and 7% averaged more than 70 hours. They had spent a mean of 15.3 years in practice (range = 1 to 51 years).

Only 55% of respondents felt they were appropriately compensated financially. Family physicians who were satisfied with their financial compensation reported more favorable views of managed care (F=10.55; df=1; P <.001), greater career satisfaction (F=27.07; df=1; P <.0001) and lower workload stress (F=10.42; df=1; P <.001).

Regarding their personal lives, 91% of these family physicians reported they were currently involved in a relationship, and 65% had children in their home. Politically, 30% identified themselves as democrats; 46%, republicans; and 24%, independents.

The responses to the questionnaire are shown in Table 2,Table 2b,Table 2c,. The results of stepwise regression models are presented in Table 3*Table w2.

Attitudes About Managed Care

The responses to items composing this factor show that this sample of family physicians was sharply critical of corporate managed care. For example, only 7% agreed or strongly agreed that corporate managed care is the best way to provide the health care America needs at a cost that society can afford.

The regression analyses summarized in Table 3 suggest that overall attitudes about managed care were predicted primarily by a cluster of 3 factors that tap into other concerns about managed care, reform, and accountability. Also, positive attitudes about managed care were best predicted by greater career satisfaction, a willingness to let others worry about the business of medicine, support of hospitalists, having children at home, and democratic political inclinations.

Satisfaction with Career

The response to items composing this factor suggests evidence of discontent among a significant minority of these family physicians. For example, knowing what they know now, if they could start over 63% would go to medical school again, and 66% would choose family practice again. Overall, 59% said they were satisfied with their professional lives.

In regression analyses, family physicians who were retrospectively satisfied with residency training, felt that they were appropriately compensated for their current work, and were satisfied with their personal lives were most likely to be satisfied with their careers. Both a positive attitude about managed care and reform-mindedness each independently predicted career satisfaction.

A decreased workload stress factor predicted increased career satisfaction; however, longer work hours were reported by those more satisfied with their careers. Women reported less satisfaction with their careers. Given their covariance, it is reasonable to view these variables as a cluster that together predicts 55% of the variance in career-satisfaction ratings.

Workload Stress

The response to items composing this factor suggests that a significant number of respondents felt their practice was very stressful. For example, only 9% reported that they are not overwhelmed by paperwork and administrative requirements, and 48% said that they had personally experienced more stress-related symptoms within the past year. Regression analyses suggested that greater workload stress was significantly predicted by dissatisfaction with either career or personal life, longer work hours, being female, and greater reform-mindedness.

Satisfaction with Personal Life

In their personal lives, 85% of these family physicians felt supported by a primary relationship, their family, or a social network. Healthy lifestyle habits that might help to buffer stress are reported by 52%. Overall, 71% said they were satisfied with their personal lives. As provided in Table 3, regression analyses showed that greater workload stress and longer work hours each predicted less satisfaction with personal life. Overall career satisfaction and being in a primary relationship predicted greater satisfaction with personal life. Having children in the home did not predict greater satisfaction with personal life.

Discussion

The optimism and career satisfaction reported among the majority of family physicians during the mid-1990s may have eroded in subsequent years. In this national survey in 1999, 63% would again choose to go to medical school, and 66% would again choose family practice. Only 55% were satisfied that they are receiving appropriate financial compensation, and 31% stated that they were “tired of being a doctor” and worried that they were “burning out.”

Although it is unlikely that financial incentives are a primary motivator for the decision to choose family practice, satisfaction with financial compensation was significantly associated with greater career satisfaction and lower work stress.

Nearly half of these family physicians reported that they had personally experienced a recent increase in stress-related symptoms. Many did not feel in control of the stressors they faced in daily practice, and most were overwhelmed by the paperwork and administrative requirements. It is no surprise that career satisfaction and workload stress are inversely related. However, it is less clear whether escalating work stress usually erodes career satisfaction or whether those who are less enamored with their career choice are more likely to experience practice demands as stressful.

Higher reported work hours were associated with greater career satisfaction as well as with higher perceived workload stress and less satisfaction with personal life. Although family physicians working the most hours may be doing so because they love what they are doing, long hours take their toll. Forty-four percent of respondents said they were working so many hours that their health or relationships were adversely affected. Several respondents wrote in the margins that they had opted for 50% to 80% of full time, because it was the only way to make practice tolerable. However, such a work arrangement often constitutes a full-time job by most standards, but for reduced pay.

