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| REVIEW ARTICLE |
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| Year : 2018 | Volume
: 2
| Issue : 2 | Page : 35-39 |
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Physicians' dissatisfaction: A short review
Giuseppe Cocco
EFESC (Emeritus Fellow of the European Society of Cardiology), Medical Office, Marktgasse 10A, CH-4310 Rheinfelden, Switzerland
| Date of Web Publication | 22-Aug-2019 |
Correspondence Address:
Prof. Giuseppe Cocco
Medical Office, Marktgasse 10A, CH-4310 Rheinfelden
Switzerland
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/hm.hm_3_19
The review deals with “physicians' dissatisfaction (PD) due to working conditions.” The definition of PD is not standardized, and therefore, published papers report different data. It is, however, undeniable that the position of the physicians within the society has altered dramatically and that these changes are distressing. Every human deserves the right to be happy and fulfilled in his/her vocation. Too many physicians dislike their work after some years in practice. Of note, the financial aspect is not the first relevant cause of their dissatisfaction. The most important causes of dissatisfaction are the loss of autonomy, political mismanagement, and many bureaucratic hurdles. The increasing dissatisfaction among many physicians cannot simply be dismissed as inconvenient. The causes of their dissatisfaction are real because they interfere with a good medical care of patients. Dissatisfied physicians can negatively influence the workplace. Physicians should enjoy good working conditions and communities to which they can connect. This will allow them to devote time and energy building ties in their communities. There is an urgent need for all stakeholders to reconsider how to create a working environment that would reduce PD. Keywords: Bureaucracy against medicine, physicians' dissatisfaction, unsatisfactory art of healing
How to cite this article:
Cocco G. Physicians' dissatisfaction: A short review. Heart Mind 2018;2:35-9 |
| Introduction | |  |
The profession of medicine has undergone dramatic changes in the last century, from a slow, glorious climb in well-being to a steep, stomach-churning fall. A growing malaise among physicians is clearly reported in all countries.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] This is a mini-review on the frequency and causes of current physicians' dissatisfaction (PD).
| Search Terms and Selection of Papers | | |
The phrase “medical dissatisfaction due to the working conditions” was searched in CardioSource, CenterWatch, ClinicalTrials.gov, Cochrane Summaries, Google Scholar, MedSearchcom, MedWatch, PubMed, and PsycInfo databases using a time frame from 1980 to 2019. This search delivered >2 million references, with the majority dealing with dissatisfaction among patients, nurses, and students. The search term next used was “physicians' dissatisfaction” and this delivered >320,000 references. Plagiarism software found that many authors wrote similar papers in different journals. A total of 100 papers reported data on PD due to working conditions. 36 most important papers were selected because of their good collecting tools. Some important papers may have been missed, but in my opinion, selected papers allow a solid review.
| Definition of Physicians' Dissatisfaction | | |
Physicians' job satisfaction research has been carried out for decades, but there is no standardized definition of PD. Indeed, there is no overview of tools used to collect data and of their validity.[1] Some authors[3] defined PD in relation to the quality of the doctor–patient interaction and reported PD rather than PD. Other authors[4] reported dissatisfaction in “medical interns” and not in terms of working physicians. Many papers rather measured physicians' burnout and stress.[2],[6],[9],[11],[14],[15],[16] These psychic changes do not always translate into PD, especially if they are combined with a successful medical profession. Here, dissatisfaction may be unrelated to working conditions. Obviously, papers deliver diverging data because they measure different things.
| Reasons For Physicians' Dissatisfaction | | |
The first question is “if” physicians are unhappier than in previous years, and if so, “why.”
It is impossible to find a single explanation for current PD and to unravel all the causes. Many factors have changed recently in how medical students study and how physicians are chosen, trained, remunerated, monitored, and treated in their profession. The complexity of medical care, patients' expectations, and wider sociopolitical and financial aspects have also changed.
