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Physicians must perform many activities within the Canadian health care system (1). In addition to fundamental responsibilities to provide care to patients and to maintain clinical skills, recent health care reforms have caused physicians to become more involved in administrative functions as well as increasing their teaching commitments and research (2). The roles of many physicians also extend beyond the professional to include various activities within their communities and neighbourhoods (3). While the motivation to carry out these activities may be complex, the quality of performance of both professional and nonprofessional activities can be affected by the physician’s level of career satisfaction (4,5). It would benefit both the health care system and physicians to identify and promote factors associated with greater career satisfaction. Many factors, including workplace stress and the ability to cope with that stress (6–11), participation in social and leisure activities (3,4,12,13,14,15,16), and the fair distribution of rewards (17–20), contribute to career satisfaction. Career satisfaction among physicians is also associated with their ability to access quality services for their patients (7), workload (4,16,21) and organizational factors, and managerial functions (4,12,22). In addition to identifying factors contributing to the career satisfaction of physicians, it is also important to acknowledge that the relative importance of these factors will vary among specialties (5,16,23,24). As such, the strategies used to promote career satisfaction are likely to vary across medical specialties. The purpose of this paper is to articulate a general model of career satisfaction for Canadian physicians and then to determine the relative contribution of these factors to the career satisfaction of 2 distinct specialty groups: surgeons and psychiatrists. MethodStudy and Sample Populations A stratified random sample of 5300 physicians was drawn from a comprehensive commercial database listing all 60 859 physicians actively practising in Canada as of January 2002. The purpose of the stratification was to ensure that sufficient numbers of physicians would be available for analysis of important subgroups of physicians in each province, notably, female specialists in the smaller provinces. We used 4 levels of strata: 1) provincial stratification was used to oversample the less populous provinces and to undersample the more populous provinces, 2) sex stratification within general practitioners was used to undersample the male population and oversample the female population, 3) sex stratification within specialists was done separately because the proportion of female specialists is less than the proportion of general practitioners, and 4) community size was used to underrepresent the large metropolitan centres of Toronto, Montreal, and Vancouver and to oversample smaller communities and rural areas. Stratification resulted in nearly equal representation for female and male physicians and good representation of both general practitioners and specialists. It also resulted in a more even distribution for those working in rural, small, medium, and urban centres. Stratification generated a reasonable distribution of the sample across the 10 provinces and 3 territories. Data Collection Data were collected between January and April 2004 through a mail-in questionnaire, according to methods established by Dillman (25). The questionnaire was previously validated by studies in 1998 and 2002, and consists of a 12-page booklet containing sections pertaining to the quality of local health care and health care financing (26,27), professional equity, time allocation, workplace stress and support, managing stress, the role of the physician in the community, career satisfaction, practice characteristics, and practice management. To check for response bias, all nonresponding physicians were sent a 1-page survey containing key items, with a cover letter and a prestamped envelope (28). Sample Weighting To allow the data to more accurately reflect the actual distribution of physicians across Canada, we applied weighting factors. Weights were based on the distribution of specified characteristics (sex, specialty, population density, and province or territory) as reported in a 2002 database supplied to the researchers by the Canadian Medical Association and calculated according to the methods of Kleinbaum and others (29) and Churchill (28). Measures The Dependent Variable—Career Satisfaction. A full spectrum of career satisfaction was captured with 16 items, including career advancement, relationships with patients, relationships with nurses, relationships with administrators, interaction with other physicians, patient diversity, ability to control schedule, ability to access resources, clinical authority, role in organizing treatment programs, ability to keep up with advances in specialty, ability to meet needs of patients, earnings as a physician, management of the practice, social and leisure activities, ability to sustain activities in the community, and ability to keep work from intruding on personal life. All items were scored from strongly disagree to strongly agree using 6-point Likert scales, yielding a reliability of a = 0.92. The correlation between the full 16-item composite scale and a 6-point global scale, “How satisfied are you with your medical career, considering your various roles and responsibilities?,” also part of the questionnaire, was very high (0.745). This suggests that the composite scale is both valid and highly reliable. The Independent Variables. Explanatory variables were arranged in a sequence consisting of demographic or control factors, stress and coping, health care system quality and access, professional equity, workload, and organizational characteristics (Figure 1).
