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Job satisfaction of physicians in

Russia

Job satisfaction
of physicians

Patrick OLeary, Natalia Wharton and Thomas Quinlan

St Ambrose University, Davenport, Iowa, USA
Abstract

221
Received 18 February 2008
Accepted 25 April 2008

Purpose The purpose of this paper is to determine the relationship between job characteristics and
job satisfaction amongst physicians in Russia.
Design/methodology/approach Overall satisfaction and relative satisfaction on the bases of
facility and gender were measured. Approaches included the perception vs expectation paradigm, and
statistical 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 female
doctors, 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 male
counterparts. The majority of physicians are dissatisfied with administration and time constraints.
Practical implications This paper provides practical advice to hospital and polyclinic managers
in 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, and
administration moderate physician satisfaction relationships in Russia, just as they do in the West.
Keywords Doctors, Job satisfaction, Russia
Paper type Research paper

Introduction
Since the fall of the Soviet Union in 1991 the health care system in the Russian
Federation has experienced dramatic changes. Although the constitution continued to
guarantee universal access to medical care, government medical spending declined by
75 percent in the decade from 1992-2002 (Webster, 2003). As a result, life expectancy
for a Russian man sank to 58.4 years, the lowest of the 53 countries in the World Health
Organizations (WHO) European region (Parfitt, 2005). In addition, poor health and
economic conditions are shrinking the countrys population by 700,000 people a year
(Aris, 2005). In this difficult and precarious environment, many physicians have left the
profession, while many others have struggled to cope. This paper examines their
perceptions of job satisfaction.
Background
In spite of the ongoing transition of the Russian economy, there is still a traditional
view of public health, which is based to a large extent on the ideals and priorities of the
Soviet period (Axelsson and Bihari-Axelsson, 2005). Created under Joseph Stalin, the
Soviet healthcare system emphasized preserving a healthy work force as a matter of
national economic policy. To accomplish this, a huge network ranging from rural
The authors wish to thank Dr Sergey Mironov and Dr Igor Anekin for their generous assistance
with this research.

International Journal of Health Care

Quality Assurance
Vol. 22 No. 3, 2009
pp. 221-231
q Emerald Group Publishing Limited
0952-6862
DOI 10.1108/09526860910953502

IJHCQA
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222

health posts to urban policlinics and hospitals was established. These were
supplemented by local health centers (usually staffed by a nurse and one or two
specialists), and specialized polyclinics. The system emphasized patient access and
prevention of infectious diseases.
It created a large integrated infrastructure and despite its many weaknesses, was
one of the first in the world to provide universal access.
The Soviet system bequeathed an abiding belief that health care is, and should
remain free at the point of use. When other sectors of society took the capitalist road to
development, 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 too
few patients, duplication of delivery systems, and a large bureaucracy. After the
demise of the Soviet Union, the economy of the Russian Federation collapsed in many
areas of society and the country experienced hyperinflation. This resulted in the drastic
devaluing of health sector expenditure and a financial crisis within the health system
(Vienonen and Vohlonen, 2001). In 1994, the Russian Health Ministry reported that half
of 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 in
order to increase their income. This led to an exodus of talented physicians from the
public sector for full private employment. For those who stayed, many coped by asking
for gifts from those they treated. A 2006 study conducted by Transparency
International, a global corruption watchdog, found that 13 percent of 1,502 respondents
who had sought medical help during the previous year paid an average of $90 under
the table (Danilova, 2007).
However, the outlook has improved. After enduring economic crisis and a $40
billion debt default of 1998, the Russian economy has posted remarkable growth
numbers over the last few years (see Table I). Much of this economic gain is the result
of high world oil prices. Revenues from oil and gas exports bring in more than $550
million a day and account for approximately 60 percent of government funds (Mityaev,
2007). Taking advantage of the windfall, President Vladimir Putin has announced
major new outlays on health care, promising to pump some US$4 billion a year into
fixing the countrys primary health care problems.
Literature
Job satisfaction is generally conceived as an attitudinal variable that reflects the degree
to which people like their jobs, and is positively related to employee health and job

