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Personal Values of Family Physicians, Practice Satisfaction, and Service to the Underserved
B. Clair Eliason, MD;
Clare Guse, MS;
Mark S. Gottlieb, PhD
Arch Fam Med. 2000;9:228-232.
ABSTRACT
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Background Personal values are defined as "desirable goals varying in importance that serve as guiding principles in people's lives," and have been shown to influence specialty choice and relate to practice satisfaction. We wished to examine further the relationship of personal values to practice satisfaction and also to a physician's willingness to care for the underserved. We also wished to study associations that might exist among personal values, practice satisfaction, and a variety of practice characteristics.
Methodology We randomly surveyed a stratified probability sample of 1224 practicing family physicians about their personal values (using the Schwartz values questionnaire), practice satisfaction, practice location, breadth of practice, demographics, board certification status, teaching involvement, and the payor mix of the practice.
Results Family physicians rated the benevolence (motivation to help those close to you) value type highest, and the ratings of the benevolence value type were positively associated with practice satisfaction (correlation coefficient = 0.14, P = .002). Those involved in teaching medical trainees were more satisfied than those who were not involved (P = .009). Some value-type ratings were found to be positively associated with caring for the underserved. Those whose practices consisted of more than 40% underserved (underserved defined as Medicare, Medicaid, and indigent populations) rated the tradition (motivation to maintain customs of traditional culture and religion) value type significantly higher (P = .02). Those whose practices consisted of more than 30% indigent care rated the universalism (motivation to enhance and protect the well-being of all people) value type significantly higher (P = .03).
Conclusions Family physicians who viewed benevolence as a guiding principle in their lives reported a higher level of professional satisfaction. Likewise, physicians involved in the teaching of medical trainees were more satisfied with their profession. Family physicians who rate the universalism values highly are more likely to provide care to the indigent.
INTRODUCTION
DISSATISFACTION and "burnout" have been reported as serious problems for physicians.1 Some reports have stated that many physicians would not choose to practice medicine again if given a choice.2-3 The increased corporatization of medicine, prolonged training, and high expectations among patients and organizations seem to be contributing to this dissatisfaction. However, surveys indicate that many physicians remain quite satisfied with their work.4 Greater understanding of factors contributing to practice satisfaction should be helpful to physicians who face many challenges in their professional career.
Personal values are defined as "desirable goals varying in importance that serve as guiding principles in people's lives."5 We previously reported on the personal values of a group of exemplary family physicians and found a positive correlation between their ratings of benevolence and practice satisfaction; ie, those who were motivated to serve and help others were more satisfied with their work.6
In addition to practice satisfaction, it is probable that the personal values of physicians are associated with other important characteristics of practice. Limited access to medical care for the underinsured has been identified as a problem in our health care system.7 This situation exists despite an adequate physician workforce. Overspecialization, economic pressures of physicians, maldistribution of physicians, insurance, and even public policy have worked against many patients and have limited their access to medical care.7-8 Current market forces may be changing this, but access to care for many remains limited.9 There is a need to understand all factors that may limit access to medical care for patients, including the personal values of physicians. Are there personal values that are associated with physicians who extend care to the underserved? If so, what are these values?
In this study we examine the personal values of practicing family physicians, their professional satisfaction, and other characteristics of the practice, including the physician's willingness to care for the medically underserved. We hypothesized that there would be a positive association between the ratings of benevolence and practice satisfaction ratings among family physicians. We also hypothesized that family physicians who care for the underserved would have higher ratings of the self-transcendent values because self-transcendent values emphasize enhancing the welfare of others and oppose self-enhancing values. Furthermore, we wished to examine associations that might exist among the value-type ratings of family physicians, practice satisfaction, and a variety of practice characteristics such as location of practice (rural vs nonrural), type of practice, board certification, sex, and the age of the family physician.
