Finding the X factor: why do physicians do the job?

It is clear that physicians are in demand. Last year the NHS was unable to fill 41% of the consultant physician posts it advertised, vacancies are present in trainee rotas and many documents coming from policymakers call for more doctors in general medicine (GIM)[1],[2]. Hospital admissions increase yearly and those patients are increasingly comorbid and ageing.

Alongside this increase in demand, there is also a decreasing interest in pursuing hospital medicine as a career and a poor satisfaction rate in GIM training. In addition, the battle over new junior doctor contracts has left hospital physicians feeling beleaguered and demotivated.

An important consequence of this demotivation is a negative impact on patient quality of care. The NHS Staff Management and Health Service Quality report[3] showed that increased medical engagement was associated with high patient satisfaction. Evidence from the US has also shown a link between burnout and poor quality and safety.[4],[5],[6]

It seems unlikely that help will come from the government to rectify this situation so we, as a profession, have to sort it out and pull back from the brink. In order to improve satisfaction rates and increase the attractiveness of internal medicine as a career, we need to first understand what influences how physicians feel about their jobs. This is likely to be different at different stages of the physician career.

Choosing hospital medicine

Notably, financial incentives are at the bottom of lists of factors. This comes as no surprise; few physicians go into hospital medicine for the money.

On the other hand, work-life balance was the most common influencing factor for rejecting hospital medicine as a career, as well as job content, the stressful environment, and competition and exams.[7],[8],[9]

There has been no specific research looking across all the different medical specialties to determine specific specialty choice. Some work has been done in geriatrics[10] showing that clinical aspects, senior influence, job ease and less research were key factors in choosing that specialty. The same study stated that the main reason both consultants and registrars regretted geriatrics as a career was status, followed by participation in GIM. There was no specific research found that looked at why physicians chose non-GIM specialties over GIM specialties.

Influencing satisfaction

Job satisfaction once in post is related to numerous factors, and there seem to be differences between countries. For instance, UK physician job satisfaction has been shown to be significantly lower compared to New Zealand physicians.[11],[12] Physicians in both countries were more likely to be satisfied with higher levels of clinical autonomy, control over pay, recognition for their work, and having less bureaucratic interference.

A survey of senior UK consultant physicians who qualified in 1993[13] highlighted factors that led to a positive job satisfaction or a negative one (see bullet point lists below). Autonomy seems to be a key factor in consultant happiness.[14],[15]

Positive:

• status, autonomy, morale, job satisfaction
• adequacy of own training
• experience of working outside NHS/medicine or abroad
• Family-friendly/part-time work, attitudes to gender, work-life balance.

Negative:

• adequacy of juniors’ training
• NHS and government policy
• Family friendly/part-time work, attitudes to gender, work-life balance
• NHS and its management
• Commitment to medicine/NHS/UK/job.

Improving working conditions is therefore important but is not a new concept. The things that doctors say need to change in the workplace are fairly consistent between surveys of both consultants and registrars[16] (RCP trainee survey, 2015 – unpublished data) and are:

• non-clinical support
• more junior team members
• mentoring
• better IT facilities
• part-time work / flexible on-calls
• training opportunities.

Once again, pay doesn’t feature in this list but its relative importance must be addressed. Until recently doctors haven’t liked talking about pay but one interesting study tried to quantify what increase in pay consultants would want to change working patterns (see box below).[17]

Part of how physicians feel about their job is related to their personality traits.[18] The profession attracts ‘highly driven individuals’ with a ‘strong sense of duty’. High levels of expectations both from themselves and patients can contribute to a degree of self-neglect and decreased satisfaction in an emotionally and physically taxing profession.

Factors that influence retention

Many doctors consider early retirement and make financial plans to do so. The main concerns given for reasons to retire early are (in order of importance):

• family reasons / time for leisure / other interests
• maintaining good health / life expectancy / good retirement
• pressure of work / exhaustion
• reduced job satisfaction resulting from management changes
• insufficient financial incentive to stay
• reduced job satisfaction working with patients.

What would stop consultants retiring early? In the same survey of senior consultant planning for early retirement, the top inducements to encourage staying were:

• workload reduction / shorter hours
• fewer NHS changes / less bureaucracy
• financial necessity
• improved working conditions (aside from hours)
• continuing/increased job satisfaction
• reduction of on-call commitments.[19]

Workload reduction was a recurring theme – not just playing a part in retirement plans – but in a desire to change job patterns or leave direct patient care.[20] Pay also seems to be higher up the lists than for other career stages.

There has been much talk recently of doctors leaving the UK to practise medicine elsewhere but most of this work has looked only at junior doctors. One study suggests that only 35% of junior doctors definitely want to stay in the UK.[21] The reasons for leaving are both positive career or life choices (better quality of life being the most commonly cited reason) or negative feelings about NHS working conditions including dissatisfaction with the NHS and pay. Despite the fact that this study is now 12 years old, it seems unlikely things have improved.

A number of respondents in the same study also indicated that they were considering leaving medicine completely. For these doctors, working conditions were more important an influencing factor, with 75% giving it as a reason to leave medicine, compared to only 23% as a positive lifestyle choice.

A more recent study in 2012 by Sharma and colleagues looked at UK-trained doctors working in New Zealand, to determine the factors that influenced their decision to leave the UK.[12] Reasons found to leave the NHS included:

• disillusionment with the NHS or life in the UK in general
• desire for a change of environment or better lifestyle in New Zealand
• a lack of jobs in the NHS and better employment opportunities in New Zealand
• previous experience of working abroad.

On the other hand, factors that might increase likelihood of return included:

• better working conditions
• changes to the NHS
• better incentives and financial remuneration
• administrative changes.

