Introduction
The rapid changes in medical practice over the last quarter
century have stimulated considerable interest in measuring physicians'
perceptions and attitudes about their work.1 Low levels of
job satisfaction among physicians may affect doctor-patient relationships
and may compromise quality of care. Dissatisfaction with professional
work among physicians has also been associated with inappropriate prescribing
patterns,2 lower levels of patient satisfaction, and decreased
patient compliance with prescribed medications and follow-up appointments.3
A recent study by researchers at the RAND Corporation
found that physician job satisfaction is linked with patient actions
that are critical to management of chronic diseases.4 The
RAND researchers followed approximately 1,800 patients with diabetes,
heart disease, high blood pressure, or depressive symptoms who visited
186 physicians practicing within HMOs,
large multispecialty groups, and solo practices in three cities. They
found that patients are more likely to follow their doctors' advice
if their doctors have busy practices, are happy in their work, take
time to answer questions, and conduct patient follow-up via phone or
office visits.
Physician turnover is also greater in organizations with
higher levels of physician dissatisfaction.5 High turnover
can disrupt continuity of care and can increase costs. Finally, high
levels of dissatisfaction decrease physicians' commitment to the practice
setting and, if persistent, can lead to mental strain and burnout.6,7
Thus, reasonable levels of physician satisfaction are prerequisites
for the stability and long-range success of HMOs.
The research literature suggests that variation in physicians'
perceptions derive from two basic sources: 1) the stress inherent in
the role of physicians,8,9 and 2) factors within a practice
or work setting.10-18 Most research has dealt with one or
the other of these sources, but no single study has analyzed their relative
importance in accounting for differences in physicians' attitudes and
perceptions.
The aims of this study were: 1) to determine whether uncertainty
in patient care affects physician satisfaction, organizational commitment,
and burnout; 2) to determine whether job characteristics of physicians
affect satisfaction, commitment, and burnout; and 3) to identify the
relative importance of uncertainty versus job characteristics in accounting
for variation in these outcomes.
Methods
Data Source/Study Setting
The data for this study, conducted in 1991-1992, were obtained by
mail surveys of physicians practicing in two Kaiser Permanente Regions:
the Northwest and the Ohio Regions. The two regions serve over 600,000
members and provide integrated, comprehensive inpatient and outpatient
care for an enrolled population. The surveys were sponsored and funded
in part by Northwest Permanente, P.C. (NWP) and Ohio Permanente Medical
Group (OPMG).
Study Subjects/Data Collection
The study group included all 526 physicians in NWP the Medical Group
affiliated with KP's Northwest Region, and all 235 physicians in OPMG,
the Medical Group affiliated with KP's Ohio Region at the time of the
study.
The survey instrument was a self-administered questionnaire
that included both structured and open-ended questions. It was sent
to each physician's home and took about two hours to complete. Each
physician could receive up to three mail contacts requesting participation
in the study. In addition, attempts were made to contact all nonrespondents
by telephone after the third mailing. The average response rate for
the two medical groups was 80%. Physician respondents in NWP and OPMG
were similar in age, but NWP respondents were more likely to be male.
NWP also had a higher proportion of family physicians and a smaller
proportion of pediatricians. For additional information about the survey
design and data collection procedures, see the article by Freeborn and
Pope.19
Brief descriptions of the study variables are given in
Table 1. All are derived from physicians' responses to the questionnaire
(self-report). More specific details on the measures and how they were
constructed are provided in the Appendix.
Outcome Measures: Dependent Variables
"Physician satisfaction" was measured by a modified version
of the measure developed by Lichtenstein.20 Three items were
included in the summary measure: the physician's satisfaction with his/
her medical career; whether the physician would choose this setting
again, given the choice; and whether the physician would recommend this
practice setting to a physician colleague (non-KP).
"Organizational commitment"21 measures
the relative strength of an individual's identification with and involvement
in a particular organization (eg, KP).
Burnout was measured by the Tedium Index, a well established
measure of "burnout."22 It represents three aspects
of tedium: physical exhaustion, emotional exhaustion, and mental exhaustion.
Independent Variables
Uncertainty
"Stress from Uncertainty (SUS)"9 measured
physicians' affective reactions to uncertainty in patient care (eg,
uncertainty of diagnosis, not being sure what is best for the patient,
etc.).