MATERIALS AND METHODS
INSTRUMENT
The Schwartz values questionnaire and instrument has been validated in multiple cultures and has been described previously.5-6,10-11 The respondent rates the importance of 56 personal values from -1 (opposed to my values) to 7 (of supreme personal importance). The value types are defined by their principal motivation and by the specific represented values. Using value types rather than single values has increased the reliability of the instrument.5 A brief definition of each value type and its dimension is included in Table 1. The value types have been organized into a 2-dimensional structure, with the self-transcendent values dimension opposing the self-enhancement values dimension, and the conservation values dimension opposing the openness to change values dimension. Schwartz has shown a dynamic relationship between the value types.5-6 Actions taken in pursuit of some values may be compatible or incompatible with other value types.10, 12
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Table 1. Value Dimensions, Value Types, and Definitions
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The practice satisfaction portion of the survey consists of 3 questions on a semantic differential scale from 1 to 7. The stem of the 3 questions is "For me the practice of medicine is . . . " with available responses anchored by the following word pairs: bad-good, unfulfilling-fulfilling, and unenjoyable-enjoyable. In addition, we asked a series of questions about demographics, the respondents' involvement with teaching, the scope of their practice, organizational type of practice, payor sources of the practice, and date of last recertification.
SURVEY
We obtained from the American Academy of Family Physicians (Leawood, Kan) 1224 physician names and addresses that had been randomly drawn from 12 groups according to age group (25-39 years, 40-54 years, or 55-70 years), rural and nonrural status, and access to the underserved (high and low access, 102 physicians in each stratum). In the high-access group, 40% to 70% of the patients in the practice were represented by Medicare or Medicaid or were indigent, compared with the low-access group, in which 0% to 30% of the patients were represented by Medicare or Medicaid or were indigent. The confidential survey, along with a return envelope, was mailed to the physicians 3 times, about 6 weeks apart, in the summer of 1996. The second and third mailings were only to those who had not responded previously.
ANALYSIS
The 10 value types were computed by averaging the ratings for the associated specific values. Value-type ratings were adjusted to account for generally high or generally low rating tendencies according to the method described by Schwartz.5 A measure of satisfaction was constructed by averaging the responses to the 3 job satisfaction questions. These measures were combined, having previously shown a reliability of of .84 as determined by Cronbach  .6 For the analyses, physicians providing care to the underserved were defined as those whose sum of the percentage midpoints of the response categories for Medicare, Medicaid, and indigent patients was 40% or higher. Partial correlations were used to examine the association between value types and job satisfaction while controlling for rating tendency and confounding variables such as sex and age. Analysis of variance and regression were used to find the relationship between demographic and practice patterns and value-type ratings, as well as job satisfaction and care to the underserved. Statistical analyses were done with the Stata Statistical Software package.13
RESULTS
Seven hundred twelve usable surveys were returned (58% response rate). Response rates were not significantly different among the 12 sampling strata. Table 2 gives the demographics and practice patterns. The mean value-type ratings from highest to lowest and the correlation with practice satisfaction ratings are presented in Table 3. The benevolence value type was rated the highest and the power value type was the lowest. The association of the ratings of the benevolence value type with the ratings of practice satisfaction was statistically significant (P = .002, correlation coefficient = 0.14). Both the self-determination value type and the hedonism value type had a negative or inverse association with the practice satisfaction ratings that reached statistical significance (P = .04, correlation coefficient = -0.008 and P = .05, correlation coefficient = -0.01, respectively). The power value-type ratings were also negatively associated with practice satisfaction, but the association was not statistically significant.
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Table 2. Demographics of Family Physicians Surveyed
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Table 3. Mean Ranking of Value Types (Highest to Lowest) and Correlation With Practice Satisfaction
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About half (52%) of the family physicians surveyed provided 40% or more care to the underserved (Medicare, Medicaid, and indigent patients). After controlling for age and sex, rural practices (P = .005) and solo practices (P = .04) were significantly more likely to provide 40% or more care to the underserved. Tradition was the only value type to be significantly associated with service to the underserved (P = .02) when age, sex, solo practice, and rural practice were controlled. However, family physicians whose practice consisted of 30% or more indigent patients rated the universalism value type significantly higher than other family physicians (P = .03).
