Satisfaction higher for physician executives who treat patients, survey finds. (Big Business/Noble Profession).

PHYSICIAN EXECUTIVES who continue to treat patients appear to be more satisfied with their jobs than those who don't see patients, a new survey shows.

The survey is believed to be the first, national empirical study to examine the relationship between physician executives' job satisfaction and their performance, their perceptions of their organization and their personal and demographic characteristics.

The study uncovered a significant relationship between job satisfaction and clinical, practice. In addition, an overwhelming majority --83%-- of those who were not satisfied with their jobs didn't see patients on a regular basis.

This echoes an earlier finding that continuing some involvement in the practice of medicine may help physician executives maintain their professional identities. (1) Another study has found that professional commitment to career is important in maintaining their intrinsic satisfaction and that being a practicing clinician is positively associated with professional commitment among physician executives. (2)

As you might expect, those who felt satisfied indicated that they were more likely to remain in their current job compared to those who were not satisfied. Physician executives who said they were improving the relationships between physicians and administrators and helping build physicians' commitment to the organization's vision, direction and priorities were also generally satisfied with their jobs.

The survey found that physician executives who are satisfied are more likely to view their organization as responsive to physician's concerns. They also view their medical staff as having structures that enable effective decision making.

Conversely, the level of job satisfaction decreased for physician executives who were viewed by fellow physicians as "just administrators.

The study also found that job satisfaction is not linked to many factors including:

* Job title

* Promotions

* Type of organization

* To whom they report

* The percentage of physicians reporting to them

* Whether their compensation package includes incentives

Satisfaction is also not associated with the profit/loss forecast of the organization, the physician executives' primary board specialty.

Despite the lack of link with forecast profit/loss, physician executives' job satisfaction is clearly correlated with the success of organizational performance improvement efforts in which they are likely to be involved. Specifically, those who are satisfied are more likely to report that the organization is successful at:

* Recruiting physicians/acquiring physician practices

* Improving the relationship between physicians and administrators

* Developing new programs/services

* Improving clinical quality

The mean age for the group of physician executives surveyed was 54. However, the research showed the age of a physician executive was not significantly different when it came to satisfaction. Additionally, the level of satisfaction was not related to the length of job tenure.

Overall, the study found about 80 percent of physician executives are satisfied with their current jobs. That's almost identical to a survey conducted about a decade ago. (3)

Three other interesting findings emerged from the survey:

Satisfaction is not related to possessing a management degree.

This result is surprising, given the commonly held beliefs that good job performance is associated with higher levels of job satisfaction and that management training is an important contributor to physician executive job performance. For example, one previous study of physician executives showed a need for further development of knowledge and skills in health care financing and organizational structure. (4)

Understandably, physicians participating in the business endeavors of a hospital and health system may need a business degree, in addition to a medical degree, to be an effective physician executive. (5)

The explanation for our finding may be that the key skills for physician executives in hospital and health systems lie more in leadership than in management. Management, the process of planning, organizing, leading and controlling resources in an environment is different from leadership. Although managers must lead, leaders have the ability to motivate, actuate and direct. (6)

While health care organizations may need both leaders and managers, a formal training program such as an advanced degree in business administration may increase physicians' knowledge of management but not necessarily the skills needed for leadership (7)

Satisfaction is related to the internal cohesion of the medical staff.

The study defined medical staff cohesion as the ability of physicians to speak with one voice on important matters as well as the presence of medical staff structures that enable effective decision making.

One reason for this finding may be that a cohesive medical staff is more likely to be an effective partner in performance improvement efforts, such as improving clinical quality and patient service or reducing the clinical cost of care.

These are all areas in which physician executives have significant responsibility.

This finding is consistent with earlier one that physician executives' orientation and commitment to the organization is associated with a favorable work environment. (8)

Satisfaction is related to relationships with physician colleagues.

As trained medical doctors, physician executives have a strong background in dealing with people and establishing relationships, including interpersonal sensitivity and being at ease with authority over others. (9)

These skills are put to the test in a new management role, which requires them to establish new bridges between their fellow physicians and administrators.