Job Characteristics
"Job demands" was measured by a single item that asked
physicians, "In order to do a good job, is your total number of
patient visits about right, too high, or too low for the number of hours
you work?" In the analysis, this variable was collapsed into two
categories (too high versus about right/too low).
"Control" was a summary measure based on four
questionnaire items (ability to influence work environment, opportunity
to participate in decision-making, the degree to which lack of autonomy
contributes to feelings of stress, and satisfaction with control over
schedule).
"Resources" was a modified version of the measure
developed by Lichtenstein.20 It captures physicians' satisfaction
with availability and adequacy of various resources such as support
staff and equipment.
"Social support" was a four-item summary measure
of the quality of colleague relations (eg, emotional support and helpfulness
among physician colleagues).
Covariates: Other Variables That May Be Related
to the Outcomes
"Workload intensity" was based on two items from the
survey: self-reported number of office visits per week, and number of
hours per week seeing patients. These two variables were divided to
give patient visits per hour.
"Caseload characteristics" were based on each
physician's estimate of the percentage of female patients in his/her
caseload and the percentage of patients 65 years old and older in his/her
caseload.
"Patient/physician relationship" was based on
a series of items that ask physicians about the extent to
which they believe patient-physician interactions are problematic or
troublesome (a correlate of dissatisfaction in many studies of HMO physicians).5,16,18,19
Physician demographics included age, gender, specialty,
time with HMO, and practice location. These were measured by individual
survey items.
Analysis
The first step in the data analysis was to examine the association
between each independent variable and each outcome measure (bivariate
analysis). The statistical procedures used included ANOVA and Pearsonian
correlations (Tables 1 and 2).
The second step consisted of a series of multivariate
analyses (multiple regression) to determine significant predictors of
the study outcomes after controlling for the effects of the other variables
(covariates) (Tables 3, 4, and 5). Key conceptual variables and factors
that were significant at the p0.05 level in the bivariate analyses were
included in the multiple regression analyses.
Results
The three outcome measures were interrelated. Physician satisfaction
and organizational commitment were highly correlated (r = 0.74; p0.05),
and both physician satisfaction (r = -0.49) and organizational commitment
(r = -0.41) were negatively correlated with burnout (p0.05). That is
to say, as physician satisfaction and organizational commitment increased,
burnout decreased.
Bivariate Analyses
All three outcomes were associated with physician age and specialty
(Table 1). Older physicians (>48 years of age) had higher mean satisfaction
and commitment scores than younger physicians, and burnout scores were
lower for younger (30-36 years of age) physicians and for older physicians
(>48 years of age) (when compared with physicians in the two middle
age categories). Pediatricians had higher mean satisfaction and commitment
scores than physicians in other specialty categories. Compared with
other specialty categories, general internal medicine had the lowest
mean satisfaction score and the highest mean burnout score.
Stress from uncertainty was weakly correlated with physician
satisfaction (r = -.13; p0.05) and was unrelated to organizational commitment
(Table 2). Stress from uncertainty was more highly correlated with burnout
(Tedium Index) than with physician satisfaction or organizational commitment
(r = 0.33; p0.05). Physicians with higher stress from uncertainty were
more likely to experience burnout (Table 2).
Job characteristics were significantly related to all
three outcomes (Tables 1 and 2). Physicians who felt their job demands
were too high had significantly lower mean satisfaction and commitment
scores and significantly higher burnout scores than physicians who felt
their job demands were about right/too low (Table 1). Perceived control,
resources, and social support were significantly and positively correlated
with both physician satisfaction and organizational commitment (Table
2). These factors were also significantly related to burnout, but the
coefficients were lower than those for satisfaction and commitment.
In the case of burnout, the correlations were negative: as perceived
control, resources, and social supports increased, burnout decreased.
In terms of the covariates, intensity of workload (patients
seen per hour) did not significantly affect any of the outcomes. The
patient-physician interaction variable was weakly correlated with the
outcomes, and the findings were similar for the caseload variables (percent
patients female, percentage patients 65 years of age and older) (Table
2).
Multivariate Analyses
Perceived control was the single most important predictor of physician
satisfaction after other factors were taken into account. Other significant
predictors included social support, stress from uncertainty, specialty,
and resources (Table 3). The model explained approximately 43% of the
total variation in physician satisfaction (R2 = .432). Perceived
control, social support, specialty, and resources were significant predictors
of commitment (Table 4), but the percentage of variation explained was
smaller (35%; R2 = .354).
