Job satisfaction among Norwegian general practitioners

Abstract

Objective. To explore the level of job satisfaction among general practitioners (GPs) and to compare it with that of hospital doctors. Design. Postal questionnaire among Norwegian doctors in 2002 and similar data from 1994 and 2000 for most of the respondents. Material. A total of 295 GPs out of 1174 doctors completed the questionnaire (73% response rate). Main outcome measures. Self-reported levels of job satisfaction according to the Job Satisfaction Scale (JSS). Results. Norwegian GPs reported a high level of job satisfaction with a mean score on the JSS of 52.6 (10 is minimum and 70 maximum). The reported level of satisfaction was highest for their opportunities to use their abilities, cooperation with colleagues and fellow workers, variation in work, and freedom to choose own method of working. The GPs’ level of job satisfaction remained stable in 1994, 2000, and 2004 in spite of major health reforms. GPs report a higher level of job satisfaction than hospital doctors. Conclusions. In spite of international discussions on unhappy doctors and doctors’ discontent, Norwegian GPs do report a high and stable level of job satisfaction.

• Discontent
• general practitioner
• job satisfaction
• well-being

According to editorials and reviews in major medical journals there seems to be a general agreement that job satisfaction among doctors is declining [1–3]. Physician discontent has been explained by growing public and patient expectation, increasing pressure on time and cost containment, and regulatory controls threatening doctors’ professional autonomy [4]. The empirical evidence for this statement is, however, weak [5], [6].

If better informed and more demanding patients and a consumerist orientation in society lead to frustrated doctors, general practitioners, working in the first line of care, should probably be the most affected group. So how are primary care physicians doing?

American studies show that doctors’ level of job satisfaction and changes in satisfaction vary greatly among regions and according to organizational models of health care. Landon et al. found no differences in career satisfaction between primary care and specialist physicians, but significant geographic variations [5]. Shearer & Toedt found unhappiness with the current healthcare system among American family physicians and a decline in career satisfaction from 1996 to 1999 [7]. General practitioners in Massachusetts showed a decline in satisfaction with most areas of practice between 1986 and 1997, and so-called open-model physicians (accepting patients from multiple health plans and insurers) were less satisfied than the others [8]. Physicians in solo and two-physician practices were less satisfied than physicians in group practices [9], [10].

Australian general practitioners report a high level of job satisfaction. Rural GPs have significantly higher job satisfaction scores than urban GPs, in particular as regards autonomy [11]. The areas of greatest satisfaction among Australian rural GPs were their relationship with patients, clinical autonomy, and life in small communities [12].

In British general practice job satisfaction declined from 1987 to 1990 and then improved from 1990 to 1998. The decline was probably caused by expectations prior to the National Health Service reform of 1990/1991 which was viewed as an attack on GPs’ independence and autonomy. The recovery in GP job satisfaction in the UK during the 1990s is interpreted as an adaptation to change [13].

The aim of this study is to explore the level of job satisfaction among general practitioners in Norway, to analyse changes over time and to compare GPs’ level of job satisfaction with hospital doctors.

Material and methods

An extensive research programme on doctors’ health and working conditions has been running in Norway over the last 10 years [14]. As part of this study a representative reference panel of Norwegian doctors has been surveyed on a regular basis. This group of 1606 Norwegian doctors was sent an 11-page questionnaire in June 2002 with one reminder in August, including several questions on subjective well-being:

• They were asked to rate on a scale from 1 (extremely dissatisfied) to 7 (extremely satisfied) the question: “When you think about your life at the moment, would you say that by and large you are satisfied with life or are you mostly dissatisfied?” Many of the same doctors had also answered this question in 1994. The distribution of responses to these questions is sufficiently close to normal to use parametric tests.

• On a three-point scale (less satisfied, as satisfied, more satisfied) they were asked to compare their own job satisfaction with the one they believe applies to nine other professional groups.

