Family Practice Vol. 17, No. 4, 309-313
© Oxford University Press 2000
Family physician job satisfaction in different medical care organization models
a Department of Epidemiological and Health Services Research and
b Medical Research Coordination, Mexican Institute of Social Security (IMSS) and
c Psychology Faculty, National University of Mexico.
CGP; Email: mcgp{at}cim.spin.comm.mx
García-Peña C, Reyes-Frausto S, Reyes-Lagunes I and Muñoz-Hernández O. Family physician job satisfaction in different medical care organization models. Family Practice 2000; 17: 309–313.
Received 7 June 1999; Revised 15 October 1999; Accepted 13 March 2000.
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Abstract |
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Objectives. The aim of the present study was to estimate physician job satisfaction at the Mexican Institute of Social Security (IMSS), the Ministry of Health (SSA) and in the private sector, and to measure the association between these different family medical care organization models.
Methods. A comparative cross-sectional design was used to investigate the job satisfaction of family physicians in private and institutional family medicine clinics. Satisfaction was measured with a previously constructed and validated instrument. The instrument measures the satisfaction in four areas: ‘global satisfaction’, ‘institution where the physician works’, ‘the patients’ and ‘themselves as physicians’.
Results. One hundred and seven IMSS physicians, 106 SSA physicians and 97 private physicians were selected randomly from a census according to the sample size. The sample was weighted. Fifty-one percent of IMSS and SSA physicians were dissatisfied, against 25% in the private sector, in the first three areas. Comparing the private model and the IMSS, differences were found (P < 0.0001) in the area of ‘global satisfaction’ [odds ratio (OR) = 2.47, 95% confidence interval (CI) 1.69–3.67], ‘institution where the physician works’ (OR = 2.12, CI 1.45–3.13) and ‘themselves as physicians’ (OR = 1.84, CI 1.28–2.65). When the private/SSA groups were compared, the differences were similar (P < 0.0001). No differences were found in terms of ‘the patients’. When stratifying, the risks increased in females, in the group aged 31–40 years and in specialists in family medicine.
Conclusions. The organization model is associated with dissatisfaction in all areas, except in ‘the patients’.
Keywords. Family physician, job satisfaction, medical care models.
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Introduction |
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The job satisfaction of the family physician is a critical factor for health systems because the primary care level is responsible for providing medical care to a greater proportion of the population than any other care level. Also, job satisfaction level could be related to the quality and efficiency of the care given. Satisfaction has been understood as the subject's perception of different areas, such as psychological and material rewards, relationship with patients, and social and intellectual work atmosphere.1 Some other authors2 have fragmented the concept even further to include the perception of autonomy, payment, number of working rules, relationship with patients and work peers, work load, prestige and status.
The impact of bureaucracy and other aspects of models of medical care organizations on the physician's perception have been analysed by several authors.3–6 Although some refer to the positive effect that a secure salary can have, the greater part agree that complex structures have negative effects on the physicians' satisfaction, due basically to loss of autonomy.7
Several authors have studied the relationship of satisfaction to some variables; however, the majority of the literature does not include family physicians, and the measuring instruments have been elaborated from only the investigators' point of view. Additionally, the reports related to institutional environments, resulting in different characteristics from those in the health system in Mexico and Latin America.8 Therefore, the objective of this investigation was to determine the association between the three organization models of medical care and the level of job satisfaction of the family physician, using a previously constructed and validated satisfaction measure instrument.9
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Methods |
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A cross-sectional design with group comparison was used. The study population was made up of practising family physicians, not working in more than one of the investigated models, and who answered the inquiry in full. The sample frame was constructed by listing all the family physicians in Mexico City who work in family medicine clinics of the Mexican Instute of Social Security (IMSS), in the Ministry of Health (SSA) and in private family medicine clinics. The subjects were selected randomly. The sample size was calculated for a cross-sectional design with an
of 0.05 and ß of 0.20, Po = 0.30 (satisfied subjects in IMSS), and P1 = 0.54 (satisfied subjects in the private sector).
