Joy In Medical Practice: Clinician Satisfaction In The Healthy Work Place Trial

It has been almost twenty years since John Eisenberg and his colleagues at the Agency for Healthcare Research and Quality coined the term “healthy workplaces.”¹ Since then, there have been numerous studies seeking optimal ways to organize a medical workplace and the benefits for clinicians and patients of doing so.^2,3 Lately there has been renewed interest in promoting clinician satisfaction, or the joy in medicine.⁴ Many clinicians have spoken and written of the challenges of contemporary medicine, including regulation, electronic medical records, care driven by relative value units, and the consequent hectic pace and long hours.⁵ These comments and studies have left medical leaders wondering about the viability of certain front-line specialties, as clinicians gravitate to careers with a tradition of better work-life balance.⁶

Clinician satisfaction is an important goal. But what is not known are the ways in which building a satisfying practice may be related to reduced adverse outcomes for clinicians (for example, burnout and intent to leave) and improved care for patients.⁷ Physician satisfaction does explain some of the variability in patient satisfaction,⁸ but its relationship to other patient outcomes is less certain.

The main goal of our study was to demonstrate the connection between clinician satisfaction and remediable work conditions. To achieve this goal, we sought to answer the following questions using data from a randomized study of primary care practices, the Healthy Work Place (HWP) trial:⁹ What are the characteristics of satisfied clinicians; how do stress, burnout, and intention to leave relate to satisfaction; which workplace structural and cultural factors are associated with satisfaction; and are improvements in satisfaction associated with improved outcomes for clinicians and patients? By answering these questions, we hoped to advance understanding of the potential benefits of increasing the joy in medical practice and gain insight into the utility of clinician satisfaction as a practice-level metric.

Study Data And Methods

Data

The Healthy Work Place trial, described in greater detail elsewhere,^9,10 was a cluster randomized trial that recruited thirty-four practices in three geographic regions (rural Midwest, suburban Midwest, and inner-city East Coast). All practices in three large health systems were invited to participate, and all clinicians (physicians and advanced practice providers—a group that includes nurse practitioners and physician assistants)—at each practice were recruited, along with six to eight of their patients with hypertension, diabetes, or both. Data were collected in the period 2011–14.

Baseline data included clinicians’ descriptions of practice work conditions (the degree of control of work; the pace of work—that is, how chaotic the workplace was; organizational culture, with domains described below; time pressure during visits; and emphasis on work-life balance) and clinician outcomes such as stress, burnout, and intent to leave the practice. For the most part, these metrics were developed and validated in the Physician Worklife Survey^11,12 and the Minimizing Error, Maximizing Outcome (MEMO) study.² Organizational culture scales were drawn and adapted from the study of medical group practices by John Kralewski and coauthors.¹³ Five cultural domains were assessed in the HWP trial: an emphasis on quality versus productivity, cohesiveness, trust in the organization, an emphasis on communication and information, and alignment of values between leaders and clinicians (for details, see online Appendix Exhibit A1).¹⁴ Time pressure was assessed by comparing time needed versus time allotted for new patient visits and follow-up appointments. The pace of work (that is, how chaotic or hectic the workplace was) was assessed with a single-item measure from the MEMO study² that emanated from physician focus groups. Work control was assessed by a thirteen-item scale from the Physician Worklife Survey that included control of the medical workplace, medical decisions, and hassles or interruptions.

Methods

The primary outcome metric for the study was a validated five-item global clinician job satisfaction measure (for the items, see Appendix Exhibit A2).¹⁴ Clinic managers provided data on practice structure (for example, staffing ratios and quality assurance practices), and our research assistants reviewed charts to assess the quality of care for controlling hypertension and diabetes and safety (medical errors, such as omitting to care for elevated blood pressure or blood sugar). These metrics are presented in detail elsewhere.^2,10

Practices were randomly assigned to control or intervention groups before baseline data collection. Providers in practices in the two groups were comparable in terms of age, sex, duration in the practice, ethnicity, and discipline, as well as in baseline assessments of work control and chaos (for details, see Appendix Exhibit A3).¹⁴

Each of the seventeen intervention practices received a copy of its baseline data in a two-page summary sheet. Each practice was asked to select potential interventions that address known predictors of burnout, such as control, chaos, time pressure, and values alignment. The practices then developed quality improvement teams to determine which interventions to implement, depending on the practice-specific data. Data collection at both the control and intervention practices was repeated approximately one year later after the collection of baseline data, to obtain follow-up information. This permitted examination of the changes in satisfaction during the study period, whether in the absence or presence of a formal intervention. The list of selected interventions was reviewed by leaders of the investigative team, which determined that they were clustered in three categories:¹⁰ workflow redesign, communication improvements, and targeted quality improvement programs that addressed issues of clinician concern in chronic disease management. For the list of selected interventions, grouped by category, see Appendix Exhibit A4.¹⁴

