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Physician well being and quality of patient care: An exploratory study of
the missing link
Jean E. Wallace
a
* and Jane Lemaire
b
a
Department of Sociology, The University of Calgary, 2500 University Drive NW, Calgary,
Alberta, Canada T2N 1N4;
b
Department of Medicine, Health Sciences Center, 3330 Hospital
Drive NW, Calgary, Alberta, Canada T4N 4N1
(Received 13 January 2009; final version received 1 May 2009)
The goal of this article is to explore physicians’ perceptions of their colleagues’
awareness of the link between physician wellness and the quality of care they
provide to their patients. In addition, we also examine potential factors that may
be related to physicians’ recognition or lack of recognition of this link. We rely on
qualitative interview data from a sample of 42 physicians representing the
spectrum of different medical specialties and work settings in a single health
region in Western Canada. Our findings suggest that many physicians believe the
link between physicians’ well being and the quality of care they provide their
patients is not necessarily at the forefront of most doctors’ awareness as they
practice medicine on a day-to-day basis. Our study participants identified a
number of factors that may explain this finding and that reflect two broad themes:
the culture of medicine and physicians’ overwhelming workload. In regards to the
culture of medicine, the physicians in our study reported how doctors view
themselves as invincible caregivers first and foremost who must look after others
before looking after themselves, who believe they do not need help from others
and who are highly committed to their patients, careers and sense of
professionalism. In regards to physicians’ workloads, our study participants
identified external pressures in the workplace in terms of how their busy schedules
and the overwhelming nature of their work are significant deterrents that often
prevent them from thinking about their own wellness. We discuss how the culture
of medicine and physicians’ workloads deter doctors from recognizing signs of
unwellness and caring for themselves. We conclude that not only individual
physicians, but also their peers, their patients, employing organizations and the
health care system must appreciate and support physicians in their efforts to
protect and maintain their personal well being.
Keywords: physician wellness; job stress; patient care; culture of medicine
Introduction
Physicians around the globe are experiencing high levels of work-related stress. This
is a concern because not only is physician wellness important to the welfare of
individual physicians, but it is also vital to the quality and safety of care their
patients receive. Research findings suggest that when physicians are experiencing
stress, burnout or general psychological distress, it is negatively related to the quality
*Corresponding author. Email: jwallace@ucalgary.ca
Psychology, Health & Medicine
Vol. 14, No. 5, October 2009, 545–552
ISSN 1354-8506 print/ISSN 1465-3966 online
Ó2009 Taylor & Francis
DOI: 10.1080/13548500903012871
http://www.informaworld.com
of patient care they provide (Firth-Cozens, 2001; Firth-Cozens & Greenhalgh, 1997;
Gunderson, 2001; Levin et al., 2007; Shanafelt, Bradley, Wipf, & Back, 2002;
Wetterneck et al., 2002; Williams, Manwell, Konrad, & Linzer, 2007). For example,
dissatisfied or burned out physicians tend to provide suboptimal care as indicated by
riskier prescribing profiles and the patient–physician interaction suffers as indicated
by less adherent and less satisfied patients (De Matteo et al., 1993; Shanafelt et al.,
2002; Williams, & Skinner, 2003).
Although these studies offer vital evidence of the link between physician well
being and patient care, they typically do not consider physicians’ awareness of the
connection. We propose that it is also critical to examine the extent to which
physicians acknowledge this important link. The goal of this article is to explore
physicians’ perceptions of their colleagues’ awareness of the link between physician
wellness and the quality of care they provide to their patients. In order to better our
understanding of the issue, we also examine potential factors that may be related to
physicians’ recognition or lack of recognition of this link. To achieve this goal, we
rely on qualitative interview data from a sample of 42 physicians representing the
spectrum of different medical specialties and work settings in a single health region in
Western Canada.
Review of the literature
In addition to stressful working conditions that negatively impact on physicians’ well
being, the literature indicates that physicians are neither very good at taking care of
themselves nor seeking help from others when they are overly stressed or burned out
(Arnetz, 2001; Firth-Cozens, 2001; Thompson, Cupples, Sibbett, Skan, & Bradley,
2001). Arnetz (2001) suggests that this is shown by doctors’ negligence in having
physical exams, their procrastination in seeking medical treatment and their higher
than average suicide and cardiovascular mortality rates. Research also shows that
doctors often adopt denial and avoidance as coping strategies, which are not usually
effective responses to stressful situations (Baldisseri, 2007; Firth-Cozens, 2001).
