In this section we present the answers to the two open-ended questions asked of the physicians. Stressors and ideas for interventions have been identified at the individual, professional, and organisational levels. As suggested by Arnetz,  a holistic conceptual framework using a socio-ecological perspective is appropriate to incorporate the many stressors inherent in medicine and is reflected in our themes and sub-themes.
Theme One: External Constraints on the Practice of Medicine (Macro level)
Stresses and Difficulties
Autonomy is the power granted to physicians to have control over their own work, and to be responsible for overall patient care. Several of the surveyed physicians felt that their autonomy has been constrained and have elaborated as follows:
Feeling of loss of control due to numerous government guidelines & protocols.
Bureaucracy in workplace can't make any decisions for myself.
Consumerism vs. professional autonomy.
Bureaucratic interference in medicine.
These are actions that create a hostile work climate through overt and covert behaviours such as belittlement, harassment, bullying, work overload and undermining, causing mental and physical distress, turnover, and reduced productivity. These behaviours hamper morale, quality of care and inhibit collaboration and are stated as follows:
Interactions with co-workers, rude/obnoxious co-workers, bullies.
Racism faced on the job (from colleagues).
Second guessing your-self to avoid unnecessary/inappropriate criticism by colleagues.
Judgmental environment (patients and colleagues)
Professionalism combines skills, attitudes, and behaviours of a collective group, which includes continuing education, integrity, ethical behaviour, honesty, respect for others, and adherence to professional codes. Lack of collegiality results in fragmented care, reduces job satisfaction, and several physicians desire better adherence to medicine's higher values. They express:
Worry about how others at work perceive your work.
Difficulty of cooperating fully with colleagues because of competitive aspects of the business side of medicine.
Lack of collegial support and lack of time to communicate.
Unprofessionalism and/or incompetence in medical/nursing colleagues.
Frankly I am very pessimistic medicine remains fraught with an exaggerated work ethic, it remains a macho culture.
Changing relationship between community doctors and hospitals/specialists.
Health Human Resource Challenges
Shortages exist for all types of health care disciplines, which creates difficulties to maintain services, constraining physicians in their medical practices. The effects on the physicians and their practices are far-reaching and this is of the greatest concern for physicians elaborated on as follows:
I think shortage of health care workers, leading to diminished time with clients, drives many of the difficulties in profession.
Chronic understaffing in the hospital setting, resulting in physician inability to implement treatment plans. We're not responsible for treatment delays, but are made to bear the brunt of the repercussions.
No accountability of administrative staff.
Emergency room on call conflicting with regular office hours. I gave up on call coverage 30 months ago.
Public Health Care Systems
Publicly funded health systems are facing escalating costs, government cutbacks and rationing, which creates difficulties for physicians to access needed resources and equipment. This has a detrimental effect on individual medical practice and the effects are described as follows:
The biggest stresses at work are related to the health care system. Inadequacies, bed shortages, waits for consults etc., combined with elevated expectations by patients, society etc.
Finding appropriate in-hospital resources to properly care for my patients.
Difficulty arranging specialists/tests for patients in a timely manner.
The length of wait times for diagnostic imaging/biopsies that delays definitive surgery.
Prolonged slowdowns to definitive surgery because of OR cut backs i.e. 10 weeks every summer.
Difficulty obtaining services and its impact on communications and stress for physician. Stress related to systems.
Health Care Administration
The governments' response to demands for universal access to health care created regional health authorities. These are responsible for planning and implementing delivery of health care services, which has created greater bureaucratisation. Physicians describe the impact of this on their medical practice:
Administrative decisions that come from higher up that add stress to my job.
Administration, bureaucrats, love my work/patients, system doing me in!
I am a psychiatrist and do not have hospital privileges so trying to get a really sick patient a hospital bed is stressful, and following that patient for at times weeks, because there aren't any beds is stressful. At times I have daily contact with really ill patients and often hours and hours on the telephone, cumulating over the course of 2–3 weeks with patient, family member etc. None of this is reimbursed, but does affect my life.
