Perceived Complexity of Care, Perceived Autonomy, and Career Satisfaction Among Primary Care Physicians

Sample

This study was a secondary analysis of data collected in 3 waves of the Community Tracking Survey (1996 to 1997, 1998 to 1999, and 2000 to 2001); these waves included different participating physicians. Data from the 2004 to 2005 survey were not included because many of the variables differed. The sampling strategy using American Medical Association and American Osteopathic Association files was designed to produce a sample representative of physicians providing direct patient care.^18,19 Office- and hospital-based physicians who had completed training and provided at least 20 hours of direct patient care weekly were included with PCPs oversampled. Of the original 18,947 eligible physicians in 1996, 12,385 (65%) were interviewed over the telephone. Item nonresponse rates were generally below 3%.

The Community Tracking Survey used a complex design with 60 sites. Although some physicians completed more than one panel, the public access files used in this survey cannot identify changes in individual physician responses over time. According to study documentation, “it is suitable for most researchers who wish to perform analyses at the national level and do not anticipate using the site-level information in their analysis”²⁰; site-level information was not used in this analysis. For this study, only PCPs (from family or general practice, general internal medicine, or pediatrics) were used.

Predictors

Predictors were clustered into 4 groups: (1) physician characteristics; (2) practice characteristics, including the use of practice improvement strategies; (3) perceived complexity of patients; and (4) physician autonomy.

Analysis

Data were weighted using the weights provided in the public access file. To assess possible interaction effects between perceived complexity of care and perceived autonomy of the predicted probability of career satisfaction, 2-way analysis of variance was conducted. To identify the relative contributions of physician characteristics, practice characteristics, improvement strategies, and physician perceptions, staged logistic regression analysis was performed for career satisfaction for each survey. Model 1 consisted of physician characteristics only and model 2 consisted of physician and practice characteristics. Model 3 included practice improvement strategies in addition to the physician and practice characteristics. In model 4, the perceived complexity of care and perceived autonomy variables were added to model 3. χ² statistics were used to assess significance of each model with P ≤ 0.05 deemed significant. Goodness-of-fit was assessed using Hosmer-Lemeshow statistics and the variance accounted for was estimated using Nagelkerke adjusted R².

Complexity-Autonomy Interaction

For all 3 panels, the adjusted probability of satisfaction is significantly associated (P < .001) with both perceived complexity of care and perceived autonomy. As Figure 1 demonstrates, physicians who report both low levels of perceived autonomy and high levels of perceived patient complexity are less likely to be very or somewhat satisfied with their career in medicine after controlling for physician, practice environment, and practice improvement characteristics. For example, predicted career satisfaction rose from 55% among 2000 to 2001 physicians who reported low perceived autonomy and high perceived patient complexity to 86% among those reporting low perceived patient complexity and high perceived autonomy.

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Figure 1.

Predicted probability of career satisfaction as interaction between patient complexity and perceived autonomy.

Correlates of Career Satisfaction

In each case, practice environment characteristics contributed the most to satisfaction, followed closely by physician perceptions (see Tables 2, 3, and 4). Across all 3 surveys, multiphysician practice; the ability to obtain high-quality ancillary services; lower proportion of revenue from managed care; lower levels of perceived complexity of patients; and perceived autonomy were consistently associated with satisfaction. Although relationships between predictors and satisfaction in the 1996 to 1997 and 2000 to 2001 surveys changed little, the results for the 1998 to 1999 survey included significant associations that were not significant previously, including physician characteristics (race [β, −0.17; P = .044]; internal medicine [β, 0.78; P = .037]; family practice [β, 0.78; P = .036], and pediatrics [β, 1.30; P = .001]); practice characteristics (ability to obtain high quality imaging [β, 0.41; P = .010]); and practice improvement strategies (computer-generated treatment alternatives [β, 0.16; P = .038]).

Career Satisfaction

Overall, approximately 80% of PCPs expressed satisfaction. This is similar to the results of Baker et al²³ among health management organization physicians. None of the analyses in this study found a relationship between satisfaction and physician race, gender, or salary status. This differs from previous studies that found associations with minority status,²³ gender,^7,9,23–25 and ownership,^21,25 employment,²⁵ and income.^11,21,26 Specialty was associated with satisfaction in the older analyses only; Sturm²² and Gazewood et al²⁴ found significant differences across specialties. Beginning practice after 1975 (perhaps a proxy for physician age) was an inconsistent predictor, consistent with previous studies.^9,11

Practice environment variables were more important to satisfaction. Our analyses found that more weeks practicing per year, more hours per week in patient care, and being in a solo practice were significant correlates of lower satisfaction. Previous studies have found that hours spent in patient care,^11,24 a solo practice,²² and the availability of assistants¹¹ were significant correlates. The ability to obtain high-quality ancillary services was a consistent predictor of satisfaction. Although revenue from Medicare was an inconsistent predictor, income from managed care was consistently and inversely related to satisfaction. Previous studies have found conflicting results concerning the relationship between managed care and satisfaction,^22,24 but incentives to reduce services seems to adversely affect satisfaction.⁸

Practice improvement strategies were not related to satisfaction. The use of performance indicators has been felt to decrease perceived autonomy even though some physicians view them as a challenge.²⁷ However, the perception that the level of perceived complexity of expected care was greater than it should be was a consistent correlate of dissatisfaction. Although not studied previously, Lin et al¹¹ found that the complexity of claims was associated with dissatisfaction among PCPs.

