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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, MEMO (Minimizing Error, Maximizing Outcome) Investigators
[+] Article, Author, and Disclosure Information

For a list of the MEMO investigators, see the Appendix.

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.

Presented in part at the 31st Annual Meeting of the Society of General Internal Medicine, Pittsburgh, Pennsylvania, 11 April 2008.

Grant Support: By the Agency for Healthcare Research and Quality (grant 5 R01 HS011955).

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.

Reproducible Research Statement:Study protocol and data set: Not available. Statistical code: Available from Dr. Brown (rlbrown3@wisc.edu).

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@medicine.wisc.edu.

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.

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.

Dr. Bobula: University of Wisconsin, Department of Family Medicine, 777 South Mills Street, Madison, WI 53715.

Dr. Brown: University of Wisconsin–Madison School of Nursing, H6/273 Clinical Sciences Center, 600 Highland Avenue, Madison, WI 53792.

Dr. Varkey: Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153.

Dr. Man: Rush Medical College, 1901 West Harrison Street, Chicago, IL 60612.

Dr. McMurray: William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI 53705.

Dr. Maguire: Medical College of Wisconsin, General Internal Medicine, Froedert East Office Building, Suite 4200, 9200 West Wisconsin Avenue, Milwaukee, WI 53226.

Dr. Horner-Ibler: Bread of Healing Clinic, 1821 North 16th Street, Milwaukee, WI 53205.

Dr. Schwartz: Veterans Affairs New York Harbor Healthcare System, 423 East 23rd Street, Suite 15N, New York, NY 10010.

Author Contributions: Conception and design: M. Linzer, L.B. Manwell, E.S. Williams, B. Man, J.E. McMurray, B. Horner-Ibler, M.D. Schwartz.

Analysis and interpretation of the data: M. Linzer, L.B. Manwell, J.A. Bobula, R.L. Brown, J.E. McMurray, M.D. Schwartz.

Drafting of the article: M. Linzer, L.B. Manwell, E.S. Williams.

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.

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.

Provision of study materials or patients: L.B. Manwell, A.B. Varkey, B. Man, A. Maguire, B. Horner-Ibler, M.D. Schwartz.

Statistical expertise: E.S. Williams, J.A. Bobula, R.L. Brown.

Obtaining of funding: M. Linzer, L.B. Manwell, E.S. Williams.

Administrative, technical, or logistic support: M. Linzer, L.B. Manwell, A.B. Varkey, J.E. McMurray, B. Horner-Ibler.

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.

Ann Intern Med. 2009;151(1):28-36. doi:10.7326/0003-4819-151-1-200907070-00006
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The primary care workplaces we studied involve many challenges for practicing physicians. Work conditions, including workflow (time pressure and a chaotic work pace), job characteristics (lack of work control), and poor organizational culture were strongly associated with adverse physician reactions. Some work conditions were associated with poorer patient care, but the associations were inconsistent. Adverse physician reactions, such as dissatisfaction, stress, and burnout, were not associated with poorer patient care. Our findings may explain current difficulties in recruiting and retaining primary care physicians but leave open the question of whether adverse work conditions influence health care quality and safety.

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Submit a Comment/Letter
Dance marathon of the new millenium
Posted on July 6, 2009
Lynn Bentson
Samaritan Health Physicians
Conflict of Interest: None Declared

So, if PCP's DO mess up , they should not be paid (eg paid enough to decrease the number of visits and phone calls they have daily) , they don't deserve it. If they DON"T mess up then everything is fine and we don;t have to improve their admittedly chaotic lives by paying them enough to hire some help or cut down on visits /day.

One response to the primary care shortage, and the one that our admin has taken is to just force the remaining docs to take more patients . Perfect--we do more (unpaid) care by phone, patients are resaonably happy, no money wasted on admittedly fruitless recruiting, and the whole problem is swept under the rug. If I finally kill someone by accident as I am charting at 11pm nightly, and the work flow is improved its too high a price.

When I was a computer programmer my products seldom crashed and had to go therough only a few trial versions. I was a prompt and effecient waitress, and a polite receiptionist. I even did a tidy ,low-error job stuffing circuit boards and wiring amplifiers . Now the fact that I can't do a workman-like job is not because of my choices. Its that the demands are set by business people who think more visits =more revenue , its better. That even means the visits you have to schedule because the patient couldn't get an appt and went to urgent care . My favorite description was "physicians are your sales force" meaning without them patients wouldn't buy the profitable stuff . The guy was serious , unfortunately .

