We are a culture infatuated by high achievement and tireless in our quest for satisfaction. We refuse to accept service that we deem substandard and, as a people, are quick to complain at being inconvenienced, made to wait, and at the first sign of being overlooked. Life, liberty, the pursuit of happiness … and customer satisfaction: those are our American ideals. Satisfaction is so important to us that we expend enormous amounts of time and energy measuring it. We devote enormous amounts of resources toward assessing and studying it. And we spend enormous sums of money on analyzing, quantifying, and communicating our level of it. We do this, by and large, through the ever-present, often aggravating, satisfaction survey.

Satisfaction surveys are everywhere. They come at us by phone, fax, and Internet, via e-mail, snail mail, the US Postal Service, FedEx, and clipboard-toting people with the audacity to knock on our front doors or stop us in our tracks at the mall. Anywhere you go in America today, and anything you do in this great country, generates a satisfaction survey. Buy a new car, and you will get a call from customer service after you drive off the lot. Have a new roof put on your home, and you will get a follow-up questionnaire in the mail. Make any online purchase, and you will get a series of inquiries in your inbox: how did we do? How would you rate your experience? How can we improve? Will you recommend us to your friends? It is exhausting.

But satisfaction is so important these days that I would bet that the majority of us have questionnaires in our very own practices designed to, among other things, gauge how our patients feel about us.

I doubt physicians 50 years ago concerned themselves much with how their patients felt about them. But because of the prevalence of satisfaction surveys, and the willingness of Americans to take them, physicians and health care organizations have come to realize that the provision of exemplary medical care is now no longer enough. In fact, from the client point of view, excellent medical care is the very least a health care organization should provide. In today’s world, the focus of medicine has had to broaden considerably, and fully encompass, the patient experience.

But how important is the patient experience, another way of saying patient satisfaction? Do we really need our patients to be satisfied, in whatever way they define it? Do we even want our patients to attempt to define their medical care in the nebulous and subjective terms that comprise satisfaction?

There are some intuitive reasons for us to want our patients to be satisfied: reducing malpractice risks and costs because satisfied patients are less likely to sue their physicians and more likely to tolerate and forgive perceived care failures; reducing patient defection from our practices; and mitigating negative word of mouth because word of mouth is the key to attracting new patients and building a practice.

Patient satisfaction also promotes better compliance with treatment plans and thus ultimately generates better outcomes because satisfied patients are typically less stressed, better able to understand treatment instructions, and able to form bonds with health care providers that encourage continuity of care.

All of these things help our practices thrive, which in turn enables us to do what we set out to do when we chose a career in medicine: to take good care of our patients and enjoy a fulfilling career in the medical profession.

But our profession is rapidly changing; in fact, few professions have experienced as much change in the past few decades as has medicine. Medical practices now face challenges on numerous fronts, including reduced reimbursement, continued high malpractice rates, costs that are outpacing revenues, and shrinking margins. And now, to continue to be compensated, we are going to have to start devoting an enormous amount of time to ensuring that patient satisfaction is at the top of our own lists of priorities.

Up to this point, we have lived in the comfortable and predictable era of fee-for-service reimbursement. This payment model allows the patient to make almost all health care decisions independently. A provider is selected, a service is rendered, payment is made, and reimbursement occurs when it is appropriate. Services are unbundled and paid for separately, so payment is dependent on the quantity of care, rather than the quality of care. But the fee-for-service model is nearly over. Very soon reimbursement will be linked to quality-measuring metrics, and our performance, now referred to as P4P (pay for performance), will be defined by national benchmarks in quality, cost, or rather, cost containment, and the patient experience.

P4P rewards physicians, hospitals, medical groups, and other health care providers for meeting certain performance measures for efficiency and quality, and quality, in this case, has less to do with medical care than it does with patient satisfaction. And although both physicians and hospitals have always felt pressure to provide excellent clinical care, the Patient Protection and Affordable Care Act law, as of March 23, 2010, has mandated it. Now failure of health care providers and hospitals to meet patient expectations will involve financial consequences. Taken together, P4P and the Patient Protection and Affordable Care Act elevate patient satisfaction to the highest priority status, and they ensure that patient satisfaction directly affects the bottom line.

Given this emphasis on patient satisfaction, it behooves each of us to give serious thought to the role the individual physician plays, asking ourselves a fundamental question: where do our patients come from in the first place, how do we keep them, and, most importantly, how do we keep them satisfied?

Where do our patients come from? Studies have shown that patients choose an individual practice 51% of the time based on the recommendation of a family member or friend. They choose a practice 38% of the time at the recommendation of health care media, 11% of the time based on an Internet rating, and only 2% of the time from printed or television media. The telephone company (yellow pages) did not make the list.

