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The Doctor’s Heart: A Qualitative Study Exploring
Physicians’ Views on Their Professional Performance
in Light of Excellence, Humanistic Practice and
Accountability
Myra van den Goor ( m.vandengoor@q3consult.nl )
Acadamic Medical Center https://orcid.org/0000-0002-6361-0178
Benjamin Boerebach
Sint Antonius Ziekenhuis
Elisa Bindels
AMC
Maas Jan Heineman
AMC
Kiki Lombarts
AMC
Research article
Keywords: Physician performance, professional values, professional development, reective practice,
humanistic practice
Posted Date: May 4th, 2020
DOI: https://doi.org/10.21203/rs.3.rs-22857/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read
Full License
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Abstract
Background In a eld as high-stakes as health care, professional values have long been recognized as an
essential mediating force for good medical practice. In the current era of changing market forces, anchoring
these values in the professional performance of daily practice can be challenging. In this study we explored
how physicians reect upon their own professional performance and whether they feel they are performing to
their best ability in light of excellence, humanistic practice and accountability.
Methods We conducted a thematic analysis of written reections from 786 hospital-based physicians,
representing 35 specialties and 18 hospitals.
Results When reecting on their professional performance, physicians differentiated between (i) their calling
for being a doctor, (ii) the translation of this calling into daily practice, and (iii) threats to their performance.
Reecting on humanistic practice triggered thoughts about the essence of being a physician in terms of
calling, meaning and purpose. Physicians described concrete actions regarding pursuit of excellence and
accountability. Furthermore, they suggested that their ability to perform optimally was put under pressure,
mainly by heavy workloads and collaboration issues. This pressure negatively affected their calling for being
a doctor and hampered the ability to be a humanistic practitioner.
Conclusions In this large inventory of reections, humanistic practice was recognized as the core value of
being a physician. However, physicians feel high performance and the ability to act as a humanistic
practitioner is hindered by heavy workloads and collaboration issues. Decreasing the clinical burden and
reinforcing humanistic and relational aspects of care could foster an environment where physicians can
perform optimally.
Background
In a eld as complex and as high-stakes as health care, professional values have long been recognized as an
essential mediating force in patient care [1,2]. The often implicit ideas about physicians’ performance are
made explicit in a variety of charters and guidelines, all having roots extending back to the classic and oldest
of all codes of conduct: the Hippocratic Oath [3,4,]. The Hippocratic Oath has survived as an ideal for almost
2500 years, inspiring physicians to reinvent and uphold valued ethical principles regarding their performance
[5]. These ethical principles capture the essence of being a physician and are described in characteristics such
as quality of care (excellence, lifelong learning, competence), quality of caring (compassion, empathy,
respect), integrity, and accountability [1,6,7,8]. Many documents translate these values into more hands-on
guidelines and formulate good medical practice in concrete terms of knowledge, skills, communication,
teamwork and maintaining trust and safety [9,10,11]. At the most practical level, competence frameworks
describe the knowledge, skills and abilities that physicians should have in order to provide high quality patient
care [12,13].
Dening professional performance is complex since it encompasses all the aforementioned perspectives
ranging from values to actual competences. Incorporating all these elements leads to denitions of
professional performance as ‘a physician committed to the health and well-being of individuals and society
through ethical practice, profession-led regulation, and high personal standards of behaviour’ [14]. From a
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more practical perspective, physician performance can be viewed as ‘that what physicians are actually seen to
do in practice’, being a reection of their adherence to values and the necessary skills and competences [15].
With the abovementioned in mind, an integrated model for physicians’ professional performance was
developed in The Netherlands by Kiki Lombarts [15]. In her view, high performance is a reection of physicians’
commitment to three pillars of professional performance: (i) constantly pursuing excellence, (ii) humanistic
practice and, (iii) being accountable for one’s professional actions. Additionally, she argues that physicians
can only sustainably provide high quality patient care if and when their commitment to these three pillars of
performance is anchored in the underlying professional values of the medical profession.
Displaying the desired commitments to the three pillars and practicing professional values in daily practice
can be a challenge. Moreover, changes in healthcare systems and settings may actually hamper physicians’
ability to perform to their highest possible levels. For example, further marketization of healthcare encourages
a shift in focus to productivity and eciency [16,17], and increased administrative workloads may result in
less face-to-face time with patients [17,18,19]. These aspects often result in physicians lacking time, energy or
inspiration, and can translate into the diminished commitment to essential professional values and of
professional performance. In light of these and many other challenges to physicians’ performance, it is in the
interest of patients and society that physicians are able and are enabled to act according to their professional
values. In this study, we were interested in hearing rst-hand from hospital-based physicians about whether
they felt they were performing to the best of their ability.
Therefore, the aim of our study was to gain insight into physicians’ perspectives on their own professional
performance. This multicentre study used written reections of nearly 800 physicians of multiple specialties.
Our research question was: how do physicians reect upon their professional performance in terms of the
pursuit of excellence, humanistic practice, and accountability?