Table I.
Economic and social
indicators for Russia

GDP growth (%)

Real disposable income growth (%)
Real wage growth (%)
Average monthly wage (USD)
Unemployment (%)
Source: World Bank (2007)

2003

2004

2005

2006

2007 (first
4 months)

7.3
14.9
10.9
179.4
8.6

7.2
9.9
10.6
237.2
8.2

6.4
8.8
10.0
301.6
7.6

6.7
10.2
13.4
394.7
7.1

n/a
11.5
18.5
459.7
7.1

performance (Spector, 1997). For many physicians, job satisfaction hinges on good
relationships with staff and colleagues, control of time off, adequate resources, and
clinical autonomy (Williams et al., 2003).
Reliable measures of physician job satisfaction help explain physicians behavior in
clinical, economic, and organizational domains, as well as re-engineering medical
workplaces to better meet the needs of doctors and patients (Konrad et al., 1999). The
consequences of dissatisfaction include increased physician turnover, decreased
continuity of care for patients, increased cost of the medical system, and increased
patient dissatisfaction (Murray, 2000).
Landon (2004) found that threats to physicians ability to manage their day-to-day
patient 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 physician
satisfaction. Rondeau and Francescutti (2005) found that institutional resource
constraints are major contributors to emergency physician job dissatisfaction. The
most 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 health
care systems. These include:
.
an education system that ensures an adequate supply of personnel with the
requisite medical, managerial, and communication skills;
.
a performance management system that uses information, structure, incentives
and 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 plans
and insurers were less satisfied than physicians who had an exclusive relationship
with a single health care plan in most aspects of practices.
International comparisons in job satisfaction are particularly difficult because of
cultural and organizational differences. Nevertheless, there is growing evidence from
many countries that health professionals have become demotivated, with growing
rates of burn-out reflecting a failure of working conditions to keep pace with the
increasing complexity of their work (Dubois et al., 2006). In a survey of over 1,000
Swiss physicians, Bovier and Perneger (2003) found that patient care, professional
relations, intellectual stimulation, and opportunities for continuing medical education
were strong predictors of satisfaction while workload, time available for family, friends
or leisure, administrative burden, and work-related income and prestige were
predictors of dissatisfaction.
Grunfeld et al. (2005) note that the greatest source of job satisfaction amongst
Canadian oncology physicians stemmed from patient care and contact, while
increasing workloads emerged as major sources of job stress. A Japanese survey of
some 4,896 doctors working for public clinics or hospitals found that continuing
medical education and interactions with municipal governments were rated as least
satisfactory (Masatoshi et al., 2004).

