Cox, Malcolm MD; Kupersmith, Joel MD; Jesse, Robert L. MD, PhD; Petzel, Robert A. MD
Dr. Cox is chief academic affiliations officer, U.S. Department of Veterans Affairs, Washington, DC, and adjunct professor of medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
Dr. Kupersmith is chief research and development officer, U.S. Department of Veterans Affairs, Washington, DC.
Dr. Jesse is principal deputy under secretary for health, U.S. Department of Veterans Affairs, Washington, DC, and professor of internal medicine/cardiology, Virginia Commonwealth University Health System, Richmond, Virginia.
Dr. Petzel is under secretary for health, U.S. Department of Veterans Affairs, Washington, DC.
Editor's Note: This is a commentary on Mohr DC, Burgess JF Jr. Job characteristics and job satisfaction among physicians involved with research in the Veterans Health Administration. Acad Med. 2011;86:938–945.
Correspondence should be addressed to Dr. Cox, U.S. Department of Veterans Affairs (10A4D), 810 Vermont Avenue, NW, Washington, DC 20420; telephone: (202) 461-9490; e-mail: firstname.lastname@example.org.
Physician satisfaction is an important contributor to a well-functioning health system. Mohr and Burgess report that physicians in the Veterans Health Administration (VA) who spend time in research have greater overall job satisfaction, that satisfaction tracks with aggregate facility research funding, and that satisfaction is higher among physicians working in VA facilities located on the same campus or within walking distance of an affiliated medical school. An environment conducive to research therefore not only advances science but also seems to be a key element of physician satisfaction. In addition to advancing scientific discovery and promoting greater physician satisfaction, these findings suggest that an environment of discovery and learning may yield benefits beyond specific academic endeavors and contribute more broadly to supporting health system performance.
When one hears the term “physician workforce,” it is usually in conjunction with workforce size (e.g., projected shortages), composition (primary or specialty care), or distribution (rural and other underserved areas) rather than in the context of professional satisfaction. Physician workforce satisfaction is a critical aspect of a well-functioning health care system, and assessments of this important metric have included factors such as job control, collegial support, income, and a variety of other incentives. An additional factor—the opportunity to conduct research—is the focus of the article by Mohr and Burgess1 in this month's issue of the journal.
The Veterans Health Administration (VA) is the largest integrated health care system in the United States and is widely recognized for its leadership in quality measurement, performance improvement, patient safety, and medical informatics as well as a variety of clinical disciplines, including geriatrics, mental health, long-term care, spinal cord injury, traumatic brain injury, and rehabilitation.2 As a high-performing, integrated health system serving nearly six million patients, VA is an ideal testing ground for examining complex interactions between individual and organizational characteristics and outcomes.
On an annual basis beginning in 2004, VA has administered a survey to all full-time employees with the goal of better understanding individual and group characteristics and preferences and promoting organizational development. Using this instrument, Mohr and Burgess found that physicians who spend at least 20% of their time in research activities have greater overall job satisfaction and are more likely to report favorable ratings on job characteristics generally considered meaningful to physicians (job autonomy, new skill development opportunities, fair and accurate performance feedback, work and family balance) than their colleagues who do not participate in research activities.
They also observed that favorable job responses track with aggregate medical center research funding, suggesting that the impact of research on job satisfaction is not only an individual but also an organizational attribute. Also evident in this study is the benefit of VA's strong partnership with academic medicine: Characteristics associated with higher job satisfaction were ranked more favorably by physicians working in VA facilities located on the same campus or within walking distance of an affiliated medical school. Taken together, these data support the long-held contention that an academic environment contributes to individual and organizational “health” by enhancing professional satisfaction.
What might it be about research that nurtures professional satisfaction? The act of discovery itself may be personally energizing, both intellectually and altruistically. With new knowledge comes the potential to cure disease, enhance health, and promote system and societal change. Moreover, research is highly valued and serves as an important arbiter of stature in the academy, often bringing with it steady career advancement. Such recognition accrues in no small part because of the spirit of inquiry and depth of expertise that researchers bring to the overall clinical enterprise.
