Doctors in Private Practice: A Systematic Review of the Perceived Working Conditions, Psychological Health, and Patient Care

Abstract

Medical doctors are at risk of poor mental health, linked to their working conditions. However, little distinction is made between private and public practice where working conditions differ. This review examines the relationship between perceived working conditions, psychological health, and patient care among doctors in private practice, considering how differences between private and public practice impact these outcomes and the implications of working across sectors. We conducted a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search encompassed Academic Search Premier, Business Source Premier, PsycInfo, PsycArticles, and Medline. Included studies were coded in line with the Job Demands–Resources model. The initial search identified 309 papers, with 14 being selected for final full-text review. Higher job demands were associated with higher levels of burnout, while social resources, job crafting, and healthy coping mechanisms were linked with lower levels of burnout. Working in private practice was associated with higher demands. Doctors in private practice had more negative perceptions of performance, less satisfactory leadership, and a lack of feedback. However, private practice also offered better work–life balance, more control, and greater reward. Notably, no study was found that examined the implications of dual roles where doctors worked across both sectors, which is common. A clear definition of private practice as well as a more granular understanding of work-related risks posed to private practice and dual roles should be the focus of future research.

1. Introduction

Doctors are at high risk of work-related stress, burnout, and mental health problems. There is strong evidence linking impaired mental health to doctors’ working conditions [1,2,3,4,5]. Almost one in every two doctors internationally have considered leaving the profession for reasons of personal wellbeing [6,7]. Burnout among doctors (estimated at 53% [7] and burnout-related turnover (27% [8], leads to approximately USD 979 million in excess expenditures. Poor wellbeing and associated factors (e.g., long hours, work–life conflict, and sickness presenteeism) not only impact staff retention but also patient outcomes and the financial performance of healthcare organisations [1,9,10]. While an integrated approach to managing health and wellbeing is required [11], clearly prevention should be a primary focus. Identifying working conditions that lead to poor wellbeing is a key point to direct future preventative measures.

To date, most research on medical doctors’ wellbeing has focused on the public sector, often overlooking the private sector and failing to distinguish between the two. With rising numbers of doctors in private practice worldwide, it is vital that we better understand the extent to which work contributes to burnout and ill health in the context of private practice and compare these dynamics across healthcare systems [12,13]. This review examines the working conditions specific to doctors in private practice, with the aim of informing future interventions to enhance their work environment, psychological wellbeing, and the quality of patient care.

1.1. Doctors’ Working Conditions

The Job Demands–Resources (JD-R) model is commonly used to categorise working conditions and explore their impact. The JD-R model classifies working conditions into two categories: job demands and job resources [14]. It distinguishes between job demands—aspects of the job that require psychological and physical energy—and job resources that help to achieve work goals, mitigate the impact of job demands, and promote personal growth and development [14]. In medical settings, common demands include high workloads, long working hours, and emotional strain from having to make difficult decisions and deliver bad news [15]. Job resources, conversely, may include a sense of psychological safety within teams [15], social support from colleagues and supervisors, and finding meaning in the work [16,17]. The JD-R model assumes a relationship between high job demands and high levels of exhaustion as well as a lack of resources and disengagement, which evidence has supported [14]. The model has been modified to include more diverse outcomes including engagement [18], with evidence supporting the relationship between job demands and job resources and both work engagement and burnout [19,20].

1.2. Doctors’ Working Conditions, Burnout, and Psychological Health

Burnout is typically characterised by three dimensions: exhaustion (individual), cynicism (interpersonal), and professional inefficacy (self-evaluative) [21]. Exhaustion refers to a lack of psychological and physical resources and energy. Cynicism represents a sense of detachment from work and the development of hostile feelings towards it. Professional inefficacy involves a reduction in productivity and feelings of diminished competence [21]. Research on interventions aimed at preventing and reducing burnout and mental ill health in healthcare professionals indicates that organisational strategies are more likely to deliver sustained benefits than individually focused initiatives [22,23]. Identifying the working conditions associated with burnout and associated outcomes can help to design effective organisational interventions to address burnout, specifically targeted to professionals in private practice.

