Doctor Satisfaction and the Effects on Quality — Discussion

Within this special issue, Casalino and Crosson (2015) ask should anyone care about doctors’ satisfaction. This paper considers this question and the extent to which evidence exists, suggesting that we should indeed care about how satisfied they are.

Although Casalino and Crosson provide many examples of the ways that the psychological state of doctors—burnout, depression, and stress—might affect the care that they give, they do not consider the extent to which these states correlate with dissatisfaction. They point out that career satisfaction is actually high in this profession, perhaps because doctors can separate satisfaction for their professional role from satisfaction with the organization for which they work. They may enjoy the work they do daily, but dislike the way that work is organized, especially if they feel it impacts upon the quality they can give. However, dissatisfaction is clearly a part of one’s emotional state, and we know that a doctor’s emotional state does affect the quality of care (Firth-Cozens, 2001). Moreover, it is possible to study the relationship of job satisfaction to mental health indirectly. For example, a clinical study evaluating psychotherapy for depressed professional staff measured attitudes to work, including a job satisfaction scale, alongside psychological symptoms over the course of therapy. The study found that all aspects of satisfaction, even concerning the adequacy of their pay, rose significantly as clinical symptoms improved (Firth-Cozens & Hardy, 1992). This suggests that looking at the effects of psychological distress as a proxy for job satisfaction, as Casalino and Crosson do, is a reasonable method to consider its effects on quality.

Doctors do have higher psychological distress than most other working populations (Wall et al., 1997). Unlike findings in burnout studies, which have unhelpfully wide ranges for the proportion of high scorers, when a population measure like the General Health Questionnaire is used to assess their mental health, around 28% of doctors consistently score above the symptom threshold (Wall et al., 1997). It is possible that a proportion of those people are stressed, dissatisfied or unhappy over long periods of time (Firth-Cozens, Caceres-Lema, & Firth, 1999) which suggests that, for some doctors, this is perhaps dispositional.

The effects of doctors’ mental health on patient care have been documented over decades (Firth-Cozens, 2001) but until recently have not included satisfaction or quality except indirectly; for example, as a predictor of early retirement (Newton, Luce, van Zwanenberg, & Firth-Cozens, 2004). However, there have been direct examples from other fields; for example, Schneider & Bowen (1985) showed that job satisfaction fed down through banks to customers: happy bank managers have happy staff and happy customers. Thanks to the annual National Health Service (NHS) survey of all English staff and patients, we do now have direct evidence for healthcare too. The NHS Staff Survey 2011 report, analyzing staff satisfaction and relating it to patient satisfaction in individual healthcare organizations, states:

Further than patient satisfaction, the survey also found that “employee engagement” affected many aspects of patient care, including infection rates, mortality, staff absence and turnover. Engagement encompasses satisfaction but also includes a positive involvement in one’s work and a commitment to one’s organization (West & Dawson, 2012). Similarly, Prins et al. (2010) found that doctors who are more engaged in their work are significantly less likely to make mistakes, while another study (Leiter, Harvie, & Frizzell, 1998) suggested that nurses with higher work engagement have safer patient outcomes. “Engagement” therefore may be a more useful construct than job satisfaction since the latter somewhat confounds satisfaction with one’s professional career choice and satisfaction with one’s organization or the quality of care it permits (Casalino & Crosson, 2015).

Many of these measures of quality—mortality, infection, error—are included in the aspects of quality discussed by Nylenna, Bjertnaes, Saunes, Lindahl (2015) though it may be that a simple snapshot of staff health could provide us with considerable information about quality in itself. However, as Nylenna et al. (2015) point out, the patients’ view of their experience needs to be included. Their expectations may have risen over the last few decades, but still the aspect of care they appear to focus upon when things go wrong is a lack of compassion and its related constructs of empathy and altruism (Francis, 2013). Generally, when doctors and nurses see poor care taking place they protect the patient, but fail to report the colleague (Firth-Cozens, Redfern, & Moss, 2004). However, the Francis report (Francis, 2013), and a string of other UK examples, make it clear that far from failing to report while still helping the patient, some doctors in these organizations allowed real harm to come to patients on a continual basis, by ignoring widespread poor care or, at least, by failing to report. It has been suggested that modern medicine has led to a decline in altruism (Jones, 2002) and certainly empathy reduces during medical training (Wear, Aultman, Varley, & Zarconi, 2006). However, there are organizational, technical and political factors which have been shown to contribute to a decrease in morale, or to an increase in burnout, and it may be this aspect of dissatisfaction, rather than any intrinsic lack of compassion, that leads to substandard care.

All NHS organizations (and most others that deliver health around the world) are under considerable financial pressure, but the NHS survey makes it clear that some of them, at least in 2011, had working for them engaged staff with low stress, high satisfaction and good quality outcomes, while others suffered the opposite. This suggests that many aspects of poor quality care, including organizational culture (Mannion et al., 2005), are likely to be the result of poor management feeding down through staff. In addition, there are other aspects of modern healthcare that have been shown to affect the morale of staff and thus quality, particularly in terms of patient experience, and these involve:

All these potentially take doctors and nurses away from any altruistic ideals they had when they chose to enter their profession; certainly they make the provision of compassionate care, which involves time and dialogue, more difficult (Firth-Cozens & Cornwell, 2009). Not feeling they are providing quality care is one reason Casalino & Casson give for any feelings of dissatisfaction in doctors, and there may then develop a vicious circle from this to the creation of poorer quality, more dissatisfaction, and so on. As one doctor from the Mid Staffordshire Inquiry said (Newdick & Danbury, 2013):

Having adequate time to spend with patients and to discuss with colleagues any difficulties within the role must affect every aspect of quality, from mistakes to compassion, and working on ways to allow this is a critical and continual task for modern healthcare.

There seems little doubt that both our evidence-based and our common sense responses to the question posed by Casalino and Crosson, of whether we should care about doctor’s satisfaction, is indeed a resounding “Yes!”