New wine in an old bottle: does alienation provide an explanation of the origins of physician discontent?

Physicians as shock absorbers: The system of structural factors driving burnout and dissatisfaction in medicine

American physicians disproportionately suffer from burnout. Despite calls for systemic solutions, however, few studies have actually examined how 'the system' works-i.e. how structural factors intersect in real-time as a system to shape wellbeing. I borrow a systems theoretical approach, which explicitly recognizes the dynamic relationships and interdependencies between different actors and factors in healthcare, to examine how structural factors work together to shape physicians' wellbeing. Drawing on an eight-month ethnography in a pediatrics clinic, I show how respondents experienced pressures from multiple structural levels: societal (including broader social inequality and changing doctor-patient relationships); organizational (centralized decision-making, economic pressures, and unresponsive leadership); and professional (specialty cultures and unhealthy norms). I find that individual physicians effectively served as shock absorbers, routinely absorbing countless, interconnected structural demands ("shocks") and converting them into competent medical care, at significant cost to their mental health. In so doing, I intervene in sociological debates about the broader fate of the medical profession and conclude that if medicine remains resilient against threats to its dominance, it may well be at the expense of individual physicians' mental wellbeing.

Feeling like the enemy: the emotion management and alienation of hospital doctors

Introduction

Globally, an epidemic of psychological distress, burnout, and workforce attrition signify an acute deterioration in hospital doctors' relationship with their work-intensified by COVID-19. This deterioration is more complicated than individual responses to workplace stress, as it is heavily regulated by social, professional, and organizational structures. Moving past burnout as a discrete "outcome," we draw on theories of emotion management and alienation to analyze the strategies through which hospital doctors continue to provide care in the face of resource-constraints and psychological strain.

Methods

We used Mobile Instant Messaging Ethnography (MIME), a novel form of remote ethnography comprising a long-term exchange of digital messages to elicit "live" reflections on work-life experiences and feelings.

Results

The results delineate two primary emotion-management strategies-acquiescence and depersonalization-used by the hospital doctors to suppress negative feelings and emotions (e.g., anger, frustration, and guilt) stemming from the disconnect between professional norms of expertise and self-sacrifice, and organizational realities of impotence and self-preservation.

Discussion

Illustrating the continued relevant of alienation, extending its application to doctors who disconnect to survive, we show how the socio-cultural ideals of the medical profession (expertise and self-sacrifice) are experienced through the emotion-management and self-estrangement of hospital doctors. Practically, the deterioration of hospital doctors' relationship with work is a threat to health systems and organizations. The paper highlights the importance of understanding the social structures and disconnects that shape this deteriorating relationship and the broad futility of self-care interventions embedded in work contexts of unrealized professional ideals, organizational resource deficits and unhappy doctors, patients, and families.

How hospital top managers reason about the central leadership task of balancing quality of patient care, economy and professionals' engagement: an interview study

PURPOSE

This study aims to deepen the understanding of how top managers reason about handling the relationships between quality of patient care, economy and professionals' engagement.

DESIGN/METHODOLOGY/APPROACH

Qualitative design. Individual in-depth interviews with all members of the executive management team at an emergency hospital in Norway were analysed using reflexive thematic method.

FINDINGS

The top managers had the intention to balance between quality of patient care, economy and professionals' engagement. This became increasingly difficult in times of high internal or external pressures. Then top management acted as if economy was the most important focus.

PRACTICAL IMPLICATIONS

For health-care top managers to lead the pursuit towards increased sustainability in health care, there is a need to balance between quality of patient care, economy and professionals' engagement. This study shows that this balancing act is not an anomaly top-managers can eradicate. Instead, they need to recognize, accept and deliberately act with that in mind, which can create virtuous development spirals where managers and health-professional communicate and collaborate, benefitting quality of patient care, economy and professionals' engagement. However, this study builds on a limited number of participants. More research is needed.

ORIGINALITY/VALUE

Sustainable health care needs to balance quality of patient care and economy while at the same time ensure professionals' engagement. Even though this is a central leadership task for managers at all levels, there is limited knowledge about how top managers reason about this.