Several factors have been found to increase the risk of burnout and mental health problems in doctors [1]. The most common causes include job demands, such as high perceived workload, increasing intensity and complexity of the work and emotional strain [5,10], rapid system changes, bullying and harassment [2], emotional ‘labour’ [24], and a lack of resources, e.g., support, reward, and recognition [2,25].

1.3. Doctors’ Working Conditions and Engagement

Work engagement describes a state of fulfilment and positive emotions at work resulting in high levels of energy and enthusiasm for the job [26]. Various studies show the positive impact of work engagement on job performance both generally [27,28] and specifically among doctors. This builds on the JD-R model, which proposes that job resources are the primary predictor of work engagement [14].

In a meta-analysis examining longitudinal associations between doctors’ working conditions and health, Teoh et al. (2023) [10] identified predictive relationships between job resources and both work engagement and emotional exhaustion, as well as between job demands and emotional exhaustion. Furthermore, job resources were positively correlated with subjective assessments of clinical care, while higher levels of job demands and emotional exhaustion were linked with perceptions of compromised clinical care. While this review advances our understanding of doctors’ working conditions, it does not distinguish between those in the private and public sectors, highlighting the need for a more granular examination of this specific population.

1.4. Doctors’ Working Conditions and Their Impact on Clinical Care

A wealth of research has examined the impact of healthcare work on employees, healthcare organisations, and clinical care. In terms of health outcomes, burnout, stress, and sleep problems have received much attention and are linked to perceptions of impaired clinical care [29,30,31,32,33,34]. Job demands, including high workload and long hours, have been linked to impaired clinical care and safety incidents [35,36,37].

1.5. Private vs. Public Healthcare Settings

While there is a vast literature on the association between working conditions—otherwise termed stressors or psychosocial risk factors—and mental health problems in public healthcare, far less is known about the experiences of doctors in private practice. There is some evidence from outside the UK, e.g., Norway [38] and the United States [39], showing that doctors in private practice report slightly better working conditions. However, potential sources of distress specific to private practice have also been identified. For example, private healthcare organisations are typically smaller than their public counterparts, meaning fewer support services will be available for doctors [40,41] and limited professional development opportunities [42]. Doctors in private practice who are self-employed may have little training in running a business or fail to have business continuity plans in place. In the UK, evidence suggests that increased numbers of people are using private healthcare due to long waiting lists in the public sector, which is placing workers under increased pressure [43]. The greater emphasis on financial targets and profitability in the private sector is likely to be an additional source of pressure, with patients expecting a higher standard of care and service delivery [44,45]. Additionally, research shows that individuals working in practices acquired by private equity report more work complexity, driven by higher spending targets and new unique patient volume [46].

It is also noteworthy that many doctors do not just work in private practice. For example, in the UK only 10% of general practitioners (GPs) work exclusively in private practice [12], indicating many doctors inhabit a dual role, working across the two sectors. There is need for a nuanced understanding of the impact of this dual role and its impact and doctors’ support requirements as compared to those working in private practice full-time. This review aims to look at both doctors exclusively in private practice and doctors working across sectors.

1.6. This Study

The primary research question guiding this systematic literature review was, ‘What is known about the relationship between perceived working conditions, mental health, and patient care among doctors in private practice?’. Secondary questions were as follows:

• What are the similarities and differences in working conditions and their impact between private and public healthcare settings?
• What are the similarities and differences in working conditions and their impact for doctors working in dual roles, in both private and public healthcare settings?

2. Materials and Methods

The review process was structured following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [47] (Table S1). A study protocol was developed internally, which then was shared with the steering group of the project. There is no registration of the protocol.

2.1. Defining the Research Question and Research Criteria

This review was commissioned to inform the development of resources to address the psychological risks experienced by doctors in private practice. The process was structured to enable the research team to review the broadest possible literature base within the available time and resources. This review built on the systemic review by Teoh et al. (2023) [10], which examined the psychological wellbeing of doctors in general. Teoh et al.’s review searched five databases (2000–2020) and identified 23 full-text studies meeting their inclusion criteria. We mirrored the search and screening approach for the time period 2020–2023 to include more recent research. All 23 studies included in Teoh et al.’s review were re-examined in our full-text screening against our additional private practice inclusion/exclusion criteria (see

Table 1. Inclusion and exclusion criteria.