Moreover, physicians are renowned for their reluctance in providing mutual support
to one another (Edwards, Kornacki, & Silversin, 2002) and the ‘‘conspiracy of
silence’’ tends to discourage doctors from sharing their concerns with someone about
a troubled colleague or their own personal distress (Arnetz, 2001). The perceived
stigma that doctors associate with seeking help is also a deterrent. As well, they may
have trepidation about the confidentiality of their treatment and worry that seeking
help will be viewed by others as an indicator of their inability to cope or perform
their job (Harrison, 2006; Thompson et al., 2001; Uallachain, 2008).
Recently, the culture of medicine has been more widely acknowledged as an
important factor that may explain why doctors have difficulty in taking care of
themselves. For example, Uallachain (2008) found that the majority of doctors in his
study have worked while they were sick and the few who took a sick day felt guilty
for it. Thompson et al.’s (2001) study similarly found that physicians feel compelled
to appear physically well, even when they are sick, because they believe their health is
viewed by patients and colleagues as a reflection of their medical competence.
Likewise, McKevitt, Morgan, Dundas, and Holland (1997) found that most of the
physicians in their study report working while they are sick and they conclude that
cultural and organizational barriers appear to reinforce one another in contributing
to doctors’ reluctance to take time off work when then are ill. These studies conclude
546 J.E. Wallace and J. Lemaire
that the culture of medicine, that is introduced and begins to take hold in medical
school, promotes the conspiracy of silence, endorses working while sick and
discourages them from sharing their health concerns with others or taking time off
when they are ill.
In this study, we ask physicians to comment on their perceptions of the attitudes
held by their medical colleagues in regards to the link between physician wellness and
patient care. In doing so, this allows us to tap into the culture of the medicine that
enables doctors to discount their own physical and mental health and the effects this
may have on the care they provide their patients.
Data and methods
Sample
The sample represents physicians practicing in a single health region encompassing a
major urban center and its surrounding rural areas in Western Canada. We used a
quota sampling strategy to select participants based on the proportion of physicians
in each specialty in the region. In selecting participants within each specialty, we also
attempted to include physicians who varied by sex, life stage, and work setting (e.g.
private clinic, hospital clinic, community clinic, hospital unit). For example, our
sample includes two male and two female anesthesiologists. They work in a variety of
settings (e.g. hospital clinic, private clinics, operating rooms (ORs) in hospital units
and in a rural setting), are at different career stages (e.g. ranging from 13 to 31 years of
medical experience) and vary by marital status (e.g. two are married, one is remarried
and one is divorced). Based on the above criteria, we developed a list of 80 potential
participants and invited 48 physicians to participate. Of the 48, 4 refused and 2 were
unavailable during the timelines of the study and 42 agreed to participate, yielding a
91% participation rate. All physicians consented to a face-to-face interview.
The average age of participants was 47 years, with 23 (55%) being male and 19
(45%) being female. Most were married (86%) and parents (90%) at the time of the
interview. The average length of time they have practiced medicine since completing
their residency was 15 years, although some were in their first year of practice and
others had practiced for over 30 years. They work on average 56 h a week (including
weekends, evenings and at home, and excluding call) ranging from 30 to 90 h a week.
Data collection
Interviews were conducted from mid-September 2006 until mid-July 2007. They
ranged from 20 to 61 min and averaged 37 min in duration. The interview consisted
mostly of open-ended questions and began by asking participants to describe their
day-to-day work experiences in terms of their workload, patient care, job stress and
coping strategies. We then asked ‘Do you think most doctors are aware of the link
between physicians’ well being or their mental and physical health and quality of
patient care? Why or why not?’. Their responses to these last two questions are the
focus of this article.
Data analysis
The authors independently reviewed participants’ responses and we did not use pre-
established categories for analyzing the interview data. Rather, we used an inductive
Psychology, Health & Medicine 547
strategy through open and selective coding to derive the predominant themes
reflected in the interview transcripts. The findings presented below are accompanied
by quotes that are used to illustrate various themes identified from the interviews.
These specific quotes were selected because they best reflect a particular theme or
they best capture the opinions and sentiments conveyed by the participants.
Results
Are most physicians aware of the link?
