Physician Dissatisfaction Research Articles

Evaluating depressive symptoms in mania: a naturalistic study of patients with bipolar disorder.

ObjectiveThis study aimed to evaluate patients with bipolar I disorder (BD-I) who have mania with depressive symptoms and who meet the new “with mixed features” specifier of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).MethodThis prospective, multinational, naturalistic study surveyed psychiatrists and their patients with BD-I from October 2013 to March 2014. Eligible patients had BD-I, had a (current) manic episode, and had experienced onset of a manic episode within the previous 3 months. Psychiatrists provided patient information on depressive symptoms (DSM-5 criteria); symptoms of anxiety, irritability, and agitation; suicide attempts; and physician satisfaction with treatment response. Data were stratified according to whether patients met the criteria for the BD-I “with mixed features” specifier of DSM-5 (≥3 depressive symptoms) or not, and characteristics were compared between the two subgroups. Patients also self-reported on depressive symptoms using the Mini-International Neuropsychiatric Interview module questionnaire.ResultsOverall, 34% of 1,035 patients met the criteria for BD-I “with mixed features,” exhibiting ≥3 depressive symptoms during their current manic episode. This correlated with the matched patient self-reports of depressive symptoms. During their current manic episode, BD-I patients “with mixed features” had more severe symptoms of anxiety, irritability, and agitation (average composite severity score of 4.1 vs 3.4), a higher incidence of suicide attempts (38% vs 9%), and more physician dissatisfaction with treatment response (22% vs 14%), compared to patients with 0–2 depressive symptoms (all P<0.05).ConclusionThis study found that patients with BD-I “with mixed features” (ie, ≥3 depressive symptoms during a manic episode), suffered, on average, from a greater burden of disease than patients with pure mania. Improved identification of these patients may help to optimize treatment outcomes.

Some Remarks on Effect Studies of Physician Dissatisfaction

I present a few general comments on the study of causality from the viewpoint of research methodology and philosophy of science. Researchers should notice that there are several conceptions of causality implicating diverse research strategies. I argue that a mechanism approach to causality is most adequate and that this approach calls attention to the level of explanation and the importance of context and intervening causal mechanisms.

Academic I.D. in jeopardy: the erosion of time, professional values, and physician satisfaction.

The American public entrusts academic medicine with a varied portfolio of critical responsibilities: the thoughtful mentoring of future generations of doctors, the engagement of cutting edge discoveries, and the empathic treatment of patients with complicated illnesses. The erosion of time to perform these duties has led to an estrangement of our key professional values and thus a loss of public trust, the inability to recognize new diseases, reduced communication in our ranks, and physician dissatisfaction. Much of this is driven by an unbalanced focus on the business model of medicine, highlighting rapid patient transactions linked to professional income with financial incentives for high-volume care. Reversing the current trends requires a new type of leadership committed to long-held professional values and a recognition of what drives professional excellence. As internists and infectious diseases specialists without procedures in our practice, we are especially vulnerable to these trends.

Characterizing the specialty palliative care workforce in the United States: Results of a national survey.

90 Background: Increasingly, oncology teams and specialty palliative care (PC) clinicians are collaborating in the care of patients with serious or advanced cancer. Because of such partnerships, PC services have grown tremendously, with teams now available in most US cancer centers. Despite increased penetrance of services, little is known about the workforce that delivers this care, including their demographics, training, and future plans. Methods: Members of the American Academy of Hospice and Palliative Medicine (e.g. advanced practice provider (APP), registered nurses, chaplains) completed a workforce characteristics survey through electronic invitation in the second half of 2013; respondents were recruited via e-mail, blog and Facebook posts, and Twitter tweets. Descriptive statistics were calculated. Results: 1,241 clinicians responded, representing approximately a third of those who received the survey; 68% were physicians and 14% were APPs. Most (56%) were older than 50 years of age; 65% were female. Of physicians, 58% were board-certified through the experiential track, while 22% had completed fellowship training. Of clinical responsibilities, about half (48%) split time between consultative PC and hospice; 30% performed PC consultations only. Regarding organization size, 35% work with 1-3 other colleagues; 8% work alone. Regarding tenure, 34% have worked in PC for &lt;5 years; 22% for &gt;10 years. 82% reported they would become a PC clinician again, if asked to revisit their career choice. Of motivations for joining clinical PC, leading reasons were “opportunity for personal growth” and “influential experience during practicing another specialty”. About half (47%) intend to leave the field within 10 years. Of reasons to leave, 49% will retire; 24% may leave due to burnout; and 20% reported dissatisfaction with practice. Conclusions: The specialty PC workforce is diverse and faces sustainability challenges due to advancing physician age, impending retirements, evolving burnout, and dissatisfaction with the profession. If patients are going to have adequate access to services, research and approaches are needed to develop solutions that sustain and grow specialty PC.

