Job satisfaction of physicians inRussia

Patrick OLeary, Natalia Wharton and Thomas QuinlanSt Ambrose University, Davenport, Iowa, USA

Abstract

Purpose The purpose of this paper is to determine the relationship between job characteristics andjob satisfaction amongst physicians in Russia.

Design/methodology/approach Overall satisfaction and relative satisfaction on the bases offacility and gender were measured. Approaches included the perception vs expectation paradigm, andstatistical techniques using chi-square, independent samples t-tests, and logistic regression.

Findings The study finds that, overall, male doctors report higher levels of satisfaction than femaledoctors, while those who work in polyclinics are more satisfied than those employed by hospitals.Female physicians are more satisfied in their relations with patients and colleagues than their malecounterparts. The majority of physicians are dissatisfied with administration and time constraints.

Practical implications This paper provides practical advice to hospital and polyclinic managersin Russia as attempts at reforming and restructuring the healthcare system gather momentum.

Originality/value There is scant empirical data on the job satisfaction of physicians in Russia.This paper found that job characteristic variables such as clinical autonomy, resources, time, andadministration moderate physician satisfaction relationships in Russia, just as they do in the West.

Keywords Doctors, Job satisfaction, Russia

Paper type Research paper

IntroductionSince the fall of the Soviet Union in 1991 the health care system in the RussianFederation has experienced dramatic changes. Although the constitution continued toguarantee universal access to medical care, government medical spending declined by75 percent in the decade from 1992-2002 (Webster, 2003). As a result, life expectancyfor a Russian man sank to 58.4 years, the lowest of the 53 countries in the World HealthOrganizations (WHO) European region (Parfitt, 2005). In addition, poor health andeconomic conditions are shrinking the countrys population by 700,000 people a year(Aris, 2005). In this difficult and precarious environment, many physicians have left theprofession, while many others have struggled to cope. This paper examines theirperceptions of job satisfaction.

BackgroundIn spite of the ongoing transition of the Russian economy, there is still a traditionalview of public health, which is based to a large extent on the ideals and priorities of theSoviet period (Axelsson and Bihari-Axelsson, 2005). Created under Joseph Stalin, theSoviet healthcare system emphasized preserving a healthy work force as a matter ofnational economic policy. To accomplish this, a huge network ranging from rural

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The authors wish to thank Dr Sergey Mironov and Dr Igor Anekin for their generous assistancewith this research.

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Received 18 February 2008Accepted 25 April 2008

International Journal of Health CareQuality AssuranceVol. 22 No. 3, 2009

pp. 221-231q Emerald Group Publishing Limited

0952-6862DOI 10.1108/09526860910953502

health posts to urban policlinics and hospitals was established. These weresupplemented by local health centers (usually staffed by a nurse and one or twospecialists), and specialized polyclinics. The system emphasized patient access andprevention of infectious diseases.

It created a large integrated infrastructure and despite its many weaknesses, wasone of the first in the world to provide universal access.

The Soviet system bequeathed an abiding belief that health care is, and shouldremain free at the point of use. When other sectors of society took the capitalist road todevelopment, the health system remained firmly rooted to socialist ideals. As a result,it remains top heavy with long hospital stays, large numbers of specialists seeing toofew patients, duplication of delivery systems, and a large bureaucracy. After thedemise of the Soviet Union, the economy of the Russian Federation collapsed in manyareas of society and the country experienced hyperinflation. This resulted in the drasticdevaluing of health sector expenditure and a financial crisis within the health system(Vienonen and Vohlonen, 2001). In 1994, the Russian Health Ministry reported that halfof the countrys 21,000 hospitals had no hot water, a quarter had no sewage systems,and several thousand had no water at all (Specter, 1995).

In this unstable environment, many physicians were forced to take a second job inorder to increase their income. This led to an exodus of talented physicians from thepublic sector for full private employment. For those who stayed, many coped by askingfor gifts from those they treated. A 2006 study conducted by TransparencyInternational, a global corruption watchdog, found that 13 percent of 1,502 respondentswho had sought medical help during the previous year paid an average of $90 underthe table (Danilova, 2007).

However, the outlook has improved. After enduring economic crisis and a $40billion debt default of 1998, the Russian economy has posted remarkable growthnumbers over the last few years (see Table I). Much of this economic gain is the resultof high world oil prices. Revenues from oil and gas exports bring in more than $550million a day and account for approximately 60 percent of government funds (Mityaev,2007). Taking advantage of the windfall, President Vladimir Putin has announcedmajor new outlays on health care, promising to pump some US$4 billion a year intofixing the countrys primary health care problems.

