Doctors’ Work Context and Occupational Stress

Australian research into GPs’ occupational stress (e.g. Dua, 1996; 1997; Schattner 1998) has utilised surveys and quantitative analysis to identify sources of stress and identified similar findings regarding occupational stress in GPs. Schattner (1998) stated that sources of stress have included work demands, such as hours of work, time pressures, expectations that they needed to work even when they were sick, government’s

interference with their work, and concerns about their work disturbing their family and leisure time. In Dua’s studies, rural practitioners reported extra pressure that included difficulties finding locums, increased after-hours work, and poor access to professional development.

3.4.1 .2 High Demand

A common cause of stress at work is perceived high work demand. Doctors’ view their work as having ongoing demands, such as high workload, long work hours, anxiety about making mistakes, and threat of litigation. Some doctors experience work and non- work inter-role conflict, that is, a sense of incompatibility between one role and another

(Kirchmeyer, & Cohen, 1999). Research regarding doctors and occupational stress suggests that the excessive work demands experienced by doctors have the potential to cause stress. These work demands may contribute to doctors’ dissatisfaction with their jobs, and, result in maladaptive strategies being adopted to deal with the demands of their work.

Occupational or job stress has been linked to a range of occupationally-related illnesses and associated organisational outcomes, such as job satisfaction, absenteeism, and turnover (LaMontagne, Olstry, & Shaw 2006). A recent review of job stress and health conducted by LaMontagne, Ostry, Louie, and Keegel, (2006), commissioned by the Victorian Health Promotion Foundation, found compelling evidence that job stress predicts mental health problems, cardiovascular disease, and a range of unfavourable health outcomes. While most studies examined in this review were cross-sectional, one longitudinal study by De Lange, Taris, Kompier, Houtman, and Bongers (2004) provided evidence of a causal link between psychosomatic complaints and psychological stress. These researchers conducted a prospective study of 668 Dutch employees using 4 waves of data collection from 1994 to 1997. Results found evidence of reciprocal causal

relationships between work characteristics and mental health. Results also indicated that a 1 year time lag provided the best model fit with adverse effects on mental health

occurring from 1 year of exposure.

Doctors face distinctive professional and personal demands that are potentially stressful due to regular contact with disease, pain, death, and suffering for which there is no cure (Winefield, Farmer, & Denson, 1998). GPs practising in rural, remote, and under- serviced urban regions may be confronted with additional demands as they endeavour to balance professional, community, and family commitments (Humphreys, Jones, Jones, & Mara, 2002; Schofield, Page, Lyle, & Walker, 2006).

3.4.1.3 Threat of Malpractice Litigation

The threat of malpractice litigation was another commonly cited occupational concern in the literature and source of work dissatisfaction (Arnetz, 2001; Charles, Wilbert, & Franke, 1985; Nocera & Khursandi, 1998). The actual incident or mishap that initiates a lawsuit may be acute, but the process of litigation is usually lengthy and, therefore, the distress associated with the process can become chronic and extend for a number of years (Charles, Wilbert, & Kennedy 1984).

In addition, changing social attitudes regarding the expectation of best care from those who provide care mean that patients now expect their doctor to fully inform them about their illness, their treatment options, and any associated risks. In the event of a medical mishap, patients in Australia are now more likely to seek compensation, and engage in mediation or litigation.

In Australia, Medical Defence Organisations (MDOs) are different from insurance companies in general. They have discretion whether to pay or to contest claims.5 The Medical Indemnity Industry Association of Australia’s (2007) annual indemnity report found that in the in the 10 years to 2005, there was a 37% rise in claims against non- procedural6 GPs, and a 19% rise against procedural GPs, although there are signs claims may have plateaued in more recent years, possibly due to state tort law reforms (Mackee, 2006).

Malpractice litigation has a professional and personal impact on doctors’ lives. A study of Chicago Medical Society members by Charles, Wilbert, and Franke (1985) found

5

A not-for-profit mutual organization created and owned by medical practitioners to provide various medical indemnity services to members.

6

The definition of procedural general practitioner adopted by the Australian Government is one who: provides non-referred services usually in a hospital theatre, maternity setting or other appropriately equipped facilities that in urban areas are typically the province of a specific referral based specialty. Most commonly this refers to the fields of surgery, anaesthetics and obstetrics.

that in response to both the threat and actuality of litigation, sued and non-sued doctors had professional reactions and symptomatic reactions. Not surprisingly, doctors who were sued reported more severe emotional disruption than non-sued doctors. Symptoms

included severe depressed mood, inner tension, anger, frustration, and physical illness. As a result of litigation doctors became more concerned about maintaining meticulous

records, ordering more (potentially unnecessary) diagnostic investigations, studying professional literature more thoroughly, and attending more continuing education courses. While such changes in professional practice may have been warranted, the additional demands on the GP also increase. These professional (and personal) changes may also have an impact on the delivery of quality health care. For example, increases in medical costs to the community, erosion of the doctor-patient relationship, and decline in doctors’ self-confidence and job satisfaction.

While many studies (e.g., Dua, 1997: Firth-Cozens, 1999; Schattner, 1998) have found that the high demand work environment of medicine contributes to doctors’ perceptions of occupational stress, perceptions of occupational stress may also be influenced by doctors’ individual characteristics.