	Inclusion Criteria	Exclusion Criteria
Participant population	- Participants had to be practicing doctors. Mixed samples of healthcare employees were only included if results for doctors were reported separately. - Doctors in private practice (or in healthcare systems where services are provided by the private sector only) were included. - Mixed samples were only included if results reported separately for doctors working in private practice.	- Studies with doctors not in private practice, medical students, trainees, nurses, and allied health professionals were excluded. - Studies conducted in only academic institutions were excluded.
Constructs	- Studies had to investigate at least two of the three constructs of interest—perceived working conditions, psychological wellbeing, and patient care—or show a comparison between private and public. - For perceived working conditions, this had to reflect the experience of individuals (e.g., workload, support) and not objective measures of working conditions (e.g., hours worked). We grouped predictors into job demands and job resources as discussed earlier.
Outcomes	- For psychological wellbeing, studies had to measure burnout (emotional exhaustion) or work engagement. - For patient care, studies had to utilise a measure that mapped onto clinical care (e.g., self-rated care provided, readmission) or patient safety (e.g., errors reported).
Study design	- All empirical research designs from January 2000 to December 2023 to supplement Teoh et al. 2023 [10]. - Statistics: Studies had to provide statistical relationships between at least two of the constructs of interest, or a test of difference between the private and public sector on any one of the constructs. - Publication type: Studies were limited to journal articles, technical reports, and dissertations. Results were limited to only English publications.	- Articles reporting expert opinions, practice or procedure guidelines, case reports, and case studies were excluded. - Conference abstracts were excluded. - Books chapters were excluded. - Unpublished papers and conference proceedings were excluded. - Studies published at the start of the pandemic, which could have skewed the included data as working conditions, doctors’ psychological wellbeing, and patient care were substantially impacted within a short period, were excluded.

), of which 7 studies met our criteria and were retained for inclusion. Given the complexities involved in defining private practice, the criteria established by Montagu (2021) [48] were used. The approach was developed through consultation with the project steering group, which comprised an international team of multi-disciplinary researchers and practitioners.

2.2. Data Sources and Search Terms

The systematic search was conducted during November and December 2023 using the EBSCO database, identifying relevant articles published in Academic Search Premier, Business Source Premier, PsycInfo, PsycArticles, and Medline. Search terms were structured around the PICO (Patient, Intervention, Context, Outcome) [49] approach for the time period 2020–2023. The complete list of search terms is presented in Appendix A and the EBSCO search string in Appendix B.

2.3. Inclusion Criteria

This review applied the PICO framework [49] to guide the inclusion of studies. Eligible participants were practicing doctors working in private practice or dual roles and studies were required to examine at least two out of the three constructs of interest (see Table 1), or report on differences between private and public practice. Outcomes had to be reported on either psychological wellbeing (such as burnout or work engagement) or patient care (including clinical care or patient safety). Lastly, included studies had to be published in English from January 2000 onward and provide statistical relationships between at least two of the three constructs of interest or on differences between public and private practice. Only journal articles, technical reports, and dissertations were included, which aligns with previous reviews in this field [10].

We excluded studies from countries with predominantly public healthcare systems, defined by Montagu (2021 [48]; see Figure 1) as those in which 80% or more of practice is publicly funded and delivered (if studies did not explicitly state they were conducted with doctors in private practice), in order to avoid diluting findings specific to private sector contexts. This decision reflects substantial differences in structure, resourcing, and contractual arrangements between public systems and the mixed or private models under review. As healthcare in the Netherlands is insurance-driven, studies involving Dutch participants were categorised as private practice and included. A full list of the inclusion and exclusion criteria is provided in Table 1.

2.4. Search Strategy

The search strategy consisted of three stages, with 309 titles initially identified through the database search. Stage one involved the removal of duplicates (n = 32) and screening of the titles (n = 277). Titles that did not mention the constructs of interest were excluded (n = 96). Any titles that could not be removed with certainty were moved into the next stage for abstract review. During stage two, the abstracts were reviewed according to the above inclusion and exclusion criteria (n = 181). This resulted in 17 papers progressing to stage three for a full paper review. After excluding 3 studies that did not meet the inclusion criteria, the final number of included papers was 14. The first author conducted the review process, while a second researcher independently reviewed 100% of the titles and a random 10% of the abstracts (agreement = 98.5%). The flow diagram in Figure 1 illustrates the process of study retrieval and selection.