Only 12% of the respondents felt that residency training had provided good training in practice administration. Despite recent efforts to create more relevant practice management curricula, ratings of this item did not vary significantly by years in practice, suggesting that most new graduates still do not feel prepared for the business of medicine.

Previous research has clearly shown that increased demands coupled with loss of control and a lack of safe outlets for frustration can lead to increased stress.¹⁴ This is the situation in which many of today’s family physicians find themselves. Residency training programs and state professional associations can play a significant role by speaking with candor about physician stress; integrating programs on stress management, career goals, and values clarification; and encouraging advocacy for constructive change of the health care system. Training programs must contemplate which changes are likely to maximize the number of graduates who become successful, satisfied practitioners in the current health care environment.

This sample of family physicians was sharply critical of a health care system driven by corporate managed care. Only 7% of family physicians agreed that corporate managed care is the best way to provide the health care America needs at a cost society can afford. Only 20% believed that managed care had accomplished improvements in both accountability and quality of care. Forty-two percent of these family physicians reported bad patient outcomes they perceived as attributable to managed care business processes. Despite the improved access touted by behavioral health carve-outs, 76% of family physicians report that obtaining good-quality behavioral or mental health treatment for their patients has gotten more difficult as such corporate entities have dominated that market.

There was virtual consensus for specific reforms. More than 85% of these family physicians agreed that all Americans should have access to redress for damages when managed care agents inappropriately delay or deny treatment and that managed care medical directors should be accountable to state boards of physician quality assurance for their decisions about patient care. Only 36% unequivocally supported a government-administered universal national health plan; however, an additional 21% who were equivocal suggested that growing discontent with the status quo could shift the balance to a majority in support.

Limitations

The numerous limitations inherent to our study include the use of a newly constructed questionnaire with design flaws, a modest response rate, the likelihood that respondents were different than nonrespondents, and poor representation of minority respondents. Comparison with data from other studies is limited by differences in study design and sample. These cross-sectional regression analyses allow only statistical prediction of associations, not cause-and-effect conclusions. This survey cannot be generalized to other physician specialties, and it is not appropriate to assume that family physicians are more discontent than other physicians, other professionals, or other workers.

Conclusions

This survey conveys a sobering glimpse of the prevalence of discontent among family physicians. Given the daily effects of upheaval in our health care system, perhaps we should be pleased that 2 out of 3 family physicians would still choose the same path if they had to do it over again. However, the next decade may answer whether our health care system can thrive if there is continued erosion of the support and confidence of skilled, committed, and reasonably content primary care physicians.

Acknowledgments

Financial assistance was provided by Medstar Research Institute. Thanks to both Ms. Michelle Appel and Medstar Research Institute for statistical consultation. The opinions expressed are the views of the authors and are not to be construed as reflecting the views of Medstar Health or the Public Health Service.

The 1990s were a time of remarkable upheaval in US health care. The input of physicians and consumers was marginalized in a market-driven system guided by insurers, employers, and government. Well-intentioned managed care concepts that many physicians would endorse were less evident than managed care business practices that sparked rancor and frustration, as well as creating time and income pressures.

Although 80% of physicians believe that the current health care system requires fundamental change,^1,2 there is little agreement about what form that change should take. For example, 25%³ to 40%⁴ of physicians in statewide surveys and 66% of students entering one medical school system⁵ endorse a single-payer national health plan. Despite the lack of consensus about what direction reform should take, there is growing skepticism about the current model. For example, only 21% of surveyed internal medicine residents believe that corporate managed care is the best model for our health care system.⁶ Among students, residents, faculty members, and deans of medical schools, 52% favor a single-payer system, while 22% favor a corporate managed care system.⁷

Coincident with marked changes in American health care, the popular press have reported deteriorating morale and career satisfaction among physicians.^8,9 For family physicians there are mixed but generally positive data about career satisfaction. Survey data report that only 52% of young family physicians would definitely again choose to become a physician,10 yet from 70%10 to 74%¹¹ would again choose family practice as a specialty. In a 1996 survey⁴ (at a time when both family practice residency applicants and salaries for new graduates peaked), 82% of family physicians reported satisfaction with their careers; 75% stated that they would again select family practice as a specialty; and 65% reported satisfaction with their compensation.⁴

Since 1996, annual surveys of the family practice residents in our own training program have shown a steady decline in the number who would go to medical school again (from 73% to 50% between 1996 and 1999). We suspected that our residents were reacting to changes and uncertainties similar to those faced by all family physicians. This prompted us to survey practicing family physicians about their experiences with and attitudes toward their practice and the US health care system.

