Psychosocial challenges facing physicians of today
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 Michael Hammer and James Champy define BPR as “identifying and abandoning the outdated rules and fundamental assumptions that underlie current business operations” (Hammer & Champy, 1998) p. 3.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.
Section snippets
Mortality and morbidity of physicians
From a theoretical point of view, a professional's health status is dependent on the individual's background, his/her occupational environment and behavioral pattern. Overall, data suggest that physicians are no better off than other learned professions. To the contrary, data indicate that cardiovascular mortality rates among physicians are the same or even higher than other professional groups (Rimpelä, Nurminen, Pulkkinen, Rimpelä, & Valkonen, 1987). Factors such as the well-known triple sign
Occupational challenges and stressors
The occupational environments of physicians are characterized by a wide range of potential stressors, challenges and rewards. A number of these stressors are intrinsic to medical practice, such as working with emotionally intense issues, suffering, fear, sexuality, failures, and death (McCue, 1982; Arnetz, Andreasson, Strandberg, Eneroth, & Kallner, 1988).
A major motivation for students to choose the medical profession in the first place is that they want to help others. They commonly state
Medical stress and impact on physicians’ well-being
There is little doubt that physicians face a number of intrinsic and extrinsic stressors as part of their medical practice. In what way might such stressors relate to and impact on the health and well-being of physicians?
Stressors identified in the medical profession are to a great extent psychosocial in their origin (McCue, 1982; Arnetz et al., 1988; Agius, Blankin, Deary, Zealley, & Wood, 1996). As a consequence, it would be expected that physicians should be at increased risk for emotional
A hospital-wide occupational health survey
Over 300 Swedish physicians in a major regional hospital responded to a questionnaire survey concerning their view of work; Organization; Future; Social life and lifestyle pattern (Arnetz, 1997). Table 1 summarizes some key findings concerning the psycho-social work environment. In general, there were few statistically significant differences between male and female physicians. However, it was significantly more common for female physicians to receive positive performance feedback from their
The QWC-method — A prospective intervention study to enhance physician well-being
Even though there are a number of studies concerning physician stressors and the importance of various modifying variables, to date there is a void of prospective intervention studies aimed at improving the work conditions of physicians. In 1993, researchers at the National Institute for Psychosocial Factors and Health and the Karolinska Institute initiated a detailed assessment of how physicians in a major regional hospital perceived, among other things, their work, skills utilization and
Integrated enhancement processes for physicians
This review points to physicians as a profession that enjoys considerable autonomy. Physicians have jobs offering ample opportunity for challenges and growth. At the same time, a number of intrinsic and extrinsic stress factors risk the long-term mental and physical well-being of physicians. Furthermore, current structural and financial changes within the health care sector have severely threatened the traditional role of the physician and point to the importance of developing new roles for
An integrated model of physicians and organizational well-being
Fig. 3 is a theoretical model, based on various studies by the author as well as others. In order to create environments that foster physicians’ and organizational well-being, we need to consider individual physician and professional characteristics, leadership style of the department, patient characteristics and organizational factors such as the mission and the vision of the hospital, the department or health center.
The model clearly identifies leadership as a key success factor. The leader
Conclusion
Physicians face a number of intrinsic and extrinsic challenges. Health care reforms around the world result in a need for physicians to reconsider their traditional role and create new roles. Our understanding of physician stressors, organizational and individual modifiers, and the impact on physicians’ health and well-being is continuously improved. We also know that in order to achieve high quality care, physicians need to enjoy both their professional and private lives. Physicians should
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