A variety of associations were found between value-type ratings, demographics, and practice patterns (see Table 4). Practice satisfaction was found to be associated with teaching medical trainees (P = .009). Those teaching medical trainees also rated the security (P = .004) and hedonism value types lower (P = .004) than those not involved in teaching.
We found significant value-type associations with both sex and age, although this was not the focus of our study. Men rated the conformity value type and the tradition value type higher than women (both P<.001). Women rated the universalism value type higher than men (P<.001). Older physicians rated the security value type higher (P<.001) and the stimulation value type lower (P = .002).
COMMENT
PRACTICE SATISFACTION
The positive association of the benevolence value type and practice satisfaction (P<.001, correlation coefficient = 0.14) is consistent with other research involving physician satisfaction and confirms our previous findings in exemplary physicians.6 In a work satisfaction survey of physicians and dentists, Lewis et al14 found that their service to humanity and direct patient care were highly satisfying elements of their professional life. Richardson and Burke15 studied stress and job satisfaction among physicians and found the major source of satisfaction to be their relationship with their patients and colleagues. Mawardi16 found high satisfaction among physicians associated with helping patients solve problems and developing relationships with patients and their families. Reams and Dunstone17 found in a qualitative study that physicians who focused mainly on patient care and less on the business aspect of medicine were more highly satisfied. Findings by Pastor et al18 were similar in a study of satisfaction among rural physicians, who derived most of their job satisfaction from patient care, while income was not a source of satisfaction.
The 67% of the respondents in our survey who participated in some teaching were as a group more highly satisfied (P = .009) than those who did not teach. Teaching of medical trainees is a helping activity that is consistent with the benevolence value type, although we did not find that those involved in teaching rated benevolence higher than those not involved in teaching. Hall et al19 found higher satisfaction among emergency room physicians who were involved with teaching residents. Lloyd et al,20 however, reported increased depression among Canadian emergency room physicians who were involved with medical education. Whether this was because they were overextended because of increased responsibilities is unclear.
The self-direction value type was the second highest-rated value type in our study, indicating that physicians value their ability to choose and be independent. Those family physicians who rated the values of self-direction highest were somewhat less satisfied (P = .04) with their practice of medicine. Many outside forces have imposed limitations on physicians' decision making. Those physicians who are able to accept many of these limitations and work within existing frameworks will likely be more satisfied. Previous studies indicate that too many regulations and restrictions lead to dissatisfaction among physicians.21-22
ACCESS TO CARE
The relationship between the personal values of physicians and access to care has been little explored in the medical literature. We hypothesized that physicians would provide more care to the underserved if they emphasized the self-transcendent value types compared with the self-enhancement value types depicted in the Schwartz values dimensions.5-6 In this values dimension structure, self-enhancing values oppose the self-transcendent value types.
The analysis of our data did show an association of family physicians whose patients were made up of more than 40% Medicare or Medicaid recipients or recipients and/or indigent patients and the traditional value type (P = .02). The traditional value type is represented by personal values, including the following categories: "humble," "accepting my portion in life," "devout," "respect for tradition," and "moderate." In the values dimension it is adjacent to the benevolence value type. A small group of family physicians in our survey whose practices consisted of more than 30% indigent patients rated the universalism value type higher (P = .03) compared with other family physicians. These findings provide general support to our hypothesis that self-transcendent value types will be rated higher by physicians who extend care to the indigent.
LIMITATIONS AND OTHER ASSOCIATIONS
The correlations between the value types and practice satisfaction are low and provide little explanation for the variation in practice satisfaction. Nevertheless, the associations found between practice satisfaction and the value types of benevolence, self-determination, and hedonism are consistent with other research and were statistically significant.