Perceived control was the most important predictor of
burnout, followed by stress from uncertainty and job demands (perceived
workload) (Table 5). Other significant predictors were social support,
physician age, and characteristics of the physicians' caseloads (percentage
of female patients, percentage of patients 65 years of age and older).
The model accounted for 36% of the total variation in the burnout variable
(Tedium Index) (R2 = .358).
Summary/Discussion
Perceived control over the practice environment, support
from colleagues, and satisfaction with availability of resources were
associated with higher levels of physician satisfaction and organizational
commitment. Stress from uncertainty in dealing with patients affected
satisfaction adversely but was unrelated to level of organizational
commitment. There were also differences in physician satisfaction and
organizational commitment by specialty. Pediatricians were more satisfied
and more committed than other specialists, a consistent finding in other
studies of HMO physicians.16,19,23
Perceived control over the practice environment was also
the single most important predictor of physician burnout. Stress from
uncertainty in patient care, job demands, and social support also affected
burnout levels among physicians. Physicians with less perceived control,
greater stress from uncertainty, higher job demands, and fewer social
supports were at greater risk for burnout. Other correlates of burnout
included physician age and characteristics of a physician's caseload.
Higher percentages of female and older patients were associated with
higher levels of physician burnout.
The problem with our study and with most of these studies
is that they are cross-sectional. There is a strong need for prospective
data and longitudinal studies on the effects of physician dissatisfaction,
burnout, and other measures of physician psychological well-being. Better
measures of physician satisfaction8,20 as well as more objective
measures of workload and practice characteristics are also needed to
clarify the real risk factors for practitioner dissatisfaction and burnout.24
Our study has many of these same problems. Another limitation is that
it focused on only one form of HMO (the nonprofit group model) and was
limited to two KP sites. In addition, many changes have occurred in
these practice sites since the early 1990s, and the larger medical environment
has also changed dramatically.
Despite these limitations, our results confirm the growing
evidence from a variety of occupations and settings that workers who
perceive more control over their work are healthier, happier, more satisfied,
and more productive. Physicians are no exception, as Wagner points out:24
"Bureaucratic efforts to micromanage their (doctors) patient care,
or control their staff or work setting need careful reexamination."
Implications for Physician Behavior
Does it matter if physicians are dissatisfied, lacking in commitment,
or burned out? What's the quality of the evidence regarding the relation
between physicians' attitudes and perceptions and their actual behavior?
Most studies have examined physician satisfaction and
its impact on various physician outcomes. The evidence is fairly strong
in terms of physician turnover. A consistent finding in the research
literature is that organizations with higher levels of physician dissatisfaction
also have higher physician turnover rates. This finding is important
because of its implications for organizational effectiveness. As Lichtenstein5
points out, "The task of retaining physicians is a crucial one,
not only because the organization must maintain its own stability and
predictability, but also because the organization must seek to maintain
the stability of the doctor-patient relationship and the continuity
of care provided by physicians to patients."
As mentioned earlier, some studies also suggest that physician
satisfaction can influence patient satisfaction,3,5,25 which
has consequences for membership retention in HMOs.19 The
evidence is weaker regarding the relation between physician satisfaction
and quality of care, but a few studies have found that physician dissatisfaction
can adversely affect quality.2,4 The findings of the Medical
Outcomes Study4 suggest that patient compliance is affected
by the attitudes of physicians and that breakdowns in compliance can
have serious adverse effects, particularly for patients with chronic
diseases.
Dissatisfied physicians may also have more costly practice
styles. Several studies have found that dissatisfied physicians use
more total outpatient procedures and make more referrals than physicians
who are satisfied, even after adjusting for case-mix and other covariates.26,27
Whether these differences affect outcomes is unclear, but greater resource
use by physicians certainly increases the cost of care.
Few studies, if any, have examined how level of commitment
to an organization (eg, KP) influences physician behavior, but because
organizational commitment and physician satisfaction were so highly
correlated in this study, one might expect that the effects would be
similar to satisfaction. Well-designed empirical studies on the effects
of physician burnout are also sparse, but the few existing studies suggest
that burned-out physicians have more problems relating to patients.
Their quality of care may also suffer.6,7,10,12,25
The tendency in today's competitive medical environment
is to emphasize financial incentives and to increase scrutiny of medical
decision-making in order to reduce costs and increase productivity.
