A Systematic Review of the Impact of Physicians’ Occupational Well-Being on the Quality of Patient Care

Background It is widely held that the occupational well-being of physicians may affect the quality of their patient care. Yet, there is still no comprehensive synthesis of the evidence on this connection. Purpose This systematic review studied the effect of physicians’ occupational well-being on the quality of patient care. Methods We systematically searched PubMed, Embase, and PsychINFO from inception until August 2014. Two authors independently reviewed the studies. Empirical studies that explored the association between physicians’ occupational well-being and patient care quality were considered eligible. Data were systematically extracted on study design, participants, measurements, and findings. The Medical Education Research Study Quality Instrument (MERSQI) was used to assess study quality. Results Ultimately, 18 studies were included. Most studies employed an observational design and were of average quality. Most studies reported positive associations of occupational well-being with patient satisfaction, patient adherence to treatment, and interpersonal aspects of patient care. Studies reported conflicting findings for occupational well-being in relation to technical aspects of patient care. One study found no association between occupational well-being and patient health outcomes. Conclusions The association between physicians’ occupational well-being and health care’s ultimate goal—improved patient health—remains understudied. Nonetheless, research up till date indicated that physicians’ occupational well-being can contribute to better patient satisfaction and interpersonal aspects of care. These insights may help in shaping the policies on physicians’ well-being and quality of care. Electronic supplementary material The online version of this article (doi:10.1007/s12529-015-9473-3) contains supplementary material, which is available to authorized users.


Introduction
Well-being of physicians is a growing concern [1,2]. Compared to the general working population, many physicians suffer from burnout [3][4][5], as they deal with high levels of work strain and emotional demands [2]. Physicians' wellbeing is vital not only to the individual physician, but also to their ability to provide high-quality patient care [2]. That is, research indicated that physicians who suffer from burnout provide less adequate patient care [6][7][8] and low levels of physicians' well-being could lead to suboptimal performing health care systems [2]. Reversely, physicians with higher levels of well-being tend to provide better patient care [9]. In Electronic supplementary material The online version of this article (doi:10.1007/s12529-015-9473-3) contains supplementary material, which is available to authorized users. particular, higher levels of physicians' satisfaction or commitment with work are associated with higher levels of patient satisfaction as well as better prevention and disease management by physicians [10,11].
High levels of work-related well-being can be conceptualized as occupational well-being, which is defined as a positive experience with or evaluation of one's work [12,13], involving satisfaction, commitment, involvement, or engagement [14][15][16]. As such, occupational well-being distinctively involves positive indicators of work experience, instead of negative indicators, such as burnout. Naturally, occupational wellbeing is vital to the daily practice of physicians and physicians can be energized and satisfied in providing their patients with the most appropriate treatment [17,18]. Indeed, many physicians experience high levels of job satisfaction and work engagement [19,20].
Most research on physicians' well-being has so far focused on negative indicators. In line with the positive psychology approach [21,22], it would provide comprehensive insight when additionally understanding the impact of positive occupational well-being of physicians. Research indicated that physicians with higher levels of work satisfaction deliver better patient care, possibly because they are motivated to make every effort for their patients [9]. Occupational well-being is accompanied by more positive emotions, energy, and concentration [12,13,23], and it is likely that physicians who experience more well-being, energy, and concentration in their work can more easily dedicate their full attention to patients' needs and provide them with optimal care. However, there is still no comprehensive synthesis of the evidence on the connection between physicians' occupational well-being and patient care quality. Therefore, it remains unclear if and which aspects of patient care quality are affected by occupational well-being of physicians. We conducted a systematic review of the effects of physicians' occupational well-being on the different aspects of quality of care.

Method
Before starting the review, all authors agreed upon the eligibility criteria, search strategy, study selection, data extraction, and quality assessment. The review process was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards [24].

Eligibility Criteria
Studies were considered to be eligible, when they examined the association between physicians' occupational well-being and the quality of patient care. This resulted in the following eligibility criteria. First, the study included empirical data; non-empirical articles, such as letters, comments, and editorials, were excluded. Second, physicians had to comprise the entire sample or results had to be available for physicians as a subgroup. Third, in order to study our research question on the impact of occupational well-being on patient care quality, we included only articles that conceptualized occupational well-being as predictor or exposure variable and patient care quality as the outcome variable. Non-English language articles were not included.

