Practice Environments and Job Satisfaction in Patient-Centered Medical Homes

INTRODUCTION

Primary care can improve health outcomes and the overall performance of the health system.^1,2 Primary care physicians, however, report lower job satisfaction than other physicians,³ and job dissatisfaction has been identified as a potential cause and result of quality problems in physician practices.⁴ Improving the practice work environment may enhance primary care job satisfaction.^4–7

In theory, patient-centered medical homes (PCMHs, or medical homes) improve job satisfaction by promoting better work environments, increasing the quality of care, and enhancing practice resources.^7–9 In theory, medical homes combine the 4 principles of primary care (first contact with the health system, continuity of care with a personal physician, a focus on the whole person, and coordination of care across the continuum), with an emphasis on care that is patient centered, team based, evidence based, and optimized through information technology.¹⁰ The ability of medical home interventions to achieve their goals, including improved professional satisfaction, is subject to empirical evaluation, however.^11,12

Better job satisfaction (specifically, lower burnout) has been reported in a single-practice pilot project conducted within the Group Health Cooperative.¹³ These findings have not yet been replicated elsewhere, and the specific factors that may mediate medical home effects on job satisfaction have not been identified. To address these gaps, we focused our study on 3 main goals. First, we evaluated longitudinal effects of 2 medical home pilot projects on multiple dimensions of practice environment and job satisfaction. Second, at the conclusion of these projects, we explored cross-sectional relationships between dimensions of practice context and clinician and staff satisfaction, stress, burnout, and intention to leave. Third, we sought to understand the benefits and challenges of medical home transformation using qualitative methods.

Published research identifies 3 main aspects of the practice environment affecting job satisfaction in primary care. First, clinicians and staff are more satisfied when their organizational cultures emphasize quality and communication.^4,9,14–16 Second, a chaotic office atmosphere is associated with job dissatisfaction and stress.^6,7 Third, clinicians and staff are less satisfied when they face difficulties in providing safe, high-quality care.^4,9

Our study addressed 2 related hypotheses (Figure 1). First, medical home pilot practices would report improvements over time in practice environment and job satisfaction. Second, at each pilot project’s conclusion, practices with better practice environments (ie, lower levels of chaos and difficulty providing safe, high-quality care) would have greater job satisfaction and lower stress, burnout, and intention to leave.

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Figure 1

Conceptual framework.

METHODS

RESULTS

Survey response rates were 61% at baseline and 80% at 30 months. (The sample size changed between time points because of the hiring of care coordinators and considerable growth in one of the practices.) Practice and respondent characteristics at baseline are summarized in Table 1.

DISCUSSION

In our study of medical home pilot projects in Rhode Island and Colorado, we found inconsistent changes in job satisfaction. For the 2 pilot projects combined, there were no statistically significant changes in job satisfaction; however, there was significant improvement in job satisfaction in the Rhode Island project and a modest, nonsignificant decline in satisfaction in the Colorado project. What explains these different results? First, baseline levels of job satisfaction were higher in Colorado, leaving less room to improve. Second, our qualitative data suggest that Colorado’s transformation work was more intensive, which could have created a “worse before better” scenario, like that described in evaluations of the TransforMed National Demonstration Project.²¹

Our findings suggest that the theoretical benefits of medical homes for clinicians and staff professional satisfaction may have been opposed by the stresses of transformation. For example, practices exhibited increasing emphasis on quality and fewer problems in providing safe, high-quality patient care. Such changes would be expected to enhance satisfaction; however, other trends seen among the practices—notably, greater office chaos—may have prevented greater job satisfaction from taking hold. Moreover, strategies aimed at reducing stress, such as reduced panel sizes, longer patient visit times, and dedicated time for care coordination (which have been featured in some medical home interventions¹³) were not included in the interventions we studied. These and similar transformation components may be necessary to foster better clinician experiences on a short timeline.

In general, fee-for-service payment does not compensate primary care physicians for non–visit-based care or coordination of care.²² The incentives provided in the pilot projects we studied may have been insufficient to encourage physicians to reduce office visit volumes while redesigning their practice. Broader payment reform may be essential for enabling transformation without increasing office chaos.

Finally, baseline levels of stress, burnout, and intention to leave were slightly lower than those previously found by Linzer et al.⁷ The practices we studied volunteered for early medical home pilot projects and so may have been better off at baseline than other practices, leaving relatively little room for improvement.

Our cross-sectional results suggest how medical home interventions can increase their chances of improving job satisfaction in primary care. Interventions that reduce difficulties in providing safe, high-quality care without increasing office chaos may offer the best chance of improving job satisfaction. The associations we observed between a quality emphasis, fewer quality problems, and job satisfaction corroborate research showing associations between greater engagement in quality-improvement activities, higher physician satisfaction, and less work-life stress.⁹ Similar to Hall et al,²³ we found that a culture of open communication was associated with greater job satisfaction and less burnout. As suggested by other studies,⁷ our cross-sectional analysis found that greater office chaos was a key driver of dissatisfaction. Finally, we found associations between greater emphasis on electronic communication and increased stress and burnout, similar to findings of other recent studies.^4,24

Our study has limitations. First, our sample size was small, limiting the power to detect longitudinal effects of project participation. Second, the observational nature of both our longitudinal and cross-sectional analyses limits causal inference. Third, no control practices were surveyed or interviewed about job satisfaction, so we cannot exclude the possibility that our longitudinal results are attributable to changes in primary care practice other than a medical home intervention. Fourth, practices in our study volunteered to be pilot project sites, and our findings may not generalize to later adopters of new practice models. Fifth, the 2 pilot projects we studied were administered by different entities and had multiple different intervention components, limiting our ability to compare the interventions directly on any single component. Sixth, we measured global job satisfaction only, limiting our ability to make inferences about subdimensions of job satisfaction. Finally, we interviewed only practice leaders, and this sampling may have yielded an incomplete or skewed perception of advances in the practice environment (ie, a rosier picture than front-line clinicians would paint).

Improving job satisfaction in primary care practices is an important goal of medical home interventions. Our findings suggest that medical home transformations that emphasize quality and open communication while minimizing office chaos may offer the best chances of improving job satisfaction.