These mechanisms increase the tension in clinical decisions and can
have unanticipated consequences with respect to physician morale and
performance. As many scholars have pointed out, organizations do not
succeed on the basis of rational incentives alone but by inducing suitable
emotions--commitment, loyalty, satisfaction, and trust--in their participants.
Internalized motivation is the most effective approach for enhancing
performance of workers in any setting.11,12,28
Acknowledgments: I wish to thank and acknowledge
the important contributions of Ralph Schmoldt, PhD, and Harvey D. Klevit,
MD, NWP Physician Emeritus. Drs. Schmoldt and Klevit assisted in the
design of the original surveys and played key roles in their implementation.
Special thanks are also in order for Ron Potts, MD, Medical Director
of the Ohio Permanente Medical Group (OPMG) at the time of the survey.
His support and assistance were crucial for the success of the OPMG
survey. I also recognize with thanks those Northwest and Ohio Permanente
physicians who made this study possible by their participation in the
surveys. Their investment of time and energy is greatly appreciated.
Finally, I'd like to thank Vicky Burnham for her skilled research assistance
and her editing expertise during manuscript preparation.
References:
-
Baker LC, Cantor JC. Physician satisfaction under
managed care. Health Aff (Millwood) 1993; 12 (suppl.):258-270.
-
Melville A. Job satisfaction in general practice:
Implications for prescribing. Soc Sci Med 1980; 14A:495-499.
-
Linn LS, Brook RH, Clark VA, et al. Physician and
patient satisfaction as factors related to the organization of internal
medicine group practices. Med Care 1985; 23(10):1171-1178.
-
DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians'
characteristics influence patients' adherence to medical treatment:
Results from the Medical Outcomes' Study. Health Psychol 1993; 12(2):93-102.
-
Lichtenstein, RL. The job satisfaction and retention
of physicians in organized settings: A literature review. Med Care
Rev 1984; 41:139-179.
-
Deckard G, Meterko M, Field D. Physician burnout:
An examination of personal, professional, and organizational relationships.
Med Care 1994; 32:745-754.
-
Schmoldt RA, Freeborn DK, Klevit HD. Physician burnout:
Recommendations for HMO managers. HMO Pract 1994 Jun; 8(2):58-63.
-
Stamps PL, Boley Cruz NT. Issues in Physician Satisfaction:
New Perspectives. Ann Arbor, MI: Health Administration Press: 1994.
-
Gerrity MS, DeVellis RF, Earp JA. Physicians' reactions
to uncertainty in patient care: A new measure and new insights. Med
Care 1990; 28(8):724-736.
-
Pines A, Kafry D, Etzion D. Job stress from a cross-cultural
perspective. In: Reid K,. Quinlan RA, (eds) Burnout in the Helping
Professions. Kalamazoo, MI: Western Michigan University: 1980.
-
Quick JC, Bhagat RS, Dalton JE, Quick JD, (eds). Work
Stress: Health Care Systems in the Workplace. New York, NY: PRAEGER:
1987.
-
Karasek R, Theorell T. Healthy Work: Stress, Productivity,
and the Reconstruction of Working Life. New York, NY: Basic Books,
Inc: 1990.
-
Eisenberg JM. The internist as gatekeeper: Preparing
the general internist for a new role. Ann Intern Med 1985; 102:537-543.
-
Mechanic D. From Advocacy to Allocation: The Evolving
American Health Care System. New York, NY: Free Press: 1986.
-
Budrys G. Coping with change: Physicians in prepaid
practice. Sociol Health Illn 1993; 15:353-373.
-
Mechanic D. The organization of medical practice and
practice orientations among physicians in prepaid and nonprepaid primary
care settings. Med Care 1975; 13:189-204.
-
Mawardi BH. Satisfactions, dissatisfactions, and causes
of stress in medical practice. JAMA 1979; 241:1483-1486.
-
Freeborn DK. Physician satisfaction in a prepaid group
practice HMO. Group Health J 1985 Spring; 6(1):3-12.
-
Freeborn DK, Pope CR. Promise and Performance in Managed
Care: The Prepaid Group Practice Model. Baltimore, MD: The Johns Hopkins
University Press: 1994.
-
Lichtenstein RL. Measuring the job satisfaction of
physicians in organized settings. Med Care 1984; 22:56-68.
-
Modway RT, Porter LW. The measurement of organizational
commitment. J Voc Behav 1979; 14:224-247.
