Association of organizational and patient behaviors with physician well-being: A national survey in China.

This study aims to investigate the association of organizational and patient behaviors (reflecting the internal and external environment of hospital, respectively) with physician well-being. A national cross-sectional survey was conducted in 77 hospitals across seven provinces in China between July 2014 and April 2015. Physician well-being was assessed with job satisfaction, career regret and happiness. Organizational behaviors were assessed with organizational fairness, leadership attention and team interaction; patient behaviors were assessed with patient trust and unreasonable requests from patients. Of a study sample of 3,159 physicians, 1,788 were men (56.6%) and 1,371 were women (43.4%). Overall, positive organizational and patient behaviors reported by physicians were relatively low. Negative organizational behaviors and patient behaviors including lower organizational fairness, lower leadership attention, lower team interaction and lower patient trust were associated with lower job satisfaction and lower life satisfaction, and higher career regret. The association between organizational behaviors and physician well-being exhibited some gender differences, while no clear gender difference was found for the relationship between patient behaviors and physician well-being. Given the importance of physician well-being for the healthcare system, interventions for improving internal and external hospital environments (e.g., organizational fairness, leadership attention, team interaction and patient trust) may benefit physician well-being.

Introduction

Physician well-being is particularly important in the healthcare system, including its impact on physicians’ own physical and mental health and career development [1-5], as well as the quality of medical services and patient satisfaction [6-9]. Studies on improving physician well-being revealed various underlying factors that may provide benefits. While some studies have emphasized the importance of individual intrinsic motivational factors [10-12], others have suggested that [6, 13], faced with widespread physicians’ distress, individual susceptibility (individual factors) may not be primary, and environmental factors (including the internal and external hospital environments) may be more important.

Most research on the internal hospital environments has focused on working environment factors [14-19], including workload, workflow, job autonomy, hospital teaching attributes, practice characteristics, scheduling issues, leadership behaviors, use of electronic health records, number of doctors (or nurses) per ward bed, average daily admissions, and average occupancy workload. In fact, factors such as job autonomy, hospital teaching attributes, practice characteristics, and scheduling issues are difficult for healthcare providers (including clinicians and hospitals/organizations) to modify [20, 21] because the internal hospital environments are broad in scope and relatively complex to examine. Compared to the structural factors of organization, organizational behaviors (e.g., organizational fairness, leadership attention, and team interaction) may be more feasible to modify. In terms of the external hospital environment including the social environment, previous research [22, 23] has focused on financial compensation, and external competition, and less on the attitudes and behaviors of patients and their families. Although previous studies have incorporated patient factors into working conditions for physicians and hospitals [6,10], patients are situated in a societal context and are affected by social environmental factors outside the hospital. Physicians have closer contact with patients in their everyday work environment than those who they receive incentives or penalties from such as medical insurance agencies; hence factors related to patients may be more relevant to improve physician well-being. In addition, some previous studies [24-27] have focused on the associations between leadership behaviors and physicians’ burnout and satisfaction, however, the types of organizational behaviors are relatively simple [24, 25, 27, 28], such as leadership and/or organization fairness, and few explanatory variables were accounted for, lacking some organizational characteristics (e.g., specialties, teaching nature, and the ratio of physicians to beds) and physicians’ family factors, etc.

The present study used data from a national survey of physicians in China to explore the association of organizational and patient behaviors (reflecting the internal and external environment of hospital, respectively) with physician well-being.

Methods

Study design and participants

We conducted a survey between July 2014 and April 2015 using stratified cluster sampling strategy. Briefly, seven provinces were selected from each geographical area, with two from each of East and West China (Shandong and Jiangsu, and Gansu and Yunnan), and one each from South, Central and North China (Guangdong, Hubei and Beijing metropolis). The details of this survey have been described in a previous report [29], and there was a total of 85 eligible hospitals in the selected regions with 77 hospitals (90.60%) agreeing to participate. In each hospital, convenience sampling was used to select four surgical departments and four internal medicine departments (excluding obstetrics and pediatrics). A total of 528 departments were selected and all of their full-time physicians (n = 5,754) were eligible and invited to participate in the survey. Trained survey interviewers sent copies of the questionnaire) to each department, along with an explanation of the survey purpose and method. After one or two days, the interviewers returned to collect completed questionnaires. Participation was voluntary, and all data was kept confidential. Finally, 4,281 (74.4% response rate) physicians responded to the survey and 634 (11.0%) invalid questionnaires were excluded. The final valid responses were 3,159 (54.9%) after excluding 488 (8.5%) responses with incomplete information (S1 Fig in S1 File).

All participants provided oral informed consent for interviews. We obtained ethical approval from the institutional review board at the Tongji Medical College, Huazhong University of Science and Technology (Wuhan, China) [No. IORG0003571].