We asked participants whether they think that most doctors are aware of the link
between physician well being and the quality of patient care they provide. Of the 40
participants who answered this question, only a small proportion (10%) believe most
doctors are aware of the link, whereas almost half (45%) do not think most doctors
are aware of this connection. One third (32%) reported that they think that most
physicians are cognizant of the link at some level, perhaps intellectually or at a
superficial level, but they are not consciously aware of it on a day-to-day basis nor as
it may apply to them personally. Participants often commented that it seems obvious
when you stop and think about it and, most physicians are probably cognizant of the
connection, but that they do not stop to think about it for a variety of reasons or
they do not think it applies to them. The following quotes illustrate how doctors in
our study expressed these points of view:
Well I think we’re all aware of it on one level, but I mean, I don’t think any of us, or I
don’t think very many of us, are aware that it can actually affect us.
I think you know that intuitively I think that just makes sense, but whether they practice
it, or cognitively look at it and say ‘‘oh if I want to be a better doctor I have to take this
time for myself’’, no, no, I don’t for most doctors.
But I’m not sure that the link between their own health and patient care is probably very
clear. Because you can’t believe that right? You can’t believe if you’re having a bad day
that you’re going to provide poor patient care ‘cause that’s just not what you do.
What factors may affect physicians’ awareness of the link?
We also asked participants to explain why they believed most physicians were or
were not aware of the link between physician well being and quality of patient care.
The following predominant themes emerged from their responses: (1) Physicians are
the ultimate helpers who do not need help from others; (2) Physicians are highly
committed to their patients, careers and sense of professionalism; (3) Physicians are
under external pressures to provide care as needed; and (4) Physicians are too
overworked and busy to think about their own wellness.
In regards to the first theme, participants described how physicians view themselves
as infallible, ‘‘super human’’ or ‘‘the ultimate helper’’ who cannot or should not seek
help from others, thus preventing them from being aware of the physician wellness-
patient care linkage. Others also explained that physicians generally do not see
themselves as vulnerable to sickness, fatigue or hunger, which many believe are seen as
indicators of weakness. The following quotes exemplify these concepts.
I was one of those people who would get the pamphlets from Physician Support from
[the provincial medical association] and just throw it in the garbage and think ‘‘oh I’ll
never need that, I’ll never need that’’. And I think that’s very common amongst
physicians. We think that we’re infallible and that we’re never going to hit that wall.
548 J.E. Wallace and J. Lemaire
I trained in [medical specialty] in the late 80s and even in the late 80s there’s no question
in my mind that people still think that physicians need to be superhuman okay, you
know that nothing outside of your medical practice should affect your quality of
practice and you should be able to overcome all adversity, never make mistakes.
Other participants suggested that doctors’ commitment to medicine, patients and
professionalism drives them to put medicine and patients first and foremost,
sometimes sacrificing their own needs and wellness. Their explanations illustrate how
physicians’ personal health and wellness are not a personal priority. Rather, the
physician’s main concern is providing the best patient care whenever it is needed,
regardless of whether it means working long hours or working when they are sick.
I’m one that puts more value on my professional performance than my wellness. . . In
medicine you can’t be mediocre; you have to do the best you can. . .
You may be sick, but it’s very rare that you’re going to cancel an OR date, because one,
the patients are waiting to get in the hospital. .. it’s not as if you can get someone to step
up and do your shift. . . so you really have to be sick before you will cancel an OR day.
Participants also explained how there are external forces pressuring doctors to see
more patients while ignoring their own fatigue, warning signs or symptoms of being
unwell. Several suggested that, even dating back to medical school, physicians initially
learn to ignore their own vulnerabilities and to believe that being sick is a sign of
weakness. As they enter medical practice, the expectation that physicians cannot be sick
or fatigued continues to be reinforced by patients, colleagues, the public at large and
health care organizations. Subsequently, physicians feel compelled to provide medical
care regardless of how they feel emotionally or physically.
I think it’s a function of the type of people that end up in medicine in part and also the
training that we receive. . . your own personal life and your own personal feelings are
actively minimized in your training and you need to put that aside and get on with your
job and so I think it’s part of our upbringing.
They see themselves as I can cope, I can do this, I just need to work harder, I need to do
more and it will settle down, and usually that works. I mean often you know, it’s been
reinforced in the past [in medical school]. Because when they’ve had all these stressors
before and they just plow through it and they got it done, it settled down, so it reinforces
that behavior.
