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'Can't get no (physician) satisfaction?'.

Aristotle did not invent the first physician satisfaction survey 2,300 years ago when he wrote the Nichomacean Ethics. But he was attempting to answer the fundamental question "What is happiness, really?"

His treatise posited that happiness is the ultimate goal of human life and can only be achieved through "virtuous living" learned by habituation and practice. He identified four cardinal virtues:

1. Courage

2. Temperance

3. Practical wisdom

4. Justice

And he declared that the prime concern of ethics is the art of living well. (1)

Fast forward to the 21st century American physician and one finds a whole industry dedicated to the study and measurement of physician happiness, or "satisfaction," as it is more euphemistically termed in the social sciences literature.

There appears to be a great deal of concern about the happiness of physicians. It seems that not a week goes by that the media presents us another survey showing how unhappy physicians are, pitting specialty against specialty for their unhappiness quotient. (2)

Dermatologists always seem to be happier than internists, specialists happier than primary care. The proverbial question, "Would you want your son or daughter to be a physician?" is answered with a louder "No!" every year, and emphasis is placed upon the increased paperwork, medical legal risks, unrealistic patient demands, and other aspects of the modern American health care system to explain this growing dissatisfaction.

The question of physician happiness is not (with apologies to Aristotle) simply academic. Some studies correlate patient outcome with physician satisfaction scores. (3) Other studies have correlated higher physician satisfaction scores with appropriate prescribing practices and patient adherence. (4,5)

Hospitals and medical groups with higher physician satisfaction scores have less staff turnover and higher patient satisfaction scores, and dissatisfied doctors have more costly practice styles and generate more outpatient procedures and referrals. Thus, physician satisfaction is regarded as one of four critical outcomes of health care, along with health status, patient satisfaction and cost. (6)

Surveys abound

An industry has arisen dedicated to measuring physician satisfaction to respond to various customers and their specific needs regarding physician satisfaction information. Some of these customers are hospitals, media groups, insurance companies, pharmaceutical and medical device companies, physician groups, and recruiters.

These customers are each buying unique products and the various types of surveys can be categorized accordingly. In general, the news media are buying interesting stories. There are not a lot of newspapers that can be sold with such headlines as "Physicians are generally satisfied with their lives" or "Doctors say 'It could be a whole lot worse, I suppose.'" Media surveys tend to be focused on questions designed to evoke specific emotional responses from a certain number of respondents. Hence, the proverbial "Would you want your son or daughter to be a doctor?" question.

On the other hand, those for whom the physicians are potential customers have a very different objective with their surveys. It is important for hospitals to be able to recruit and to retain an active medical staff in today's competitive health care market. So the hospital industry has been the consumer of physician satisfaction surveys by companies that have a database of huge numbers of hospitals across the nation and can quantify responses of physicians that are pertinent to their medical staff experience relative to those of their peers at other institutions.

The physician recruitment industry uses surveys to place doctors in positions where they will stay, thereby improving their retention rates and their own business success. Within this context, physician recruitment groups focus on the physicians they have recruited for a group within the first two years of their new job. Likewise, there are physician satisfaction surveys that focus on job satisfaction aspects.


Is anybody happy?

But do all these attempts at quantifying physician satisfaction really get to the essence of human happiness? Can it be that physicians--with wealth and health undreamed of in Aristotle's' time--are really all that unhappy?

Actually, revisiting Aristotle's four virtues is not a bad place to reevaluate physician satisfaction to come to a better understanding of what physician satisfaction surveys can and cannot tell us.

Aristotle's first virtue is courage, which is concerned with the right relation to pain and fearful things. Physicians have been honored throughout human history for their sacred place in the lives of their fellow man in times of suffering.

Modern American medicine juxtaposes some of the greatest advances in human history in medicine with the resurgence of infectious diseases on a pandemic scale. Physician satisfaction may be impacted by the intimate exposure we have to a world where an ICU can render either miraculous cures, or expensive, uncompassionate and futile care.

We are intimately involved in a health care system that has wrought heart transplants and stem cell research, but one in which 35 percent of the African subcontinent is infected with the HIV virus and where 40 million of our own citizens are uninsured.