Theme One: External Constraints on the Practice of Medicine
Ideas for Interventions
There is better need to develop values as a professional group in order to support better quality of care, and to enhance supportive networks and relationships. Physicians suggest the following as ways to encourage professionalism:
Emphasize the fun of the profession, outweighs by far ones income.
Programs to recognize and encourage inter-physician support is lacking. Could be ethically based network support building exercise.
The most helpful factors for me are having control over aspects of my work life and very supportive/fun colleagues.
Hippocratic Oath be stressed and followed i.e. my colleagues will be my brother (or sister), teach & be taught.
Ensure all members maintain high standards and not succumb to societal, political or unfounded consumer pressures.
Empower/teach physicians how to take back some of the control in the medical system.
The following physicians feel that working with other health care professionals as part of a collaborative team effort will enhance quality of care and improve medical practice:
A much more collaborative approach with health care professional colleagues, nurses, social workers, psychologists, counsellors, ethicists, communicators.
Increase support for other health care professionals as part of the primary care system.
Need to enhance the profile of the profession in terms of profile with other professions (pharmacists, nurses, administrators).
Health Human Resource Strategies
Finding and keeping physicians requires both intrinsic and extrinsic rewards. Health care is interdisciplinary, and shortages of other health providers across disciplines, places a strain on the entire system. Strategies for retention are provided as follows:
Support rural physicians with policies that enable easier recruitment & retention.
Higher pay is good, but good working conditions still most important – sometimes physicians don't recognize this.
Take a more assertive role in retaining skilled para-professional i.e. nurses.
Using principles of adult learning and prevention, this involves addressing current issues in the public health realm. Much greater involvement in educating the public needs to occur in a collaborative fashion, and physicians reiterate as follows:
Help to educate the public and government to the reality that we're trained to a very high level but cannot supply care to the same elevated level when resources are not at the same level.
Get politicians to fund a campaign of information about the position of the physicians/family physicians in the health care system (re decision-making) for the general population, because physicians being in the firstline of health care are frequently blamed for shortcomings of the health care system.
Reducing Health Care Administration
The additional layers of paperwork and administration due to health care administration, makes it harder to cope with an already stressful and busy work schedule, and physicians recommend that to help them manage, the following should be done:
Stronger stance against administration and more resources where rubber meets the road. Its becoming harder to get the smallest things done.
There needs to be less bureaucracy and regulation by the authorities, ........ to stop "protecting their turf" and cooperate to help patients and doctors.
Better and stronger advocacy for accountability within the hospitals...... and entire health system. A cost per case (patient) would be a necessity.
Streamline licensing procedures and other paperwork that physicians must do.
Find a way to be paid for multiple problems in one visit i.e. be able to bill for the four or five problems patients bring in rather than one "diagnosis" per visit with payment for that one "diagnosis".
Theme Two: Issues at the Professional/Institutional Levels (Meso level)
Stresses and Difficulties
Licensure and Patient Complaints Process
Physicians indicate that improvements are needed regarding how patient and family complaints and the licensure process are handled by the provincial medical regulatory body:
Patient complaints and how they are dealt with. It seems that doctors are put on the defensive with little or no support from any complaints – trivial or otherwise.
Unwarranted bias ....... concerning trivial patient complaints, encouraging patients to complain.
Do not threaten us make us feel like humans, and not sheep. Respect us as we do respect you. Make room for our real talents and skills and not treating us like a piece of paperwork. South Africans feel negative in general. Can we give them more to feel wanted?
Some physicians felt that that support around emotional, counselling and psychological needs should be stronger, especially during their training:
Inadequate university support for training physicians/residents.
I feel strongly that skills to "cope with the challenges of the profession" needs to be addressed at the medical student level more effectively.
Improve education of medical students to be more culturally aware.
