DOES MICROPRACTICE LEAD TO MACROSATISFACTION?

Meaghan Combs MD MPH, Elizabeth Paddock MD, Melissa Stiles MD, Ron Price MSUniversity of Wisconsin, Department of Family Medicine, Madison WI

WHY THIS STUDY:

Fall 2010. Independently wondering about the micropractice model.

Questions: How do they work? Are physicians practicing in this model happier

when compared to more traditional practices? What has to “give” to make this work? Could applying some of these “tricks” make

primary care more palatable to medical students?

MICROCLINIC Independent Low overhead Extended time with patients Guru: Gordan Moore MD

“Ideal Medical Practice” Goals:

Best care Less time documenting Appropriate referrals Decreased costs to the system Appropriate compensation for good care Increased happiness with career choice

NO COMPARISONS

Review of literature showed no studies comparing physician satisfaction between the micropractice model and traditional medical practices.

We know that physician quality of work life is a key component in physician career choice and retention

Study conducted late winter 2011. Comparison of physicians employed by the UW-

DFM and physicians working in micropractice clinics across the USA (self-identified)

METHODS• Validated survey assessed physician

satisfaction with current employment• 5 point Likert response scale (scored 1-5,

where 5 was the most positive response)• Survey invitation emailed to UW-DFM

residency clinic and community clinic physicians and a national sample of self-identified micropractice physicians

• Surveys were completed through online survey tool (http.//survey.wisc.edu)

• Responses were all anonymous• 92 total respondents• University of Wisconsin IRB approval

ANALYSIS

Individual items assessed via non-parametric tests: Chi square for nominal items, Kruskal Wallis for oridinal scale items

Alpha criterion of p<0.05 used for all tests

Composite satisfaction score created from sum of 8 satisfaction/outcomes items

RESULTS

Comparisons between residency clinic based family physicians, family medicine community clinic based family physicians and micropractice clinicians.

N=92 Residency clinic: 44% Community clinic: 32% Micropractice clinic: 32%

RESULTS: SATISFACTION

Micropractice providers reported: The least satisfaction with income The greatest satisfaction with family time The greatest satisfaction with the ability to

provide continuity of care

SATISFACTION

RESULTS: OUTCOMES

Given the total work situation, micropractice clinicians rate the overall quality of the medical care they provide higher than residency or community clinicians.

Practitioners in the microclinic model rate their ablility to achieve professional goals the highest

Microclinic practitioners were the least likely to be planning to leave their practice.

OUTCOMES

RESULTS: PRACTICE

Microclinic: Least likely to work under time pressures Have the most influence over management

decisions affecting their practice Are more often able to match the degree of

complexity of a patient to the amount of time spent.

Most satisfied with opportunities to fully utilize skills.

PRACTICE

SCOPE OF PRACTICE

Only 16% of those in a micropractice do inpatient medicine (vs 91% residency and community)

Only 9% do OB. (vs 44% community and 65% residency)

RESULTS: COMPOSITE SATISFACTION

Composite “Satisfaction” scale based on 8 items that asked directly about satisfaction

• One item deleted (“plan to leave workgroup in near future”) because substantially lowered overall reliability of scale

• Final scale had reliability of alpha = 0.77 (acceptable/good)

COMPOSITE SATISFACTION

Community Clinic

24.8

Microclinic 29.1

Residency Clinic

25.6

Practice models differ in Composite Satisfaction (P < 0.001)

DIFFERENT CHARACTERISTICS CONFOUNDERS?

Age, gender, years since residency, and number of hours spent on patient care each week do not differ significantly among practice models

Years in Current Practice and Practice Setting (urban-suburban-rural) do differ

PRACTICE SETTING

Although the setting differs among the 3 practice models, Microclinic practices have the most balanced distribution of the 3 models, so not likely the cause of greater satisfaction

Practice setting compared for Community, Microclinic, and

Residency clinic models

YEARS IN THE SAME PLACE

Those with less than 5 and more than 20 years in the same clinic are most satisfied (top)

And those in Microclinic practices definitely fall into the “fewer than 5” category” (bottom)

Satisfaction and years in clinic – all 3 practice models

Years in current clinic by practice model

YEARS IN THE SAME PLACE

However, if we look at only the Residency and Community clinic physicians, it is clear that those with fewer than 5 years in the same clinic are more satisfied within those settings as well.

Satisfaction and years in clinic – Residency and Community Clinics only

DISCUSSION-

Community clinics: Sense of organization being “too big”, that

physicians are not a part of the decision making team. Not enough support for primary care.

Sense that “one size does not fit all”

DISCUSSION

Residency clinics: Not enough support/positive reinforcement.

Seems like organization only cares about RVUs. Feel pressure to produce, to reach protocol

standards, to have patients be “very satisfied”…no time left to think deeply about anything

Difficulty in continuity of care in residency clinics

Battle between clinic productivity, teaching, researching, leadership roles

Teaching/educating role seems to mitigate some of the negatives- other studies support this finding.

DISCUSSION

Micropractice: Low income Still working other jobs Trying to work outside insurance system Happy to be off “hamster wheel” Great to be own boss Loss of procedures/hospital credentialing Probably going to need an assistant

COMMON THEMES

Role of support staff Frustrations with the roles of specialist-

taking over patients after a consult Communication Primary care as undervalued Stretched too thin Insurance Unpaid work

CONCLUSIONS

Overall physician satisfaction is greater for those working in a micropractice clinic.

Micropractice clinicians have an overwhelmingly narrower scope of practice.

FUTURE

Are micropractice clinics financially viable? Can the features of a practice that make

microclinic providers happier be applied to more traditional models of practice?

REFERENCES: Beasley et. al. Quality of Work life of Independent vs Employed Family

Physicians in Wisconsin: A WReN study. Annals of Family Medicine. Vol 3,No 6. Nov/Dec 2005

Linzer, M, et. al. Physician stress: results from the physician work life study. Stress health. 2002; 8:37-42

Moore  LG.  Going solo: one doc, one room, one year later.  Fam Pract Manag. March2002:25–29.

Moore LG. The Ideal Medical Practice Model: Improving Efficiency, Quality and the Doctor-Patient Relationship. Fam Pract Manag. 2007 Sep;14(8):20-24