We are with people at some of the most vulnerable moments of their lives, when they are born, sick, giving birth, dying. Aristotle would say that happiness would require a good helping of courage for such a life. Moderns would suggest that intimacy with such things is in itself a cause of stress.

His second virtue is temperance and is concerned with the right relation to pleasures, especially bodily pleasures. Aristotle placed the virtue of temperance in the middle of self-indulgence and insensitivity.

For physicians, we spend the years of our youth and young adulthood in an academic experience that is more disciplined and more intense than our peers. We may sacrifice leisure or family time to study for the organic chemistry exam and the physics final, then the MCAT and the medical school boards. This is followed by an internship, residency and fellowship.

We work a "humane" 80 hours a week. We get ourselves into more educational debt than any other student group, and then we anticipate higher incomes than any other profession with which to reward ourselves for all of our intense work. Is this temperance? Rarely do physicians boast of moderation. We are trained for extreme behavior.

The third Aristotelian virtue is justice. In fact, it was Aristotle who coined the term "distributive justice" that forms much of the ethical construct of our Western legal tradition. He was concerned that everyone should get what they deserve.

I believe that it is within the context of distributive justice that most physician dissatisfaction seems to arise. After years of study, sleep deprivation, and various forms of abuse, the physician finds a medical system set up to restrain excess. It's restrained through the malpractice system, government regulations, and managed care--and the doctor says "Not fair!"

Distributive justice is about fairness. It is about each getting what they deserve. Herein lays the crux of much current physician dissatisfaction. Doctors have sacrificed. They have suffered. They really have. For a profession built upon delayed gratification it is not fair that, at the end of all the hard work and sacrifice and all that training and achievement, we go up against managed care, Medicare, six-figure student loans and malpractice.

In a recent book review in the Journal of the American Medical Assocation, G.F. Anderson concludes that the malpractice issues are "so intertwined with the other health policy issues that it will be difficult to address malpractice reform until these other issues are addressed."

The perspectives of various stakeholders regarding U.S. health care policy are very incongruent when it comes to "fair." A malpractice attorney's perspective on fairness is focused upon a plaintiff with a poor outcome. A governmental body may be prioritizing resource allocation. A physician is certainly thinking about the lack of control that he or she truly has in a world of people/death/imperfect science/imperfect medicine/unrealistic expectation and human error.

A physician's perspective on distributive justice may be diametrically opposed to an attorney's perspective: "How can they sue me for missing that lesion on that chest X-ray that was buried in that report when I studied so hard, gave up so much to get here, and suffered so much?"

"Physician dissatisfaction" is a euphemism for suffering. Suffering is a word reserved for patients, and it has not been part of our professional training to admit we suffer. But we are allowed to be dissatisfied.

Aristotle's fourth virtue is practical wisdom--the skill of making the right judgment in particular situations. It is here that physicians often find their bliss. When we are able to use our training and experience to connect with our patient and to help and to heal them, or to be there with them to relieve their suffering, we can be happy.

Numerous physician surveys correlate a perceived strong physician-patient relationship with greater satisfaction scores. Within the context of these instruments, physician perception of high quality of care is a major predictor of high satisfaction scores. As physician executive leaders, if we are able to impact systems and processes that allow physicians to improve the quality of their patient interactions and their outcomes, we should have happier colleagues.

Robert J. Wolosin, PhD, Research Product Manager of Press Ganey Associates agrees that measuring physician perception of quality of care correlates with their satisfaction. He references Dr. Albert Jonsen's classic essay in the New England Journal of Medicine published in 1983, "Watching the Doctor":
 A profound moral paradox pervades medicine. That paradox arises from
 the incessant conflict of the two most basic principles of morality:
 self-interest and altruism. Certainly, every human being feels, from
 time to time, the tug of these principles. Every profession and
 occupation is marked, to some extent, by the tension. But the
 opposition is, I believe, built into the very structure of medical
 care and woven into the fabric of physicians' lives. The many
 particular moral problems encountered in medicine are symptoms of this
 profound paradox. Many of the social and economic features of medical
 care are, in some way, outgrowths of this paradox. Many of the
 psychological troubles of physicians (and their families) are fomented
 by the inability to manage the pressures of this paradox. Of course I
 cannot support these assertions with solid epidemiologic studies or
 statistically impressive empirical research. I merely propose them as
 the reflections of a sympathetic and experienced doctor watcher. (7)

Wolosin states that Jonsen got it right when he focused upon just two motives that drive people to go to medical school, namely, altruism and self-interest.

