We find challenges associated with the ideals of being good hospital doctors in the collegial community, in terms of leading and being led, and in the work-life balance. Norwegian and international studies show that many doctors go to work even though they are ill, and they expect their colleagues to do the same (18). On the one hand, this is a matter of loyalty; they do not wish to burden their colleagues with extra work. On the other hand, absence may be a threat to the ideal of the professionally dedicated doctor’s stamina and work capacity. One example of this is when younger colleagues prioritise other aspects of life and thereby challenge the attitudes of their older colleagues regarding the degree of dedication required of a «good doctor». The clarity with which the senior consultants emphasised that the professional culture should not be open to whiners was a factor when some specialty registrars failed to report the challenges they encountered in achieving the expected degree of attendance. Because many specialty registrars experience challenges in living up to the norms of the collegial community, and for as long as the degree of professionalism at least in part appears to be measured in terms of the number of hours worked, this generational gap between doctors will persist (9). Such internal conflicts among doctors may cause challenges to be individualised, because they are hard to structure at an organisational level.
Today, both male and female doctors tend to have partners who have careers of their own, and the partner will often also be a doctor (19). This notwithstanding, the professional culture appears to maintain the notion that showing consideration for the family is irreconcilable with being a «good doctor». This is consistent with the findings from a study undertaken among general practitioners, for whom appearing healthy was important, because they felt that their state of health was used as an indicator of their medical competence (20). Given that social support from colleagues has been shown to enhance well-being (21), disassociating from this type of notion is especially difficult.
One obvious way to reduce stress associated with the work-life balance is to reduce working hours (19), but in Norway as well as internationally it is being debated whether a further reduction of doctors’ working hours may lower the level of specialist training (22). Moreover, the quality of health services may be linked to the doctors’ well-being (23), although this has not been widely studied in Norwegian hospitals.
This study has shown that the norms of attendance and work capacity challenge concerns for personal matters, but also help maintain full staffing at work. When absence is dealt with internally among colleagues, it is unlikely that much of this information will ever reach the management. For managers to be able to facilitate opportunities for absence, they require to know about needs. There is a discrepancy between the large degree of independence and self-management enjoyed by doctors and their concurrent expectation that the management should observe and cater to their needs. This may give rise to uncertainty and lack of involvement on the part of the management in matters such as dealing with absence. A Swedish study has shown that hospital managers often apply a weak, indistinct and partly absent management style vis-a-vis doctors (12). It is questionable whether Norwegian hospital managers enjoy sufficient trust and recognition from the medical collegium to succeed in their management of doctors.
Doctors working in Norwegian hospitals have clinical as well as organisational responsibilities. The combination of the doctors’ insufficient training and experience in management (24) and the fact that the legitimacy of a manager in charge of doctors depends on recent clinical experience may render leadership positions quite challenging and reduce their attractiveness in the eyes of doctors. This contrasts with the situation for nurses, who gain in status through accepting administrative and management positions (25). In addition, many doctors claim that it is crucial for colleagues to accept management positions to contribute professional competence and to have a say in the design of the doctor’s role in the health services of the future.
There is a clear need for more recognition, in the medical collegium as well as by hospital management, of the fact that doctors also are entitled to be absent when they or their children are ill. This will be a challenge to hospital staffing plans. Clearer leadership, combined with better mutual understanding, may help facilitate structural changes that would benefit the doctors’ working situation as well as quality and safety in their work with patients.
As a methodological comment, we would like to add that the strength of a qualitative study is its ability to generate experience-based knowledge, more than quantitative rankings (26). The external validity of the study’s findings is nevertheless maintained by the inclusion in the material of doctors from a large, centrally located hospital and a small, local hospital, from a diversity of disciplines, and specialty registrars as well as senior consultants (26).
The recruitment may have resulted in a sample of doctors who have a particular interest in the topic and better opportunities to work long hours, because the interviews were largely conducted at the end of the working day. In focus groups, the participants may influence each other, thus producing a larger consensus effect than might perhaps have been obtained by individual interviews (26). The fact that the moderators were doctors may on the one hand have helped promote understanding and recognition of the matters described, but on the other may also entail a risk that certain factors specific to doctors might have been 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 clinical and research fora, and the participants have been provided with an opportunity to read through the results and approve the use of quotations. The results of the study indicate some possible implications and proposals for measures for which various stakeholders may assume responsibility. The Norwegian Medical Association could promote a discussion on the balance between professional dedication and consideration of personal needs as a topic in various specialist training programmes and managerial training courses, to make this a natural part of identity development as a doctor. In addition to the advisory services available to individual doctors through the peer counselling scheme (27) and Villa Sana (28) it is crucial to enable doctors to cater better to their own needs at an individual and collegial level.
The hospital doctors themselves may help establish a wider space for voicing reflections in the collegium on the challenges inherent in being a good doctor while also catering to personal needs. Acceptance among colleagues and better mutual knowledge between doctors and managers regarding the values and responsibilities of the other party will represent key premises for undertaking structural changes, such as life-stage adaptation of the hospital doctor’s job. To achieve change, it will be crucial that those responsible for organisation of the health services at various levels help facilitate and enable such processes as have been described above.