Once they have come to our practice, what keeps our patients coming back? What creates patient satisfaction?

First, patients want to be treated with dignity and respect. Second, they want an attentive physician who listens carefully to their health concerns. Patients also want good, clear communication from a doctor who is easy to talk to and understand. They want a doctor who is willing to spend time with them, both talking about and dealing with their health concerns, and lastly, they want to feel that their physician truly cares about the patient and his or her health issues. You may have noticed that this list contains no mention of the physician’s ability to diagnose and treat medical conditions and no concern for where the physician received medical training. These things, according to research, do not factor into patient satisfaction.

What do patients indicate when asked what they dislike most about an experience with a physician? The most often cited failure on the part of the physician is a failure to listen, a breakdown in doctor/patient communications. Failure to return phone calls is next, followed by a lack of respect or concern for the patient’s health problems. The fourth most often-cited failure comes from not spending enough time with the patient, and the fifth failure is not answering the patient’s questions adequately. When you consider this list, you will see why a number of studies indicate that medical negligence often is not the motivating factor when a patient files a malpractice claim. Malpractice claims, more often than not, result from a breakdown in communication and a failure to empathize with the patient’s condition.

What do patients feel will enhance their patient experience? The first thing is reduced waiting times, which may include self-service check-in, palm readers, and tablets. The second is by using web-based services, which can be used for logistical operations, such as directions, maps, appointment scheduling, and office hours, as well as financial transactions, such as bill paying, and secure messaging, for relaying test results and lab reports. Increasing accessibility is the third way physicians can increase patient satisfaction by providing convenient and creative appointment options and maximized communication, via modernized phone systems and live answering services is the fourth way to increase patient satisfaction. Lastly, patients want improved responsiveness to their requests and needs. In a nutshell, patients want to leave a physician’s office satisfied that they have been attended to with care, concern, and respect.

When patients do not feel that way, the Internet makes it very easy for them to find a new physician. Websites, such as vitals.com, drscore.com, and angieslist.com, provide quick and easy ways for patients to share and compare their experiences in the medical community, as well as identify physicians they believe will better meet their personal needs. And although the Internet has made finding a doctor easier than ever, it has also made the travel time of information from person to person faster than ever.

If you were to imagine an iconic 1950s-era beauty shop, at first glance it might appear to be a simple place of American business. But in reality, it is a buzzing hive of information, a regional network and referral center so deeply entrenched, and so well informed, that it is the envy of government agencies and spy organizations everywhere. In it you will find an infinite databank of information, some pertinent and some not so much, on every physician, lawyer, dentist, and deacon in town. Add modern technology to it, and you have an information dispersal system that makes traditional advertising look like a Pleistocene-era relic. Factor in human behavior, which makes it far more likely that we will tell our friends about a bad experience than a good one, and the words of a dissatisfied, unhappy, patient can now travel at the speed of sound. The modern patient is very mobile, and word of mouth is more powerful than ever.

All of the things that generate positive word of mouth and keep patients returning to our practices (communication, attentiveness, accessibility, respect, compassion) fall under the physician’s responsibility toward patient satisfaction. But there is another interesting aspect to the discussion of patient satisfaction, and that is physician satisfaction.

Studies have shown that physicians who are satisfied with their careers are far more likely to provide better health care than those who are dissatisfied, and furthermore, high physician satisfaction is likely to result from good outcomes with patients. Thus, physician satisfaction may be an indirect measure of patients’ outcomes. In addition, patients who are cared for by satisfied physicians have more trust and confidence in their physicians, and the satisfied doctors themselves have better continuity, higher patient satisfaction survey scores, lower no-show rates to office visits, less malpractice claims, and better compliance. In a nutshell, a satisfied physician makes a better, and more effective, doctor, which in turn leads to a higher level of patient satisfaction.

But are we satisfied? In a 2008 study, 20% percent of all physicians polled reported that they were dissatisfied with their careers. Some of the factors they cited included loss of autonomy, economic pressures, an increasing degree of government and insurers’ control over their practices, requirements for electronic health record keeping, the ongoing liability crisis, a divergence between professional and personal expectations, physicians’ personal high career expectations, and finally a desire for more time for family and self. Dissatisfied physicians are more likely to unionize, strike, experience personal medical problems, exit medicine altogether, and avoid recommending a medical career to family or others. Furthermore, dissatisfied physicians show increased rates of medical errors, thus jeopardizing patient safety. There are a number of factors that make a physician dissatisfied with his or her career, and they include, but are not limited to, gender, age, and medical specialty.

The complexion of the medical profession has changed dramatically in the past 25 years. The previously male-dominated profession is now gender equal, and in some specialties, female dominant. This rapid gender shift in medicine has been blamed for some of the decline in physician satisfaction, and indeed, there are a number of gender-related differences in the medical workforce characteristics: women continue to conceive, gestate, and deliver 100% of the babies.

