Abstract

Objective To explore how factors associated with various compensation models affect job satisfaction of family physicians.

Data sources Three databases were searched (Web of Science, Embase, and MEDLINE) with 3 keywords (MeSH headings) used: family physician, payment model, and job satisfaction.

Study selection To be included articles had to be peer reviewed, at least 50% of study participants had to be family physicians practising longitudinal or comprehensive care, and articles had to address career satisfaction in relation to compensation models. Twenty-seven studies were included.

Synthesis An extraction form was used to synthesize key details from each study, followed by thematic analysis. Four predominant job satisfaction factors were identified: workload or administrative burden, autonomy, income security, and justice or fairness of compensation. Five distinct models, representing both direct and indirect compensation, were identified in the literature most frequently: salaried, fee-for-service, capitation, loan repayment programs or incentives, and pay-for-performance. Each payment model had merits and drawbacks in relation to job satisfaction. Salaried physicians tended to experience less stress associated with administrative and management responsibilities; capitation models appeared to be associated with less workload stress; and fee-for-service models tended to be associated with a greater sense of autonomy. Income security, as provided by capitation and salaried models, was generally positively associated with job satisfaction.

Conclusion Use of blended models has the potential to address job satisfaction issues uncovered in this review and to maximize satisfaction among family physicians. Current changes and enhancements being made to compensation models in Canada present opportunities to further study their effects on family physician career satisfaction and attractiveness of the profession.

Policy-makers in Canada and elsewhere are introducing new compensation models for family physicians, accelerated by the current crisis related to shortages of professionals and the growing number of Canadians without access to a family doctor.1,2 Various compensation models are available, each with pros and cons.3 Governments are seeking mechanisms to attract and retain family physicians with added incentives4,5 and to shift from the most popular method of fee-for-service (FFS) payment to capitation or alternative payment models.6 According to the Canadian Institute for Health Information, FFS is the most prevalent compensation model in Canada, representing approximately 70% of all clinical payments to physicians from 2020 to 2021.7

While payment models have been introduced to address external policy objectives such as access to care,8 quality of care,9 or cost containment,10 it is now recognized that payment models factor into career choices for family physicians and affect job satisfaction.11 With interest in family medicine declining in Canada,2,12-14 there is a need to better understand how compensation factors into career choices and how it affects decisions to enter the profession, to remain in practice, and where to practise.

In Canada the entire health system is in crisis, with health human resource issues at the forefront of concerns15 and pertinent to all health care workers. Data from Canada and European countries have shown how shortages of family physicians directly affect patient care,16 emergency department burden,17 physician burnout,18 and dissatisfaction with career choice,19 with each challenge exacerbating shortages further. Complacency is unacceptable. Family physicians are feeling undervalued and discouraged,20 and when compensation is viewed as unfair or unsatisfactory, migration to regions offering more attractive compensation packages (and therefore potentially greater career satisfaction) may become more likely.

Other reviews have addressed wages and satisfaction among health care workers, including family physicians, exploring how quality of care, access to care, and satisfaction with levels of pay are affected.21 No reviews on career satisfaction were found to synthesize the literature solely from the perspective of family physicians. We undertook our review to explore how compensation models affect the satisfaction of family physicians, which could include ease of use of the model, receipt of fair pay for workload, and attractiveness of the compensation package and its alignment with expectations of family physicians.

As governments move to adopt enhanced compensation models, it is important to understand how physicians providing longitudinal or comprehensive care view these models and whether these strategies contribute to or detract from career satisfaction. The purpose of this scoping review aligns with Arksey and O’Malley’s description of scoping studies, which includes identifying knowledge gaps, mapping key concepts within a research area, and informing decision making.22 The research questions guiding this knowledge synthesis are: 1) What factors contribute to increased levels of job satisfaction? and 2) Is there a payment scheme associated with greater levels of satisfaction among family physicians?

METHODS

Protocol development was guided by the Joanna Briggs Institute methodology for scoping reviews.23

Data sources

Three databases were used in our search (Web of Science, Embase, and MEDLINE), conducted on May 9, 2023, to identify empirical articles published between January 1, 2000, and April 30, 2023. We pilot tested our screening process to ensure collective understanding of inclusion and exclusion criteria prior to embarking on a full review. Keywords, MeSH headings, and search strategies are defined in Appendix A, available from CFPlus.* A search of grey literature was not conducted.

Study selection

Inclusion criteria were developed to identify peer-reviewed articles that addressed career satisfaction in relation to compensation models, that were written in English, and in which at least 50% of participants were family physicians practising longitudinal or comprehensive care. All study designs were eligible.

Four reviewers (P.K., D.P., C.G., and S.C-N.) shared title and abstract screening independently, with 2 reviewers per paper; conflicts were resolved by a third reviewer. Where necessary, conflicts were discussed among reviewers. This process was repeated for the full-text review. While no formalized critical appraisal checklists were used, the overall quality of studies was judged through numerous discussions among 3 reviewers (P.K., D.P., and C.G.) to identify those most relevant to the research questions and those where study design was evident, methodology was well described, and risk of bias appeared to have been mitigated.