Methods
Setting and participants
We conducted this study in the Netherlands, where physicians are either employed by hospitals or organized in
independent entrepreneur partnerships. All licensed physicians must periodically demonstrate that they are up
to date and t to practice for recertication as a physician, being the equivalent of revalidation in the United
Kingdom or maintenance of certication in the USA [9,20,21]. In this mandatory process in The Netherlands,
physicians gather feedback from multiple colleagues and also self-assess and reect on their performance. To
guide the assessment and reection, an assessment tool including a few reective questions based on the
three performance pillars as described in the introduction was provided [22]. The reections were for personal
use only and were not shared with colleagues, managers or the revalidation authority. For this study, we used
physicians’ reections on their performance, as written in the context of their recertication process.
Participants were all hospital-based physicians, representing various specialties from several (academic and
non-academic) hospitals.
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Instrument
As part of performance assessment in the context of the above mentioned recertication process, multisource
feedback tools are used to facilitate the reective process. Physicians collect feedback from multiple
colleagues and also self-assess their performance. Physicians reect on the obtained feedback and formulate
professional development goals, often in consultation with a trained facilitator [23,24]. In The Netherlands, one
such assessment tool is the Inviting Co-workers to Evaluate Physicians - Tool (INCEPT) [22]. This tool is
designed to capture various respondent groups’ perspectives on physicians’ professional performance and
also includes a physician self-assessment questionnaire. The information is collected digitally and
anonymously. The self-assessment questionnaire contains performance items to be rated as well as reective
open-ended questions to stimulate introspection. Although it could be argued that, in general, the rating of self-
assessment questionnaires can differ from the ratings of respondent groups, this study only targets at the
written reections of the self-assessment and does not take the ratings of the questionnaire into account, The
framework of these open ended questions is based on Lombarts’ pillars of professional performance: (i) the
pursuit of excellent care, (ii) humanistic practice, and (iii) accountability (see supplementary le 1). In this
study, we were interested in physicians’ perceptions and reections on their own performance and
improvement needs, including a reection of their adherence to values and the necessary skills and
competences. We therefore used physicians’ written reections on the following two open-ended questions: (i)
what aspect(s) need(s) your (extra) attention in order to maintain or improve your performance, and (ii) when
reecting on your own performance, how do you perceive the balance between the three pillars of professional
performance. These open ended questions suited our purpose in stimulating thoughts on a more practice-
based level (what aspect(s) need(s) your (extra) attention in order to maintain or improve your performance?)
and on a reective level (when reecting on your own performance, how do you perceive the balance between
the three pillars of professional performance?). These two questions were preceded by a denition of
professional performance and some sample key words for each of the three pillars, as described in Appendix
1. Physicians were not obliged to answer these questions and their answers did not need to be discussed with
a facilitator or anyone else; the written reections would be added to their personal portfolio for themselves to
read and ponder upon.
Data collection
Data used for this study consist of physicians’ written reections on their own performance. We included all
available written reections - 786 in total - from hospital-based physicians that used the INCEPT tool between
January 2016 and January 2017.
Data analysis
For the purposes of data analysis, we used a thematic analysis approach, a qualitative, independent and
descriptive method particularly useful for large sets of written data [25]. It can be described as ‘a method for
identifying, analysing and reporting patterns (themes) within the data’ [26]. The analytical process is
characterized by description and interpretation, integration of manifest and latent contents and by drawing a
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thematic map that consists of the major themes and topics emerging from the data [25]. Following this
approach, we focused on the content of the text, on ‘what’ is said more than ‘how’ it is said [27]. Since
researchers bring their own backgrounds to the analytical process, practicing reexivity is critical. In this
reective spirit, we provide the following contextual information: the lead author (MvdG), is currently working
as CEO and management consultant, guiding physicians on performance, reection and collaboration and
also worked as a general practitioner for many years; her collaborators for this research represent various
backgrounds including health sciences, education and methodology (BB), art history and clinical
neuropsychology (EB), medicine and member of hospital board of directors (MH), and health service research
and medical professionalism (KL). The rst author (re)coded all reections and a total of 300 reections were
independently double-coded by a second researcher (BB). All aspects of coding were discussed until
consensus was reached in order to establish trustworthiness in the interpretation of the data [28]. The lead
author started with an overall inspection of all reections to formulate a rst understanding, in line with the
thematic analysis approach [26]. After this orientation, the research team chose to translate the two reective
questions into a pre-dened coding template. Four themes thus originated as top-level codes: related to the
rst question: (i) pursuit of excellence, (ii) humanistic practice, (iii) accountability, and related to the second
question, (iv) threats to optimal performance. Further analysis outlined a higher order level emerging from the
theme of humanistic practice; this level was dened as the ‘calling for being a doctor’. The theme ‘threats’
could be divided into individual aspects and work related aspects. This resulted in minimal adjustment of the
initial coding template into the following topics: (i) the calling for being a doctor, (ii) translation of the calling
into daily practice (comprising pursuit of excellent care, humanistic practice, and accountability of care) and
(iii) threats to optimal performance (containing individual- and work-related aspects). The rst author recoded
previous reections into the new template and subsequent original reections were coded accordingly. The
themes coded in the nal template are shown in Table 1, including exemplar quotations. We used the
qualitative data analysis software Dedoose to support the thematic analysis.
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Table 1
Coding Template with Examplar Quotations
level code Second level
code Third level code Examplar quotations
Why: the essence
of being a doctor Doctor-patient
relationship Giving lots of attentione and TLC [tender.
