Moral distress among physicians in Norway: a longitudinal study.

OBJECTIVES: To explore and compare physicians' reported moral distress in 2004 and 2021 and identify factors that could be related to these responses. DESIGN: Longitudinal survey. SETTING: Data were gathered from the Norwegian Physician Panel Study, a representative sample of Norwegian physicians, conducted in 2004 and 2021. PARTICIPANTS: 1499 physicians in 2004 and 2316 physicians in 2021. MAIN OUTCOME MEASURES: The same survey instrument was used to measure change in moral distress from 2004 to 2021. Logistic regression analyses examined the role of gender, age and place of work. RESULTS: Response rates were 67% (1004/1499) in 2004 and 71% (1639/2316) in 2021. That patient care is deprived due to time constraints is the most severe dimension of moral distress among physicians, and it has increased as 68.3% reported this 'somewhat' or 'very morally distressing' in 2004 compared with 75.1% in 2021. Moral distress also increased concerning that patients who 'cry the loudest' get better and faster treatment than others. Moral distress was reduced on statements about long waiting times, treatment not provided due to economic limitations, deprioritisation of older patients and acting against one's conscience. Women reported higher moral distress than men at both time points, and there were significant gender differences for six statements in 2021 and one in 2004. Age and workplace influenced reported moral distress, though not consistently for all statements. CONCLUSION: In 2004 and 2021 physicians' moral distress related to scarcity of time or unfair distribution of resources was high. Moral distress associated with resource scarcity and acting against one's conscience decreased, which might indicate improvements in the healthcare system. On the other hand, it might suggest that physicians have reduced their ideals or expectations or are morally fatigued.

How stable are moral judgements? A longitudinal study of context dependency in attitudes towards patient responsibility.

BACKGROUND: Whether patients' life-style should involve lower priority for treatment is a controversial question in bioethics. Less is known about clinicians' views. AIM: To study how clinical doctors' attitudes to questions of patient responsibility and priority vary over time. METHOD: Surveys of doctors in Norway in 2008, 2014, 2021. Questionnaires included statements about patients' lifestyle's significance for priority to care, and vignettes of priority cases (only in 2014). RESULTS: Attitudes were fairly stable between 2008 and 2021. 17%/14% agreed that patients' lifestyle should count, while 19%/22% agreed that it should involve lower priority to scarce organs. 42/44% agreed that smokers should have lower priority. Substantially more agreed in 2014. Regression analyses showed that being male, working in hospital, and younger age increased the likelihood of agreeing. CONCLUSION: A substantial minority of doctors agreed that lifestyle should be a priority criterion, possibly contrary to Norwegian legislation and professional ethics. The finding might be explained by the unspecified meaning of priority, increased scarcity-awareness, or socio-cultural trends towards individualism. The 2014 results indicate a framing effect; the vignettes may have primed the respondents towards accepting lifestyle as a criterion. We conclude that attitudes to normative questions are unstable and depend on context. A substantial minority of doctors seems to be positive to deprioritizing patients allegedly responsible for their illness. However, what deprioritization implies in practice is not clear.

Educational supervision in internal medicine residency training - a scoping review.

BACKGROUND: Although supervision is an important part of residency training, its scope and how it relates to other types of support, such as mentoring, precepting and feedback, remain unclear. While clinical supervision consists of ongoing instructions and feedback in the workplace setting, educational supervision is a formalized component of postgraduate medical educational and supports the process that facilitates a trainee's progression throughout their training. Since medical specialties have different supervisory traditions, this study focuses on educational supervision in internal medicine. Our aim was to investigate what is known about educational supervision practices in internal medicine and the role of educational supervision in supporting residents' learning. METHODS: We conducted a scoping review of the literature on educational supervision in residency training in internal medicine based on Levac et al.'s modification of Arksey and O'Malley's six-step framework. The literature search was performed in the following databases: Medline, Embase, Web of Science and the Educational Resources Information Center. In addition, we conducted a handsearch in Medical Teacher and Google Scholar. We followed the PRISMA guidelines for systematic research. RESULTS: Eighteen of the 3,284 identified articles were included in the analysis. We found few empirical studies describing how educational supervision is conducted and what effect routine educational supervision has on residents' learning. Our findings suggest that the terminology can be confusing and that educational supervision practices in internal medicine has a weak theoretical foundation. CONCLUSION: The distinction between educational supervision and other support structures, such as mentoring and feedback, has not been clearly defined in the research literature. We argue that shared terminology is needed to better understand current educational practices and to facilitate clear communication about how to help residents learn.

