The strength of this study is its prospective design; we have been able to obtain data from the same doctors at two different time points. We do not have data to control whether any of the doctors changed their employment situation, either by altering their job within the same health trust or by moving to another. It is therefore not certain that the work environment evaluated in 2000 is the same as that evaluated in 2004. Nevertheless, should a change in employment situation have been motivated by a lack of professional right of voice, this should have resulted in an increased feeling of freedom and have the opposite effect of that found in this study.
The central theme of this research is the doctors'' opinion on how easy or difficult it is to express critical points of view on «the system». We used the relatively imprecise term «criticise». This can obviously mean anything from bringing up a case in the work environment which one feels should be handled, or should have been handled in a better way, up to criticising the health service via the mass media. A previous study has shown that 50 % of Norwegian doctors believe it is difficult to complain about unethical and professionally reprehensible practice in the work environment (2). It also appears that doctors are not only apprehensive about their superiors, but also, to a large extent, find the criticism of their colleagues difficult. In our opinion it is important to differentiate between «whistle blowing» and «criticism»; whistle blowing arises first when criticism is interpreted or suppressed or when those who are criticising are opposed. Definitions of whistle blowing have included «an attempt, in good faith and in the public interest, to disclose and resolve in a reasonable and non-vexatious manner, but in the face of significant institutional or professional opposition, a significant deficiency in the quality or safety of health care» (3). A work environment in which there is little acceptance of criticism will suppress those signals which are necessary to enable improvements, and thus be a threat both to patient safety and to ethical reflection. A work environment in which there is hostility towards necessary criticism will also, according to this definition, result in a greater degree of whistle blowing, which otherwise should have been perceived as constructive criticism. Such a culture can easily cause good colleagues, who are concerned about quality and ethics, to become involuntary whistle blowers.
The fact that older doctors fear sanctions to a lesser extent than younger doctors if they speak out about unsatisfactory conditions, cannot only be because older doctors are more thick-skinned. Perhaps it is because they have more extensive experience with the health bureaucracy and endless new directors? We found that psychiatrists and doctors working in the surgical field in particular considered demands for loyalty towards the leadership to be a threat to their professional right of voice. For many years, psychiatrists have contended with increased demands and lack of resources. Many psychiatrists have a daily struggle with sub-optimal conditions; a struggle which occasionally comes up in the mass-media (4, 5).
Obviously we cannot establish that the hospital reform alone has been the reason for a deteriorating relationship of trust between doctors and administrators - this is an international trend (6). The transformation of hospitals from monolithic, doctor-managed organisations to modern, commercial enterprises began long before 2000 (7). The success criteria for such reorganisations are improved budget management, shorter waiting lists, and fewer corridor patients, that is, efficiency targets. Maintenance of, and possibly improvements in, professional and ethical standards appears to be a secondary consideration (8). This alone is an important explanation of why the experts can assert that the distance between clinical personal and the leadership has increased.
This assessment provides no information on whether the degree to which doctors'' experience the risk associated with their professional right of voice reflects reality. Doctors frequently oppose changes, even changes which later have been shown to be expedient. When important decisions are taken by the administrators without medical competence, this can obviously cause frustration, although there are good grounds to assert that doctors must also respect administrative or political decisions that are not always popular, e.g. in prioritising work. In this it is important to differentiate between essential political management and loyalty requirements that that can threaten patient safety, as well as professional and ethical standards (3, 9). But the administrative leadership is dependent on good communication with the clinical leadership. The fact that many more clinicians now believe critical comments can result in sanctions, is worrying, both with respect to patients and the profession as such. Although our findings can be rebutted on the basis that they do not demonstrate genuine problems - only the doctors'' interpretation of the situation - nevertheless, leaders within health services should take these signals seriously and encourage an open and continuous dialogue around difficult ethical and medical questions - a dialogue in which there is also room for criticism. And the doctors themselves should work actively to break down the concept that a culture open to criticism is not collegial (10).