Bergus, George R. MD; Randall, C. S. PhD; Winniford, Michael D. MD; Mueller, Charles W. PhD; Johnson, Susan R. MD
Dr. Bergus is associate professor, Departments of Family Medicine and Psychiatry, Dr. Randall is research assistant, Department of Family Medicine, Dr. Winniford is professor, Department of Internal Medicine, Dr. Mueller is professor, Department of Sociology, and Dr. Johnson is professor, Department of Obstetrics and Gynecology, and associate dean for academic affairs. All are at the University of Iowa College of Medicine, Iowa City.
Correspondence and requests for reprints should be addressed to Dr. Bergus, Department of Family Medicine, 01292-C PFP, University of Iowa, College of Medicine, Iowa City, IA 52242; telephone: (319) 384-7566; fax: (319) 384-7822; e-mail: 〈email@example.com〉.
Presented in part at the Thirty-second Annual Meeting of the Society of Teachers of Family Medicine, Seattle, Washington, May 1999.
Purpose. A few medical schools are highly successful in obtaining research funding and producing primary care physicians. The authors compared the job satisfaction of primary and specialty care faculty at one of these bimodal schools.
Methods. In 1998, all full-time physician—faculty (n = 408) in 15 clinical departments at the University of Iowa College of Medicine (a bimodal medical school) were sent a questionnaire based on the Price—Mueller model of job satisfaction. Faculty rated their global job satisfaction and perceptions about 18 workplace characteristics, stressors, and supports. Responses of primary and specialty care physicians were compared in these domains.
Results. A total of 71% of surveyed faculty (n = 341) returned usable questionnaires. Primary and specialty care faculty reported similar levels of job satisfaction (p = .20), and similar percentages (51% versus 54%, p = .63) reported overall satisfaction with their jobs at the medical school. However, primary care faculty perceived less opportunity to advance (p < .01), greater professional-role ambiguity (p = .02), less collegiality (p = .02), and less ability to make full use of their clinical skills (p = .01). Primary and specialty care faculty reported similar intentions of leaving the medical school within the coming year (p = .41).
Conclusions. Primary and specialty care physicians at one bimodal medical school reported similar levels of job satisfaction. However, the primary care physicians rated several important job-related domains lower than did their specialty care colleagues, most notably the opportunity to advance within the medical school.
Physician's job satisfaction has been shown to be related to the quality of medical care that the physicians provide,1 patients' satisfaction with the physicians,2 and physician turnover.3,4,5 Within an academic setting, the job satisfaction of physicians may be particularly important because faculty's encouragement of students to pursue training in their specialty is thought to influence students' career choices.6,7
There are several reasons why primary care physicians working within academic medical centers might experience less job satisfaction than do their specialty care colleagues. Many academic medical centers do not encourage primary care. Most medical school faculty do not believe that primary care tasks require a high level of skill, yet nearly 40% of specialty faculty will not endorse a generalist to treat patients with simple medical problems.8 Few learners at academic medical centers report that specialists have positive attitudes towards primary care physicians.8 Research-intensive academic centers may be particularly unsupportive of primary care. Students at these schools are less likely to enter primary care or to report encouragement to enter primary care.6,9 The cultures of these centers are believed to be major influences on students' specialty choices.10
However, there are medical schools that excel at both biomedical research and steering students towards primary care careers. This type of school is called a “bimodal medical school,” and the University of Washington and the University of North Carolina are well-known prototypes.11 Because of the lack of information about the job satisfaction of faculty at any of the biomodal medical schools, we surveyed primary and specialty care physician—faculty at one of these schools about the workplace's attributes and job satisfaction to determine whether primary and specialty care physician—faculty differed in any of these important realms.
The University of Iowa College of Medicine is a bimodal medical school with a highly productive research-oriented culture and a strong record of students entering into primary care. In FY 1999 it was rated tenth in public schools receiving National Institutes of Health funding and 26th overall.12 This institution is also highly successful in terms of the proportion of its graduates who enter family practice residencies. An average of 28.8% of its graduates went onto family practice residencies during a three-year period ending in 1998.13
In the spring of 1998, we sent a questionnaire based on the Price—Mueller job satisfaction model to all full-time physician—faculty (n = 480) in 15 clinical science departments at the University of Iowa College of Medicine. The Price—Mueller model is one of several job-satisfaction models that provide a comprehensive framework for analyzing and understanding employees' job satisfaction. It has previously been used in health care settings to study job satisfaction of nurses,14 hospital workers,15 and primary care residents at an academic health center.16 For our survey, we adapted the Price—Mueller model by using a focus group of physician—faculty and by pilot testing the instrument. The model contained 18 work-related variables pertaining to workplace characteristics, supports, and stressors (see List 1). Because the Price—Mueller model was developed to predict turnover, physician—faculty were also asked about their intentions of leaving the medical school in the coming year.