"If you buy his argument, then a good physician satisfaction survey will basically focus upon those two motives. How does the altruistic motive become manifest? How is self-interest manifest? The Press Ganey physician satisfaction survey focuses upon standard questions regarding quality of care, because this is how the altruistic motivations are expressed. On the other hand, ease of practice questions get at the self-interest motivations. A third important set of questions concerns relationships with leaders. If a physician feels he get along with the leadership of his organization, then he can influence him and is happier." (8)

In a similar tone, Mark Miller writes in the American Medical Group Association Group Practice Journal that there are essentially only four variables that make up the lion's share of variance in physician satisfaction in the surveys that group does:

1. Time spent working

2. Quality of care

3. Compensation

4. Leadership and communication

The division of these into categories of self-interest and altruism is easily made. (9)

If Jonsen is correct that the physician is in a unique place because of the inherent stress between self-interest and altruism that is so intense in our profession, what are we as physician leaders to do with the discouraging decline in various physician satisfaction scores over the past decades?

Is the profession of medicine becoming too stressful to provide physicians with a satisfying life? One solution is to not look at the motivators of self-interest and altruism as either of equivalent importance or mutually exclusive.

Maslow suggested six concentric hierarchical levels of human motivation, with the basic human needs requiring fulfillment before the higher motivators could come in to play. I would suggest that there are really only three basic motivators for any individual at any point in time:

1. Seeking survival

2. Seeking pleasure

3. Seeking to matter

People who are able in their personal and professional life to have a balance between pleasure (self-interest) and their efforts to make a difference (altruism) will be happier.

Essentially the physician satisfaction surveys attempt to quantify this. Presumably those of us in physician leadership are attempting to qualify this by improving the conditions in which our colleagues practice.

Grace E. Terrell, MD, MMM, CPE, is a general internist in private practice at Cornerstone Medical Associates, High Point, NC. She can be reached at



1. Aristotle, Nicomachean Ethics, translated by F.H. Peters, Barnes and Noble, New York: 2004.

2. Leigh JP, Kravitz RL, Schembri M, Samuels SJ, Mobley S, Physician Career Satisfaction Across Specialties, Arch Intern Med, 162 (14):1577-84, July 22, 2002.

3. Haas JS, Cook EF, Puopolo AL, Burstin HR, Cleary PD, Brennan TA. Is the Profession Satisfaction of General Internists Associated with Patient Satisfaction? J Gen Int Med, (2) 122-8, Feb 15, 2000.

4. Melville A. Job Satisfaction in General Practice: Implication for Prescribing. Soc Sci Med, 14A(6):495-9, Dec 1980.

5. DiMatteo MG, Sherbourne CD, Hays RD, and others. Physician Characteristics Influence Patients Adherence to Medical Treatment: Results from the Medical Outcome Study. Health Psychol, 12 (2):93-102, Mar. 1993.

6. Grembowski, D, Ulrich, CM, Paschane, MS, Kiehr, DD, Katon, W, Martin, D, Patrick, DL, and Velicer, L Manage Care and Primary Physician Satisfaction. JABFM 16:783-93, 2003.

7. Jonsen AR, Watching the Doctor. NEJM, 308(25):1531-5, Jan 23, 1983.

8. Personal interview with Robert J. Wolosin, PhD Research Product Manager, Press Ganey Associates, Inc. March 9, 2007.

9. Miller M, What Drives Provider Satisfaction? It Depends on the Provider Group Practice Journal, 57(1), Jan. 2007.

By Grace Emerson Terrell, MD, MMM, FACPE, CPE
COPYRIGHT 2007 American College of Physician Executives
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Title Annotation:Searching for Satisfaction
Author:Terrell, Grace Emerson
Publication:Physician Executive
Date:Sep 1, 2007
Previous Article:A decade of patient satisfaction survey results: lessons learned in a large multispecialty group practice.
Next Article:Physician relations: now more than ever.

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