Hiba Ashraf ( Department of Family Medicine, FMH College of Medicine and Dentistry, Lahore. )
Nasir Shah ( Department of Family Medicine, FMH College of Medicine and Dentistry, Lahore. )
Fahad Anwer ( Department of Family Medicine, FMH College of Medicine and Dentistry, Lahore. )
Hina Akhtar ( Department of Family Medicine, FMH College of Medicine and Dentistry, Lahore. )
Mairaj Anwar Abro ( Primary Health Care Center, Nainsukh. )
Asma Khan ( Department of Family Medicine, FMH College of Medicine and Dentistry, Lahore. )
Objective: To assess the level of professional satisfaction amongst family physicians of Pakistan and to identify the factors associated with professional dissatisfaction.
Methods: The study was part of a larger national survey for "Status of Postgraduate Training and Continuing Medical Education of Family Physicians in Pakistan" which was a cross-sectional, postal survey of family physicians conducted over 10 months between November 2009 and September 2010. The main outcome variables were professional satisfaction, as well as reasons for professional satisfaction and dissatisfaction. SPSS 17 was used for data analysis. Multivariable logistic regression was used to determine factors associated with professional dissatisfaction.
Results: Of the total 1200 survey forms distributed, 288 (24%) were received back. The mean age of the participants was 37±9 years with a range between 26 and 72 years. Of the total, 226 (78.5%) were males. Overall, 213 (74%) family physicians were satisfied with their profession. The factors significantly associated with professional dissatisfaction included the participants opinion that they were not respected by the public (OR: 11.6, C.I: 1.9-71.5); as well as regretting being a doctor (OR:62.9, C.I: 8.4-469.8).
Conclusions: Most of the family physicians had professional satisfaction, but a minority had regrets about being a doctor and were dissatisfied over how their profession affected their family life. Further research may be needed to study work-life balance amongst family physicians of Pakistan.
Keywords: Professional job satisfaction, Family physicians, Pakistan. (JPMA 64: 442; 2014).
Family physicians or general practitioners have always been the "primary" healthcare providers of any community, having a pivotal role in not only providing coordinated and continuous primary healthcare, but also forming the basic structure of the healthcare system.1 In an American survey in 1996, 62% Americans reported "family physician" as an individual provider of their source of care as opposed to 16% opting for an internist and 15% for a paediatrician.2 In Pakistan, according to the World Health Organisation (WHO) statistics of April 2011, for every 10,000 people approximately 8.1 physicians are needed to cater to their health needs.3,4 The scarcity of trained physicians and increasing demand makes it imperative to promote professional job satisfaction amongst the physicians. Job dissatisfaction amongst doctors does not only result in their own poor mental health,3,5,6 but is also associated with poor quality of care of the patient, decreased patient satisfaction,7-9 and increased rate of medical errors, putting patients at risk.10
Globally, healthcare systems are undergoing drastic changes, focussing on Community Oriented Primary Care (COPC) approach to healthcare.11 Due to family physicians\' background and association with the families, they are uniquely qualified to serve as patient\'s advocates in health-related issues as well as to make judicious use of referrals to consultants, community resources and health services.12 With this paradigm shift, it is vital to assess the level of job satisfaction amongst already practising family physicians and to understand the factors that lead to job dissatisfaction amongst them.
Although numerous studies have addressed the level of job satisfaction among physicians in Pakistan,13-15 but most of them have been done on doctors working in hospital or institutional settings. Previous studies have not focussed on assessing the level of satisfaction amongst family physicians working in the community. This study intended to find the level of professional satisfaction amongst family physicians of Pakistan and factors that lead to decreased satisfaction, so that those factors can be addressed to improve professional job satisfaction, and indirectly improve quality of care and patient satisfaction.
Subjects and Methods
The is a secondary analysis of a larger research project entitled "Status of Postgraduate Training and Continuing Medical Education of Family Physicians in Pakistan", which was a cross-sectional, postal survey conducted over 10 months between November 2009 and September 2010 across Pakistan.16 The data for the main study was collected through a self-completed, structured questionnaire which was designed in the Department of Family Medicine, Fatima Memorial Hospital College of Medicine and Dentistry, Lahore, after detailed discussions with a group of doctors, hospital administrators, and statistician. It was then piloted on 15 (5%) practising family physicians, who were the honorary faculty members of the department.