Make better choices regarding specialty they choose.
Organisational/Professional Culture Clashes
Differences in values cause clashes between the dominant professional sub-culture and organisational culture and ultimately decrease quality of care and are described as follows:
The feeling that "big brother" is watching you, frustration at not having skills recognized by the authorities.
Pressure from "authority" to see more patients, work faster.
Getting treated as if I am a child, feeling as if every action is being monitored.
Intense scrutiny and unproductive criticism from bosses.
Theme Two: Issues at the Professional/Institutional Levels
Ideas for Interventions
Improving Patient Complaints Process
To be confronted with a complaint is very stressful, and can cause severe disruption and threats to ones medical practice, and the following have been suggested to improve upon this process:
Be more supportive toward physicians especially when complaints arise. Less formal approach toward resolution of patient/family complaints and faster resolution.
Not to act as a punishing institution, but rather as an educational and a damage controlling agency/teaching agency.
Disregard/deal with more empathy with frivolous complaints from patients and colleagues. Deal more fairly with physicians needing help.
Provide info on conflict/mediation services proactively, so doctors can meet these people before difficulties arise and contact them early, not late during problems.
Physician Support Mechanisms
Medical practice is inherently stressful. Supportive mechanisms in an atmosphere of impartiality are beneficial to physical and mental health and help to prevent burnout:
Confidential physician help line for advice, support information etc.
Increased awareness of problem, de-stigmatize trouble coping.
Counselling services (not addiction related)
Reducing Organisational/Professional Cultural Clashes
Lack of mutual goals between managers and physicians creates adversity, and the following have been suggested as ways in which to bridge this gap:
Maybe have evening sessions every few months to discuss concerns etc. ...... ensuring that management has a clue what MD's life is like (e.g. seminar)
Better understand our frustrations.
Theme Three: Issues at the Individual Practice Level (Exo level)
Stresses and Difficulties
Patients and Patient Care
Patient negative emotions are difficult to manage, and the frustration is evident in the written comments by three physicians:
We're not meant to be doormats. The increasingly and aggressive demanding attitude of patients.
Patients very confrontational.
A retired physician has now assumed a different role as a patient and wrote the following comment:
In my years of active practice it would seem unnecessary to give particular thought to the many categories listed in the questionnaire. Probably because most physicians were dedicated to the practice full-time because of the positive response received from the patients. Financial matters were rarely discussed, the hours devoted to patient care were not recorded – patients were treated as people with medical problems, not as just medical problems. In other words, we cared for people the way we would want to be treated. I am aware of the gradual change in attitude of many practitioners.... Having required a lot of surgical medical care in the last six years, I am happy to benefit from the advances in surgery but not happy in the total (art) of patient care.
The proliferation of health information provided via the media is not always accurate. This influences patients' views of illness and decision-making, and concern is expressed by one physician:
Inappropriate internet and lay press information.
Physicians experience disappointment and misgivings because of mitigating factors that interfere with patient care and desired outcomes:
Patients make numerous excuses why they can't change behaviour as roadblocks to change (especially with regards to obesity). They are unwilling to accept that they need to do something to help themselves i.e. want a quick fix.
Patients whose needs cannot be met.
Inability to give best treatment due to inadequate facilities and staffing.
When treatments do not work as I had hoped.
The North American culture is more dangerous to the health of people than any other culture I know e.g. eating too much, eating the wrong things, spending too much time in front of TV or computer.
Lack of follow-through is present in all patients – born Canadians as much as more recent citizens. Patients' cultural beliefs do not interfere with my diagnosis at all – but I recognize that they often do not follow my recommended treatment – which is their privilege.
Maintenance of medical practice includes administration associated with patient care, and the following physician comments describe the stresses that form part of this function:
Worried about being audited, worried about doing something wrong, missing something important.
Extreme difficulty in getting as well as retaining competent office assistant – I have had a run of poor assistants for the past 18 months!