Data collection

Exposure factors include three specific aspects of organizational behaviors (organizational fairness, leadership attention, team interaction) and two aspects of patient behaviors (patient trust and unreasonable requests from patients). One of the commonly used measurement for organizational behaviors is Colquitt’s Organizational Justice Scale [30, 31], which contains 4 dimensions and 20 items, although the length of this questionnaire limits its feasibility in nationwide studies. Based on the literature and expert consultation [32-36], we adopted similar survey indicators and methods in the current study. Organizational fairness was assessed using two single-item measures adapted from the full Colquitt’s Organizational Fairness Scale: pay fairness (reflecting distributional fairness), and task fairness (reflecting procedural fairness). Similarly, leadership attention was assessed using two single-item measures: interests attention (reflecting attention to physicians’ material needs) and opinions attention (reflecting attention to physicians’ emotional needs). Team interaction [37] was assessed using two single-item measures: number of dinners with colleagues per month (reflecting social interaction) and number of clinical case discussions with colleagues per month (reflecting work interaction). Unlike some prior studies [38-40], patient behaviors in this study were measured from the physicians’ perspective as two items of patient trust (intrinsic behavior) and unreasonable requests from patients (explicit behavior) were used as measures for patient behaviors. Each question was answered on a 5-point Likert scale and we recoded each question into four categories (see Table 2).

Table 2

The characteristics of physicians’ self-perceived organizational and patient behaviors.

	Men(n = 1788)	Women(n = 1371)	P Value
Organizational behaviors
Organizational fairness
Pay fairness
Very poor	533(29.8)	359(26.2)	<0.001
Poor	504(28.2)	374(27.3)
Average	619(34.6)	512(37.4)
Good/Very good	131(7.3)	124(9.1)
Task fairness
Very poor	295(16.5)	188(13.7)	0.002
Poor	388(21.7)	295(21.5)
Average	877(49.1)	696(50.8)
Good/Very good	227(12.7)	191(13.9)
Leadership attention
Interests attention
Very small	595(33.3)	409(29.8)	0.009
Smalle	413(23.1)	334(24.4)
Average	606(33.9)	513(37.4)
Large/Very large	172(9.6)	115(8.4)
Opinions attention
Very small	634(35.5)	439(32.0)	0.020
Smalle	419(23.5)	337(24.6)
Average	542(30.3)	485(35.4)
Large/Very large	192(10.7)	110(8.0)
Team interaction
The number of dinners with colleagues per month
≥4times	147(8.3)	80(5.9)	<0.001
3times	101(5.7)	53(3.9)
2times	279(15.76)	145(10.6)
0-1time	1255(70.4)	1090(79.7)
The number of clinical case discussions per month
≥4times	831(46.7)	460(33.8)	<0.001
3times	273(15.3)	215(15.8)
2times	327(18.4)	290(21.3)
0-1time	350(19.7)	395(29.0)
Patient behaviors
Patient trust
Very low	267(15.0)	174(12.8)	0.642
Lower	497(27.9)	409(30.1)
Average	801(45.0)	645(47.4)
Higher/Very high	214(12.0)	133(9.8)
Unreasonable requests from patients
A lot	112(6.3)	80(5.8)	0.031
More	477(26.7)	412(30.1)
Average	601(33.7)	470(34.3)
Less/Rarely	595(33.3)	408(29.8)

There were three outcome variables: job satisfaction, career regret and happiness. In reference to prior studies [11], three outcome variables were assessed using three single-item measures respectively in the current study. Job satisfaction was examined using the question “Overall, how would you rate your satisfaction with your work?”. Career regret was examined with the question “If you had an opportunity to choose your profession, would you become a physician again?” and the response was reverse coded to measure the degree of “regret”. Happiness was assessed with the question “Overall, what do you think your happiness score is?” and the response for happiness was reverse-coded as categorical variables (80–100 = “very high”, 60–79 = “higher”, 40–59 = “average”, 20–39 = “lower” and 0–19 = “very low”). Each question was answered using a 5-point Likert scale with response options ranging from “very low” to “very high”. Finally, all responses for the three outcome variables were recoded as binary variables: low (“very low/lower/average”) versus high (“higher/very high”).

In addition, we measured a number of factors previously reported to be associated with well-being of physicians, including socio-demographics (age, gender, marital status, education level, economic status and professional ranking), hospitals and department characteristics (hospital level, hospital type, academic status, physician specialty and the ratio of physicians to beds) and family support. Data of hospitals and department characteristics was obtained from the unit heads.

Statistical analysis

To adjust for nonresponses, the data was weighted by respondents’ age and gender, according to the hospitals’ demographic information issued by the National General Hospital in 2015.

For crude comparisons, we used chi-square tests or Kruskal-Wallis tests for categorical variables and used binary logistic regression models to examine the association of organizational and patient behaviors with physician well-being. Given that women are considered having more family care responsibility whilst work obligations negatively impact family care roles [41, 42], there may be a gender difference for the impact of organizational and patient behaviors on physician well-being; hence the analysis of this study did a gender stratification. Two-sided tests were used for all the analyses, and P values of 0.05 or less were considered statistically significant. All analyses were performed using SPSS, version 22.0 (SPSS Inc., Chicago, IL, USA).

Results

The primary characteristics of participants, departments and hospitals were summarized in Table 1. Among 3,159 respondents, 1788 were men (56.6%) and 1,371 were women (43.4%). More than 80% of physicians were married and less than 10% reported good financial conditions. In terms of gender difference, females were less likely to be surgeons than males (vs 25.8% vs 63.3%, P<0.001).

Table 1

The primary characteristics of participants, hospitals and departments.