LiteratureJob satisfaction is generally conceived as an attitudinal variable that reflects the degreeto which people like their jobs, and is positively related to employee health and job

2003 2004 2005 20062007 (first4 months)

GDP growth (%) 7.3 7.2 6.4 6.7 n/aReal disposable income growth (%) 14.9 9.9 8.8 10.2 11.5Real wage growth (%) 10.9 10.6 10.0 13.4 18.5Average monthly wage (USD) 179.4 237.2 301.6 394.7 459.7Unemployment (%) 8.6 8.2 7.6 7.1 7.1

Source: World Bank (2007)

Table I.Economic and socialindicators for Russia

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performance (Spector, 1997). For many physicians, job satisfaction hinges on goodrelationships with staff and colleagues, control of time off, adequate resources, andclinical autonomy (Williams et al., 2003).

Reliable measures of physician job satisfaction help explain physicians behavior inclinical, economic, and organizational domains, as well as re-engineering medicalworkplaces to better meet the needs of doctors and patients (Konrad et al., 1999). Theconsequences of dissatisfaction include increased physician turnover, decreasedcontinuity of care for patients, increased cost of the medical system, and increasedpatient dissatisfaction (Murray, 2000).

Landon (2004) found that threats to physicians ability to manage their day-to-daypatient interactions and their time, as well as their ability to provide high-quality care,are most strongly associated with changes in career satisfaction. Stoddard et al. (2001)reported that the level of income and clinical autonomy are related to physiciansatisfaction. Rondeau and Francescutti (2005) found that institutional resourceconstraints are major contributors to emergency physician job dissatisfaction. Themost significant resource factors were availability of emergency room physicians,access to hospital technology and emergency beds, and stability of financial(investment) resources.

Martinez and Martineau (1998) identified several components of successful healthcare systems. These include:

. an education system that ensures an adequate supply of personnel with therequisite medical, managerial, and communication skills;

. a performance management system that uses information, structure, incentivesand rewards to achieve the best possible outcomes in the most efficient way; and

. innovations in working conditions and culture.

Murray et al. (2001) found that physicians who had to deal with multiple health plansand insurers were less satisfied than physicians who had an exclusive relationshipwith a single health care plan in most aspects of practices.

International comparisons in job satisfaction are particularly difficult because ofcultural and organizational differences. Nevertheless, there is growing evidence frommany countries that health professionals have become demotivated, with growingrates of burn-out reflecting a failure of working conditions to keep pace with theincreasing complexity of their work (Dubois et al., 2006). In a survey of over 1,000Swiss physicians, Bovier and Perneger (2003) found that patient care, professionalrelations, intellectual stimulation, and opportunities for continuing medical educationwere strong predictors of satisfaction while workload, time available for family, friendsor leisure, administrative burden, and work-related income and prestige werepredictors of dissatisfaction.

Grunfeld et al. (2005) note that the greatest source of job satisfaction amongstCanadian oncology physicians stemmed from patient care and contact, whileincreasing workloads emerged as major sources of job stress. A Japanese survey ofsome 4,896 doctors working for public clinics or hospitals found that continuingmedical education and interactions with municipal governments were rated as leastsatisfactory (Masatoshi et al., 2004).

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MethodologyAlthough physicians job satisfaction is a multidimensional construct (Nixon andJaramillo, 2003) the facets generally accessed in research include rewards, other people,nature of the work, and organizational context (Spector, 1997). The main theoreticalframework underlying this study is the concept of job characteristics developed byHackman and Oldham (1976, 1980). The model relates skill variety, task significance,feedback, autonomy, and friendship opportunities with both affective and behavioraljob outcomes. A meta-analysis by Loher et al. (1985) shows a positive relationshipbetween job characteristics and job satisfaction while a meta-analysis of 312 samplesby Bono et al. (2001), estimated a mean correlation between overall job satisfaction andjob performance to be 0.30.

The instrument used in this study was based on the Physician Worklife Survey(PWS) created by Konrad et al. (1999), and representing the Society for General InternalMedicine. The PWS employed a national sample of 2,325 physicians to validate theinstrument and reported reliabilities ranging from 0.65 to 0.77 on the ten-facetsatisfaction scale. Three scales measuring global job, career, and specialty satisfactionwere also constructed with reliabilities ranging from 0.84 to 0.88.