Keeping staff happy and ensuring enough staff.
One administrative physician discusses the difficulties associated with a managerial role
Management decisions.... I am middle mgmt.
High volumes of patients, interruptions, and miscommunication causes delays and frustration:
Double booked appointments and suddenly being asked to drop what I am doing to accommodate someone who didn't organize their time well.
A cumbersome or inadequate physical work space affects patient safety, concentration and health. A physician and surgeon describe problems with their physical work environment:
Poor organisation of operating room.
Loud environment, constantly being interrupted by RN's, other MD's, secretaries etc., no personal space, MD's work in one big room.
Physicians are required to participate in post-graduate education activities to maintain licensure, and to keep abreast of new advances in medical care. Medicine continues to evolve and change with new procedures, protocols, and greater expectations, which causes stress to keep up:
Trying to keep up to date.
Concerns about lack of knowledge and expertise.
Fear of failure.
Being bombarded by literature and drug company info.
Theme Three: Issues at the Individual Practice Level
Ideas for Interventions
Continuing Professional Development
Educational seminars could help teach about coping with stress, as well as a wide range of other educational and practice needs elaborated as follows:
Make available courses (not mandatory) re: emotional problem management.
Dealing with death or mistakes.
Need help & advice on how to avoid lawsuits........
Provide some personnel management courses, i.e. how to tell if an office assistant is going to be useful prior to hiring them.
Educational seminars provide insight on how to strengthen the physician-patient relationship and physicians indicate what areas are needed:
Understand the advocacy stances of interpreters.
Improving communication and empathy towards patients especially those of different cultures.
How to deal with adverse/violent patient and families.
Cultural teaching sessions.
Diversifying Medical Practice
Applying a range of practice solutions helps to prevent practice stagnation, and increase personal accomplishment. This can be facilitated by experiential learning and the following are suggestions provided by physicians:
I am of an ethnic minority and speak another language, this helps me understand ethnic groups. Have worked in foreign countries 21 different times, 3–7 weeks at a time, so I am familiar with all kinds of cultural variations and expectations and build them into my attitude in dealing with different cultural and socioeconomic backgrounds.
Blend work life. I do part time clinical practice, health research & health administration. The mix provides a good balance in achieving short, medium & long-term goals, respectively. I work at three different sites.
Health Policy Initiatives
These are initiatives that help to improve access, quality of care, cost of care, and have a major impact on the delivery of care. Physicians understand the impact that lack of policy has on their practice, and recommend that policies be formulated in the following areas:
More established and experienced bank of interpreters.
Increase support for office based practice (management training, management tools).
Encourage and help fund more CME.
Reinstate clinical practice guidelines so individuals do not have to keep up with the literature in all areas- can depend on guidelines in some practice areas.
Advocate for physician work hour reform. Advocate for streamlining billing & licensing procedures.
Theme Four: Work/Life Balance (Micro level)
What causes imbalance
Responsibility in relation to one's spouse, partner, dependents, children or other family members to whom one is liable for care and support. Work/life conflict is now a pressing concern for health care professionals, and families in general, and are expressed as follows:
Pressures of home life/family competing with work pressures.
Child and elderly parent issues (illness, disabilities, school).
Demands of caring for 4 young children while husband has own medical career..............
Being a solo parent, sometimes hard to sympathize with others not carrying this combined workload.
Parental health concerns, family conflict.
Worry regarding nuclear family development and extended family challenges.
These are symptoms or behaviours that contribute to or cause poor mental or physical health described as:
My own physical health is fragile so balancing my need for rest with my responsibilities requires savvy.
Lack of sleep due to infant children.
Not enough energy to care for self. i.e. exercise.
Major depression in 92.
High levels of physical or psychologically intense work over prolonged periods taxes a person's ability to meet the demands in their personal and professional life, leading to emotional exhaustion. This is a major cause of burnout and is described as follows:
It is unclear why in 2006 some/most residents still are in the hospital for over 100 hours some weeks and we are looking for reasons why people may be experiencing stress, job dissatisfaction and feelings of not being in control of ones life.