	Men(n = 1788)	Women(n = 1371)	P Value
Socio-demographics
Age, y
≤34	519(29.0)	398(29.0)	<0.001
35–44	620(34.7)	476(34.7)
≥45	649(36.3)	498(36.3)
Marital status
Single/Other	252(14.7)	254(19.1)	0.001
Married	1466(85.3)	1076(80.9)
Education level
Undergraduate and below	893(50.7)	739(55.9)	0.010
Master	636(36.1)	464(35.1)
Doctor	234(13.3)	120(9.1)
Economic status
Very poor	227(12.7)	183(13.4)	0.889
Poor	392(22.0)	251(18.4)
Average	1011(56.6)	828(60.6)
Good	155(8.7)	105(7.7)
Professional ranking
Primary/Other	374(23.0)	300(25.6)	<0.001
Intermediate	490(30.2)	397(33.8)
Senior	761(46.8)	477(40.6)
Hospitals and departments characteristics
Hospital level
Secondary Hospital	255(14.3)	207(15.1)	0.509
Tertiary Hospital	1533(85.7)	1164(84.9)
Hospital type
Traditional Chinese Medicine	470(26.3)	413(30.1)	0.017
Western Medicine	1318(73.7)	958(69.9)
Academic status
No	1402(78.4)	1134(82.7)	0.003
Yes	386(21.6)	237(17.3)
Physician specialty
Internal medicine	656(36.7)	1018(74.3)	<0.001
Surgery	1132(63.3)	353(25.8)
The ratio of physicians to beds
<0.20	473(26.8)	389(28.9)	0.020
0.20–0.30	777(44.0)	485(36.1)
≥0.30	517(29.3)	471(35.0)
Family support
Very small/Small	71(4.0)	37(2.7)	0.023
Average	330(18.5)	215(15.7)
Large/Very large	1384(77.5)	1118(81.6)

Table 2 showed the characteristics of physicians’ self-perceived organizational and patient behaviors. Overall, the rates of positive responses regarding organizational and patient behaviors reported by physicians were relatively low. Less than 10% of physicians reported good pay fairness and large interests attention from leaders. More than 70% of physicians had only 0–1 dinner with colleagues per month and 30–40% of physicians had ≥4 clinical case discussions with colleagues per month. Less than 15% reported high patient trust. Concerning gender difference, females were more likely to report fewer dinner with colleagues per month than males (70.4% vs 79.7%, P<0.001) and clinical case discussions (19.7% vs 29.0%, P<0.001).

Table 3 reported gender differences on job satisfaction, career regret and level of happiness. More than half of physicians felt high level of happiness, however, physicians were not optimistic about their work, with low job satisfaction (30%–40%) and high career regret (nearly 70%). Additionally, differences in level of happiness between men and women were observed. Females reported higher level of happiness than males(54.6% vs 51.9%, P<0.05).

Table 3

Job satisfaction, career regret and happiness of physicians by gender.

	Men(n = 1788)	Women(n = 1371)	P Value
Job Satisfaction
Very low	157(8.8)	93(6.8)	0.314
Lower	176(9.8)	153(11.2)
Average	810(45.3)	601(43.8)
Higher	506(28.3)	372(27.1)
Very High	139(7.8)	152(11.1)
Career Regret
Very low	61(3.4)	36(2.6)
Lower	142(7.9)	134(9.8)	0.686
Average	394(22.0)	288(21.0)
Higher	322(18.0)	254(18.5)
Very High	869(48.6)	659(48.1)
Happiness
Very low	198(11.1)	130(9.5)
Lower	230(12.9)	141(10.3)	0.002
Average	432(24.2)	352(25.7)
Higher	684(38.3)	517(37.7)
Very High	244(13.7)	231(16.9)

Table 4 summarized the association of organizational and patient behaviors with physician well-being after adjusting for all other explanatory variables. In general, patient behaviors were more significantly associated with physician well-being than organizational behaviors. In terms of patient behaviors, lower patient trust was associated with lower job satisfaction (OR total = 0.22, 95% CI: 0.15–0.33, OR men = 0.21, 95% CI: 0.12–0.36, OR women = 0.18, 95% CI: 0.09–0.37) and lower level of happiness (OR total = 0.32, 95% CI: 0.21–0.49, OR men = 0.34, 95% CI: 0.19–0.58, OR women = 0.22, 95% CI: 0.10–0.48) and higher career regret (OR total = 5.32, 95% CI: 3.34–8.46, OR men = 4.99, 95% CI: 2.75–9.07, OR women = 8.20, 95% CI: 3.68–18.24). With regards to organizational behaviors, lower pay fairness was positively associated with higher career regret (OR total = 2.80, 95% CI: 1.74–4.51, OR men = 2.85, 95% CI: 1.48–5.49, OR women = 3.07, 95% CI: 1.44–6.54); lower task fairness was positively associated with lower level of happiness (OR total = 0.43, 95% CI: 0.28–0.67, OR men = 0.42, 95% CI: 0.23–0.75, OR women = 0.41, 95% CI: 0.21–0.82) and more frequent clinical case discussions with colleagues per month was positively associated with higher job satisfaction (OR total = 1.46, 95% CI: 1.15–1.86, OR men = 1.43, 95% CI: 1.02–1.99, OR women = 1.68, 95% CI: 1.15–2.46).

Table 4

Multivariable logistic regression results for association of organizational and patient behaviors-related effects for physicians well-being.

