|Home | About | Journals | Submit | Contact Us | Français|
To describe doctors' views on, and responses to, their professional working lives in the UK National Health Service (NHS).
Qualitative study using semi structured interviews.
Two district hospitals and primary care settings in the North of England.
Fifty-two doctors participated in the study – 47 worked in hospital and five worked in general practice.
Qualitative information regarding doctors' views on their working lives.
The study provided insights into the views of their working lives of a sample of doctors in the NHS. Feelings they articulated contained a number of ambivalences. Feelings about the future were coloured by concerns about the impact of regulatory changes and processes of modernization on the experiential knowledge of doctors.
These insights into doctors' views of their working lives might usefully inform those involved in the planning and overseeing of changes to health service structures and systems.
Recent years have seen doctors in the UK, as in many other countries, subjected to a range of changes in the regulatory and social context within which they practice. They have witnessed a decrease in professional autonomy and increasing external accountability, monitoring and managerial controls.1–3 At the same time there has been a profound shift in what patients expect of their doctors, reflecting, at least in part, an increasing consumerist ethos in society and a greater availability of medical knowledge.4
The ways in which doctors perceive their working lives within this changed context have been the subject of little formal study. Whilst there has long been a fascination with the thoughts and emotions of doctors in the popular media, this interest has not generally been matched by health service researchers. One medical sociologist has recently argued that the discipline lacks much in the way of a compassionate appreciation of the lives of doctors.5 Although there have been many studies of the views of doctors on specific issues,6–12 there are few that investigate doctors' emotional responses to their work in general. In contrast, there is a large body of work which explores patients' understandings of, and feelings about, their experiences of health and healthcare.
Thus although the performance of the medical profession has come under increasing scrutiny in recent years, and the healthcare environment subjected to frequent re-structuring and policy change, there is currently very little understanding of how doctors feel about being a doctor in the contemporary context. We undertook this study to describe doctors' views on, and responses to, their professional working lives in the UK National Health Service (NHS).
In-depth, semi-structured interviews were undertaken between mid-2005 and mid-2006 with doctors working in two district hospitals and primary care settings in the north of England. One of the hospitals was a large teaching hospital serving an ethnically heterogeneous and predominantly socially disadvantaged area; the other was a smaller hospital serving a more affluent, predominantly white population. The general practices represented both urban and rural locations within the catchment areas of the study hospitals. We obtained ethical approval from the appropriate multi-centre research ethics committee. Doctors were recruited purposively in order to capture a diverse range of perspectives and ensure variability in terms of age, gender, seniority and ethnicity. The sample was also designed so as to include a range of medical specialties, including areas of medicine and surgery (e.g. neurology, dermatology, cardiology and orthopaedics) and representatives from other specialties (e.g. pathology and anaesthetics). Doctors were able to choose whether they were interviewed at work, home or some other suitable location.
Interviews were carried out by one of the authors (SN) and covered four broad areas:
The interviews lasted a minimum of one hour; all were digitally recorded, transcribed verbatim and entered into Atlas.ti for analysis. We coded data line-by-line, organized similar concepts into categories and constantly compared these with concepts from earlier data to produce themes.
Fifty-two doctors participated in the study. Twenty worked in the large teaching hospital and 27 worked in the smaller hospital. Five worked in general practice, with both urban and rural locations being represented. Thirty-nine were consultants and eight were training grade doctors. In the whole sample, five had trained overseas and six were from minority ethnic groups. The age range of the sample was 25–65 years, with the youngest consultant being 35. All doctors talked candidly and in a highly engaged manner. Saliently, a number of them talked about how much they enjoyed the interview and that they welcomed the opportunity to reflect on their work.
Despite changes to the context in which medicine is practiced, for doctors in the study, its core purpose of working to alleviate suffering, treat disease and prevent ill health remains unchanged. A recurrent theme in our data was that working with people, seeing them get better, supporting them through difficult times and doing something for the benefit of human kind was gratifying. Many of the doctors said that they felt that they were in a privileged position; they were given access to peoples' private and personal lives, and on occasions influenced them. Overwhelmingly, working with patients appeared to give rise to the main source of fulfilment and sense of achievement. Fostering good relationships, learning about peoples' lives and their stories were repeatedly reported to be a source of satisfaction and pride. Doctors reported that the majority of patients were grateful and that on occasion expressions of gratitude could be humbling. Whilst most doctors recalled particular patients whom they felt had touched their sensibilities, it was felt that controlling emotions and retaining rationality was an important aspect of being an effective doctor.
‘So I do perceive myself as socially useful and I do derive some satisfaction from that. I have a lot of patients I enjoy talking to because they are interesting and the core bit about medicine is the interest you have in the human condition’ (Consultant, male, 40s)
‘I love it, there are frustrations, but there are frustrations in every job. Every job has boring bits. My job is so special; you can make a difference. Every day is different, so you meet some amazing people, some nasty people. I absolutely love my job and I wouldn't change it for the world’ (SHO, female, 20s)
Although working with patients was a major source of job satisfaction, it was also one of the main factors that eroded it. Some patients were described as ‘rude’, ‘demanding’ and ‘ungrateful’, which generated feelings such as hurt, anger and frustration. When talking about formal complaints made by patients, terms such as ‘vulnerable’ and ‘bitter’ were common. Doctors felt that they were ‘invariably trying to do their best’ and found it upsetting when they were subject to criticism. Being in receipt of a complaint, whether felt to be justified or not, could result in loss of sleep, strained relations with family, and sometimes, when an error had been made, deep feelings of shame and regret. Most doctors reported concerns about the scope for error and were sensitive to uncertainties in their work.