Variables
The independent variable was the medical care organization model, defined as the way to structure the work of health personnel. Three models were included: IMSS, SSA and the private system. The differences between the models can be seen in Table 1
. The dependent variable was job satisfaction defined as the affective state related to the perception that the individual has in three areas: the institution where they work, their patients and themselves as physicians. General, economic and academic characteristics and work backgrounds were also studied.
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Job satisfaction measuring instrument
The instrument used was constructed and validated previously in the population under study.9 Eighty items measure the areas of ‘global satisfaction’, ‘institution where the physician works’, ‘the patients’ and ‘themselves as physicians’. The methodology that we used has been documented previously.9
Data analysis
An ‘intelligent capture’ system in dbase language was designed. The general variables among each of the institutions were compared using chi-square. The total of family physicians representing each group was considered. The means obtained from the validation in the satisfaction instrument were taken as reference, and the proportion of satisfaction, by areas, and for each group, was obtained. A bivariate analysis with chi-square was carried out, obtaining odds ratios (ORs) and 95% confidence intervals (CIs). A stratified analysis using the general variables with Mantel and Haenzel was done.
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Results |
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Population description
A census was taken of 1447 family physicians in 42 IMSS family medicine clinics, 504 physicians in the SSA, and 150 physicians in private family medicine clinics. A total of 107 IMSS physicians (1:13.5 of total), 106 from the SSA (1:4.7) and 97 private physicians (1:1.6) were included. The rate of non-response was >10% in all groups. More than half of the physicians in all groups were males; among private physicians, the proportion reached 75.3% (P < 0.03). Nearly 50% of private and SSA physicians were between 36 and 40 years of age; in the case of IMSS physicians, the majority were between 36 and 45 years of age. The mean age for IMSS physicians was 42 years, for SSA it was 40 years and for private physicians, 39 years (P < 0.03). Almost all physicians were married, the highest percentage (84.5%) being found for private physicians (P < 0.03). Fifty-three percent (n = 57) of the IMSS physicians, 49% (n = 48) of private physicians and 23% (n = 25) of the SSA physicians had specialized in family medicine (P < 0.001) (Table 2
).
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The proportions of satisfied physicians were higher in the private physicians group in all areas except ‘the patients’, and varied between 63 and 73%. The lowest proportion (45%) of satisfied physicians was that of the SSA in the ‘themselves as physicians’ area, but in ‘the patients’, this model had the highest proportion of satisfied physicians (67%) (Table 3
).
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Bivariate analysis
Comparing the SSA and private groups in the area of ‘global satisfaction’, the probability of no satisfied physicians was 2.33 more in the SSA than in the private group (95% CI 1.55–3.55); for dissatisfaction with the ‘institution where the physician works’, the SSA showed a probability of 2.60 (95% CI 1.73–3.96). For ‘themselves as physicians’, the probability of dissatisfaction was 2.26 (95% CI 1.53–3.35). The probabilities obtained for these areas were similar to those obtained when comparing private and IMSS physicians. Dissatisfaction probabilities were not obtained for ‘the patients’ for the SSA (OR = 0.83, 95% CI 0.56–1.23). Comparing the IMSS group with SSA, there was a statistically significant dissatisfaction probability of 1.22 in the ‘institution where the physician works’ (95% CI 1.00–1.50) and of 1.23 for ‘themselves as physicians’ (95% CI 1.00–1.51) (Table 4
).
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Stratified analysis
When comparing the private–IMSS groups, being female was maintained as a constant dissatisfaction risk for all areas, except for ‘the patients’, with probabilities that varied between 3.13 and 5.07, all with statistically significant intervals. Similar dissatisfaction probabilities for the same areas were obtained in the age groups of between 31 and 40 years. Being a specialist in family medicine increased the probability of dissatisfaction to 3.19 in the ‘global satisfaction’ area (95% CI 1.76–6.04, P = 0.000).