Lastly, a number of participants indicated that with such excessive workloads,
large numbers of patients and long patient waiting lists, there is very little time for
physicians to take stock of their physical and emotional wellness, never mind
actually spend time taking care of themselves.
I feel like it’s an epidemic of being overworked in medicine. . . it’s just an epidemic.
Everybody is just way over stretched, way over stretched and just way over
committed. . . if you don’t have the time to even learn it, how are you going to have
the time to even practice it or try to incorporate it into your life.
I think it’s because we have, since the minute we stepped into medical school, been asked
to do way too much. . . I think as a group, we are perfectionistic, and that we always
think that we’re trying to do the very best job we can and so we don’t really recognize
when all that other stuff interferes with what we’re doing.
Discussion and conclusions
The goal of this article was to explore whether physicians feel most of their medical
colleagues are aware of the connection between their personal health and well being
Psychology, Health & Medicine 549
and the quality of care they provide to their patients. This approach allowed us to
tap into the culture of the medicine that enables doctors to discount their own
physical and mental health and the effects this may have on the care they provide
their patients. In addition, we examined potential factors related to physicians’
awareness or lack of awareness of this link. Surprisingly, very few participants felt
that most physicians are fully aware of this link on a conscious level on a day-to-day
basis, and almost half of the study participants do not think that most doctors are
aware of this link. Perhaps the most striking finding in our study was that a third of
the participants report that although most doctors are intellectually cognizant of the
connection at some level, they are unable to actualize their knowledge of the link,
thus suggesting a lack of insight. Paradoxically, the physicians in our study displayed
considerable insight as they described the multiple factors that may relate to
physicians’ lack of awareness of this link, factors so powerful that they may prevent
physicians from recognizing their need for self care.
Our study participants identified a number of factors that may explain why most
doctors are not aware of the link that reflect two broad themes: the culture of
medicine and physicians’ overwhelming workload. In regards to the culture of
medicine, our participants explained how many doctors view themselves as invincible
caregivers first and foremost who must look after others before looking after
themselves, who do not need help from others and who are highly committed to their
patients, careers and sense of professionalism. Internalization of the culture of
medicine results from their socialization and training in medical school, as well as the
norms and expectations subsequently imposed upon them in the workplace by
colleagues, health care organizations, and patients.
As we consider the influence of the culture of medicine, future research might
explore the processes through which physicians internalize the ideas that they must
be infallible and ‘‘super human’’ and that they are not allowed to be vulnerable to
sickness or stress or take time to care for themselves (Haidet & Stein, 2006). In
addition, future research might explore how educators, medical schools and
organizations that employ physicians promote and reinforce these unrealistic
expectations. As well, evaluative work is needed to assess the effectiveness of
strategies used to promote physician wellness and self care in addition to programs
designed to care for impaired or unhealthy physicians (West & Shanafelt, 2007).
The second theme identified by our study participants reflects external pressures
in the workplace, in terms of how physicians’ busy schedules and overwhelming
workloads are significant deterrents that often prevent them from thinking about
their own wellness. Firth-Cozens (2008, p. 218) notes how the ‘‘fast, hectic pace,
conflicting demands, too little resource or support, too long hours of work and,
conversely, too little sleep’’ are factors contributing to physicians’ excessive work-
load that ultimately lead to job stress and burnout. In addition, workplace demands
may make it difficult for physicians to consciously and/or practically recognize their
vulnerabilities and take time to care for themselves. Future research might explore
the extent to which simple coping strategies such as taking a time out (e.g. coffee
break, short walk, quiet time), talking with colleagues, or asking for help from
colleagues and/or other staff may grant physicians the opportunity to assess their
work situation, their physical and mental well being and the effectiveness of their
coping strategies on a more frequent and proactive basis (Wallace & Lemaire, 2007).
In closing, the results of this study suggest that physicians are extremely
dedicated to providing quality care to their patients but they often do so at the
550 J.E. Wallace and J. Lemaire
expense of their own personal wellness. Through raising awareness of this important
link between physician wellness and quality patient care, the benefits are multi-
layered and far reaching – from the individual physician to his or her patients to the
employing organization and to the health care system at large. It is not enough for
only individual physicians to acknowledge or be aware of this link. Their peers, their
patients, employing organizations and the health care system must also appreciate
and support physicians in their efforts to protect and maintain their personal well
being. Ultimately, research will be needed to evaluate the most effective methods for
promoting physician wellness that assesses not only the outcomes of these strategies
for physicians but also the benefits for their patients.