-
Pines A, Aronson E, Kafry D. Burn Out: From Tedium
to Personal Growth. New York, NY: The Free Press: 1981
-
Baker LC, Cantor JC, Miles EL, et al. What makes young
HMO physicians satisfied? HMO Pract 1994; 8(2):53-57.
-
Wagner EH. Clinical and outcomes research. HMO Pract
1994; 8(2):54.
-
Buller MK, Buller DB. Physicians' communication style
and patient satisfaction. J Health Soc Behav 1987; 28:375-388.
-
Eisenberg JM. Doctors' Decisions and the Cost of Medical
Care: The Reasons for Doctors' Practice Patterns and Ways to Change
Them. Ann Arbor, MI: Health Administration Press: 1986.
-
Freeborn DK, Johnson RE, Mullooly JP. Physicians'
Use of Ambulatory Care Resources in a Prepaid Group Practice HMO.
Final Report for grant no. 18-P-9799319-02, HCFA. Portland, Oregon:
Kaiser Permanente Medical Care Program, Health Services Research Center:
1984.
-
Katz D, Kahn RL. The Social Psychology of Organizations.
(ed 4). New York, NY: John Wiley and Sons: 1978.
Appendix: Measures
Global Satisfaction
The global satisfaction measure was a modified version of the global
satisfaction measure developed by Richard Lichtenstein.20
It was composed of three questionnaire items: Q.121. "In general,
how satisfied are you with your career in medicine so far?"; Q.125.
"If a physician friend of yours told he/she was interested in taking
a position similar to yours, what would you tell him/her?"; Q.126.
"If you could choose all over again, would you choose KP as a place
to practice?" The values for each question were reversed so that
a higher score represented higher global satisfaction. The new values
for each of the questions were as follows: Q.121. "1=very dissatisfied,
2=dissatisfied, 3=satisfied, 4=very satisfied"; Q.125. "1=I
would advise against it, 2=I would have doubts about recommending it,
3=I would have no trouble in recommending this position, 4=I would strongly
recommend this position"; Q.126. "1=would definitely not choose
KP, 2=would probably not choose KP, 3=not sure, 4=would probably choose
KP, 5=would definitely choose KP." The global satisfaction score
was produced by summing the values of the individual items for each
person and dividing by the number of items answered by the individual.
If the number of missing responses was >1, the scale was not scored
for that individual. Cronbach's coefficient alpha for NWP+OPMG was 0.72.
Organizational Commitment
The organizational commitment score was a modified version of the
Organizational Commitment Questionnaire (OCQ) developed by Porter (21).
The eight items (Q119a to Q119h) were as follows: Q.119a. "I am
willing to put in a great deal of effort beyond that normally expected
in order to help this organization to be successful"; Q119b. "I
talk up this organization to my friends as a great organization to work
for"; Q119c. "I find that my values and the organization's
values are very similar"; Q119d. "I am proud to tell others
that I am part of this organization"; Q119e. "This organization
really inspires the very best in me in the way of job performance";
Q119f. "I am extremely glad that I chose this organization to work
for over others I was considering at the time I joined"; Q119g.
"I really care about the fate of this organization"; Q119h.
"For me this is the best of all possible organizations for which
to work." A five-point Likert scale was used and was reversed so
that the higher score would indicate a higher commitment to the organization.
The reversed scale was as follows: 1=strongly disagree, 2=disagree,
3=neutral, 4=agree, and 5=strongly Agree. The organizational commitment
score was produced by summing the scores of the individual items for
each person and dividing by the number of items answered by the individual.
Those individuals who did not answer any of the eight items were excluded
(n=4). Only one other individual did not respond to all items (ie, responded
to six of the eight). That score was divided by six. Cronbach's coefficient
alpha for the eight standardized items for NWP+OPMG was 0.88.