Loving Care], should be the basis in my
opinion, and doing this with optimal effort
(P662)
I am motivated to help others, ever since I
was young; that's why I love my job! (P711)
How: translation
of the essence
into daily
practice
Pursuit of
excellent care Gathering
knowledge and
competence
I'm always looking to introduce the newest
techniques (P670)
It is important to study and stay up to date
(P724)
Sharing knowledge
and competence Discussing complex patients or
complications, heart team meetings, transfer
meetings: that's all part of how we work as a
team (P 628)
Transferring
knowledge and
competence
Teaching residents also keeps you sharp
and up to date, their input is very valuable to
me (P387)
Humanistic
practice Attention,
compassion,
empathy
I try my best to give my full attention in every
consultation (P204)
Accountability Being transparent It gets to me when my diagnosis is too late
or not correct; when that happens, I take my
responsibility and discuss this openly with
my patients (367)
Register/administer Registrating and administrating are part of
the responsibility that you have and are part
of your job; you have to earn the trust (P84)
Meeting
professional
standards
It is important to do your best to meet your
care to current standards and conditions
(P65)
Threats to
optimal
performance
Work-related Heavy -
administrative-
workload
I distaste these current systems (of
checkmarks) that complicate my job and
interfere with what’s really important: my
patients (p 680)
Collaboration-
issues I would like to have a more inspiring context,
our group is full of negativity (P218)
Individual Physical wellbeing I do hope the arthrsos in my hands will not
obstruct my job (P470)
Mental wellbeing Body and mind need maintanance; making
time to do so should be possible without
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feeling guilty about it (P141)
Results
Participants
We collected reections of 786 physicians (56% female), aged 32 to 66 years, representing 35 different
(sub-)specialties at 18 hospitals. A total of 737 physicians (94%) completed the reective questions, which we
subsequently analysed; 38 physicians (5%) used ‘not applicable’ or comparable short statements of less than
50 characters. Most physicians, however, reected more extensively. The mean reection length was 503
characters, ranging from 83 to 2963 characters.
Overall ndings
The majority of physicians reected on all three pillars of professional performance. They described concrete
actions in terms of must do’s and should do’s regarding pursuit of excellence and accountability. Reections
on humanistic practice mainly triggered thoughts about the essence of being a physician. The professional
performance model (Figure 1) captures how physicians perceive their professional performance. The
participating physicians differentiated between their calling of being a doctor, the translation of this calling
into daily practice and the threats to their performance, both on an individual and work-related level. Most
salient in forming the model was the nding that physicians felt that humanistic practice was at the heart of
their profession, referring to humanistic practice in terms of their calling, both on a professional level (meaning
of work) as well as on a personal level (purpose in life). Physicians also experienced that their ability to
perform well is under pressure, and there is a palpable threat to their ability to live up to their calling and to act
as a genuinely caring practitioner. We will now describe these ndings in more detail.
Why: the calling for being a doctor
Physicians perceive the doctor-patient relationship as the heart of being a physician. They describe earning a
patient’s trust as an important foundation for this relationship. As pointed out by the following physicians,
respect, engagement, and genuine interest in the patient as a person are key components in order to earn such
trust:
My motto is to be there for my patients, treat them to the best of my abilities and as respectful
as possible. You should treat your patients as you would want your parents to be treated
(P 426)
Being competent and trustworthy to my patients, that is what I am trying to be aware of
every single time
(P 548)
I need to be intrinsically motivated, to meet the demands that people put on me when they
need my care, to not disappoint the trust that they put in me
(P 651)
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Many physicians describe this relationship as the reason why they wanted to become a physician in the rst
place and what they still consider as the most important aspect of their job. They experience this relationship
as motivating and inspiring, the reason for putting effort in understanding and helping their patients,
illustrated by the following statements:
Getting to know the person behind the patient creates understanding, a deeper
relationship and motivation to meet the goal for the patient
(P107)
My heart sends me to the hospital with joy; patients and their families still touch
and inspire me every single day and that’s exactly what being a physician is all about
for me
(P374)
Contact with patients is the reason that I became a physician. I view all my patients as the
human beings that they are and try to put myself in there position, thinking what I would want
in their situation
(p 580)
Helping other people has always been very important to me, I was raised that way, and as a
physician it is something that I hope to pass to all the people I work with
(P 597)
The How: translation of the calling for being a doctor into daily practice
Physicians reect on all three pillars of professional performance, i.e. (i) the pursuit of excellence, (ii)
humanistic practice, and (iii) accountability in terms of concrete actions.