Acknowledgements
Support for this research was provided by a Research Grant from the Alberta Heritage
Foundation for Medical Research’s (AHFMR) Health Research Fund and financial and in-
kind support from the Calgary Health Region (CHR). The opinions contained in this paper
are those of the authors and do not necessarily reflect the position or policy of AHFMR or the
CHR. This paper was written while Dr. Wallace was supported by a Killam Resident
Fellowship at the University of Calgary.
References
Arnetz, B.B. (2001). Psychosocial challenges facing physicians of today. Social Science and
Medicine,52, 203–213.
Baldisseri, M.R. (2007). Imparied healthcare professional. Critical Care Medicine,35(2),
S106–S116.
De Matteo, M.R., Sherbourne, C.D., Hays, R.D., Ordway, L., Kravitz, R.L., McGlynn, E.A.,
et al. (1993). Physicians’ characteristics influence patients’ adherence to medical treatment:
Results from the medical outcomes study. Health Psychology,12(2), 93–102.
Edwards, N., Kornacki, M.J., & Silversin, J. (2002). Unhappy doctors: What are the causes
and what can be done? British Medical Journal,324, 835–838.
Firth-Cozens, J. (2001). Interventions to improve physicians’ well being and patient care.
Social Science and Medicine,52, 215–222.
Firth-Cozens, J., & Greenhalgh, J. (1997). Doctors’ perceptions of the links between stress and
lowered clinical care. Social Science and Medicine,44, 1017–1022.
Gunderson, L. (2001). Physician burnout. Annals of Internal Medicine,135(2), 145–148.
Haidet, P., & Stein, H.F. (2006). The role of the student-teacher relationship in the formation
of physicians: The hidden curriculum as process. Journal of General Internal Medicine,21,
S16–S20.
Harrison, J. (2006). Illness in doctors and dentists and their fitness for work – Are the
cobbler’s children getting their shoes at last? Occupational Medicine,56(2), 75–76.
Levin, S., Aronsky, D., Hemphill, R., Han, J., Slagle, J., & France, D. (2007). Shifting toward
balance: Measuring the distribution of workload among emergency physician teams.
Annals of Emergency Medicine,50(4), 419–423.
McKevitt, C., Morgan, M., Dundas, R., & Holland, W.W. (1997). Sickness absence and
‘working through’ illness: A comparison of two professional groups. Journal of Public
Health Medicine,19(3), 295–300.
Shanafelt, T.D., Bradley, K.A., Wipf, J.W., & Back, A.L. (2002). Burnout and self-reported
patient care in an internal medicine residency program. Annals of Internal Medicine,136,
358–367.
Thompson, W.T., Cupples, M.E., Sibbett, C.H., Skan, D.I., & Bradley, T. (2001). Challenge
of culture, conscience, and contract to general practitioners’ care of their own health:
Qualitative study. British Medical Journal,323, 728–732.
Uallachain, G.N. (2008). Attitudes towards self-health care: A survey of GP trainees. Irish
Medical Journal,100(6), 489–491.
Wallace, J.E., & Lemaire, J. (2007). On physician well being – You’ll get by with a little help
from your friends. Social Science and Medicine,64, 2565–2577.
Psychology, Health & Medicine 551
West, C.P., & Shanafelt, T.D. (2007). Physician well-being and professionalism. Minnesota
Medicine,90(8), 44–46.
Wetterneck, T.B., Linzer, M., McMurray, J., Douglas, J., Schwartz, M.D., Bigby, J.A., et al.
(2002). Worklife and satisfaction of general internists. Archives of Internal Medicine,162,
649–656.
Williams, E.S., & Skinner, A.C. (2003). Outcomes of physician job satisfaction: A narrative
review, implications and directions for future research. Health Care Management Review,
28, 119–140.
Williams, E.S., Manwell, L.B., Konrad, T.R., & Linzer, M. (2007). The relationship of
organizational culture, stress, satisfaction, and burnout with physician-reported error and
suboptimal patient care: Results from the MEMO study. Health Care Management
Review,32, 203–212.
552 J.E. Wallace and J. Lemaire