In 2016, the National Health Service (NHS) junior physicians protested by holding placards, proclaiming that they were devaluated, demoralized, and depressed. These three adjectives perhaps best sum up the prevailing mood of many physicians across the world.
A study[18] examined the satisfaction of USA physicians in 1986 and again in 1997. Overall, in 1997, physicians were less satisfied in every aspect of their professional life than in 1986. Differences were significant in three areas: time spent with individual patients, autonomy, and leisure time.
In 1981, 1999, and 2001, the Kaiser Family Foundation[20] conducted postal surveys of physicians' opinions based on representative random samples. Physicians reported that medical morale had gone down in recent years, and nearly half would not recommend the profession today. Administrative hassles and loss of autonomy were cited as the main reasons for dissatisfaction, followed by excessive professional demands, less respect for the medical profession, and inadequate financial rewards. Other studies have also shown greater dissatisfaction and worsening of well-being in recently qualified physicians compared to older ones.
Using the same methodology, Rout et al.[2] surveyed English general practitioners eight times between 1998 and 2015. The 2015 survey showed the lowest levels of job satisfaction and highest levels of stress since the start of the survey series, as well as an increase in the proportion of general practitioners intending to quit direct patient care within the next 5 years.
In 2017, the Royal Medical Benevolent Fund conducted a postal survey[18] of almost 2000 senior physicians. Ninety-two percent said that working conditions in the UK hospitals had deteriorated in the past decade. The physicians who trained before 2000 recall fondly their team working with other physicians. They agree that, however, tired they were, it was better to be a trainee physician in the past than it is now.
Finally, recent research by experts at the American Medical Association and the Mayo Clinic[19] regarding the professional satisfaction of the USA physicians suggests burnout, dissatisfaction with digital health records, and challenges with work–life integration. These facts could cause physicians to leave their profession and profoundly affect the projected shortage of USA physicians. Roughly, 20% of physicians intend to reduce clinical work-hours in the next year. One in 50 physicians intends to leave medicine for a different career entirely in the next 2 years. Dissatisfaction with work–life integration and dissatisfaction with the digital health record systems were also the contributing factors.
[Table 1] summarizes the reported reasons for PD, the causes being given with decreasing importance.
| General Physicians' Dissatisfaction | | |
Konrad et al.[20] used a valid questionnaire which was dealing with satisfaction–dissatisfaction related to the medical profession and compared their data with meta-analyses report data from thousands of USA physicians. This is a good paper to understand how many physicians are dissatisfied and their reasons. One might object that these USA data might not be applicable to other countries. However, the working conditions are similar in Western countries and are perhaps worse in most East European, South American, Asian, and African countries. Thus, USA data can be generalized. Konrad's paper shows that generalists and specialists have generally comparable levels of dissatisfaction, whereas physicians in the oldest age group have indicated greater satisfaction than younger ones. Twenty-seven percent of physicians anticipated a moderate-to-definite likelihood of leaving their practices within 2 years. The percentage that anticipated leaving varied with physicians' age, starting at 29% of those 34 years or younger, steadily decreasing with age until a nadir of 22% of those from 45 to 49 years, then reversing direction to steadily increase thereafter. Relative dissatisfaction with financial remuneration and with relationships with communities was associated with plans for leaving in nearly all physician groups. For specific specialty and age groups, anticipated departure also correlated with relative dissatisfaction with other selected areas of work. Papers from other countries, with smaller number of cases and with less good methods of assessment, come to very similar data and conclusions.[2],[7],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30]
| Medical Training and Dissatisfaction | | |
Some USA medical schools changed the training program: Students spend less time in class or studying compared to students in “traditional” medical schools. A student with the new program reports lower stress, less exhaustion, a greater sense of engagement, and improved quality of life, mental health, and academic performance. It is possible that this novel teaching program may improve satisfaction when students become physicians. However, current PD is mainly related to poor working conditions and remuneration, and in my opinion, it is likely that PD will remain.