Factors associated with job satisfaction among public-sector physicians in Belo Horizonte, Brazil.

Evidence indicates an association between job satisfaction and illness among physicians. There are also negative consequences of physician dissatisfaction on the quality of medical services. With this in view, a cross-sectional study of a stratified random sample of physicians (n = 266) was conducted in the municipal public health care system in Belo Horizonte, Brazil. Participants answered a questionnaire about job satisfaction, sociodemographic and lifestyle characteristics, work and employment conditions, and health status. Of the 232 respondents, 150 (64.94%) declared themselves satisfied with the work, with no significant difference between male and female physicians (66.4% vs. 64.2%; p = 0.74). The number of physicians satisfied with their work was significantly higher among those who experienced a high level of social support at work (p < 0.01) and was significantly lower among those working under high-strain conditions (p = 0.01) and those who screened positive for the presence of common mental disorders (p < 0.01). These findings suggest that policies to promote social support and mental health in the workplace, as well as the implementation of strategies to increase physicians' control over their work activities, can have a positive effect on the job satisfaction of these professionals.

A Performance Improvement Project: Reducing Emergency Department Blood Culture Contamination Rate Using Six Sigma Methodology

The blood culture (BC) contamination rate in our hospital’s Emergency department (ED) was high in Calendar Year (CY) 2011 compared to the national benchmark of ≤ 3%. This led to increased health care costs, increased length of stay, over utilization of resources, unnecessary antibiotic use and physician dissatisfaction. The estimated additional cost of each contaminated BC is $5,000. We deployed Six Sigma Methodology to reduce our BC contamination rate in the ED.

Motivators and Hygiene Factors Among Physicians Responding to Explicit Incentives to Improve the Value of Care

Physician's dissatisfaction is reported to be increasing, especially in primary care. The transition from fee-for-service to outcome-based reimbursements may make matters worse. To investigate influences of provider attitudes and practice settings on job satisfaction/dissatisfaction during transition to quality-based payment models, we assessed self-reported satisfaction/dissatisfaction with practice in a Rochester (New York)-area physician practice association in the process of implementing pay-for-performance. We linked cross-sectional data for 215 survey respondents on satisfaction ratings and behavioral attitudes with medical record data on their clinical behavior and practices, and census data on their catchment population. Factors associated with the odds of being satisfied or dissatisfied were determined via predictive multivariable logistic regression modeling. Dissatisfied physicians were more likely to have larger-than-average patient panels, lower autonomy and/or control, and beliefs that quality incentives were hindering patient care. Satisfied physicians were more likely to have a higher sense of autonomy and control, smaller patient volumes, and a less complex patient mix. Efforts to maintain or improve satisfaction among physicians should focus on encouraging professional autonomy during transitions from volume-based to quality/outcomes-based payment systems. An optimum balance between accountability and autonomy/control might maximize both health care quality and job satisfaction.

Implementation of a Pre-Anesthesia Clinic at a Cancer Institution

Efficient use of operating room time is critical to surgical management. Unexpected case delays and cancellations create ineffective utilization of operating room time and lead to patient, staff, and physician dissatisfaction. Establishing a preanesthesia clinic for early identification of the perioperative needs of complex oncologic surgical patients demonstrated an efficient, individualized, and cost-effective perioperative patient management system.

First Case On-Time Start Initiative

A significant amount of delays in first case start times became apparent to staff and leadership. Delays at the beginning of the day often result in need for overtime, dissatisfaction of patients, staff and physicians. A case beginning after 7:35am is considered a late start. Due to this problem a collaborative initiative was launched in pre-operative area to identify the main causes attributing to delays. We implemented a strategy to decrease the delays and achieve an on time start rate of 55% or higher.