	Job Satisfaction			Career Regret			Happiness
	Total OR(95%CI)	Men OR (95%CI)	Women OR 95%CI)	Total OR(95%CI)	Men OR(95%CI)	Women OR(95%CI)	Total OR(95%CI)	Men OR(95%CI)	WomenOR(95%CI)
Organizational behaviors
Organizational fairness
Pay fairness
Very poor	1.44(0.91,2.28)	1.25(0.66,2.37)	1.53(0.75,3.13)	2.80(1.74,4.51)***	2.85(1.48,5.49)**	3.07(1.44,6.54)**	0.88(0.54,1.44)	0.64(0.32,1.26)	1.41(0.67,2.96)
Poor	0.91(0.59,1.40)	0.86(0.47,1.57)	0.92(0.47,1.83)	2.85(1.84,4.39)***	2.13(1.19,3.83)*	4.70(2.30,9.58)***	0.88(0.55,1.40)	0.61(0.32,1.15)	1.35(0.67,2.75)
Average	1.13(0.75,1.69)	1.49(0.85,2.60)	0.76(0.40,1.44)	1.99(1.34,2.98)***	1.46(0.85,2.50)	3.16(1.62,6.15)***	0.88(0.57,1.36)	0.74(0.40,1.35)	1.00(0.51,1.98)
Good/Very good	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00
Task fairness
Very poor	0.50(0.33,0.75)***	0.36(0.21,0.63)***	0.71(0.36,1.41)	1.24(0.77,2.00)	1.24(0.65,2.34)	1.11(0.50,2.46)	0.43(0.28,0.67)***	0.42(0.23,0.75)**	0.41(0.21,0.82)*
Poor	0.68(0.47,0.91)***	0.65(0.40,1.05)	0.66(0.36,1.20)	1.09(0.75,1.59)	1.33(0.80,2.19)	0.79(0.41,1.51)	0.52(0.36,0.76)***	0.53(0.33,0.88)*	0.49(0.27,0.87)*
Average	0.60(0.44,0.83)***	0.47(0.31,0.71)***	0.86(0.51,1.44)	0.98(0.71,1.35)	1.21(0.79,1.84)	0.65(0.37,1.13)	0.73(0.52,1.02)	0.64(0.41,1.00)*	0.89(0.53,1.52)
Good/Very good	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00
Leadership attention
Interests attention
Very small	0.43(0.27,0.67)***	0.66(0.37,1.18)	0.20(0.09,0.42)***	1.54(0.95,2.49)	0.73(0.38,1.38)	4.73(2.03,11.04)***	0.74(0.46,1.18)	0.80(0.43,1.48)	0.67(0.31,1.47)
Smalle	0.46(0.31,0.70)***	0.57(0.33,0.98)*	0.29(0.14,0.60)***	1.76(1.16,2.69)	0.89(0.51,1.56)	5.06(2.37,10.77)***	0.83(0.54,1.28)	1.00(0.57,1.76)	0.62(0.30,1.30)
Average	0.55(0.38,0.79)***	0.71(0.44,1.14)	0.34(0.18,0.65)***	1.20(0.83,1.74)	0.66(0.41,1.08)	3.41(1.74,6.67)***	0.87(0.59,1.29)	0.94(0.57,1.56)	0.76(0.39,1.48)
Large/Very large	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00
Opinions attention
Very small	1.19(0.75,1.87)	1.05(0.58,1.87)	1.29(0.59,2.84)	1.35(0.84,2.18)	2.29(1.24,4.24)**	0.73(0.30,1.74)	0.86(0.53,1.37)	0.95(0.52,1.75)	0.62(0.27,1.40)
Smalle	1.09(0.71,1.66)	1.18(0.69,2.03)	0.83(0.39,1.74)	0.92(0.60,1.40)	1.35(0.78,2.31)	0.52(0.24,1.14)	1.09(0.70,1.70)	1.16(0.66,2.03)	0.87(0.40,1.89)
Average	1.35(0.92,1.97)	1.30(0.81,2.10)	1.22(0.62,2.39)	0.80(0.65,1.17)	1.04(0.65,1.67)	0.51(0.25,1.04)	1.03(0.69,1.55)	1.21(0.73,2.00)	0.74(0.36,1.52)
Large/Very large	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00
Team interaction
The number of dinners with colleagues per month
≥4times	0.69(0.48,1.00)**	0.95(0.61,1.48)	0.37(0.18,0.77)**	0.58(0.40,0.83)***	0.49(0.32,0.77)**	0.78(0.39,1.56)	1.48(1.03,2.14)***	2.07(1.32,3.25)**	0.67(0.35,1.30)
3times	1.30(0.86,1.97)	1.05(0.62,1.76)	2.28(1.07,4.85)	0.89(0.58,1.35)	1.01(0.60,1.69)	0.65(0.31,1.38)	1.89(1.21,2.95)***	1.86(1.08,3.21)*	2.57(1.10,6.02)*
2times	0.80(0.61,1.05)	0.95(0.68,1.32)	0.61(0.36,1.02)	0.96(0.73,1.26)	0.99(0.70,1.40)	0.89(0.54,1.47)	1.35(1.03,1.76)***	1.26(0.90,1.75)	1.57(0.96,2.57)
0-1time	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00
The number of clinical case discussions per month
≥4times	1.46(1.15,1.86)***	1.43(1.02,1.99)*	1.68(1.15,2.46)**	0.98(0.76,1.27)	1.13(0.80,1.61)	0.85(0.57,1.27)	0.93(0.73,1.18)	0.85(0.61,1.19)	1.08(0.74,1.56)
3times	1.10(0.82,1.47)	1.42(0.94,2.12)	0.88(0.55,1.42)	1.11(0.81,1.52)	1.31(0.85,2.03)	0.88(0.54,1.45)	0.89(0.66,1.20)	0.78(0.52,1.18)	1.10(0.70,1.73)
2times	0.90(0.68,1.20)	0.83(0.56,1.24)	1.03(0.67,1.57)	1.07(0.80,1.43)	0.97(0.65,1.45)	1.20(0.75,1.91)	0.96(0.73,1.26)	1.06(0.72,1.55)	0.86(0.57,1.31)
0-1time	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00
Patient behaviors
Patient trust
Very low	0.22(0.15,0.33)***	0.21(0.12,0.36)***	0.18(0.09,0.37)***	5.32(3.34,8.46)***	4.99(2.75,9.07)***	8.20(3.68,18.24)***	0.32(0.21,0.49)***	0.34(0.19,0.58)***	0.22(0.10,0.48)***
Lower	0.23(0.17,0.33)***	0.20(0.13,0.31)***	0.25(0.14,0.45)***	3.95(2.80,5.58)***	3.81(2.45,5.94)***	5.28(2.89,9.64)***	0.48(0.33,0.69)***	0.55(0.35,0.86)**	0.33(0.17,0.64)**
Average	0.37(0.27,0.51)***	0.31(0.21,0.46)***	0.39(0.22,0.67)***	1.89(1.39,2.57)***	1.93(1.30,2.85)***	2.36(1.36,4.09)**	0.70(0.50,0.99)***	0.72(0.47,1.11)	0.55(0.29,1.06)
Higher/Very high	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00
Unreasonable requests from patients
A lot	0.84(0.54,1.30)	0.88(0.48,1.60)	0.81(0.41,1.60)	3.37(1.70,6.69)***	3.31(1.40,7.82)**	2.78(0.86,8.97)	0.52(0.32,0.84)***	0.52(0.26,1.02)	0.44(0.21,0.92)*
More	0.70(0.55,0.90)***	0.71(0.51,0.99)*	0.62(0.41,0.92)*	1.53(1.18,1.98)***	2.04(1.44,2.91)***	1.14(0.75,1.72)	0.58(0.45,0.73)***	0.64(0.46,0.88)**	0.45(0.30,0.66)***
Average	0.82(0.66,1.02)	0.83(0.62,1.11)	0.79(0.55,1.14)	1.21(0.96,1.52)	1.21(0.91,1.63)	1.27(0.87,1.86)	0.73(0.58,0.91)***	0.89(0.66,1.19)	0.54(0.37,0.78)***
Less/Rarely	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00

