Relationships Between Physician Professional Satisfaction and Patient Safety

by Mark Friedberg, MD, MPP

Perspective

As several authors have noted previously, there are good reasons to care about professional satisfaction among physicians.(1-3)

First, better professional satisfaction in any field (including more "joy in practice" [2] for physicians) is inherently good.

Second, some have warned that the United States faces a looming shortage of physicians. Better professional satisfaction could address impending shortages by improving recruitment among college students (which may not be necessary, given that medical school applications are on the rise) and encouraging fully trained physicians to spend more hours in practice per week and have longer careers. However, the accuracy of predicted physician shortages is unclear, as the Institute of Medicine pointed out in its recent report on graduate medical education reform.(4)

Third, greater physician professional satisfaction might lead to higher quality care and improved patient safety. This idea certainly has intuitive appeal. After all, who wouldn't feel uncomfortable receiving care from a burned-out, possibly depressed physician who is on the cusp of quitting? It seems completely reasonable to assume that a happier, more professionally satisfied physician would deliver better care.

Despite the face validity of this association, empirical evidence to support it is sparse. One of the most comprehensive quantitative investigations of this topic, the Minimizing Errors, Maximizing Outcomes (MEMO) study by Linzer and colleagues, found no associations between physicians' overall professional satisfaction and measures of technical quality and errors in ambulatory care.(5) And when observational studies have found quantitative associations between physician professional satisfaction and quality of care, the direction of causation is unclear.(1) In other words, it just isn't apparent which is driving which.

What could explain the absence of strong empirical links between physician professional satisfaction and the quality and safety of care? On one hand, there might be no true relationship. On the other hand, there might truly be a relationship, but the available measures of quality and safety could be too narrow or insensitive to detect it. Or, perhaps this is the wrong question. In studies based on physicians' overall levels of satisfaction, analytic models typically treat all "satisfied" physicians as if they are alike. In reality, the reasons for professional satisfaction and dissatisfaction can vary from physician to physician, and even satisfied physicians encounter frustrations in day-to-day patient care. Some of these frustrations, which are poorly captured by overall satisfaction measures, may have direct implications for quality and safety.

This brings us to a fourth reason to care about physician professional satisfaction: as an indicator of health system performance. Proponents of this idea, including me, believe that when a group of physicians is dissatisfied, stressed, or burned out, the key step is to investigate why these physicians are so miserable. If the underlying causes of physician dissatisfaction also seem likely to threaten the safety of patients and quality of care, these factors may be high-priority targets for remediation. In this view, physician professional satisfaction can serve as the proverbial "canary in a coal mine" for health systems problems that also affect patients. But everything hinges on detailed investigation. Some causes of professional dissatisfaction may have little to do with patient care (just as canaries can die from causes other than poison gas), and it is not reasonable to expect physicians to be perfectly satisfied with every aspect of their professional lives, even in an optimal health system.

In a 2013 study carried out by RAND and the American Medical Association, our team undertook a detailed mixed-methods analysis of contributors to physician professional satisfaction.(6) We found that in general, the main, unifying determinant of professional satisfaction was physicians' perceptions that they were delivering safe, high-quality care. Conversely, physicians were annoyed, frustrated, angered, and otherwise dissatisfied by factors that they perceived as limiting their ability to provide optimal care. To illustrate this point, the greatest predictor of professional dissatisfaction in the quantitative portion of the study (judging by estimated effect magnitude) was agreement with the statement "I am overwhelmed by the needs of my patients."

In both qualitative and quantitative analyses, we found many specific factors contributing to physician professional dissatisfaction that will probably sound familiar to patient safety experts. These included clinic leaders who ignored physicians' ideas for improving patient care, payers that refused to cover necessary services, practice models that did not foster collegiality with other care providers, schedules that prevented physicians from spending enough time with each patient, and mandated activities that physicians perceived as distractions from patient care. Physicians also reported frustrations with certain aspects of electronic health records that can undermine patient safety (7): crowded and poorly designed user interfaces, lack of health information exchange, and degradation of the quality of clinical documentation (including the proliferation of information that physicians do not trust).

I believe that health system leaders should view regular and detailed assessment of physician professional satisfaction as an invaluable early warning system for potential threats to quality and safety. But simply surveying physicians on their overall levels of job satisfaction isn't enough. It is far more useful, as the qualitative component of our study demonstrated, to talk with frontline physicians at length and ask tough questions: What is and isn't working? What are the obstacles to providing optimal patient care in your day-to-day practice? What are the main sources of frustration at work? When the answers to these questions suggest that problems are present in patient care delivery, the best leaders will avoid the temptation to dismiss physician reports as whining or to apply quick but ineffective fixes. Instead, as with other indicators of threats to quality and safety, the best responses to physicians' perceptions of these problems will be to seek corroborating evidence, assess the magnitude of threat, carefully design and implement solutions, and check to make sure the solutions worked—ideally with the same physicians who reported the original problem.

Mark Friedberg, MD, MPP
Senior Natural Scientist
RAND
Boston, MA

References

1. Friedberg MW. The potential impact of the medical home on job satisfaction in primary care. Arch Intern Med. 2012;172:31-32. [go to PubMed]

2. Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11:272-278. [go to PubMed]

3. Crosson FJ, Casalino L. Physician practice satisfaction: why we should care. May 9, 2013.[Available at]

4. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: Institute of Medicine, National Academies Press; July 29, 2014. [Available at]

5. Linzer M, Manwell LB, Williams ES, et al. Working conditions in primary care: physician reactions and care quality. Ann Intern Med. 2009;151:28-36. [go to PubMed]

6. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Santa Monica, CA: RAND Corporation; 2013. [Available at]

7. Wachter RM. The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age. New York, NY: McGraw-Hill; 2015. ISBN: 9780071849463.