Moral distress, autonomy and nurse-physician collaboration among intensive care unit nurses in Italy

To explore the level of moral distress and potential associations between moral distress indices and (1) nurse-physician collaboration, (2) autonomy, (3) professional satisfaction, (4) intention to resign, and (5) workload among Italian intensive care unit nurses. Poor nurse-physician collaboration and low autonomy may limit intensive care unit nurses' ability to act on their moral decisions. A cross-sectional correlational design with a sample of 566 Italian intensive care unit nurses. The intensity of moral distress was 57.9 ± 15.6 (mean, standard deviation) (scale range: 0-84) and the frequency of occurrence was 28.4 ± 12.3 (scale range: 0-84). The mean score of the severity of moral distress was 88.0 ± 44 (scale range: 0-336). The severity of moral distress was associated with (1) nurse-physician collaboration and dissatisfaction on care decisions (r = -0.215, P < 0.001); and (2) intention to resign (r = 0.244, P < 0.0001). The frequency of occurrence of moral distress was associated with the intention of nurses to resign (r = -0. 209, P < 0.0001). Moral distress seems to be associated with the intention to resign, whereas poor nurse-physician collaboration appears to be a pivotal factor accounting for nurses' moral distress. Enhancement of nurse-physician collaboration and nurses' participation in end-of-life decisions seems to be a managerial task that could lead to the alleviation of nurses' moral distress and their retention in the profession.

Adapting to the New Healthcare Market

THE FEATURE ARTICLES included in this issue of Frontiers of Health Services Management, authored by John Toussaint and Gary Kaplan, have much in common. Both address one of the most critical mandates in healthcare delivery: the need for transformational change. Both share essential guidance-which leaders may find difficult accept-on how be successful in adapting today's healthcare market. And both have documented measurable outcomes that demonstrate marked improvements in their respective organizations, allowing them verify the effectiveness of the improvement process and promote its continued use.I can attest the importance of the authors' suggested improvement approaches because I and other senior leaders implemented similar principles and practices at two healthcare organizations. In my 12 years as CEO of CHRISTUS Health, in Irving, Texas, and during my nine-month tenure as the interim CEO at Parkland Health & Hospital System, in Dallas, I witnessed gains at both organizations as they developed verifiable and measurable improvements in the quality and safety of the clinical services they provided at their numerous hospitals and clinics.THE PRESENT UNSUSTAINABLE HEALTHCARE ENVIRONMENTBoth Toussaint and Kaplan define in their opening paragraphs the operational characteristics of most healthcare delivery today, which industry leaders generally accept as valid. I attribute the poor performance outcomes they note four drivers of the need for transformational change, a critical factor for future success that both authors mention in their articles.The first driver is the lack of consistency and coordination of services among providers that results in much of the poor quality of care delivered today. Toussaint highlights this problem by noting the excessive levels of medical errors, readmissions within 30 days of discharge, and unnecessary deaths.The second driver is the high cost of care in the United States, where prices and charges bear no relationship actual cost structures. Exacerbating the high cost of poor outcomes is the unnecessary duplication of services and tests caused by the aforementioned absence of care coordination among providers.The third driver is increased physician dissatisfaction, often triggered by physicians' realization that they are being asked relinquish their independent practice style. Although Toussaint knows firsthand that doctors in training are taught that individual judgment is more important than best-practice protocols and independence is more important than group critical thinking, he understands that this mind-set no longer has a place in today's healthcare marketplace.The fourth driver is a misaligned vision of leadership teams that results in a focus on illness rather than wellness and on volume rather than value. Kaplan and the leadership team at Virginia Mason Medical Center confront this driver by working to avoid the mentality that bigger is inherently better (page 24).When considering these four drivers of change, it appears that the only health systems that will survive in the future are those that can prove by their outcome metrics that they are providing consistent, high-quality, and safe services at accessible sites and times and at affordable costs.THE KEY QUESTION AND KEY ANSWERSBoth authors ask this critical question: What must we do ignite the enthusiasm and will in our organization - at the front lines, in the leadership and management teams, and in the board and governance processes - create not only a sustainable but a thriving healthcare industry for all who enter our doors?Not surprisingly, Toussaint and Kaplan provide similar answers. Each repeatedly stresses that transformational change throughout all levels of the delivery system is essential, noting that changing the way the people in the organization think and perform is the most important step toward ensuring success in the future marketplace. …

