It’s Not Just About How Much You’re Paid

Journal of General Internal Medicine, Mar 2018

David M. Levine, Bruce E. Landon

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It’s Not Just About How Much You’re Paid

It's Not Just About How Much You're Paid David M. Levine Bruce E. Landon 0 Department of Health Care Policy, Harvard Medical School , Boston, MA , USA 1 Harvard Medical School , Boston, MA , USA 2 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital , Boston, MA , USA 3 Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center , Boston, MA , USA - P cians is a national priority, particularly in primary care romoting wellness and preventing burnout among physiwhere a burgeoning work force shortage is looming.1 Prominent national physician organizations including the American College of Physicians, The American Medical Association, and the American Academy of Family Physicians are dedicating significant resources to programs to improve physician work life and well-being. Prior research on physician career satisfaction has shown that satisfaction is related to many aspects of physician work place conditions including time pressures, a lack of control over day-to-day decisions affecting patient care, and collegiality.2 Work place satisfaction is strongly associated with burnout and stress, as well as intent to leave and actually leaving practice,3 and some data suggest that physician satisfaction might be associated with patient satisfaction and quality of care.4 Yet, for the hundreds of articles written about physician satisfaction and dozens of national trainings available to improve physician work place conditions, the relationship between compensation and physician work place satisfaction is relatively poorly understood. Clearly, compensation, at least to some extent, drives career choices. For instance, medical students increasingly gravitate to specialties that are more highly compensated and have a better potential for work life balance.5 Primary care and other cognitive specialties wherein most compensation is derived from evaluation and management services rather than performing procedures has been particularly impacted, and this is thought to be one of the primary reasons that fewer medical students choose to enter these fields. However, those choosing to enter primary care know this information at the time they are making their choices and one might expect that those who think primary care compensation Bunfair^ would choose to enter another field. The determinants of fairness in physician compensation thus likely are multifactorial and might relate to the frame of reference. At one extreme, physicians might compare themselves to those in other professions they might have selected such as law or finance, which might leave even those in high-paying medical specialties feeling like their pay is not fair. At the other extreme, physicians might compare relative pay within their field (or even their practice). Lastly, rather than focusing on exact compensation, fairness might be judged by understanding and agreeing with the methods used to determine pay in their particular setting.6 High-performing organizations nurture work place cultures built upon a foundation of trust and mutual understanding, and the methods used to determine compensation and reward performance can be an important contributor to workplace culture. In this issue of JGIM, Kao and colleagues examine the association between physicians’ perception of how fairly they are paid with work satisfaction, intent to leave practice, and personal health.7 They surveyed a random sample of 4000 physicians from the Physician Masterfile by mail, ultimately collecting 2263 responses for an adjusted 63% response rate. The sample included physicians from all specialties. Importantly, primary care physicians were not over-sampled and the response rate by specialty is not shown. As in most studies of physician career satisfaction, most physicians were satisfied at work, were unlikely to leave their practice, and were in very good or excellent self-reported health. Those with higher compensation were more satisfied and less likely to leave practice, but intriguingly, after adjusting for perceived pay fairness, there was no significant relationship between higher compensation and satisfaction, intent to leave, or health. Yet, it is not clear how physicians interpreted some of the single item non-validated questions used and to what extent missing data could have altered the study’s conclusions. Although this study provides potentially important insights for practicing physicians and those managing physician practices, it also raises several questions. First, although the survey instrument was cognitively tested, no information is presented on how physicians actually interpreted the question on compensation fairness. As noted above, it may be the case that physicians judge the fairness of their pay relative to the pay of others in the same specialty in the same geographic region of the country. Thus, it would be interesting to see results stratified by region and specialty within region. Second, it also might be important to understand how compensation had changed over time. For instance, radiology, which is considered relatively well compensated, has seen pay decreases over some recent years, which also might influence their perceptions of fairness.8 Third, little is known about other aspects of