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223

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224

Methodology
Although physicians job satisfaction is a multidimensional construct (Nixon and
Jaramillo, 2003) the facets generally accessed in research include rewards, other people,
nature of the work, and organizational context (Spector, 1997). The main theoretical
framework underlying this study is the concept of job characteristics developed by
Hackman and Oldham (1976, 1980). The model relates skill variety, task significance,
feedback, autonomy, and friendship opportunities with both affective and behavioral
job outcomes. A meta-analysis by Loher et al. (1985) shows a positive relationship
between job characteristics and job satisfaction while a meta-analysis of 312 samples
by Bono et al. (2001), estimated a mean correlation between overall job satisfaction and
job 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 Internal
Medicine. The PWS employed a national sample of 2,325 physicians to validate the
instrument and reported reliabilities ranging from 0.65 to 0.77 on the ten-facet
satisfaction scale. Three scales measuring global job, career, and specialty satisfaction
were 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 into
five sections: training and current practice, ideal job, workload, job satisfaction, and
demographic information. The 38 satisfaction questions closely resembled those used
in the PWS survey but with modifications to suit the Russian context. One of the
primary researchers has experience as a primary care physician in Russia and
convened a focus group of five Russian physicians to ensure the survey captured the
subtleties of physician satisfaction in contemporary Russia. As a result, some new
satisfaction questions were developed. These included such areas as gifts from
patients, fictional paperwork, and feeling responsible for patients after discharge. The
instrument was created in English, translated into Russian, and back-translated into
English to ensure accuracy.
As noted by Vlachoutsicos and Lawrence (1996), in Russia researchers must
surmount a number of obstacles, including the inefficiencies and lack of dependability
of the postal system, the reticence toward Westerners, and the distrust of surveys that
remains from the Soviet era. Therefore, instead of relying on the traditional mail
survey technique, we asked health professional volunteers to solicit participation in the
study. The rationale for this approach was that health professionals would have more
personalized relationships with physicians, thus increasing the likelihood of
participation 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 collaborative
links had been established among study investigators through personal contacts,
Sister Cities International, and church-sponsored projects. The cities vary in terms of
location, population, and income. Summary indicators for each region and the country
as 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, Vladimir
in June 2006, and Dubna in July 2006.
Access to physicians was primarily through their administrators who were
thoroughly briefed on the background of the study, the aims of the research, and the
need for confidentiality. Participation was purely voluntary and physicians were under

Vladimir

Dubna

Russian
Federation

Indicator

St Petersburg Rostov-on-Don

Location

Federal City
North West

North Caucasus 115 miles NE Borders

of Moscow
Moscow

Comprises 88
regions

Population

4,838,000

1,023,200

315,000

60,951

141 million

Income per head

(% of federal
average)

112

61

58

69

100

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

Job satisfaction
of physicians

225
Table II.
Selected variables of four
cities used in study

no pressure to participate. In some cases, the process of gathering the surveys was
entrusted to heads of departments. In others, surveys were distributed at
administrative gatherings, and completed surveys were left in a container. In no
instance did subjects return their survey to their supervisors or head of department
directly.
Results
There were 203 usable surveys for a response rate of 67 percent. Nine respondents were
in work assignments that were neither hospital nor polyclinic. Overall, 72 percent were
female, the average age was 44 years, the length of the average workweek was 43
hours, and the respondents reported an average of 15 years in practice.
Table III is a comparison of hospital employment vs polyclinic employment. There
were significant differences in gender, age, and years of practice. Staffing at both types
of facilities was overwhelmingly female. The polyclinics had proportionately more
female doctors than did the hospitals. Polyclinic doctors tended to be older than those
employed by the hospitals. The polyclinic doctors also had longer experience, reflected
as years in practice. The difference between the two types of facilities in terms of
length of the workweek was not statistically significant.

Variable

Hospital

Polyclinic

Gender
Female (%)

67.3

87.2

Age in years
Mean
Std dev.

43.230
11.189

48.210
10.042

Hours worked per week

Mean
Std dev.

43.671
18.752

38.6625
21.301

Years in practice
Mean
Std dev.

Sig.
0.015
0.009

0.499

0.027
13.955
9.532

18.000
9.905

Table III.
Comparison of hospital
and polyclinic
respondents

IJHCQA
22,3

Notes
A chi-square two-tail test of significance was used for gender. Independent samples
t-tests were used for the other variables (equal variances not assumed). Sample size
varied from 58 to 155 for the hospital grouping, and from ten to 39 for the polyclinic
grouping. The reason is because many of the respondents did not answer some of the
questions.

