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The good doctor – strong and persevering

Tuva Kolstad Hertzberg, Helge Skirbekk, Reidar Tyssen, Olaf Gjerløw Aasland, Karin Isaksson Rø About the authors

Many requirements and expectations are associated with the tasks that a doctor shall perform, the means to be used to solve them and the role that doctors should assume when encountering stakeholders. Many different actors have opinions about what makes for a good doctor (1). What do the doctors themselves think it means to be a good doctor today?

There is an ample literature defining expectations for the ideals and commitments of the medical profession (2 – 4). The notion of the doctor as an unselfish helper who wants to do everything possible for the patient, including disregarding his or her own personal needs (5), has roots going back to the writings of Hippocrates. Based on these notions, doctors were for a long time permitted to operate quite freely within their professional area. Starting from the 1970s, an increasing scepticism arose with regard to the way in which doctors handled this professional freedom. Social scientists such as Krause (6) and Freidson (7) claimed that the doctors’ professional role had increasingly yielded to financial and market considerations and therefore ought to be regulated.

In today’s Norwegian health services, the roles and functions of doctors are regulated in a number of ways. The Health Personnel Act, which in 1999 replaced the Act relating to medical practitioners, no longer uses the term «medical profession», only the collective noun «health personnel». Emphasis is increasingly placed on knowledge-based guidelines (evidence-based medicine) for doctors, of which the establishment of the Knowledge Centre for the Health Services provides an example (8). Today, patients have other expectations and requirements than previously, with a stronger emphasis on shared decision making as described in the Patients’ Rights Act (9). Patient autonomy and user participation are new ethical principles to which doctors need to relate (10). Complicated organisational and social structures impact on the role of hospital doctors (11), with new modes of work in the health services, such as more teamwork between doctors and across professions (12), as well as higher demands for cost effectiveness in the hospital trusts (13).

Challenges to the traditional role of the doctor can be addressed in various ways. The profession itself can attempt to improve the performance of its members through evidence-based guidelines and by realising the ideals of the good doctor through internal discipline and collegial control (14). The Norwegian Medical Association’s Code of Ethics for Doctors represents one example, which should help ensure that values are upheld in work with patients: «The doctor shall cure, alleviate and console» (15).

Doctors in many countries are concerned that the health services are managed according to business principles rather than with a view to providing patients with high-quality services (16, 17). Many doctors claim that this impacts on the preconditions for exercising good medical judgement, and feel alienated (16, 18). It is interesting to see how this affects future generations of doctors.

How do hospital doctors balance these preconditions and expectations of their role today? We wished to investigate how hospital doctors themselves perceive what it means to be «a good doctor» in Norway today.

Material and method

We chose a qualitative method because we were interested in studying the doctors’ own attitudes and perspectives (19). Data were collected in eight focus-group interviews and three individual interviews during the period 2010 – 2012 with a total of 48 hospital doctors – 22 specialty registrars and 26 senior consultants – in psychiatry (n = 19; 58  % women), internal medicine (n = 15; 40  % women) and surgery (n = 14; 71  % women). We informed about the study through union representatives, leaders or those responsible for the doctors’ meetings. We recruited a strategic sample of senior consultants and specialty registrars in relevant specialties in one large and one small hospital. In medicine and surgery we interviewed groups of senior consultants and specialty registrars respectively. Since it turned out to be difficult to convene busy hospital doctors to group interviews, we conducted three individual interviews with participants who were unable to attend the focus groups. Both interviews in psychiatry were conducted at an internal meeting of doctors and included senior consultants and specialty registrars. The interviews (1 – 1.5 hours) were led by a moderator and one or two assistants (Tuva Kolstad Hertzberg, Karin Isaksson Rø and Olaf Gjerløw Aasland), all of whom are doctors from a variety of backgrounds and with no affiliation to the hospital departments in question.

By way of introduction, the moderator opened the conversation as follows : «How to achieve an appropriate work-life balance as hospital doctors?» The interviews were recorded digitally, then transcribed and anonymised in accordance with ethical guidelines. The texts were analysed with the aid of systematic text condensation, a four-step method of analysis inspired by Giorgio and developed and modified by Malterud (20). Two of the interviews were coded into categories by Tuva Kolstad Hertzberg and Karin Isaksson Rø, who subsequently discussed their coding with Helge Skirbekk. During the first coding of the data, notions about what it means to be a good doctor emerged as a key topic associated with the work-life balance as a doctor. To examine this in more detail, the data were analysed in light of «what it means to be a good doctor» as a general topic.

Finally we re-contextualised the results in light of the data material to reveal similarities that would corroborate our findings and dissimilarities that would refute them (21). The relevant subcategories that define the general topic are presented in the results section as textual summaries, with some quotations for illustration. The participants were offered an opportunity to read through the results section to approve the quotations.