2.5. Quality Assessment

The Newcastle–Ottawa Quality Assessment Scale for cohort studies was used to assess the quality of one study [50]. The rating system allows categorisation of papers into good quality, fair quality, and poor quality. The remaining studies were not suitable for assessment using this scale. Instead, the Quality Assessment Checklist for Survey Studies in psychology (Q-SSP) was used [51]. The Q-SSP categorises studies as having acceptable or questionable quality.

2.6. Data Extraction

The data extraction tool used was adapted from that applied in Teoh et al. (2023) [10], with additional criteria related to private practice to better align with the needs of the current review. Data were initially extracted from three papers, with refinements made following consultation with the research team before completing data extraction. One researcher carried out the data extraction and consulted other team members for clarification or support when faced with ambiguous data.

2.7. Data Analysis and Synthesis

The following data were extracted from the articles reviewed (if reported): lead author, study year, title, country of study, sample details (size, type, participants), percentage of sample in private practice, study design, effect measure, inclusion/exclusion criteria, measures used and their validation, type of statistical analysis, key findings, differences between private and public practice, limitations, and recommendations for future study.

Factors relating to implementation were coded and synthesised using inductive and deductive thematic analysis following the six-phase analytical process developed by Braun and Clarke (2006) [52]: (1) familiarisation with the data, (2) generating initial codes, (3) generating themes, (4) reviewing potential themes, (5) defining and naming the themes, (6) reporting. The JD-R-model was used as a framework for the coding system (deductive) and subcodes regarding specific demands and resources (inductive) were discussed between researchers. The findings were shared with the project steering group who confirmed that the identified themes were comprehensive and aligned with the review’s objectives.

2.8. Research Paradigm and Reflexivity

The findings reported are influenced by our own beliefs, judgments, and practices throughout the scoping, conduct, and interpretation of this review. The interdisciplinary composition of the research team and steering group helped to ensure the rigour, relevance, and contextual sensemaking of this review.

2.9. Ethics

All data analysed were from previously published studies, and no new data collection involving human participants was conducted. As no primary data was gathered as part of the study, ethical review was not required. The research team is comprised of psychologist and doctors, and all adhere to the ethical principles determined by their professional body, the British Psychological Society and the General Medical Council UK, respectively [53].

3. Results

3.1. Study Characteristics

The 14 papers obtained from the systematic review are listed in

Table 2. Characteristics of included studies.

Paper No.	Author	Year	Country	Design	Participant No.	Participants	Career Stage/Work Experience (Years), M (SD) *	Specialism	Clinical Setting	Reported Differences Between Private and Public Sector	Burnout Prevalence
1 [54]	Gordon et al.	2018	The Netherlands	Cohort study	119	Medical specialists	Experimental group: 22.5 (9.1); control group: 22.4 (8.7)	n.a.	n.a.	n.a.	n.a.
2 [55]	Houkes et al.	2008	The Netherlands	Cohort study	261	GPs	Actively working	n.a.	GP	n.a.	EE ** (time1): 25.4%; (time2): 13.5%
3 [56]	Mache et al.	2009	Germany	Cross-sectional	203	Family physicians	Mixed	Internal medicine, surgery, paediatrics, and neurology	Hospital	Yes	n.a.
4 [57]	Adžić et al.	2013	Croatia	Cross-sectional	125	Family physicians	Work experience at current position (years): M = 13.3	n.a.	Family medicine	No	42.4% high score for EE
5 [58]	Prins et al.	2007	The Netherlands	Cross-sectional	158	Medical residents	Medical residency	n.a.	Hospital	n.a.	n.a.
6 [59]	Prins et al.	2008	The Netherlands	Cross-sectional	158	Medical residents	Medical residency	Mixed	Hospital	n.a.	n.a.
7 [60]	Schaufeli et al.	2009	The Netherlands	Cross-sectional	2115	Doctors	Junior doctors	n.a.	Hospital	n.a.	n.a.
8 [61]	Kurtzthaler et al.	2021	Austria	Cross-sectional	481	GPs and other specialists	GPs: 15.3 (10.4); specialists: 14.1 (9.6)	Mixed	Mixed	n.a.	High burnout (CBI *** total > 50): GPs = 26.9%; specialists = 22%
9 [62]	Dutheil et al.	2021	France	Cross-sectional	1926	GPs	20.7 (11.2)	n.a.	GP	n.a.	44.8%
10 [63]	Marshall et al.	2020	USA	Cross-sectional	3603	Physicians	n.a.	Mixed	Mixed	Yes	43.7% (academic); 43.0% (private)
11 [64]	Mahoney et al.	2021	USA	Cross-sectional	3807	Surgeons	Academic: 18; private practice: 22	Mixed	Mixed	Yes	n.a.
12 [65]	Cheng et al.	2020	USA	Cross-sectional	476	Urologists	Nearly 50%: 11–30	Urology	Mixed	Yes	49.6%
13 [66]	Coetzee & Kluyts	2020	South Africa	Cross-sectional	498	Anaesthetists	45%: >15	Anaesthetics	Mixed	Yes	22.7% clinically burned out