The survey used in this study contained a total of 75 questions and was divided intofive sections: training and current practice, ideal job, workload, job satisfaction, anddemographic information. The 38 satisfaction questions closely resembled those usedin the PWS survey but with modifications to suit the Russian context. One of theprimary researchers has experience as a primary care physician in Russia andconvened a focus group of five Russian physicians to ensure the survey captured thesubtleties of physician satisfaction in contemporary Russia. As a result, some newsatisfaction questions were developed. These included such areas as gifts frompatients, fictional paperwork, and feeling responsible for patients after discharge. Theinstrument was created in English, translated into Russian, and back-translated intoEnglish to ensure accuracy.

As noted by Vlachoutsicos and Lawrence (1996), in Russia researchers mustsurmount a number of obstacles, including the inefficiencies and lack of dependabilityof the postal system, the reticence toward Westerners, and the distrust of surveys thatremains from the Soviet era. Therefore, instead of relying on the traditional mailsurvey technique, we asked health professional volunteers to solicit participation in thestudy. The rationale for this approach was that health professionals would have morepersonalized relationships with physicians, thus increasing the likelihood ofparticipation and reducing non-response bias.

The survey was distributed to physicians in four Russian cities: St Petersburg,Rostov-on-Don, Vladimir, and Dubna. These cities were chosen because collaborativelinks had been established among study investigators through personal contacts,Sister Cities International, and church-sponsored projects. The cities vary in terms oflocation, population, and income. Summary indicators for each region and the countryas a whole are shown in Table II. The dates of the surveys varied for logistical reasons.Rostov-on-Don was surveyed in October 2005, St Petersburg in March 2006, Vladimirin June 2006, and Dubna in July 2006.

Access to physicians was primarily through their administrators who werethoroughly briefed on the background of the study, the aims of the research, and theneed for confidentiality. Participation was purely voluntary and physicians were under

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no pressure to participate. In some cases, the process of gathering the surveys wasentrusted to heads of departments. In others, surveys were distributed atadministrative gatherings, and completed surveys were left in a container. In noinstance did subjects return their survey to their supervisors or head of departmentdirectly.

ResultsThere were 203 usable surveys for a response rate of 67 percent. Nine respondents werein work assignments that were neither hospital nor polyclinic. Overall, 72 percent werefemale, the average age was 44 years, the length of the average workweek was 43hours, and the respondents reported an average of 15 years in practice.

Table III is a comparison of hospital employment vs polyclinic employment. Therewere significant differences in gender, age, and years of practice. Staffing at both typesof facilities was overwhelmingly female. The polyclinics had proportionately morefemale doctors than did the hospitals. Polyclinic doctors tended to be older than thoseemployed by the hospitals. The polyclinic doctors also had longer experience, reflectedas years in practice. The difference between the two types of facilities in terms oflength of the workweek was not statistically significant.

Indicator St Petersburg Rostov-on-Don Vladimir DubnaRussianFederation

Location Federal CityNorth West

North Caucasus 115 miles NEof Moscow

BordersMoscow

Comprises 88regions

Population 4,838,000 1,023,200 315,000 60,951 141 million

Income per head(% of federalaverage) 112 61 58 69 100

Sources: Central Intelligence Agency (2007); Norwegian Institute of International Affairs Center forRussian Studies (1995)

Table II.Selected variables of four

cities used in study

Variable Hospital Polyclinic Sig.

Gender 0.015Female (%) 67.3 87.2

Age in years 0.009Mean 43.230 48.210Std dev. 11.189 10.042

Hours worked per week 0.499Mean 43.671 38.6625Std dev. 18.752 21.301

Years in practice 0.027Mean 13.955 18.000Std dev. 9.532 9.905

Table III.Comparison of hospital

and polyclinicrespondents

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NotesA chi-square two-tail test of significance was used for gender. Independent samplest-tests were used for the other variables (equal variances not assumed). Sample sizevaried from 58 to 155 for the hospital grouping, and from ten to 39 for the polyclinicgrouping. The reason is because many of the respondents did not answer some of thequestions.

FindingsMale doctors report higher levels of satisfaction than female doctors. This finding isbased on a comparison of the ideal job questions (expectations) from the survey versusthe satisfaction questions (perceptions). On this basis, most differences are expected tobe negative, and in this survey, all are negative. This reflects the widespread view thatrespondent expectations tend to be high (Parasuraman et al., 1986). The means for themale doctors are less negative than those for the female doctors. Most of thesedifferences are not statistically significant except for time. Table IV contains asummary for this finding.