As this was the secondary analysis of a larger research project, the sample size was taken as that of the primary study, which was collected through computer-generated simple random sampling.16 The pre-tested, structured questionnaire was mailed with the pre-paid self-addressed return envelopes to the selected 1200 family physicians. All the respondents were assured of confidentiality through covering letters. At least one telephone call and one SMS were sent as a reminder to all those who did not respond to the questionnaire. Data collection was stopped after five months of mailing and the questionnaires were numbered and verified for any mistakes.
Data was collected on demographic and professional characteristics which included age, gender, province, years since MBBS graduation, any postgraduate degree or training, inclination towards any postgraduate training in the future, daily hours of practice, any part-time job, membership with any society of family physicians, level of job satisfaction, reasons for job satisfaction, reasons for job dissatisfaction, regrets on becoming a doctor or a family physician, inclination to pursue family medicine if given a chance again, how do the family physicians\' rate themselves when compared to specialists, how does general public rate family physicians, and how do specialists rate family physicians in comparison to themselves. Data collected on personal characteristics included time for exercise, time for recreation, time for studies, time for family, weekly or annual holidays, effect of job on marital life, effect of job on children, and effect of job on health.
SPSS version 17 was used for data entry and analysis. Frequency and percentage of all the qualitative variables were computed. Chi-square test or Fisher exact test or likelihood ratio test was used to find association between various categorical variables and professional satisfaction. Point biserial correlation was computed to check association between various quantitative variables and professional satisfaction. Variables that were found to be significantly associated with the outcome variable professional satisfaction were included in the univariate binary logistic regression analysis and those variables that were significant in univariate analysis were included in multivariate binary logistic regression analysis. P-value <0.05 was considered significant. The main outcome variables were job satisfaction, reasons for job satisfaction and dissatisfaction.
Ethical approval was obtained from the Institutional Review Board. A written consent providing the details of the study was obtained from each participant. Complete confidentiality of the information was maintained, and the data was only accessible to the researchers.
Out of 1200 questionnaires distributed, a total of 288 were received back, yielding a response rate of 24%. The mean age of the participants was 37± 9, ranging between 26 to 72 years. For the purpose of analysis, age was divided into categories of ten years. The age group between 41-50 years was most common (n=107, 37%). Of the 288 participants, majority were males (n=226, 78.5%) while 62 (21.5%) were females. Most of the participants were from Punjab 147 (51%), followed by Sindh 72 (25%), Khyber Pakhtoonkhwa 55 (19%) and Balochistan 14 (5%).
Professional background: Among the respondents, most had graduated in the 1980s (n=123, 42.7%) and a very small proportion in 1960s or earlier (1.4%) 30. Most of the participants had not undergone any postgraduate training (63.9%; n=184) and only 30.2% (n=87) had a formal postgraduate degree. Nearly half of the respondents (n=152, 52.8%) were interested in receiving postgraduate training in the future. The mean daily working hours of the family physicians were 5.97 hours (range 0-14 hours; SD 3.15) with the maximum number of family physicians working around 8 hours per day (n=58, 20.1%). Most of the participants (n=157, 54.5%) did not have a part time job whereas 45.5% (n=131) did. One hundred and thirty eight (47.9%) of the participants were members of an academic society. The professional demographic details are given in Table-1. Of the 288 family physicians, 267 (92.7%) were happy with their married life and 4.8% blamed their profession for any marital disharmony.
Professional Job Satisfaction of Family Physicians: In all 61.8% versus 59% of the participants never regretted to be a doctor and family physician respectively, however 26.4% reported they regret a little to be a doctor and family physician and only 10.1% versus 5.9% responded yes when asked ever regret to be a doctor and family physician respectively (Table-1). To the question "if you were given a second chance to be a family physician, would you?" 31.3% (n=90) answered with a "no", 39.6% (n=114) answered with "yes" and 19.4% (n=56) answered "don\'t know) (Not shown in the table).