Changes in weekly working hours, proportion of doctors with hours above the limitations of European Working Time Directive (EWTD) and time spent on direct patient care for doctors in Norway from 2016 to 2019: a study based on repeated surveys.

OBJECTIVES: To compare the total weekly working hours, proportions with work hours above the limitations of European working time directive (EWTD) and time spent on direct patient care in 2016 and 2019 for doctors working in different job positions in Norway. DESIGN: Repeated postal surveys in 2016 and 2019. SETTING: Norway. PARTICIPANTS: Representative samples of doctors; the response rates were 73.1% (1604/2195) in 2016 and 72.5% (1511/2084) in 2019. MAIN OUTCOME MEASURES: Self-reported weekly working hours, proportions with hours above the limitations of EWTD defined as >48 hours/week and time spent on direct patient care. ANALYSES: Linear mixed models with estimated marginal means and proportions. RESULTS: From 2016 to 2019, the weekly working hours increased significantly for male general practitioners (GPs) (48.7 hours to 50.9 hours) and male hospital doctors in leading positions (48.2 hours to 50.5 hours), and significantly decreased for female specialists in private practice (48.6 hours to 44.9 hours). The proportion of time spent on direct patient care was noted to be similar between genders and over time. In 2019, it was higher for specialists in private practice (66.4%) and GPs (65.5%) than for doctors in other positions, such as senior hospital consultants (43.5%), specialty registrars (39.8%) and hospital doctors in leading positions (34.3%). Working >48 hours/week increased significantly for both male and female GPs (m: 45.2% to 57.7%; f: 27.8% to 47.0%) and hospital doctors in leading positions (m: 34.4% to 57.1%; f: 17.4% to 46.4%), while it significantly decreased for female specialty registrars (13.2% to 6.9%). CONCLUSIONS: Working hours increased significantly for GPs and hospital doctors in leading positions from 2016 to 2019, resulting in increased proportions of doctors with work hours above the EWTD. As work hours above the EWTD can be harmful for health personnel and for safety at work, initiatives to reduce long working weeks are needed.

Understanding peer support: a qualitative interview study of doctors one year after seeking support.

BACKGROUND: Doctors' health is of importance for the quality and development of health care and to doctors themselves. As doctors are hesitant to seek medical treatment, peer support services, with an alleged lower threshold for seeking help, is provided in many countries. Peer support services may be the first place to which doctors turn when they search for support and advice relating to their own health and private or professional well-being. This paper explores how doctors perceive the peer support service and how it can meet their needs. MATERIALS AND METHODS: Twelve doctors were interviewed a year after attending a peer support service which is accessible to all doctors in Norway. The qualitative, semi-structured interviews took place by on-line video meetings or over the phone (due to the COVID-19 pandemic) during 2020 and were audiotaped. Analysis was data-driven, and systematic text condensation was used as strategy for the qualitative analysis. The empirical material was further interpreted with the use of theories of organizational culture by Edgar Schein. RESULTS: The doctors sought peer support due to a range of different needs including both occupational and personal challenges. They attended peer support to engage in dialogue with a fellow doctor outside of the workplace, some were in search of a combination of dialogue and mental health care. The doctors wanted peer support to have a different quality from that of a regular doctor/patient appointment. The doctors expressed they needed and got psychological safety and an open conversation in a flexible and informal setting. Some of these qualities are related to the formal structure of the service, whereas others are based on the way the service is practised. CONCLUSIONS: Peer support seems to provide psychological safety through its flexible, informal, and confidential characteristics. The service thus offers doctors in need of support a valued and suitable space that is clearly distinct from a doctor/patient relationship. The doctors' needs are met to a high extent by the peer-support service, through such conditions that the doctors experience as beneficial.