And one might deduce that women reduce their clinical activity during child-bearing and child rearing, and they also retire 5.5 years earlier than men do. In obstetrics, women younger than 40 years are 4 times more likely to reduce work hours, or stop practicing altogether, than male obstetricians are. Among surgeons, 90% of women live in dual-career households compared with only 50% of men. And when the surgeon is male, children are cared for by spouses in 63% of households, but when the surgeon is female, children are cared for by an employee in 88% of households. And, among surgical subspecialists, women are more likely to be divorced or separated and to have fewer, or no, children. However, data suggest that among full-time academic faculty without children, productivity and career satisfaction are the same for women as for men. And although it has been suggested that women prefer to work fewer hours than men, evidence indicates that younger men share the desire to work less and spend more time with family. And a recent study of internists found few gender differences in the work/life balance, work hours, and the overall attitude toward patient care. So, taken altogether, these studies tend to suggest that gender is not the primary cause of physician dissatisfaction.

Age is another factor often cited in measuring physician satisfaction. The Baby Boomer generation of physicians (born between 1946 and 1964) is rapidly being replaced with Generation X (born between1965 and 1980) and Generation Y (born between 1981 and 2000) physicians. Much of the discussion of physician dissatisfaction has contrasted Baby Boomers with subsequent generations and for good reason: the Boomer physician is more likely to be male, to work long hours, and to see his professional life as his primary function in the world. The Boomer physician is also far more likely to have a traditional marriage, in which the stay-at-home mother is doing the vast majority of parenting and household engineering.

By contrast, the Generation X and Y physicians have lives in which gender equality is the norm. Far more X and Y physicians are in dual-career couples, and thus, their own careers require career flexibility and variety. Generation X and Y physicians place a much higher value on personal time and lifestyle, and therefore, they tend to choose specialties that are more likely to give them better control over their workloads.

This leaves us with the factor that seems to have the largest impact on physician satisfaction: medical specialty. For many years, geriatrics has ranked high in physician satisfaction. In addition to steady, nonerratic work hours, encounters with inspirational seniors and enduring doctor/patient relationships are cited as reasons for the high ranking of this specialty. Pediatrics and pediatric subspecialties also rank high in satisfaction. It has been suggested that this is because children tend to be more joyful than adults and because many health problems in children are easily resolved, which allows the pediatrician to feel effective.

In addition, it has been suggested that adults who elect to work with children may themselves be more joyful than other adults and that pediatricians may encounter less work stress than other physicians. Dermatology is currently ranked the highest in physician satisfaction, and, indeed, a 2011 study reports that a whopping 93% of dermatologists are satisfied with their career choice. Explanations for this high level of satisfaction include stable work hours, prosperous employment opportunities, and treatment outcomes that are direct and obvious to the patient, which in turn enhances the patient-physician interaction. Those who have chosen geriatrics, pediatrics, and dermatology as their specialties are the most satisfied physicians.

By contrast, neurologic surgery and obstetrics and gynecology rank lowest in terms of physician satisfaction. The causes include irregular work hours, medical lawsuits, loss of autonomy, and a decline in pay compared with other specialties. Part of this low career satisfaction might also be explained by the high expectation obstetrics and gynecology physicians had when they entered this specialty vs the current realities of practice. Given this fact, it seems paradoxical that the obstetrics and gynecology specialty remains very popular among US medical school seniors, according to the National Residency Matching Program’s 2011 Match Report. Of the 1205 postgraduate year 1 positions available in obstetrics and gynecology, 1192 were filled (98.9%), with 5.3% of all applicants choosing obstetrics and gynecology. These percentages have remained fairly constant since 2007.

The 2011 Medscape Physician Compensation Survey was recently released. It includes responses from 15,794 physicians across 22 specialties, whose answers were collected in February and March of 2011. According to the survey, the median salary for obstetrics and gynecology physicians in 2010 was $225,000, up from $210,000 in 2005, with half of respondents noting no change in salary since 2009. Compared with physicians in the other specialties, the median salary of obstetricians and gynecologists ranked 14 of 22, with orthopedic surgery and radiology ranking highest, both in the $350,000 range and primary care practitioners and pediatricians lowest, with salaries in the $148,000 range. Female obstetricians and gynecologists reported lower salaries, in the $200,000 range, than their male counterparts, whose salaries hovered around $245,000. This disparity is likely explained by the creative job situations that many women take, to allow more control over personal time and more time with their families. It is important to note that the starting salaries are generally equal for both men and women.