Not being able to take time off work because of own medical illness – minor like colds, GI infections, because no one to provide back-up.
Being on call – hours are unhealthy and demoralizing.
Constraints on Personal Time
A heavy workload with an irregular and unpredictable work schedule and sometimes-unsupportive community creates an imbalance between work and personal time and are described as follows:
Being away from my family and not being accepted in Canada as a foreigner.
Lack of time to cultivate friendships out of work place.
Dealing with some contentious issues in my own community (outside my work).
No quality time to spend with wife and kids.
Unpredictability in Work and Home Life
Careful planning at home does not always ensure that things turn out as we wish, causing anxiety and stress when they don't. The difficulties associated with being on call and staffing problems, create difficulties fulfilling obligations in one's personal life:
Vacation time schedule being pulled or change of schedules.
Unpredictable events in family life.
Unexpected costs require adjustments to other financial obligations, which create a re-alignment between wants and needs:
Moderate financial concerns i.e. children in university out of town, requiring support.
Theme Four: Work/Life Balance
Ways to Restore
These are learning experiences which favourably influence understanding, attitudes, and behaviour relating to individual as well as community health. The focus is on attitudes, behaviours, and assistance in making informed decisions regarding prevention, behaviour change, and problem solving. Health education needs are described as follows:
Publications/workshops on physician health.
More educational services re: lifestyle etc. More open discussions regarding above issues.
Workshops for physicians to learn of the signs of "burnout" etc.
Time and life management.
Teaching sessions regarding balanced lifestyle for physicians.
Perhaps Physician Wellness Centre or Cont Ed could organize 1/2 day or 1–2 day workshops on coping/communications/stress. However, for privacy, I would prefer to do it in another province.
Programs, sessions about managing stress.
Workshops in self-care.
Health promotion is a process of enabling people to increase control over and improve their health, and is both a philosophy (way of being) and a practice (way of doing). This change is facilitated through increased awareness, behavioural change, and emphasis on creating environments that support good health practices. To promote physician health, the following are recommended:
Increase availability or provide incentive/facilitation to allow for personal mental/physical health initiatives re: reduced gym membership, etc.
Promote time for self e.g. exercise, massage, other stress reduction, health promotion activities. Hire a massage therapist for their members.
Liaise with businesses to offer recreational activity, deals, packages, but could be less costly if the numbers are right.
Need physician health team to help physicians find their own family doctors etc.
Active role in med school, residency + beyond to give physicians practical advice on ways to lower stress, make positive changes in work environment etc.
Community and Social Outlet
Having a social outlet provides a sense of social connection and a way to express oneself in the surrounding environment. Included are relationships at work, with family, friends and community groups:
Identify solo specialists who are at risk by being isolated/encourage members to have an active family life/set boundaries at work particularly encourage members to talk regularly with their colleagues about their patients and their personal issues. This really helps.
I am less stressed at this particular point in my life than any other period. I only practice within my cultural group for the most part. Have never required an interpreter.
Healthy Work Place Initiatives
These are initiatives that improve the physical environment (safety, ergonomics) and organisational climate (supportive culture, autonomy), and promote wellbeing:
Reduce on call shifts for residents. No one should ever be expected to do in-house call for 24–30 hrs straight!
Better maternity leave benefits. Help with after hours childcare when on call.
Make it easier again to "import" doctors from outside Canada to lighten the workload.
By finally establishing our fee structure to pay us for things like committee work and after hrs premiums, I am now able to work less office hours and maintain my income. This means more free time and a much happier and effective & efficient doc.
Provide back-up services and locums.
Continue supporting initiatives such as parental leave and reduced fees for part-time working members.
Look for ways to make practice more attractive so the number of physicians would increase and to make the workload decrease.