* M = mean; SD = standard deviation; ** EE = emotional exhaustion; *** CBI = Copenhagen Burnout Inventory. n.a. = not applicable.

.

Nine studies were conducted in Europe, including five from the Netherlands and one each from Austria, Croatia, France, and Germany. Three were conducted in the United States and two in South Africa. In terms of participants, four studies involved medical specialists from various fields (e.g., urologists and anaesthetists), three comprised a mixed group of doctors, two focused exclusively on GPs, two on family physicians, two on medical residents, and one study broadly on doctors without noting specialty.

Most studies involved mixed work settings. Four were hospital-based, two were conducted in general practice, one in family medicine, and one did not specify the work environment.

Twelve studies employed a cross-sectional study design and two used a longitudinal cohort study design. One study reported on an intervention (job crafting intervention), while the remainder examined associations between different perceived working conditions and outcomes such as wellbeing, burnout, work engagement, and clinical care. A detailed list of the examined constructs is presented in

Table 3. List of examined constructs.

Paper No.	Perceived Working Conditions		Outcomes
	Job Demands	Job Resources	Burnout	Work Engagement	Clinical Care
1		Job crafting	Dutch version of Oldenburg Burnout Inventory	Engagement	Adaptive, task, contextual performance—self-rated performance
2	Workload (quantitative and qualitative), work–family interference	Work control; social support from colleagues	MBI *	-	-
3	Quantitative, emotional demands, demands for hiding emotions	Possibilities for development; Degree of freedom at work: influence at work; social relations; sense of community; social support; quality of leadership; feedback at work	-	-	-
4	-		MBI	-	Self-rated quality of care by patients
5	-	Support (emotional, appreciative, informative)	MBI	-	-
6	-	Reciprocity	MBI	-	-
7	Demands (mental, organisational, emotional), inter-role conflict	-	MBI	-	Reduced medical accomplishment (instead of personal accomplishment scale in Maslach Burnout Inventory)
8	Violence in patient care	-	MBI	-	-
9	-	Work support	Copenhagen Burnout Inventory	-	-
10	Work–life integration	-	MBI	-	-
11	Competition with others as threat to financial security, work–life balance	Job benefits (formal leave, paternity leave, maternity leave, job sharing); on-site day care; financial compensation	-	-	Involvement in malpractice case(s)
12	Stressors related to burnout (qualitative question)	-	MBI	-	-
13			MBI	-	-
14	Workload	Control, reward, fairness, community, values	MBI	-	-

* MBI = Maslach Burnout Inventory.

.

Two studies focused exclusively on the private sector [61,62], while twelve compared private and public settings or were conducted in the Netherlands, where the healthcare system can be classified as private practice.

None of the studies reported data on dual roles; therefore, no findings are available regarding the specific challenges associated with holding dual roles.