Conflict of Interest:

None declared

Primary care: Workforce not working conditions need to change
Posted on July 9, 2009
Edward J. Volpintesta
No Affiliation
Conflict of Interest: None Declared

I doubt seriously that the authors' suggestion of the patient- centered medical home will do much to improve the chaotic and dissatisfying professional lives that most primary care physicians endure. In fact, the medical home will increase the mind- numbing scut work that constantly interrupts their work flow and composure.

The authors use phrases like "poor organizational culture", "chaotic work pace", and "time pressure" to describe some of the negative factors that make primary care physicians' lives unfulfilling professionally, but there are many others and the medical home will only make them worse. Why? Because the typical primary care doctor's life is increasingly less occupied with direct medical care. Instead their days have become one long disconnected and frenetic attempt to balance patients' demands with an ever-increasing amount of side-issues like dealing with insurers, home health agencies, and pharmacies. These and many other issues create endless interruptions that stultify and fluster primary care doctors.

Many patients rely on their primary care doctors for tracking down X- ray reports, scans, and lab tests that were done by specialists to whom they were sent. Many CAT scans disclose "incidentalomas" that require phone calls and further work-up and further consultations (this is one area that is time-intensive and the satisfaction pay- back is minimal).

Via their constantly running fax machines primary care doctors receive all the lab reports and imaging studies that other doctors have ordered. This forces them to read and react to innumerous bits of information throughout the day. In my two-doctor group I spend about 30- 45 minutes every day before I even see my first patient going over all the reports that have come in during the night. Not to mention to mention those that come throughout the day.

All of the scut work, euphemistically called coordinating work, that other health care workers enjoy doing will now being laid at the door step of primary care physicians, once it is known that they are getting paid for the added work. But no amount of money will ever make up for the added stress and confusion and chaos that the medical home will bring. Even if they are paid more,primary care physicians will have to hire more ancillary staff to help deal with the work which will nullifies any financial benefits.

The point is that what primary care needs is more man power to handle the load. Shortening the training period of primary care doctors by less intense exposure to the basic sciences and shortening the college years so that their training reflects what the reality of medicine requires of them. Another is using nurse practitioners to act independently in some primary care areas. Finally, some specialists could very well act as primary care doctors for some of their patients(this will give them a great opportunithy to experience primary care first-hand). All of these plans could increase the primary care work force.

Primary care physicians' quiet desperation is nothing to laugh at. The solution requires bold innovation. Organizational changes have their place, but only by increasing the primary care workforce will the work load, the stress, and the chaos that exists come under control.

Conflict of Interest:

None declared

Hamster Health Care
Posted on July 19, 2009
Caroline Poplin
Conflict of Interest: None Declared

When I read academic proposals for primary care, I often wonder: Why don't they ask us?

I am a general internist. I practiced primary care in what today would be called an "Accountable Healthcare Organization," the favored delivery system of many in Washington. My situation was exactly as described by Linzer, et al.(1) and Professor Mechanic(2); chaotic and frantic, with numerous, ever-changing requirements imposed by others, without input from us. The killer requirement was productivity; so many patients a day. It was a turbo-charged assembly line. If I was not seeing a patient, as far as the system was concerned, I was not working. There was no time to consult with specialists about mutual patients. Everything other than office visits"”telephone calls, emails, reviewing patient records and reports, answering questions, visiting my hospitalized patients"”was pushed into my own time, after work.

Thus, even though our system was not financed by fee-for-service, and we were all on salary (so no incentive for needless "volume"), we pushed tasks into office visits whenever possible, to avoid half again as much work after the workday as during it.

Productivity requirements defeat the whole idea of substituting quality for quantity. To improve quality, the system has to trust physicians to decide the best use of their time: sometimes calling patients, consulting with colleagues, or reviewing records, is more efficient than additional office visits(3). Gordon, et al.(4) demonstrate what happens when physicians are required to see patients continuously; they sometimes miss important results. And this in a system with a first-rate EMR, and, per Mechanic(2), contented physicians (although he offers no evidence for this).

However appealing the AHO may appear in theory, it is the exact opposite of what patients and physicians seek; instead, they want more time together, so that the physician can conscientiously care for the whole patient, and the patient learns to trust the physician. Together, physicians and well-to-do patients have developed a simpler, more humane alternative, the "concierge" practice. We could finance concierge practices for everyone by reprogramming money from expensive procedures, tests and imaging, and holding specialists (who understand them best) accountable for recommending them more judiciously.