Physician participation in quality improvement work- interest and opportunity: a cross-sectional survey.

BACKGROUND: Lack of physician involvement in quality improvement threatens the success and sustainability of quality improvement measures. It is therefore important to assess physicians´ interests and opportunities to be involved in quality improvement and their experiences of such participation, both in hospital and general practice. METHODS: A cross-sectional postal survey was conducted on a representative sample of physicians in different job positions in Norway in 2019. RESULTS: The response rate was 72.6% (1513 of 2085). A large proportion (85.7%) of the physicians wanted to participate in quality improvement, and 68.6% had actively done so in the last year. Physicians' interest in quality improvement and their active participation was significantly related to the designated time for quality improvement in their work-hour schedule (p < 0.001). Only 16.7% reported time designated for quality improvement in their own work hours. When time was designated, 86.6% of the physicians reported participation in quality improvement, compared to 63.7% when time was not specially designated. CONCLUSIONS: This study shows that physicians want to participate in quality improvement, but only a few have designated time to allow continuous involvement. Physicians with designated time participate significantly more. Future quality programs should involve physicians more actively by explicitly designating their time to participate in quality improvement work. We need further studies to explore why managers do not facilitate physicians´ participation in quality improvement.

Guidelines and clinical priority setting during the COVID-19 pandemic - Norwegian doctors' experiences.

BACKGROUND: In the first phase of the COVID-19 pandemic, strong measures were taken to avoid anticipated pressure on health care, and this involved new priorities between patient groups and changing working conditions for clinical personnel. We studied how doctors experienced this situation. Our focus was their knowledge about and adherence to general and COVID-19 specific guidelines and regulations on priority setting, and whether actual priorities were considered acceptable. METHODS: In December 2020, 2 316 members of a representative panel of doctors practicing in Norway received a questionnaire. The questions were designed to consider a set of hypotheses about priority setting and guidelines. The focus was on the period between March and December 2020. Responses were analyzed with descriptive statistics and regression analyses. RESULTS: In total, 1 617 (70%) responded. A majority were familiar with the priority criteria, though not the legislation on priority setting. A majority had not used guidelines for priority setting in the first period of the pandemic. 60.5% reported that some of their patients were deprioritized for treatment. Of these, 47.5% considered it medically indefensible to some/a large extent. Although general practitioners (GPs) and hospital doctors experienced deprioritizations equally often, more GPs considered it medically indefensible. More doctors in managerial positions were familiar with the guidelines. CONCLUSIONS: Most doctors did not use priority guidelines in this period. They experienced, however, that some of their patients were deprioritized, which was considered medically indefensible by many. This might be explained by a negative reaction to the externally imposed requirements for rationing, while observing that vulnerable patients were deprioritized. Another interpretation is that they judged the rationing to have gone too far, or that they found it hard to accept rationing of care in general. Priority guidelines can be useful measures for securing fair and reasonable priorities. However, if the priority setting in clinical practice is to proceed in accordance with priority-setting principles and guidelines, the guidelines must be translated into a clinically relevant context and doctors' familiarity with them must improve.

Conditions for gatekeeping when GPs consider patient requests unreasonable: a focus group study.

BACKGROUND: Requests from patients that are regarded by GPs as unreasonable are a source of conflict between GPs and patients. This makes gatekeeping challenging, as GPs negotiate a struggle between maintaining the doctor-patient relationship, protecting patients from the harms of medical overuse and acting as stewards of limited health care resources. More knowledge of how GPs can succeed in these difficult consultations is needed. OBJECTIVE: To explore Norwegian GPs' perceptions of conditions that can promote their ability to act as gatekeepers when facing patient requests which they consider 'unreasonable'. METHODS: A qualitative study based on three focus groups with Norwegian GPs conducted in 2019, exploring consultations in which the patient made a seemingly unreasonable request, but the GP was able to navigate the consultation in a clinically appropriate manner. Thematic cross-case analysis of verbatim transcripts from the focus groups was carried out using Systematic Text Condensation. RESULTS: The analysis revealed three major themes among the conditions that the GPs considered helpful when faced with an 'unreasonable' patient request: (i) professional communication skills; (ii) a long-term perspective; (iii) acknowledgement and support of GPs' gatekeeping role among peers and from authorities. CONCLUSION: Professional communication skills and relational continuity need to be prioritized for GPs to maintain their role as gatekeepers. However, support for the gatekeeping role within the profession as well as from society is also required.

