The secret to satisfaction: empowerment for all.

“Tsunami,” “sea change,” and “revolution”—these are some of the terms used to describe what is happening in medicine. All of us have experienced the change in one way or another. None of us knows what it will eventually produce. Few people really embrace change; for physicians, the process has been particularly unsettling. So what does Freeborn's study have to do with change? The widely held perception is that physicians are unhappier than ever—they are leaving medicine at higher rates, they are increasingly applying for disability, and they are less willing to recommend medicine as a career to others. Physicians cite rising workloads and falling reimbursement as the agents of their unhappiness. This article indicates the influence of physicians' perception of control on their satisfaction and well-being. The survey was done nearly 10 years ago, in a setting that represents only a fraction of American physicians. Still, does it tell us something that is relevant to all physicians, or could workload and income really be what is behind physician dissatisfaction in settings other than Kaiser? My own conversations with physicians suggest that these factors do have some effect on physicians, but they are not the primary drivers of dissatisfaction. Physicians are used to working hard and willingly impose heavy workloads on themselves. Moreover, working hard, as indicated by Freeborn's study, is not a powerful indicator of dissatisfaction. What about income? The study is silent on this point. However, an older study showed that physicians, when faced with changes in reimbursement, tended to optimize, rather than maximize, their income.1 Physicians expect a reasonable income, but few chose to practice medicine as a way of becoming wealthy. This brings us back to control. In the study, it was defined as “the ability to influence work environment, opportunity to participate in decision making, the degree to which lack of autonomy contributes to feelings of stress, and satisfaction with control over schedule.” The importance of control is not unique to physicians. Psychological studies from the 1970s revealed that, under stress, people who had a greater sense of control over what occurred in their lives remained healthier than those who felt powerless in the face of external forces.2 The need for a sense of control may, in fact, play a central role in all of our lives.3 For physicians, it does indeed seem as if the control has gone elsewhere. It is in the hands of the insurance companies, the government, the employers, and yes, the patients. What can be changed? Because Freeborn's study underscores the central role of physicians' influence over their practice environment, perhaps therein lies the potential for improvement. Organizations that involve their physicians in the design of how service is delivered are likely to have more satisfied, happy, and committed physicians. We must also remind ourselves that we will not be returning to the “good old days.” Ultimately, control will be in patients' hands. Most physicians applaud this trend. To them, real empowerment lies in the relationship that creates a true partnership between physician and patient. Even now, the perceived loss of control is not a universal phenomenon. Many physicians do not feel powerless. What is it that differentiates the empowered physician from the powerless one? Context certainly counts, but other factors play a role, too—one's intrinsic sense of optimism, sometimes known as “hardiness,” seems to affect one's sense of control under stress. The degree of support from colleagues and family is another factor. Finally, it may be that some physicians have already embarked on a change process that contributes to a sense of control and, thus, improved well-being. In the meantime, what's to be done? How do we imbue more physicians with a greater sense of control? I believe the answer comes from recalling why it is that we became physicians in the first place. In the words of Don Berwick: I envision a system in which those who depend on us have total access to the help they need in the form they need it when they need it, freed from the tyranny of individual visits with overburdened professionals as the only way to find a healing relationship, absolutely committed to excellence as the standard, guaranteeing a match between the work that is done and the best known forms for that work anywhere, valuing such excellence over ill-considered autonomy, promising safety in our hands, and capable of nourishing trusting interactions in which information is open, quality is individually defined—“every patient is the only patient”—control resides first and always with the patients whose lives we enter for a while, and trust grows in dignified transparency and daylight on our work.4 If we can achieve this vision, we will be true professionals, and control will not be an issue.