Data Sources and Searches
We searched the electronic databases MEDLINE, Embase, and PsycINFO from inception until August 12, 2014. A preliminary search was conducted with assistance of a clinical librarian to develop our search strategy and specify our keywords. We used both free text and MeSH (MEDLINE) or thesaurus (Embase and PsycINFO) terms on the following subjects: physicians, occupational well-being, and quality of patient care.
Occupational well-being was defined as a positive experience with or evaluation of work [12,13] and was searched with the terms job satisfaction, career satisfaction, professional satisfaction, job commitment, and work engagement. To reduce the chance of missing any relevant articles, we also included several synonyms (see Additional file).
We used the definition for quality of care provided in a framework introduced by Donabedian (1966) [25] which is widely used in quality of care research [26]. The framework distinguishes three elements of patient care quality: the quality of the structures (organizational factors of the health care system), processes (actual delivery of patient care), and outcomes of patient care (consequences of delivered care) [25]. For this review, we only included processes and outcomes of care, as the structure element of the Donabedian framework focuses on the system of patient care and not on individual physicians' delivery of patient care. Based on the definitions of processes and outcomes of patient care [25], we included the following search terms: patient centeredness, patient satisfaction, patient enablement, patient safety, and patient health outcomes (see Additional file). Finally, we performed a hand search on references of eligible articles to obtain additional eligible studies.

Study Selection
One author (RS) performed the search, which was duplicated by a clinical librarian. Subsequently, one author (RS) screened both title and abstract. Clearly, irrelevant studies were excluded at this point when both title and abstract did not include physicians, occupational well-being, or quality of patient care. Non-empirical articles (letters, comments, and editorials) were also excluded at this stage.
After screening, titles and abstracts of the remaining studies were independently reviewed by two authors (RS and BB). If abstracts were unavailable, the full-text article was retrieved and reviewed by one author (RS), following the same procedure as for the abstracts. If full text was unavailable as well, two authors (RS and BB) independently reviewed each title. Two authors (RS and BB) independently reviewed the full texts of all remaining articles. When no consensus was reached, a third author (KL) reviewed the article (for two studies in total).

Data Extraction and Quality Assessment
Data on study design, participants and setting, measures and measurements, and study findings were extracted by one author (RS) and duplicated by a second author (BB). When no consensus was reached, a third author (KL) assisted.
We used the Medical Education Research Study Quality Instrument (MERSQI) [27] to assess study quality on ten criteria: study design, number of institutions, response rate, type of data, internal structure, content validity, criterion validity, appropriateness and sophistication of data analyses, and outcome level. The ten MERSQI items form six domains, each with a maximum score of 3. The possible total MERS QI score can range from 5 to 18 [27]. Validity evidence of the MERSQI showed to be strong [27,28]. Two authors (RS and BB) independently scored five studies using the MERSQI criteria, after which they agreed upon a uniform scoring procedure.

Data Synthesis and Analysis
We intended to perform a meta-analysis to pool the findings of studies. However, meta-analyses can only yield valid results if the heterogeneity between studies is limited. In this review, the heterogeneity between studies was large, so no meta-analysis could be performed. We presented the findings of the individual studies descriptively in the text and tables. We categorized the different findings based on the different forms of occupational well-being as well as the different patient care quality categories of the Donabedian framework (see Tables 1 and 2).

Search Results
The search yielded 5944 unique hits (see Fig. 1, flow chart). Screening of title and abstract resulted in 387 potentially eligible articles. After abstract review, 89 articles remained and were independently reviewed and discussed on their full text. Finally, our systematic search resulted in 18 included articles. Hand search did not result in additional articles.