The pursuit of excellence; gathering, sharing, and transferring knowledge and competence
Knowledge and competence are central elements in the pursuit of excellent patient care in general. Physicians
emphasize aspects as gathering new knowledge and competence for example by keeping up with new
insights, attending courses or seeking new and innovative techniques:
I want the very best for every patient, meaning a perfect narcosis, without any complications
and a patient waking up without nausea and pain. Although this isn’t always possible, I
always strive for that
(P491)
I am eager to learn something new regarding my eld of expertise every week
(P725)
Next Generation Sequencing, that is a new technique that I will get into because it is THE new
evolution in the area of molecular diagnostics
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(P773)
Consulting colleagues, asking each other for help, discussing outcome measures, and reecting on
performance are also mentioned in aspiring toward the best possible care:
We ask each other for help and consult one another very easily in my team, whether it is about
medical or more ethical questions, that enhances the strength of our team
(P 128)
My group invests in reecting on our performance since we believe that is conditional in
striving for the best care for our patients
(P362)
Physicians recognize that optimal performance is enhanced by transferring knowledge through education and
science:
I am very interested in the relationship between food and health and I advice colleagues on
this topic
(P 413)
Our goal is to publish the results of our studies in peer reviewed journals
(P 661)
Humanistic practice; compassion, empathy, and attention
According to the participants, patients deserve their fullest attention at all times. As participants rmly noted,
being empathic and attentive seem to be crucial conditions for a compassionate doctor-patient relationship.
Physicians perceive humanistic practice as self-evident and an essential condition for being able to be a
physician. Giving patients time and attention, being a good listener, and being open to patients’ wishes, ideas,
and fears are mentioned as important components according to the following accounts:
Compassion is self-evident to me since genuine attention for patients’ wishes and
concerns emerge from this compassion
(P352)
I try to give my patients the feeling that they have sucient time to tell me their story and
concerns. That is how they can conde in me and how I can give the best care to them
(P 484)
When I inform patients or do a procedure, I treat the person in front of me and not a disease.
My patients’ perceptions matter, since every patient has the right to make a decision that
suits him or her. I notice that patients value profound explanation of things so they feel
they can really make a choice
(P 628)
Accountability; transparency, administration and professional standards
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Physicians perceive accountability of care delivery as two-faced. They acknowledge their responsibility in and
the importance of being transparent, of registering patient information as well as quality measures, and
following professional standards:
I take time to inform my patients, to explain things that can happen. That is being
transparent to me, being open about my actions, in order to be trustworthy for them
(P 50)
I try to be open about my performance and explain why I do the things I do, so
that my colleagues and patients have condence in me
(P349)
I would like to have more time to check professional standards; within my work with the
fragile elderly, you deviate form guidelines regularly. However, it is instructive to check
the standards, to prevent a patient from receiving ‘inferior’ care and to netune the
best care for this specic patient
(P 693)
However, the downside of the growth in accountability is frequently mentioned as well since physicians
perceive a decline in time and attention for their patients as a result of these bureaucratic requirements.
Nowadays, I spend way too much time on administrating and registration, which has a
negative effect on the time I can (and should) spend with my patients
(P 76)
Registration is important, of course, but it should not take almost all of our time. It does not
feel good that I cannot spent enough time with patients because of that
(P 99)
Threats to optimal performance
When reecting on their performance, many physicians describe situations that hinder them to perform to the
best of their abilities. These situations either hamper their pursuit for excellence or put their purpose of being a
physician under pressure. They perceive that such individual- and work related situations obstruct, and thus
pose a threat to, optimal performance.
Individual aspects; physical and mental wellbeing
Physicians acknowledge the potential negative effect of low levels of vitality on their professional
performance. They detect the impact of insucient mental energy in lacking time and attention for oneself as
resulting in loss of attention, inspiration, and enthusiasm during their contact with patients and colleagues.
Physical inabilities are also mentioned as posing a potential threat to optimal performance.
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I should somehow keep my motivation and inspiration, in order to give the best care, but
to be honest that is hard right now given my situation at home
(P 4)
I experience lack of time, miss the attention for myself and I wonder: how am I
going to keep up with this and enjoy it?
(P83)
I had low levels of vitality due to a combination of a long period of hard work and physical complaints,
that balance has restored because I work part-time now
(P321)
Striving for the best possible care is very important for me, unfortunately, that has not been
possible the last year due to my herniation
(P 682)
Work related aspects; workload and collaboration issues
The majority of physicians appoint work related factors as threats to optimal performance. They describe the
negative effects of their heavy workload, and more specically the increasing administrative tasks due to
accountability and national or local policies. This leads to a lack of time for their patients, creating frustration
and diminishing motivation. In particular, the purpose of being a physician and of humanistic practice is
described as being under pressure by a heavy work- and administrative load.
I am forced to spend a lot of time doing non-patient- related activities. When I look deep
into my heart, I must confess that I feel I do not meet the professional demands that one
could expect from me
(P48)
I feel that administration is taking over all over our hospital; that frustrates me and has a
negative effect on my passion and inspiration
(P106)
The current heavy workload is a real threat for my vitality as a professional
(P 693)
Being compassionate denitely suffers from time-constraints since adequate
communication needs more time than is foreseen in the production-deals
(P737)
The negative impact of hospital mergers is also mentioned as having an effect on physicians’ performance.