Four of the authors are doctors with a background in psychiatry/occupational medicine and research on the health, work and quality of life of doctors. One of the authors is a sociologist with a research focus on issues of communication and trust in the health services.

The study was approved by the Regional Committee on Medical and Health Research Ethics.

Results

In the interviews, it was clearly expressed that in order to learn, practise and update oneself in the profession, theoretically as well as in terms of practical skills, a willingness to maintain a high degree of availability in the workplace and high work capacity are required. We have referred to this as «professional dedication». This appeared to be the key characteristic of a good hospital doctor and applied across specialties, but was to some extent perceived differently by specialty registrars and senior consultants.

«We are doctors, and that’s not a profession, it’s a lifestyle»

Specialty registrars and senior consultants both described professional dedication as essential for appropriate examination and treatment of diseases in individual patients. Irrespective of specialty and career length, the profession was described as «fun» and «exciting». Many described the professionally dedicated practice of «their craft» as «what they were trained to do».

Being professionally dedicated appeared as a self-evident confirmation of identity, as something that resulted in recognition and legitimacy among colleagues. A male physician described his admiration for the professional dedication of his colleagues in these words:

«Some come in during their time off if they have some skill that a particular patient may be in need of. They just come in and do it, but receive nothing in return. There is not even any gratitude, other than perhaps we may nod our heads a little like this in the morning meeting». (Group 4)

The goal of becoming or being a skilled professional appeared to be a limitless, lifelong process for many doctors. Some stated that they aimed to do «a little extra». The somewhat unattainable ideal of the medical profession was emphasised as a motivating factor by some, especially the senior consultants. Many felt that they had little time for professional immersion and research in their work schedule, and therefore had to do this in their leisure time.

A psychiatrist stated the following:

«… because here (note: in this job), training never stops, you’re never good enough, never clever enough, and you go to work every day for the rest of your life learning something new.» (Group 1)

Senior consultants and specialty registrars differed in their views on willingness to give less priority to concerns in life other than professional ones. To the senior consultants, being a doctor appeared to be a major part of their own identity and lifestyle. Many of the senior consultants talked about «being a doctor», while the specialty registrars talked about «working as a doctor».

«I took holiday, but only for one week at a time»

Many stated that in order to be a skilled professional, presence at the hospital is crucial. A male psychiatrist said:

«I believe that unremitting hard work is needed to achieve high success criteria. I believe that being present is essential. Here, we make it a point of honour that things go well.» (Group 1)

Attendance on the ward, especially when on duty, was described as crucial to gain experience, learn procedures and obtain knowledge about the patients. Some senior consultants who were over 60 years of age and no longer needed to work shifts wished to continue their duty work to avoid becoming professionally marginalised. Specialty registrars who wanted to demonstrate their professional dedication had noticed that their colleagues expected them to be present beyond regular working hours. Many senior consultants claimed that the specialty registrars had considerably less responsibility than they had had themselves during their time as specialty registrars. For them, their frequent attendance at work was felt to be natural, and other aspects of their life had been adapted to this. This was illustrated by a humorous discussion between three senior consultants about holidays:

«Senior consultant 1: I have never had a guilty conscience while on holiday.

Senior consultant 2: No, because you never went on holiday before.

Senior consultant 1: No, I didn’t.

Senior consultant 3: I had been here for two or three years before you started (note: to go on holiday).

Senior consultant 1: I went on holiday, but only for one week at a time.

Senior consultant 2: One day at a time.» (Group 1)

«But everybody gives 110  %. You’re expected to give 110  %.»

To be frequently available, having a high work capacity was required of each doctor. Work capacity was described as «the willingness to put in some extra effort, work overtime and work efficiently».

Because of the workload they were dependent on well-functioning members of the group, who were seldom absent, worked hard and remained loyal. Because putting in extra effort was expected, negative reactions ensued when these expectations were not met, but when they were honoured there were rarely any positive reactions:

«… nobody really said anything, but you could hear from the comments and see it in their eyes that not everybody thought much of it.» (Group 3)

In recruitment processes, having high work capacity was emphasised as a key criterion by many senior consultants. One of them described the recruitment policy thus:

«… I have largely recruited the staff members who work here. In reality, I am now being managed by my former disciples, and they are a hand-picked bunch of top-notch people, aren’t they, who have been given everything possible through the years, and who are both determined enough and skilled enough to succeed, really succeed. And all the others have made different choices, haven’t they, those who were less ambitious (…).» (Individual interview 2)

We found no clear gender differences in the material.

Discussion

In this study, what it means to be a good doctor is described as being a professionally dedicated doctor, who is highly available in the workplace and willing to work efficiently and make supreme efforts to achieve this (high work capacity). Maintaining excellent professional skills appeared to be a fundamental precondition for most of the doctors.