Until then, physicians will resent systems that do not respect them as professionals(5), and will continue to vote with their feet. Sick patients may still find themselves handed off like widgets.

Medicine is more than metrics. We are helping people, not manufacturing health.


1. Linzer M., Manwell LB, Williams ES, Bobula JA, Brown RL, Varkey AB et al; MEMO Investigators. Working conditions in primary care: physician reactions and care quality. Ann Intern Med. 2009;151:28-36.

2. Mechanic D. The Uncertain Future of Primary Medical Care. Ann Intern Med. 2009;151:66-67.

3. Poplin C. Productivity in primary care: work smarter, not harder. Arch Intern Med. 2000;160:1231-1233.

4. Gordon JR, Wahls T, Carlos RC, Pipinos II, Rosenthal GE, Cram P. Ann Intern Med. 2009;151:21-27.

McDonald R, Roland M. Pay for performance in primary care in England and California: comparison of unintended consequences. Ann Fam Med. 2009;7:121-127.

Conflict of Interest:

None declared

The primary care treadmill:can nurse practitioners and physician assistants help?
Posted on July 25, 2009
Edward J. Volpintesta
No Affiliation
Conflict of Interest: None Declared

Dr. Caroline Poplin's rapid response (Hamster Health care, July 20) merits a comment.

First, although the concierge mode of practice, as she suggested is successful with well-to-do patients, extending it to everyone would be almost impossible because there are not enough primary care doctors around to do the job.

Second, she mentioned an article in which a large number of clinicians using electronic medical records had not recorded that an abdominal aortic aneurysm had been reported by a radiologist. Her point about primary care doctors who are simply seeing too many patients in order to make a living is an excellent one. Missing an important piece of clinical information as a result of information over load could also be generalized to other imaging tests and laboratory results as well.

The point is that many primary care doctors are simply working too hard to do a good job. And working too hard and seeing too many patients increases their chances of missed diagnoses and increased medical liability, besides robbing them of job satisfaction and their patients of "encounter satisfaction."

Perhaps if advanced practice nurses and physician assistants were to play larger and more independent roles in delivering some aspects of primary care it might work both of these problems would be alleviated. But the political challenges are immense.

Conflict of Interest:

None declared

Physician adverse reactions may not associate with technical quality of care.
Posted on August 6, 2009
Makiko Ozaki
Kitano Hospital The Tazuke Kofukai Medical Research Institute
Conflict of Interest: None Declared

In the article (1), Linzer and colleagues mentioned that their findings were inconsistent with previously reported the relationships between adverse outcomes of providers and lower quality of patient care. However, the inconsistency seems reasonable because the component of quality measured by Linzer and colleagues (processes and outcomes in terms of technical quality of care) differed from that in the previous studies (interpersonal quality of care).

In his conceptual model, Donabedian (2) defined three components of quality: technical quality of care, interpersonal quality of care, and amenities. Technical quality of care describes the extent to which the use of health care services meets predefined standards of acceptable or adequate care relative to need, i.e. patient receipt of the recommended care. Interpersonal quality describes the characteristics of interaction between provider and patient. Although most of the previous studies describing the associations between adverse physician reactions and the quality of patient care have used elements of interpersonal care, such as patient satisfaction, as the quality of care measures, the relationship between physician reactions and technical quality of care has not been established.

Our recent study which examined the relationship between job satisfaction of hospital physicians in Japan and the technical quality of care, with an emphasis on process qualities as measured by quality indicators, also showed no association between physician job satisfaction and the technical quality of care(3). Although work conditions of Japanese hospital physicians are much poorer than those of the physicians in the US, they have not translated their dissatisfaction into lower-quality of technical care so far. However, the increases of hospital physician resignations have resulted in a number of Japanese hospitals curtailing or failing to provide services.

The physicians are likely to leave in silence from the dissatisfied, stressful workplaces rather than compromising the technical quality of care they provide.


1. Linzer M, Manwell LB, Williams ES, Bobula JA, Brown RL, Varkey AB, et al. Working conditions in primary care: physician reactions and care quality. Ann Intern Med. 2009 Jul 7;151(1):28-36, W6-9.

2. Donabedian A. Explorations in Quality Assessment and Monitoring. Ann Arbor, MI: Health Administration Pr.; 1980.

3. Utsugi-Ozaki M, Bito S, Matsumura S, Hayashino Y, Fukuhara S. Physician job satisfaction and quality of care among hospital employed physicians in Japan. J Gen Intern Med. 2009 Mar;24(3):387-92.

Conflict of Interest:

None declared

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