Each variable in the model was measured using two to five separate items adapted from previously standardized instruments.14,15,16 Physician—faculty were asked to rate their levels of agreement with statements on five-point Likert scales. Statements on the questionnaire were framed positively and negatively. The responses to the negatively framed questions were reverse coded. The scores of the individual items of each domain were summed and the mean was then used as the measure for that component.
Last, we collected data on the demographics of the individuals (faculty track, rank, age, gender, and duration of being a faculty member). Physician—faculty were asked to self-identify whether they were primary care or specialty care physicians. They were also asked to report their present work-time allocations between administration, patient care, teaching, and research.
After the responses were received, we used item means to input scattered missing data about the different work-related variables. When demographic data were missing, however, we dropped the respondent from the analysis. We undertook univariate analyses, using t-test and chi-square, to compare primary and specialty care physicians. We used two-way ANOVA to compare allocations of work time for the two groups of faculty while controlling for career track. The University of Iowa College of Medicine has two faculty career tracks: the traditional tenure track and the more recent clinical track, created for expert clinicians desiring to focus on patient care and teaching instead of research. We assessed the relationship between workplace characteristics in the Price—Mueller model and faculty specialization using logistic regression. We performed a Pearson correlation test between an individual physician—faculty member's work satisfaction and his or her intent to leave the medical school. All tests were two-tailed with a level of significance of .05 and were performed using a standard statistical software package.
Demographics and Work-time Allocation
After three mailings, 78% of the physician—faculty (n = 374) returned questionnaires, but 33 questionnaires were returned blank or with incomplete demographic information. Thus, this analysis is based on the responses of 341 physician—faculty, for an effective response rate of 71%. Responding physician—faculty were representative of the surveyed sample in terms of career track and gender (p > .05 for both).
A total of 67 of the 341 respondents (20%) reported being primary care physicians. The remainder (n = 274) self-identified as specialty care physicians. A greater percentage of the primary care physicians were women, although this difference did not reach statistical significance (27% versus 17%, p = .07). Primary care physicians were younger than were their specialty peers (44 years versus 49 years, p < .01) and were more likely to be on the non-tenured clinical career track (37% versus 19%, p < .01). There was a significant difference in how the two physician—faculty groups were distributed by faculty rank (p < .01); 39% of primary care physicians were assistant professors and 24% were full professors, compared with 26% and 43%, respectively, of specialty care physicians.
The primary care physicians reported spending less of their work week doing research than did the specialty care physicians (p = .01), but the two groups of physician—faculty spent similar amounts of time in the areas of clinical care, teaching, and administration (p > .05 for each). After factoring in the career-track influence, primary and specialty care physician—faculty spent similar amounts of time in the different work domains (p > .05 for all work domains), including research.
Job Satisfaction and Job Characteristics
Job satisfaction was assessed using three separate questions. Cronbach's alpha for these items was .91, indicating high internal consistency. On the five-point scale (5 = strongly agreed that they were satisfied with their jobs), the respondents reported a mean satisfaction of 3.2. Primary and specialty care physician—faculty reported similar levels of job satisfaction (3.1 versus 3.3, p = .20). Similar percentages of the two groups were satisfied with their jobs; 51% and 54% of the physician—faculty in these two groups reported job satisfaction scores of 3.0 or higher (p = .63). Gender and career track were not associated with job satisfaction (p = .47 and .31, respectively), but faculty rank was: full professors reported the highest job satisfaction (3.4) and associate professors reported the lowest (3.0; p < .01).
Primary and specialty care physicians gave significantly different ratings to six of the 18 work domains in the Price—Mueller job satisfaction model (see Table 1). The greatest difference was in opportunity to advance; the primary care physicians perceived significantly less opportunity to advance within the medical school than did their specialty care peers (p < .01). We did not find differences in the remaining 12 domains, including workload, continuity of care, role conflict, co-worker support, adequacy of resources, work motivation, or fairness (p > .05 for each). A multivariate model was created using logistic regression with selection, starting with work factors demonstrating p values of .10 or less in the univariate analyses. In this model, only opportunity to advance remained significantly associated with physicians' specialization. Compared with specialty care physician—faculty, primary care physician—faculty reported less opportunity to advance within the medical school (β = −0.42, p < .01).
The respondents reported a mean intention to leave their jobs at the medical school of 2.1 (on a five-point scale, 5 = strongly agreed to having plans to leave within the coming year). There was a strong negative relationship between the job satisfaction of individual physician—faculty and their plans to leave the medical school (r = -.50, p < .0001). Primary and specialty care physicians reported similar intentions of leaving (2.1 versus 2.1, p = .56), and similar percentages of these physician—faculty groups indicated that it was likely they would be leaving within a year (4.5% versus 7.3%, p = .41).
Although research-intensive medical schools, in general, have not been supportive of primary care,9,10 a small number of schools excel at both research and training primary care physicians.11 At one of these bimodal medical schools, the University of Iowa College of Medicine, we found that primary and specialty care physician—faculty reported similar levels of job satisfaction.
