Psychosocial challenges facing physicians of today

Abstract

Fundamental changes in the organization, financing, and delivery of health care have added new stressors or opportunities to the medical profession. These new potential stressors are in addition to previously recognized external and internal ones. The work environment of physicians poses both psychosocial, ergonomic, and physico–chemical threats. The psychosocial work environment has, if anything, worsened. Demands at work increase at the same time as influence over one's work and intellectual stimulation from work decrease. In addition, violence and the threat of violence is another major occupational health problem physicians increasingly face. Financial constraint, managed care and consumerism in health care are other factors that fundamentally change the role of physicians. The rapid deployment of new information technologies will also change the role of the physician towards being more of an advisor and information provider. Many of the minor health problems will increasingly be managed by patients themselves and by non-physician professionals and practitioners of complementary medicine. Finally, the economic and social status of physicians are challenged which is reflected in a slower salary increase compared to many other professional groups. The picture painted above may be seen as uniformly gloomy. In reality, that is not the case. There is growing interest in and awareness of the importance of the psychosocial work environment for the delivery of high quality care. Physicians under stress are more likely to treat patients poorly, both medically and psychologically. They are also more prone to make errors of judgment. Studies where physicians’ work environment in entire hospitals has been assessed, results fed-back, and physicians and management have worked with focused improvement processes, have demonstrated measurable improvements in the ratings of the psychosocial work environment. However, it becomes clear from such studies that quality of the leadership and the physician team impact on the overall work atmosphere. Physicians unaware of the goals of the department as well as the hospital, that do not receive management performance feedback, and who do not get annual performance appraisals and career guidance, rate their psychosocial environment as more adverse than their colleagues. There is also a great need to offer personally targeted competence development plans. Heads of department and senior physicians rate their work environment as of higher quality than more junior and mid-career physicians. More specifically, less senior physicians perceive similar work demands as their senior colleagues but rate influence over work, skills utilization, and intellectual stimulation at work as significantly worse. In order to combat negative stressors in the physicians’ work environment, enhancement initiatives should be considered both at the individual, group, and structural level. Successful resources used by physicians to manage the stress of everyday medicine should be identified. Physicians are a key group to ensure a well-functioning health care system. In order to be able to change and adapt to the ongoing evolution of the Western health care system, more focus needs to be put on the psychosocial aspects of physicians’ work.

Introduction

The Health care system is undergoing major structural and financial changes. The role of the physician, both within the health care hierarchy and within society at large is challenged. New challenges are added to more traditional occupational health risks, such as infectious diseases, psychological stressors, night call duties and threats of malpractice.

Methods derived from industry that are designed to enhance efficacy are applied uncritically to the health care sector to ensure higher medical output with fewer resources. Thus, business process reengineering (BPR), that has been heralded as the solution to a range of complex problems facing industry during the last decade, is currently applied within the health care sector. Michael Hammer and James Champy define BPR as “identifying and abandoning the outdated rules and fundamental assumptions that underlie current business operations” (Hammer & Champy, 1998) p. 3. However, independent research of BPR has not been able to substantiate many of the original success claims (Strebel, 1996).

The art and science of medicine is increasingly industrialized. Smaller units are merged into larger ones. Large-scale payers such as governments, employers, and insurance companies negotiate and contract with large-scale providers (Winkenwerder & Ball, 1988; Iglehart, 1994). As a consequence, the role of the physician is changing into one of a typical employee in the framework of large bureaucratic organizations. Furthermore, the physician-patient relationship is transformed from being based on a covenant of trust to a contractual relationship (Winkenwerder & Ball, 1988).

Increasingly, health care is perceived as a commodity. However, the amount of medical service available tends to be dependent on the purchasing power of the buyers.

The focus on excellence and quality of organizations also brings out the importance of further improving systems for medical quality control and quality enhancement systems within the health care sector (Arnetz & Arnetz, 1996).

Since a large proportion of the gross national product is spent on health care, and apparent needs far exceed available resources, it is important to ensure that inefficient preventive, diagnostic and treatment procedures are phased out. In order for this to happen it is necessary that physicians, to a larger degree than is currently the case, base their decisions on outcome studies. At the same time, outcome studies probably underestimate the difficulties in establishing the effectiveness of various medical procedures (Tanenbaum, 1993). The art of medicine and the uniqueness of each individual physician–patient encounter cannot merely be transformed into statistics. Nevertheless, physicians should be at the forefront in designing better methods to assess the efficacy of various medical procedures, constructing public data bases of medical outcomes, and in ensuring continuous substitution of less efficient methods with more efficient ones. Various initiatives to develop better information on acceptable ranges of practices have been taken. Such initiatives include the Clinical Efficacy Assessment Project of the American College of Physicians and the Medical Necessity Project of the Blue Cross and Blue Shield Association (Tanenbaum, 1993).

Outcome research should not and cannot be the only ground for clinical decision-making. It should however be kept in mind that in their clinical decision-making processes physicians draw on all their knowledge and experience and a complex reasoning model is used to reach a final decision. A poor psychosocial work environment might impact negatively on this delicate decision-making process (Tanenbaum, 1993; Greco & Eisenberg, 1993). The medical profession can only guard their autonomy in decision-making processes if reliable data on the safety and efficiency are available. Otherwise, increasingly we will see non-medical professions and economists defining what are acceptable treatments. It is also important that the profession police its members. It is all too common that colleagues that perform below an acceptable level of competence are not adequately dealt with within the profession. Why is it that the medical profession is rather poor in handling such colleagues? Unless the profession is more willing to deal with this difficult challenge in a more forthcoming way, others will.

This paper presents some morbidity and mortality statistics for physicians, as well as stressors and challenges that face them in their professional role.