Methods

We designed a 41-item questionnaire that focused on family physicians’ observations related to corporate managed health care and personal perception of their own well-being and career. Family physicians were asked to rate each item on a 5-point scale (where 1=strongly disagree, and 5=strongly agree). Additional items focused on demographic information, nature of practice, presence of a primary relationship, presence of children in the home, political inclination, extent of managed care participation, and both the nature and perceived adequacy of compensation. The final questionnaire was the product of pretesting and feedback by 6 of the family practice faculty members from our residency training program and consultation with researchers.

We selected a random national sample of 800 practicing members of the American Academy of Family Physicians (AAFP) in June 1999. A 6-page survey was mailed to each family physician, accompanied by a cover letter requesting participation and a postcard by which a summary of the final survey results could be requested. We sent a second mailing 5 weeks later to those who had not yet responded.

We examined the data from all 41 items that were rated on a Likert scale using principal component factor analysis and varimax rotation with Kaiser normalization.¹² The 4 factors of highest reliability (a >0.650) and highest eigenvalue were chosen post hoc as dependent variables (ie, attitudes about managed care, satisfaction with career, workload stress, and satisfaction with personal life) and analyzed by stepwise regression using all remaining factors and personal and practice variables as independent variables.

Results

A total of 361 completed surveys were returned; 16 surveys were returned as undeliverable (response rate=46%). The mean physician age was 46 years (range=27-77 years); 74% were men, 26% were women. Most were white/non-Hispanic; only 1.1% were Hispanic, 1.7%, African-American, and 4.8%, Asian-American. Practice characteristics are shown in Table 1. The characteristics of these respondents were very similar to those reported for the AAFP membership in December 2000.¹³ The exceptions were that minority family physicians were underrepresented among respondents to our survey and that respondents averaged nearly 5 more years in practice than the AAFP membership mean.

Among this sample of family physicians, 51% received all of their income by salary. Only 10% reported that more than half their income was capitated; 72% still received no income through capitation. The respondents reported working a mean of 51 hours per week; however, 33% reported averaging more than 60 hours, and 7% averaged more than 70 hours. They had spent a mean of 15.3 years in practice (range = 1 to 51 years).

Only 55% of respondents felt they were appropriately compensated financially. Family physicians who were satisfied with their financial compensation reported more favorable views of managed care (F=10.55; df=1; P <.001), greater career satisfaction (F=27.07; df=1; P <.0001) and lower workload stress (F=10.42; df=1; P <.001).

Regarding their personal lives, 91% of these family physicians reported they were currently involved in a relationship, and 65% had children in their home. Politically, 30% identified themselves as democrats; 46%, republicans; and 24%, independents.

The responses to the questionnaire are shown in Table 2,Table 2b,Table 2c,. The results of stepwise regression models are presented in Table 3*Table w2.

Attitudes About Managed Care

The responses to items composing this factor show that this sample of family physicians was sharply critical of corporate managed care. For example, only 7% agreed or strongly agreed that corporate managed care is the best way to provide the health care America needs at a cost that society can afford.

The regression analyses summarized in Table 3 suggest that overall attitudes about managed care were predicted primarily by a cluster of 3 factors that tap into other concerns about managed care, reform, and accountability. Also, positive attitudes about managed care were best predicted by greater career satisfaction, a willingness to let others worry about the business of medicine, support of hospitalists, having children at home, and democratic political inclinations.

Satisfaction with Career

The response to items composing this factor suggests evidence of discontent among a significant minority of these family physicians. For example, knowing what they know now, if they could start over 63% would go to medical school again, and 66% would choose family practice again. Overall, 59% said they were satisfied with their professional lives.