Effect of burnout among physicians on observed adverse patient outcomes: a literature review.

BACKGROUND: Physician burnout has potentially harmful effects for both physicians and their patients. Despite relationships between physician burnout and lowered patient satisfaction and clinician-rated adverse patient outcomes, there is scarce literature regarding effects on objective patient outcomes. This study aimed to examine the relationship between physician burnout and observed adverse patient outcomes via a review of the literature. METHODS: A search was performed on the MEDLINE, EMBASE and PsychINFO databases, using keywords and Medical Subject Headings. The identified studies were in English, published from 2007 to 2019, measured burnout among physicians using the Maslach Burnout Inventory (MBI), and included observed adverse patient outcomes. In total, 360 eligible articles were identified, and 11 were included in the final review. All included studies measured patient outcomes by observed clinical measures (e.g. quality of care and medical errors). RESULTS: Four studies found a clear significant relationship between physician burnout and observed adverse patient outcomes, while 6 did not. One study found a significant relationship with one of the MBI subscales. Burnout was, in contrast to depression, only partly associated with observed patient outcomes. CONCLUSIONS: This review illustrates the need for a validation of physician burnout measured by MBI with respect to observed patient outcomes. Further studies are required to investigate the effects of physician burnout on observed quality of their patient care.

Why are doctors opting out of general practice? / Hvorfor velger leger seg bort fra allmennmedisin?

BACKGROUND: There has been a sustained focus on the lack of recruitment to general practice in Norwegian politics, media and research. We have little knowledge of the reasons that have been prominent for doctors who have actively opted out of general practice. We therefore wished to investigate what types of doctors choose not to work in general practice and why. MATERIAL AND METHOD: The data are based on a questionnaire that was sent to the 2 195 members of the Medical Panel in 2016/17. The response rate was 73.1 %. We used graphics and descriptive analyses to study inter-group differences between those who had considered general practice but made another choice, and those who had quit general practice. RESULTS: Of the 1 153 doctors who were not general practitioners, 44.1 % had not considered this as an option. 39.9 % had considered it, but chosen differently, and 16.0 % had previously worked as GPs, but quit. The administrative burden and small professional community were the main reasons for doctors to opt out of general practice. INTERPRETATION: The administrative burden and small professional community were key reasons why doctors opted out of general practice or quit the specialty. A number of other factors also played a role, and the efforts to recruit and retain GPs should therefore be seen in a wider and more overarching context.

Medical students' attitudes and expectations for future working conditions. / Medisinstudenters holdninger og forventninger til fremtidige arbeidsvilkår.

BACKGROUND: The doctors' strike in 2016 highlighted an ongoing debate on the tightening of working conditions for doctors. With this strike as a backdrop, we wanted to investigate the attitudes and expectations for future working conditions among medical students. MATERIAL AND METHOD: Four focus-group interviews with a total of 21 medical students (48 % women, age 21-38 years) in their third to sixth year of study were conducted and analysed with the aid of systematic text condensation. RESULTS: The students described how the doctors' efforts to help each other had a positive effect on the working environment, but might also paradoxically worsen the working conditions of the collegial community. They highlighted the importance of consensus around public health services, a good professional community and idealism, but perceived that these aspects could be threatened by competition for positions and distrust in political governance processes. The need to be competent and succeed in competing for temporary jobs, as well as a strong motivation to become a doctor, made the students vulnerable to accepting tough working conditions. The students' attitudes and expectations had mainly been formed through work placement experience and by family members, but the strike had impacted particularly the older cohorts' assessment of their future working situation. INTERPRETATION: Medical students express concerns about accepting entry into a system that they are not immediately able to change, and where safeguarding their own needs and a favourable work-life balance might be difficult. This has implications for raising awareness of these issues during the medical studies and developing an organisational culture that ensures justifiable and sustainable working conditions for doctors.

