By Nigel Edwards

Unhappy doctors are a worldwide phenomenon.

• Several reports from around the world describe declining morale among doctors, but little is known about the reasons
  
• Workload and pay, though important, do not fully explain the problem
  
• A key factor seems to be a change in the psychological compact between the profession, employers, patients, and society so that the job is now different from what doctors expected
  
• Developing a new compact that is more acceptable to the profession is important
  
• Clinical leaders have a potentially crucial role in developing a new compact
  

Potential Causes Of Unhapiness

Pay and workload are obvious causes for unhappiness among doctors. However, evidence from systems with much higher pay and longer consultation times suggests that these are not enough by themselves to ensure high morale.

Several of the causes are probably the result of changes in the expectations of patients, governments, and employers; and there may also be causes within medicine itself.

The developed world has seen significant reductions in medical autonomy and increases in accountability as a result of the growing evidence base and a long running attempt to bring medicine under managerial and cost control by governments, payers, and employers.

This has resulted in the growing use of guidelines, protocols, audit, regulation, and inspection that many doctors perceive as eroding their control over their professional lives.

Though there are benefits from these changes, having control over work is important for the job satisfaction of clinicians and can have implications for overall health of employees. A related change in the relationship with employers has been the increased emphasis on numerical targets, efficiency, and volumes of work that dates from the late 1970s.

The changes in relationships with patients and society are particularly important. There has been a decline in deference for all professions and a perceived loss of trust, coinciding with a feeling that the media has become much more hostile.

In fact doctors are a highly trusted profession, and the proportion of negative news stories is fairly constant although the total number of stories has increased.

At the same time, patients are increasingly active consumers and they demand and have been encouraged to expect enhanced services, including extended hours and rapid access.

The easy availability of health information coupled with a sense of entitlement is shifting the power in the doctor-patient relationship and causing unease.

This is compounded by sometimes unrealistic expectations about the power of medicine to solve the ills of modern life. This is a bogus contract between the profession and patients but one that doctors have themselves sometimes encouraged.

Medical Causes

Several causes relate to medicine itself. The job is difficult and emotionally demanding, and doctors are more likely to be self-critical and have other personality traits associated with work related stress.

The poor record of the profession in giving mutual support or giving and receiving feedback aggravates this. Working in teams is also associated with being better able to cope with stress, but skills in team working are not universal in the profession. The selection, training, and socialization of doctors has tended to compound the problems of high workload, stress, and reaction to changes in the job.

Medicine has been based on a model in which doctors are trained to deal with individuals, not organizations; to take personal responsibility rather than delegate; and to do their best for each patient rather than make trade-offs in a resource constrained environment.

These factors make high workloads and high levels of workplace stress all the harder to deal with. They also create a real problem in that professional values and training based on an individualistic orientation do not prepare doctors to function successfully as members of large, complex organizations. Little training is given to equip doctors for this, and the difficulty that many consequently experience leads to stress and frustration.

Failing To Deliver What Was Promised

An important theme in all of these changes is the dissonance between what doctors might have reasonably expected the job to be and how it now is. The psychological contract or compact is a useful concept to explain this problem.

This is the implicit deal between doctors, patients, employers and society that defines what the parties to the relationship give and what they get in return. This seems to have changed without any explicit discussion with those involved and without being replaced with an equally meaningful or rewarding alternative.

British Medical Journal April 6, 2002;324:835-838