3.1.1. Measures of Working Conditions and Outcomes

Most studies examined traditional JD-R dimensions such as workload (demands) and social support or control (resources), with burnout as the predominant outcome. Few studies considered outcomes beyond psychological health, such as clinical care or malpractice. Measures for working conditions appear to have been designed for the purpose of the specific study; there was no indication in any papers reviewed that validated measures of perceived working conditions were used (Table 3). Notably, all studies measuring burnout used reliable validated measures: Maslach Burnout Inventory (Cronbach’s Alpha 0.71–0.88) [67], Dutch version of Oldenburg Burnout Inventory (Cronbach’s Alpha 0.85) [68], or Copenhagen Burnout Inventory (Cronbach’s Alpha 0.85–0.87) [69]. The one study that examined work engagement used the Utrecht Work Engagement Scale [1]. Various aspects of clinical care were assessed using a single item from the Sullivan and Karlsson’s (1998) SF-36 Health Survey [70], the Patient Enablement Instrument, or a self-constructed scale consisting of six items.

3.1.2. Quality Assessment

The one study assessed by the Newcastle–Ottawa Quality Assessment Scale for cohort studies achieved a fair quality rating. For the remaining studies, assessed by the Q-SSP, nearly 77% can be categorised as having acceptable quality. The remaining studies only achieved a rating of questionable quality.

3.2. Working Conditions and Their Relationship with Psychological Health, Engagement, and Clinical Care

3.2.1. Job Demands and Associated Outcomes

Across eight studies, job demands—including quantitative, emotional, organisational, and mental demands, as well as inter-role conflict, workload, competition with others as a threat to financial security, workplace violence, and challenges with work–life integration—consistently predicted burnout. For example, Schaufeli et al. (2009) [60] reported that higher emotional, mental, and organisational demands were associated with higher levels of burnout (r = 0.42, 0.22, 0.35, respectively). This study also reported a significant positive relationship between inter-role conflict and burnout (r = 0.52). Two studies identified significant positive associations between workload and burnout. Both Houkes (2008) [55] and Coetzee & Kluyts (2020) [66] found higher workload (quantitative and qualitative) was associated with higher burnout (Houkes et al., 2008 [55]: r between 0.49 and 0.57; Coetzee & Kluyts, 2020 [66]: b = −6.66). Kurtzthaler et al. (2021) [61] found a significant positive relationship between workplace violence and burnout (b = 0.09).

Evidence for engagement was limited, with one study [54] showing that a reduction in demands predicted a subsequent decrease in work engagement (t = −3.78). No studies examined job demands in relation to clinical care.

3.2.2. Job Resources and Their Relationship with Psychological Health, Engagement, and Clinical Care

Eight studies examined job resources, most commonly administrative support, colleague support, supervisor support, and job crafting. Across these, greater resources were associated with lower burnout and, in one intervention study, with higher engagement and performance. Prins et al. (2007) [58] reported relationships between dissatisfaction with supervisor support (emotional, appreciative, and informative support) and burnout (r = 0.42; 0.32; 0.17). The study also found that dissatisfaction with appreciative support from patients was related to burnout (r = 0.20), whereas dissatisfaction with emotional and appreciative support from supervisors predicted emotional exhaustion (b = 0.44); b = 0.30). Houkes et al. (2008) [55] found positive relationships between social support and the three aspects of burnout, i.e., emotional exhaustion (r = 0.21), depersonalisation (r = 0.18), and personal accomplishment (r = −0.23). Dutheil et al. (2021) [62] reported that administrative support reduced burnout prevalence.

Prins et al. (2008) [59] also examined the perceived reciprocity of relationships at work. The discrepancy between perceived and preferred reciprocity in relationships with supervisors was significantly related to emotional exhaustion (r = 0.38), while perceived reciprocity in relationships with supervisors and nurses also significantly predicted emotional exhaustion (ANOVA: F(2, 143) = 6.65; ANOVA: F(2, 142) = 3.52). Specifically, authors found that under-benefitting (i.e., where doctors felt that the relational effort was not reciprocated) was significantly associated with higher emotional exhaustion.

The job crafting intervention (Gordon et al., 2018 [54] showed that both seeking challenges (b = −3.20) and seeking resources (b = −3.50), two aspects of job crafting, were associated with emotional exhaustion. This study was also the only one reviewed that examined the relationship between job resources and work engagement and clinical care. Seeking challenges was positively associated with work engagement (b = 2.40) as well as an increase in task, adaptive, and contextual performance (b = 1.80, 2.38, 3.50). Seeking resources also predicted an increase in adaptive and contextual performance (b = 10.0, 4.13), demonstrating the positive role job crafting can play in protecting health and performance.

