CALLING AND COMRADESHIP - Unravelling the essence of physician performance
Due to the COVID-19 crisis measurements the PhD defence of Myra van den Goor will take place online without the presence of an audience.
The recording of this defence will be added to the video overview of recent defences.
Myra van den Goor is a PhD student in the research group Human Resource Management (HRM). Her supervisors are prof.dr. T. Bondarouk and prof.dr. J.A.M. van der Palen from the Faculty of Behavioural, Management and Social Sciences (BMS).
Physician performance is essential for delivering high quality of patient care. Changing market forces, high stakes and increasing bureaucracy proportionally challenge physicians in performing to the best of their abilities. Despite these constant changing and dynamic conditions, the majority of physicians keep performing on a high level. I wondered what exactly ‘made doctors tic’, thus in this thesis, I sought to find the essence of physicians’ performance. Since doctors increasingly work in teams rather dan individually, interpersonal connection and interaction becomes an important aspect of performance, besides the individual competence. Through my explorations, I hope to contribute to an intensified understanding of physician performance and to knowledge on how to best support doctors to be able to perform at their best.
The aim of this thesis was to unravel the essence of physician performance by addressing two challenges. The first challenge was based on existing knowledge of peer-interaction as being important for professional learning an quality of care. I sought to investigate how peer-interaction affects individual physician performance. The second challenge focussed on the individual physician, were I explored physicians’ own perceptions of performance. Since the aim was to explore physician performance in depth, it seemed self-evident to turn to doctors themselves for answers. I relied on their stories, narratives, reflections, sentiments and opinions, putting the doctor in my scientific spotlight. This resulted in six research projects.
Pulling the six research projects together, two overarching themes emerged, expressing the essence of physician performance: Comradeship (i.e. positive and supporting relationships based on mutual trust, safety and responsibility for each other) and Calling (i.e. having a career that provides a sense of meaning or purpose and is used to help others).
In the search to meet the first challenge, i.e. investigating how peer-interaction affects individual performance, comradeship arose as key component. The overall conclusion of our findings indicates that physicians perceive a safe and supportive environment not only as one of the most important drivers, but as a vital dimension of optimum individual performance. Individuals can only truly blossom in an environment that breathes a collaborative mindset, where sharing is about caring and mutual trust, and where cohesion and peer-support are felt.
These conclusions are based on four research projects, encompassing a variety of angles and analytical approaches. In chapter 2, I started at the ‘downside’ end of the performance spectrum, i.e. poor performance, considering that a situation where relationships are likely to be strained would provide valuable information on how peers interact with each other. Ten electronic databases were analysed, 25 disciplinary law verdicts reviewed and 12 experts were interviewed. This research showed that low levels of comradeship, reflected in insufficient collaboration and a lack of addressing and speaking up amongst peers, provide fertile ground for individual performance issues to flourish and potentially develop into poor performance. This finding underscores the need to create a culture of speaking up and blame-free discussion of performance concerns in order to stimulate optimum performance. In creating such culture, periodically reflecting and discussing individual performance within the peer group can be helpful in lowering the threshold for addressing individual performance concerns. Our findings contribute to the discourse on under-performance by highlighting that individual performance occurs as an interplay of the individual and their professional context. Thus, performance should be viewed in a broader context than just the sum of individual competences.
Moving from poor performance to addressing performance concerns in the second study, physicians expressed that they feel they are the best positioned ones to detect deviances in a peer’s behaviour, communication or appearance (Chapter 3). As a colleague, they feel co-responsible for their peers’ wellbeing: a striking example of comradeship. Our findings showed that physicians feel the need to take care of each other by actively picking up on signals or concerns and then offering a helping hand. Openly and periodically discussing individual and group performance, including positive themes such as inspiration and ambition, is helpful in supporting a culture of comradeship and speaking up.
Creating a psychologically safe environment not only upholds such supportive behaviour, it also encourages speaking up in terms of giving and receiving performance feedback (Chapter 4). The link between psychological safety and performance feedback was explored in depth in Chapter 4, showing that performance feedback is more positively perceived by physicians who experience a higher level of psychological safety within their team. Thus medical teams should invest in improving the quality of interpersonal relationships and building trust within their teams. Team-building activities, gathering and discussing 360˚ feedback, and planning social activities all contribute to building trust. Furthermore, helping a colleague when they are facing an adverse event or medical error, labelled peer support, builds fruitful relationships. Inviting peers to speak, explicitly showing appreciation and proactively asking for other opinions, i.e. inclusive leadership behaviour, also all improve the quality of interpersonal peer-relationships.