In regression analyses, family physicians who were retrospectively satisfied with residency training, felt that they were appropriately compensated for their current work, and were satisfied with their personal lives were most likely to be satisfied with their careers. Both a positive attitude about managed care and reform-mindedness each independently predicted career satisfaction.

A decreased workload stress factor predicted increased career satisfaction; however, longer work hours were reported by those more satisfied with their careers. Women reported less satisfaction with their careers. Given their covariance, it is reasonable to view these variables as a cluster that together predicts 55% of the variance in career-satisfaction ratings.

Workload Stress

The response to items composing this factor suggests that a significant number of respondents felt their practice was very stressful. For example, only 9% reported that they are not overwhelmed by paperwork and administrative requirements, and 48% said that they had personally experienced more stress-related symptoms within the past year. Regression analyses suggested that greater workload stress was significantly predicted by dissatisfaction with either career or personal life, longer work hours, being female, and greater reform-mindedness.

Satisfaction with Personal Life

In their personal lives, 85% of these family physicians felt supported by a primary relationship, their family, or a social network. Healthy lifestyle habits that might help to buffer stress are reported by 52%. Overall, 71% said they were satisfied with their personal lives. As provided in Table 3, regression analyses showed that greater workload stress and longer work hours each predicted less satisfaction with personal life. Overall career satisfaction and being in a primary relationship predicted greater satisfaction with personal life. Having children in the home did not predict greater satisfaction with personal life.

Discussion

The optimism and career satisfaction reported among the majority of family physicians during the mid-1990s may have eroded in subsequent years. In this national survey in 1999, 63% would again choose to go to medical school, and 66% would again choose family practice. Only 55% were satisfied that they are receiving appropriate financial compensation, and 31% stated that they were “tired of being a doctor” and worried that they were “burning out.”

Although it is unlikely that financial incentives are a primary motivator for the decision to choose family practice, satisfaction with financial compensation was significantly associated with greater career satisfaction and lower work stress.

Nearly half of these family physicians reported that they had personally experienced a recent increase in stress-related symptoms. Many did not feel in control of the stressors they faced in daily practice, and most were overwhelmed by the paperwork and administrative requirements. It is no surprise that career satisfaction and workload stress are inversely related. However, it is less clear whether escalating work stress usually erodes career satisfaction or whether those who are less enamored with their career choice are more likely to experience practice demands as stressful.

Higher reported work hours were associated with greater career satisfaction as well as with higher perceived workload stress and less satisfaction with personal life. Although family physicians working the most hours may be doing so because they love what they are doing, long hours take their toll. Forty-four percent of respondents said they were working so many hours that their health or relationships were adversely affected. Several respondents wrote in the margins that they had opted for 50% to 80% of full time, because it was the only way to make practice tolerable. However, such a work arrangement often constitutes a full-time job by most standards, but for reduced pay.

Only 12% of the respondents felt that residency training had provided good training in practice administration. Despite recent efforts to create more relevant practice management curricula, ratings of this item did not vary significantly by years in practice, suggesting that most new graduates still do not feel prepared for the business of medicine.

Previous research has clearly shown that increased demands coupled with loss of control and a lack of safe outlets for frustration can lead to increased stress.¹⁴ This is the situation in which many of today’s family physicians find themselves. Residency training programs and state professional associations can play a significant role by speaking with candor about physician stress; integrating programs on stress management, career goals, and values clarification; and encouraging advocacy for constructive change of the health care system. Training programs must contemplate which changes are likely to maximize the number of graduates who become successful, satisfied practitioners in the current health care environment.

This sample of family physicians was sharply critical of a health care system driven by corporate managed care. Only 7% of family physicians agreed that corporate managed care is the best way to provide the health care America needs at a cost society can afford. Only 20% believed that managed care had accomplished improvements in both accountability and quality of care. Forty-two percent of these family physicians reported bad patient outcomes they perceived as attributable to managed care business processes. Despite the improved access touted by behavioral health carve-outs, 76% of family physicians report that obtaining good-quality behavioral or mental health treatment for their patients has gotten more difficult as such corporate entities have dominated that market.

