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By Nigel
Edwards
Unhappy
doctors are a worldwide phenomenon.
- Several reports from around
the world describe declining morale among doctors, but little is known
about the reasons
- Workload and pay, though
important, do not fully explain the problem
- A key factor seems to be
a change in the psychological compact between the profession, employers,
patients, and society so that the job is now different from what doctors
expected
- Developing a new compact
that is more acceptable to the profession is important
- Clinical leaders have a
potentially crucial role in developing a new compact
Potential
Causes Of Unhapiness
Pay and workload are obvious
causes for unhappiness among doctors. However, evidence from systems with
much higher pay and longer consultation times suggests that these are
not enough by themselves to ensure high morale.
Several of the causes are probably
the result of changes in the expectations of patients, governments, and
employers; and there may also be causes within medicine itself.
The developed world has seen
significant reductions in medical autonomy and increases in accountability
as a result of the growing evidence base and a long running attempt to
bring medicine under managerial and cost control by governments, payers,
and employers.
This has resulted in the growing
use of guidelines, protocols, audit, regulation, and inspection that many
doctors perceive as eroding their control over their professional lives.
Though there are benefits from
these changes, having control over work is important for the job satisfaction
of clinicians and can have implications for overall health of employees.
A related change in the relationship with employers has been the increased
emphasis on numerical targets, efficiency, and volumes of work that dates
from the late 1970s.
The changes in relationships
with patients and society are particularly important. There has been a
decline in deference for all professions and a perceived loss of trust,
coinciding with a feeling that the media has become much more hostile.
In fact doctors are a highly
trusted profession, and the proportion of negative news stories is fairly
constant although the total number of stories has increased.
At the same time, patients
are increasingly active consumers and they demand and have been encouraged
to expect enhanced services, including extended hours and rapid access.
The
easy availability of health information coupled with a sense of entitlement
is shifting the power in the doctor-patient relationship and causing unease.
This is compounded by sometimes
unrealistic expectations about the power of medicine to solve the ills
of modern life. This is a bogus contract between the profession and patients
but one that doctors have themselves sometimes encouraged.
Medical
Causes
Several causes relate to medicine
itself. The job is difficult and emotionally demanding, and doctors are
more likely to be self-critical and have other personality traits associated
with work related stress.
The poor record of the profession
in giving mutual support or giving and receiving feedback aggravates this.
Working in teams is also associated with being better able to cope with
stress, but skills in team working are not universal in the profession.
The selection, training, and socialization of doctors has tended to compound
the problems of high workload, stress, and reaction to changes in the
job.
Medicine has been based on
a model in which doctors are trained to deal with individuals, not organizations;
to take personal responsibility rather than delegate; and to do their
best for each patient rather than make trade-offs in a resource constrained
environment.
These factors make high workloads
and high levels of workplace stress all the harder to deal with. They
also create a real problem in that professional values and training based
on an individualistic orientation do not prepare doctors to function successfully
as members of large, complex organizations. Little training is given to
equip doctors for this, and the difficulty that many consequently experience
leads to stress and frustration.
Failing
To Deliver What Was Promised
An important theme in all of
these changes is the dissonance between what doctors might have reasonably
expected the job to be and how it now is. The psychological contract or
compact is a useful concept to explain this problem.
This is the implicit deal between
doctors, patients, employers and society that defines what the parties
to the relationship give and what they get in return. This seems to have
changed without any explicit discussion with those involved and without
being replaced with an equally meaningful or rewarding alternative.
British
Medical Journal April 6, 2002;324:835-838
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