The impact of practice setting and financial incentives on career satisfaction and perceived practice limitations among surgeons.

OBJECTIVE: To study how practice setting and financial incentives affect career satisfaction and perceived impact on practice in surgery.
METHODS: Data are from the Community Tracking Study (CTS) physician survey, a national survey of active physicians in the United States fielded between August 1996 and August 1997. Surveys with 1,738 practicing surgeons were completed. To be eligible, surgeons had to have completed their medical training (which excludes residents, interns, or fellows), be practicing in the contiguous United States, and be providing direct patient care for at least 20 hours per week. The dependent variables measured are career dissatisfaction and perceived limitations/pressures on time spent with patients, clinical freedom, income, and continuity. The dependent variables are regressed on practice setting, percentage of managed care practice revenue, individual financial incentives, age group, gender, international medical graduate, and board certification.
RESULTS: Working in a small practice is the strongest predictor of career dissatisfaction, with about twice the adjusted rate of career dissatisfaction (26%) than other practice settings (13% in group practices, 16% in staff-model HMOs, 9% in medical schools, 18% in hospitals). Managed care plays a much smaller role; an increase in the dependence on managed care equivalent to the difference between 25th and 75th percentile only increases career dissatisfaction by 3 percentage points. Surgeons in solo or two physician practices are also more likely than surgeons in other settings to report that income pressure and limitations on clinical freedom and patient continuity compromise quality of care.