There was virtual consensus for specific reforms. More than 85% of these family physicians agreed that all Americans should have access to redress for damages when managed care agents inappropriately delay or deny treatment and that managed care medical directors should be accountable to state boards of physician quality assurance for their decisions about patient care. Only 36% unequivocally supported a government-administered universal national health plan; however, an additional 21% who were equivocal suggested that growing discontent with the status quo could shift the balance to a majority in support.

Limitations

The numerous limitations inherent to our study include the use of a newly constructed questionnaire with design flaws, a modest response rate, the likelihood that respondents were different than nonrespondents, and poor representation of minority respondents. Comparison with data from other studies is limited by differences in study design and sample. These cross-sectional regression analyses allow only statistical prediction of associations, not cause-and-effect conclusions. This survey cannot be generalized to other physician specialties, and it is not appropriate to assume that family physicians are more discontent than other physicians, other professionals, or other workers.

Conclusions

This survey conveys a sobering glimpse of the prevalence of discontent among family physicians. Given the daily effects of upheaval in our health care system, perhaps we should be pleased that 2 out of 3 family physicians would still choose the same path if they had to do it over again. However, the next decade may answer whether our health care system can thrive if there is continued erosion of the support and confidence of skilled, committed, and reasonably content primary care physicians.

Acknowledgments

Financial assistance was provided by Medstar Research Institute. Thanks to both Ms. Michelle Appel and Medstar Research Institute for statistical consultation. The opinions expressed are the views of the authors and are not to be construed as reflecting the views of Medstar Health or the Public Health Service.

The 1990s were a time of remarkable upheaval in US health care. The input of physicians and consumers was marginalized in a market-driven system guided by insurers, employers, and government. Well-intentioned managed care concepts that many physicians would endorse were less evident than managed care business practices that sparked rancor and frustration, as well as creating time and income pressures.

Although 80% of physicians believe that the current health care system requires fundamental change,^1,2 there is little agreement about what form that change should take. For example, 25%³ to 40%⁴ of physicians in statewide surveys and 66% of students entering one medical school system⁵ endorse a single-payer national health plan. Despite the lack of consensus about what direction reform should take, there is growing skepticism about the current model. For example, only 21% of surveyed internal medicine residents believe that corporate managed care is the best model for our health care system.⁶ Among students, residents, faculty members, and deans of medical schools, 52% favor a single-payer system, while 22% favor a corporate managed care system.⁷

Coincident with marked changes in American health care, the popular press have reported deteriorating morale and career satisfaction among physicians.^8,9 For family physicians there are mixed but generally positive data about career satisfaction. Survey data report that only 52% of young family physicians would definitely again choose to become a physician,10 yet from 70%10 to 74%¹¹ would again choose family practice as a specialty. In a 1996 survey⁴ (at a time when both family practice residency applicants and salaries for new graduates peaked), 82% of family physicians reported satisfaction with their careers; 75% stated that they would again select family practice as a specialty; and 65% reported satisfaction with their compensation.⁴

Since 1996, annual surveys of the family practice residents in our own training program have shown a steady decline in the number who would go to medical school again (from 73% to 50% between 1996 and 1999). We suspected that our residents were reacting to changes and uncertainties similar to those faced by all family physicians. This prompted us to survey practicing family physicians about their experiences with and attitudes toward their practice and the US health care system.

Methods

We designed a 41-item questionnaire that focused on family physicians’ observations related to corporate managed health care and personal perception of their own well-being and career. Family physicians were asked to rate each item on a 5-point scale (where 1=strongly disagree, and 5=strongly agree). Additional items focused on demographic information, nature of practice, presence of a primary relationship, presence of children in the home, political inclination, extent of managed care participation, and both the nature and perceived adequacy of compensation. The final questionnaire was the product of pretesting and feedback by 6 of the family practice faculty members from our residency training program and consultation with researchers.

We selected a random national sample of 800 practicing members of the American Academy of Family Physicians (AAFP) in June 1999. A 6-page survey was mailed to each family physician, accompanied by a cover letter requesting participation and a postcard by which a summary of the final survey results could be requested. We sent a second mailing 5 weeks later to those who had not yet responded.

