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Society’s increasing expectations and the transition from traditional to regional bureaucracies, combined with advances in medicine, pressure physicians into increasing their teaching and research commitments and into becoming more involved in administrative functions. In addition to their clinical duties, many physicians have taken on varying amounts of teaching, research, and administrative duties (1– 4). Further, the practice of medicine has always intruded on physicians’ personal lives, particularly in rural areas and where there are few specialists. Consequently, the organization of medical practice has shifted toward group practice and clinical decision making has evolved from highly independent consultations to the sharing of expertise (5,6). It is not surprising that measures of career satisfaction have emphasized professional and personal dimensions; however, they fail to address physicians’ higher-order needs (7,8) and are of limited value as sources of motivation for achieving and sustaining superior job performance (9–11). The purpose of this paper is to establish a reliable and concise measure of career satisfaction that addresses higher-order needs and documents these dimensions of satisfaction among the major medical specialties and across varying patterns of clinical practice. Establishing the Cornerstones of Career Satisfaction Career satisfaction extends beyond traditional dimensions of personal and professional satisfaction. Inherent satisfaction with the practice of medicine and performance satisfaction address higher-order needs and should also be incorporated into measures of career satisfaction. The inherent satisfaction dimension taps directly into the need for interesting and challenging work as an important source of motivation. Inherent satisfaction seeks to measure whether physicians find their work interesting and gratifying in terms of satisfaction with doctor–patient relationships, interactions between colleagues, diversity of patients, and career advancement. Only recently have surveys measuring career satisfaction included physicians’ performance satisfaction as it relates to their ability to meet patients’ needs (12) or their ability to provide good quality care (13). Each of these measures, however, relied on a single item. Other surveys conflate patients’ demands with their real medical needs (14). Items in our survey (Table 2) that are directly related to clinical performance include satisfaction with “your success in meeting the needs of your patients” and satisfaction with “your capacity to keep up with advances in your clinical specialty.” Other items, such as satisfaction with “your ability to access resources needed to treat your patient” and satisfaction with “your role in organizing treatment programs for patients in your community,” are related to organizational issues that have increasingly affected physicians’ clinical performance (5,15–18). Dimensions associated with basic needs and personal and professional satisfaction were drawn from the many existing surveys measuring career satisfaction (13,14,19–23). This study defined, developed, and tested a 16-item measure of career satisfaction consisting of 4 dimensions. Of these, the inherent and performance satisfaction dimensions focused on higher-order needs, and the other 2 dimensions focused on traditional or basic needs of professional and personal satisfaction. Documenting Dimensions of Career Satisfaction Across Specialties There is some evidence that physicians in certain specialties are consistently less satisfied with their careers than those in other specialties. Traditionally, especially in the United States, procedural specialties, such as surgery, ophthalmology, otolaryngology, obstetrics–gynecology, and urology, were among the higher earning, prestigious specialties, compared with the cognitive specializations, such as infectious diseases, pediatrics, internal medicine, and psychiatry (24). Physicians specializing in family medicine, primary care, and community medicine have not been rewarded as well as those in the cognitive or procedural specializations (25). It has been suggested that the choice of specialization is a matter of self-selection and personality (26). Some have suggested that some specializations are narrowly focused on defined knowledge and skill sets, whereas others offer more control over scheduling and lifestyle (27). Our study went beyond overall career satisfaction to examine specific dimensions of satisfaction for the major groups of medical specialties across Canada. Documenting Dimensions of Career Satisfaction According to Practice Profile The development of regional health authorities and the implementation of clinical protocols and other resource review processes have caused physicians to become more involved in administrative functions and to increase their teaching and research commitments (1,28). Most physicians do not find administrative roles beyond the paperwork associated with their own practices particularly satisfying because additional administrative duties detract from clinical duties and are not related to their training or because they are inadequately compensated for such duties (29). Academic responsibilities are related to clinical duties and are highly satisfying for many physicians. However, it is often stressful for a physician to complete his or her clinical work in a timely fashion while effectively conducting research and teaching (6,14). Owing to smaller and simpler caseloads, it is a challenge to maintain high-quality teaching in smaller communities (30). This study examines the effect of administrative and academic work on specific dimensions of satisfaction across varying patterns of duties. MethodsThis study draws data from the Emerging Issues in the Work of Physicians study conducted by the MERCURi Group at the University of Saskatchewan in early 2004. Comprehensive questionnaires were sent to a stratified sample of 5300 physicians across Canada. Questionnaires contained sections on quality of health services, health policy issues, professional equity, time spent on activities, stress and management of stress, practice organization, career satisfaction, and demographics. The sample was stratified to overrepresent female specialists, physicians practising in smaller communities, and physicians practising in less populous provinces. Of these, 149 respondents were ineligible for various reasons (retirement or reduction to part-time practice, maternity leave, return to medical school, lack of involvement in clinical care, serious illness, and in 3 cases, death), and 193 respondents had moved. This resulted in an eligible study population of 4958 physicians. Of these, 2810 returned completed questionnaires (56.7% response). To check for response bias, we sent one page surveys containing key items from the original questionnaire to all 2148 nonresponders. Subsequently, 686 were returned by mail or fax. Nonresponse bias was not detected on the basis of support for the Canadian health system, authority to make clinical decisions, location, specialty, language, or sex. Adjustments for bias were therefore unnecessary. Our career satisfaction measure (Figure 1) contained 17 items with 4 dimensions, each consisting of 4 items. These items related to personal, professional, inherent, and performance issues; as well, a global item asked physicians “How satisfied are you with your medical career, considering your various roles and responsibilities?” Each item was scored on a 6-point Likert scale in which 1 = very dissatisfied, 2 = dissatisfied, 3 = somewhat dissatisfied, 4 = somewhat satisfied, 5 = satisfied, and 6 = very satisfied.