Work-home balance in two cohorts of Norwegian doctors. / Jobb­hjem-balanse i to kohorter av norske leger.

BACKGROUND: Stress linked to the balance between work and home, so-called work-home interface stress, may affect the health and life situation of doctors. Reports have shown an increase in job-related stress among Norwegian doctors. We wished to investigate the development trends for this type of stress in the period 2003-14. MATERIAL AND METHOD: Work-home interface stress was measured with the aid of three questions from a validated scale, on which the respondents reported their level of stress on a scale from 1 (no stress) to 5 (very high level of stress). The measurements were made 10 and 15 years after graduation in two cohorts of doctors who had received their training within six years of each other. We used the t-test and chi-square test to compare the cohorts and to compare gender within each cohort, and linear regression analysis to adjust for any confounding factors. RESULTS: Doctors who had graduated later (later cohort, n = 248) reported significantly lower levels of work-home interface stress than doctors who had completed their studies six years earlier (early cohort, n = 197) (average score (standard deviation) 2.2 (1.0) vs. 2.6 (1.0), p = 0.001). This correlation remained significant after adjusting for other explanatory variables, such as gender (woman), number of children, weekly working hours and collegial and partner support. Fifteen years after graduation there were no differences between the cohorts in terms of perceived work-home interface stress. Within the cohorts there were no significant gender differences at any point of measurement. After adjustment for partner support and working hours, being a woman gave a significantly increased risk of experiencing work-home interface stress. INTERPRETATION: Doctors who graduated later, experienced less work-home interface stress than those who had received their training earlier. The experience of stress was buffered in women who perceived their partner as supportive and had reduced working hours.

How do doctors experience the interactions among professional fulfilment, organisational factors and quality of patient care? A qualitative study in a Norwegian hospital.

OBJECTIVES: Doctors increasingly experience high levels of burnout and loss of engagement. To address this, there is a need to better understand doctors' work situation. This study explores how doctors experience the interactions among professional fulfilment, organisational factors and quality of patient care. DESIGN: An exploratory qualitative study design with semistructured individual interviews was chosen. Interviews were transcribed verbatim and analysed by a transdisciplinary research group. SETTING: The study focused on a surgical department of a mid-sized hospital in Norway. PARTICIPANTS: Seven doctors were interviewed. A purposeful sampling was used with gender and seniority as selection criteria. Three senior doctors (two female, one male) and four in training (three male, one female) were interviewed. RESULTS: We found that in order to provide quality care to the patients, individual doctors described 'stretching themselves', that is, handling the tensions between quantity and quality, to overcome organisational shortcomings. Experiencing a workplace emphasis on production numbers and budget concerns led to feelings of estrangement among the doctors. Participants reported a shift from serving as trustworthy, autonomous professionals to becoming production workers, where professional identity was threatened. They felt less aligned with workplace values, in addition to experiencing limited management recognition for quality of patient care. Management initiatives to include doctors in development of organisational policies, processes and systems were sparse. CONCLUSION: The interviewed doctors described their struggle to balance the inherent tension among professional fulfilment, organisational factors and quality of patient care in their everyday work. They communicated how 'stretching themselves', to overcome organisational shortcomings, is no longer a feasible strategy without compromising both professional fulfilment and quality of patient care. Managers need to ensure that doctors are involved when developing organisational policies, processes and systems. This is likely to be beneficial for both professional fulfilment and quality of patient care.

Doctors' attitudes to assisted dying. / Legers holdninger til aktiv dødshjelp.