Évaluation du niveau de stress et de ses principaux indicateurs chez les praticiens de bloc opératoire

A questionnaire (146 questions) devised by ASSPRO Scientifique (Association de prévention du risque opératoire - Association for the prevention of surgical risk) and covering the professional and personal indicators likely to be involved in stress was used to assess the level of satisfaction or dissatisfaction of physicians and the level of stress. The collected data were analysed using frequency distribution tables and cross tabulations. Of the completed questionnaires returned by 1272 physicians (21.9% of the sampled physicians), 1204 questionnaires could be used. Of the total sample, 85.5% was male, between 35 and 64 years old (92.8%); they were anaesthetists (29.6%), orthopaedists (29.4%) or obstetrician gynaecologists (12.8%) attending a single workplace (67.9%) in sector 2 (64%). More than one quarter of these physicians reported feelings of exhaustion after work and one quarter of them had a fear of the workload ahead. Overall, the mean level of happiness (on a scale from 0 to 10) was quite high (6.7) and the mean stress level (graded from 0 to 10) was 5.9 (above or equal to 8 in 29.8%). The links between the stress level and the behaviour or the frame of mind at work were especially clear and significant for the following factors (stress level on a scale from 0 to 10): fear of the workload ahead (8.3), feeling of exhaustion (7.6), inability to 'switch off' (7.5) or to distance oneself from the difficult times of the day (7.3), sleeping disturbances (7.3), back pain (6.9) and headaches (6.9), which factors seem to be strong indicators of an advanced state of stress.

New Wine in an Old Bottle: Does Alienation Provide an Explanation of the Origins of Physician Discontent?

We have witnessed transformational changes to the U.S. health care system over several decades. Alongside these changes is an increasing number of research reports and commentaries on physician workplace dissatisfaction and discontent. Primary care physicians, in particular, report dissatisfaction with conditions on the ground. Is there solid evidence concerning the magnitude of doctors' discontent, and how is it changing over time? Is it confined to the United States, or is it also occurring in other countries with different health care systems? Does physician discontent affect the processes, quality, and outcomes of medical care? This article addresses these questions. It considers the dimensions of physician dissatisfaction, whether there is a problem, and competing contributions to physician discontent. The authors suggest that the classic concept of alienation may build upon valuable earlier work and provide a new, coherent explanation of the workplace origins of physician discontent. Alienation theory combines both structural and psychological components associated with workplace discontent and has the potential to explain the changing position of knowledge workers (such as physicians) in the new economy.

Satisfaction, motivation, and intent to stay among Ugandan physicians: a survey from 18 national hospitals

Uganda faces a colossal shortages of human resources for health. Previous literature has largely focused on those who leave. This paper reports on a study of physicians working in 18 public and private facilities in Uganda as part of a larger study of more than 641 hospital-based health workers in Uganda. We report what could entice physicians to stay longer, satisfaction with current positions, and future career intentions. This study took place in 18 Ugandan hospitals. We describe the 49 physicians who participated in 11 focus groups and the 63 physicians who completed questionnaires, out of a larger sample of 641 health workers overall. Only 37% of physicians said they were satisfied with their jobs, and 46% reported they were at risk of leaving the health sector or the country. After compensation, the largest contributors to dissatisfaction among physicians were quality of management, availability of equipment and supplies (including drugs), quality of facility infrastructure, staffing and workload, political influence, community location, and professional development. Physicians in our study were highly dissatisfied, with almost half the sample reporting a risk to leave the sector or the country. The established link in literature between physician dissatisfaction and departure from the health system suggests national and regional policy makers should consider interventions that address the contributors to dissatisfaction identified in our study.