In the private–SSA groups, the probability of dissatisfaction was increased in the ‘global satisfaction’ and ‘institution where the physician works’ areas from 2.51 to 4.25 due to being a specialist in family medicine, of female gender and/or of an age between 36 and 40 years (P 
0.000). Being aged between 31 and 35 years and between 31 and 40 also increased the dissatisfaction probability for ‘institution where the physician works’ and ‘themselves as physicians’ to 4.08 and 7.46, respectively (P 0.000). Unlike the private–IMSS groups, the fact of not being a specialist in family medicine increased the dissatisfaction probability for ‘themselves as physicians’ to 2.97 (95% CI 1.74–5.17, P = 0.001) in the private–SSA groups. When stratifying, the comparison between IMSS and SSA groups did not give statistically significant data (Table 5).
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Discussion |
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In 1969, Engels4 studied the impact that bureaucracy had on the job satisfaction of physicians. He found that complex structures transformed the nature of the physicians' task, and focused the physicians' attention towards the institutions and not towards the patients. The starting point of this study is based on this report written 25 years ago.
There are several aspects that make comparison with our results difficult. There are very few references from Mexico, and none compare different organization models; on the other hand, the methodology followed for the construction and validation of the measuring instrument has not been used in the investigation area of health services.
Private physicians were the most satisfied group in three of the four areas. The groups of physicians from IMSS and SSA had a lower and very similar level of satisfaction in the areas of ‘global satisfaction’ and ‘institution where the physician works’.
These findings coincide with what has been reported in the literature.10,11 It is known that low autonomy, excessive norms and stress are aspects related to job dissatisfaction and, therefore, it is to be expected that not only the IMSS but also the SSA have a lower proportion of satisfied physicians. In the area of ‘the patients’, the proportion of satisfied physicians was somewhat higher in the SSA than in the private and IMSS groups, findings that were confirmed in the bivariate and stratified analyses. No differences existed in the perception that physicians have of their patients in any of the three groups, i.e. the physician–patient relationship is an important source of satisfaction.12,13
In the ‘themselves as physicians’ area, the highest proportion of satisfied physicians was found in the private group; it was lower in the IMSS, and even lower in the SSA, which is confirmed in the bivariate analysis. This area is related to the perception that the physicians have of themselves regarding knowledge and status levels. We think that the institutional characteristics have influenced the loss of self-esteem, as the physicians in both the IMSS and SSA must comply with a series of rules in order to render care, which has restricted the freedom of autonomy and self-responsibility.
The relationship between the level of satisfaction and the models does not decrease in any of the areas when stratifying with the intervening variables. In both the SSA and IMSS, being female increased the probability of dissatisfaction in most of the areas. The findings in the literature14,15 are contradictory, but we think that a greater difficulty in obtaining professional recognition for women is an important factor in this finding. The dissatisfaction probability is also increased in the young physician group. It is possible that the young physicians have greater demands and, as age advances, the possibility to adapt increases.16
Being a specialist in family medicine produced a greater dissatisfaction probability in the IMSS and SSA. There are no reports in the literature on this subject, but we suppose that specialists have greater improvement perspectives and, on entering a model that does not meet these expectations, they feel more dissatisfied.
For the area ‘themselves as physicians’, the dissatisfaction probability is almost twice as high, as it is more difficult to become a specialist in the SSA model, and this fact can be seen as a self-fulfilment possibility.
The dissatisfaction probabilities obtained for the IMSS and SSA models speak favourably to the fact that bureaucratic organizations frequently are in discordance with the professionals who work there.17 It is probable that the situational aspects,18 i.e. the extrinsic aspects, on the individual most frequently are related to job dissatisfaction, as none of the individual characteristics resulted in the model.
In this regard, aspects such as personality, mental health, etc. have little relationship to job satisfaction. However, we know that future investigations must delve into the study of intrinsic factors and their relationship to job satisfaction, as it will also be necessary to explore the satisfaction related to the quality of the care given.
We consider that the future challenge dwells in diminishing bureaucracy in health institutes, and in increasing autonomy, protecting the social security and equality principles in such a manner that the satisfaction of the family physician can be increased.
A full copy of the questionnaire used in this study can be obtained from the corresponding author.
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Acknowledgments |
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The project was supported by the National Council of Science and Technology (CONACYT).
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