Occupational Well-Being and Quality of Patient Care
Given the diversity of included studies, we presented an overview of the direction of the study results in Table 2. The detailed results per study are presented in Table 3.
Eight studies reported on occupational well-being in relation to technical aspects of patient care. These showed contrasting results. Specifically, physicians with higher levels of Melville et al. [29] Williams et al. [30] Grol et al. [31] Perez-Carceles et al. [32] Grembrowski et al. [33] Haas et al. [34] Mache et al. [35] Szenenyi et al. [36] Dimatteo et al. [37] Conway et al. [ Negative association Studies that appear more than once in this table analyzed multiple associations between multiple variables occupational well-being reported less medical errors in two studies [30,42], while these associations were not reported in two other studies on this topic [43,45]. In addition, physicians' job satisfaction was not associated with avoidant or superfluous medical care in consultations [31]. Another study showed that satisfied physicians prescribed less medicine which are considered indicators of incautious prescribing [29]. Two studies showed that satisfied physicians were not more likely to perform adequate clinical procedures for hypertension patients, diabetes patients [43,44], asthma patients, or crosscutting care [44]. Physicians satisfied with their career were more likely to counsel 50-75-year-old patients regarding mammography [39], which can be considered a quality aspect of prevention as these involve a risk group for developing breast cancer (Table 3). With regard to interpersonal aspects of patient care, family physicians who were satisfied with their work were more open to the patient and paid more attention to psychosocial aspects [31] (see Table 3). In addition, satisfied physicians informed their patients more frequently about diagnosis, prognosis, treatment, complementary examinations, and the work and social/family impact of the illness process [32].
Five studies showed positive associations between physicians' job or career satisfaction and patient satisfaction in various specialties, i.e., family medicine, internal medicine, and surgery [33][34][35][36]40]. Furthermore, one study on patient adherence showed that patients of satisfied physicians adhered better to recommended medication, exercise, and diet than patients of physicians who were dissatisfied with their work [37]. Another study reported no associations between physicians' job satisfaction and patient satisfaction [46] (Table 3).
Physicians with higher levels of job satisfaction reported less suboptimal care (i.e., inadequate patient discharge, not performing a diagnostic test because of patients' desires, medication errors, and a lack of discussion of treatment with patients) [30]. Congruently, two studies showed that satisfied physicians reported better patient care quality than physicians who were less satisfied [38,41].
One study researched occupational well-being in relation to patient health outcomes. This study showed that job satisfaction of physicians was not associated with patients' selfreported pain and depressive symptoms [33].

Explanation of Findings
The findings of this review indicate that patients of physicians with high levels of occupational well-being were more satisfied with their treatment [33][34][35][36]40] and adhered better to treatment guidelines [37]. Physicians with higher levels of occupational well-being have a positive attitude toward work and are more    There was a significant correlation between satisfaction of the physician colleagues and patients' satisfaction with the organization of the practice (r=0.17, p=0.004), while there was no significant 12 Yes Ordinary-least square regression analysis Career satisfaction was positively related to quality of care (β=0.14, p<0.01).

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Yes likely to be optimistic and helpful to others [20]. Possibly, more satisfied and engaged physicians cross over their optimism and positive attitude to patients [48,49] [48,49] and leave the patient more satisfied and motivated to follow up on treatment recommendations. Ultimately, better adherence to treatment recommendations indirectly contributes to better health and wellbeing of patients [50]. Positive effects of occupational wellbeing are also visible in other health care professions. Research reported that, according to their supervisors, nurses engaged with their work perform better [51]. Also, on the long term, work engagement showed to benefit work performance [52] .
As physicians with high levels of occupational well-being experience less stress and more positive emotions [12,13,20], they have more energy and mental resources to direct full attention to patients. This resonates with our findings that physicians who experience high levels of occupational well-being are likely to direct more attention to patients' psychosocial aspects [31] and inform them more frequently about the process of care and on the social impact of the illness process [32]. Also, other research showed that physicians' well-being may positively influence interpersonal aspects of patient care, as physicians with positive affect generally talk more with patients [53].
Ultimately, the health care system is targeted at achieving better health and well-being for patients [50]. A vital and engaged physician workforce is thought to be one of the conditions under which optimal patient care can take place [2]. Strikingly, research so far failed to clarify the impact of physicians' occupational well-being on health care's ultimate goal-improved health of patients. In particular, only one study attempted to elucidate this issue. This study showed that occupational wellbeing did not affect pain and depressive symptoms of patients [33]. As this is only one study, clearly, more research is needed to draw nuanced conclusions on the impact of occupational well-being on patient health outcomes. This research could consider to involve both processes and outcomes of care, as it is reasonable to assume that occupational well-being directly affects care processes, i.e., physicians' behaviors, which ultimately contribute to patients' health.
Although most research on occupational well-being in relation to aspects of patient care quality shows rather consistent results, findings for technical aspects of patient care were conflicting. Technical aspects of patient care refer to all medical or clinical behaviors that physicians undertake in their treatment for patients, i.e., prescribing medicine or performing a physical examination [25]. Our review indicates that physicians with high levels of occupational well-being show more adequate prescribing behavior [29]. Previous research-outside the scope of this review-showed that physicians with higher levels of well-being (in terms of positive affect) prescribed less medicine to patients [53]. Nonetheless, higher levels of occupational well-being did not prevent physicians from delivering superfluous medical care, i.e., care which is not necessary according to the most recent standards [31]. Other conflicting findings were also reported for technical aspects of patient care in terms of medical errors, as two studies showed positive associations of physicians' occupational well-being with medical errors [30,42] and two others did not [43,45]. This could be due to the variation in measures, as medical errors may refer to various contents, ranging from missed diagnoses to guideline non-adherence. Future research on occupational well-being could benefit from standardized measures on technical aspects of patient care. Some studies in this review studied specific aspects of patient care (i.e., informing patients); others reported overall patient care quality and did not specify the specific content or aspects of patient care quality [30,38,41]. These studies on overall quality consistently showed that physicians with higher levels of occupational well-being report better quality of patient care. More than the other studies included in this review, these studies used self-reported measures for patient care quality. Therefore, these findings should be interpreted with caution, as these findings could possibly be associated with so-called rose-colored glasses [54]. That is, a general positive attitude of physicians with higher levels of occupational well-being could account for the following positive perception of their own delivery of care [55]. Nonetheless, these findings on the positive impact of occupational well-being resonate with a previous review on negative consequences of physicians' lack of wellbeing [2]. That is, as previous research reported negative consequences of physicians' lack of well-being on the quality of care [2], it is not unreasonable to assume that the presence of physicians' occupational well-being indeed induces positive effects on overall quality of care [56].
The majority of the included studies in this review focused on job satisfaction as a measure of occupational well-being; other forms of occupational well-being are understudied. For example, we only found one study on work engagement. Compared to job satisfaction, other forms of occupational well-being such as work engagement, have shown to induce larger effects on work performance in non-medical professions [57], therefore, more extensive research on these forms may be relevant for clinical practice.