• Ten different aspects of working conditions (responsibility, variation, collaborators, physical working conditions, possibility of using own skills, overall job satisfaction, choice between work methods, positive feedback for good work, pay, and working hours) make up the job satisfaction scale (JSS) which has been developed by Warr et al. [15]. Each item was rated on a seven-point scale from 1 (extremely dissatisfied) to 7 (extremely satisfied) and added up to a JSS scale with a theoretical range from 10 (dissatisfied with job) to 70 (satisfied with job). The distribution of the JSS summary score is close to normal, whereas some of the single items have a rather skewed distribution. JSS results were also available for 1994 and 2000 for most of the respondents.

Based on reported main occupation the doctors were classified as general practitioners, hospital doctors and others (public health doctors, administrators, researchers etc).

Comparisons of the variables over time were made with paired samples t-tests and between groups with the Wilcoxon signed-rank test or Student's t-test.

Results

A total of 1174 doctors completed the questionnaire (369 women [31%], 805 men [69%]) which gave a response rate of 73%. Of these, 295 were general practitioners and 514 were hospital doctors.

In total, 49% of the GPs reported a very high level of life satisfaction (6 or 7 on a scale from 1 [extremely dissatisfied] to 7 [extremely satisfied]). The mean was 5.26 (95% confidence interval 5.12–5.40). The mean values for 227 of the GPs who answered the same question both in 1994 and 2002 were 5.29 and 5.30 respectively (p = 0.919, paired samples t-test).

With the exception of aviation pilots and lawyers, who were thought to have a similar level of job satisfaction, most of the GPs thought themselves to be more satisfied with their job than other professional groups (Table I).

Table I.  How satisfied are you with your work compared with how satisfied you believe other professional groups to be? Answers given by GPs as percentages for each professional group (n = 295).

Profession	Less satisfied	As satisfied	More satisfied
Lawyers	12	63	26
Clergymen	5	42	53
Teachers	7	18	75
Aviation pilots	18	60	22
Psychologists	6	58	36
Nurses	6	25	70
Craftsmen	11	58	32
Farmers	8	39	54
Policemen	5	37	58

The mean value on the Job Satisfaction Scale was 52.6 for the GPs and 50.2 for hospital doctors (t = − 3.62, p < 0.001) The level of satisfaction among GPs was highest for their opportunities to use their abilities, cooperation with colleagues and fellow workers, variation in work, and freedom to choose own method of working. Lowest satisfaction score was reported for working hours (Figure 1). GPs reported significantly higher levels of satisfaction than hospital doctors for physical working conditions, recognition for good work, freedom to choose own method of working, and payment. Hospital doctors reported a higher level of satisfaction with the given amount of responsibility (Table II).

Figure 1.  Box-plots of the ten items of the Job Satisfaction Scale showing the median, interquartile range, outliers (o), and extreme cases (*). GPs only (n = 291).

Table II.  Mean ranks, Z-values and p-values (Mann–Whitney U-tests) for comparisons between the 10 items of the Job Satisfaction Scale, and means and t-test of the JSS sum score. Each item is scored on a scale from 1 (extremely dissatisfied) to 7 (extremely satisfied) by general practitioners and hospital doctors.

	General practitioners (n = 291)	Hospital doctors (n = 509)	Z-value	p-value
Amount of responsibility given	431.5	382.8	−3.00	0.003
Variation in work	383.5	410.2	−1.64	0.102
Colleagues and fellow workers	382.7	410.7	−1.72	0.085
Physical working conditions	336.9	436.9	−6.01	<0.001
Opportunities to use abilities	380.2	412.1	−1.95	0.051
Overall job satisfaction	395.7	403.2	−0.47	0.640
Freedom to choose own method of working	351.0	428.8	−4.74	<0.001
Recognition for good work	379.7	412.4	−1.97	0.049
Rate of pay	314.3	449.8	−8.13	<0.001
Working hours	397.8	402.0	−0.25	0.80
	mean	mean	t-value	p-value
Job Satisfaction Scale	52.6	50.2	−3.62	<0.001

Job satisfaction data was available for 1994 and 2000 in addition to 2002 for 188 of the GPs and 321 of the hospital doctors. The level of job satisfaction among GPs has been stable over this period and at all three times higher than for hospital doctors as shown in Figure 2.