226
Findings
Male doctors report higher levels of satisfaction than female doctors. This finding is
based on a comparison of the ideal job questions (expectations) from the survey versus
the satisfaction questions (perceptions). On this basis, most differences are expected to
be negative, and in this survey, all are negative. This reflects the widespread view that
respondent expectations tend to be high (Parasuraman et al., 1986). The means for the
male doctors are less negative than those for the female doctors. Most of these
differences are not statistically significant except for time. Table IV contains a
summary for this finding.
A similar comparison was made on the basis of facility. Polyclinic doctors report
higher levels of satisfaction than those employed by hospitals (the means are positive
or less negative). However, most of these differences are not statistically significant
except for compensation and colleague relationships. This is based on a comparison of
the ideal job questions (expectations) versus the satisfaction questions (perceptions).
On this basis, most differences are expected to be negative. On this survey, only one is
positive, meaning that perceptions actually exceeded expectations with respect to
patient relationships in the polyclinic environment. See Table V.
Another way of assessing satisfaction is to look at the percentages of respondents
who awarded 4s and 5s agree and strongly agree with the satisfaction statements.
These are compared against the percentages of 2s and 1s disagree and strongly
disagree. An award of 3 neither agree nor disagree is the neutral value. The results
are in Table VI.
Satisfaction is indicated by majority or plurality. Plurality does not imply
consensus. On this basis, the majority of doctors are satisfied with patient
relationships, colleague and staff relationships, and prestige. The majority of
physicians are dissatisfied with administration and time constraints.

Table IV.
Relative satisfaction on
the basis of gender

Resources
Patient relationships
Autonomy
Compensation
Colleague relationships
Patient care issues
Administration
Prestige
Staff relationships
Time

Male

Female

Significance

21.65
20.20
20.98
21.34
20.40
20.85
21.79

21.77
20.36
21.37
21.41
20.43
21.03
22.04

0.585
0.688
0.054
0.690
0.829
0.198
0.182

20.54
21.04

20.96
21.72

0.459
0.006

Note: Prestige had no matching questions against which to compare

Resources
Patient relationships
Autonomy
Compensation
Colleague relationships
Patient care issues
Administration
Prestige
Staff relationships
Time

Hospital

Polyclinic

Significance

21.79
20.48
21.29
21.55
20.53
21.07
22.10

21.59
0.44
21.47
20.92
20.07
20.95
21.77

0.309
0.090
0.448
0.006
0.003
0.449
0.151

20.88
21.65

20.87
21.33

0.970
0.310

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

Resources
Patient relationships
Autonomy
Compensation
Colleague relationships
Patient care issues
Administration
Prestige
Staff relationships
Time
Combined

Satisfied

Dissatisfied

0.29
0.72
0.26
0.43
0.77
0.34
0.24
0.50
0.62
0.28
0.45

0.40
0.15
0.43
0.31
0.05
0.33
0.58
0.30
0.12
0.55
0.31

Outcome

Strength

Dissatisfied
Satisfied
Dissatisfied
Satisfied
Satisfied
Satisfied
Dissatisfied
Satisfied
Satisfied
Dissatisfied
Satisfied

Plurality
Majority
Plurality
Plurality
Majority
Plurality
Majority
Majority
Majority
Majority
Plurality

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 make
gift payments to their physicians. In our survey, we asked physicians whether gifts
from patients had become a significant part of total physician compensation. A total of
14 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 of
satisfaction. We constructed a similar table reflecting nearly similar results for female
physicians in Russia (see Table VII).
Russian female physicians have significantly greater odds of demonstrating
satisfaction in their relationships with patients and colleagues, and lower odds,
suggesting dissatisfaction with levels of autonomy and resources. Although similar
numbers reflecting dissatisfaction with the amount of personal time and
administrative issues did not reflect statistical significance in McMurray et al.
(2000), these issues demonstrated statistical significance in our study. A dissimilar
finding in our study of Russian physicians is that women physicians appear more
likely to be satisfied with their compensation than do their male counterparts.

