OBJECTIVE:To examine the differences in physician satisfaction associated with open-versus closed-model practice settings and to evaluate changes in physician satisfaction between 1986 and 1997. Open-model practices refer to those in which physicians accept patients from multiple health plans and insurers (i.e., do not have an exclusive arrangement with any single health plan). Closedmodel practices refer to those wherein physicians have an exclusive relationship with a single health plan (i.e., staff-or group-model HMO). DESIGN:Two cross-sectional surveys of physicians; one conducted in 1986 (Medical Outcomes Study) and one conducted in 1997 (Study of Primary Care Performance in Massachusetts).SETTING: Primary care practices in Massachusetts. PARTICIPANTS: General internists and family practitioners in Massachusetts.MEASUREMENTS: Seven measures of physician satisfaction, including satisfaction with quality of care, the potential to achieve professional goals, time spent with individual patients, total earnings from practice, degree of personal autonomy, leisure time, and incentives for high quality. RESULTS:Physicians in open-versus closed-model practices differed significantly in several aspects of their professional satisfaction. In 1997, open-model physicians were less satisfied than closed-model physicians with their total earnings, leisure time, and incentives for high quality. Openmodel physicians reported significantly more difficulty with authorization procedures and reported more denials for care. Overall, physicians in 1997 were less satisfied in every aspect of their professional life than 1986 physicians. Differences were significant in three areas: time spent with individual patients, autonomy, and leisure time (P .05). Among openmodel physicians, satisfaction with autonomy and time with individual patients were significantly lower in 1997 than 1986 (P .01). Among closed-model physicians, satisfaction with total earnings and with potential to achieve professional goals were significantly lower in 1997 than in 1986 (P .01).CONCLUSIONS: This study finds that the state of physician satisfaction in Massachusetts is extremely low, with the majority of physicians dissatisfied with the amount of time they have with individual patients, their leisure time, and their incentives for high quality. Satisfaction with most areas of practice declined significantly between 1986 and 1997. Openmodel physicians were less satisfied than closed-model physicians in most aspects of practices.

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Part-time physicians perform as well as full-time physicians in most aspects of primary care, including all interpersonal aspects of care, as reported by patients. Patients of physicians working more than 65 hours per week experienced higher levels of visit-based continuity of care than patients of physicians working fewer hours, but this appears to carry a cost to those physicians in the area of personal and professional satisfaction. Subsequent research should examine the relationship between physician workload and technical aspects of care.