We examined the data from all 41 items that were rated on a Likert scale using principal component factor analysis and varimax rotation with Kaiser normalization.¹² The 4 factors of highest reliability (a >0.650) and highest eigenvalue were chosen post hoc as dependent variables (ie, attitudes about managed care, satisfaction with career, workload stress, and satisfaction with personal life) and analyzed by stepwise regression using all remaining factors and personal and practice variables as independent variables.

Results

A total of 361 completed surveys were returned; 16 surveys were returned as undeliverable (response rate=46%). The mean physician age was 46 years (range=27-77 years); 74% were men, 26% were women. Most were white/non-Hispanic; only 1.1% were Hispanic, 1.7%, African-American, and 4.8%, Asian-American. Practice characteristics are shown in Table 1. The characteristics of these respondents were very similar to those reported for the AAFP membership in December 2000.¹³ The exceptions were that minority family physicians were underrepresented among respondents to our survey and that respondents averaged nearly 5 more years in practice than the AAFP membership mean.

Among this sample of family physicians, 51% received all of their income by salary. Only 10% reported that more than half their income was capitated; 72% still received no income through capitation. The respondents reported working a mean of 51 hours per week; however, 33% reported averaging more than 60 hours, and 7% averaged more than 70 hours. They had spent a mean of 15.3 years in practice (range = 1 to 51 years).

Only 55% of respondents felt they were appropriately compensated financially. Family physicians who were satisfied with their financial compensation reported more favorable views of managed care (F=10.55; df=1; P <.001), greater career satisfaction (F=27.07; df=1; P <.0001) and lower workload stress (F=10.42; df=1; P <.001).

Regarding their personal lives, 91% of these family physicians reported they were currently involved in a relationship, and 65% had children in their home. Politically, 30% identified themselves as democrats; 46%, republicans; and 24%, independents.

The responses to the questionnaire are shown in Table 2,Table 2b,Table 2c,. The results of stepwise regression models are presented in Table 3*Table w2.

Attitudes About Managed Care

The responses to items composing this factor show that this sample of family physicians was sharply critical of corporate managed care. For example, only 7% agreed or strongly agreed that corporate managed care is the best way to provide the health care America needs at a cost that society can afford.

The regression analyses summarized in Table 3 suggest that overall attitudes about managed care were predicted primarily by a cluster of 3 factors that tap into other concerns about managed care, reform, and accountability. Also, positive attitudes about managed care were best predicted by greater career satisfaction, a willingness to let others worry about the business of medicine, support of hospitalists, having children at home, and democratic political inclinations.

Satisfaction with Career

The response to items composing this factor suggests evidence of discontent among a significant minority of these family physicians. For example, knowing what they know now, if they could start over 63% would go to medical school again, and 66% would choose family practice again. Overall, 59% said they were satisfied with their professional lives.

In regression analyses, family physicians who were retrospectively satisfied with residency training, felt that they were appropriately compensated for their current work, and were satisfied with their personal lives were most likely to be satisfied with their careers. Both a positive attitude about managed care and reform-mindedness each independently predicted career satisfaction.

A decreased workload stress factor predicted increased career satisfaction; however, longer work hours were reported by those more satisfied with their careers. Women reported less satisfaction with their careers. Given their covariance, it is reasonable to view these variables as a cluster that together predicts 55% of the variance in career-satisfaction ratings.

Workload Stress

The response to items composing this factor suggests that a significant number of respondents felt their practice was very stressful. For example, only 9% reported that they are not overwhelmed by paperwork and administrative requirements, and 48% said that they had personally experienced more stress-related symptoms within the past year. Regression analyses suggested that greater workload stress was significantly predicted by dissatisfaction with either career or personal life, longer work hours, being female, and greater reform-mindedness.

Satisfaction with Personal Life

In their personal lives, 85% of these family physicians felt supported by a primary relationship, their family, or a social network. Healthy lifestyle habits that might help to buffer stress are reported by 52%. Overall, 71% said they were satisfied with their personal lives. As provided in Table 3, regression analyses showed that greater workload stress and longer work hours each predicted less satisfaction with personal life. Overall career satisfaction and being in a primary relationship predicted greater satisfaction with personal life. Having children in the home did not predict greater satisfaction with personal life.