A similar comparison was made on the basis of facility. Polyclinic doctors reporthigher levels of satisfaction than those employed by hospitals (the means are positiveor less negative). However, most of these differences are not statistically significantexcept for compensation and colleague relationships. This is based on a comparison ofthe ideal job questions (expectations) versus the satisfaction questions (perceptions).On this basis, most differences are expected to be negative. On this survey, only one ispositive, meaning that perceptions actually exceeded expectations with respect topatient relationships in the polyclinic environment. See Table V.

Another way of assessing satisfaction is to look at the percentages of respondentswho awarded 4s and 5s agree and strongly agree with the satisfaction statements.These are compared against the percentages of 2s and 1s disagree and stronglydisagree. An award of 3 neither agree nor disagree is the neutral value. The resultsare in Table VI.

Satisfaction is indicated by majority or plurality. Plurality does not implyconsensus. On this basis, the majority of doctors are satisfied with patientrelationships, colleague and staff relationships, and prestige. The majority ofphysicians are dissatisfied with administration and time constraints.

Male Female Significance

Resources 21.65 21.77 0.585Patient relationships 20.20 20.36 0.688Autonomy 20.98 21.37 0.054Compensation 21.34 21.41 0.690Colleague relationships 20.40 20.43 0.829Patient care issues 20.85 21.03 0.198Administration 21.79 22.04 0.182PrestigeStaff relationships 20.54 20.96 0.459Time 21.04 21.72 0.006

Note: Prestige had no matching questions against which to compare

Table IV.Relative satisfaction onthe basis of gender

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Previously mentioned in this paper was a 2006 report by Transparency International(Danilova, 2007) that 13 percent of those seeking medical help were required to makegift payments to their physicians. In our survey, we asked physicians whether giftsfrom patients had become a significant part of total physician compensation. A total of14 percent stated that such was the case.

In their research on the work lives of American female physicians, McMurray et al.(2001) used data from the PWS to set up a logistic regression across the facets ofsatisfaction. We constructed a similar table reflecting nearly similar results for femalephysicians in Russia (see Table VII).

Russian female physicians have significantly greater odds of demonstratingsatisfaction in their relationships with patients and colleagues, and lower odds,suggesting dissatisfaction with levels of autonomy and resources. Although similarnumbers reflecting dissatisfaction with the amount of personal time andadministrative issues did not reflect statistical significance in McMurray et al.(2000), these issues demonstrated statistical significance in our study. A dissimilarfinding in our study of Russian physicians is that women physicians appear morelikely to be satisfied with their compensation than do their male counterparts.

Hospital Polyclinic Significance

Resources 21.79 21.59 0.309Patient relationships 20.48 0.44 0.090Autonomy 21.29 21.47 0.448Compensation 21.55 20.92 0.006Colleague relationships 20.53 20.07 0.003Patient care issues 21.07 20.95 0.449Administration 22.10 21.77 0.151PrestigeStaff relationships 20.88 20.87 0.970Time 21.65 21.33 0.310

Note: Again, prestige had no matching questions against which to compare

Table V.Relative satisfaction on

the basis of facility

Satisfied Dissatisfied Outcome Strength

Resources 0.29 0.40 Dissatisfied PluralityPatient relationships 0.72 0.15 Satisfied MajorityAutonomy 0.26 0.43 Dissatisfied PluralityCompensation 0.43 0.31 Satisfied PluralityColleague relationships 0.77 0.05 Satisfied MajorityPatient care issues 0.34 0.33 Satisfied PluralityAdministration 0.24 0.58 Dissatisfied MajorityPrestige 0.50 0.30 Satisfied MajorityStaff relationships 0.62 0.12 Satisfied MajorityTime 0.28 0.55 Dissatisfied MajorityCombined 0.45 0.31 Satisfied Plurality

Table VI.Strength of satisfaction

on each dimension

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Again, similar to McMurray et al. (2000), we found no significant difference in global(job) satisfaction. Nevertheless, women did suggest greater career satisfaction than didthe men. No significant differences were detectable in terms of specialty satisfaction.