the workplace for respondents including work hours and conditions, the functionality of the electronic health record, expectations of productivity, work flow, and availability and types of support staff. It is likely that perceptions of pay fairness also are associated with other aspects of the workplace making it difficult to know if there are other confounders. For instance, physicians who perceive their pay to be fair might be more likely to work in supportive settings with a positive workplace environment. More importantly, because of the cross-sectional nature of this study, it is difficult to tell if the observed associations are causal. For instance, physicians who are dissatisfied with their current workplace are the most likely to leave and might point to inadequate compensation as one of the reasons. Finally, there was substantial missing data (over 20%) for the compensation question, and these data likely were not missing at random, which might introduce bias into some of the analyses. So how should our profession proceed? First, as the authors point out, the human resources literature already has clearly described the phenomenon of perceived pay fairness. One tried and true method used in human resources is the use of 360-degree feedback and other strategies that improve transparency and perceived fairness. Anecdotally, this rarely happens in clinical medicine but could be adapted to improve perceived pay fairness. Second, as reimbursement shifts from fee-for-service to value, we need to be cognizant that that we do not increase perceived unfairness, as many do not agree with the measures used to determine quality bonuses, the timeliness of data and feedback, or the algorithms that are used to attribute patients to clinicians or organizations for purposes of accountability. Third, given that employees who understand the process for determining compensation and understand all the factors affecting their pay perceive pay to be fair, it would likely benefit organizations to practice highly transparent hiring and salary practices. Fourth, in the healthcare context, we likely should not perceive this to be a problem only of physicians. Interestingly, a very similar study completed among nurses reached similar conclusions, and there is no reason to think that medical assistants and other key staff in practices would not have similar views.8 Perhaps, lessons can be learned from other healthcare professional leadership, or a concerted approach can be taken together. The bottom line: it is time to pay attention to how physicians perceive their paycheck. Doing so might be one easily implemented strategy for promoting workplace wellness and preventing burnout, something that most studies and trainings have failed to do. It may even help direct more physicians toward primary care and lower-paying specialties. It is important that this study reminds us that it is not just about the level of compensation, but also the extent to which physicians perceive their compensation as fair. Future work to improve perceptions around compensation may be among the most impactful burnout prevention tools seen to date. Corresponding Author: Bruce E. Landon, MD MBA MSc; Department of Health Care Policy Harvard Medical School, Boston, MA 02115, USA (e-mail: ). Compliance with Ethical Standards: Conflict of Interest: The authors declare that they do not have a conflict of interest. 1. Kirch DG , Petelle K. Addressing the physician shortage . JAMA 2017 ; 317 ( 19 ): 1947 . doi:https://doi.org/10.1001/jama. 2017 . 2714 . 2. Rabatin J , Williams E , Baier Manwell L , Schwartz MD , Brown RL , Linzer M. Predictors and outcomes of burnout in primary care physicians . J Prim Care Community Health 2016 ; 7 ( 1 ): 41 - 43 . doi:https://doi.org/10. 1177/2150131915607799. 3. Landon BE , Reschovsky JD , Pham HH , Blumenthal D. Leaving medicine: the consequences of physician dissatisfaction . Med Care 2006 ; 44 ( 3 ): 234 - 242 . doi:https://doi.org/10.1097/01.mlr. 0000199848 . 17133. 9b . 4. Linzer M , Gerrity M , Douglas JA , McMurray JE , Williams ES , Konrad TR . Physician stress: results from the physician worklife study . Stress Health 2002 ; 18 ( 1 ): 37 - 42 . doi:https://doi.org/10.1002/smi.917. 5. Rogers L , Fincher R , Lewis L . Factors influencing medical students to choose primary care ... : Academic Medicine. Acad Med . 1990 ; 65 ( 9 ). https://journals.lww.com/academicmedicine/Abstract/1990/09000/ Factors_influencing_medical_students_to_ choose.38.aspx. Accessed 6 Feb 2018 . 6. Clough JD , McClellan M. Implementing MACRA : implications for physicians and for physician leadership . JAMA 2016 ; 315 ( 22 ): 2397 - 2398 . doi:https://doi.org/10.1001/jama. 2016 . 7041 . 7. Kao AC , Jager A , Koenig B , Moller AC , Tutty M , Williams GC , Wright S. Physician perception of pay fairness and its association with work satisfaction, intent to leave current practice, and personal health . J Gen Intern Med DOI: https://doi.org/10.1007/s11606-017-4303-8. 8. Bernstein N. Job Prospects Are Dimming for Radiology Trainees . The New York Times. http://www.nytimes.com/ 2013 /03/28/health/trainees -inradiology-and-other-specialties-see-dream-jobs-disappearing . html. Published March 27 , 2013 .


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David M. Levine, Bruce E. Landon. It’s Not Just About How Much You’re Paid, Journal of General Internal Medicine, 2018, 1-2, DOI: 10.1007/s11606-018-4394-x