Journal Club

The impact of the changing health care environment on the health and well-being of faculty at four medical schools. Schindler BA, et al., Academic Medicine 81(1): 27-34.

Reviewed by Elizabeth Stuart, Stanford University

Background: This is a descriptive study that broadly explores the issue of faculty well-being in US medical schools. Though studies are few, available evidence on the well-being of medical school faculty suggests that environmental changes, including shifts in funding, increasing emphasis on research, and growing pressure to generate clinical revenues have had an adverse impact on this group as well. Schindler et al. expand on previous studies, examining health and well-being in a large group of faculty in multiple disciplines at four institutions. The authors hypothesized that changes in the academic health care environment, institutional instability would have had a negative impact on the personal and professional lives, mental and physical health of full-time academic faculty, particularly older faculty. They also hypothesized that changes in the health care environment would have different effects on faculty in different disciplines.

Methods: Study participants were 3519 clinical and basic science faculty members, working at least half-time, at four geographically diverse medical schools. The authors developed a 136-item, self-administered questionnaire, adapted from the Linn et al study in 1984. The questionnaire included five pre-existing scales exploring physician job satisfaction, anxiety and depression, life satisfaction, and work related strain.

Findings: 1951 faculty members (54.3%) returned the questionnaire. The largest groups of respondents were in internal medicine (29%), pediatrics (13%), and surgery (8%). Faculty were distributed evenly across academic ranks. 66% of the respondents were male; 34% female (in keeping with the composition of the general academic faculty population published by the AAMC in 2001.) Respondents' mean age was 47%. 90% reported being in a stable marriage or partnership.

Among the study's many findings, here are a few highlights:

Compared to respondents in the Linn et al. 1984 study, academic physicians in 2001 reported spending more of their time in patient care (41 vs. 23%), less time doing research (29 vs 15%); and less time supervising residents and students (21 vs. 15%). 21% of questionnaire respondents reported symptoms of depression using the CES-D; rates were fairly similar in men vs. women. To put this in context, the authors note in their discussion that the prevalence of depression in the general, non-patient population is roughly 9%, with higher rates in women. The rate of depression among faculty in the 1984 study was 14%. Women were slightly more likely than men to report depression and anxiety. Younger age was negatively correlated with depression and anxiety, positively correlated with job satisfaction, work-related strain, and life satisfaction. Respondents exercised infrequently (32% never to several times per month); only 23% reported getting adequate amounts of sleep; and 29% reported withdrawing emotionally from family and friends up to several times a month. Health-related problems and depression scores were similar across institutions.

Respondents reported being moderately satisfied on most measures of job satisfaction scale. They were most satisfied in terms of "status and prestige associated with your work," "ability to remain knowledgeable and current," "ability to derive personal gratification from your work," and "the degree to which your work is educationally stimulating." In rating their institutions' financial health, only 19% of respondents had a positive outlook - choosing either "we're in pretty good shape" or "the best it's ever been."

Limitations: As with most survey-based investigations, the questionnaire response rate was fairly low. The authors note, however, that 54% is consistent with return rates in other physician surveys and higher than they had expected given the length and sensitive nature of the survey. Considering the content of the questionnaire, the potential for selection bias seems high, though the large number of respondents and consistency in findings across institutions suggest that the sample may be reasonably representative. As a descriptive study involving correlations among variables, the paper is limited to raising questions, rather than providing answers, on the impact of the changing health care environment.

Implications: As the authors note, their findings "add to the growing evidence that American medicine is in trouble." A prime concern is that our students' teachers and role models are increasingly depressed, dispirited, and discontent in their jobs. The authors call for additional research to look more closely at causes of faculty distress and encourage institutions to develop strategies (e.g. CME, faculty development programs) to help faculty members cope with ongoing pressures. Though the findings of the study are in general disheartening, the authors do note the presence of a "reservoir of satisfaction and well-being" - reflected in positive responses regarding the educationally stimulating, personally gratifying nature of academic life. Tapping this reservoir may be an important component of helping faculty respond to rapid change.

(Comment: I find this article even sadder than the one before. Medicine is a wonderful profession, filled with great challenges and profound rewards. How do we take back our profession, and our lives, thereby providing the best care possible to our patients and our learners? I know at least one important avenue: the fellowship and support of the COMSEP membership. - Leslie Fall)