American College of Physicians: Internal Medicine — Doctors for Adults ®

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A look at physician satisfaction in a time of change

From the March 1998 ACP Observer, copyright 1998 by the American College of Physicians.

By Deborah Gesensway

Life as a practicing doctor has changed radically since the medical boom years of the half century that followed World War II, and the 21st century promises even greater change. But even as some older physicians are eyeing early retirements and some mid-career physicians are reorganizing and relocating, medicine's furious pace of change doesn't seem to be scaring away the next generation of physicians.

"The upcoming swell of premedical students and medical students and residents doesn't seem to be complaining about their lives," said Charles E. Lewis, MACP, a professor at the University of California, Los Angles (UCLA) and author of a number of studies that look at doctors' satisfaction with medical practice. "The over-the-hill crowd is very distressed because they've lost a lot of what they considered to be the privileges of being a physician, namely autonomy. On the other hand, those that have never known that think they are fortunate if they can find a place to practice what they were trained in."

The handful of studies that explore physician satisfaction show that younger doctors seem generally contented with their chosen profession, even though they know that they will have to compete for their livelihoods in ways that older physicians cannot imagine.

In the not-so-long-ago past, one good thing about being a doctor was that you could always find work in whatever community you wanted to live. While there aren't yet tales of doctors who are forced to drive taxicabs, the number of job options has shrunk dramatically.

A survey of nationwide residency directors published in the June 1997 Journal of the American Medical Association (JAMA) found that about 60% of cardiology graduates and 50% of gastroenterology graduates that year took a job in a state other than the one in which they did their residency, compared to 38% of general internists and 33% of family practitioners. Because the assumption is that a good many of these new doctors relocated because they had to in order to get a job, many see this trend as evidence of a glut of subspecialists, Dr. Lewis said.

That study also found that 2.2% of all 1995 graduates (the most recent group studied) were either unemployed or had taken a position in a specialty or subspecialty different from the one for which they were last trained. Another 6.3% of the graduates "experienced difficulty finding a suitable position," and the specialties that reported the largest percentage of graduates who were either unemployed or under-employed were part of internal medicine: nephrology (8.1%), pulmonary disease (6.2%), critical care medicine (5.4%) and endocrinology, diabetes and metabolism (5.3%). Once again, the conclusion is that prospects for subspecialists are dimmer than ever.

And when asked by these researchers if they thought their 1996 graduates would have a harder time finding a job in their specialty than their graduates from the year before, all of the nation's residency directors, except those in family practice and geriatric medicine, answered "yes."

Nonetheless, college students aren't shying away from choosing medical careers. It may not be as secure as in the past, but medicine still offers more job security and prospects of a good income than many other careers these students might consider. And surprisingly enough, even the older generation of physicians seems to be satisfied with medical practice, despite data that would seem to indicate otherwise. The reason seems to be simple: the doctor-patient relationship. Doctors, in general, chose their profession to be able to take care of patients, and despite all the frustrations they may have with managed care, they seem to be willing to put up with a lot for the sake of patient care. For the second year in a row, ACP's survey of internists and managed care shows that the doctor-patient relationship is the main reason internists are satisfied with their careers. (See "At press time," for more details.)

Experts, however, worry whether physician satisfaction will hold up under the pressure of continuing changes, especially the new marketplace's potentially serious threats to the doctor-patient relationship.

James Tulsky, ACP Member, assistant professor at Duke University and a member of ACP's Ethics and Human Rights Committee, has done research focusing on doctor-patient communication. He said that managed care brings three main challenges to the doctor-patient relationship: time, discontinuity and the effects of capitated payment.

Dr. Tulsky explained that the time issue relates to the fact that many health plans have been shrinking the time available for appointments, a strategy he said is dangerous. "It's like the horse that you realize you can feed less and less and it still works for you," Dr. Tulsky said. "At some point, you stop feeding it and it dies. If the primary care encounter is supposed to mean anything, then that is developing a relationship and trust—a trust in the system, a trust in future decision-making. You need some time to develop that trust."

The continuity part of the problem is raised in several ways. If patients have to change doctors every few years when their employers change health plans, there is an obvious discontinuity of care. A study in the September/October 1997 issue of Health Affairs, for instance, found that 67% of doctors in states with high levels of managed care reported a "serious problem ... with movement of patients in and out of your practice because of changes in insurance coverage," compared with 42% of doctors in states with much lower penetrations of managed care. For specialists, gatekeeper models often mean that they must break off longtime relationships with patients who have chronic conditions.

Finally, in terms of payment, Dr. Tulsky said that the problem isn't that capitation is an inferior way to pay for medical services but rather that it is less familiar and harder for many patients to understand. Fee-for-service, on the other hand, is very up front. "The surgeon recommends the he take out your gall bladder, and you know that he is making money. You weigh into your decision of whether or not to have him do it your suspicion that part of reason that he is making the recommendation is that his kids are in college and he needs tuition money," he said. The incentives are so clear that they didn't even need to be stated, Dr. Tulsky said.

With capitation, however, patients don't understand the complicated financial incentives offered to physicians. As a result, patients often distrust their doctors' recommendations, even if they are the right ones. "The patient ends up thinking that you just don't want to give [this test, procedure or service] because you are being cheap," Dr. Tulsky said. He recommends more disclosure.

ACP's Executive Vice President Walter J. McDonald, FACP, said this is why the profession is reinvigorating parts of the internal medicine curriculum that stress patient-physician communication. And the College has strengthened sections of the "ACP Ethics Manual" that have to do with doctor-patient communication. (The revised edition is scheduled to be published in the April 1 issue of Annals of Internal Medicine.)

Dr. McDonald also noted that this points to the need for universal access to health care. "We have to eliminate the barriers to professionalism," he said. And the lack of universal access to health insurance is a major barrier to professionalism, he said.

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