Amongst the 288 participants, 132 (45.8%) rated themselves inferior to the specialists, whereas almost one-third (35.8%) considered themselves equal to specialists. A larger proportion of family physician\'s with job satisfaction (61.2%) perceived that other specialists considered them superior in comparison to nearly 35% who did not have job satisfaction (Table-1).
Overall, 213 (74%) of the family physicians were satisfied with their profession, while 58 (20.1%) were not satisfied, and 17 (5.9%) were unsure (Table-1). Those who were not satisfied with their profession, when asked if they ever regretted being a doctor, 21 (36.2%) responded with a "yes" while 20 (34.5%) with "a little," whereas 17 (29.3%) never had any regrets (P-value <0.0001). When questioned about whether they ever regretted being a family physician, 11 (19%) and 19 (32.8%) responded with a "yes" and "a little" respectively, while 18 (31%) never regretted being a family physician (P-value <0.0001, Table-1).
Table-2 enlists the most common reasons of job satisfaction and dissatisfaction.
Potential risk factors for professional satisfaction: Univariate binary logistic regression analysis was conducted to determine parameters with a significant association with profession satisfaction (Table-3).
Only those variables were included that were found to have significant association in Table-1. The final multivariable binary logistic regression was built including only those factors that were statistically significant in univariate logistic regression analysis.
In the final multivariable binary model, factors significantly associated with professional dissatisfaction included the participant were of the opinion that they were not respected by the public (OR:11.6, C.I: 1.9-71.5); as well as regretting being a doctor (OR:62.9, C.I: 8.4-469.8). Family physicians that were of the opinion that his/her profession affected the children were almost six times more likely to have professional dissatisfaction; albeit not statistically significant in the presence of other factors (Table-3).
Several studies have reported that job satisfaction amongst doctors leads to better quality of care and better patient satisfaction.8,9,17 With the primary care physicians providing healthcare to more than 70% of the population in Pakistan, it was of considerable importance that their level of job satisfaction be assessed. This is not the first study that addresses job satisfaction in Pakistan per se;13,14 however this is the first national survey of its kind that assesses the level of job satisfaction in family physicians nationwide. Several studies in Pakistan have shown the level of job dissatisfaction amongst doctors ranging between 56-68%,13,14 which is comparable to international data from US and India.18,19 In contrast to the surveys conducted worldwide as well as in Pakistan,13,14,18,19 in this study majority of the family physicians were satisfied with their profession (74%).
Mostly international and local studies have identified doctors to be dissatisfied with their working hours, salary, working environment, and service structure.14,19,20 This proved to be similar in our study where the most common reason for job dissatisfaction was found to be the "very demanding nature of the job" (14.6%) and "low income" (9.7%). A study conducted in Pakistan reported that high level of job stress led to increased job dissatisfaction and adversely affected personal and family life.13
As this study was part of a larger research project,16 relationship amongst various factors like effect of job on health, personal life, recreational activities etc. can be ascertained. This study is also first of its kind that assessed job satisfaction amongst a large population of family physicians all over Pakistan. As this study covered a vast majority of family physicians, it makes the results of this study generalisable.
It is difficult to make a causal inference from cross-sectional studies as it is a snapshot in time, which is a limitation inherent with this type of study design. Another limitation of this survey was a low response rate of 24% (288/1200) compared to previous survey on physicians conducted in Pakistan.13 One of the reasons for this could be that the family physicians who were dissatisfied may have been less willing to participate. The data in this survey was self-reported, hence there may have been a chance of reporting bias. In this study, females were found to be more dissatisfied as compared to males; however we did not find any differences in our study.
As this study was a secondary analysis of a larger study, the results might serve as a platform for further research to find out the reasons of professional dissatisfaction amongst family physicians.
Most of the participating family physicians were satisfied with their profession. Most common reasons for job satisfaction were respect in society, blessed life in the hereafter, and self satisfaction. Most common reasons for job dissatisfaction were very demanding nature of the job, low income, and adverse effects on family life. More research is needed about work-life balance amongst family physicians of Pakistan to improve career and lifestyle harmony.