3.2.3. Psychological Health and Clinical Care

Evidence linking doctors’ psychological health with clinical care was limited. Schaufeli et al. (2009) [60] found a significant association between perceptions of reduced medical accomplishment and emotional exhaustion (r = 0.42). Adžić et al. (2013) [57] found no significant relationships between burnout and patient enablement, which describes the self-rated confidence of patients after visiting a doctor regarding their consultation in general, the information they received, and their diagnosis.

3.3. Differences Between Private and Public Healthcare Settings

Six studies compared the demands experienced by doctors in private and public settings, with mixed findings. Mache et al. (2009) [56] found doctors working in private non-profit hospitals perceived higher quantitative demands. Marshall et al. (2020) [63] and Mahoney et al. (2021) [64] found that doctors working in private practice were less likely to be satisfied with their work–life integration. Conversely, doctors in private practice typically perceived their work allowed sufficient time for their family, particularly those in academic roles.

Four studies compared the resources in the different practice setting, also with mixed results. Mache et al. (2009) [56] found doctors in private for-profit hospitals reported lower perceptions of quality in leadership and feedback. Three studies examined control over work (e.g., degree of freedom and influence at work), possibilities for development reward, fairness, and values alignment. (Mache et al., 2009 [56]; Coetzee & Kluyts, 2020 [66]; Houkes et al., 2008 [55]. However, only Coetzee & Kluyts (2020) [66] found a difference, with doctors in the public sector reporting lower scores found for control and reward in the public sector. Additionally, Mahoney et al. (2021) [64] found that malpractice cases were more prevalent in private practice than academic settings (81% vs. 70%).

4. Discussion

This review examined the relationship between perceived working conditions, mental health, and patient care among doctors in private practice. It contributes to our understanding of working in private practice in three ways. First, it reinforces findings from public sector studies by showing that high job demands, such workload, workplace violence, and role conflicts, are associated with higher levels of burnout in private sector settings. Second, it highlights the value of job resources, specifically the ability to engage in job crafting and supportive relationships, by highlighting links with engagement and lower levels of burnout. Third, it uncovers differences between public and private healthcare settings that have implications for the psychological wellbeing and patient care of doctors in private practice. These findings broadly support the dual pathways proposed by the Job Demands–Resources model but highlight conceptual gaps in how demands and resources are operationalised in private healthcare research.

This review provided some evidence that doctors in private practice experience higher demands, more self-reported cases of malpractice, and less satisfaction with leadership and feedback in comparison to those in public practice settings. The association between high job demands and burnout was consistent across studies and similar for both groups. Doctors in private practice reported a better work–life balance and more control and reward than those working in public practice, which could be a function of the increased autonomy they have in managing their schedules and patient loads. However, the organisation of private healthcare varies substantially across countries, and the findings may not be generalisable. For example, UK-based research suggests that running a business may introduce financial stressors [53,71] which could, for example, lead to overscheduling with a negative impact on wellbeing; such pressures may not be as relevant in insurance-driven or mixed systems. It could also be argued that these financial stressors increase workload in private practice, along with the many roles doctors in private practice inhabit due to the nature of their work (running a business, admin work, medical work, etc.) [53]. Again, these potential mechanisms should be considered tentative explanations and warrant further investigation.

While none of the included studies looked at the dual role, several reported differences between private and public practice (such as higher demands, more cases of self-reported malpractice, lower levels of leadership and feedback, but better work–life balance and more control and reward).

Social support emerged as an important resource in private practice. Previous studies conducted in the healthcare sector more generally have identified positive relationships between social support and mental health [72,73,74]. However, while those studies especially focus on social support from family and friends, this review confirms that professional relationships at work, such as with supervisors and colleagues, as well as administrative support may reduce the risk of burnout.

No studies directly examined differences in levels of social support between private and public practice. Nonetheless, working in private practice was associated with lower levels of feedback and leadership, suggesting that doctors working in this sector may receive lower levels of leadership support. The lack of feedback may plausibly be explained by several factors. First, the high job demands in private may leave little time for feedback. Second, financial drivers may encourage practitioners to prioritise profit over creating a supportive environment. Third, the nature of solo practice means that some doctors may not have line managers to provide feedback. These potential explanations are supported by wider commentary [53,71] but warrant further examination. Overall, further research is needed to better understand the support available to doctors in private practice and the extent to which it mitigates the demands they experience.