The value type and practice pattern associations found in Table 4 are interesting and possibly meaningful, but should be interpreted cautiously. About 5% of statistical association (P = .05) will occur by chance. Because we did not make prior hypotheses about specific associations in this part of the study, these associations must be interpreted more cautiously. Those associations with a lower P value (P<.005) are more likely to be significant. The negative associations between the high ratings of the value types of security and hedonism with the teaching of medical trainees is statistically significant (P = .004 and P = .006, respectively) and is consistent with the Schwartz values dimension.5-6 Teaching is generally an activity for which there is less personal economic gain and that involves actions that assist others. Thus, one might expect a negative association with the value types of hedonism and security.
A possible limitation in this study is the potential for self-reporting bias. A written score on a questionnaire does not necessarily translate to actual deeds. The confidentiality of the questions would weigh against this because the family physicians had no apparent personal gain. Schmitt et al11 have also demonstrated 6-week test/retest reliability of the value type indices, ranging from 0.70 to 0.90.
The definition of providing care to the underserved in this study resulted in an underserved group that included Medicare patients. The literature demonstrates that Medicare patients who are white, educated, upper class, and have supplemental insurance are not underserved.23 There is evidence, however, that signficant segments of the Medicare population are underserved. This includes the following: (1) those without supplemental insurance,23-24 (2) those from core urban and rural areas,23, 25-26 (3) minority elders such as African Americans,23, 25-26 (4) low-income, and sometimes middle-income Medicare recipients,23, 26-27 (5) elders whose mobility is impaired,28 and (6) those who are less well educated.23 Because we were not able to further identify these subgroups of Medicare patients, the access to care for this group may range from poor to good. For these reasons, our ability to find a significant relationship between the self-transcendent values and providing care to the underserved may have been reduced.
CONCLUSION
This study found associations between practice satisfaction and teaching medical trainees, as well as between practice satisfaction and ranking of the benevolence value type or the self-direction value type. Two value types were found to be associated with providing care to the underserved, universalism and tradition. These associations raise interesting questions as to cause and effect that cannot be answered definitively by a cross-sectional study such as this one. Does the involvement in teaching contribute to practice satisfaction or do satisfied physicians gravitate toward teaching? Are values mutable and, if so, would changes toward increased benevolence or self-direction increase professional satisfaction? Or could the problem of underserved populations be addressed by a shift in physician values toward universalism and tradition? These questions will challenge future researchers.
At this juncture, practicing physicians who are dissatisfied with their work may benefit by identifying values that are important to them and looking for positions that will allow them to follow those values. It might also behoove them to become more involved in providing leadership at all levels within health care organizations and thereby have a hand in shaping the environment in which they work.
Most would agree that we need more physicians who are satisfied with their work and who have motivation to be of service to their patients and to help provide care to the underserved of our society. This study suggests that such physicians would give high ratings to the self-transcendent values. Practicing physicians who are dissatisfied with their work may benefit by focusing on activities that involve helping and serving their patients, not on business and financial issues.
The current medical climate, in which practice guidelines, nonphysician case managers, and regulatory efforts are prevalent, will likely lead to increased dissatisfaction among physicians who rate the self-direction value type high. Medical organizations that employ physicians may find that their physician employees are more satisfied if they are not overregulated. Family physicians in turn need to be more assertive in providing leadership in health care organizations at all levels or they may find themselves increasingly dissatisfied as they lose their autonomy.
We have previously recommended6 and recommend again consideration of personal values in the selection of medical students, because practice satisfaction and the benevolence value-type rating have consistently shown a positive association at least in primary care specialties.
Finally, additional research would be helpful to further clarify the relationships that might exist among personal values, practice satisfaction, and the provision of medical care to the underserved.
AUTHOR INFORMATION
Accepted for publication July 16, 1999.
Reprints: B. Clair Eliason, MD, Department of Family and Community Medicine, University of Illinois College of Medicine at Rockford, 1601 Parkview Ave, Rockford, IL 61107-1897.
From the Department of Family and Community Medicine, University of Illinois College of Medicine at Rockford (Dr Eliason); and the Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee (Ms Guse and Dr Gottlieb).
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