Finding the solutions

There are no simple answers to the multiple issues that contribute to the reduction in physician morale. One obvious method would be to take the above contributors to dissatisfaction, and ‘fix’ them. However, while working within an environment with controlled resources and spiralling debt, this is not going to be easy. Increasing the number of doctors will undoubtedly help but will take time, will be expensive, and will require changes to immigration policy to provide short-term solutions. Increasing numbers of other professionals such as physician associates will help with workload and technology may also provide some answers.

Are there any other ways we can help doctors feel better about their jobs? One interesting approach is the application of self-determination theory (SDT).[22] This theory categorises motivation behaviours as either intrinsic or extrinsic. Intrinsically motivated behaviours are performed because they are inherently enjoyable. Extrinsically motivated behaviours, on the other hand, are performed with the promise of a reward or avoidance of pain. Alongside these two groups of factors are three universal human psychological needs:

• autonomy (having choice)
• relatedness (having valued relationships with other people)
• competence (believing that one is effective and capable at what one does).

According to SDT, we are naturally geared towards performing intrinsically motivated behaviours. However, extrinsically motivated behaviours can also be encouraged, by encouraging the fulfilment of one of the three universal psychological needs while performing the behaviour. For example, if you had an examination that you wanted to do well in, leading you to make a decision to study harder than usual for it, the autonomous decision to study will give you more motivation than being forced to study for the exam.

On this basis, it could be that if we allow doctors to take more opportunities to exert control over their working lives and encourage better team working between hospital staff, morale is likely to improve. If doctors are unhappy with the delivery of a particular service, it would be useful to have them trained in change management, then allowed to take responsibility for implementing change or improvements in partnership with management staff, as is happening in pockets around the country already.

The most important thing about SDT is not to try and come up with simple solutions but to recognise the profession as humans with the same universal psychological needs as other professions, and to seek to fulfil them where possible.

This article appears in the August 2016 issue of Commentary, the membership magazine of the RCP.

References

[1] Federation of the Royal Colleges of Physicians of the UK. Census of consultant physicians and higher specialty trainees in the UK 2014–15: data and commentary. London: RCP, 2016.

[2] Centre for Workforce Intelligence. Shape of the Medical Workforce: Informing medical training numbers. London: DH, 2011.

[3] NHS Staff Management and Health Service Quality. London: DH, 2011.

[4] Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and dissatisfaction. J Am Med Assoc. 2002;288(16):1987–93

[5] Aiken Linda H, Sermeus Walter, Van den Heede Koen, Sloane Douglas M, Busse Reinhard, McKee Martin et al. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States BMJ 2012; 344 :e1717

[6] Dewa CS, Loong D, Bonato S, Thanh NX, Jacobs P. How does burnout affect physician productivity? A systematic literature review. BMC Health Services Research 2014;14:325

[7] Goldacre MJ, Goldacre R, Lambert TW. Doctors who considered but did not pursue specific clinical specialties as careers: questionnaire surveys. J R Soc Med 2012;105(4):166-176.

[8] Smith F, Lambert T and Goldacre M. Factors influencing junior doctors’ choices of future specialty: trends over time and demographics based on results from UK national surveys. J R Soc Med 2015;108:396–405

[9] Lambert T, Goldacre R, Smith F, Goldacre MJ. Reasons why doctors choose or reject careers in general practice: national surveys. Brit J Gen Pract 2012;62(605):e851-e858.

[10] Briggs, Atkins, Playfer and Corrado. Why do doctors choose a career in geriatric medicine. Clin Med 2006; 6(5):469-72

[11] Grant P.Physician job satisfaction in New Zealand versus the United Kingdom. N Z Med J 2004 Oct 22;117(1204):U1123.

[12] Sharma A, Lambert TW, Goldacre MJ. Why UK-trained doctors leave the UK: cross-sectional survey of doctors in New Zealand. J R Soc Med 2012;105(1):25-34.

[13] Lambert TW, Smith F, Goldacre MJ. Views of senior UK doctors about working in medicine: questionnaire survey. JRSM Open 2014;5(11)

[14] Edwards N, Kornacki MJ, Silversin J. Unhappy doctors: what are the causes and what can be done? BMJ 2002;324(7341):835-838.

[15] Scheurer D, McKean S, Miller J, Wetterneck T. U.S. physician satisfaction: a systematic review. J Hosp Med 2009;13:560–568

[16] Dornhorst A, Cripps J, Goodyear H, et al. Improving hospital doctors’ working lives: online questionnaire survey of all grades. Postgraduate Medical Journal 2005;81(951):49-54

[17] Ubach C, Scott A, French F, Awramenko M, Needham G. What do hospital consultants value about their jobs? A discrete choice e World Medical Association. WMA Statement on Physician Well-being. WMA General Assembly Moscow. Oct 2015xperiment. BMJ 2003;326(7404):1432.

[18] World Medical Association. WMA Statement on Physician Well-being. WMA General Assembly Moscow. Oct 2015

[19] Taylor K, Lambert T, Goldacre M. Future career plans of a cohort of senior doctors working in the National Health Service. J R Soc Med 2008;101(4):182-190

[20] Degen C, Li J, Angerer P. Physicians’ intention to leave direct patient care: an integrative review. Hum Resour Health 2015;13:74

[21] Moss PJ, Lambert TW, Goldacre MJ, Lee P. Reasons for considering leaving UK medicine: questionnaire study of junior doctors’ comments. BMJ 2004;329(7477):1263. doi:10.1136/bmj.38247.594769.AE.

[22] Pinder C. Work motivation in organizational psychology. 2nd edn. Hove: Psychology Press, 2008