Predictors of work alienation: differences between hierarchical levels

Purpose

The current study is aimed at analyzing whether and how organizational constraints (i.e. lack of autonomy) and individual characteristics (i.e. psychological capital) are related to work alienation in subordinates and supervisors, and whether the often hypothesized relationship between autonomy and work alienation is moderated in a three-way interaction (autonomy × psychological capital × hierarchical level). The hypotheses are developed by drawing on the tenets of the job demands-resources model.

Design/methodology/approach

The study is based on two-wave survey data from 294 Dutch employees (subordinates and supervisors).

Findings

The paper finds that autonomy is more negatively related to work alienation for subordinates with low psychological capital than for subordinates with high psychological capital. Autonomy is negatively related to work alienation for leaders, independent of their level of psychological capital.

Originality/value

Antecedents of work alienation have received substantial attention from researchers. The authors aim to better understand these antecedents by highlighting differences between supervisors and subordinates.

Changes in work stress among doctors in Norway from 2010 to 2019: a study based on repeated surveys

OBJECTIVES

To explore and discuss the changes in the levels of work stress for Norwegian doctors in different job positions (hospital doctors, general practitioners (GPs), private practice specialists, doctors in academia) from 2010 to 2019.

DESIGN

Repeated questionnaire surveys in 2010, 2016 and 2019, where samples were partly overlapping.

SETTING

Norway.

PARTICIPANTS

A representative sample of 1500-2200 doctors in different job positions. Response rates were 66.7% (1014/1520) in 2010, 73.1% (1604/2195) in 2016 and 72.5% (1511/2084) in 2019.

MAIN OUTCOME MEASURE

Validated 9-item short form of the 'Effort-Reward Imbalance' questionnaire. A risky level of work stress was defined as an effort/reward ratio above 1.0.

ANALYSES

Linear mixed models with estimated marginal means of job positions controlled for gender and age. Proportions with 95% CIs.

RESULTS

From 2010 to 2016 and further to 2019, GPs reported a significant increase in levels on the effort scale (ES: 2.96, 3.25, 3.51) and significant decrease in levels on the reward scale (RS: 4.27, 4.05, 3.67). No significant changes were reported by hospital doctors (ES: 3.13, 3.10, 3.14; RS: 4.09, 3.98, 4.04), private practice specialists (ES: 2.58, 2.61, 2.59; RS: 4.32, 4.32, 4.30) and doctors in academia (ES: 2.63, 2.51, 2.52; RS: 4.09, 4.11, 4.14). The proportion of doctors with risky levels of work stress increased significantly for GPs (10.3%, 27.7%, 40.1%), but did not significantly change for hospital doctors (23.0%, 27.3%, 26.9%), private practice specialists (8.2%, 12.7%, 9.4%) and doctors in academia (11.9%, 19.0%, 16.4%).

CONCLUSION

During a 9-year period, the proportion of risky levels of work stress increased significantly for GPs but did not significantly change for other job positions. This may be partly due to changes in expectations of younger GPs and several healthcare reforms and regulations.

Changes in job satisfaction among doctors in Norway from 2010 to 2017: a study based on repeated surveys

OBJECTIVE

To assess job satisfaction for different categories of Norwegian doctors from 2010 to 2016-2017.

DESIGN

Cross-sectional surveys in 2010, 2012, 2014 and 2016-2017 of partly overlapping samples.

SETTING

Norway from 2010 to 2016-2017.

PARTICIPANTS

Doctors working in different job positions (hospital doctors, general practitioners (GPs), private practice specialists, doctors in academia). Response rates were 67% (1014/1520) in 2010, 71% (1279/1792) in 2012, 75% (1158/1545) in 2014 and 73% (1604/2195) in 2016-2017. The same 548 doctors responded at all four points in time.

MAIN OUTCOME MEASURE

Job Satisfaction Scale (JSS), a 10-item widely used instrument, with scores ranging from 1 (low satisfaction) to 7 (high satisfaction) for each item, and an unweighted mean total sum score.

ANALYSIS

General Linear Modelling, controlling for gender and age, and paired t-tests.

RESULTS

For all doctors, the mean scores of JSS decreased significantly from 5.52 (95% CI 5.42 to 5.61) in 2010 to 5.30 (5.22 to 5.38) in 2016-2017. The decrease was significant for GPs (5.54, 5.43 to 5.65 vs 5.17, 5.07 to 5.28) and hospital doctors (5.14, 5.07 to 5.21 vs 5.00, 4.94 to 5.06). Private practice specialists were most satisfied, followed by GPs and hospital doctors. The difference between the GPs and the private practice specialists increased over time.