There is also disparity of income in work venues across the United States. Obstetricians and gynecologists in the north central states of Iowa, Missouri, Kansas, Nebraska, and the Dakotas earn an average $290,000, the highest median income. Practitioners in the Northeast and mid-Atlantic states have the lowest incomes, with $210,000 and $240,000, respectively, which can largely be explained by the higher concentration of physicians in these states as well as higher overhead costs. Urban vs rural setting also plays a role, with physicians practicing in small towns and rural areas reporting a median income of $242,000 and those practicing in the suburbs of large cities reporting a median income of $216,000.

Practice setting also influences salary, with multiple-specialty practice, which averages $250,000, and single-specialty practice, which averages $244,000, being the highest. Hospital employees, including those who work for health care organizations, make slightly less than that, coming in around $240,000, but they outpace partners in private practice, who average $219,000. Solo practitioners and independent contractors report the lowest salaries, at $170,000 and $168,500, respectively.

The Medscape survey gives us further insight into dissatisfaction among obstetricians and gynecologists. In it, 69% of responding physicians answered that they would choose to pursue a career in medicine again, whereas 19% of respondents were unsure, and12% stated outright that they definitely would not. Fifty-three percent would choose obstetrics and gynecology as their specialty, whereas 25% would definitely not choose obstetrics and gynecology, and the remaining 22% of respondents were unsure about obstetrics as a specialty.

Those respondents who indicated that they would choose a career in medicine again were asked to identify the specialties they found most attractive, and they named gastroenterology, cosmetic surgery, dermatology, genetics, general pediatrics, ophthalmology, orthopedics, and pathology as their top 8 choices. Those who stated outright that they would not choose medicine again were asked to indicate alternate career paths that they felt were better options. Predictably, many respondents indicated an interest in business, law, and education, whereas others identified engineering, research, information technologies, architecture, politics, veterinary medicine, dentistry, and orthodontics as possible paths. Some indicated that they would opt to be midlevel providers. But others took more unusual routes, and among the possible professions that were listed as being more desirable than being a physician, we found flight attendant, pastry chef, cheese maker, military forester, riverboat pilot, short-order cook, and soda jerk.

Physician dissatisfaction exists, that has been well established, and we know that some specialties, namely obstetrics and gynecology, report higher levels of it than others. So what can be done to reduce physician dissatisfaction? One suggestion has been to reduce the number of work hours and use work shifts. It has been well established that excessive work hours and fatigue are prime ingredients of physician burnout and may compromise both patient safety and physician well-being. As a result, reduced work hours have been adopted in resident medical education since 2003.

It is, perhaps, time for practicing physicians to also reduce work hours, voluntarily, before the federal government steps in to mandate limitations on the hours we work. Job sharing and part-time employment have also been shown to reduce physician dissatisfaction, and these practices have become common-place, but perhaps these practices should become standardized, and even incentivized, in our industry. The creation of part-time professional liability insurance policies would be one example of how to promote such arrangements, with policy premiums being prorated according to the amount of clinical time worked as well as the physician’s quality metrics, those metrics that, you will remember, are on the immediate horizon.

In addition, new practice models could be expanded or implemented, such as the use of laborists and midlevel providers. The hospital-based laborist concept, which is well established in many health care communities, not only provides a safer environment for patients but also improves rapid-response teams and offers a structured work/life balance for those choosing to practice obstetrics compared with the traditional format. The success of laborists is evidenced by the establishment of the Society of OB/GYN Hospitalists, which is gaining steady growth and momentum. And lastly, we must make it possible for physicians to acquire top-notch time- and money-management skills because of the many stressors related to limits on time and money that physicians face on a daily basis.

In the end, it all comes down to satisfaction: patient satisfaction, physician satisfaction, and self-satisfaction. But of the multitude of satisfaction surveys we will face in our lives, which one matters the most? I contend it is the one that we take for ourselves, the one in which we ask the questions, we write the answers, and we live the responses.

Stephen Beeson, in his book Practicing Excellence , summarizes how I feel about this subject. He writes, “So we talk of physician satisfaction. Is it the workload, money, and autonomy that we hear over and over again? Not really, and certainly not entirely. The greatest predictor of physician satisfaction is our decision to make it so. To be driven by values, purpose, and making a difference in the lives of the patients we treat; to heal, to touch, to care, to make others better. Medicine is far from perfect, but life is too short to spend precious time dismantling and complaining about one of the greatest professions known by anyone. The greatest thing that medicine has to offer is simply there for the taking, requiring only that we slow down enough to find it. There is no doubt; we can receive the amazing gift of a brilliant career with the simple offering of our commitment to others.”

Satisfaction, knowing that we are making a difference in the world, despite the challenges we face, is ours for the taking. My hope is that each of us will find a way to maintain our commitment to being driven by our values and, motivated by the simple desire to do what we set out to do, to heal others and improve this brief life that we have been given to live.