Health care organizations see physician-managers as a group that improves the likelihood of cooperation from their professional colleagues. (10) In order to develop and maintain trust and collegiality, physician executives must maintain links with their fellow physicians even after assuming the management position. However, physician executives may also draw apart their core professional identities and contribute to a discontinuity that produces distrust and conflict.

To some extent, this conflict and distrust may lead to interruption of work and alienation from the physicians in the hospital and system. This phenomenon has been commonly referred to as the conflict between dominant culture (physicians in general) and deviant culture (physician executives) as observed in other working environments. (11)

Generally, the findings from this study suggest that, in order to have a satisfying career as a physician executive, physicians need to be:

* Involved in continuing clinical practice

* Associated with their medical colleagues on a constant basis

* Have an affiliated medical staff with a significant level of internal cohesion

It seems to suggest that any detachment from the rank-and-file physicians will have a negative impact on physician executives' satisfaction with their career.

Patient Care and Job Satisfaction

Here's a look at selected nominal variables that are significantly
associated with physician executives' job satisfaction.

                                       Level of Satisfaction (%)
                             Satisfied  Neither   Dissatisfied
                              (n=257)   (n=42)       (n=23)         p

Still see patients on
 a regular basis

 Yes                            44        52           17          .05
 No                             56        48           83

Planning to remain in the
 job for the next 12 months

 Yes                            83        68           13         .001
 No                              4        12           43
 Unsure                         13        20           43

Chi-square tests were performed for the level of satisfaction by each of
the two variables.
Perception and Performance

Here are selected continuous variables significantly associated with
physician executive job satisfaction.

                                          Level of Satisfaction (%)
                                          Satisfied     Neither
                                           (n=257)       (n=42)

Your involvement and role in the             4.6 (a)      4.4
organization
(1=no responsibility at all, 5=high
responsibility)

Improving the relationship between
physicians & administrators

I put a great deal of time and energy        4.4 (a)      4.4
into...
(1=strongly disagree, 5=strongly agree)

Building physician commitment to the
org. vision, direction & priorities

Your perception of the your organization     3.5 (a)      3.2
(1=strongly disagree, 5=strongly agree)

This organization is responsive to
physicians' concerns

The physicians support strategies and        3.6 (a)      3.7
priorities of organization

The physicians are able to speak with        2.6 (a)      2.2
one voice on important matters

The physicians have a structure for          3.2 (a)      2.7 (b)
effective decision making and follow
through

The physicians view me as "just an           2.5 (b)      2.5
administrator"

Your organizations performance               3.4 (a)      3.2
(1=not successful at all, 5=very
successful)

Recrutiting physicians/acquiring
physician practice

Improving the relationship between           3.6 (a)      3.2 (b)
physicians and administrators

Improving patient service and                3.7 (a)      3.4
satisfaction

Developing new programs/services             3.7 (a)      3.5

Improving clinical quality                   3.8 (a)      3.7 (a)

                                          Level of Satisfaction
                                          (%)
                                          Dissatisfied
                                             (n=23)        p

Your involvement and role in the            4.2 (b)      .01
organization
(1=no responsibility at all, 5=high
responsibility)

Improving the relationship between
physicians & administrators

I put a great deal of time and energy       4.0 (b)      .05
into...
(1=strongly disagree, 5=strongly agree)

Building physician commitment to the
org. vision, direction & priorities

Your perception of the your organization    3.0 (b)      .01
(1=strongly disagree, 5=strongly agree)

This organization is responsive to
physicians' concerns

The physicians support strategies and       3.3 (b)      .05
priorities of organization

The physicians are able to speak with       2.0 (b)      .01
one voice on important matters

The physicians have a structure for         2.7          .01
effective decision making and follow
through

The physicians view me as "just an          3.0 (a)      .01
administrator"

Your organizations performance              2.7 (b)      .01
(1=not successful at all, 5=very
successful)