Control Factors. The control factors were sex, family responsibility, years in practice, community size, and self-reported health status. The family responsibility variable was based on ranked age groupings of children and recognized infants and toddlers, who require the most parental attention, followed by preschoolers, and then older children (30). The community size variable was coded so that adjacent bedroom communities were included within larger central communities. Stress and Coping. Many studies of stress intertwine perceived stress, strain, and burnout, often combining elements of each under the common label of stress (31). Our study focused on perceived stress and was labelled “distress” to distinguish it from job strain (32,33) and burnout (34). The distress scale had very good reliability (a = 0.81), with 10 items, each scored on a 7-point scale ranging from never to every day. Physicians were also asked to indicate their ability to cope with stress on a single 5-point scale. Community roles and activities may either contribute to or help alleviate stress. To establish a relationship between career satisfaction and roles and activities in the community, we used a matrix of activities and roles, including time spent on 6 categories of activities (sporting and recreation, cultural and arts, spiritual or religious, community and charity, health care, and other activities) and time spent on 6 types of specific roles in increasing levels of intensity (attendance and participation, volunteering, providing medical expertise, coaching or instruction, fundraising, and leadership). Collegiality. We measured collegiality with 3 items: “when you need to talk about a problem there are colleagues available who can give you sound advice”, “a colleague is willing to take on extra work so that you can take time for special training or CME,” and “if you needed a week off to attend to special needs a colleague would fill in for you.” Each of the 3 items was measured on a 6-point scale (strongly disagree to strongly agree). The collegiality scale had very good reliability (a = 0.84). Quality and Access. We asked physicians to report their views on the quality of health services in their local communities from an overall perspective according to 5 global items rating access to services, quality of services, efficiency of the system, coordination of services, and collaboration among different providers in the community as identified by the benchmarking studies of Daniels and others (35). This 5-item scale was highly reliable (Cronbach a = 0.83). We also asked physicians to rate their assessments of access to, and the quality of, 5 specific services (community, mental health, hospital, rehabilitation, and nursing home services) according to individual grading scales. These two 5-item scales measuring access (a = 0.82) and quality (a = 0.86) corroborated the overall assessment of health service quality. Professional Equity. The association between satisfaction and equity as it relates to fair remuneration is well established (17–20). In assessing professional equity, however, physicians are concerned with more than monetary rewards. An assessment of equity also includes social rewards such as appreciation, respect, and the content of the work itself (36). The benefits and contributions associated with activities such as patient care, teaching, research, and the administration of clinical programs are also expected to contribute to professional equity but may be valued differently by specific physician groups when establishing a fair exchange (37,38). The equity measured in this study is based on a previously developed scale (27) that measured 3 aspects of equity: intrinsic equity (a = 0.81), recognition equity (a = 0.75), and financial equity (a = 0.93). This scale was augmented by a fourth subscale, input equity (a = 0.71), which included items relating to physical and intellectual effort, mental empathy, diligence with paperwork, and investment in equipment and staff. Workload. Clinical workload was measured by summing the number of weighted cases handled by the physician (routine cases = 1.0, complex medical cases = 1.25, cases with serious personal problems such as substance abuse and battering = 1.25, and cases characterized by both complex medical and personal problems = 1.5). Mainous and his colleagues used a similar approach in their physician work life studies (10,39). The number of hours of work, time on call, and extent of academic responsibilities were also captured. Organizational Factors.The study captured whether the physician was part of an individual or group practice, shared revenues and (or) expenses, was on contract with a health organization, or participated in alternative funding programs. With respect to methods of payment, physicians were asked to indicate the distribution of income between fee-for-service, salary, capitation, and sessional contracts. Management variables consisted of 2 scales pertaining to levels of organizational formality and managerial decision making. The first scale comprised 7 items related to carrying out a range of management activities, including strategic planning, setting budgets, conducting staff performance appraisals, evaluating the efficiency of operations and the quality of services, and holding meetings to discuss administrative and clinical issues. The scale was very reliable (a = 0.89). The second, a managerial decision-making scale, comprised 7 items related to taking on new physicians, hiring and setting pay levels of staff, purchasing supplies and medical equipment, selecting clinical services, and facility financing. This scale was also very reliable (a = 0.92). Analysis We used a multiple regression model with beta values and individual and cumulative coefficients of determination R2 to verify the direction and magnitude of relations within the model (40,41). We conducted separate regressions for the 231 psychiatrists and 148 surgeons selected from the 2810 responding physicians. ResultsOf the questionnaires sent to 5300 physicians across Canada, 149 were deemed ineligible for various reasons (retirement or reduced practice, maternity leave, return to medical school, not involved in clinical care, serious illness, and in the case of 3 respondents, death); 193 physicians moved, leaving 4958 eligible physicians. Of these, 2810 (56.7%) returned completed questionnaires. Of the 2144 single-page nonresponder questionnaires sent to nonresponding physicians, 686 (32.0%) were completed and returned. Response bias was not detected on the basis of support for the Canadian health care system, authority to make clinical decisions, location, specialty, language, or sex. Nonresponding physicians were slightly, but not significantly, more satisfied with their careers (4.16) than were physicians responding to the full survey (4.13). From these results, we deemed adjustments for response bias unnecessary. We grouped physicians responding to the study into one of 17 categories based on the 53 specializations recognized by the College of Physicians and Surgeons of Canada (Table 1). The respondents were reasonably distributed across Canada (Table 1). The mean age of psychiatrists was 50.14 years. The mean age of surgeons was 49.17 years. More than 80% of respondents were between the ages of 35 and 54 years (Table 2). Slightly more than one-half (52.4%) of the responding psychiatrists were women. Almost one-quarter (23.1%) of the responding surgeons were women.
Psychiatrists were slightly more satisfied with their careers (4.17 out of 6 on the composite scale) than surgeons (4.03), with most indicating satisfied or very satisfied (Table 3). Very few physicians indicated they were either dissatisfied or very dissatisfied with their career. The multivariate models of career satisfaction explained 90.4% of the variance in career satisfaction for surgeons and 81.0% of the variance in career satisfaction for psychiatrists (Table 5). The explanatory variables, however, differed somewhat between the 2 specialties (Tables 4 and 5).
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