Although previous analyses of the HWP trial data focused on comparisons between the intervention and control practices, between-group differences in outcomes were not a focus of this study. Therefore, data from the two groups at each point in time (baseline and follow-up) were pooled for our analyses. These data included descriptive statistics to describe the characteristics of clinicians who were satisfied at baseline (that is, those with scores of 3.5 or higher on the 5-item satisfaction metric, where 3 is neutral), as well as associations between specific work conditions (for example, manageable stress, high control of work, moderate pace of work) and job satisfaction. A score of 4 represented “agree” on the 1–5 scale of satisfaction. A score of 3.5 was considered as the lower limit of satisfaction when individuals circled 3 and 4 as their choice. Two-level hierarchical logit models were constructed with clinicians nested within clinics to assess correlates of satisfaction at baseline. Hierarchical regressions in an improvement analysis assessed all clinicians who became more satisfied during the trial for clinician outcomes (such as increased intent to stay with the practice) and patient outcomes (for example, improved care for diabetes or hypertension). Models controlled for age, sex, and provider specialty (family medicine versus general internal medicine) and were structured for two-level analyses.

Limitations

Our study had several limitations: Our sample included a large proportion of satisfied clinicians, which provided a potential ceiling effect; had a limited number of patient types and outcomes; and had a relatively short time between initiation of the interventions and the follow-up assessment. Only certain geographic regions were represented. In addition, it is not clear with what fidelity the interventions were carried out. These limitations may minimize the generalizability of our results and may have reduced our ability to show an impact on patient outcomes.

The HWP trial also had several strengths, including the longitudinal study design and the use of well-validated metrics to define organizational culture, work conditions, and clinician outcomes.

Study Results

There were 168 clinicians (146 physicians and 22 advanced practice providers) in 34 clinics in the baseline sample. Of the clinicians, 52 percent were female, and 64 percent were internists (versus family physicians). At baseline, 74 percent indicated job satisfaction. Exhibit 1 shows the relationships at baseline between satisfaction and aspects of the workplace, including time pressure, work control, work pace (how chaotic the workplace was) and organizational culture variables. Pace was associated with satisfaction, as were three of five organizational culture variables (cohesion, communication and trust).

Exhibit 2 shows the associations between satisfaction and clinician reactions at baseline, with strong association between satisfaction, stress, burnout, and intent to leave. For example, 50 percent of clinicians who intended to leave were satisfied, while 83 percent of the clinicians who planned to stay were satisfied.

Exhibit 3 shows the results of two-level logit models that used work conditions and organizational culture to predict both satisfaction at baseline and the relationships between satisfaction and other clinician outcomes at baseline, including stress, burnout, and intent to leave. There were strong relationships between satisfaction and work pace (odds ratio: 0.21). In other words, the odds of satisfaction were 79 percent less if the workplace was chaotic. Satisfaction was also related to culture—especially cohesiveness and trust (ORs: 4.5 and 4.2, respectively)—and to all clinician outcomes including stress, burnout, and intent to leave (ORs: 0.19, 0.08, and 0.18, respectively).

One hundred thirty-five clinicians in thirty-two clinics were available for follow-up. The 20 clinicians (16 percent of the 129 with satisfaction data at both baseline and follow-up) with improved satisfaction showed significant improvements in burnout and intent to leave (data not shown). Burnout scores improved for 38 percent of clinicians with improved satisfaction, but for only 13 percent of those without improvements in satisfaction (that is, clinicians were 2.9 times more likely to reduce their burnout if they were more satisfied; $p=0.001$). Intent to leave scores improved for 34 percent of the clinicians who became more satisfied during the study period, but for only 4 percent of those without improved satisfaction (clinicians were 8.7 times more likely to improve in intent to leave if they were more satisfied at study completion; $p<0.001$).

Patient outcomes in terms of quality of care and medical errors for patients with hypertension and diabetes were not associated with higher satisfaction at baseline. Nor did they improve more for patients of those clinicians whose satisfaction improved versus patients of clinicians whose satisfaction did not improve (data not shown).

Discussion

In this prospective study of 168 clinicians in thirty-four medical practices, we found that job satisfaction (joy in practice) was associated with both structural and cultural aspects of the work environment: slower paced, less chaotic environments were far more satisfying, as were practices with cohesion, good communication, high clinician trust in the organization, and high alignment of values between clinicians and leaders. Clinicians’ job satisfaction at baseline was strongly associated with lower stress, lower burnout, and less intent to leave the practice, while clinicians who improved their satisfaction were almost three times less likely to burn out and over eight times as likely to intend to stay with the practice.

While no changes were seen in patient outcomes with improved satisfaction, other research has demonstrated that higher rates of burnout are associated with increased medical errors,^15,16 lower-quality patient outcomes in people with diabetes, and lower patient satisfaction with care and adherence to treatment recommendations.^17,18 In addition, studies have demonstrated the value of continuity, which results in fewer emergency department visits and hospital admissions.^19–22 It remains to be determined whether improved continuity of care related to physician retention that in turn is related to increased satisfaction will result in improved patient outcomes over time.