CONCLUSIONS

From 2010 to 2016-2017 job satisfaction for Norwegian doctors decreased, but it was still at a relatively high level. Several healthcare reforms and regulations over the last decade and changes in the professional culture may explain some of the reduced satisfaction.

How do doctors experience the interactions among professional fulfilment, organisational factors and quality of patient care? A qualitative study in a Norwegian hospital

OBJECTIVES

Doctors increasingly experience high levels of burnout and loss of engagement. To address this, there is a need to better understand doctors' work situation. This study explores how doctors experience the interactions among professional fulfilment, organisational factors and quality of patient care.

DESIGN

An exploratory qualitative study design with semistructured individual interviews was chosen. Interviews were transcribed verbatim and analysed by a transdisciplinary research group.

SETTING

The study focused on a surgical department of a mid-sized hospital in Norway.

PARTICIPANTS

Seven doctors were interviewed. A purposeful sampling was used with gender and seniority as selection criteria. Three senior doctors (two female, one male) and four in training (three male, one female) were interviewed.

RESULTS

We found that in order to provide quality care to the patients, individual doctors described 'stretching themselves', that is, handling the tensions between quantity and quality, to overcome organisational shortcomings. Experiencing a workplace emphasis on production numbers and budget concerns led to feelings of estrangement among the doctors. Participants reported a shift from serving as trustworthy, autonomous professionals to becoming production workers, where professional identity was threatened. They felt less aligned with workplace values, in addition to experiencing limited management recognition for quality of patient care. Management initiatives to include doctors in development of organisational policies, processes and systems were sparse.

CONCLUSION

The interviewed doctors described their struggle to balance the inherent tension among professional fulfilment, organisational factors and quality of patient care in their everyday work. They communicated how 'stretching themselves', to overcome organisational shortcomings, is no longer a feasible strategy without compromising both professional fulfilment and quality of patient care. Managers need to ensure that doctors are involved when developing organisational policies, processes and systems. This is likely to be beneficial for both professional fulfilment and quality of patient care.

The association between workplace violence and physicians' and nurses' job satisfaction in Macau

Background

This paper describes the association between workplace violence and job satisfaction among physicians and nurses in Macau. Convenience sampling was sourced from six health centers under the Macau Health Bureau.

Methods

This study uses a cross-sectional self-administrative survey. The study used case studies research instruments for workplace violence in the health sector by country (from the ILO, ICN, WHO, PSI), the Minnesota Satisfaction Questionnaire and Perceived Stress Scale. The data collection period spanned from August to December, 2014.

Data analysis

Multiple logistic regression examines levels of intrinsic and extrinsic satisfaction in physicians and nurses and significant correlates affecting their job satisfaction.

Results

A total of 720 (14.9% physicians) participants were recruited. 57.2% of participants reported physical and psychological workplace violence in the preceding year. The most common forms of workplace violence were verbal abuse (53.4%), physical assault (16.1%), bullying / harassment (14.2%), sexual harassment (4.6%) and racial harassment (2.6%). Nurses were at a significantly higher risk of physical assault and verbal abuse compared to physicians. Patients, patients’ relatives, and colleagues were the main perpetrators. Worry about WPV, on-call duty and shift work, experience of bullying and verbal abuse and employment sector emerged as significant correlates affecting the intrinsic and extrinsic job satisfaction of physicians and nurses. Frontline staff, aged 30 and 39, coming from an ethnic minority, and perceived stress were significant correlates affecting nurses’ job satisfaction.

Conclusions

WPV remains a significant concern in healthcare settings in Macau. Stakeholders should legally enforce a zero-tolerance policy towards WPV within healthcare workplaces. WPV is detrimental to healthcare professionals’ mental wellbeing, risking irreversible physical and psychological harm for its victims.

