Participants
We collected reflections of 786 physicians (56% female), aged 32 to 66 years, representing 35 different (sub-)specialties at 18 hospitals. A total of 737 physicians (94%) completed the reflective questions, which we subsequently analysed; 38 physicians (5%) used ‘not applicable’ or comparable short statements of less than 50 characters. Most physicians, however, reflected more extensively. The mean reflection length was 503 characters, ranging from 83 to 2963 characters.
Overall findings
The majority of physicians reflected on all three pillars of professional performance. They described concrete actions in terms of must do’s and should do’s regarding pursuit of excellence and accountability. Reflections on humanistic practice mainly triggered thoughts about the essence of being a physician. The professional performance model (Figure 1) captures how physicians perceive their professional performance. The participating physicians differentiated between their calling of being a doctor, the translation of this calling into daily practice and the threats to their performance, both on an individual and work-related level. Most salient in forming the model was the finding that physicians felt that humanistic practice was at the heart of their profession, referring to humanistic practice in terms of their calling, both on a professional level (meaning of work) as well as on a personal level (purpose in life). Physicians also experienced that their ability to perform well is under pressure, and there is a palpable threat to their ability to live up to their calling and to act as a genuinely caring practitioner. We will now describe these findings in more detail.
Why: the calling for being a doctor
Physicians perceive the doctor-patient relationship as the heart of being a physician. They describe earning a patient’s trust as an important foundation for this relationship. As pointed out by the following physicians, respect, engagement, and genuine interest in the patient as a person are key components in order to earn such trust:
My motto is to be there for my patients, treat them to the best of my abilities and as respectful
as possible. You should treat your patients as you would want your parents to be treated
(P 426)
Being competent and trustworthy to my patients, that is what I am trying to be aware of
every single time
(P 548)
I need to be intrinsically motivated, to meet the demands that people put on me when they
need my care, to not disappoint the trust that they put in me
(P 651)
Many physicians describe this relationship as the reason why they wanted to become a physician in the first place and what they still consider as the most important aspect of their job. They experience this relationship as motivating and inspiring, the reason for putting effort in understanding and helping their patients, illustrated by the following statements:
Getting to know the person behind the patient creates understanding, a deeper
relationship and motivation to meet the goal for the patient
(P107)
My heart sends me to the hospital with joy; patients and their families still touch
and inspire me every single day and that’s exactly what being a physician is all about
for me
(P374)
Contact with patients is the reason that I became a physician. I view all my patients as the
human beings that they are and try to put myself in there position, thinking what I would want
in their situation
(p 580)
Helping other people has always been very important to me, I was raised that way, and as a
physician it is something that I hope to pass to all the people I work with
(P 597)
The How: translation of the calling for being a doctor into daily practice
Physicians reflect on all three pillars of professional performance, i.e. (i) the pursuit of excellence, (ii) humanistic practice, and (iii) accountability in terms of concrete actions.
The pursuit of excellence; gathering, sharing, and transferring knowledge and competence
Knowledge and competence are central elements in the pursuit of excellent patient care in general. Physicians emphasize aspects as gathering new knowledge and competence for example by keeping up with new insights, attending courses or seeking new and innovative techniques:
I want the very best for every patient, meaning a perfect narcosis, without any complications
and a patient waking up without nausea and pain. Although this isn’t always possible, I
always strive for that
(P491)
I am eager to learn something new regarding my field of expertise every week
(P725)
Next Generation Sequencing, that is a new technique that I will get into because it is THE new
evolution in the area of molecular diagnostics
(P773)
Consulting colleagues, asking each other for help, discussing outcome measures, and reflecting on performance are also mentioned in aspiring toward the best possible care:
We ask each other for help and consult one another very easily in my team, whether it is about
medical or more ethical questions, that enhances the strength of our team
(P 128)
My group invests in reflecting on our performance since we believe that is conditional in
striving for the best care for our patients
(P362)
Physicians recognize that optimal performance is enhanced by transferring knowledge through education and science:
I am very interested in the relationship between food and health and I advice colleagues on
this topic
(P 413)
Our goal is to publish the results of our studies in peer reviewed journals
(P 661)
Humanistic practice; compassion, empathy, and attention
According to the participants, patients deserve their fullest attention at all times. As participants firmly noted, being empathic and attentive seem to be crucial conditions for a compassionate doctor-patient relationship. Physicians perceive humanistic practice as self-evident and an essential condition for being able to be a physician. Giving patients time and attention, being a good listener, and being open to patients’ wishes, ideas, and fears are mentioned as important components according to the following accounts:
Compassion is self-evident to me since genuine attention for patients’ wishes and
concerns emerge from this compassion
(P352)
I try to give my patients the feeling that they have sufficient time to tell me their story and
concerns. That is how they can confide in me and how I can give the best care to them
(P 484)
When I inform patients or do a procedure, I treat the person in front of me and not a disease.
