Motivation and Emotion, Iiol. 19, No. 3, 1995

Satisfaction in Generalist Care: An Individualist Approach

Mark A. Stafford 1 University of Alabama at Birmingham

Physician dissatisfaction with primary care practice is influenced by many external factors--income, work hours, and an increased burden of paper work. It may be possible to use psychometric tests to select medical students with a strong internal locus of control who might adapt better to the work of primary care practice.

There is nothing as easy as denouncing. It don't take much to see that something is wrong, but it takes some eyesight to see what will put it right again.

Will Rogers

America is scrutinizing its health care delivery system. The cost of special- ist-driven medical care and the public's increasing demand for attention to psychosocial issues in medicine is fueling a renewed interest in providing long-term relationships with primary care physicians (O'Neil, 1993). While medical school applications have recently rebounded, the number of stu- dents selecting primary care fields has continued to decrease. This disparity in the need for primary care physicians and the scarcity of students enlisting has prompted a reevaluation of what factors influence career choice and predict professional satisfaction. Medical educators are trying to understand the factors drawing students away from primary care careers so that changes can be implemented to make primary care more attractive.

IAddress all correspondence to Mark A. Stafford, M.D., University of Alabama at Birmingham, Department of Medicine, Division of General Internal Medicine, 62I Sixth Avenue, Alabama 35294-3296.

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0146-7239/95/0900-0217507.50/0 © 1995 Plenum Publishing Corporation

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The causes for the primary care crisis are multifactorial. The com- munity backgrounds of a medical school class seldom mirrors the medical needs of its state. Students are exposed primarily to specialty faculty as role models and perceive greater prestige for these specialists. The cost of medical education combined with the opportunity for higher reim- bursement encourages students to choose specialties. Finally, the contrast between dissatisfied, overburdened community primary care providers and their colleagues' more opulent lifestyles understandably increases the imbalance.

Proposed strategies to correct these sources of dissatisfaction have been outlined by health policy planners (Lewis, Prout, Chalmens, Leake, 1991; O'Neil, 1993). Strategies include changes in medical school admission policies to include more minorities and students from underserved areas, curricular changes to emphasize psychosocial issues in doctor-patient rela- tionships, and financial incentives to exchange student indebtedness for the selection of a primary care practice. Graduate medical education planners have set a goal of having half of all trainees in primary care programs by the year 2000 (O'Neil, 1993). Within academic medical centers, changes in career promotion policies within academic medical centers that recognize primary care leadership and increase the perceived status of primary care providers have been suggested. Targeted relief from the traditional practice stressors such as increased paper work, complicated insurance "hassles," and unbridled malpractice liability have also been suggested to make pri- mary care more attractive (Lewis et al., 1991). Some have called for a fun- damental shift in the orientation of medicine away from the reductionist trends of post-World War II toward a more integrated model of patient care (Lewis et al., 1991). While these changes in the work environment and health care policy are important steps in resolving our nation's primary care crisis, I believe these changes will not guarantee long-term satisfaction for physicians entering primary care.

Surveys of physician dissatisfaction show weak correlations of profes- sional unhappiness with systemic changes such as declining income, loss of status, or increasing number of hours worked (Lemkau, Purdy, Rafferty, Rudisill, 1988; May, Revicki, & Jones, 1983; McCranie & Brandsma, 1988; Whippen & Canellos, 1991). Individuals may have relatively fixed person- ality traits that are predictive of satisfaction or dissatisfaction regardless of external factors (Conley, 1984; Costa & McCrae, 1980; Costa, McCrae, & Norris, 1981). Furthermore, a medical student's personality profile may help identify unique psychosocial needs that would allow counselors to pre- dict future stressful scenarios (Garms, 1994). Valiant's landmark work on physicians' psychological vulnerabilities indicates that life adjustments be- fore medical school are better predictors of subsequent professional and

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personal distress than overwork or differences in demographics (Valiant, Sobowale, & McArthur, 1972). Valiant et al. further speculated that the increased incidence of psychological distress in primary care physicians when compared to surgeons or administrative physicians may reflect an at- tempt to provide compassionate care in response to their own unmet de- pendency needs. Family practice physicians experiencing significant professional stress are more likely to blame external agents in their envi- ronment for personal stress (May et al., 1983). This tendency to demon- strate an external locus of control reflects the extent to which an individual believes that external factors influence or control his or her life events or experience. While physicians operating from an external locus of control are more likely to view their professional contentment as a byproduct of favorable circumstances, such contentment is insecure and subject to the inevitable vicissitudes of daily life (Orman, 1989). Although long-term stud- ies of professional satisfaction in primary care physicians are lacking, pro- posed changes in health care policy and improvements in the generalists' workplace will not guarantee happy, fulfilling lives for these doctors.

Clearly, there is no magic bullet to solve the primary care crisis. Many of the changes in the reimbursement, prestige, academic promotion, and work environment of primary care physicians are long overdue (Maslach, 1976). Health policy changes and government mandates to increase the numbers of primary care doctors will probably be successful. But increased numbers of providers will not solve the primary crisis. Patients are becom- ing more assertive in proclaiming their psychosocial needs and consumer rights. Adequate numbers of new, idealistic primary care physicians who have unrealistic expectations and no knowledge of the "givens" of front-line medicine will equal wholesale burnout after 5 to 7 years of practice. Aca- demic medicine must spearhead efforts to address the personal factors in- volved in physician satisfaction.

In addition to changes in the work environment and health care policy, academic medicine must lead a third effort to successfully resolve the primary care crisis. Beginning at the undergraduate level, students should be encour- aged, but not required, to have psychometric testing to better determine their personality traits. Counseling and education regarding the significance of these personality profiles and how such tendencies might influence career satisfaction could be implemented (Mawardi, 1979). The problem with risk- pool modification in medical school selection has been addressed (McCranie & Brandsma, 1988). Interventions to help individuals learn more effective coping skills and institutional support for such interventions at the faculty level would send a strong message to students, house officers, and faculty about the value physicians ascribe to their own well-being. Longitudinal stud- ies are needed to define better the factors involved in physician satisfaction

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among primary care providers. Identifying personality traits using validated psychometric instruments will allow comparison of groups of physicians matched for demographics, practice content, income, and personality. Only when research has controlled for these fundamental differences will data re- veal other areas where changes might be beneficial.

Medicine is past the point where professional and personal fulfillment is a "given," a natural byproduct of being a physician. The "golden age" of medicine with unlimited earning potential, autonomy, and positive pa- tient feedback is gone. Many physicians grieve over this passing and its finality. Physicians now seek satisfaction in a sea of professional and per- sonal stressors. Despite these changes, bright people continue to choose careers in medicine. But the knowledge and insight needed to navigate among these stressors is not intuitive for the gifted individual. Academic medicine needs to incorporate the teaching of these essential coping skills into and heighten the self-awareness of students as part of the medical school curriculum. All physicians need to be reminded and encouraged to develop an internal locus of control that allows contentment to be less de- pendent on the rapidly changing health care environment.

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