Physician survey shows many ophthalmologists dissatisfied

A survey showed ophthalmology ranked among the specialties in which physicians are most dissatisfied.

SACRAMENTO, Calif. – Ophthalmology was among several specialties that ranked low in satisfaction in a national survey of physicians.

“Procedural” specialties such as ophthalmology, pulmonary medicine, otolaryngology and orthopedic surgery tended to rank relatively low in physician satisfaction in the survey, while “cognitive” specialties geriatrics ranked higher.

It should be noted that more than 70% of the physicians surveyed reported being satisfied or very satisfied with their careers. Less than 20% reported being dissatisfied overall.

In ophthalmology, 21% of respondents reported dissatisfaction with their careers. According to the data analysis, ophthalmology is 1.5 times more likely than family medicine to be dissatisfying. On the plus side, 41% of responding ophthalmologists reported being satisfied with their careers.

The study was performed by a group of researchers from the Center for Health Services Research in Primary Care here in Sacramento and from the University of California, San Francisco. The first author was J. Paul Leigh, PhD.

Career dissatisfaction is a concern not just for the physicians themselves but for their patients, the researchers said, because of long-term changes that dissatisfaction may bring.

“[First,] current dissatisfaction may forecast future declines in numbers of practitioners within a specialty. Second, dissatisfaction if prolonged, may result in health problems for the physicians themselves. Third, dissatisfied physicians may be more inclined to unionize and strike,” the report said.

Part of the reason for dissatisfaction in the surgical specialties may be the effects of Medicare payment reform and control by managed care.

“There has been considerable loss of income, autonomy and job openings for procedural specialties over the past 15 years with the advance of managed care,” the researchers said.

Several studies have explored whether physician dissatisfaction has affected the quality of health care, but no previous study had ranked physicians’ satisfaction across medical specialties, Dr. Leigh said in an interview.

To expand on the study by Dr. Leigh and colleagues, Ocular Surgery News asked ophthalmologists and a practice management experts for their views on the issue of career satisfaction. Those interviewed agreed that dissatisfaction in ophthalmology may stem from changes in reimbursement and practice patterns, and that for some physicians unattained expectations may be an issue. They noted that dissatisfaction is related more to problems affecting health care in general than to ophthalmology in particular.

Reasons for dissatisfaction

Dr. Leigh and colleagues analyzed data from the Community Tracking Study (CTS) of more than 12,000 physicians in 1996 and 1997. The data are meant to be representative of physicians within the country.

Of the 341 ophthalmologists surveyed, 41.4% said they were very satisfied with their careers in medicine, 21% were dissatisfied, and 37.6% had other responses.

“Ophthalmology [was ranked] dissatisfying as compared to the other 33 specialties. Few other specialties had a dissatisfaction rate as high as 21%,” Dr. Leigh said.

To assess how physicians ranked their specialties, the researchers performed two analyses.

Dr. Leigh explained: “One analysis was done of doctors who answered ‘very satisfied’ vs. all other responses. A binary (0,1) variable was created. A second analysis was done on doctors with either ‘somewhat’ or ‘very’ dissatisfied vs. all other responses. A different binary variable was created for that analysis.”

Other variables measured included age, sex, whether the physician was board-certified, whether trained in a foreign medical school and how much experience the physician had with managed care.

Specialties were ranked in comparison to family practice. Ophthalmology was ranked more often as dissatisfying when compared against family medicine, Dr. Leigh noted.

AAO study similar

The American Academy of Ophthalmology has conducted surveys that measured satisfaction among its members in 1998, 1999 and 2001. The data were assessed by Harry Zink, MD, AAO secretary for member services. They were prepared for internal use by the AAO and have not been formally published.

Dr. Zink noted that the 1999 AAO survey results are “fairly close” to Dr. Leigh’s study in response to the question, “Are you happy with your practice situation?” Of the 732 AAO members who responded, 19% rated themselves as dissatisfied and 45% rated themselves as very or extremely satisfied.

“The study in the Archives of Internal Medicine and ours were done before the recent large cuts in Medicare. … Both may not be completely valid today,” Dr. Zink said.

He noted that the reasons for dissatisfaction that appear in the AAO survey are the same throughout medicine. Ophthalmologist respondents ranked certain problems as practice concerns. Reimbursement levels topped the list at 90%. High practice costs, billing problems, keeping current with insurance plan guideline and rule changes, and payment denial by managed care plans were also high on the list. Malpractice concerns were ranked fairly low in 2001, although this has since become a more urgent concern. (See accompanying chart on page 50.)

Career satisfaction and age

In the study by Dr. Leigh and colleagues, satisfaction was linked to age and income regardless of specialty. Physicians younger than 35 years and those 65 and older had a higher tendency to rate their specialty as satisfying.