Primary and specialty care physician—faculty were fairly similar in their assessments of workplace characteristics, supports, and stressors except for several notable differences. The primary care physician—faculty perceived less opportunity to advance within the institution. They also reported less collegiality, being less able to make full use of their skills, and having less opportunity to grow professionally. While we found several differences in the ratings of workplace characteristics, these differences were not associated with job satisfaction. An earlier survey of job satisfaction among generalist faculty at another research-oriented center also did not find a clear association between job satisfaction and opportunity for advancement or collegiality.3 Factors reported to be associated with the job satisfaction of primary care faculty—autonomy and availability of clinical resources—were not rated significantly differently by the primary and specialty care physician—faculty at our institution.
While these data suggest that primary care physician—faculty at research-oriented medical centers may report job satisfaction as high as that of their specialty-care peers, we do not know whether these findings generalize to other bimodal medical schools. Additionally, further research is needed to answer several other important questions. We are not able to analyze the job satisfaction of the primary care physician—faculty by department because we did not collect these data. Separate analysis might be important, because there may be significantly different perceptions about working conditions among the different primary care specialties at an academic center. Also, we do not know whether the job satisfaction of specialty care faculty at other academic centers differs significantly from the level reported by our study. While over half of the physician—faculty reported satisfaction with their jobs, their mean level of satisfaction was lower than were those previously recorded for non-faculty health care professionals. Using similar Price—Mueller instruments, staff nurses have reported a mean job satisfaction level of 3.5,14 primary care residents a level of 3.4,16 and hospital employees a level of 3.5.15 We do not know whether the lesser satisfaction of medical faculty in our study is a function of the profession, of our subjects, or of the institution in which they work.
Despite these limitations, however, our findings provide insight into physician—faculty's work satisfaction, because this project has several important strengths. The response rate was high and the respondents were representative of the faculty in terms of gender and career track. Additionally, the questionnaire was based on a validated instrument extensively used in research on job satisfaction. The questions used to ascertain job satisfaction had good reliability in our population and, as measured by the Price—Mueller model, have been shown to have validity by their ability to predict employee turnover. Although we are unable to link individuals' satisfaction levels to subsequent turnover, the job satisfaction of these physician—faculty showed a negative association with intent to leave the institution. This association has been reported in other faculty satisfaction studies.3,5
In conclusion, primary and specialty care physician—faculty at one bimodal medical school reported similar levels of job satisfaction. If primary care faculty at other academic medical centers report disparate and lower levels of job satisfaction, one might consider interventions to improve their work environments, because it is possible for primary care physicians to find working in large academic medical centers as satisfying as their specialty colleagues do.
1. Weisman CS, Nathanson CA. Professional satisfaction and client outcomes: a comparative organizational analysis. Med Care. 1985;23:1179–92.
2. Haas JS, Cook EF, Puopolo AL, Burstin HR, Cleary PD, Brennan TA. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15:122–8.
3. Coyle YM, Aday LA, Battles JB, Hynan LS. Measuring and predicting academic generalists' work satisfaction: implications for retaining faculty. Acad Med. 1999;74:1021–7.
4. Price JL, Mueller CW. Absenteeism and Turnover among Hospital Employees. Greenwich, CT: JAI Press, 1986.
5. Kay LE, D'Amico F. Factors influencing satisfaction for family practice residency faculty. Fam Med. 1999;31:409–14.
6. Block SD, Clark-Chiarelli N, Singer JD. Mixed messages about primary care in the culture of U.S. medical schools. Acad Med. 1998;73:1087–94.
7. Osborn EH. Factors influencing students' choices of primary care or other specialties. Acad Med. 1993;68:572–4.
8. Block SD, Clark-Chiarelli N, Peters AS, Singer JD. Academia's chilly climate for primary care. JAMA. 1996;276:677–82.
9. Whitcomb ME, Cullen TJ, Hart LG, Lishner DM, Rosenblatt RA. Comparing the characteristics of schools that produce high percentages and low percentages of primary care physicians. Acad Med. 1992;67:587–91.
10. Colwill JM, Perkoff GT, Blake RL Jr, Paden C, Beachler M. Modifying the culture of medical education: the first three years of the RWJ Generalist Physician Initiative. Acad Med. 1997;72:745–53.
11. Osborn EHS, O'Neill EH. Bimodal medical schools: excelling in research and primary care. Acad Med. 1996;71:941–9.
13. Kahn NB Jr, Schmittling GT, Graham R. Entry of US medical school graduates into family practice residencies: 1998–1999 and 3-year summary. Fam Med. 1999;31:542–50.
14. Wakefield DS, Curry JP, Price JL, Mueller CW, McCloskey JC. Differences in work unit outcomes. Job satisfaction, organizational commitment, and turnover among hospital nursing department employees. West J Nurs Res. 1988;10:98–105.
15. Agho AO, Mueller CW, Price JL. Determinants of employee job satisfaction: an empirical test of a causal model. Human Relations. 1993;46:1007–27.
16. Randall CS, Bergus GR, Schlechte JA, McGuinness G, Mueller CW. Factors associated with primary care residents' satisfaction with their training. Fam Med. 1997;29:730–5.