DiscussionIn Russia, health care services are undergoing dramatic changes in structure andfinancing. The purpose of the study was to examine the relationship between jobexpectations and job perceptions among physicians in Russia. The study found thatdoctors were more likely to be satisfied if they maintained clinical autonomy, were paidwell, did not have excessive bureaucratic interference, and maintained positiverelationship with patients and colleagues.

This study also had an unusually high number of neutral responses (i.e. neitheragree nor disagree). Considering that most respondents entered the system in theSoviet times, this ambiguity is not surprising. Soviet doctors never enjoyed the statusand money of their Western counterparts. The medicine they practiced was consideredto be sub par, the system suffered from endemic shortages, and the social status of ageneral practitioner was respectable but modest.

Russia has 42.5 physicians and 105 beds per 10,000 people (Aris, 2005). This dwarfsthe corresponding numbers for the USA 28.1 and 27 respectively (HealthcareMarketplace Project, 2004). Young doctors in Russia earn less than $100 a month,senior doctors $200, and surgeons about $500 (Osborne, 2005). Despite low pay,imbalances in staffing, poor working conditions, regulatory and financial barriers tochange, this study found that job expectations are high. One plausible explanation forthis is high level of satisfaction derived from relationships with patients andcolleagues.

Polyclinic doctors were generally more satisfied than their hospital colleagues. Thisis not surprising as polyclinics are the dominant point of contact with the health caresystem. One out of three of Russias 400,000 doctors work at a polyclinic (Aris, 2005).Each polyclinic has its own territory of care responsibility. They have their own

Measure Odds ratio

Lowerconfidence

interval(95 percent)

Upperconfidence

interval(95 percent)

Significance( p-value)

Autonomy 0.51 0.33 0.78 0.002Patient relationships 18.33 5.79 58.04 0.000Colleague relationships 49.00 12.11 198.20 0.000Patient care issues 0.56 0.30 0.95 0.066Staff relationships 6.21 3.53 10.93 0.000Time 0.36 0.24 0.54 0.000Prestige 0.31 0.20 0.49 0.000Compensation 2.50 1.26 4.95 0.009Administration 0.14 0.08 0.93 0.000Resources 0.46 0.28 0.85 0.003Global job 4.41 0.24 80.88 0.317Global career 3.50 1.98 6.18 0.000Global specialty 7.73 0.56 107.24 0.128

Table VII.Dimensions of careersatisfaction in femalephysicians

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laboratories, diagnostic equipment, drug store, emergency cars, and specialists.Polyclinic doctors act like a family practitioner and will often visit patients at home.They may have as many as 2,000 patients under their supervision, assigned bygeographic area.

This research had a large majority of female respondents 67 percent hospital, 87percent polyclinic. Although the physician workforce in Russia is predominantlyfemale, there are significant persistent differences between men and women in severalof the dimensions of job satisfaction. In Russia, the healing professions are typicallythe domain of women. Many men enter medical school with the idea of becomingsurgeons or administrators. Women also reported more time pressure than men.Patient mix, including greater proportions of female patients may explain some of this,but other explanations are needed. Like most women in Russia, female physicians arealso primarily responsible for the family.

ConclusionThis paper provides empirical support for the multidimensionality of physicians jobsatisfaction and is consistent with the work of the PWS. Job characteristic variablessuch as resources, time, and administration moderate the practice arrangements andphysician satisfaction relationships. This remains so despite the working assumptionthat patients are best served when they have several physicians working together todevelop and monitor a coordinated plan of care.

A limitation of this study is its reliance on convenience samples drawn fromhospitals and clinics in four Russian cities. This strategy limits the generalizability ofthe results. Nevertheless, despite differences in the demographic, geographical, andsocio economic characteristics of the regions and physicians studied, a broad similarityof experiences and satisfaction emerged. This consistency suggests that our resultsmay be applicable to the rest of the countrys 88 regions and we invite futureresearches to investigate this proposition.

In the past few years, attempts at reforming and restructuring healthcare systems inRussia have gathered momentum. The structure is shifting away from over-reliance onspecialist/hospital care and towards more integrated primary care. Clinics andhospitals are reducing the number of beds, adopting modern treatment protocols andretraining physicians and health staff. With a refined focus on strengthening thetraining of primary care physicians, making providers autonomous entities, limitingthe bureaucracy of medicine, and emphasizing independence of action, it is likely thatRussian physicians can become more engaged and satisfied in their work settings.

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Corresponding authorPatrick OLeary can be contacted at: olearypatrickf@sau.edu

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