My patients’ perceptions matter, since every patient has the right to make a decision that
suits him or her. I notice that patients value profound explanation of things so they feel
they can really make a choice
(P 628)
Accountability; transparency, administration and professional standards
Physicians perceive accountability of care delivery as two-faced. They acknowledge their responsibility in and the importance of being transparent, of registering patient information as well as quality measures, and following professional standards:
I take time to inform my patients, to explain things that can happen. That is being
transparent to me, being open about my actions, in order to be trustworthy for them
(P 50)
I try to be open about my performance and explain why I do the things I do, so
that my colleagues and patients have confidence in me
(P349)
I would like to have more time to check professional standards; within my work with the
fragile elderly, you deviate form guidelines regularly. However, it is instructive to check
the standards, to prevent a patient from receiving ‘inferior’ care and to finetune the
best care for this specific patient
(P 693)
However, the downside of the growth in accountability is frequently mentioned as well since physicians perceive a decline in time and attention for their patients as a result of these bureaucratic requirements.
Nowadays, I spend way too much time on administrating and registration, which has a
negative effect on the time I can (and should) spend with my patients
(P 76)
Registration is important, of course, but it should not take almost all of our time. It does not
feel good that I cannot spent enough time with patients because of that
(P 99)
Threats to optimal performance
When reflecting on their performance, many physicians describe situations that hinder them to perform to the best of their abilities. These situations either hamper their pursuit for excellence or put their purpose of being a physician under pressure. They perceive that such individual- and work related situations obstruct, and thus pose a threat to, optimal performance.
Individual aspects; physical and mental wellbeing
Physicians acknowledge the potential negative effect of low levels of vitality on their professional performance. They detect the impact of insufficient mental energy in lacking time and attention for oneself as resulting in loss of attention, inspiration, and enthusiasm during their contact with patients and colleagues. Physical inabilities are also mentioned as posing a potential threat to optimal performance.
I should somehow keep my motivation and inspiration, in order to give the best care, but
to be honest that is hard right now given my situation at home
(P 4)
I experience lack of time, miss the attention for myself and I wonder: how am I
going to keep up with this and enjoy it?
(P83)
I had low levels of vitality due to a combination of a long period of hard work and physical complaints, that balance has restored because I work part-time now
(P321)
Striving for the best possible care is very important for me, unfortunately, that has not been
possible the last year due to my herniation
(P 682)
Work related aspects; workload and collaboration issues
The majority of physicians appoint work related factors as threats to optimal performance. They describe the negative effects of their heavy workload, and more specifically the increasing administrative tasks due to accountability and national or local policies. This leads to a lack of time for their patients, creating frustration and diminishing motivation. In particular, the purpose of being a physician and of humanistic practice is described as being under pressure by a heavy work- and administrative load.
I am forced to spend a lot of time doing non-patient- related activities. When I look deep
into my heart, I must confess that I feel I do not meet the professional demands that one
could expect from me
(P48)
I feel that administration is taking over all over our hospital; that frustrates me and has a
negative effect on my passion and inspiration
(P106)
The current heavy workload is a real threat for my vitality as a professional
(P 693)
Being compassionate definitely suffers from time-constraints since adequate
communication needs more time than is foreseen in the production-deals
(P737)
The negative impact of hospital mergers is also mentioned as having an effect on physicians’ performance.
No balance for me right now, I am easily irritated and agitated, it takes a lot of effort and
energy to find stability in our new merged department
(P 658)
There are seriously disturbed relationships because of the merge, within the ‘old’ and the
‘new’ team. I feel that I am treated without any respect, therefor I will probably seek
a job somewhere else
(P 661)
Collaboration issues within the physician group such as disturbed relationships or negativity are also mentioned as hindering aspects:
I need to keep my engagement and motivation up, which is difficult for me right now since I
really struggle with feeling any compassion for my colleagues
(P 484)
It isn’t always easy to hang on in a team where being open and honesty are not considered
a positive thing and a change to improve. My colleagues make me seem ‘weak’ and
‘vulnerable’. I really need to work on my skills to be able to stand straight in this environment
(and be appreciated)
(P 573)