Recrutiting physicians/acquiring
physician practice

Improving the relationship between          3.1 (b)     .001
physicians and administrators

Improving patient service and               3.4 (b)      .01
satisfaction

Developing new programs/services            3.2 (b)      .01

Improving clinical quality                  2.9 (b)     .001

The total number of respondents may vary among the variables. F-tests
were performed on the comparisons of the three levels of satisfaction
(groups) for each, and Tukey post hoc tests were performed following
significant F-tests. The superscripts indicate significant comparisons
(Tukey tests) among the levels for the particular variable (a > b). In
this table, for instance, these who felt satisfied had a higher
responsibility on improving the relationship between the physicians and
administrators than those who reported dissatisfied. However, there were
no significant differences among the 'neither satisfied nor
dissatisfied" with either of the two groups.

References

(1.) Wolinsky, FD. 1988. "The professional dominance perspective, revisited." Milbank Memorial Quarterly 66 (Suppl. 2), 33-47.

(2.) Hoff, TJ. "Professional commitment Among U.S. Physician Executives in Managed care." Social Science and Medicine. 2000, 50:1433-1444.

(3.) Kimmy, JR and Haddock, CC. "Physician Executives' Characteristics and Attitudes." The Physician Executive. 1992, 18 (3): 3-8.

(4.) Lane, DS and Ross, v. "Defining competencies and Performance Indicators for Physicians in Medical Management." American Journal of Preventive Medicine. 1998, 14 (3): 229-236.

(5.) Hoff, TJ. "The Paradox of Legitimacy: Physician Executives and the Practice of Medicine." Health Care Management Review. 1999. 24 (4): 54-64.

(6.) Kotter, JP. "What Leaders Really Do." Harvard Business Review. 1990. 68 (3): 3-11.

(7.) Merry, M. "Wanted: A New Breed of Physician Drivers for Healthcare's Nitroglycerin Trucks." Frontiers of Health Services Management. 1999, 12 (4): 29-35.

(8.) Hoff, TJ. "Exploring Dual Commitment Among Physician Executives in Managed Care." Journal of Healthcare Management. 2001, 46 (2): 91-109.

(9.) Hagland, MM. "Physician Executives Bring Clinical Insight to Non-clinical Challenges." Hospitals. 1991, 65 (18): 42,44,46-48.

(10.) Schneller, ES, Greenwald, HP, Richardson, ML, Ott, J. "The Physician Executive: Role in the Adaption of American Medicine." Health Care Management Review 1997. 22 (2): 90-96.

(11.) Reuss-Ianni, P. and Ianni, FA. "Street Cops and Management Cops: The two Cultures of Policing." In M. Punch (Ed.) Control in Police Organization. Cambridge, MIT Press. 1983, pp. 251-273.

RELATED ARTICLE: Details of the Job Satisfaction Study

The national mail survey of senior physician executives in hospitals and health systems was conducted in early October, 2000. The survey population consisted of physician executives belonging to the American College of Physician Executives (ACPE) and the Society for Chief Medical Officers (SCMO).

There were 1,410 physician executives listed either in the databases of the ACPE or the SCMO with the titles of chief medical officer (CMO) and/or vice president of medical affairs (VPMA) who worked in hospitals or health care system as of October 2000.

These 1,410 physician executives represent the sample of the study. Each physician executive received the questionnaire, along with a cover letter, a postcard to send away for the survey results and a description of an incentive for completing the survey. It should be noted that, due to a restriction on multiple mailings to the members of the organizations, only one mailing was allowed in the study.

The survey instrument

An extensive literature review was performed to compile the initial list of questions. The list was revised through consultation with physician executives, physician administrators of the Jefferson Medical College and The Bard Group. The exact wording of the variables was finalized after a pretest with a group of physician executives (n5). The final questionnaire consisted of a total of 42 items with six distinct components.

1. Personal and organizational characteristics

This category included: length in their current position, job title, whom they report to, type of organization, number of beds, budget amount, organization's forecasted profit or loss and whether or not respondents were promoted to their current job from within the organization.