Herve M. Byron, MD, Practice Management Section Editor for Ocular Surgery News, said career satisfaction in ophthalmology is affected by age. He said young ophthalmologists are often unaware of the challenges they face after residency.

“The same situation exists in the ophthalmic marketplace as in all other areas of employment – too many applicants for too few jobs. Opening a solo private practice in today’s economy, with the competitive eye care environment and high initial investment, is unwise unless one goes into an area that is in real need of an ophthalmologist. Thus, for the young ophthalmologist, this discouraging realization causes disappointment,” Dr. Byron said.

For middle-aged ophthalmologists, Dr. Byron said dissatisfaction is often caused by the economic factors mentioned by Dr. Leigh and colleagues. Physician net incomes have decreased, managed care has more control over their practices, Medicare payments have decreased, and malpractice premiums have increased.

Dr. Byron said depression can result. “The incidence of suicide among ophthalmologists is near the top of the list among all physicians,” he said.

For the senior age group, Dr. Byron said many ophthalmologists opt for early retirement for many of the same reasons. Many, however, prefer not to retire completely.

“Their personal ratio of satisfaction to aggravation has changed profoundly during the last decade. They feel comfortable about transitioning to a different challenge rather than completely retiring,” he said. “This is distinctly different from the past when physicians usually practiced until they were unable to do so.”

Unmet expectations

Richard L. Lindstrom, MD, in private practice in Minneapolis and Chief Medical Editor of Ocular Surgery News, said dissatisfaction among ophthalmologists is linked to unmet expectations. He too, cited the increased influence of managed care, Medicare cuts and rising malpractice premiums as prime reasons for career dissatisfaction.

“I believe midcareer ophthalmologists are less satisfied with their careers than they were 30 years ago when I started in ophthalmology,” Dr. Lindstrom said. “The senior ophthalmologists seem to be happier with their careers, and the younger ones seem fairly happy with their choice. Just like with our patients, the chief cause of dissatisfaction is usually unrealistic expectations.”

The expectations of midcareer ophthalmologists, with regard to income and the health care system, were different when they entered the specialty, Dr. Lindstrom said. Medicare and managed care have made it more difficult for some to practice, thus changing their outlook.

“The typical middle-aged ophthalmologist anticipated a more financially rewarding career with less third-party, government interference and paperwork hassles. Most also expected less competition and more appreciative patients with less concern for malpractice,” Dr. Lindstrom said. “They are surprised how litigious our society has become and how competitive the field has become with less collegiality. All of these add up to some level of disappointment.”

Medicare’s surgeon fee for cataract surgery has declined from $1,500 or $2,000 15 years ago to $500 to $600 today, Dr. Lindstrom noted. Surgeons also did not anticipate interference from managed care plans in the treatment of their patients, he said.

Dissatisfaction and income

In the study by Dr. Leigh and colleagues, physicians with incomes below $100,000 were more likely to rate their careers as dissatisfying.

Medicare cuts have especially decreased ophthalmologists’ incomes, Dr. Zink said.

“Dissatisfaction has increased in the last 2 years among doctors in general, and ophthalmologists are not immune. I don’t think it’s any worse for us than for many other specialties,” Dr. Zink said.

Jonathan C. Javitt, MD, MPH, OSN Section Editor for Epidemiology and Health Care Delivery, said the specialty has been especially affected by changes in health care.

“Many ophthalmologists have retired early, moved into industry or downsized their lifestyle. Others who used to make a living in glaucoma or neuro-ophthalmology have been forced to move into refractive surgery and similar pursuits to keep things going. There is a pervasive feeling that ophthalmology is much less valued as a specialty than it was 20 years ago,” Dr. Javitt said.

For Your Information:

• Herve M. Byron, MD, can be reached at (212) 249-8494; e-mail: byronmd@rcn.com,
• Jonathan C. Javitt, MD, MPH, can be reached at Health Directions, 7201 Wisconsin Ave., Ste. 620, Bethesda, MD 20814; (301) 654-8999; fax: (301) 951-5349; e-mail: jjavitt@healthdirections.net.
• J. Paul Leigh, PhD, can be reached at the Center for Health Services Research in Primary Care, PSSB Suite 2500 UCD Medical Center, Sacramento, CA 95817; e-mail: jpleigh@epm.ucdavis.edu.
• Richard L. Lindstrom MD, can be reached at Minnesota Eye Associates, 710 E. 24th St., Suite 106, Minneapolis, MN 55404: (612) 813-3600; fax: (612) 813-3660; e-mail: rllindstrom@mneye.com.
• Harry Zink, MD, can be reached at 3519 Friendville Rd., Wooster, OH 44691; (330) 345-7200; fax: (330) 345-8029; e-mail: weyezink@aol.com.

References:

• Leigh, JP et al. Physician career satisfaction across specialties. Arch Intern Med. 2002;162:s1577-s1584.
• Zink, Harry. 2001 Membership survey American Academy of Ophthalmology.