Lessons for the Health-care Practitioner from Buddhism

From its earliest days, Buddhism has been closely intertwined with the practice of medicine, both being concerned in their own way in the alleviation and prevention of human suffering. However, while the connection between Buddhism and healthcare has long been noted, there is scarce literature on how Buddhist philosophy can guide health-care practitioners in their professional as well as personal lives. In the sutras, we find analogies that describe the Buddha as a doctor, knowledge of Dharma as the treatment, and all lay people as patients. The occurrence of disease is closely related to one's mental, physical and spiritual health, society, culture, and environment. It is not enough to approach medicine in a manner that simply eradicates symptoms; the psychosocial aspects of disease and its mind based causes and remedies must be a primary consideration. Holistic care involves harmonization of all these elements, and the Buddhist philosophy offers great insight for the physician. The Buddhist medical literature lays out moral guidelines and ethics for a health-care practitioner and this has corollaries in the principles of medical ethics: nonmaleficence, benevolence, justice, and autonomy. There is emphasis on loving-kindness, compassion, empathy, and equanimity as key attributes of an ideal physician. The practice of medicine is a stressful profession with physician burnout an often neglected problem. Mindfulness meditation, as developed in Buddhism, can help health-care professionals cope up with the stress and develop the essential attributes to improve patient care and self-care. This article outlines the spiritual and ethical values which underlie Buddhist concern for the sick and gives an overview of lessons which health-care practitioners can imbibe from Buddhism.

Correlates of work-alienation and positive job attitudes in high- and low-status workers

Purpose

The concept of alienation boasts a long history in the academic literature. However, their empirical relations are not clear. The purpose of this paper is to test a model of predictors and outcomes of alienation. Since occupational status plays a key role in alienation processes, such model was tested with high- and low-status workers.

Design/methodology/approach

Participants were 340 workers holding high-status (n=98) and low-status (n=242) positions. Data were collected through a self-report questionnaire. The authors verified the hypothesized relationships by means of a structural equation modelling, simultaneously tested on high- and low-status workers.

Findings

Results showed that individual determinants of alienation, i.e. locus of control, appear to play a more relevant role for high-status professionals, whereas organizational dimensions, i.e. perception of decision making, have an impact only for low-status workers. Relational variables, i.e. work-family conflict, fostered alienation, regardless the status. Concerning outcomes, alienation decreased both job satisfaction and job involvement.

Research limitations/implications

The specificities of the cultural context have to be considered. Generalizing the results to other cultural contexts requires caution.

Practical implications

Work alienation has a negative influence on work attitudes that can be better managed by the knowledge of alienation’s correlates and peculiarities.

Originality/value

The study confirms the relevance of alienation for workers’ satisfaction and involvement highlighting the difference between high- and low-status workers.

The good doctor - strong and persevering

BACKGROUND

In today’s society, doctors are confronted with a number of opposing interests, from other colleagues, patients and employers. The development and regulation of the medical profession have been widely studied. However, less research has been devoted to the doctors’ own perception of what it means to be a good doctor.

MATERIAL AND METHOD

We conducted eight focus-group interviews and three individual interviews among senior consultants and specialty registrars in the areas of surgery, psychiatry and internal medicine in two different hospitals. Total N = 48, of which 56  % were women. The interviews were analysed with the aid of systematic text condensation.

RESULTS

«Professional dedication» demonstrated through «a high degree of attendance in the workplace» and «a high work capacity» were key topics for good doctors. Having a «high work capacity» was defined as being willing to go to great lengths, work overtime and work effectively. The senior consultants perceived their job as doctors more as a «lifestyle», while the specialty registrars more frequently regarded their work as a «job».

INTERPRETATION

Norwegian hospital doctors wish to appear dedicated to their profession. They can demonstrate this by showing great willingness to work intensively and effectively with patients, while also going to great lengths to be available beyond normal working hours.

The Moderating Effect of Job Satisfaction on Physicians' Motivation to Adhere to Financially Incentivized Clinical Practice Guidelines

We examined moderating effects of professional satisfaction on physicians' motivation to adhere to diabetes guidelines associated with pay-for-performance incentives. We merged cross-sectional survey data on attitudes, from 156 primary physicians, with prospective medical record-sourced data on guideline adherence and census data on ambulatory-care population characteristics. We examined moderating effects by testing theory-driven models for satisfied versus discontented physicians, using partial least squares structural equation modeling. Results show that attitudes motivated, while norms suppressed, adherence to guidelines among discontented physicians. Separate models for satisfied versus discontented physicians revealed motivational differences. Satisfied physicians disregarded intrinsic and extrinsic influences and biases. Discontented physicians, alienated by social pressure, favored personal inclinations. To improve adherence to guidelines among discontented physicians, incentives should align with personal attitudes and incorporate promotional campaigns countering resentment of peer and organizational pressure.

