Satisfaction and Depression in German Primary Care Doctors

This issue of the Deutsches Ärzteblatt International contains the reports of two studies on job satisfaction (1) and mental health (2) among primary care doctors. These studies appear to have yielded contradictory findings.

Primary care doctors’ dissatisfaction with the health-care system was already revealed in an earlier publication (3). The study by Unrath et al. goes farther, showing what seems at first glance to be a link between job dissatisfaction and depression in this subset of physicians. The depressive symptoms that were assessed by the instrument used in this study (a questionnaire) do not merely reflect the sadness from which we all suffer now and then: This becomes obvious from the fact that 17.5% of the respondents said they had taken a psychoactive drug at least once in the past year—a third of them regularly. Thus, among the one-third of the primary care doctors surveyed who responded to the questionnaire, the prevalence of poor mental health seems worrisome, and considerably higher than in the general population. Some allowance must be made, however, for the methodological difficulty of comparing results across different population studies.

Depression and job dissatisfaction reinforce each other

A further finding of Unrath et al. is that the factors most strongly associated with the use of psychoactive drugs were leisure-time stress, a personality type predisposing to negative emotions and simultaneously to inhibition of the display of such emotions, and, lastly, a lack of job satisfaction. The concept of “association” does not in itself imply, however, that job dissatisfaction or leisure-time stress plays a major role in the causation of depression. The reverse could just as easily be the case, and there might be causation in both directions.

And so we arrive once again at the same question that gave rise to so much debate four decades ago, when an association was found between poor mental health and low socioeconomic status: Which one is the cause, and which one the effect? Further studies, employing increasingly sophisticated methods, eventually led to the conclusion that a mutual reinforcement of these two factors is responsible for the observed association, which is still present today.

Extrapolating this to the findings of Unrath et al., we can say the following: Among persons at the border between mental stability and depression, some will certainly be pushed toward depression by external conditions such as an unsatisfactory work environment or an unsatisfactory personal life. On the other hand, there will certainly be other physicians whose personality type was in some way depressive from the start and who may well have chosen their profession under the influence of personality traits that go along with this personality type.

Thus, we should take note of the finding that job dissatisfaction (among other things) is associated with depression, and we should look forward to future studies that might explain why this is so. We should by no means conclude, however, that being a primary care doctor in itself causes depression; for all we know, other medical specializations might even carry a higher risk of mental illness.

Many physicians are highly satisfied with their work

The study by Behmann and Schmiemann, et al., which is also published in this issue, led to a rather different result. With one-third of the primary care doctors surveyed responding to the questionnaire (just as in the other study), most respondents said they were satisfied or highly satisfied with their work. Indeed, more than 90% said they were satisfied with the part of their job that involves patient contact, which is, of course, the central element of a primary care doctor’s professional work. Most, however, were dissatisfied with the administrative tasks that they had to carry out, and about half were dissatisfied with their remuneration.

As we know, even if primary care doctors earn less than other specialized physicians, they are still among the top money-earners in Germany. I therefore doubt that dissatisfaction with income could have any appreciable effect on their mental health. Likewise, having to perform administrative tasks may indeed be bothersome, but I question whether it could actually cause disease. Earning well, but less then other physicians, might give rise to emotional discomfort; yet it seems questionable whether this discomfort could actually go so deep as to harm a primary care doctor’s mental health.

Conceivably, the findings of Behmann and Schmiemann, et al. may have been skewed in the direction of job satisfaction by an over-representation of primary care doctors who were enthusiastic about their work (and thus not dissatisfied with it), because the main focus of the questionnaire was palliative care; the study on work satisfaction was only a side aspect. Of the five other studies on this topic that are all cited by the authors, four also revealed a high level of job satisfaction among primary care doctors, but not as high as was found in this one.

Conclusion

Drawing on my own experience as a primary care doctor, I conclude from these studies that German primary care doctors are highly satisfied with the work activities that constitute the core of their job—in particular, working with patients. This is hardly surprising: Primary care doctors have a great deal of individual control over what they do, their working day is more highly varied than that of practically any other type of physician, and their patients regularly and directly show their gratitude and loyalty. In sum, the working conditions of primary care doctors seem highly conducive to good mental health. Surely, this matters much more than any resentment over the unequal income between medical specialties, or exasperation with pointless paperwork.