‘A bad day that really gets under my skin will be one where someone walks in and says “I don't want to see you” just outrageously rude to me, sometimes I'll try and win them over. People that are unnecessarily rude’ (SR, female, 30s)
‘You don't sleep, well two things, I mean you know you've got it wrong, you have a death and you know it's technically wrong. Fortunately it's only about once every two or three years but it still knocks the shit out of you, cos you're ashamed inside’ (Consultant, male, 60s)
A dominant theme for senior doctors was feelings of nostalgia for their early career when many of the changes to the health care environment outlined in the introduction had not been introduced. McDonald and her colleagues have argued that these nostalgic discourses may be used by doctors in order to question and challenge processes of modernization.13 Memories of working long hours, extreme fatigue and carrying out new procedures without guidance in the middle of the night were often described in affectionate terms. Many older doctors happily reminisced about the camaraderie of their time as junior doctors. Another aspect of the reminiscences was talk about the mavericks and larger-than-life characters who were to be found in medicine. Outrageous and scurrilous behaviour was recalled with affection, but thought to be outdated. Feelings of nostalgia were not universal, however. Lost opportunities and memories of exhaustion for some were tinged with regret. Some doctors had witnessed overt discrimination and bullying at some point in their careers, but many were dismissive of it.
Within hospital settings the scope for informal support was thought to be on the wane. Regret was expressed for the loss of informal spaces where doctors could meet – the consultant's dining room, the doctors mess and social events. There were thought to be few places where doctors, particularly non-consultant hospital doctors, could retreat from the public gaze. Not all consultants had their own offices and so had to share with other consultants and/or their secretaries. This is in marked contrast to general practitioners who reported having ample discussions with their colleagues who were on ‘public view’ only for clearly demarcated periods. While many doctors reported a demise of opportunities for informal social contact, the recent policy agenda has enhanced formal contact by establishing team meetings and professional development programmes. Such opportunities to formalize exchanges with colleagues were generally valued and when they worked well could be a source of enjoyment and support. Feeling supported in ones' working environment, however, still seemed something of a haphazard affair. All the doctors who felt supported in their working environment described themselves as ‘lucky’ – because they all had experiences of isolation and in some cases bullying and discrimination.
‘We had a mess and we all lived in. We used to just cook food and you would sit and whinge or play bridge, because we were a group, there were always people around. It's not just the social side. It's the support aspect; you need support because it's hard’ (Consultant, female, 50s)
‘If you had a problem you would say to the medics “look at this ECG, what do you think of this” and you knew who they were to talk to. Nowadays you don't because you don't see them. You're never all together in the mess because there is no reason to be’ (Consultant, female, 40s)
‘I feel I lost my twenties and early thirties slaving away and in hindsight I could have done other things with my life and that is one of the biggest bits that gets me’ (Consultant, male, 40s)
Of the many structural, societal and policy changes to impact on the NHS in recent years, a common area of comment concerned the working hours of doctors, both in terms of regulatory changes that have reduced hours at work3 and perceived cultural changes within the profession itself (a topic much debated in the medical press). Many practitioners expressed a desire for a ‘work-life balance’, and although not an aspiration shared by all, it was an issue that all doctors in the sample appeared to be aware of. Doctors spoke of a cultural change in medicine in which changes in motivational structures meant that medicine was no longer the dominant force in doctors' working lives that it was once perceived to be. Some of the older, male doctors explained that with hindsight they could now see that they got the balance wrong earlier in their careers, and this was why their marriages had failed and why they had not given their children the time or attention they felt they should have.
Reductions in working hours3 are interlinked with developments in training (www.mmc.nhs.uk/default.aspx), and concerns were expressed that doctors in training are no longer getting sufficient clinical experience. Virtually all the doctors interviewed articulated concerns that doctors are not getting sufficient ‘hands-on work’. Such experience was viewed as important, not just for developing practical skills but also for other aspects of knowledge. Terms such as ‘instinct’, ‘pattern recognition’ and ‘intuition’ were used by the study participants. The importance of practical experience was mentioned not just by surgeons but emphasized by the full range of doctors. Some indicated that experiential knowledge was a key feature of the uniqueness of being a doctor. There was substantial concern expressed by study participants that the perceived negative impact on experiential learning resulting from recent cultural and organizational changes would have adverse effects on the future of the medical profession and patient care.
‘There seems to be a prevailing idea that you can learn to do certainly clinical medicine by reading books and journals, obviously that's very important. But there's absolutely no doubt that you learn to be a good pathologist, a gooddiagnostic pathologist by looking down a microscope at a lot of cases. Because you learn to, to be able to interpret the spectrum of changes’ (Consultant, male, 48)
‘Sometimes you have intuition about something not being right, and you don't know why it's not right and I don't know whether that is experience in clinical medicine, I don't think it's the pharmacology knowledge, I think it's the hours you've spent on the ward building up your clinical base’ (Consultant, male, 48)
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.
Competing interests In addition to his academic responsibilities, IW works as a General Practitioner
Funding Economic and Social Research Council (project number RES-000-22-1158)
Ethical approval Granted by Northern & Yorkshire Multi-Centre Research Ethics Committee, REC Reference Number: 05/MRE03/41
Contributorship SN was the principal researcher, collected the data and led the analysis. RB and IW gave ongoing support to the project and contributed to the analysis and interpretation of data. IW wrote the first draft of the paper andSN and RB contributed to editing subsequent drafts
We thank all study participants for their involvement in the study. Luana Pritchard is to be thanked for arranging the interviews. We also thank Ms Sandi Newby for her help in the preparation of this manuscript