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Working Conditions in Primary Care: Physician Reactions and Care Quality
- Mark Linzer, MD;
- Linda Baier Manwell, MS;
- Eric S. Williams, PhD;
- James A. Bobula, PhD;
- Roger L. Brown, PhD;
- Anita B. Varkey, MD;
- Bernice Man, MD;
- Julia E. McMurray, MD;
- Ann Maguire, MD, MPH;
- Barbara Horner-Ibler, MD, MASW;
- Mark D. Schwartz, MD; and
- for the MEMO (Minimizing Error, Maximizing Outcome) Investigators*
- From the University of Wisconsin School of Medicine and Public Health, and Medical College of Wisconsin, Madison, Wisconsin; University of Alabama, Tuscaloosa, Alabama; University of Wisconsin School of Nursing, Madison, Wisconsin; Loyola University Medical Center, Maywood, and Rush Medical College, Chicago, Illinois; and New York University School of Medicine, New York, New York.
Abstract
Background: Adverse primary care work conditions could lead to a reduction in the primary care workforce and lower-quality patient care.
Objective: To assess the relationship among adverse primary care work conditions, adverse physician reactions (stress, burnout, and intent to leave), and patient care.
Design: Cross-sectional analysis.
Setting: 119 ambulatory clinics in New York, New York, and in the upper Midwest.
Participants: 422 family practitioners and general internists and 1795 of their adult patients with diabetes, hypertension, or heart failure.
Measurements: Physician perception of clinic workflow (time pressure and pace), work control, and organizational culture (assessed survey); physician satisfaction, stress, burnout, and intent to leave practice (assessed by survey); and health care quality and errors (assessed by chart audits).
Results: More than one half of the physicians (53.1%) reported time pressure during office visits, 48.1% said their work pace was chaotic, 78.4% noted low control over their work, and 26.5% reported burnout. Adverse workflow (time pressure and chaotic environments), low work control, and unfavorable organizational culture were strongly associated with low physician satisfaction, high stress, burnout, and intent to leave. Some work conditions were associated with lower quality and more errors, but findings were inconsistent across work conditions and diagnoses. No association was found between adverse physician reactions, such as stress and burnout, and care quality or errors.
Limitation: The analyses were cross-sectional, the measures were self-reported, and the sample contained an average of 4 patients per physician.
Conclusion: Adverse work conditions are associated with adverse physician reactions, but no consistent associations were found between adverse work conditions and the quality of patient care, and no associations were seen between adverse physician reactions and the quality of patient care.
Primary Funding Source: Agency for Healthcare Research and Quality.
Article and Author Information
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Presented in part at the 31st Annual Meeting of the Society of General Internal Medicine, Pittsburgh, Pennsylvania, 11 April 2008.
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Grant Support: By the Agency for Healthcare Research and Quality (grant 5 R01 HS011955).
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Potential Financial Conflicts of Interest: Employment: Dr. Man was formerly employed at one of the study sites. Grants received: M. Linzer (Agency for Healthcare Research and Quality). Ms. Manwell's salary was partially funded by the grant from the Agency for Healthcare Research and Quality.
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Reproducible Research Statement: Study protocol and data set: Not available. Statistical code: Available from Dr. Brown (rlbrown3{at}wisc.edu).
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Requests for Single Reprints: Mark Linzer, MD, University of Wisconsin School of Medicine and Public Health, General Internal Medicine, 310 North Midvale Boulevard, Suite 205, Madison, WI 53705; e-mail, mxl{at}medicine.wisc.edu.
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Current Author Addresses: Dr. Linzer and Ms. Manwell: University of Wisconsin Section of General Internal Medicine Scholars, 310 North Midvale Boulevard, Suite 205, Madison, WI 53705.
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Dr. Williams: Department of Management and Marketing, Culverhouse College of Commerce and Business Administration, University of Alabama, 164 Alston Hall, Box 870225, Tuscaloosa, AL 35487-0225.
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Dr. Bobula: University of Wisconsin, Department of Family Medicine, 777 South Mills Street, Madison, WI 53715.
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Dr. Brown: University of Wisconsin–Madison School of Nursing, H6/273 Clinical Sciences Center, 600 Highland Avenue, Madison, WI 53792.
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Dr. Varkey: Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153.
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Dr. Man: Rush Medical College, 1901 West Harrison Street, Chicago, IL 60612.
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Dr. McMurray: William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI 53705.
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Dr. Maguire: Medical College of Wisconsin, General Internal Medicine, Froedert East Office Building, Suite 4200, 9200 West Wisconsin Avenue, Milwaukee, WI 53226.
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Dr. Horner-Ibler: Bread of Healing Clinic, 1821 North 16th Street, Milwaukee, WI 53205.
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Dr. Schwartz: Veterans Affairs New York Harbor Healthcare System, 423 East 23rd Street, Suite 15N, New York, NY 10010.
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Author Contributions: Conception and design: M. Linzer, L.B. Manwell, E.S. Williams, B. Man, J.E. McMurray, B. Horner-Ibler, M.D. Schwartz.
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Analysis and interpretation of the data: M. Linzer, L.B. Manwell, J.A. Bobula, R.L. Brown, J.E. McMurray, M.D. Schwartz.
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Drafting of the article: M. Linzer, L.B. Manwell, E.S. Williams.
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Critical revision of the article for important intellectual content: M. Linzer, L.B. Manwell, E.S. Williams, J.A. Bobula, R.L. Brown, A. Maguire, M.D. Schwartz.
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Final approval of the article: M. Linzer, L.B. Manwell, E.S. Williams, R.L. Brown, A.B. Varkey, A. Maguire, B. Horner-Ibler, M.D. Schwartz.
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Provision of study materials or patients: L.B. Manwell, A.B. Varkey, B. Man, A. Maguire, B. Horner-Ibler, M.D. Schwartz.
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Statistical expertise: E.S. Williams, J.A. Bobula, R.L. Brown.
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Obtaining of funding: M. Linzer, L.B. Manwell, E.S. Williams.
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Administrative, technical, or logistic support: M. Linzer, L.B. Manwell, A.B. Varkey, J.E. McMurray, B. Horner-Ibler.
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Collection and assembly of data: L.B. Manwell, J.A. Bobula, A.B. Varkey, B. Man, J.E. McMurray, A. Maguire, B. Horner-Ibler, M.D. Schwartz.
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