Constructive peer-relationships are fertile ground for professional development and performance improvement. In order to ensure optimum care quality, all licensed doctors must periodically demonstrate that they are up-to-date with developments and fit to practice. These processes focus in part on individual 360˚ performance feedback. Since peer-interaction has been shown to be important for professional development, I dug deeper into this topic in the fourth study, specifically within this mandatory process (Chapter 5). By investigating the potential power of peer-group reflection on individual performance, I connected peer interaction and individual development. I found that sharing is actually caring; the results of this study indicated that peer-group reflection offered the possibility to discuss and compare one’s own and others’ perceptions, thereby gaining a nuanced insight into one’s professional performance. Sharing reflections was experienced as a source of social support and deepened communal relationships on a group level. On the individual level, sharing reflections was seen as helpful in realising actual change and creating a sense of urgency for improvement. The findings thus point to a positive effect on the team as well as the individual performance level, indicating a close correlation. From this, I concluded that performance should not be viewed on an individual level, it should always incorporate the context of the individual.
Although primary designed to correspond to the second challenge, i.e. exploring how physicians perceive performance, the two subsequent studies also provided information on comradeship. Chapter 6 showed the negative effect of inadequate peer-relations in that physicians mentioned that collaboration issues within the peer group hindered their wellbeing and performance. Some even considered a change in workplace because of collaboration issues. Emphasising the essence of comradeship, they mentioned collaboration aspects such as social cohesion, mutual trust and a positive supportive environment as vital dimensions alongside calling, the second key component of high performance (Chapter 7).
With the overall aim to unravel the essence of physician performance, the second challenge focussed on the individual physician whereby I explored physicians’ own perceptions of performance. Participating doctors in our studies feel an intense dedication to their patients and consider humanistic practice at the heart of being a doctor. Hence the use of the term ‘calling’, i.e. having a career that provides a sense of meaning or purpose and is used to help others, became the second component in unravelling the essence of physician performance. The overall conclusion from the findings show that physicians view the medical profession as one that provides a deep sense of meaning and purpose, where motivation and inspiration derive from their dedication to helping their patients.
Aspects of a calling, dedication and humanistic practice were central topics in the two studies used to explore how physicians perceive performance (Chapter 6 and Chapter 7). My analysis of nearly 800 written reflections point towards physicians seeing being a humanistic practitioner at the heart of their performance (Chapter 6). They feel that all other activities build on this, translating humanistic practice into daily practice by striving to do the best for their patients. Gaining and sharing knowledge and competences, being accountable and being transparent are means that can contribute to the best patient care.
Interviewing 28 physicians and 7 HR professionals highlighted the perception of a doctor as a deeply dedicated and committed professional, going that extra mile for their patients (Chapter 7). That extra mile was even demonstrated by doctors participating in interviews after working hours, wanting to contribute to improvements, giving up their time to talk, despite their workloads and time restraints. Their strong dedication to their patients resulted in their opinion that dedication is more than just an antecedent of high performance, as it is described in most research. They felt dedication was an essential component of high performance. Based on these findings, I concluded that dedication, passion, commitment and intrinsic motivation shape the ‘sense of meaning and purpose’ of physicians’ calling; concepts that are all intertwined and positively related to high performance. The findings of the final study underline this even further by pointing out that passion and ambition are incorporated in physicians’ culture and thus shape their view of high performance (Chapter 7).
Humanistic practice arises from dedication, passion and ambition, forming the heart of being a doctor. However, this humanistic care seems to be supressed by today’s more business-like climate in healthcare. My findings show that increasing and heavy administrative workloads are perceived by physicians as an alarming threat to their performance. They feel that this threat negatively affects their calling as a doctor and hampers their ability to be a humanistic practitioner (Chapter 6). The doctors in my research confirmed findings elsewhere that the increasing clerical burden is leading to limited face-to-face time with patients. Curtailing what primarily inspires doctors will eventually lead to doctors no longer having the time, energy and motivation to deliver the best possible care.