Note: All Models for total participants adjusted for socio-demographics (gender, age, marital status, education level, economic status and professional ranking), hospitals and department characteristics (hospital level, hospital type, academic status, physician specialty and the ratio of physicians to beds) and family support. The stratified analysis adjusted for all the covariates except for the stratified variable

*p<0.05

** p<0.01

*** p<0.001

In addition, significant gender differences were observed in the relationship between some organizational behaviors and physician well-being. Specifically, females who reported lower leadership attention to interests were more likely to have lower job satisfaction (OR women = 0.20, 95% CI: 0.09–0.42) and higher career regret (OR women = 4.73, 95% CI: 2.03–11.04). Male physicians who reported lower leadership attention to opinions were more likely to have higher career regret (OR men = 2.29, 95% CI: 1.24–4.24). Having dinners with colleagues three times per month was associated with higher job satisfaction (OR women = 2.28, 95% CI: 1.07–4.85) and higher level pf happiness (OR women = 2.57, 95% CI: 1.10–6.02) of women physicians, while having dinners with colleagues ≥4 times was associated with lower career regret (OR men = 0.49, 95% CI: 0.32–0.77) and higher level of happiness (OR men = 2.07, 95% CI: 1.32–3.25) of men physicians.

Discussion

To our knowledge, this study is the first study of physician well-being and its relevance to organizational and patient behaviors using a national representative sample in China. In general, more negative organizational behaviors and patient behaviors were positively associated with lower job satisfaction, lower level of happiness and higher career regret. Poor well-being and negative organizational and patient behaviors are common issues that confronts both male and female physicians in China, despite slight gender differences in various aspects.

These findings are relevant to current clinical practice and can apply to other countries, given the prevailing focus on physician well-being internationally. The current results confirm that the physician well-being should be approached from the perspective of internal and external environments. Whether organizational behaviors of the internal environment or patient behaviors of the external environment, healthcare providers (including hospital organizations and clinicians) can take action to change these behaviors, which can be modified to modify than structural factors of organization. The distribution of the exposure factors revealed that the proportion of positive responses was relatively low for both organizational and patient behaviors. Combined with the association of organizational and patient behaviors (reflecting the internal and external environment of hospital, respectively) with physician well-being, the current findings suggest that addressing these factors could substantially improve physician well-being.

