A tale of two cultures

Design

To understand the main concern encountered by physicians in their working relationships and to develop a model for resolution of this concern, grounded-theory approach was used.^18,19 Grounded theory is best for research questions that ask “what are the interactions or processes going on here?”¹⁸ Grounded theory was developed in sociology and uses a constant comparative method.²⁰ Our aim was to develop an understanding of the working relationships between family physicians and other physicians.

The study received ethical approval from the Health Research Ethics Board of the University of Alberta.

Setting and study sample

The research team consisted of a family physician, a psychologist, a researcher with expertise in grounded theory, and an infectious disease specialist. Ideally, researchers using grounded theory should do so without preconceived ideas of the subject under study. This was not the case in our study, as the family physician identified respect from specialists as a concern for family physicians in previous research,^8,9 the psychologist dealt with problematic physician working relationships, and the specialist thought there was a need to model ideal family physician and specialty working relationships for learners. The team was cognizant of these potential biases and attempted to seek findings other than those supporting their preconceived ideas.

The research setting included 2 inpatient family practice units located in Edmonton, Alta. Both units involved academic family physicians. One was a tertiary care hospital with 12 family physicians, and the other was a community hospital with 15 to 18 family physicians. In these settings family physicians work closely with nurses, nurse practitioners, and specialist consultants. Learners included occasional medical students, family medicine residents, and specialty residents whose preceptors were consulted about particular patients.

Purposeful sampling identified key informants to represent junior and senior family physicians, residents, general internists, and other physicians who worked closely with each unit. The researchers interviewed a family physician from each unit to obtain an understanding of the working environment in each unit and to help identify potential participants. Potential informants were invited to participate, and all those who were approached agreed to participate. They were given an information letter describing the project.

The 11 participants graduated from medical school between 1977 and 2001 (Table 1). This physician sample varied in sex, age, years in practice, and specialty and was selected using maximum variation sampling to identify and describe common patterns that transcended a focused sample, providing themes that were common to all.^21,22 As an understanding of physician working relationships emerged, theoretical sampling²³ was used to inform the selection of informants and collect information from relevant sources not previously considered. We assumed that emergency physicians and general internists would perceive themselves to be specialists; however, we found that they perceived themselves to be generalists, as they treated undifferentiated illness and, like other generalists, were frustrated with the specialist approach. Hence, theoretical sampling²³ was used to identify a subspecialist with a focus on specific organ systems. Theoretical saturation was obtained at the sixth interview, as new information did not provide further insight in the categories of information obtained.²²

Data collection

Two guiding questions and a semistructured interview guide were developed based on the research team’s collective experience, the related literature, and discussions with other physicians (Box 1). These were presented at a Department of Family Medicine Research Forum to solicit further input and feedback from academic family physicians.

Individual semistructured interviews were conducted by the family physician and psychologist to obtain candid, unencumbered information from each informant.²² The interviews took 1 to 1.5 hours to conduct, in order to obtain each informant’s detailed story, and they were audiotaped and transcribed verbatim. The interview guide helped to ensure that key areas were discussed, and it was modified as interviews progressed to accommodate emerging questions. Field notes were recorded immediately after each interview, including descriptions of where the interview was held; reflections on how the interview went, including visual cues such as body language; and memorandums on possible relationships or issues to consider exploring in future interviews.

Journal entries were made throughout the project. These included memorandums or comments about possible linkages or relationships between data, ideas on emerging themes or areas that need further exploration, the researchers’ evolving perceptions and understandings, potential biases, and contradictory information that needed further exploration.

Data analysis

Analysis involved coding and categorizing the transcribed information. This was initially done manually, then with the use of NVivo software. The transcripts and memorandums were read and reread. Initially, open coding was used, with each idea given a code name (a word or phrase summarizing the main idea). Two investigators (D.M. and L.B.) coded approximately 5 pages of the document independently and then met to discuss and develop consensus on the coding.

The codes were grouped according to their properties and types, and they were grouped into categories. Through coding and developing categories, relationships between different ideas began to emerge and these were written as memorandums. Sorting the memorandums helped to clarify themes and, through theoretical coding, a framework emerged. This model followed Glaser’s description of a grounded-theory approach.^19,23

Rigour of the study

Several methods were used to ensure the study was rigorous and trustworthy. Coding was initially done independently by 2 researchers. Regular meetings were held with team members to review the evolving understanding. Varied perspectives from the research team challenged preconceived ideas. The grounded-theory concept of interchangeability of indicators²⁰ was achieved, as various indicators described in the discussion could be interchanged and still lead to the same core variable. Feedback was solicited from participants, a social worker, and a palliative care physician.

Our work addressed Glaser’s²³ 4 criteria for doing and judging grounded theory: fit (the concept expressed fit the pattern in the data), workability (the conceptualization obtained accounts for how the main concern is resolved), relevance (the study deals with the real concern of physicians feeling overwhelmed), and modifiability (the theory can be modified).