What I have learnt from this thesis is that physicians view performance through the lens of calling and comradeship. For doctors, it is all about dedication to the patient, passion, motivation, supportive peer relations, mutual trust and safety. My findings suggest that physician performance can only flourish in an environment that recognises and reinforces these humanistic and relational values. However, the current commercialisation trend in healthcare puts the spotlight on process, rules, accountability and efficiency. Aspects that have gained popularity in an era of declining societal trust in the medical profession due to critical incidents and modern society’s demands for greater transparency, accountability and measurable outcomes.
Based on my findings, I strongly advocate countering this climate of commercialisation by putting people in the spotlight ahead of process and productivity. The results of this thesis represent a scientific argument for a broader societal call for change to ‘soften’ the current business-like environment that healthcare has become.
Recommendations for the individual level
To be a dedicated doctor and colleague, it is crucial to take care of oneself and those around. Physicians’ self-care could be viewed as an element of professional behaviour. That is, to perform optimally is conditional on taking care of one’s own physical and mental wellbeing. This research identified a desire in doctors for improved leadership and collaboration skills. This could be realised on an individual level in post-academic training programmes. From a leadership perspective, I found that inclusive leadership behaviour is beneficial in improving the quality of interpersonal relationships; inviting peers to speak, explicitly showing appreciation, proactively asking for other opinions, offering a helping hand, reflecting on and giving feedback, sharing and self-disclosure. This can, and should, be enacted by all physicians, whether or not they have a ‘formal’ leadership position. Medical Leadership 2.0 stands for (self-)reflective capabilities and agency by all actors in the healthcare arena, in order to contribute to social cohesion and an increase in wellbeing and ‘work-happiness’.
Recommendations for the department/group level
Individuals can only blossom within a culture of trust and safety, and therefore investing in developing such a culture seems essential, especially since the absence of psychological safety often contributes to breakdowns in collaboration. Peer groups or departments can invest in psychological safety by periodically collectively discussing and reflecting on individual and group performance. Group reflection encourages professional development, performance, lowers the threshold for speaking up and creates an opportunity to help and advise each other. In the context of recertification, these benefits are increasingly recognised and group-reflection is becoming more common in the Netherlands. Groups and departments should in general invest in optimising group cohesion since this is known to build trust within a team. Cohesion can be built through various activities such as discussing adverse events and supporting each other in such circumstances, having group discussions regarding medical topics and teambuilding activities. In addition to the work context, social activities are also important in optimising interpersonal connections. Furthermore, teams should build on the unique talents and motivations of the individual physicians within the group since such a strength-based climate is a prerequisite for positive effects and, in turn, will lead to better job performance.
Recommendations for the organisational level
Given their strong links to quality of care, patient safety and patient satisfaction, having an engaged and collaborative physician workforce is critical for healthcare organisations. To foster dedicated doctors working in dedicated teams, healthcare organisations should invest in a collaborative mindset. Facilitating groups and departments to optimise their group cohesion would be helpful in achieving this collaborative mindset. Since the hospital board and the medical board are jointly responsible for the quality and wellbeing of their physicians, facilitating groups to spend time together and invest in their team should not be optional and solely a group’s responsibility. A collaborative mindset can be enhanced by formal support or coaching programmes, investing in multidisciplinary collaboration and performance evaluations on a team level, followed by guiding and support. Physicians deal with unique challenges (such as medical errors and malpractice suits) and have a professional identity and role that is distinct from other disciplines and, because of this, fruitful peer interaction and peer support have always been part of how physicians deal with these circumstances. The topic of peer support is gaining popularity and formal peer support programmes are implemented in many institutions. However, the more informal support aspects and interactions have become more difficult given a more productivity-driven, time and resource effective mindset. This mindset has led to an erosion of peer support and a greater sense of isolation for many physicians.
In an attempt to counterbalance these eroding forces, the Mayo Clinic created dedicated meeting spaces for physicians and scientists with free fruit and beverages, computers and lunch tables. These spaces were successful in generating a sense of community and comradeship. To promote engagement and satisfaction within their staff, they further funded small groups of physicians to have a meal together every other week and discuss topics that explored the virtues and challenges of being a physician. These sessions led to improvements in both meaning in work and burnout for participants.
Nowadays, it is believed that every encounter should be as ‘efficient’ as possible. With this side-effect of the current commercialisation of healthcare, the benefits of organically spending time together, sharing with and helping colleagues seem to be becoming overshadowed. In order to restore a healthy balance, such encounters should be re-enabled, if not organically, then through institutionalisation.