This study found a consistent association between perceived autonomy and career satisfaction. Not surprisingly, this relationship has been documented previously.^{21,24–26,28} In fact, Baker et al²³ found that perceived autonomy was the most important predictor of satisfaction among health management organization physicians. Our study also found considerable overlap among consistent predictors (the ability to obtain high-quality services, the proportion of revenue from managed care, and the perceived complexity of care expected greater than it should be). Previous work found that perceived autonomy was related to financial autonomy,¹⁴ discipline,²² solo practice,²² and managed care revenues,²⁴ perhaps because of the effect of incentives to reduce services.⁸ Thus, these outcomes are related but not identical.

Implications

Although this study represents 3 cross-sectional, and not causal, analyses, there is reason to consider some to be cause-and-effect relationships. If so, one implication of this analysis is that factors which influence perceived complexity or perceived autonomy will probably influence satisfaction as well. In particular, the ability to obtain high-quality services and minimizing the proportion of revenue from managed care are important factors in maximizing satisfaction. Second, the use of practice improvement strategies had a minimal effect on satisfaction. Although these strategies emphasize the conflict between providing what is best for the illness versus the patient,²⁹ they should have little effect on satisfaction. Third, the perception that physicians are expected to provide care at an inappropriately high level of complexity was consistently negatively associated with satisfaction. This is a concerning finding because not only is the complexity of health care increasing,³⁰ but this is particularly true of primary care.³¹ In fact, by its very nature, primary care is more complex than specialty care.³² To deal with this rise in the perceived complexity of expected care, the PCP must be able to respond with flexible decision making³³ and creativity.³⁰ Generally, combined strategies are required to deal with complex problems.³⁴

But at a higher level, what are the implications for keeping PCPs and attracting new physicians into primary care? Whether or not approaches such as practice improvement strategies, managed care, and the use of incentives that limit the availability of services will help control health care costs, perceived autonomy and/or perceived complexity of care being greater than should be are clearly associated with career satisfaction. This is very relevant to the growing crisis of our inability to recruit and keep physicians in primary care. The interaction between low perceived autonomy and high perceived complexity of care creates a situation in which physicians feel they have a lot of responsibility but little authority; it is little wonder that satisfaction would be adversely affected. Yet, the Future of Family Medicine Project has emphasized the need to enhance the attractiveness of family medicine through recognition, resolution of the tension between the need for increased office visits and the provision of quality care, and addressing the challenges posed by managed care.³⁵ These issues will inevitably affect the quality and attractiveness of primary care. In addition, because the practice environment of chronic care is unlikely to change, we need to consider ways to better prepare physicians in training to cope with this high-complexity, low-autonomy reality. Through the establishment of realistic expectations and improved training in dealing with the realities of practice, physicians may alter their definitions of high-complexity care.

Limitations

There are several limitations of this study. First, the perceived complexity variables used deal with perceptions of complexity of care; the actual complexity of care was not assessed. In addition, because “complexity is greater than it should be” implies a negative assessment, its relationship to career satisfaction is somewhat circular. Second, the 1996 to 1997 regressions had poor goodness-of-fit statistics, raising concern about the validity of their results. Third, the predictors of career satisfaction accounted for <15% of the variance. In fact, for both outcomes, the predictors could not explain most of the variance; there is much more involved in satisfaction and perceived autonomy than what was measured. Fourth, comparing the regressions across surveys is concerning. Not only were different groups of physicians participating in each survey, but some predictors were not assessed in all 3 surveys. The exclusion of results from the 2004 to 2005 survey limits the timeliness of the data. The 2004 to 2005 Community Tracking Survey found that almost 84% expressed satisfaction (http://ctsonline.S-3.com/psurvey.asp). Thus, the level of satisfaction among PCPs may be increasing.

Conclusion

There was considerable interaction among perceived complexity of care, perceived autonomy, and career satisfaction and consistent predictors were identified. Practice variables as well as perceived complexity and perceived autonomy accounted for most of the variance in career satisfaction. If the shortage of PCPs is to be addressed, we must resolve issues surrounding the availability of services, the challenges of managed care, the impact of practice improvement strategies, and the perceived complexity of expected care.