An extraction form was used to organize and synthesize key details from each of the studies, including type of payment model, measures of satisfaction, authors, country of origin, and publication date. Authors met frequently during the analysis stage to complete thematic analysis using dual coding, developing a codebook, and identifying themes present in the articles included.

SYNTHESIS

The search strategy retrieved 7717 articles and was documented in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocols.24 After eligibility screening, 27 studies were included for final data analysis (Figure 1).25-51 Most included studies were conducted in the United States (30%), the United Kingdom (22%), or Canada (15%). Among the 34,002 participants in the 27 studies, at least 14,277 (42%) were family physicians; the remaining participants included individuals from other medical specialties or health care professions. We did not achieve the goal of including only studies in which at least 50% of participants were family physicians; instead, authors discussed the inclusion worthiness of articles based on study design and applicability to the research topic, despite some ambiguity as to the precise number of family physician participants.

Figure 1.

Flowchart for literature search and study selection

Main factors

Four predominant job satisfaction factors were identified: workload or administrative burden, autonomy in practice, income security, and justice or fairness of compensation. Five models were identified most frequently (Table 1). These included 4 direct compensation types (salaried, FFS, capitation, and pay-for-performance [P4P]) and 1 indirect compensation model (loan repayment program or incentives [LRP-I]). Each model had merits and drawbacks associated with job satisfaction (Table 2).25,27-31,33,34,36,37,41-44,49,50

Table 1.

Compensation model characteristics

Table 2.

Pros and cons associated with compensation models

Workload or administrative burden. Workload was pivotal to job satisfaction and influenced by payment model in more than 62% of the studies. A greater load of administrative tasks, or “desktop medicine,”25 was associated with increased workload stress and, while not fully compensated in any model, was frequently cited as a source of dissatisfaction among those working in FFS or P4P models in several countries.26-30 One paper noted salaried physicians in the United Kingdom experienced less stress associated with administrative and management responsibilities.31 Decreased satisfaction was specifically noted when compensation models required physicians to see many patients with complex needs32-34 or increase their panel size to cover overhead costs.35 Capitation models appeared to induce less workload stress,36 whereas compensation linked to incentives based on clinical performance and quantity of work led to pressure to take on more work, which increased stress and decreased satisfaction.37,38

Autonomy in practice. Autonomy, or the ability to practise without substantial restrictions imposed by the payment model, influenced job satisfaction in 44% of the studies. Payment models that placed restrictions on practising family physicians—including the salaried, P4P, and LRP-I compensation types—were shown to lead to a reduced sense of autonomy and an overall decrease in job satisfaction.32,39,40 Restrictions requiring limited referrals to specialists27,41 were associated with salaried and P4P models, either as a constraint of the model or to fulfill a performance metric. Fee-for-service models were associated with a greater sense of autonomy, allowing physicians more flexibility in their practices with fewer restrictions.28,34

Income security. Income security, defined as predictable compensation or a pre-defined income (as in the capitation or salaried models), was generally positively associated with job satisfaction and identified as a factor in 30% of the studies. In a Norwegian study, income stability was valued by those considered less risk-tolerant and less prestige-oriented and tended to be preferred among women.42 Conversely, when payment models did not prioritize income stability, such as when the Alberta government changed billing codes43 or when earned payments were delayed or inconsistently applied in the United States,35 this led to distrust and dissatisfaction. One study from Tanzania noted that incentives, considered a non-uniform compensation model, were associated with lower retention rates for physicians.44

Justice or fairness of compensation. Justice or fairness of compensation was related to whether pay was seen as commensurate with the work or services provided, a factor identified in 22% of the studies. Clarity of expectations regarding the work and consistency in remuneration were factors aligned with fair compensation, with P4P models identified as both positively associated with job satisfaction29 and, when unfairly calculated, negatively affecting satisfaction.27 Verulava suggests justice at work is relevant to job satisfaction.30

Compensation models and general job satisfaction

Some articles found introducing different compensation models had overall effects on satisfaction. Godwin et al noted a neutral to positive change among participants in a shift from FFS to capitation models at 1 site in Ontario,45 Karakolias et al found salaried models were preferred in Greece,46 and Green et al found non-FFS models were associated with higher levels of work satisfaction in Ontario.47 One study in the United Kingdom found job satisfaction did not change following the introduction of a P4P model, despite indicators to the contrary that had prompted the study.48 In the United States, LRP-I models were associated with enhanced recruitment and retention owing to greater job satisfaction49,50 and were particularly beneficial in attracting family physicians to rural and underserved regions.51

DISCUSSION

Understanding the importance of compensation models to career satisfaction is vital for governments seeking to recruit and retain family physicians. Our review found 27 studies that addressed job satisfaction in relation to compensation models, highlighting factors that either fostered or diminished satisfaction. Untenable workloads, particularly administrative burdens, are a substantive factor when exploring preferred compensation models. Autonomy, income security, and justice are each viewed as components of job satisfaction and are each influenced by the compensation model. This review uncovered benefits and challenges with each but did not present conclusive evidence as to which type of compensation led to optimal job satisfaction for family physicians.

