• Nancy L Keating, Bruce E Landon, John Z Ayanian, Catherine Borbas, and Edward Guadagnoli.
• Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA. keating@hcp.med.harvard.edu
• J Gen Intern Med. 2004 May 1; 19 (5 Pt 1): 410418410-8.

ObjectiveTo describe the practice settings, financial arrangements, and management strategies experienced by generalist physicians and identify factors associated with reporting pressure to limit referrals, pressure to see more patients, and career dissatisfaction.DesignCross-sectional mail survey.Participants And SettingSix hundred nineteen generalist physicians (62% response rate) caring for managed care patients in 3 Minnesota health plans during 1999.Measurements And Main ResultsTwenty-six percent of physicians reported pressure to limit referrals. In adjusted analyses, female physicians and those who were board certified acted as gatekeepers for most of their patients, received incentives based on performance reports and quality profiles, and received direct income from capitation, and were more likely than others to report this pressure (all P <.05). Sixty-two percent reported pressure to see more patients. In adjusted analyses, this pressure was more frequent among physicians in practices owned by health systems, those using physician extenders, and among physicians paid by salary with performance adjustment or those receiving at least some capitation (all P <.05). One-quarter (24%) of physicians were dissatisfied with their career in medicine. In adjusted analyses, physicians reporting pressure to limit referrals (risk ratio, 1.12; 95% confidence interval, 1.01 to 1.19) and those reporting pressure to see more patients (risk ratio, 1.37; 95% confidence interval, 1.08 to 1.66) were more likely to be dissatisfied than other physicians.ConclusionsPressures to limit referrals and to see more patients are common, particularly among physicians paid based on productivity or capitation, and they are associated with career dissatisfaction. Whether future changes in practice arrangements or compensation strategies can decrease such physician-reported pressures, and ultimately improve physician satisfaction, will be an important area for future study.

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