Current training medical rotations are different from the past. Training physicians move frequently from hospital to hospital and operate more like itinerant workers than stable residents. These factors undermine the ability to build physicians' cohesion and also continuity of patients' care. Yet, it is exactly continuity, in terms of location, medical contacts with peers, trainers, healthcare personal and not less important of caring for patients from admission to discharge, that is so important for the well-being of physicians and patients.[4]
| Physicians' Gender and Dissatisfaction | | |
Physicians' gender has changed in the last years. A paper from the USA[31] found that in 2017, 20% of medical school graduates were male, 40% of the training residents became a specialist, and 60% of practicing specialists were male. On the other hand, in 2017, women made up the majority of entrants to medical schools and just 14% of American medical students were male. This compared with 49.8% in 2016. In the USA, female matriculants increased by 3.2% in 2017, while male matriculants declined by 0.3%. Since 2015, the number of female matriculants has grown up by 9.6%, while the number of male matriculants has declined by 2.3%. The situation is similar in Europe and in many other countries. At present, women make up the majority of entrants to medical schools, and just 14% of medical students are male. These data confirm that physicians' gender has changed and is still changing.
In 2013, a study[15] found that some 20 years ago, when the trend of feminization in medicine started, the dissatisfaction of female specialists was due to loss of professional autonomy and loss of income. Female physicians have different roles in the medical activity, and there is the unproven suggestion[18] that female physicians are more willing to disclose stress. However, this is probably wrong because female physicians report the same causes of dissatisfaction as male physicians. Therefore, dissatisfaction is not affected by gender.
| Physicians' Ethnicity and Dissatisfaction | | |
At least in the USA and England, non-Caucasian physicians seem to be more dissatisfied than Caucasians. However, the quality of available data is poor, and in my opinion, it seems than anecdotal reports deal more with a personal and social dissatisfaction than with work-related problems.
| The Corporatization of Healthcare | | |
Medicine is a hard taskmaster and healthcare environments have always been emotional places to work in. However, what happens in hospitals is of marginal importance, whereas it is essential how medicine is delivered and staffs are treated.[30],[31],[32],[33],[34],[35],[36] Indeed, even excellent articles about PD[7],[20] do not mention that healthcare is increasingly dominated by large organizations whose leaders may sometimes be incompetent, self-interested, and even corrupted.[30],[31],[32],[33],[34] Physicians now complain of having little control over their working hours, job security, authority, days off, and insufficient support from superiors when things go wrong. The growing culture of litigation and media scrutiny leaves little room for error and increasingly calls for physicians to be named, blamed, and shamed.[5],[7],[20],[33],[34],[35],[36] Physicians are caught in the crossfire of the changing positions of individual in society and especially the redistribution of power and authority. Furthermore, the industrialization of medicine, with its focus on productivity and profit, conflicts with the values of medicine and causes widespread anxiety.[33],[34],[35],[36] This situation impacts especially medical professional self-identity, changing the role of medicine from a craft concerned with the uniqueness of each encounter with patients to mass manufacturing industry. As power is concentrated in larger organizations, the ability of their leaders to do good or ill also increases. Medical school and hospital officials often behave as if those institutions were producing goods or cereals.[32],[33],[34],[35] Multiple anecdotes about bad leadership have appeared in the local USA news media but are rarely mentioned in the medical, health research, and policy literature. For example, the ultimately bankrupt Allegheny Health, Education, and Research Foundation, assembled by a chief executive officer who paid huge management salaries, covered up increasing debt and was convicted of misapplying charitable funds.[34] Physicians who must deal with such leadership cannot help but be demoralized and even despairing.