4.1. Avenues for Future Research

Further research is required in three areas. First, future studies should employ nuanced measures that reflect the working conditions in private healthcare and the resources that will mitigate the demands they experience. To understand and therefore take action on the specific psychosocial risks experienced by, and the resources that can benefit, doctors, there is need to move beyond broad terms of ‘demands’ and ‘support’ and utilise established measures of working conditions (e.g., COPSOQ). According to the JDR-model, demands and resources can be broken down further: job demands into challenge and hindrance demands, and job resources into structural and social resources. Furthermore, to restrict the scope of this review, we focused on studies that examined perceived working conditions, excluding studies examining objective measures of working conditions (such as hours worked per day). Future studies could benefit from examining the concordance between objective and subjective measures of working conditions.

Second, no studies included in our review examined the impact of working across private and public practice, i.e., in dual or multiple roles. With private and public practice co-existing in many countries across the globe, the prevalence and experience of working in dual roles across sectors and organisations is warranted. This review highlighted challenges relating to the working conditions in both public and private sectors. For doctors working in dual roles, this may mean exposure to demands from both settings, which may overlap or differ in nature. At the same time, these doctors may also gain access to a wider pool of job resources, potentially broadening the range of support available and offering flexibility in how they manage sector-specific demands. For example, team-based working in the public sector could buffer the effects of limited support in private practice. However, we currently lack knowledge about how demands and resources interact across work settings. Better understanding this could inform new approaches of work design, interventions, and structural changes.

Finally, further intervention research is urgently needed. Only one study in this review reported on an intervention to manage burnout in medical settings [54]. Future research might particularly benefit from seeking to develop and evaluate interventions to help reduce job demands to lessen the risk of burnout, but more research is needed in the private sector to inform the type of intervention that would be most effective. An intervention by [54] applied a general job crafting focus that appeared to reduce emotional exhaustion. A growing body of research demonstrates the efficacy of job crafting interventions [75,76,77] suggesting that opportunities exist to test how such interventions translate into private practice settings.

4.2. Strengths and Limitations of This Review

This review follows good practice in conducting and reporting systematic reviews [47]. The research questions and approach were informed through consultation and discussion with the project steering group and a rapid literature search. Special care was taken to acknowledge the researchers’ role throughout the process, particularly when extracting and analysing data.

There are three key limitations of this study. First, many of the included studies were methodologically weak, particularly due to the absence of standardised, validated measures, despite the wide range of established tools available and commonly used in research and practice. Second, the absence of a standardised definition of private practice across different countries, and the lack of consistent reporting by researchers in this area, means that we may have missed or excluded evidence of relevance. Third, most studies included in the review were conducted in high-income countries, and almost all reflected health systems where private practice co-exists with public provision. We therefore caution against the generalization of findings across all contexts, given the international heterogeneity of private healthcare systems, ranging from predominantly insurance-based to fully market driven to hybrid public–private models. Findings may not apply universally, particularly in low- and middle-income countries where private practice provision is expanding [78,79]. Furthermore, very few studies examined the impact of working in public–private partnerships which are also becoming more common [80,81].

5. Conclusions

Despite the widespread prevalence of private healthcare, robust, high-quality research into the working conditions of doctors in private practice, and those who work across private and public sectors, remains scarce. This review shows that, while doctors working in private practice face many of the same psychosocial risks as those in the public sector, they also encounter distinct challenges related to financial pressures, reduced support, and risk of malpractice. These interpretations should be treated cautiously, however, as they were not consistently or directly measured in the included studies and are likely to vary across healthcare systems.

Based on the current evidence, we propose three priorities to guide future research and practice. First, researchers and employers should collaborate to establish and consistently identify a standardised definition of private practice across healthcare systems to aid evidence synthesis and comparisons. Second, future studies should investigate the working conditions of doctors in private practice and across dual roles. Third, policymakers and healthcare organisations could prioritise the development, implementation, and evaluation of system-level interventions in private practice environments where support systems may be limited or inconsistent. Such interventions should be carefully tailored to national healthcare contexts and informed by further empirical research, particularly in relation to financial pressures, malpractice risks, and support structures.