Support of discovery and learning are components of VA's core mission. For 65 years, VA and academic medicine have enjoyed a unique partnership in education, research, and patient care.3 Beginning with its first medical school affiliation in 1946, VA's academic affiliations have become a cornerstone of American health professions education. Today, VA is the largest single provider of clinical training in the United States, hosting almost 115,000 health professions trainees annually in disciplines ranging from medicine, dentistry, and nursing to a wide variety of other health professions. Many VA physicians hold dual appointments at affiliated universities, facilitating collaboration in education and research and providing broader access to clinical care for veterans.
The commitment to support a broad portfolio of pioneering basic and applied research within an integrated health system promotes excellence in both clinical investigation and clinical care. The VA Research and Development program has used this opportunity to define a unique model for collaborative research.3 As evidence of the high quality of VA research, VA investigators have won three Nobel prizes and six Lasker awards.
The VA is committed to building a “learning organization” with the goal of creating a more flexible, adaptable, and productive organization driven toward excellent individual and system performance that continuously strives for high quality and transparency, rapidly adopts innovation and best practices, and motivates its employees to be curious and excited about learning. The study by Mohr and Burgess, coming from VA's Center for Organization, Leadership and Management Research, is one example of the many returns that come from investing in learning.
The opportunity to support physicians in teaching and research, as well as clinical practice, distinguishes the VA from many other health care systems. Although teaching and research activities take time away from direct patient care, the return on investment is substantial. Surveys of VA trainees and staff consistently demonstrate that those who have clinical educational experiences in VA are more likely to seek employment with the agency following completion of training.4 Moreover, many local, regional, and national VA leaders were initially drawn to the agency because of the opportunity for engagement in academic work, including both research and teaching. Thus, the added costs of learning and discovery return tangible workforce benefits.
The authors' major finding that organizational support for physicians to engage in research not only advances science but also seems to be a key element of physician satisfaction has important implications for the health care workforce. Given that greater physician satisfaction is associated with better patient outcomes,5,6 there is some urgency to defining factors that enhance professional satisfaction (and therefore recruitment and retention) and to encouraging health care organizations to adopt the lessons learned. In this regard, one wonders whether the authors' results would be replicable outside the VA system, where the potential for generating clinical income is higher and may obscure research-related job satisfaction differences. Unfortunately, few other health systems are presently well positioned to conduct these types of large-scale studies.
In short, Mohr and Burgess provide an important demonstration of how high-performing health care systems can serve as platforms for further investigating the role of research in the professional satisfaction of physicians and other health care providers. What other lessons might be learned from this work? Perhaps that an environment that encourages discovery and learning yields unique benefits and contributes more broadly to supporting a high-performing health system. This would not be a surprising association to Abraham Flexner and his intellectual heirs, who have emphasized the importance of scientific research to the success of academic medicine.
One might also reflect that the future development of the U.S. health care system offers unique opportunities to explore fundamentally new and better models of patient care, education, and research. Given its enduring partnership with the academic community, its past and present investments in academic infrastructure, and its particular expertise in system redesign, VA is well positioned to continue its leadership role in educating the present and future health care workforce, advancing clinical science, and helping to transform the U.S. health care system for the 21st century.
The views expressed in this article are those of the authors and do not necessarily reflect the positions or policy of the U.S. Department of Veterans Affairs.
1 Mohr DC, Burgess JF Jr. Job characteristics and job satisfaction among physicians involved with research in the Veterans Health Administration. Acad Med. 2011;86:938–945.
2 Trivedi A, Matula S, Miake-Lye I, et al. Systematic review: Comparison of the quality of medical care in Veterans Affairs and non-Veterans Affairs settings. Med Care. 2011;49:76–88.
3 Cheadle WG. The Veterans Affairs research program: Scientific and clinical excellence relevant to veterans' healthcare needs. Am J Surg. 2005;190:655–661.
5 Haas JS, Cook EF, Puopolo AL, et al. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15:122–128.
6 DeVoe J, Fryer GE, Hargraves JL, et al. Does career dissatisfaction affect the ability of family physicians to deliver high-quality patient care? J Fam Pract. 2002;51:223–228.