This study has sought to provide insights into the views of a sample of doctors in the NHS about their working lives. The feelings they articulate contain many ambivalences between, for example, satisfaction and frustration, accomplishment and regret, blamelessness and guilt, and fun and sadness. Nostalgia for the past highlighted a view of many doctors that opportunities for informal mutual support were reducing, almost akin to a reduction of social capital within the profession. Feelings about the future were extensively coloured by concerns about the impact of regulatory changes and processes of modernization on the experiential knowledge of doctors – or what has historically been called the ‘art of medicine’.
Qualitative research does not aim to produce findings that are generally transferable to other people. There was considerable consistency across our data in the themes highlighted in the interviews, however, and this study may highlight feelings that are shared by many doctors in the UK. Compared to national statistics our sample contained a disproportionate number of doctors on more senior grades, allowing us to hear accounts of their reflections of their changing experiences of working life whilst still allowing for inputs from younger doctors about contemporary experiences. Our sample contained good coverage of the various medical specialities. That the number of GPs in our study (n=5) is small reflects our intention to explore the views of a wide range of specialties rather than contrast hospital with community practice. The recruitment of doctors from ethnic minority groups proved difficult. Nationally it is estimated that almost 60% of doctors working in the hospital sector are white British, whilst in our sample 86% could be so classified. Although negotiation of access and setting up of interviews was difficult, once the doctors agreed to participate, they were very forthcoming and open.
Sociological research has tended to focus upon the structural dimensions of doctors' roles, rather than examining the views of doctors themselves. By contrast this study sought to achieve an empathetic understanding of the everyday experiences of doctors by listening to their accounts of their routines, activities and views in relation to their work. Popular perceptions still view the medical profession as a relatively powerful social elite who occupy a structurally advantageous position in society.14
Our data give an impression of ordinary men and women who, like those working in many other occupations, are juggling the routine realities of everyday work. The doctors in our sample were attempting to balance effectively their own needs and those of their patients, their frustrations and achievements, the dictates of regulatory environments and professional integrity, and work and home. Their feelings are likely to not just reflect their own views, independently formed, but to be inextricably interlinked with the assumptions, expectations and prescriptions about medicine that prevail in wider society. Biomedical science, and attendant evidence-based practice, presupposes a form of expertise that is unconnected to personal relations and local situations, with little room for feelings or emotions. Yet at the same time patient expectations and new definitions of medical professionalism require doctors to respect human dignity, be caring and express feelings such as empathy, sympathy and emotional sensitivity.4,15
Within this context we would suggest there is a tension in which doctors work to balance their rational and emotional selves. It is perhaps not surprising that there are ambivalences articulated in our interviews by doctors who are working in a system which requires them to be objective, effective and reliable at the same time as being caring, intuitive and sensitive. Our study also discovered concerns that doctors' informal support mechanisms were decreasing. Such support might help doctors to cope with tensions caused by the ambivalences they articulated, with potential knock-on benefits for patient care. As one influential report into medical professionalism recently stated: ‘the future for professionalism in medicine depends on creating an enabling environment for professional values to flourish’.4
The nature of support mechanisms for doctors, and our understanding of the importance of such mechanisms for good professional practice and patient care, would benefit from further research.
There did seem to be real anxiety amongst the doctors we interviewed about the impact on patient care of recent changes in the NHS, particularly with respect to medical training, modes of governance and reductions in working hours. In particular, our data highlighted perceptions of many interviewed that we seem to be witnessing a loss of tacit and experiential knowledge in doctors. These concerns that changes in working practices may contribute to less hands-on experience and the inculcation of a ‘nine-to-five’ mentality were also found in the qualitative data gathered alongside a national survey of doctors in Scotland.16
If real, we cannot say whether this makes for better or worse doctors, but we suggest that the consequences may at least be double edged. Such knowledge, often thought to reflect the art of medicine, has been criticized for being subjective, inconsistent and used as a barrier to the external evaluation of practice and also for sustaining social hierarchies and discrimination.17
However, intuitive knowledge gained through experience could have a value that has hitherto not been fully appreciated. Indeed, there is a small but growing body of empirical work that reveals the salience of such knowledge in specific clinical settings.18
Concerns about the impact of standardizing skills training and formalizing knowledge to the detriment of opportunities to develop experiential and tacit knowledge have been raised in settings other than medicine; for example in a study of the railway industry.19
Polyanyi has argued that the essence of tacit knowledge is that we ‘know more than we can tell’ – in other words, it is often impossible to make what we know explicit discursively, and that tacit knowledge relies on hands-on experience.20
From our data it would seem that doctors feel they are changing their working practices in the face of modes of governance and this may have consequences that were unintended and unanticipated by policy makers. It is certainly likely to have implications for medical professionalism and professional identities, particularly as other professional groups and even the lay public benefit from the wider availability of formal medical knowledge. Future research would be useful to further explore trends in tacit knowledge in doctors and investigate its function and value.
Some observers have argued that we are witnessing the ‘end of the golden age of doctoring’21
and have explained this in terms of growing bureaucratization, the democratization of knowledge, consumerism and the relative increase of power of related professions. Against this background we have sought to provide an empathetic exploration of doctors' views of their working lives. Analysis of the data has identified a degree of ambivalence in the feelings that doctors have in relation to their working lives, a potential loss of support mechanisms, and concerns about a loss of tacit and experiential knowledge in medical practice. These findings and their implications would benefit from being addressed further in future research. However, we would argue that such insights might usefully inform professional leaders, health service managers and policy makers as they plan and oversee changes to health service structures and systems, and the nature of medical professionalism itself.