To determine the underlying dimensions, we performed factor analysis on the 16 specific items, using principal component analysis with varimax rotation. We used factor loadings and reliability analysis of the items associated with individual factors to confirm the existence of the 4 hypothesized dimensions. We used total variance captured by the 16 items to verify that the 4 dimensions reasonably portrayed career satisfaction; the correlation between the summed 16-item scale and the global item was used to verify construct validity. ResultsThe distribution of responding physicians shows reasonable representation of all major specializations across Canada (Table 1). There are 53 different specializations recognized by the Royal College of Physicians and Surgeons of Canada. These have been grouped into 17 categories, both for practicality (that is, the combination of some of the smaller groups of specialists) and to identify details of some of the major specializations (Table 1, notes).
Establishing the Cornerstones of Career Satisfaction The factor structure of our measure of career satisfaction demonstrated that the personal, professional, inherent, and performance dimensions were significant factors in physician satisfaction (Table 2).
The items loaded onto the hypothesized dimensions in terms of item content and minimal cross loadings. The total variance explained by the scale was 60.4%. Further, the summed 16-item scale was highly reliable (á = 0.90) and correlated highly (P = 0.74) with the global item (Figure 1). The reliabilities of the dimensions (Table 2) were personal satisfaction, a = 0.81; professional satisfaction, a = 0.70; performance satisfaction, a = 0.75; and inherent satisfaction, a = 0.72. Competing explanations did not outweigh the hypothesized factors in that cross loadings were exceeded by dominant loadings for every dimension (Table 2). The first dimension, personal satisfaction, consisted of 4 items:
The factor loadings for the first 3 items were very high, exceeding 0.75 (Table 2). The fourth item was weaker at 0.432. This item cross loaded with the professional issues dimension at 0.358, compared with the dominant loading of 0.432 of the personal dimension. There were no other cross loadings above 0.300. Interitem correlations ranged from 0.363 to 0.710 (Table 3a). The ability to control work schedule correlated highly with preventing work responsibilities from intruding on personal life (0.709) and with sustaining activities in the community (0.710). The reliability of this subscale was a = 0.81.
The second dimension, professional satisfaction, also consisted of 4 items:
The factor loadings for the first 3 items exceeded 0.6 (Table 2). The fourth item was weaker at 0.453. There were 3 cross loadings above 0.300. Clinical authority cross loaded with the performance dimension at 0.306, compared with a dominant loading of 0.670 for the professional dimension. Relationships with nurses cross loaded with the inherent dimension at 0.437, compared with a dominant loading of 0.605 for the professional dimension. Earnings cross loaded with the performance dimension at 0.328, compared with a dominant loading of 0.453 for the professional dimension. Interitem correlations ranged from 0.250 to 0.513 (Table 3b). There was a weak but significant correlation between earnings and all 3 of the other items. The reliability of this subscale was a = 0.70.
The 4 items of the third dimension, performance satisfaction, were:
The factor loadings for the first 2 items exceeded 0.7 (Table 2). The factor loadings for the third and fourth items were 0.594 and 0.555, respectively. There were 3 cross loadings above 0.300. Ability to access resources cross loaded with the professional dimension at 0.309, compared with a dominant loading of 0.763 for the performance dimension. Success in meeting needs cross loaded with the inherent dimension at 0.322, compared with a dominant loading of 0.742 for the performance dimension. The role in organizing treatments cross loaded with the professional dimension at 0.450, compared with a dominant loading of 0.555 for the performance dimension. Interitem correlations ranged from 0.383 to 0.534 (Table 3c). The reliability of this subscale was a = 0.75.
The 4 items of the fourth dimension, inherent satisfaction, were:
The factor loadings for the first 2 items exceeded 0.7 (Table 2). The factor loading for the third and fourth items were 0.585 and 0.406, respectively. There were 3 cross loadings above 0.300. Interactions with other physicians cross loaded with the professional dimension at 0.393, compared with a dominant loading of 0.585 for the inherent dimension. Career advancement in medicine cross loaded with the personal dimension at 0.347 and with the professional dimension at 0.378, compared with a dominant loading of 0.406 for the inherent dimension. Interitem correlations ranged from 0.383 to 0.534 (Table 3d). Interitem correlations ranged from 0.295 to 0.530. The correlation of career advancement with doctor–patient relationships was only 0.302. The reliability of this subscale was a = 0.72.
Documenting Dimensions of Career Satisfaction Across Specialties As indicated by the Satscale scores, general practitioners were the least satisfied with their overall careers (3.98 out of a possible score of 6), and clinical (4.47), administrative (4.46), and research physicians (4.45) were the most satisfied with their careers (Table 4).
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