Job Stress and Job Satisfaction among Health-Care Workers of Endoscopy Units in Korea

Background/Aims:

The management of job-related stress among health-care workers is critical for the improvement of healthcare services; however, there is no existing research on endoscopy unit workers as a team. Korea has a unique health-care system for endoscopy unit workers. In this study, we aimed to estimate job stress and job satisfaction among health-care providers in endoscopy units in Korea.

Methods:

We performed a cross-sectional survey of health-care providers in the endoscopy units of three university-affiliated hospitals in Korea. We analyzed the job stress levels by using the Korean occupational stress scale, contributing factors, and job satisfaction.

Results:

Fifty-nine workers completed the self-administered questionnaires. The job stress scores for the endoscopy unit workers (46.39±7.81) were relatively lower compared to those of the national sample of Korean workers (51.23±8.83). Job stress differed across job positions, with nurses showing significantly higher levels of stress (48.92±7.97) compared to doctors (42.59±6.37). Job stress and job satisfaction were negatively correlated with each other (R²=0.340, p<0.001).

Conclusions:

An endoscopy unit is composed of a heterogeneous group of health-care professionals (i.e., nurses, fellows, and professors), and job stress and job satisfaction significantly differ according to job positions. Job demand, insufficient job control, and job insecurity are the most important stressors in the endoscopy unit.

Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study

PURPOSE

Burnout, attrition, and low work satisfaction of primary care physicians are growing concerns and can have a negative influence on health care. Interventions for clinicians that improve work-life balance are few and poorly understood. We undertook this study as a first step in investigating whether an abbreviated mindfulness intervention could increase job satisfaction, quality of life, and compassion among primary care clinicians.

METHODS

A total of 30 primary care clinicians participated in an abbreviated mindfulness course. We used a single-sample, pre-post design. At 4 points in time (baseline, and 1 day, 8 weeks, and 9 months postintervention), participants completed a set of online measures assessing burnout, anxiety, stress, resilience, and compassion. We used a linear mixed-effects model analysis to assess changes in outcome measures.

RESULTS

Participants had improvements compared with baseline at all 3 follow-up time points. At 9 months postintervention, they had significantly better scores (1) on all Maslach Burnout Inventory burnout subscales-Emotional Exhaustion (P =.009), Depersonalization (P = .005), and Personal Accomplishment (P <.001); (2) on the Depression (P =.001), Anxiety (P =.006), and Stress (P = .002) subscales of the Depression Anxiety Stress Scales-21; and (3) for perceived stress (P = .002) assessed with the Perceived Stress Scale. There were no significant changes on the 14-item Resilience Scale and the Santa Clara Brief Compassion Scale.

CONCLUSIONS

In this uncontrolled pilot study, participating in an abbreviated mindfulness training course adapted for primary care clinicians was associated with reductions in indicators of job burnout, depression, anxiety, and stress. Modified mindfulness training may be a time-efficient tool to help support clinician health and well-being, which may have implications for patient care.

The effects of work alienation on organisational commitment, work effort and work-to-family enrichment

AIM

The aim of this study was to analyse the effects of work alienation on organisational commitment, work effort and work-to-family enrichment.

BACKGROUND

There is substantial research on the effects of work alienation on passive job performance, such as organisational commitment. However, studies analysing work alienation on active performance, such as work effort, and outside work, such as work-to-family enrichment, are scarce.

METHOD

Two dimensions of work alienation are considered: powerlessness and meaninglessness. Hypotheses are tested using surveys collected among a national sample of midwives in the Netherlands (respondents: 790, response rate 61%).

RESULT

the findings indicate that work alienation (powerlessness and meaninglessness) influence organisational commitment, work effort and--to a lesser extent--work-to-family enrichment. High work meaninglessness, in particular, has negative effects on these outcomes.

CONCLUSION

When people feel that they have no influence in their work (hence, when they feel 'powerless') and especially when the feel that their work is not worthwhile (when they feel 'meaningless') this has substantial negative effects.