No balance for me right now, I am easily irritated and agitated, it takes a lot of effort and
energy to nd stability in our new merged department
(P 658)
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There are seriously disturbed relationships because of the merge, within the ‘old’ and the
‘new’ team. I feel that I am treated without any respect, therefor I will probably seek
a job somewhere else
(P 661)
Collaboration issues within the physician group such as disturbed relationships or negativity are also
mentioned as hindering aspects:
I need to keep my engagement and motivation up, which is dicult for me right now since I
really struggle with feeling any compassion for my colleagues
(P 484)
It isn’t always easy to hang on in a team where being open and honesty are not considered
a positive thing and a change to improve. My colleagues make me seem ‘weak’ and
‘vulnerable’. I really need to work on my skills to be able to stand straight in this environment
(and be appreciated)
(P 573)
Discussion
Main ndings
In this study we investigated physicians’ reections on the three pillars of professional performance, dened
as excellence, humanistic practice, and accountability. Humanistic practice was found to emerge as
physicians’ ‘why,’ that is, the heart of being a physician. Excellence and accountability were depicted as ‘how’;
a means to translate the essence of being a physician in daily practice. Humanistic practice was considered
both a means as well as a state of being. Physicians report their ability to optimal performance is put under
pressure by heavy workloads and collaboration issues. These threats to high performance in particular affect
their ability to live up to their calling for being a genuinely caring physician.
Explanation of the ndings
Our ndings illustrate that physicians nowadays still sense the signicance of their calling and that their
motivation and inspiration primarily originates from this calling. Reecting on their performance, they
extensively reect upon their essence - the heart - of being a physician. Physicians consider caring about
patients and their families, putting patients’ interests and concerns rst, and gaining and deserving the
patient’s trust, as this essence. This is consistent with the humanistic realm of actually being with patients
when they are suffering, exactly what many patients want and expect from their physician [29]. These ndings
conrm what has long been recognized, that is motivation is a driving force of behaviour and performance,
extending out from the realm of philosophy to the psychological, behavioural and management domains [30].
The rich variety of motivation theories range form Herzberg’s [31] motivation hygiene theory (hygiene factors
in the context surrounding a job predict satisfaction and future motivation), Locke and Latham’s [32] goal
setting theory (task performance is enhanced by specifying targets to achieve) to the more modern theories as
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Ryan & Deci’s [33,34] Self Determination Theory (the nature of motivation predicts outcomes such as
psychological health and wellbeing) and Bakker & Demerouti’s [35,36] Job Demands Resources Theory
(performance blossoms when job resources ate widely available). In addition, this study highlights physicians
also report and expose a deeper seated sense of meaning, resulting in dedication to their patients, when
humanistic practice is made the focus of their clinical practice. Physicians thus experience having a calling,
dened by Dik & Duffy as a sense of purpose and meaning that this is the work that one was meant to do,
reecting the belief that the career is central part of a broader purpose in life and is used to help others [37].
Our ndings underscore that physician performance still primary seems to originate from values and that the
universal values of medical professionalism are deeply imbibed by physicians in their views on their
profession and performance [7]. This may soften the view often put forward in health services and economic
contribution, that money is regarded a motivator priority for physicians [38]. To the contrast, in this study, none
of the physicians mentioned in their reections ‘money’, ‘income’ or ‘nancial incentives’ in relation to
performance. This is in line with literature emphasizing non nancial motivators like mastery and social
purpose for changing physician behaviour [39]. This may be considered a reassuring nding, since
professional values have long been recognized as fundamental for good patient care [1,2], and in our view still
are.
In order to live up to their professional performance, physicians cultivate certain professional practices. They
attend courses to stay afresh of the latest knowledge, introduce new techniques, participate in consultation
and discussion with colleagues, share their knowledge, maintain transparency about choices they make and
keep an adequate registration in the patients’ interest, including managing electronic patient records and
participating in quality assurance registries. However, our results also indicate that physicians experience
threats in actually accomplishing these actions in practice. They mention that collaboration issues such as
disturbed relationships, feelings of being hold back, insucient space to voice their opinions and a lack of
openness within their peer group negatively inuence their performance. This is a disturbing nding, since
effective teamwork is linked to quality and safety of patientcare [40,41], and indicative for wellbeing and job
satisfaction [42,43]. Additionally, psychological safety and speaking up behaviour are known to be driving
forces for a safe and stimulating learning environment where performance can ourish [44,45,46].
Physicians furthermore express that they spend time on administration at the cost of (being with) their
patients. This is consistent with international research indicating that increasing clerical burden is leading to
limited face-to-face time with patients and that for every clinical hour spent on face-to-face interactions with
patients, physicians spend an additional two hours on administrative tasks [17,19]. This worrisome nding
seems to reect the current era of marketisation in healthcare, shifting from people to processes, productivity
and eciency [16]. Physicians consider administrative tasks to be a serious threat to their performance, while
time and attention for patients are known to be powerful drivers of physician satisfaction and the ability to
provide high quality care [18,47]. Curtailing what primarily inspires physicians might eventually lead to
physicians no longer having the time, energy and motivation to deliver the best possible care. Thus, a high
clerical burden is challenging high performance not only by taking time from patients but also by potentially
disconnecting physicians from their purpose of caring for patients [48]. Fortunately, multiple healthcare
stakeholders now seem to take the adverse events of too much administration seriously. In the Netherlands,
for example, the Department of Health and Welfare, the Health Care Inspectorate, and the Dutch Federation of
Physicians joined hands and published a manifest to de-regulate healthcare [49].