Another problem with a negative impact on medical satisfaction comes from a huge and often useless bureaucracy. This is poisonous because less and less time is being spent by physicians doing what they were actually trained to do. They face a mountain of nonmedical administrative tasks to deal with.[37] For instance, some studies suggest that new interns are spending as little as 10% of their day in direct patient care. If the essence of any trained physicians' day is so much changed from what they are supposed to do, they will not react well to this. The burden of digital medical records and massive data-entry requirements have changed physicians from highly trained persons into data entry clerks.[2],[6],[7],[8],[9],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38]
| Artificial Intelligence | | |
Artificial intelligence has come, and enormous advances in this technology are occurring at a fast speed. According to the experts in the next years, artificial intelligence will play a major role in healthcare system.[39] Artificial intelligence may be extremely useful in diagnostics and therapeutics, but in the hands of non-medical medical school and hospital managers it may undermine the quality of life of physicians and also collect data in their private life.
| Cost of Healthcare | | |
The costs of our healthcare system are unsustainable. The USA spends trillions on healthcare.[33],[34],[35] To put that into perspective, that is more than the total gross domestic product (GDP) of most countries in the world. Germany, next on the list, has an entire GDP of $3.4 trillion. If the brakes are not somehow applied, spending could reach over a third of the entire GDP within 30 years. These costs would destroy the economy of most countries. Currently, most Western countries spend almost double the OECD GDP average percentage. Yet, the present outcomes are not near to what they should be because the population is aging and treatments are getting more and more expensive, all against a backdrop of rising expectations. The pressure to reduce costs is filtering through to all levels of our healthcare systems, but it is ineffective and has a negative impact on the medical satisfaction because it reduces the possible therapy for too many patients.
| Conclusions | | |
Many deteriorating causes of PD are intangible and amorphous. Collected data are not standardized and deliver different figures. However, it is undeniable that the position of the physicians within society has altered dramatically and that this change is causing distress. Published data do not explain whether we are measuring physicians' well-being more stringently, whether physicians are now more able to disclose distress than previous generations might have been, or whether PD has increased. One might object that measured PD would be different depending on the used methods. Nonetheless, almost without exception, published studies report that too many physicians are dissatisfied and indicate that past generations of physicians were more satisfied. Of note, the financial aspect is not the first relevant cause of PD. More important causes of PD are loss of autonomy, political mismanagement, and useless and excessive bureaucratic hassles. While most physicians still take satisfaction in their work, we face an epidemic of PD and burnout.[17],[20] Some researchers shockingly suggest that this tops 50% for all physicians. This dissatisfaction may contaminate the others, putting physicians off a profession, which is still satisfactory, well paid, and rather secure. The increasing dissatisfaction among many physicians cannot simply be ignored or dismissed as inconvenient. So what happened? Over the last 20 years, we have faced a storm of factors coming together. Practicing physicians do not any longer practice independently with an appropriate degree of autonomy and control. The current regulatory and reimbursement environment makes it very difficult for physicians in independent practice. The employee model may bring some benefits in terms of perceived “job security” but that comes at a great price as well. Physicians, by their nature, are very independent-minded and free-thinking souls, and this does not always sit well in a controlled employer–employee-type relationship. Bureaucracy is poisonous for the medical profession. Hospital and healthcare systems should not be managed as if they were goods production factories.[33],[35] It is time for the healthcare and political communities to address these issues and to stop financial and political actions which would further reduce the physicians' responsibilities and satisfaction.[22] A major problem for physicians arises from “what to do and what not to” do by all kinds of “upstairs” nonmedical administrators. Indeed, when this question was posed to physicians working for the NHS in the UK, the most common answer was perceived loss of control over how they could do their medical profession, being told how to do it.[9] Too many physicians are now being forced into cutting back their hours, looking for alternative ways to work, and additional income streams. Altogether too many are leaving clinical medicine. It is vital for any society to have good and motivated physicians. If we are now in a situation where we just accept that many physicians are destined to dislike their work after some years in practice, this shall have huge consequences for any country. Working physicians should get appropriate compensation in communities to which they can connect. Once there, they should devote time and energy building ties in their communities. Every human deserves the right to be happy and fulfilled in their vocation. This ship needs to be somehow turned around. Moreover, it needs to happen fast.
Acknowledgment
The author thanks Mrs. Jacqueline Bugmann for the secretarial work.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1]
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