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Unauthorized posting of RAND electronic documents to a non-RAND website is prohibited. RAND electronic documents are protected under copyright law. Permission is required from RAND to reproduce, or reuse in another form, any of our research documents for commercial use. For information on reprint and linking permissions, please see RAND Permissions. This report is part of the RAND Corporation research report series. RAND reports present research findings and objective analysis that address the challenges facing the public and private sectors. All RAND reports undergo rigorous peer review to ensure high standards for research quality and objectivity. RESEARCH REPORT Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy Mark W. Friedberg • Peggy G. Chen • Kristin R. Van Busum • Frances M. Aunon Chau Pham • John P. Caloyeras • Soeren Mattke • Emma Pitchforth Denise D. Quigley • Robert H. Brook • F. Jay Crosson • Michael Tutty C O R P O R A T I O N RESEARCH REPORT Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy The RAND Corporation Mark W. Friedberg • Peggy G. Chen • Kristin R. Van Busum • Frances M. Aunon Chau Pham • John P. Caloyeras • Soeren Mattke • Emma Pitchforth Denise D. Quigley • Robert H. Brook American Medical Association F. Jay Crosson • Michael Tutty Sponsored by the American Medical Association HEALTH The research described in this report was sponsored by the American Medical Association, and was produced within RAND Health, a division of the RAND Corporation. Library of Congress Cataloging-in-Publication Data is available for this publication. ISBN 978-0-8330-8220-6 The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. 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RAND OFFICES SANTA MONICA, CA • WASHINGTON, DC PITTSBURGH, PA • NEW ORLEANS, LA • JACKSON, MS • BOSTON, MA DOHA, QA • CAMBRIDGE, UK • BRUSSELS, BE Preface The American Medical Association (AMA) has adopted, as a core strategic objective, the advancement of health care delivery and payment models that enable high-quality, affordable care and restore and preserve physician satisfaction. The AMA has undertaken this commit- ment in the belief that such change can and should result in a more sustainable and effective health care system with a highly motivated physician workforce. At the same time, the AMA has noted challenges for physicians interested in payment and delivery reform, including exist- ing variability in the degree of care integration, the need for new skills and resources, and the uncertainty created by the emergence of as yet untested new payment models. Therefore, the AMA’s objective includes facilitating transition, for physicians who are seeking a path to more integrated practice models, in a manner that supports professional satisfaction and practice sustainability. This objective is consistent with the mission of the AMA: To promote the art and science of medicine and the betterment of public health. This project, sponsored by the AMA, aimed to characterize factors that influence physi- cian professional satisfaction. By using a mixed-methods (primarily qualitative) design, the project sought to identify a broad array of potential targets for interventions to improve physi- cian professional satisfaction. In accordance with the AMA’s strategic objective and in the con- text of recent health reform legislation (including but not limited to the Affordable Care Act), changing fee-for-service payment rates, and perceived consolidation of independent physician practices by larger delivery systems, the influences of physician practice model (e.g., physician ownership versus hospital or other corporate ownership) and practice sustainability on profes- sional satisfaction were of particularly high interest. The project began on October 22, 2012, and was completed on September 30, 2013. An advisory committee convened by the AMA provided input on key study activities, includ- ing data collection methods and interpretation of results. Committee membership is listed in Appendix A. Using project findings and input from other sources, including its membership and experts in physician practice design, the AMA plans to develop resources to assist physicians seeking to improve practice effectiveness, efficiency, sustainability, and professional satisfaction. This work was sponsored by the American Medical Association. The research was con- ducted by RAND Health, a division of the RAND Corporation. A profile of RAND Health, abstracts of publications, and ordering information can be found at www.rand.org/health. iii Contents Preface ........................................................................................................... iii Figures ........................................................................................................... xi Tables ...........................................................................................................xiii Executive Summary ...........................................................................................xv Acknowledgments .......................................................................................... xxiii Abbreviations ................................................................................................. xxv CHapteR ONE Introduction ..................................................................................................... 1 Methodology ..................................................................................................... 1 Organization of This Report .................................................................................... 2 CHapteR TWO Background: Scan of the Literature on Physician Professional Satisfaction ........................ 3 Overview .......................................................................................................... 3 Physician Demographics ........................................................................................ 4 Physician Age ................................................................................................... 4 Domestic Versus Foreign Medical School .................................................................. 4 Physician Race and Ethnicity ................................................................................ 5 Physician Specialty ............................................................................................. 5 Workplace Factors ................................................................................................ 6 Practice Structure .............................................................................................. 6 Geographic Location .......................................................................................... 6 Patient Population ............................................................................................. 7 Working Environment ........................................................................................ 7 Relationships with Coworkers ................................................................................ 8 Perceived Quality of Patient Care ............................................................................ 8 Electronic Health Records .................................................................................... 8 Physician Income .............................................................................................. 9 Health System Changes ........................................................................................