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Strengths and Limitations
This study provided us with the opportunity to analyse a substantial sample of written reections from a
representative group of hospital-based physicians. Our data were collected in a pre-dened format, coming
with the limitation that this method could have potentially narrowed the focus and depth of the reection
process. Another point of consideration is the setting in which the study was conducted. Since the participants
were all hospital-based physicians in The Netherlands, the ndings reported may not be transferable to
practices and physicians outside the hospital environment and/or the Dutch healthcare system. Lastly,
researchers bring their own backgrounds to the analytical process, therefore this study might have been
inuenced by the medical and consultancy background of the principal author, being both a potential
limitation and a strength. To strengthen data analysis and interpretation, we sought diversity within the
background proles of the research collaborators.
Implications/ recommendations
Since humanistic practice is considered to be at the heart of being a physician and indispensable for high
quality care in the future, humanism should be at the top of physicians’ priority list when practicing medicine.
Because the lack in research on supporting and increasing humanistic practice in healthcare professionals,
there is a need for more research on this topic [50]. In practice, physicians should pay attention to their
personal well-being, since research indicates a relationship between physician well-being and the quality of
patient care [51, 52]. Given their strong links to quality of care and patient safety, having an engaged physician
workforce that experiences a sense of meaning is critical for healthcare organisations [53,54]. Organizational
interventions directed at enabling physicians to focus on their core tasks in patient care could enhance
physicians’ experience of meaningful work. Best practices like the Mayo Clinics could be followed, where the
creation of dedicated meeting spaces for physicians boosted engagement and dedication [55] and where
funding of small groups of physicians to have a meal together and discuss topics that explored the virtues
and challenges of being a physician, led to improvements in both meaning in work and burnout for
participants [53]. Since peer support has always been part of how physicians deal with intense circumstances,
this could be enhanced on the organizational level by formal peer support or coaching programmes [55,56].
Furthermore, investments could be made to create a psychologically safe environment by facilitating (peer)
reection and discussion regarding engagement, vitality, and humanistic practice. Rider et al. have recently
underscored the importance of reinforcing humanistic and relational aspects of care on an organizational
level [29]. Focus on decreasing the actual clinical burden will be constructive in creating such an environment.
In The Netherlands for example, the Health Care Inspectorate and hospital organizations have become
increasingly selective in what quality parameters should be used. Lastly, the profession could pay specic
attention on aspects such as the essence of being a physician and professional values during training and in
clinical practice.
Conclusion
This large inventory of physicians’ reections indicates that being a humanistic practitioner is at the heart of
professional performance, referred to in terms such as calling, meaning or purpose. Physicians translate this
Page 15/20
calling further into everyday practice by explicit focus on striving for excellence, humanistic practice and
accountability. They feel their high performance is hindered by threats deriving from a perceived extensive
administrative workload as well as collaboration issues. These threats negatively affect the calling for being a
doctor and hamper the ability to be a humanistic practitioner.
Abbreviations
INCEPT: Inviting Co-workers to Evaluate Physician Tool
Declarations
Ethics and consent to participate
Permission to use the INCEPT data anonymously for scientic purposes was granted in advance by the
medical board, on behalf of all participating physicians, of the hospitals involved, being conform the General
Data Protection Regulation Implementing Law. Prior to usage of the INCEPT tool, an informational meeting
was held per institution, to inform all physicians about the tool an about the anonymized usage of the data for
scientic purposes and research for any -including the current- study. The leading author was involved in this
process in order to answer any questions. All physicians were subsequently part of the decision-making
process to actually continue with the INCEPT tool in their hospital.
Consent to publish
Not applicable.
Availability of data and materials
Due to the sensitive nature of the raw data on which the conclusions of the manuscript rely, it is not publicly
available. Please contact the authors for further information. The raw data were digitally collected and
encrypted in accordance with the General Data Protection Regulation Implementing Law. The data-
administrator granted the leading author permission to use the encrypted data for the current study.
Competing interests
The authors declare that they have no competing interests.
Funding
No funding was obtained for this study.
Authors’ contributions
MG was the initiator of this study, drafting the study design. All authors contributed to the study design. MG
led the process of analysis and interpretation of the data. BB participated in the analysis through additional
coding. BB, EB, MH and KL additionally contributed to interpretation of the data through discussion of and
reection on the analysis. MG wrote all the drafts, which were revised with input from all authors. All authors
Page 16/20
agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or
integrity of any part of the work are appropriately investigated and resolved. All authors approved the nal
manuscript for publication.
Acknowledgements
Not applicable for this study.
Author’s information
Myra van den Goor, MD, leading and corresponding author, m.vandengoor@q3consult.nl
CEO and researcher at Q3 BV, Company for Professional Development, Den Bosch, The Netherlands.
Benjamin Boerebach, PhD, benjaminboerebach@gmail.com
Consultant at the Department of Value-Based Healthcare, St. Antonius Hospital, Nieuwegein, the Netherlands.
Elisa Bindels, MSc, e.bindels@amsterdamumc.nl
PhD candidate, Center for Professional Performance & Compassionate Care, Department of Medical
Psychology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
Maas Jan Heineman, MD, PhD, m.j.heineman@amsterdamumc.nl
Counsellor at the Center for Professional Performance & Compassionate Care, Department of Medical
Psychology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
Former member of the hospital board of directors at the University Medical Centre of Amsterdam, Amsterdam,
The Netherlands.