Previous research [43, 44] indicates that low levels of organizational fairness can make employees feel excluded, potentially explaining the association of organizational fairness with physicians’ job satisfaction, level of happiness and career regret in this study. Specially, lower pay fairness was positively associated with higher career regret, and lower task fairness was positively associated with lower level of happiness. Prior work [45] indicates that, compared with distribution fairness [46] (reflected by pay fairness in this study), procedural fairness (reflected by task fairness in this study) may have a significant impact on people’s psychological health, attitudes and values, which is consistent with the results of this study.

In general, the mechanisms underlying the association between leadership attention and physician well-being by gender were less clear. Specially, lower leadership attention to interests was positively associated with lower job satisfaction and higher career regret of female physicians, and lower leadership attention to opinions was positively associated with higher career regret of male physicians. This gender difference may be related to traditional cultural difference between men and woman that men are concerned about their career while women are more concerned about their family responsivities. Additional studies will be required to explore this issue in more depth in future.

It may be unsurprising that more frequent clinical case discussions with colleagues per month was positively associated with higher job satisfaction which indicated, the important role of case discussions on professional development, which is not related to gender [47, 48]. However, having more dinners with colleagues per month were beneficial to both male and female physicians. Specially, having dinners with colleagues 3 times per month was associated with higher job satisfaction and higher level of happiness of women physicians, while having dinners with colleagues ≥4 times was associated with lower career regret and higher happiness of men physicians. This finding may have occurred because women tend to carry greater family responsibilities than men in China, having high-intensity social interaction may place a disproportionate burden on women [49, 50].

This study confirmed the important role of patient trust as there was a positive association between patient trust and physician well-being which was consistent with findings from previous studies [51-53].

Notably, China’s health care systems are based on public hospitals, and they follow the principles of cost control, efficiency improvement and patient-centered service, which are the same for countries with different health care systems around the world. Therefore, the lessons learnt from this study in relation to organizational behavior and patient behavior of public hospitals may be applicable to other countries.

As a strength of our study, the current analysis combined multiple organizational and patient behaviors, and the data was adjusted for a broad array of hospital organization and physicians’ demographic characteristics and family support factors known to influence physicians’ well-being. Importantly, our study involved several limitations. First, although we conducted a national survey, our study design did not enable us to identify differences between responding and non-responding physicians. Accordingly, the data was weighted by respondents’ age and gender to adjust for nonresponses. Second, data was self-reported by physicians. Thus, both underreporting and overreporting may have occurred, with the potential for variation in overreporting and underreporting regarding organizational and patient behaviors, as well as physician well-being, introducing uncertainty regarding the generalizability of our study findings. Third, given the busyness of participants’ job and the feasibility in a nationwide survey, the outcome variables in this study were measured using single-item indicators [5, 11, 32], and the measurement bias was possible. Fourth, the observational cross-sectional nature of the analyses precluded the ability to draw causal inferences. Nonetheless, the current study provided a large sample and multivariate evidence for in-depth investigation, which may enlighten future research.

Conclusions

The national sample investigated physician well-being and its relevance to organizational behaviors and patient behaviors in China. In general, more negative organizational and patient behaviors (e.g., organizational fairness, leadership attention, team interaction and patient trust) were positively associated with lower physician well-being. The association between organizational behaviors and physician well-being exhibited some gender differences, while no clear gender difference was found for the relationship between patient behaviors and physician well-being. Given the prevailing international research interest in distress among physicians, interventions from the perspective of the internal and external hospital environment may provide a valuable approach for improving physician well-being.

(DOCX)

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1 Apr 2021

PONE-D-20-31349

Association of Organizational and Patient Behaviors with Physician Well-being: A National Survey in China

PLOS ONE

Dear Dr. Liang,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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The key concerns noted by the reviewers relate to the assessment tools and their underlying constructs, as well as the rationale for stratifying all analyses by gender. These issues impact the interpretation of the results and should be explored.

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I have several concerns with the assessment tools utilized in the study

Overall, what do you think your happiness score is? – these are validated QoL measures that should have been used if the authors were interested in evaluating QoL

If you had an opportunity to choose your profession, would you become a physician again – this does not measure intention to leave/turnover but rather career regret

Leadership scores could have been assessed using validated tools

Team interaction being assessed by number of times that teams go out to dinner is highly subjective and likely not generalizable.

Unclear how patient behavior was assessed but these findings go against prior research (patient expectations and gender disparities in medicine).

Unclear how pay fairness in China is generalizable to other countries given the profoundly different pay structure

Reviewer #2: This study used a national physician survey in China to examine the association of organizational characteristics and patient behaviors with physician well-being. The authors found that organizational characteristics were substantially associated with physician job satisfaction, turnover intention, and life happiness.

[1] Major

1. Pages 6-7. Statistical analysis and results

The authors conducted all analysis stratified by physician gender.

(1) Please clarify the logic underlying why the authors stratified the entire analyses by physician gender. For example, I was wondering if the authors assume physician gender is the most critical component that influence or differentiate physician well-being. Although some estimation results were different by physician gender, differences could be observed even when the authors stratified the analysis by other factors such as physician specialty, hospital level (secondary vs. tertiary), or hospital type (traditional Chinese medicine vs. western medicine).