BAKGRUNN: Aktiv dødshjelp er ulovlig i Norge, men et flertall av befolkningen støtter legalisering. Legers holdninger til aktiv dødshjelp ble sist undersøkt i 1993. Har legers holdninger endret seg? MATERIALE OG METODE: To spørreundersøkelser sendt til Legeforskningsinstituttets legepanel i henholdsvis 2014 og 2016 inneholdt spørsmål om aktiv dødshjelp. Svarene ble analysert med deskriptiv statistikk og logistisk regresjonsanalyse. RESULTATER: Svarprosenten var henholdsvis 75,0 (2014) og 73,1 (2016). Majoriteten var motstandere av legalisering av aktiv dødshjelp. I 2016-undersøkelsen sa 9,1 % av respondentene seg «svært enig¼ og 21,5 % «litt enig¼ i at legeassistert selvmord bør tillates for personer som har «en dødelig sykdom med kort forventet levetid¼. Yngre og ikke-religiøse var oftere positive til legalisering. I 2014-undersøkelsen svarte 8,6 % at de ville ha vært villige til å utføre legeassistert selvmord hvis dette ble tillatt. FORTOLKNING: Som i 1993 var et flertall av norske leger imot aktiv dødshjelp, men det synes å være flere enn før som støttet legalisering i visse tilfeller. De færreste var selv villige til å utføre aktiv dødshjelp hvis det ble tillatt.

Doctors as targets of unwanted sexual attention. / Uønsket seksuell oppmerksomhet rettet mot leger.

BAKGRUNN: #MeToo-kampanjen satte søkelys på forekomst av uønsket seksuell oppmerksomhet innenfor ulike yrkesgrupper. Vi ønsket å undersøke uønsket seksuell oppmerksomhet rettet mot leger, og så på omfang og endring over tid i to representative datasett innsamlet før kampanjen. MATERIALE OG METODE: I 1993 og 2014/15 ble det gjennomført spørreundersøkelser om arbeidsforhold, inkludert opplevd uønsket seksuell oppmerksomhet, i representative utvalg av norske leger. Disse dataene ble analysert ved sammenligning av andeler og logistisk regresjon med hensyn til kjønn og alder. RESULTATER: Andelen leger som rapporterte opplevd uønsket seksuell oppmerksomhet, økte signifikant fra 2,7 % (95 % KI 2,1-3,3) i 1993 til 4,6 % (3,4-5,8) i 2014/15. Det å være kvinne og å være ung ga økt risiko for opplevd uønsket seksuell oppmerksomhet. FORTOLKNING: Vi finner en økning i opplevd uønsket seksuell oppmerksomhet blant leger fra 1993 til 2015. Det kan reflektere en reell økning eller endret terskel for rapportering. I fremtidige studier bør man undersøke hvem den uønskede oppmerksomheten kommer fra, samt alvorlighetsgrad og konsekvenser av hendelsene.

How general practitioners understand and handle medically unexplained symptoms: a focus group study.

BACKGROUND: Medically unexplained symptoms (MUS) are a common yet challenging encounter in primary care. The aim of this study was to explore how general practitioners (GPs) understand and handle MUS. METHODS: Three focus group interviews were conducted with a total of 23 GPs. Participants with varied clinical experience were purposively recruited. The data were analysed thematically, using the concept of framing as an analytical lens. RESULTS: The GPs alternated between a biomedical frame, centred on disease, and a biopsychosocial frame, centred on the sick person. Each frame shaped the GPs' understanding and handling of MUS. The biomedical frame emphasised the lack of objective evidence, problematized subjective patient testimony, and manifested feelings of uncertainty, doubt and powerlessness. This in turn complicated patient handling. In contrast, the biopsychosocial frame emphasised clinical experience, turned patient testimony into a valuable source of information, and manifested feelings of confidence and competence. This in turn made them feel empowered. The GPs with the least experience relied more on the biomedical frame, whereas their more seasoned seniors relied mostly on the biopsychosocial frame. CONCLUSION: The biopsychosocial frame helps GPs to understand and handle MUS better than the biomedical frame does. Medical students should spend more time learning biopsychosocial medicine, and to integrate the clinical knowledge of their peers with their own.