Kiki Lombarts, MSc, PhD, M.J.Lombarts@amsterdamumc.nl
Professor Professional Performance at the Center for Professional Performance & Compassionate Care,
Department of Medical Psychology, Amsterdam University Medical Centers, University of Amsterdam,
Amsterdam, The Netherlands.
References
1. Vaismoradi M & Turunen H. Content analysis and thematic analysis: implications for conducting a
qualitative descriptive study. Nursing& Health Sciences, 2013;15:398-405.
2. Overeem K, Wollersheim HC, Arah O et al. Evaluation of physicians' professional
performance: an iterative development and validation study of multisource feedback
BMC Health Serv Res, 2012;12:80.
3. Ng SL, Kinsella EA, Friesen F et al. Reclaiming a theoretical orientation to reection in medical education
research: a critical narrative review. Med Educ, 2015;49:461-75.
4. Van der Meulen MW, Boerebach BCM, Smirnova A et al. Validation of the INCEPT: A Multisource Feedback
Tool for Capturing Different Perspectives on Physicians' Professional Performance. J Contin Educ Health
Prof
,
2017;37:9-18.
Page 17/20
5. Royal Dutch Medical Association. Decision recertication medical specialists. Published
september 2015.
. Dutch Federation of Medical Specialists. Vision Document Medical Specialist 2025; ambition,
trust cooperation. 2017. Available at:
https://www.demedischspecialist.nl/sites/default/les/FMS_visiedoc_MS2025(eng)_2017_PL_v02(lr).pdf
7. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship Between Clerical Burden and
Characteristics of the Electronic Environment With Physician Burnout and Professional
Mayo Clin Proc
,
2016;91(7): 836-848.
. Dugdale DC, Epstein R, Pantilat SZ. Time and the patient-physician relationship. J Gen Intern
Med, 1999;14:S34-40.
9. Sinsky C, Colligan L, Li L et al. Allocation of Physician Time in Ambulatory Practice: A
Time and Motion Study in 4 Specialties. Ann Intern Med, 2016; 165:753-760.
10. Bonfrer I, Figueroa JF, Zheng J et al. Impact of nancial incentives on early and late adopters among US
hospitals: observational study.
BMJ
, 2018; Jan 3;360:j5622. doi: 10.1136/bmj.j5622.
11. Lombarts K. Physicians’ Professional Performance between Time and Technology.
2010Uitgevers, Rotterdam, 2019. ISBN 978-94-90951-53-5.
12. Frenk J, Chen L, Bhutta ZA et al. Health professionals for a new century:
transforming education to strengthen health systems in an interdependent world. Lancet,
2010;376(9756):1923-1958.
13. Ten Cate O, Snell L, Carracio C. Medical competence: the interplay between
individual ability and the health care environment. Medical Teacher, 2010:32(8):669-
14. Frank JR & Danoff D. The CanMEDS initiative: implementing an outcomes-based
framework of physician competencies. Medical Teacher, 2007;29(7): 624-647.
15. Royal Dutch Medical Association. Medical Professionalism Manifesto, 2007. Available at:
https://www.knmg.nl/web/le?uuid=90993000-e3b8-4713-9e8d-28a7d85eb918&owner=5c945405-d6ca-
4deb-aa16-7af2088aa173&contentid=1571.
1. Medical Board of Australia. Good Medical Practice: a Code of Conduct for doctors in
Australia, issued March 2014.
17. General Medical Council. Ready for revalidation; the Good medical practice framework for appraisal and
revalidation. Published March 2013, Manchester, United Kingdom.
1. Rider EA, Kurtz S, Slade S et al. The International Charter for Human Values in Healthcare: An
interprofessional global collaboration to enhance values and communication in healthcare. Patient Educ
Couns, 2014; 96:273-80.
19. Medical Professionalism Project. Medical Professionalism in the new millennium: a
physicians’ charter. The Lancet, 2002; 359:520-22.
20. Cassel CK, Hood V, Bauer WA. Physician Charter: The 10th Anniversary. Ann
Intern Med, 2010;157:290-1.
Page 18/20
21. Askitopoulou H & Vgontzas AN. The relevance of the Hippocratic Oath to the
ethical and moral values of contemporary medicine. Part 1: The Hippocratic Oath
from antiquity to modern times. European Spine Journal, 2017; Oct 27. doi:10.1007/s00586-017-5348-4.
[Epub ahead of print].
22. Sritharan, K., Russel, G., Fritz, Z. et al. Medical Oaths and Declarations: A
Declaration Marks an Explicit Commitment to Ethical Behavior. British Medical Journal, 2001;
323(7327):1440.
23. Royal Dutch Medical Association. Nederlandse artseneed, 2004. Available at:
https://www.knmg.nl/advies-richtlijnen/knmg-publicaties/artseneed.htm
24. Relman AS. Medical Professionalism in a Commercialized Health Care Market. JAMA, 2007;
298:2668-70.
25. Lesser CS, Lucey CR, Egener B, et al. A Behavioral and Systems View of Professionalism. JAMA, 2010;
304:2732-37.
2. Braun V & Clarke V. Using thematic analysis in psychology. Qualitative Research in
Psychology, 2006;3:77-101.
27. Riessmann CK. Narrative analysis (Qualitaive Research Methods Series). 1993; California: SAGE
Publications, Volume 30.