(2) If the table space allows, I recommend presenting estimation results among the total study population (in which physician gender and all explanatory variables are adjusted) and stratifying by physician gender.

2. Page 7, fourth paragraph

I recommend deleting this paragraph and the associated results in the appendix table for two reasons:

(1) The authors have three co-primary outcomes (job satisfaction, turnover intention, life happiness). In their "sensitivity analysis," the same variable was used as an outcome variable in one estimation, but as an explanatory variable in another estimation (e.g., job satisfaction is an outcome variable, then becomes an explanatory variable for turnover intention). In statistics, this implies simultaneity between two outcomes, which would require a more advanced estimation model to generate unbiased estimates.

(2) I am not sure whether “sensitivity analysis” usually refers to the adjustment of additional explanatory variable(s) while all other parts of the empirical design (e.g., applicable study population, categorization of outcome/independent variable) are the same.

[2] Minor

1. P.6. Statistical analysis

The authors stated, “Data were weighted to adjust for non-responses so that physician responding to the initial questions were matched to the demographics of the total hospitalized population issued by the National General Hospital.” Please clarify whether this means that adjusting weight made the data nationally representative at the physician level.

2. P.7. Results section

(1) Please include the 95% confidence interval for each odds ratio (OR).

(2) Please specify whether the difference in association of organizational/patient characteristics with outcomes between men and women is a difference in magnitudes (i.e., OR) or statistical significance. Indeed, estimates show that some associations are statistically significant among men but not among women, and vice versa.

3. Please clarify some terminologies in the text. I have two examples:

(1) Page 7, second paragraph. The authors stated, “Table 4 …. after adjustment for potentially confounding factors.” I suggest replacing “potentially confounding factors” with “all other explanatory variables” because the term “confounding factors” usually means unobserved factors included in the error term, which are correlated with independent variables and cause bias in estimates.

(2) Page 7, fourth paragraph. I am not sure whether “sensitivity analysis” is the correct terminology in this context.

**********

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: PLOS ONE Review.docx

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8 May 2021

please see the file named with "Response to Reviewers 2021-4-27"

Submitted filename: Response to Reviewers 2021-4-27.docx

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7 Jun 2021

PONE-D-20-31349R1

Association of Organizational and Patient Behaviors with Physician Well-being: A National Survey in China

PLOS ONE

Dear Dr. Liang,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

In addition to the reviewers’ comments, please note a few points:

(1) The reviewers were concerned that some of the responses to the previous comments were not complete. Specifically, the discussion of the limitations in methods (e.g., validity of the variables) requires a clearer statement.

(2) Please briefly discuss similarities and differences in (a) health care systems between China and other countries, and (b) study outcomes and policy implications from your study and relevant literature from other countries. This would be helpful to emphasize your contribution to the literature.

(3) The reviewer recommended including interaction terms between gender and other explanatory variables.

(a) I would recommend adding an interaction term between gender and one primary explanatory variable (e.g., hospital teaching status) per multivariable regression and checking whether the interaction term is statistically significant.

(b) Repeat (a) for a few explanatory variables that the authors believe are most important.

(c) If no interaction term is statistically significant, please summarize the results in a few sentences.

(d) If any interaction term is statistically significant, please

(d.i) derive adjusted predicted outcome, average marginal effect, and difference-in-differences given that interpretation of interaction term in a non-linear model is different from that in a linear model, and

(d.ii) report them in a few sentences (or the authors may want to write an appendix table).

Please submit your revised manuscript by August 5, 2021. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see:  http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at  https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Hyo Jung Tak, PhD

Academic Editor

PLOS ONE

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Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: Thank you for the opportunity to review your manuscript "Association of Organizational and Patient Behaviors with Physician Well-being: A National Survey in China". The physician's well-being is important for physicians themselves and the quality of care to patients. Please see my comments below. Thank you.

Reviewer#1

1. Comment 1 - This is a limitation of the study by not using validated measures of QoL.

2. Comment 4 has not been well addressed by the authors. The author-cited reference does not support the authors’ choice of the variable “number of times that teams go out to dinner”. The literature talks about various meetings in an organization, such as regular problem-solving team meetings, managerial meetings, or focus group meetings. These meetings are to facilitate interactions between team members and leadership in order to improve communication and coordination among members, and these activities are likely taking place in their regular work settings.

3. Comment 5 could be another limitation of the study as it did not capture patients’ perspectives directly from patients.

4. Comment 6 – Given China-specific data and context, the findings are likely limited for other countries.

Reviewer#2

1. [2] Minor Comment 1 – The author’s response is still vague whether the estimation in the study is nationally representative by incorporating survey design features, such as stratification,…… Please clarify it.

Additional comments

Abstract

1. Given the study has been conducted in one country, the findings may not be generalizable to other countries, and so caution should be taken with stating policy implications.

Introduction

1. As the study is about physician well-being, not distress, the 1st sentence in the 1st paragraph could divert readers from the focus. It could be relocated elsewhere or removed.

2. In the 2nd paragraph, the authors limited the working environment factors to those (job autonomy, workload, scheduling…) and separated organizational behaviors (organizational fairness, team interaction, and so on). Whether they are job-specific factors or organizational behaviors, both constitute a working environment. I would suggest making sure consistency with the literature in using and defining these languages.