We are grateful to all the family physicians for their participation and cooperation. Thanks are also due to Mr. Ishtiaq Ahmed, Secretary of Family Medicine at Fatima Memorial Hospital, Lahore, for data management; Mr. Abdul Rehan for data organisation and verification; and Ms. Sundus Iftikhar of the Indus Hospital Research Centre, Karachi, for statistical analysis.
1. Montegut AJ, Schirmer J, Cartwright C, Holt C, Thi Kim Chuc N, Nhat An P, et al. Creation of postgraduate training programs for family medicine in Vietnam. Fam Med 2007; 39: 634-8.
2. Fryer GE, Dovey SM, Green LA. The importance of having a usual source of health care. Am Fam Physician 2000; 62: 477.
3. Blenkin H, Deary I, Sadler A, Agius R. Stress in NHS consultants. BMJ 1995; 310: 534.
4. World Health Organization. (Online) (Cited 2013 May 1). Available from URL: http://www.who.int/gho/countries/pak.pdf.
5. Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM. Mental health of hospital consultants: the effects of stress and satisfaction at work. Lancet 1996; 347: 724-8.
6. Kapur N, Borrill C, Stride C. Psychological morbidity and job satisfaction in hospital consultants and junior house officers: multicentre, cross sectional survey. BMJ 1998; 317: 511-2.
7. Weisman CS, Nathanson CA. Professional satisfaction and client outcomes. A comparative organizational analysis. Med Care 1985; 23: 1179-92.
8. Haas JS, Cook EF, Puopolo AL, Burstin HR, Cleary PD, Brennan TA. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med 2000; 15: 122-8.
9. Harms R. Physician professionalism and organizational efforts to improve quality: a systems perspective. WMJ 2004; 103: 63-64.
10. Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ 2008; 336: 488-91.
11. International Conference on Primary Health Care. Declaration of Alma-Ata. WHO Chron 1978; 32: 428-30.
12. AAFP. Family Physicians Scope of Practice. (Online) (Cited 2013 May). Available from URL: http://www.aafp.org/online/en/home/ policy/state/issues/scope/fpscope.html.
13. Khuwaja AK, Qureshi R, Andrades M, Fatmi Z, Khuwaja NK. Comparison of job satisfaction and stress among male and female doctors in teaching hospitals of Karachi. J Ayub Med Coll Abbottabad 2004; 16: 23-7.
14. Shakir S, Ghazali A, Shah IA, Zaidi SA, Tahir MH. Job satisfaction among doctors working at teaching hospital of Bahawalpur, Pakistan. J Ayub Med Coll Abbottabad 2007; 19: 42-5.
15. Shaikh NA, Baloch AA, Siddiqui AS, Baig MY, Qadri MZ, Lal H. Professional Satisfaction Amongst Postgraduate Trainees of Civil Hospital, Karachi. Med Chanl 2010; 16: 497-501.
16. Shah N, Ashraf H, Anwar F, Khan A, Akhtar H, Abro MA. Status of Postgraduate Training and Continuing Medical Education of Family Physicians in Pakistan. Pak J Med Sci 2011; 28: 4-8.
17. Grol R, Mokkink H, Smits A, van Eijk J, Beek M, Mesker P, et al. Work satisfaction of general practitioners and the quality of patient care. Fam Pract 1985; 2: 128-35.
18. Frank E, McMurray JE, Linzer M, Elon L. Career satisfaction of US women physicians: results from the Women Physicians\' Health Study. Society of General Internal Medicine Career Satisfaction Study Group. Arch Intern Med 1999; 159: 1417-26.
19. Kaur S, Sharma R, Talwar R, Verma A, Singh S. A study of job satisfaction and work environment perception among doctors in a tertiary hospital in Delhi. Indian J Med Sci 2009; 63: 139-44.
20. Walker KA, Pirotta M. What keeps Melbourne GPs satisfied in their jobs? Aust Fam Physician 2007; 36: 877-80.