Negative attitudes regarding relationships with colleagues, dissatisfaction or stressful relations with patients, and negative attitudes about organizational control of practice were also associated with burnout (p = .001). From 1991 to 1999, the number of physicians reporting great stress from long hours increased from 15 to 41%, physicians reporting great stress from inadequate time for patient visits increased from 37 to 48%, and the number of physicians reporting that the visit rate was too high to do a good job increased from 31 to 54% (p = .001 for all). The quality of professional relations was perceived to be worsening by 20% of physicians in 1991 but by 40% in 1999 (p = .001). Although satisfaction with patient relations and continuity of care remained stable, physicians experienced higher levels of stress from demanding patients in 1999 than in 1991 (p = .004). Measures of perceived organizational control of practice were unchanged. CONCLUSION: Key correlates of the increased burnout rates noted in 1999 appear to be stress from workload factors, stress from demanding patients, and perceptions of declining quality of professional relations. Further research needs to elucidate organizational and structural changes that can prevent burnout by modifying perceptions of physician workload and improving relationships with colleagues and patients. RESULTS: Most clinic encounters were satisfying to physicians and patients. The mean physician satisfaction score was 4.01, SD .92 (5-point scale) and the mean patient satisfaction score was 9.46, SD 1.13 (10-point scale). Continuity of care was associated with patient satisfaction. Patient satisfaction was 9.65 if they had seen the physician previously; whereas, it was 9.24 if they had not seen the physician previously (t = 3.61, p = .0004). However, physician satisfaction was not influenced by previously seeing the patient. Physician satisfaction for an encounter was greatest if the patient was the first of the clinic day compared to all others (4.15 vs. 3.96, t = 3.05, p = .002) . Similarly, patient satisfaction was greatest if they were the first patient of the clinic day (9.69 vs. 9.39, t = 3.13, p = .001). Physician satisfaction with the immediately preceding patient encounter also appears to influence satisfaction within a clinic visit. Physician satisfaction with a clinic visit is lower if the physician was dissatisfied with the patient from the immediately preceding clinic visit (p = .001). However, physician satisfaction with the preceding clinic visit does not influence patient satisfaction. CONCLUSION: The majority of clinic visits are satisfying to physicians and patients. However, clinic continuity, the order in which patients are seen and even the previous patient can influence satisfaction within a clinic visit. These insights can guide the development of educational strategies to improve the patient-physician interaction, which in turn should enhance the satisfaction of physicians and patients with clinical encounters. RESULTS: Overall unadjusted in-hospital mortality was 12.2%, and was similar during July ± September and October ± June in major (14.2% vs. 14.5%; p = .37) and minor (11.5% vs. 11.5%; p = .97) teaching hospitals, but differed in non-teaching hospitals (10.3% vs. 11.3%; p < .001).