New Strategies for Medical Data Mining, Part 1: Dynamic and Performance-Based Reimbursement

The current professional reimbursement model within medicine was created more than 20 years ago in response to physician dissatisfaction and health care inflationary pressures. Despite many resulting improvements, several deficiencies currently exist within the current reimbursement model, related to transparency, accountability, and quality. As the tenets of evidence-based medicine and pay for performance become ingrained within health care delivery, it would be beneficial to modify the existing reimbursement model to reflect these principles. The opportunity to accomplish this goal is advanced through the continued evolution of information systems technologies and data mining. The author discusses the existing deficiencies in medical reimbursement and makes a number of recommendations for improvement. The ultimate goal is to incorporate objective and standardized data into a transparent and readily accessible database, which can be used to enhance performance, education, and informed decision making.

Ethical Choice in the Medical Applications of Information Theory

Alongside advances in medical information technology (IT), there is mounting physician and patient dissatisfaction with present-day clinical practice. The effect of introducing increasingly complex medical IT on the ethical dimension of the clinical physician's primary task (identified as direct patient care) can be scrutinized through analysis of the EMR software platform. We therefore (1) identify IT changes burdensome to the clinician in performing patient care and which therefore lower quality of care; and (2) suggest methods for clinicians to maintain high quality patient care as IT demands increase. Elemental relationships from information theory and physical chemistry are applied to the profit-generating creation and flow of medical information between patients, physicians, administrators, suppliers, and insurers. Ethical implications for patient care and the doctor-patient relationship are drawn in the light of these relationships. WHERE ARE WE NOW?: Little has been accomplished, or even discussed, regarding limiting healthcare IT growth. Quality of patient care is expected to suffer unless physicians carefully scrutinize, refine and occasionally reject portions of the increasing healthcare IT burden being placed upon them. WHERE DO WE NEED TO GO?: Better medicine, simply understood as more effective prevention and treatment of musculoskeletal disease, is our professional goal. We need to establish mechanisms whereby we can limit, control or even reverse IT changes that hinder this goal. Clinicians must confront the negative impact many healthcare IT changes have on patient care. HOW DO WE GET THERE?: Suggestions for maintaining high standards of practice in the face of the new IT burden include: (1) Increasing IT time-awareness. Clinicians should examine actual time spent in clinical versus computer-based activity and implement changes if that ratio is too high. (2) Increasing IT goal awareness. (3) Examine the software creating a medical record to see how much of what it records is there for financial, as opposed to medical reasons. Is the software helping my patient or someone else's bottom line? Is it for talking to colleagues about sick people or to insurance companies?

Irradiated Autologous Breast Reconstructions: Effects of Patient Factors and Treatment Variables

Postmastectomy irradiation often negatively impacts breast reconstruction outcomes. Further investigation is necessary to recognize factors contributing to adverse results. The purpose of this study was to (1) accurately assess the impact of radiation on autologous breast reconstruction and (2) identify patient and treatment factors affecting reconstructive outcomes. One hundred twenty-six patients were considered after postmastectomy breast reconstruction and irradiation. The records of 76 patients were studied after excluding for radiation therapy before reconstruction, complications before irradiation, implant reconstruction, mastectomy for recurrent disease, and history of cancer. Patient demographics and comorbidities, operative details, adjuvant therapy, and treatment outcomes were assessed. Seventy-six patients underwent autologous microsurgical breast reconstruction. Complications occurred in 53 patients (70 percent) 7.2 +/- 6 months after irradiation; 36 cases (47 percent) required reoperation for postirradiation effects. Parenchymal complications (fat necrosis or parenchymal fibrosis) were noted in 19.7 percent, skin complications (tissue envelope retraction or hypertrophic scarring) were recorded in 30.3 percent, and general dissatisfaction (physician or patient dissatisfaction) arose in 27.6 percent of patients. Parenchymal complications were associated with smoking (odds ratio, 9.3; p = 0.03), type II diabetes mellitus (odds ratio, 8.5; p = 0.02), and age (odds ratio, 1.1; p = 0.02). Neoadjuvant chemotherapy increased the development of complications (odds ratio, 4.4; p = 0.04), particularly skin changes (odds ratio, 2.4; p = 0.01). Patient-specific factors, including diabetes mellitus and smoking, increase the risk of postirradiation parenchymal changes, and neoadjuvant chemotherapy is associated with a greater than twofold increase in skin complications. Breast reconstruction followed by irradiation can be successful, but patients with specific risks should be aware of increased complication rates.