3. In the same paragraph, a sentence starting with “Although previous studies have incorporated….”. Please cite a reference to support authors’ argument.

4. The next sentence starting with “compared with macro financial policy,..”. What is macro financial policy? And the whole sentence is not clear. Please rephrase it.

5. The sentence “types of organizational behaviors are relatively simple” needs supporting evidence.

6. Given this study is specific in China, more discussion of the background/context would be useful to help readers get better understanding. Also, I would suggest briefly discussing potential or expected contributions out of the study.

Data collection

1. In measuring team interaction, is there any justification/validation for including ‘number of dinners with colleagues per month’? This is quite subjective.

Statistical analysis

1. Were survey design features accounted for in the analyses to make it nationally representative? If so, please state it.

2. When it comes to gender difference, what authors did seems to be a sub-group analysis within each gender. If authors intended to compare genders in the outcomes of interest as seen throughout the manuscript, I would recommend using an interaction effect using gender with other explanatory variables.

Results

1. In the 3rd paragraph, P-value in the text is different from the one in Table.

2. It would be more appropriate to use ‘association’ than ‘correlates’ for the title of Table 4.

3. In Table 4, please add statistical significance, such as using p-values. And, revise “for physicians” to “physician well-being”

4. Throughout the manuscript, be consistent by using “gender” to indicate men or women.

Discussion

1. In the 1st paragraph, the 2nd sentence can be separated, one for the overall association and the other one by gender.

2. Delete current from “current findings”, and the phrase “which can be modified to some extent” is unclear.

3. In the 3rd paragraph, the 1st sentence would be part of study limitations “, and it is unclear about what the “psychological state” means and how the study findings are relevant to it.

4. In the 4th paragraph, the sentence starting with “It may be related….” seems to be not solely based on the study findings. For example, what authors say “women may be more concerned about their family” is not convincing.

5. In the 5th paragraph, please cite relevant literature as necessary.

6. In the 6th paragraph, ‘association’ than ‘correlation’ would be a better term and be consistent across the manuscript.

7. In the 7th paragraph, “Compared” is inappropriate since it does not compare between the number of unreasonable requests from patients and patient trust. It could confuse readers. And, is there any justification for the interpretation in “A possible explanation…”? And the following sentence “patients’ distrust is not related to their medical knowledge” is unclear and unconvincing. Also, “excellent techniques” itself is confusing.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #3: No

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

31 Oct 2021

Please view the uploaded files (named "PONE-S-20-39067 Response to Reviewers 2021-11-1") directly.

Submitted filename: PONE-S-20-39067 Response to Reviewers 2021-11-1.docx

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30 Dec 2021

Association of Organizational and Patient Behaviors with Physician Well-being: A National Survey in China

PLOS ONE

Dear Dr. Liang,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Feb 13 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

26 Feb 2022

Response to the editor’s and reviewers’ comments

（February 13, 2020）

PONE-D-20-31349R2

Association of Organizational and Patient Behaviors with Physician Well-being: A National Survey in China

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: We thank the editor for this comment and reminding.

We did not cite papers that have been retracted in our manuscript.

Additional Editor Comments (if provided):

[1] Major comments. None

[2] Minor comments. Please make sure all terms and numbers are consistent throughout the abstract, text, and tables. For percentages, please write the first decimal point only (e.g., 11.02% - > 11.0%; both in text and tables).

Response: We thank the reviewers for this kind reminders, and we have done as suggested.

Reviewers' comments:

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

Response: We thank the reviewer for the positive comments.

Reviewer #3:Comments to authors

I appreciate the revisions from authors.

Minor

1. Table. Interaction

I would suggest modifying the wording in Table for readability. For example, Gender*Pay fairness -> Men*Pay fairness.

Response: We thank the reviewer for this kind reminders, and we have revised the wording in Table of the last response (November 1, 2021).

2. The statement “Therefore, the study of organizational behavior and patient behavior of public hospitals in China may be universally applicable to other countries.”: This seems too generalizing the study findings. As the authors noted, the study effectively focuses on “organizational behavior” and “patient behavior” in public hospitals in one country. The findings could be relevant to some extent but should be interpreted with caution when it comes to different settings for example in other countries with healthcare systems that have a unique payment system, policy, regulation, culture,…...

Response: We thank the reviewer for this kind reminders, and we have revised as following:

The original

Therefore, the study of organizational behavior and patient behavior of public hospitals in China may be universally applicable to other countries.

The revised

Therefore, the study of organizational behavior and patient behavior of public hospitals in China may be partially applicable to other countries..

3. 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #3: No

Response: We thank the reviewer for the constructive comments.

Submitted filename: PONE-S-20-39067 Response to Reviewers 2022-2-26.docx

Click here for additional data file.

27 Apr 2022

Association of Organizational and Patient Behaviors with Physician Well-being: A National Survey in China

PONE-D-20-31349R3

Dear Dr. Liang,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Hyo Jung Tak, PhD

Guest Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

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Reviewer #3: Yes

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

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Reviewer #3: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

20 May 2022

PONE-D-20-31349R3

Association of Organizational and Patient Behaviors with Physician Well-being: A National Survey in China

Dear Dr. Liang:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

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on behalf of

Dr. Hyo Jung Tak

Guest Editor

PLOS ONE