IMPLICATIONS FOR NURSING MANAGEMENT

Managers should increase the meaningfulness that people attach to their work, thereby maintaining a high-quality workforce. Possible strategies include: (1) improving person-job fit, (2) developing high-quality relationships, (3) better communicating the results people help to deliver.

In search of joy in practice: a report of 23 high-functioning primary care practices

We highlight primary care innovations gathered from high-functioning primary care practices, innovations we believe can facilitate joy in practice and mitigate physician burnout. To do so, we made site visits to 23 high-performing primary care practices and focused on how these practices distribute functions among the team, use technology to their advantage, improve outcomes with data, and make the job of primary care feasible and enjoyable as a life's vocation. Innovations identified include (1) proactive planned care, with previsit planning and previsit laboratory tests; (2) sharing clinical care among a team, with expanded rooming protocols, standing orders, and panel management; (3) sharing clerical tasks with collaborative documentation (scribing), nonphysician order entry, and streamlined prescription management; (4) improving communication by verbal messaging and in-box management; and (5) improving team functioning through co-location, team meetings, and work flow mapping. Our observations suggest that a shift from a physician-centric model of work distribution and responsibility to a shared-care model, with a higher level of clinical support staff per physician and frequent forums for communication, can result in high-functioning teams, improved professional satisfaction, and greater joy in practice.

Social and diagnostic inequality in health

Aims: Empirical studies of social inequalities in health commonly take the diagnosing of disease for granted. Social inequalities in health are seen as the result of social processes, yet the diagnosis itself is rarely considered to contribute to such inequality. We argue that the influence of sociocultural and cognitive bias in the diagnosing process follows a social pattern, such that certain diagnoses are disproportionally over- or underrepresented in different socioeconomic groups due to interpretive bias of underlying symptoms. Methods: Norwegian data on sick leave for diffuse musculoskeletal and diffuse psychiatric disease in 2006 were analysed to study the distribution of the two diagnoses in different status groups. Socioeconomic status was measured by years of education. Diagnoses and occupational codes were based on national registers; diagnoses in accordance with the International Classification of Primary Care second edition. We compared occupations in technical sectors to occupations in the health sector and the relative number of cases of sick leave controlled for years of education, gender, occupational sector, and diagnosis. Data were analysed by cross-tabulation, ratio of diffuse psychiatric/musculoskeletal diseases, and logistic regression. Results: The ratio of diffuse psychiatric/musculoskeletal diseases increases with education and decreases if the employee works in a technical job. Conclusion: The results challenge the traditional explanation that job features alone can explain the distribution of disease and suggest that a part of the persistent social inequality in health can be caused by the diagnosing process. In order to reach a better understanding of the processes behind the social inequalities in health, the diagnosing process itself should also be studied.

Job stress and job satisfaction of physicians in private practice: comparison of German and Norwegian physicians

PURPOSE

This study examined job satisfaction and job stress of German compared to Norwegian physicians in private practice.

METHODS

A representative sample of physicians in private practice of Schleswig-Holstein, Germany (N = 414) and a nationwide sample of Norwegian general practitioners and private practice specialists (N = 340) were surveyed in a cross-sectional design in 2010. The questionnaire comprised the standard instruments "Job Satisfaction Scale (JSS)" and a short form of the "Effort-Reward Imbalance Questionnaire (ERI)".

RESULTS

Norwegian physicians scored significantly higher (<0.01) on all items of the job satisfaction scale compared to German physicians (M 5.57, SD 0.74 vs. M 4.78, SD 1.01). The effect size was highest for the items freedom to choose method (d = 1.012), rate of pay (d = 0.941), and overall job satisfaction (d = 0.931). While there was no significant difference in the mean of the overall effort scale between German and Norwegian physicians, Norwegian physicians scored significantly higher (p < 0.01) on the reward scale. A larger proportion of German physicians (27.6%) presented with an effort/reward ratio beyond 1.0, indicating a risky level of work-related stress, compared to only 10.3% of Norwegian physicians. Working hours, effort, reward, and country differences accounted for 37.4% of the explained variance of job satisfaction.

CONCLUSIONS

Job satisfaction and reward were significantly higher in Norwegian than in German physicians. An almost threefold higher proportion of German physicians exhibited a high level of work-related stress. Findings call for active prevention and health promotion among stressed practicing physicians, with a special focus on improved working conditions.