Figure 2.  Job Satisfaction Scale – mean values (with 95% confidence intervals) in 1994, 2000, and 2002 for general practitioners (n = 188) and hospital doctors (n = 321)

Discussion

Doctors’ satisfaction and dissatisfaction vary across specialties [16]. Knowledge of GPs’ level of job satisfaction is of interest to patients, politicians, health administrators, and doctors alike.

The limitations of our study lie primarily in the validity and reliability of questionnaire data on subjective well-being. Reliability tests suggest that some respondents may indicate different levels of satisfaction over a short period of time. Our sample of 295 GPs make up a 7–8% random sample of all Norwegian GPs and with a response rate of 73% they are representative of the whole group. The Job Satisfaction Scale (JSS) is a well-proven instrument, which makes comparisons with other studies possible [13], [15].

The Norwegian healthcare system is based on strong primary care with the administrative responsibility laid on each of the nation's 434 municipalities. GPs are highly estimated and well paid. Norwegian GPs regard themselves as more satisfied with their work than they believe other professionals to be (see Table I). They are content and enjoy most aspects of their work. This contrasts with a general international impression of doctors’ discontent [1–4] and former studies showing that Norwegian doctors are “doing well” but “feeling bad” [17], [18]. The high level of job satisfaction has been stable over almost a decade. The GPs in Norway report a higher level of job satisfaction than hospital doctors, the opposite of the situation in the UK [19]. When compared with data from the UK, Norwegian GPs report a higher level of job satisfaction for most aspects of their work than their British colleagues [13].

In a major study, Landon et al. conclude that the strongest and most consistent predictors of job satisfaction are changes in measures of clinical autonomy, which involve the ability to manage their time and day-to-day patient interactions [5]. This fits well with one study of changes related to the implementation of a capitation system in Norway in June 2001, which found that low level of job satisfaction was associated with high workload and long waiting lists [20]. In the new capitation system a GP is responsible for a defined and limited population (on average 1200 patients per GP) and each citizen is listed with one GP. GPs may limit their lists and patients may change doctor twice a year. More than 99% of the population have signed up and almost all the approximately 4000 Norwegian GPs have joined. Though the system initially was controversial among doctors, it has been well received among patients and GPs alike, and the reform does not seem to affect the level of job satisfaction. This finding is in line with most other Norwegian studies [21], [22], though a slight decline in job satisfaction after the reform has been indicated by some [23]. One likely explanation for the stable level of job satisfaction is that the capitation system has not influenced the GPs’ clinical autonomy substantially.

When compared with their colleagues in hospital the GPs report a higher level of satisfaction with their freedom to choose their own method of working. This is an important part of professional autonomy. In spite of a probable increase in external regulations [4], the level of autonomy still seems to be acceptable.

International comparisons of working conditions and job satisfaction are difficult to perform. The healthcare systems, and the tasks of GPs, differ between countries – and differences are marked even within countries [5]. Why Norwegian GPs are more satisfied with their job than Norwegian hospital doctors, while in the UK it is the other way round, is one example of differences that are not easily explained. It is probably related to all aspects of doctors’ working conditions as well as to the relative status of primary care compared with specialized medicine.

Both GPs and hospital doctors in Norway enjoy a high level of job satisfaction [6]. A recent study among Swedish residents in specialist training supports this finding [24]. Most doctors continue to report overall job satisfaction in spite of the growing concern about a collective “medical depression”. This gives reasons to ask whether the international focus on doctors’ discontent is well founded. Our study also suggests that it is possible to implement a major health system reform without affecting the job satisfaction of GPs, as long as their autonomy is preserved.

Key Points

Growing expectations, increasing pressure on time and cost containment, and threats to doctors’ professional autonomy have been thought to lead to a decline in job satisfaction among doctors.

• In spite of this and of major health reforms being introduced, a high and stable level of job satisfaction has been found among Norwegian general practitioners from 1994 to 2002.

• General practitioners reported higher levels of satisfaction than hospital doctors for physical working conditions, recognition of good work, freedom to choose own method of working, and payment.