Firstly, employing data obtained from 640 randomly sampled primary care physicians working in three different health care systems, the United States, the United Kingdom, and Germany, we observed significant differences in mean level of psychosocial stress at work, measured by the effort-reward imbalance model. The highest level of work stress was reported by physicians in Germany and the lowest level by physicians in the UK, with US physicians reporting intermediate levels. The robustness of this finding is reinforced by the consistent results from the replication in the US CHD study. Differences were largely due to the reward component of the model. This finding was not modified when the impact of physician characteristics (gender, level of clinical experience) and of features of physicians’ work environment were examined (solo versus group practice; staff/physician ratio; time constraints regarding patient appointments; resources available to physicians). Secondly, we found a consistent (though not always significant) association of work stress with lack of professional autonomy. Lower levels of administrative and clinical autonomy were associated with higher work stress in all countries, most markedly in the US and the UK system.
We now turn to possible explanations for the observed differences in work stress, and specifically in work-related rewards, between the samples of physicians in the three health care systems? A methodological interpretation points to cultural or semantic differences in evaluating these aspects of subjectively perceived stressful work. For instance, physicians in the UK may be less inclined than their US and German colleges to express negative feelings about work. While we cannot rule out this argument it should be observed UK physicians score highest in expressing their negative feelings about limited professional autonomy. It is unlikely that they apply different evaluative standards to their judgments about the two topics.
Another interpretation emphasises the health policy context of physicians’ professional status at the time of data collection. Contrasting with the situation in the United States, practicing physicians in Germany were recently exposed to substantial changes in the organisation and remuneration of their work (Stock, Redaelli, & Lauterbach, 2007
; Wörz & Busse, 2005
). The implementation of disease management programs designed to promote quality of care and to foster competition were perceived as threats by many physicians, after an extended period of high professional independence and satisfying revenues. In line with this interpretation, we observe the clearest difference between Germany and the other countries under study on the scale measuring work-related rewards, in particular undesirable changes in one’s work situation and imbalance between efforts or achievements and income (). In the UK, primary care physicians received a 25 percent pay increase and stopped doing out-of-hours work when our study was conducted. This organizational change may have had a favourable impact on their evaluation of job-related rewards (Whalley, Gravelle, & Sibbald, 2008
). While these post facto interpretations seem plausible a more detailed examination of organisational features within each health care system was unfortunately not within the scope of our study.
Scoring high on effort-reward imbalance at work was shown to be associated with elevated risks of stress-related physical and mental disorders and with poor functioning in a variety of occupational groups in prospective epidemiological studies (Kuper, Singh-Manoux, Siegrist, & Marmot, 2002
; Siegrist, 2005
; Stansfeld, Bosma, Hemingway, & Marmot, 1998
). While prospective epidemiologic evidence of the effects of work stress among physicians is not available currently, at least three cross-sectional studies document significant associations of effort-reward imbalance at work with physicians’ reduced self-reported health and level of functioning and have shown that differences in the quartiles of effort-reward imbalance scores are meaningful in explaining elevated risks of subjective and objective health (Calnan et al., 2000
; Li et al., 2006
; Richter et al., 2007
; Salavecz, Chandola, Pikhart, Dragano, Siegrist, Jöckel et al., 2010
Thus, the measure used in this study was shown to have external validity. Moreover, results are in line with descriptive findings on adverse effects of high work stress on physicians’ health and well being that were not based on a specific theoretical model (Firth-Conzens & Payne, 1999
; Linzer et al., 2002
; Routh et al., 1996
; Spickard et al., 2002
; Uncu et al., 2007
). The fact that physicians in the UK exhibit lower work stress (especially in terms of reward) than their US colleagues may reflect less concern about job security and income in a nationalized health care system (Gillies, Chenok, Shortell, Pawlson, & Wimbush, 2006
Our study has several strengths and limitations. To our knowledge, this is the first report comparing a theoretically defined stressful psychosocial work environment of practicing physicians in different types of health care systems. Although reduced professional autonomy is associated with elevated work stress, this former condition does not account for the observed differences between health care systems. The same holds true for selected physician characteristics and features of the work setting. Second, we undertook this research in samples of randomly selected participants, and we combined data from two studies based on a largely identical study design (UK, Germany, and US). A second study within the US health care system tests the robustness of the results. Third, using analysis of variance, we tested main effects and two way and three way interactions with design variables to rule out confounding influences.
Despite these strengths several limitations are obvious. First, given a limited overall sample size (n = 640) and different size of the country sub-samples, results should not be generalized to all primary care physicians within each health care system. Yet, within the selection criteria stated, sample bias seems limited. An analysis of non-response within one country revealed that younger, female and urban physicians were somewhat more likely to participate in the study than the remaining groups and as mentioned earlier, UK participants may have had more opportunity for self-selection. (Bönte, 2008
). Second, the study design only provides cross-sectional data, precluding any statements concerning the temporal sequence of associations. Reporting bias may account for associations of perceived work stress with reported professional autonomy. Moreover, cross-cultural comparability of the meaning of operational measures of work stress has not been sufficiently explored with item response theory (Raczek, Ware, Bjorner, Gandek, Haley, Aaronson et al., 1998
). Third, as mentioned, our study did not identify in more detail those traits of the health care systems under study that may affect most directly physicians’ level of work stress and their restriction of clinical and administrative autonomy. Thus, the interpretation of respective findings was not embedded in theoretical reasoning about health system determinants of physicians’ work stress. Finally, we were not able to link variations of work stress with physicians’ level of performance, a critically important link in terms of policy implications of our findings (Firth-Conzens & Greenhalgh, 1997
; Landon, Zaslavsky, Bernard, Cioffi, & Cleary, 2004
In conclusion, this study revealed that physicians’ level of psychosocial stress at work varies considerably between the US, the UK and the German health care systems. As indicated by the theoretical model employed in this investigation, effort-reward imbalance, a substantial part of this variation appears due to work-related rewards in terms of money, career opportunities and esteem/recognition. Balancing efforts and rewards in physicians’ work may help to reduce the burden of their work-related stress. Whether there will be a sufficient number of primary care physicians in the future, or even a future for the field of primary care, is a source of concern in many countries (McKinlay & Marceau, 2009). To the extent that work-related stress contributes to this, reliable identification of its organizational origins across different health care systems may provide opportunities for future remedial interventions.