Acceleration in the adoption of new compensation models for family physicians in Canada is promising,52,53 particularly as the primary factor leading to job satisfaction (workload or administrative burden) is being addressed with blended compensation models that recognize this factor.54-56 The College of Family Physicians of Canada has described moving away from the traditional FFS model as “a welcome change.”54 It is worth watching and learning from this time of experimentation by governments. The premise of a satisfying career in family medicine includes values of fairness, compensation stability, the capacity to be autonomous, and minimal unpaid work (administrative in most cases).

Governments must also consider factors beyond what this review has uncovered, particularly in attracting a new generation to family medicine. Some evidence suggests resident physicians now place greater emphasis on achieving balance between work and leisure than in the past, prioritizing vacation time and benefit packages that align with salaried compensation models. Results of a 2018 Resident Doctors of Canada national survey indicated 54.3% of respondents were willing to sacrifice clinical autonomy in exchange for salaried compensation.57 Furthermore, given the amount of debt one accumulates before entering independent practice in primary care, it is worth considering the value of loan repayment programs, loan forgiveness, and incentives that support start-up costs for new physicians.51 In 2024 the Canadian government announced increases in student loan forgiveness available to family physicians, nurses, and nurse practitioners who choose to work in rural or underserved regions, an example of policy change recognizing challenges faced by early-career professionals.58

Shortages of family physicians in Canada are evident. An accelerated effort is needed to recruit and retain family physicians and allow them to experience a high degree of satisfaction in a rewarding career with fair compensation. Regions that successfully revamp compensation models for family physicians could be enticing to those considering relocation to achieve greater career satisfaction.59

Limitations

Limitations of our study include our inability to ensure that 50% of participants in included studies are family physicians, as not every study differentiated results by type of professional, with the overall proportion of family physician participants estimated to be 42%. Inclusion of grey literature may have provided additional insight into government policy or family physician association initiatives geared to support the adoption of 1 or more compensation models, but this was deemed beyond the scope of this study. Additionally, although we know total compensation is a factor in job satisfaction of family physicians,60 specifically because there is substantial disparity between family medicine and other specialties, this review focused solely on attributes of compensation models and their effects on job satisfaction. Given that other reviews have previously explored this phenomenon, studies related to compensation levels were considered beyond the scope of our review.21

Conclusion

The importance of attracting, training, recruiting, and retaining family physicians has reached a critical point for governments in Canada and beyond. Our review examined models of compensation for family physicians and identified aspects of job satisfaction affected by each. Salaried physicians experienced less stress associated with administrative and management responsibilities. Capitation models appear to be associated with less workload stress. Fee-for-service models were associated with a greater sense of autonomy. Income security, as found in capitation or salaried models, tended to be positively associated with job satisfaction. While no one model meets all career satisfaction criteria, the blending of models—currently being introduced throughout Canada—has the potential to maximize satisfaction by minimizing administrative burden, providing a degree of autonomy and security, and supporting fairness and justice. Further research would allow an exploration of key metrics of job satisfaction among family physicians in Canada in relation to compensation models. With some provinces transitioning to enhanced models, the time is ripe to study the impact of this change.

Acknowledgment

Financial support was received in the form of studentships for the work of Patrick Kim and Devyani Premkumar on this review. The Centre for Studies in Primary Care received financial support from the Medical School Excellence Fund at Queen’s University for salary and benefits for Dr Sophy Chan-Nguyen’s contribution to this study.

Footnotes

↵* Appendix A is available from available from https://www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.

Contributors

Patrick Kim made substantial contributions to the conceptualization and design of this work, including acquiring and analyzing data, drafting and reviewing the manuscript, and providing final approval of the manuscript. Devyani Premkumar made substantial contributions to the conceptualization and design of this work, including acquiring and analyzing data, drafting and reviewing the manuscript, and providing final approval of the manuscript. Dr Jane Philpott contributed expertise to conceptualizing this work, reviewing the aggregated results, drafting and reviewing the manuscript, and providing final approval of the manuscript. Dr Sophy Chan-Nguyen contributed expertise to conceptualizing and designing this work, analyzing data, drafting and reviewing the manuscript, and providing final approval of the manuscript. Dr Colleen Grady, as principal investigator, made substantial contributions to the conceptualization and design of this work, including acquiring and analyzing data, drafting and reviewing the manuscript, and providing final approval of the manuscript.

Competing interests

None declared

This article has been peer reviewed.

Cet article a fait l’objet d’une révision par des pairs.

Copyright © 2025 the College of Family Physicians of Canada