Statements by doctors in this study to the fact that they extended their working hours to upgrade their professional knowledge are confirmed by previous studies, in which hospital doctors in a number of specialties stated that at least 45 hours per week are needed to ensure adequate specialisation (22). Self-imposed overtime among doctors has previously been shown to reflect the distance between the doctors’ own assessments of the time needed to maintain a sufficient level of professionalism on the one hand and demands for cost-effectiveness on the other (23).

Attendance beyond normal working hours and «the willingness to put in some extra effort» may be similar to the ideals of the unselfish helper who disregards his or her own needs. Little has been written about the practical implications of altruism (24). The absence of a norm regarding what is «good enough» may complicate the search for a work-life balance.

We are aware of few other studies that investigate doctors’ views of what it means to be a good doctor, but much research has been undertaken on medical professionalism. Good professionalism is often defined indirectly through descriptions of unprofessional behaviour (10). We therefore needed to explore indirect ways to describe what a «good doctor» is. Instead of speaking about what it means to be a good doctor, the doctors spoke about colleagues who did not «adapt» or were insufficiently «ambitious». In line with our study, previous international research has pointed out the difference between regarding the medical profession as a lifestyle as opposed to regarding it as a job (25, 26).

Many of our respondents believe that the younger generation has replaced the ideal of altruism with their own interests when placing greater emphasis on their private lives and families (26, 27). The structure of the split duty periods and shorter working hours may have caused younger doctors to feel less personally responsible for their patients (28) and thus less committed to their work as doctors.

The trend towards constantly new subdivision of tasks and sub-specialties may come at the cost of continuity of treatment. Technological advances and dealing with new biomedical knowledge often tend to displace the more humanistic aspects of medicine (29). On the other hand, senior consultants’ and specialty registrars’ differing views on the doctor’s role may also represent a cohort effect, meaning that today’s young doctors will be socialised into the role of the doctor as «a lifestyle» later in their careers.

These expectations for intensive and effective work corroborate previous research showing that hard work is a ubiquitous norm in the medical profession (30). The willingness to put in extra effort appeared to be fundamental to the doctors, as well as an expression of dedication, as something that endowed them with legitimacy among their colleagues. Experience is crucial in the medical profession, and obtaining medical competence is a matter of life-long learning. The challenge that emerges here is the question of whether it is at all possible to be «good enough» as a doctor.

With regard to the general topic of what it means to be a good doctor, the differences that we found between the senior consultants and the specialty registrars were more pronounced than those between the genders. Few differences between male and female doctors have previously been found in terms of job satisfaction (31). As regards the everyday consequences of such job ideals, however, it has been shown that women and men handle the work-life balance differently. Women reduced their number of hours worked to a greater extent than men, despite an equally large care burden measured by their number of children (32). This non-reduction of working hours among men is correlated with emotional exhaustion (burn-out) later in their careers (33).

Using the available data material, we have also analysed the challenges that hospital doctors face when seeking to live up to the ideals of the good doctor. The results will be presented in a separate article.

The strength of a qualitative study is that it generates experience-based knowledge, rather than quantitative rankings. This restricts its generalisability. However, the external validity of this study’s findings is enhanced by the inclusion in the material of doctors from a large, centrally located and a small, local hospital, doctors from various medical specialties, and specialty registrars as well as senior consultants (34).

Recruitment for the study may have resulted in a sample of doctors who had a particular interest in the topic. We may also have selected doctors with better opportunities to work long hours, because the interviews were conducted at the end of the working day. The fact of having three individual interviews and eight group interviews may have affected the results because of the different dynamics inherent in the two forms of interviewing. The participants in the individual interviews would have had less time to speak in a group, and their statements would have been affected by what others said, and vice versa. This may have caused us to give these participants more space in our study than the individual participants in the focus groups.

The fact that the moderators were doctors may on the one hand have facilitated understanding and recognition of what was described, but also entails the risk that one’s own assumptions may have affected this understanding. The «insider» perspective may have caused some factors that were assumed to be known to all doctors to be taken for granted and not explicitly mentioned. During the analysis, we have looked for variations around the main topics in order to reinforce the internal validity of the findings. The findings have also been presented and discussed in various fora and submitted to the participants.

Conclusion

Our findings indicate that in the doctors’ opinion, being a good doctor is closely associated with a professional dedication that increases the willingness to put in extra effort in terms of attendance in the workplace and effectiveness in work with patients, irrespective of the circumstances. It will be important to see what consequences are entailed for doctors to live up to these expectations of being a good doctor.

MAIN MESSAGE

According to hospital doctors, being a good doctor means demonstrating a high degree of professional dedication.

Professional dedication is demonstrated through a strong willingness to work intensively and effectively with the patients, while also going to great lengths to be available beyond regular working hours.

Becoming a good doctor is described as a lifelong process.

We wish to thank the doctors who participated in the interviews and those who helped us arrange the initial information meetings.
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