Discussion

The optimism and career satisfaction reported among the majority of family physicians during the mid-1990s may have eroded in subsequent years. In this national survey in 1999, 63% would again choose to go to medical school, and 66% would again choose family practice. Only 55% were satisfied that they are receiving appropriate financial compensation, and 31% stated that they were “tired of being a doctor” and worried that they were “burning out.”

Although it is unlikely that financial incentives are a primary motivator for the decision to choose family practice, satisfaction with financial compensation was significantly associated with greater career satisfaction and lower work stress.

Nearly half of these family physicians reported that they had personally experienced a recent increase in stress-related symptoms. Many did not feel in control of the stressors they faced in daily practice, and most were overwhelmed by the paperwork and administrative requirements. It is no surprise that career satisfaction and workload stress are inversely related. However, it is less clear whether escalating work stress usually erodes career satisfaction or whether those who are less enamored with their career choice are more likely to experience practice demands as stressful.

Higher reported work hours were associated with greater career satisfaction as well as with higher perceived workload stress and less satisfaction with personal life. Although family physicians working the most hours may be doing so because they love what they are doing, long hours take their toll. Forty-four percent of respondents said they were working so many hours that their health or relationships were adversely affected. Several respondents wrote in the margins that they had opted for 50% to 80% of full time, because it was the only way to make practice tolerable. However, such a work arrangement often constitutes a full-time job by most standards, but for reduced pay.

Only 12% of the respondents felt that residency training had provided good training in practice administration. Despite recent efforts to create more relevant practice management curricula, ratings of this item did not vary significantly by years in practice, suggesting that most new graduates still do not feel prepared for the business of medicine.

Previous research has clearly shown that increased demands coupled with loss of control and a lack of safe outlets for frustration can lead to increased stress.¹⁴ This is the situation in which many of today’s family physicians find themselves. Residency training programs and state professional associations can play a significant role by speaking with candor about physician stress; integrating programs on stress management, career goals, and values clarification; and encouraging advocacy for constructive change of the health care system. Training programs must contemplate which changes are likely to maximize the number of graduates who become successful, satisfied practitioners in the current health care environment.

This sample of family physicians was sharply critical of a health care system driven by corporate managed care. Only 7% of family physicians agreed that corporate managed care is the best way to provide the health care America needs at a cost society can afford. Only 20% believed that managed care had accomplished improvements in both accountability and quality of care. Forty-two percent of these family physicians reported bad patient outcomes they perceived as attributable to managed care business processes. Despite the improved access touted by behavioral health carve-outs, 76% of family physicians report that obtaining good-quality behavioral or mental health treatment for their patients has gotten more difficult as such corporate entities have dominated that market.

There was virtual consensus for specific reforms. More than 85% of these family physicians agreed that all Americans should have access to redress for damages when managed care agents inappropriately delay or deny treatment and that managed care medical directors should be accountable to state boards of physician quality assurance for their decisions about patient care. Only 36% unequivocally supported a government-administered universal national health plan; however, an additional 21% who were equivocal suggested that growing discontent with the status quo could shift the balance to a majority in support.

Limitations

The numerous limitations inherent to our study include the use of a newly constructed questionnaire with design flaws, a modest response rate, the likelihood that respondents were different than nonrespondents, and poor representation of minority respondents. Comparison with data from other studies is limited by differences in study design and sample. These cross-sectional regression analyses allow only statistical prediction of associations, not cause-and-effect conclusions. This survey cannot be generalized to other physician specialties, and it is not appropriate to assume that family physicians are more discontent than other physicians, other professionals, or other workers.

Conclusions

This survey conveys a sobering glimpse of the prevalence of discontent among family physicians. Given the daily effects of upheaval in our health care system, perhaps we should be pleased that 2 out of 3 family physicians would still choose the same path if they had to do it over again. However, the next decade may answer whether our health care system can thrive if there is continued erosion of the support and confidence of skilled, committed, and reasonably content primary care physicians.

Acknowledgments

Financial assistance was provided by Medstar Research Institute. Thanks to both Ms. Michelle Appel and Medstar Research Institute for statistical consultation. The opinions expressed are the views of the authors and are not to be construed as reflecting the views of Medstar Health or the Public Health Service.