Implications: Restoring The Joy In Practice

These findings from the Healthy Work Place trial provide empirical support for the current movement aiming to restore the joy in practice.^4,23 Indeed, many providers in the trial were satisfied with being a clinician, although they experienced stress from adverse work conditions. Many roadblocks to joy in practice exist, including regulations, electronic medical records, the push for productivity, and the challenges of promoting work/life balance.²³ Our data show that a large number of practicing clinicians are satisfied, but their satisfaction might be improved by addressing the work environment (making it less chaotic) and by promoting a more positive organizational culture, including cohesion, trust, values, and an emphasis on good communication. For practices struggling to maintain efficiency, building cohesion, aligning clinicians’ and leaders’ values, and building trust through better communication may be mechanisms to support a more efficient and sustainable practice.

Less chaotic workplaces were highly associated with satisfaction. Chaos in the clinic predicts adverse outcomes for clinicians and patients.²⁴ Chaos is prevalent (existing in 40 percent of primary care practices) and associated with less teamwork and professionalism and with more bottlenecks—such as during patient registration and check-out, over the telephone, and at the pharmacy.^2,24 Chaotic clinics have also been found to have more medical errors. Thus, careful attention to work pace and engineering clinical spaces for quiet and smooth connections and communication may benefit both clinicians and patients.

Organizational culture played a prominent role in satisfaction, with four of the five dimensions of culture predictive of satisfied clinicians. There are practical implications to these findings.^25–27 If an organization wishes to promote clinician job satisfaction, reduce burnout, and increase loyalty to the organization (as measured by intent to stay), these culture domains may be critical areas for quality improvement. Values alignment, which was shown in the MEMO study to be associated with favorable clinician and patient outcomes,² appears to be a key component of a well-functioning practice: Aligning clinicians’ and leaders’ values (for example, in values-defining sessions) can help front-line clinicians get through challenging times. Avoiding a “Relative Value Unit mentality”²⁸ by emphasizing quality over productivity may further enhance the organizational culture and improve clinicians’ job satisfaction.

With the rapid pace of change in medicine, the benefits of frequent and effective communication cannot be overemphasized.

In the HWP trial,¹⁰ interventions that improved communication between provider groups or those that emphasized interventions chosen by practices to address clinician-identified problems through workflow redesign were best at improving satisfaction. Clinics undergoing these interventions had three times the odds of demonstrating improved provider satisfaction.⁹ These data support the current emphasis in the literature on workflow redesign to reduce pressure on busy clinicians^29–32 and extend the focus to include interventions that improve communication between provider groups (for a list of interventions, see Appendix Exhibit A4).¹⁴ With the rapid pace of change in medicine, the benefits of frequent and effective communication from leaders, and between clinicians and clinic staff members, cannot be overemphasized.

Our findings also suggest that substantial benefits may result from improving clinician job satisfaction: Burnout scores were reduced in almost three times more clinicians, while intent-to-leave scores were improved in over eight times the number of providers. Thus, efforts to improve job satisfaction may pay for themselves, as each departing primary care clinician can cost $250,000 to replace³³—with recent estimates exceeding $500,000^34,35 for recruitment and ramp-up costs for subspecialty clinicians.

Satisfaction at baseline and improved satisfaction during the study period were not associated with improved patient outcomes (as measured by quality of care and frequency of medical errors). Improvements in quality and errors may take longer or stronger interventions. While satisfied clinicians are associated with satisfied patients,⁸ the percentage of variability of patient satisfaction that is explained by clinician satisfaction may be fairly low. Thus, clinician satisfaction may be more important in terms of morale, loyalty to the organization, and reductions in turnover than in terms of direct improvements in patient satisfaction and other patient outcomes. Longer-term studies may find that as unsatisfied clinicians leave the practice, declining patient continuity leads to lower quality scores.

Conclusion

Our findings suggest that clinicians’ job satisfaction may be an important metric for clinical practices and large practice organizations. Practice-specific interventions to improve work conditions may catalyze an increase in clinician job satisfaction. Because improved satisfaction in our study was associated with decreases in burnout and intent to leave among physicians and advanced practice providers, the joy in practice may be of considerable importance to primary care clinicians and their practices.

ACKNOWLEDGMENTS

Financial support was provided by the Agency for Healthcare Research and Quality (Grant No. 1R18 HS018160-01). The Healthy Work Place (HWP) investigators, in addition to the authors, were Anita Varkey, Chicago, IL; Steven Yale, Gainesville, FL; Ellie Grossman, Somerville, MA; Diane Kornhurst, Marshfield, WI; Jill Wallock, Chicago, IL; Michael Barbouche, Madison, WI; and Lanis Hicks, Columbia, MO.

NOTES

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