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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Satisfaction and Parenting
Where does the Fairhurst/May paper lead us?
Shall We Dance?
Bravo!
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Dan J Schmidt, Moscow, ID, USA Family Medicine
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I was struck that the GP's interviewed by Fairhurst and May would so willingly reflect. But, as mentioned in the discussion section, this may be a process of self selection. Often I find Family Doctors in this country resistant to reflection and self examination. But the most interesting issue for me has to do with the differences in the British system(if I understand it correctly) and the American and how that may affect satisfaction. The list of patients "assigned" to the GP in England aren't unlike your 'Children', that is, they can't easily fire you and you didn't request that specific "kind" of kid. In America, disatisfying a patient is not good business. Our patients are customers and shopping is encouraged. These two models have different consequences, influences. One GP spoke of prescribing a medication to promote "buy-in", gain trust, with a patient, to eventually teach a different model of care. I believe in the US we have a very difficult time maintaining this "higher focus", again, much like parents must for their children, because we are threatened with the patient firing us, moving on, seeing a different doctor who would give them what they want. The goal of changing behavior can be mutually avoided, to short term satisfaction and log term frustration. One unspoken but fascinating consequence of this is how doctors practices in the US reflect their own personal strengths/ weaknesses. Parenting, promoting growth, learning, is a most satisfying job. But, like our children, we have to keep a sense of greater good and not succumb to satisfying short sighted demand. Competing interests: None declared |
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Paul R Thomas, London, UK General Practitioner
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I very much enjoyed the paper by Fairhurst and May that explored the things that make general practitioners (GPs) enjoy our work. Like their respondent quoted on page 503 I also find it very satisfying to help a patient make sense of multiple symptoms, and consider this to be at the heart of quality general practice. But this recognition does not help me face a critic who says “how indulgent, that you expect to enjoy your work – what matters is the health of the patient!” In truth the authors do offer a reply to such a critic, but I want to elaborate. The health of a patient has as much to do with their ability to make sense of the complex interplay of various aspects of their life as with effective treatment of their discrete diseases. This argument can be played out through the language of economics – when patients understand how different aspects of their health impact on each other, they become better at improving their own health themselves, and ease the burden on the State. It can be argued through the language of risk – when a patient is able to reframe complaints in more connected way, they avoid the dangers of worsening one thing while they improve another. It can be argued through the language of causality, appealing to Antonowski’s work on salience of life – when individuals find their whole life story to be coherent they have fewer diseases. The (first) Wanless Report (http://www.hm- treasury.gov.uk./media/44F/3F/wanless) in 2001 provided evidence in Chapter 7 (page 84) that GPs were the most trusted of all public servants. I believe that one reason for this is the preparedness of many GPs to help patients make sense of the complexities of their health and diseases, as the authors commend. However, in Chapter 5 of the same report (page 59) he also provided evidence that the UK compares unfavorably with Australia, Canada, France, Germany, the Netherlands, New Zealand and Sweden when it comes to measures such as life expectancy, infant mortality and survival rates from various diseases. So modern-day general practice needs both – whole person care and good disease management. The theoretical basis of how to do both at the same time is contested. The recent government review of “how to make the very best of the resources that we devote to health research” largely ignores the question (http://www.hm- treasury.gov.uk/media/56F/62/pbr06_cooksey_final_report_636.pdf). So where does the Fairhurst/May paper lead us. I think it challenges us to describe the general practitioner role as helping people to make sense of the complexities in their life, as well as treating their diseases. It challenges us to describe a primary care research agenda that does justice to the moving and multifaceted world that our patients encounter, including randomized controlled trials as a part of the strategy. It challenges us to evaluate the inter-dependence of team, organization and whole system efforts, as well as individual agency. It reminds us that we must argue at every level that relationships matter – doctor-patient relationships, personal relationships of all kinds, and also the relationships between the different aspects of a patient’s health – people really are more than the sum of their medical diagnoses. We must also remember that we promised our country a National Health Service – not a National Disease Service. Thank you for a thought-provoking paper. Competing interests: None declared |
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Sharon B. Buchbinder, RN, PhD, Towson, MD, USA Professor & Chair, Dept of Health Science
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Job satisfaction is “a pleasurable or positive emotional state resulting from the appraisal of one’s job or job experiences.”(1) Previous research has demonstrated the link between primary care physician (PCP) perceptions of overuse of standardized protocols, PCP job dissatisfaction, and turnover or quit behavior.(2) Physician job dissatisfaction and turnover are important research phenomena because there are high costs associated with recruiting and replacing PCPs.(3) In their article, “What General Practitioners Find Satisfying in Their Work: Implications for Health System Reform,” Fairhurst and May have provided us with a day in the life of a GP. Some patient encounters are most satisfying and some are least satisfying. At the heart of this inquiry is the question, “Why?” What is most important to me about this in-depth qualitative research is that the authors sat down with the physicians, after analyzing the data, and asked the GPs to dig deep within themselves and ask, “Why?” By urging them to reflect on these encounters, the authors enabled the GPs to pinpoint their actions, the patient’s reactions, and the interplay, or “dance,” between them. This opportunity for reflection is a gift to the GP and the patient, because it is the “reflective practitioner” who takes the next step to ponder what he or she should have done differently and better, to improve the interplay and the dance the next time.(4) The majority of physicians undergo the rigors of medical education and training because they want to help people. It is part of their identity when they arrive at colleges and universities and declare, “I’m Pre-Med.” To deny this need is to negate who they are. Thus, it was reinforcing to see the authors’ results that the major factors influencing GP satisfaction with encounters were: perceived patient outcomes, the interpersonal relationship between the doctor and patient, and the impact of the experience of the encounter on the doctor’s identity. Their goals were the same as when they were younger: helping people. As the practice of medicine evolves in response to consumers, governments, health plans, evidence-based medicine, and practice guidelines, the distance between physician and patient grows, and the risk of physician job dissatisfaction and turnover increases. As we move forward in our quest to improve health outcomes, let us not forget that at the heart of it all lies the unique relationship between each physician and patient, and the dance to restore the patient’s health. 1. Locke EA. The nature and causes of job satisfaction. In: Dunnette M, ed. Handbook of Industrial and Organizational Psychology. New York: NY: John Wiley & Sons; 1983:1297-1349. 2. Buchbinder SB, Wilson MH, Melick CF, & Powe NR. Primary care physician job satisfaction and turnover. Am J Manag Care. 2001; 7:701-713. Available at 3. Buchbinder SB, Wilson MH, Melick CF, & Powe NR. Estimates of costs of primary care physician turnover. Am J Manag Care, 1999; 4:1431- 1438. Available at 4. Schön DA. The reflective practitioner: How professionals think in action. New York, NY: Basic Books; 1983. Competing interests: None declared |
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Patricia R. Reiff MD, Phoenix, AZ 85007 USA Physician - solo
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The very intimate but impersonal relationship between doctor and patient continues to require clarification and appreciation. The US system is imbedded with insurance companies trying to get between doctor and patient. A case comes to mind of a patient who flew to Thailand for a sex-change operation: s/he needs both mammograms (for the high dose oestrogens) and PSA testing, but no paps. Try to put that in a quality control computer! Once a nurse-reviewer cited me for not documenting discussion of birth control for a lesbian patient! I feel up to my neck in alligators, and find fighting these companies impedes the joy. Competing interests: None declared |
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