2. Pope C, Ziebland S, Mays N. Qualitative research in health care. Analyzing qualitative data. BMJ,
2000;320:114-6.
29. Rider EA, Gilligan MAC, Osterberg LG et al. Healthcare at the crossroads: the need to shape an
organizational culture of humanistic teaching and practice. J Gen Intern Med, 2018;33:1092-9.
30. Steers RM, Mowday RT, Shapiro DL. The future of work motivation theory. Academy of Management
Review, 2004;29(3);379-387.
31. Herzberg, F. Work and the nature of man. 1966. Cleveland: World Publishing.
32. Locke EA & Latham GP. A theory of goal setting and task performance. 1990. Englewood Cliffs, NJ:
Prentice-Hall.
33. Ryan RM & Deci EL. Self-determination theory and the facilitation of intrinsic
motivation, social development, and well-being. American Psychologist, 2000;55(1):
68-78.
34. Deci EL & Ryan RM. Self-determination theory: A macrotheory of human motivation, development, and
health. Canadian Psychology/Psychologie canadienne, 2008;49(3), 182–185.
35. Bakker AB & Demerouti E. The Job Demands-Resources model: State of the art.
3. Journal of Managerial Psychology, 2007; 22(3):309-328.
37. Bakker AB. An evidence-based model of work-engagement. Current Directions in
3. Psychological Science, 2011;20(4): 265-269.
39. Dik BJ & Duffy RD. Calling and vocation at work. The counseling psychologist, 2009;9;37:424–45.
40. Shortell & Kaluzny’s Health Care Management Organization, Design & Behavior. Centage
Learning, Inc. January 2011.
Page 19/20
41. Phipps-Taylor, M & Shortell, SM. More Than Money: Motivating Physician Behavior Change in
Accountable Care Organizations. The Milbank Quarterly, 2016;94(4), 832-864.
42. Baker DP, Day R, Salas E. Teamwork as an Essential Component of High-Reliability Organizations. Health
Research and Educational Trust, 2006; DOI:10.1111/j.1475-6773.2006.00566.x
43. Weller J, Boyd M, Cumin D. Teams, tribes and patient safety: overcoming barriers
to effective teamwork in healthcare. Postgraduate Medical Journal, 2014;90(1061):149–
44. Merlani P, Verdon M, Businger A, et al. Burnout in ICU caregivers: a multicenter
study of factors associated to centers. American Journal of Respiratory and Critical
Care Medicine, 2011;184(10):1140–6.
45. Grumbach K & Bodenheimer T. Can health care teams improve primary care
practice? Journal of the American Medical Association, 2004;291(10):1246-1251.
4. Edmondson A. Psychological safety and learning behavior in work teams.
Administrative Sci Q
,
1999;44(2):350-383.
47. Nawaz H, Edmondson A, Tzeng T et al. Teaming: An approach tot he growing complexities in health care.
J Bone Joint Surg Am, 2014;96:e184.
4. Ginsburg L. “Speaking up” climate; a new domain of culture to measure and explore.
BMJ
Qual Saf,
2015;24:661-663.
49. Friedberg M, Chen PG, Van Bussum KR et al. Factors affecting physician professional
satisfaction and their implications for patient care, health systems and health policy. Rand
Health Quarterly, Winter, 2014;3(4):1.
50. Wright AA & Katz IT. Beyond burnout – redesigning care to restore meaning and sanity for
N Engl J Med, 2018;387:309-311.
51. Dutch Department of Health and Welfare. (De)Regulate Healthcare, 2018. Available at:
https://www.rijksoverheid.nl/documenten/publicaties/2018/05/23/actieplan-ontregel-de-zorg
52. Lown BA, Rosen J, Marttila J. An agenda for improving compassionate care: a
survey shows about half of patients say such care is missing. Health Aff, 2011;
30(9):1772–8.
53. Scheepers RA, Boerebach BCM, Arah OA et al. A systematic review of the impact of physicians’
occupational well-being on the quality of patient care. International Journal of Behavioral Medicine,
2015;22(6), 683-698.
54. Panagioti M, Geraghty K, Johnson J, et al. Association Between Physician Burnout and Patient Safety,
Professionalism, and Patient Satisfaction. JAMA Intern Med., 2018;178(10):1317-1331.
55. West CP, Dyrbye LN, Satele D, et al. A randomized controlled trial evaluating the effect of COMPASS
(COlleagues Meeting to Promote And Sustain Satisfaction) small group sessions on physician well-being,
meaning, and job satisfaction. Journal of General Internal Medicine, 2015;30:S89.
5. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among
American surgeons. Annals of Surgery, 2010;251(6):995-1000.
57. Shanafelt TD & Noseworthy JH. Executive Leadership and Physician Well-being: Nine
Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clinic Proceedings,
Page 20/20
2017;92(1):129-146.
5. Hu Y, Fix ML, Hevelone ND, et al. Physicians’ needs in coping with emotional stressors: the case for peer
support. Arch Surg., 2012;147(3):212–217.
Figures
Figure 1
The Professional Performance Model
Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download.
CodingTemplatewithexamplarQuotations.pdf
ProfessionalPerformanceModel.pdf
Appendix1.pdf
