Understanding physicians' intentions to withdraw from practice: The role of job satisfaction, job stress, mental and physical health

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Until recently, it was widely perceived that physicians had good jobs, even if the jobs were difficult, challenging, and, at times, stressful. The jobs were perceived to be socially useful, and medicine, as a profession, was accorded high esteem by the public. Physicians were seen as surrounded by accommodating subordinates, respectful colleagues, and trusting patients. They were held up by occupational sociologists as representing the consummate example of professional dominance: they had clinical autonomy, power to determine working conditions, considerable financial rewards, and job security (Freidson, 1970). Things have changed since the golden age of medicine, and the sources of change are numerous and well documented (Scott, 1993; Starr, 1982). Financial, technological, and delivery system changes have been important, but more directly affecting physician job satisfaction and stress levels have been changes in the actual organization of the medical workplace. Many observers have suggested that the autonomy of physicians is being constrained (Navarro, 1988) as purchasers, employers (McKinlay & Stoeckle, 1988), and consumers (Haug, 1988; Haug & Lavin, 1983) exercise countervailing power (Light, 1993).Physicians' reactions to these changes have been documented in various sources. Newspapers chronicle the woes of a medical career, linking surging disability claims to job dissatisfaction (Altman & Rosenthal, 1990; Hall, 1995; Hilzenrath, 1998). Similarly, research journals have reported links between satisfied physicians and patient compliance (DiMatteo et al., 1993) and patient satisfaction (Linn et al., 1985), and go further to suggest that dissatisfied physicians may have riskier prescribing profiles (Melville, 1980). Associated with this decrease in satisfaction is a corresponding increase in perceived levels of stress, which may lead to such outcomes as burnout, mental health problems, or even suicide (Arnetz et al., 1987). Equally important is the linkage of stress with disruption of work performance, including absenteeism, turnover, poor job performance, accidents and errors, and alcohol and drug abuse, documented in a recent review of the general stress literature (Kahn & Byosiere, 1992). Taken together, these findings suggest that distress and dissatisfaction have significant costs not only to physicians, but to patients and health care organizations as well. One study estimated that the cost of primary care physician turnover ranged from $236,383 for a family practitioner to $264,345 for a general pediatrician (Buchbinder et al., 1999). These findings and their costs will become even more important as increasing numbers of physicians practice in organized settings.In looking for insights on how to manage these issues, the physician job satisfaction and job stress literature should be investigated. However, these literatures are subject to two critical limitations. The first is that they are chiefly devoted to description and prescription. From this, we have a rather good conceptual picture of what job satisfaction and job stress mean to physicians, in addition to some nascent theorizing on the causes and consequences of stress and satisfaction. Many articles make recommendations that are often based upon common sense or intuition rather than empirical evidence. The second limitation is that most of the empirical studies in both literatures focus on predicting the causes of job satisfaction and job stress for physicians. Relatively few studies look at the effects that these two variables have on the physicians themselves, their patients, or their health care organizations. The purpose of the study on which this article is based is to provide empirically based evidence upon which recommendations can be made to physicians, managers, and policymakers. The following section presents a conceptual model of physician stress that explores its relationship with job satisfaction, physical and mental health, and four types of withdraw intentions.

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