Software-Assisted Spine Registered Nurse Care Coordination and Patient Triage-One Organization's Approach

Back disorders encompass a spectrum of conditions, from those of acute onset and short duration to lifelong disorders. The use of a traditional spine center model of patient flow, in which the patient is scheduled the first available appointment without an initial assessment of spine-related symptoms at West Virginia University Spine Center, Morgantown, West Virginia, resulted in frustration and delays for the spine patient and referring physician dissatisfaction. Today, the use of a software-assisted spine patient triage and registered nurse care coordinator patient navigation system in this multidiscipline, multimodality comprehensive spine program provides quick and efficient patient triage to the appropriate level of spine care (surgeon vs. nonsurgeon). The model consists of five major steps, which are explored in this article: medical history intake; films or studies retrieval; rapid review of the patient's medical condition and diagnostics by a spine specialist preappointment and subsequent triage to the appropriate level of spine care; registered nurse care coordinator patient education and guided navigation through the patient's preferred treatment plan; and last, diagnostic study, pain injection, and provider scheduling. Patient satisfaction scores, referring physician satisfaction scores, and resultant impact on referral volumes, ancillary utilization, workload productivity, and surgical yield demonstrate that this new approach to patient triage has made significant improvements in efficiency, productivity, and service.

The effects of physicians’ communication satisfaction and their perceptions of empowerment on their likelihood to recommend a hospital to their peers

PurposeThe purpose of this paper is to examine factors that may contribute to physicians’ dissatisfaction with their work environment, and subsequently, their likelihood to recommend a hospital to their peers.Design/methodology/approachA mixed method research design was used to identify, through qualitative interviews and focus groups, and measure, through quantitative surveys, physicians’ satisfaction with organizational communication, perceptions of empowerment and their likelihood to recommend a hospital to their peer physicians.FindingsThe results of the study indicate that physicians’ communication satisfaction and perceptions of empowerment contribute both directly and indirectly to their likelihood to recommend their organization to peers. The findings suggest that hospitals that facilitate positive workplace communications and provide work environments that allow professional discretion and autonomy are more likely to have satisfied physicians and positive word‐of‐mouth referrals.Research limitations/implicationsAlthough multiple methods of data collection were used to triangulate the findings, there is the potential of common‐method variance and response bias from the use of single source questionnaire data. Ideally, future studies would use longitudinal data and a more comprehensive model of antecedents and consequences of physician satisfaction.Practical implicationsBy understanding sources of physician dissatisfaction, hospitals can develop appropriate interventions to minimize the adverse effects of dissatisfaction on costs, quality of care, and physician turnover.Originality/valueThis study focuses on physicians’ satisfaction with their hospital work environment, an often overlooked area in studies of the health care industry that more commonly center on patient–physician satisfaction. The current study's results provide suggestions for better hospital management and further insight into the challenges of improving physician satisfaction in the health care industry.

How Strategies for Managing Patient Visit Time Affect Physician Job Satisfaction: A Qualitative Analysis

There is much physician discontent regarding policies that limit time for patient visits and contribute to physician dissatisfaction with the medical profession as a whole. Yet little is known about how physician strategies for managing time limits correspond to job satisfaction. The goal of this study was to identify strategies physicians use for managing time with patients and the effects these strategies have on job satisfaction. In-depth interviews with primary care providers in various clinical settings (academic medical centers, community-based centers, solo practices, nonacademic group practices) were audiorecorded. Primary care physicians (n = 25). Transcribed audiorecordings of physician interviews were coded using a modified grounded theory approach. An open coding process was used to identify major themes, subthemes, and the interrelationships among them. Three main themes emerged. (1) Study physicians disregarded time limits despite the known financial consequences of doing so and justified their actions according to various ethical- and values-based frameworks. (2) Disregarding time limits had a positive impact on job satisfaction in the realm of direct patient care. (3) The existence of time limits had a negative impact on overall job satisfaction. For the study physicians, disregarding time limits on patient visits is an adaptive short-term strategy that enhances satisfaction with direct patient care. It is unlikely that such a strategy alone will help physicians cope with their broader- and growing-dissatisfaction with the profession.