Medical cultures

Two distinct cultures emerged from the analysis: a specialist culture and a generalist or comprehensive culture. Distinctions in knowledge, skills, and values between the 2 cultures could be summarized as focused versus comprehensive. A specialized medical culture delineated areas of focus and expertise by limiting access to valued resources, setting boundaries, and socializing others according to their areas of expertise. The main concern generalists identified was feeling that they were left holding the bag—that they felt overwhelmed when they perceived specialists to be imposing work on them without negotiation. A comprehensive medical culture valued people and relationships, bridging silos by being accessible, developing mutual empowerment through negotiation of boundaries, and socializing others about everyone’s roles and responsibilities.

An overwhelmed medical system

An overwhelmed medical system was described as lacking the resources to deal with the large number of patients. Many problems that physicians dealt with were not medical in nature but were the result of deficiencies in the system, such as the inability to move patients out of the hospital into long-term care beds.

Yeah, you can’t get them off the ward, so it all funnels down to emergency eventually; and we’re hearing that there’s difficulty and even fear about getting people transferred onto a long-term care bed.

(Interview 6)

Highly skilled specialists often lacked the skills to manage general medical and nonmedical problems, and having them manage these types of problems was seen as a poor use of their resources and time in the tertiary care hospital. Consequently, overworked generalists, who might be more familiar with managing systemic issues, felt obliged to provide comprehensive medical care to those who most required it. As the general medical and nonmedical problems did not go away, generalists often had to deal with them, leaving the generalists with a perception that work was imposed upon them without negotiation—that they were left holding the bag.

Holding the bag meant that generalists were left with the responsibility for patients specialists refused or were unable to provide care for, but they were unsure of their role. Were they responsible for providing comprehensive care for the specialists’ patients as consultants or as the responsible physicians?

In the specialist culture, the specialist was better able to control resources, set boundaries, and socialize learners to adopt these values, which often resulted in the generalists, once again, holding the bag (Figure 1).

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Figure 1

Holding the bag: Specialized medical culture values technology and specialized knowledge and skills.

In the comprehensive culture, a work culture that valued both the specialist and generalist was described. The organizational structure in the community hospital reinforced common values and facilitated the development of peer-to-peer working relationships, thus bridging the silos. The workload was negotiated, leading to a sense of sharing the load (Figure 2).

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Figure 2

Being valued: Comprehensive medical culture values people and relationships.

I’m hearing it’s sort of from the top down in terms of the organizational structure, where it’s got a clear mission that pretty well everyone agrees to and wants to work together, and they realize that these are long-term relationships.

(Interview 6)

Three themes emerged as key to either developing healthy balanced peer-to-peer relationships or leading to increased isolation. These were accessibility, negotiation of boundaries, and socializing learners and others.

Consequences of the medical cultures

A specialized medical culture that limits accessibility through controlling resources, setting boundaries, and socializing learners and others to adopt these values can lead to increased isolation (Figure 1). This might have contributed to the development of silos and a sense of isolation in the tertiary care hospital. One participant commented, “We practise in stove pipe isolation. I come in and I give my [specialty] advice, cardiology comes in and gives their cardiology advice, and endocrine gives their diabetes advice.” (Interview 11)

Specialist physicians practising in isolation focused on being valued and on their boundaries in the hierarchical system, and they sometimes did not recognize others’ expertise or roles in the system, as one participant commented: “[T]he other specialists don’t necessarily recognize that we have that expertise.” (Interview 7)

Physicians sought to become valued in a specialist culture by adopting a specialized focus: “Now, family medicine hasn’t been immune from those pressures, because what’s happening in family medicine? There’s more and more specialization within family medicine.” (Interview 4) Generalists who specialized reduced the pool of generalists available to deal with the ever increasing undifferentiated, complex workload.

[The workload] just became overwhelming, you know, and actually [a number of doctors] gave up medicine privileges because of that. But then the hospital was left still with all the patients coming in, you know.

(Interview 6)

A comprehensive medical culture with appropriate accessibility and sharing of resources, negotiation of boundaries that mutually empowers physicians, and socialization of learners to adopt these values might contribute to collaborative physician relationships that reduce isolation and overwork through bridging silos (Figure 2).

Limitations

Our project focused on inpatient family medicine units in a large urban centre. Participants consisted of physicians who worked within this Canadian setting in Alberta. Nonphysician clinicians, medical students, and administrative staff were not interviewed and might have perspectives worth exploring. The researchers involved in the project had preconceived ideas from their previous work, which could contribute to a biased perspective.

Conclusion

We found that a specialist culture that values technology and focused interests might lead to increased physician isolation and the development of silos, leaving generalists feeling overwhelmed. This might contribute to problems within the system. A comprehensive culture that values relationships might lead to increased collaboration through improved accessibility by negotiated access to resources, mutual empowerment with negotiation of roles and responsibilities, and improved socialization of learners and others to adopt these values.

Considerations for further research include exploring what is valued in various medical systems and how to shift from valuing focused interests to developing and valuing relationships; and research broadening the issue of working relationships and environments to include other health care providers, as well as addressing the effects on learners, is needed.