Doctor discontent

OBJECTIVE: To examine the differences in physician satisfaction associated with open- versus closed-model practice settings and to evaluate changes in physician satisfaction between 1986 and 1997. Open-model practices refer to those in which physicians accept patients from multiple health plans and insurers (i.e., do not have an exclusive arrangement with any single health plan). Closed-model practices refer to those wherein physicians have an exclusive relationship with a single health plan (i.e., staff- or group-model HMO). DESIGN: Two cross-sectional surveys of physicians; one conducted in 1986 (Medical Outcomes Study) and one conducted in 1997 (Study of Primary Care Performance in Massachusetts). SETTING: Primary care practices in Massachusetts. PARTICIPANTS: General internists and family practitioners in Massachusetts. MEASUREMENTS: Seven measures of physician satisfaction, including satisfaction with quality of care, the potential to achieve professional goals, time spent with individual patients, total earnings from practice, degree of personal autonomy, leisure time, and incentives for high quality. RESULTS: Physicians in open- versus closed-model practices differed significantly in several aspects of their professional satisfaction. In 1997, open-model physicians were less satisfied than closed-model physicians with their total earnings, leisure time, and incentives for high quality. Open-model physicians reported significantly more difficulty with authorization procedures and reported more denials for care. Overall, physicians in 1997 were less satisfied in every aspect of their professional life than 1986 physicians. Differences were significant in three areas: time spent with individual patients, autonomy, and leisure time (P≤.05). Among open-model physicians, satisfaction with autonomy and time with individual patients were significantly lower in 1997 than 1986 (P≤.01). Among closed-model physicians, satisfaction with total earnings and with potential to achieve professional goals were significantly lower in 1997 than in 1986 (P≤.01). CONCLUSIONS: This study finds that the state of physician satisfaction in Massachusetts is extremely low, with the majority of physicians dissatisfied with the amount of time they have with individual patients, their leisure time, and their incentives for high quality. Satisfaction with most areas of practice declined significantly between 1986 and 1997. Open-model physicians were less satisfied than closed-model physicians in most aspects of practices. This research was supported by grant number R01 HS08841 from the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research) and by grant number 035321 from the Robert Wood Johnson Foundation, Funding from those sources permitted us to obtain survey data from Massachusetts primary care physicians in February 1997 and to analyze them, along with Medical Outcomes Study data, for this article. The Medical Outcomes Study (MOS) physician survey data used for these analyses were obtained in 1986 through a generous grant from the Henry J. Kaiser Family Foundation.     

The Plague Doctor of Venice

There is a distinctive Venetian carnival mask with sinister overtones and historical significance to physicians because it belongs to the ‘Doctor of the Plague’. The costume features a beaked white mask, black hat and waxed gown. This was worn by mediaeval Plague Doctors as protection according to the Miasma Theory of disease propagation. The plague (or Black Death), ravaged Europe over several centuries with each pandemic leaving millions of people dead. The cause of the contagion was not known, nor was there a cure, which added to the widespread desperation and fear. Venice was a major seaport, and each visitation of the plague (beginning in 1348) devastated the local population. In response, Venetians were among the first to establish the principles of quarantine and ‘Lazarets’ which we still use today. Plague outbreaks have occurred in Australia, notably in Sydney (1900–1925), and continue to flare up in poorer communities, most recently in Madagascar (2017). Antibiotics are the mainstay of treatment, but there are concerns regarding the emergence of resistant pathogenic strains of Yersinia pestis, and their potential use in bio‐terrorism.     

Doctor performance and public accountability

Public concern about the quality of health care has motivated governments, health-care funders, and clinicians to expand efforts to improve professional performance. In this paper, we illustrate such efforts from the perspective of three countries, the UK, the USA, and the Netherlands. The earliest strategies, which included continuing professional education, clinical audits, and peer review, were aimed at the individual doctor, and produced only modest effects. Other efforts, such as national implementation of practice guidelines, effective use of information technologies, and intensive involvement by doctors in continuous quality-improvement activities, are aimed more broadly at health-care systems. Much is yet unknown about whether these or other strategies--such as centralised supervision or regulation of quality improvement, or use of financial incentives--are effective. As demands for greater public accountability rise, continuing performance improvement efforts of each of our countries offer us opportunities to learn from one another.