Burnout: Tedium Index
The primary burnout measure is a modified version of the Tedium
Index developed by Pines, Aronson, and Kafry.22 This measure
represents three aspects of tedium: physical exhaustion, emotional exhaustion,
and mental exhaustion. The 22 items (Q.21a to Q.21v) were presented
in random order and were evaluated on a five-point scale: 1=never, 2=seldom,
3=sometimes, 4=frequently, 5=always. They are included in the basic
question, "While at work, how often do you have any of the following
experiences?" Q.21a. "Being tired;" Q.21b. "Feeling
depressed"; Q.21c. "Having a good day"; Q.21d. "Being
physically exhausted"; Q.21e. "Being emotionally exhausted";
Q.21f. "Being happy;" Q.21g. "Being 'wiped out';"
Q.21h. "Feeling 'burned-out';" Q.21i. "Being unhappy;"
Q.21j. "Feeling run-down;" Q.21k. "Feeling trapped;"
Q.21l. "Feeling worthless;" Q.21m. "Being weary;"
Q.21n. "Being troubled;" Q.21o. "Feeling
disillusioned and resentful about people;" Q.21p. "Feeling
angry;" Q.21q. "Feeling weak;" Q.21r. "Feeling hopeless;"
Q.21s. "Feeling rejected;" Q.21t. "Feeling optimistic;"
Q.21u. "Feeling energetic;" Q.21v. "Feeling anxious."
The scale was reversed for four of the items (having a good day, being
happy, feeling optimistic, and feeling energetic). The overall index
score (Tedium Score) was produced by summing the scores of the individual
items for each person and dividing by the number of items answered by
the individual. A higher score indicated higher tedium/burnout. If all
of the items had missing responses, the scale was not scored for that
individual. Cronbach's coefficient alpha for the 22 standardized items
for NWP+OPMG was 0.94.
Physicians' Reactions to Uncertainty
The Stress from Uncertainty measure is a modified version of the
Stress from Uncertainty scale developed by Gerrity et al.8
A factor analysis and a correlational analysis were used to compare
our results with those of Gerrity et al. The 13 items (Q.56a to Q.56m)
were evaluated on a five-point scale: 1=strongly agree, 2=agree, 3=neutral,
4=disagree, 5=strongly disagree. The 13 items were included in the basic
question, "Please indicate the extent to which you agree or disagree
with the following statements:" Q.56a. "The uncertainty of
patient care often troubles me;" Q.56b. "Not being sure of
what is best for a patient is one of the most stressful parts of being
a physician;" Q.56c. "I am tolerant of the uncertainties present
in patient care;" Q.56d. "I find the uncertainty involved
in patient care disconcerting;" Q.56e. "I usually feel anxious
when I am not sure of a diagnosis;" Q.56f. "When I am uncertain
of a diagnosis, I imagine all sorts of bad scenariospatient dies, patient
sues, etc.;" Q.56g. "I am frustrated when I do not know a
patient's diagnosis;" Q.56h. "I fear being held accountable
for the limits of my knowledge;" Q.56i. "Uncertainty in patient
care makes me uneasy;" Q.56j. "I worry about malpractice when
I do not know a patient's diagnosis;" Q.56k. "The vastness
of the information physicians are expected to know overwhelms me;"
Q.56l. "I frequently wish I had gone into a specialty or subspecialty
that would minimize the uncertainties of patient care;" Q.56m.
"I am quite comfortable with the uncertainty in patient care."
Eleven of the items were reversed to ensure that a greater score represented
a greater stress from uncertainty. The Stress from Uncertainty score
was produced by summing the 13 individual items for each person and
multiplying this sum by (13 divided by (13 minus the number of missing
responses)). If the number of missing responses was >5, the scale
was not scored for that individual. Cronbach's coefficient alpha for
the 13 standardized items for NWP+OPMG was 0.88 (0.90 for Gerrity et
al.), demonstrating excellent internal consistency for the scale items.
Perceived Control
This measure was composed of four questionnaire items: Q.5d. "How
satisfied are you with the ability to impact your work environment?";
Q.5e. "How satisfied are you with the opportunity to participate
in making decisions that affect your clinical practice or professional/clinical
duties?"; Q.20p. "How much does the lack of autonomy contribute
to your feelings of stress?"; and Q.76c. "In general, how
satisfied are you with control over your own work schedule?" The
values for each question were reversed so that a higher score represented
higher perceived control (more satisfied with impacting work environment,
more satisfied with participation in decision-making, less stress from
autonomy, and more satisfied with control over work schedule). The new
values for each of the questions were as follows: Q.5d. "1=very
dissatisfied, 2=dissatisfied, 3=neutral, 4=satisfied, 5=very satisfied;"
Q.5e. "1=very dissatisfied, 2=dissatisfied, 3=neutral, 4=satisfied,
5=very satisfied;" Q.20p. "1=very great deal of stress, 2=great
deal of stress, 3=moderate stress, 4=very little stress, 5=no stress
at all;" Q.76c. "1=very dissatisfied, 2=dissatisfied, 3=neutral,
4=satisfied, 5=very satisfied." This measure was produced by summing
the values of the individual items for each person and dividing by the
number of items answered by the individual. If the number of missing
responses was >1, the scale was not scored for that individual (no
individual had all questions missing). Cronbach's coefficient alpha
for the standardized variables for NWP+OPMG is 0.81.