2. Involvement and role in the organization

The second section of the survey addressed two categories. The respondents' responsibility in the areas of improving clinical quality, reducing cost, recruiting physicians, improving patient service and improving the relationship between the physician and the administration. And the amount of time physician executives spend on the job, including planning and budgeting, coping with the complexity of the organization, solving conflicts, promoting efficiency and/or quality of care, coping with changes in the competitive environment, strategizing, building physician commitment and motivating.

3. Perception of the organization

Component three contains two categories. The first consisted of eight statements regarding respondents' perception of the organization: physicians' concerns, physicians' support of strategies and priorities, physicians' role in planning and budgeting, physicians' unity, decision making process, physicians' and organization's views of the physician executive and physicians' involvement in the physician executives' selection for employment.

The second category asked about the current performance of the organization, which includes recruiting physicians/acquiring physician practices, improving the relationship between physicians and administration, improving patient service, developing new programs, improving clinical quality and reducing clinical cost of care.

4. Job satisfaction

The physician executives were asked to indicate to what extent they were satisfied or dissatisfied with their current job.

5. Demographics and medical practice

This section of the survey captured birth date, gender, specialty, whether or not they see patients on a regular basis, whether or not they hold a business/management degree and whether their compensation package includes a bonus incentive component.

6. Future plans

The physician executives were asked to indicate whether or not they were planning to remain in their current job for the next 12 months.

For components 2, 3 and 4, the standardized 5-point Likert-type scale was employed with appropriate wording anchored from the favorable to unfavorable ends.

For instance, respondents evaluated their job satisfaction on a five point scale with very dissatisfied=l and very satisfied=5.

Statistical data analysis

Initial data analysis revealed that a majority of the respondents gave "4" or "5" ratings on the 5-point satisfaction scale, indicating that they are generally satisfied with their job.

Since the response is heavily skewed, we grouped the 5-point scale into three distinct categories for comparison: "4" or "5" = "satisfied"; "3" = "neither satisfied nor dissatisfied"; "1" or "2" = "dissatisfied."

Chi square tests were performed on each of the nominal variables by their level of satisfaction to determine the statistically significant differences of the nominal data. The mean differences of continuous variables were analyzed using F-tests with the satisfaction as the independent variable. Post-hoc Tukey tests were performed following a significant F-test. The probability of a Type I error was set at .05 for each test.

Of the 1,410 surveys sent out, one mailing yielded 326 useable responses for a response rate of approximately 23 percent.

About 80 percent of the respondents indicated that they are satisfied or very satisfied with their current job (n=257), compared to 7 percent who were dissatisfied or very dissatisfied with their job (n=23). About 13 percent gave a neutral response (n=42). Four respondents did not express opinion on this question and they were excluded from further data analyses.

There are several limitations to this study:

It includes only physician executives belonging to the American College of Physician Executives and the Society for Chief Medical Officers, groups that may not be completely representative of the larger physician executive population.

However, these organizations are well-recognized national organizations and professional groups. The use of their databases in conducting studies has been documented in the literature. (5,8)

A relatively lower response rate with only one mailing and the difficulty of making comparisons between non-responders and responders limits the ability to make generalizations from the study. Also, other factors not examined in the study, such as actual compensation, may influence physician executive satisfaction.

John R O'Connor, PhD is at The Baldwin School, Bryn Mawr, Pa.

David B. Nash, MD, MBA, is the Dr. Raymond C. and Doris N. Grandon professor of health policy, associate dean of Jefferson Medical College, director of the office of health policy and clinical outcomes at Thomas Jefferson University, Philadelphia, Pa.

Michael L. Buehler, MA is director of research and development, The Bard Group, Newton, Mass.

Marc Bard, MD, is a founding partner at The Bard Group, Newton, Mass.

Authors' note:

This research was supported in part by the Bard Group, Newton, Mass.

We would especially like to thank Reuel May for his assistance in clerical work and data collection.