Limitations
Like many systematic reviews, our review could have suffered from publication bias [24]. Based on the MERSQI quality criteria, we could conclude that most studies were of average quality [27] and many studies were multicenter, showed reasonable response rates, and used validated measurements. Yet, some studies had limitations, such as the use of physicians' self-reported data of patient care delivery [54]. In addition, the heterogeneity of measures of occupational well-being was large, hindering comparison of results and meta-analysis. On the other hand, both occupational well-being and quality of patient care are not one-dimensional constructs. Therefore, the heterogeneity provided a multifaceted view on occupational well-being in relation to the quality of patient care.
We included studies from many countries and different health systems. Because of the differences between health care systems, the working conditions of physicians and, ultimately, their occupational well-being could differ between systems [58,59]. The aim of this study was to present an overview of the empirical literature on physicians' occupational wellbeing in relation to quality of care. Additional research is needed to understand the (possible) variations in this link across health care systems.

Implications
In the last decade, research and society increasingly focused on the prevention of burnout or other negative forms of physician well-being, in order to prevent physicians from delivering suboptimal patient care [2]. As an addition hereupon, this review yields starting points to enhance quality of patient care by mapping the effects of positive occupational well-being. Following the findings of this systematic review, patient satisfaction, patient adherence to treatment recommendations, and interpersonal aspects of patient care are most likely to benefit from increased occupational well-being of physicians. To that end, health care organizations could focus on creating optimal working conditions for physicians, possibly beneficial for their occupational well-being and, ultimately, quality of patient care. Future research could facilitate this process, by studying which specific working conditions positively contribute to occupational well-being of physicians. Although research already systematically summarized studies on the working conditions, work hours, shift length, night float, and protected sleep time [60,61], there is little research on the effects of many other influential working conditions in medical practice (e.g., performance feedback and autonomy).
As patient care can increasingly be characterized by multidisciplinary teamwork [62,63], future research could focus on how levels of occupational well-being among team members interact in producing better patient care. Positive feelings about work appear to cross over between colleagues in work teams [64,65] and might boost quality of teamwork [66].

Conclusions
Although there is substantial research on potential consequences of physicians' well-being, the impact on patient care's central goal-improved patient health-remains understudied. Nonetheless, research provided clarity on the association of occupational well-being with other aspects of patient care quality. This research found that physicians' occupational well-being could positively contribute to patient satisfaction and the quality of interpersonal aspects of care. Therefore, physicians' occupational well-being not only is vital to a healthy physician workforce, but also may contribute to better treatment and positive experiences of patients [50].