Social Support: (Physician Relations)
This measure was composed of four items from one question: Q.7a.
"How would you rate the quality of the working relationships among
NWP/OPMG physicians?"; Q.7b. "How would you rate the quality
of the helpfulness among NWP/OPMG physicians?"; Q.7c. "How
would you rate the quality of the emotional support among NWP/OPMG physicians?";
Q.7d. "How would you rate the quality overall of relations among
NWP/OPMG physicians?" The values for each question were reversed
so that a higher score represented a higher positive evaluation of physician
relations. The new values for each of the questions were as follows:
1=negative, very negative; 2=neutral; 3=positive, very positive. The
physician relations score was produced by summing the values of the
individual items for each person and dividing by the number of items
answered by the individual. If the number of missing responses was >1,
the scale was not scored (no individual had all questions missing).
Cronbach's coefficient alpha for the standardized variables for NWP+OPMG
was 0.87.
Satisfaction with Resources
This measure was a modified version of the measure developed by
Richard Lichtenstein.20 His measure was based on 13 questionnaire
items whereas our measure used eight: Q6b. "How satisfied are you
with your department's nursing team?; Q.6c. "How satisfied are
you with the clerical staff in your medical office?"; Q.6d. "How
satisfied are you with the equipment in your medical office?";
Q.6e. "How satisfied are you with the supplies of your medical
office?";
Q.6f. "How satisfied are you with the size of your medical office?";
Q.6j. "How satisfied are you with the organization and management
of your medical office?"; Q.6n. "How satisfied are you with
the medical records of your medical office?"; Q.6p. "How satisfied
are you with the pharmacy service of your medical office?" Lichtenstein
used a different scale of values (seven-point response scale ranging
from "almost never" to "almost always"). We used
a five-point response scale ranging from "very satisfied"
to "very dissatisfied." The values for each were reversed
so that a higher score represented higher satisfaction with resources.
The new values for each of the questions were as follows: 1=very dissatisfied,
2=dissatisfied, 3=neutral, 4=satisfied, 5=very satisfied. The measure
was produced by summing the values of the individual items for each
physician and dividing by the number of items answered by the individual.
If the number of items missing was >3, the scale was not scored for
that individual. Cronbach's coefficient alpha for the eight standardized
items for NWP+OPMG was 0.74.
Patient-Physician Relationships
Physicians were asked to indicate whether they felt various potential
problems with patients were troublesome or not. A correlational analysis
and a factor analysis were used to identify which were the most highly
interrelated. (The two items excluded were Q.60g. "waiting too
long before coming for care" and Q.60f. "language, communication
problems.") The seven remaining items were as follows:Q.60a. "How
large a problem is over-concern with minor symptoms, running to a doctor
for every little thing in your practice?"; Q.60b. "How large
a problem is noncompliance with treatment recommendations in your practice?";
Q.60c. "How large a problem is not following advice regarding diet,
smoking, or other health practices in your practice?"; Q.60d. "How
large a problem is chronic dissatisfaction with treatment or care, i.e.
demand unnecessary services or treatment, in your practice?"; Q.60e.
"How large a problem is neurotic personality in your practice?";
Q.60h. "How large a problem is shopping around from doctor to doctor
and/or "working the system" in your practice?"; Q.60i.
"How large a problem is drug-seeking patients with addictive behavior
in your practice?" Each item was evaluated on a three-point scale:
1=troublesome problem, 2=somewhat of a problem, 3=little or no problem.
The scale was reversed for all seven items to ensure that a greater
score represented a greater problem. The problems index was produced
by summing the scores of the individual items for each physician and
dividing by the number of items answered by the individual. If the number
of missing responses was >2, the scale was not scored for that individual.
Cronbach's coefficient alpha for the seven standardized items for NWP+OPMG
was 0.80.
A version of this paper was presented
at the 68th Annual Pacific Sociological Association Meeting, San Diego,
California, April 17-20, 1997.