Job satisfaction
of physicians

227

Table V.
Relative satisfaction on
the basis of facility

Table VI.
Strength of satisfaction
on each dimension

IJHCQA
22,3
Measure

228

Table VII.
Dimensions of career
satisfaction in female
physicians

Autonomy
Patient relationships
Colleague relationships
Patient care issues
Staff relationships
Time
Prestige
Compensation
Administration
Resources
Global job
Global career
Global specialty

Odds ratio

Lower
confidence
interval
(95 percent)

Upper
confidence
interval
(95 percent)

Significance
( p-value)

0.51
18.33
49.00
0.56
6.21
0.36
0.31
2.50
0.14
0.46
4.41
3.50
7.73

0.33
5.79
12.11
0.30
3.53
0.24
0.20
1.26
0.08
0.28
0.24
1.98
0.56

0.78
58.04
198.20
0.95
10.93
0.54
0.49
4.95
0.93
0.85
80.88
6.18
107.24

0.002
0.000
0.000
0.066
0.000
0.000
0.000
0.009
0.000
0.003
0.317
0.000
0.128

Again, similar to McMurray et al. (2000), we found no significant difference in global

(job) satisfaction. Nevertheless, women did suggest greater career satisfaction than did
the men. No significant differences were detectable in terms of specialty satisfaction.
Discussion
In Russia, health care services are undergoing dramatic changes in structure and
financing. The purpose of the study was to examine the relationship between job
expectations and job perceptions among physicians in Russia. The study found that
doctors were more likely to be satisfied if they maintained clinical autonomy, were paid
well, did not have excessive bureaucratic interference, and maintained positive
relationship with patients and colleagues.
This study also had an unusually high number of neutral responses (i.e. neither
agree nor disagree). Considering that most respondents entered the system in the
Soviet times, this ambiguity is not surprising. Soviet doctors never enjoyed the status
and money of their Western counterparts. The medicine they practiced was considered
to be sub par, the system suffered from endemic shortages, and the social status of a
general practitioner was respectable but modest.
Russia has 42.5 physicians and 105 beds per 10,000 people (Aris, 2005). This dwarfs
the corresponding numbers for the USA 28.1 and 27 respectively (Healthcare
Marketplace 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 to
change, this study found that job expectations are high. One plausible explanation for
this is high level of satisfaction derived from relationships with patients and
colleagues.
Polyclinic doctors were generally more satisfied than their hospital colleagues. This
is not surprising as polyclinics are the dominant point of contact with the health care
system. 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

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 by
geographic area.
This research had a large majority of female respondents 67 percent hospital, 87
percent polyclinic. Although the physician workforce in Russia is predominantly
female, there are significant persistent differences between men and women in several
of the dimensions of job satisfaction. In Russia, the healing professions are typically
the domain of women. Many men enter medical school with the idea of becoming
surgeons 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 are
also primarily responsible for the family.
Conclusion
This paper provides empirical support for the multidimensionality of physicians job
satisfaction and is consistent with the work of the PWS. Job characteristic variables
such as resources, time, and administration moderate the practice arrangements and
physician satisfaction relationships. This remains so despite the working assumption
that patients are best served when they have several physicians working together to
develop and monitor a coordinated plan of care.
A limitation of this study is its reliance on convenience samples drawn from
hospitals and clinics in four Russian cities. This strategy limits the generalizability of
the results. Nevertheless, despite differences in the demographic, geographical, and
socio economic characteristics of the regions and physicians studied, a broad similarity
of experiences and satisfaction emerged. This consistency suggests that our results
may be applicable to the rest of the countrys 88 regions and we invite future
researches to investigate this proposition.
In the past few years, attempts at reforming and restructuring healthcare systems in
Russia have gathered momentum. The structure is shifting away from over-reliance on
specialist/hospital care and towards more integrated primary care. Clinics and
hospitals are reducing the number of beds, adopting modern treatment protocols and
retraining physicians and health staff. With a refined focus on strengthening the
training of primary care physicians, making providers autonomous entities, limiting
the bureaucracy of medicine, and emphasizing independence of action, it is likely that
Russian physicians can become more engaged and satisfied in their work settings.
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Corresponding author
Patrick OLeary can be contacted at: olearypatrickf@sau.edu

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