Challenges in preserving the “good doctor” norm: physicians' discourses on changes to the medical logic during the initial wave of the COVID-19 pandemic

IntroductionThe COVID-19 pandemic was a tremendous challenge to the practice of modern medicine. In this study, we use neo-institutional theory to gain an in-depth understanding of how physicians in Sweden narrate how they position themselves as physicians when practicing modern medicine during the first wave of the pandemic. At focus is medical logic, which integrates rules and routines based on medical evidence, practical experience, and patient perspectives in clinical decision-making.MethodsTo understand how physicians construct their versions of the pandemic and how it impacted the medical logic in which they practice, we analyzed the interviews from 28 physicians in Sweden by discursive psychology.ResultsThe interpretative repertoires showed how COVID-19 created an experience of knowledge vacuum in medical logic and how physicians dealt with clinical patient dilemmas. They had to find unorthodox ways to rebuild a sense of medical evidence while still being responsible for clinical decision-making for patients with critical care needs.DiscussionIn the knowledge vacuum occurring during the first wave of COVID-19, physicians could not use their common medical knowledge nor rely on published evidence or their clinical judgment. They were thus challenged in their norm of being the “good doctor”. One practical implication of this research is that it provides a rich empirical account where physicians are allowed to mirror, make sense, and normalize their own individual and sometimes painful struggle to uphold the professional role and related medical responsibility in the early phases of the COVID-19 pandemic. It will be important to follow how the tremendous challenge of COVID-19 to medical logic plays out over time in the community of physicians. There are many dimensions to study, with sick leave, burnout, and attrition being some interesting areas

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.publishedVersio

Insights Gained From a Re-analysis of Five Improvement Cases in Healthcare Integrating System Dynamics Into Action Research

Background Healthcare is complex with multi-professional staff and a variety of patient care pathways. Time pressure and minimal margins for errors, as well as tension between hierarchical power and the power of the professions, make it challenging to implement new policies or procedures. This paper explores five improvement cases in healthcare integrating system dynamics (SD) into action research (AR), aiming to identify methodological aspects of how this integration supported multi-professional groups to discover workable solutions to work-related challenges. Methods This re-analysis was conducted by a multi-disciplinary research group using an iterative abductive approach applying qualitative analysis to structure and understand the empirical material. Frameworks for consultancy assignments/client projects were used to identify case project stages (workflow steps) and socio-analytical questions were used to bridge between the AR and SD perspectives. Results All studied cases began with an extensive AR-inspired inventory of problems/objectives and ended with an SDfacilitated experimental phase where mutually agreed solutions were tested in silico. Time was primarily divided between facilitated group discussions during meetings and modelling work between meetings. Work principles ensured that the voice of each participant was heard, inspired engagement, interaction, and exploratory mutual learning activities. There was an overall pattern of two major divergent and convergent phases, as each group moved towards a mutually developed point of reference for their problem/objective and solution, a case-specific multi-professional knowledge repository. Conclusion By integrating SD into AR, more favourable outcomes for the client organization may be achieved than when applying either approach in isolation. We found that SD provided a platform that facilitated experiential learning in the AR process. The identified results were calibrated to local needs and circumstances, and compared to traditional top-down implementation for change processes, improved the likelihood of sustained actualisation.publishedVersio

Insights gained from a systematic reanalysis of a successful model-facilitated change process in health care

Health care is a complex system with multiprofessional staff and multiple patient care pathways. Time pressure and minimal margins for error make it challenging to implement new policies or procedures, no matter how desirable. Changes in health care also requires the participation of the staff. System dynamics (SD) simulations can lead to shared systems understanding and allows for the development and testing of new scenarios in silico before implementing solutions. However, research shows that the actual implementation rate of simulations is low. This paper presents a reanalysis of a successful change project in health care combining SD principles with basic action research (AR) premises. The analysis was done by a multidisciplinary research group using qualitative methodology and identifies that a fruitful combination of AR inquiry and SD modelling potentially can improve implementation rates.publishedVersio

Physicians' engagement: qualitative studies exploring physicians' experiences of engaging in improving clinical services and processes

Background: Physicians are engaged in the bio-medical and technical development of health care. In spite of consensus between researchers and practitioners that change initiatives benefit from engaging multiple care professionals, it is a persistent and well documented problem that physicians’ engagement in developing clinical services and processes often is limited or missing. Aim: The overall aim was to explore physicians’ experiences of engagement in improving clinical services and processes, in order to gain more understanding about why such initiatives have problems engaging physicians. Methods: Qualitative and explorative studies with semi-structured physician interviews as data collection method were used. Particular analytical approaches facilitated paying close attention to individual physician’s experiences, while at the same time analytically striving towards finding an empirically grounded conceptualization of their experiences. Results: Striving for professional fulfillment was found to be a central motivator affecting physicians’ engagement for both clinical and development work. This conceptual model had two dimensions: being useful and making progress. Engagement was reinforced if the task at hand was experienced as contributing to professional fulfillment. Which tasks contributed to professional fulfillment was related to how medical practice was understood. Two alternative understandings emerged: the traditional doctor role and the employeeship role. Continuity, recognition, task clarity and role clarity were organizational conditions that facilitated engagement (I). Physicians and manager have different mindsets. This hinders cooperation. In order to improve the situation managers need to be appreciative of the mindset of physicians, and physicians need to better understand the mindset of managers (II). Physicians’ experiences from the patient-centered and team-based ward round were predominantly found to contribute to better informed clinical decisions, fewer follow-up questions from patients and increased professional fulfillment. The new ward round also led to challenging experiences of reduced autonomy and exposing knowledge gaps in front of others (III). Different ways to understand medical practice were found based upon physicians’ focal points during ward rounding; the We-perspective and the I-perspective. The We-perspective adheres to a more comprehensive and inclusive understanding of medical practice than the I-perspective (IV). Conclusion: Physicians’ engagement was enhanced by experiences of professional fulfillment. Which tasks contributed to this was related to individual understanding of medical practice. The societal demand for patient-centered healthcare could be experienced as an identity challenge for physicians with a professional identity grounded in a traditional bio-medical understanding of medical practice. If this challenge to identity is not handled resistance toward the societal demand is likely to follow

Challenges in preserving the “good doctor” norm : Physicians' discourses on changes to the medical logic during the initial wave of the COVID-19 pandemic

Introduction: The COVID-19 pandemic was a tremendous challenge to the practice of modern medicine. In this study, we use neo-institutional theory to gain an in-depth understanding of how physicians in Sweden narrate how they position themselves as physicians when practicing modern medicine during the first wave of the pandemic. At focus is medical logic, which integrates rules and routines based on medical evidence, practical experience, and patient perspectives in clinical decision-making. Methods: To understand how physicians construct their versions of the pandemic and how it impacted the medical logic in which they practice, we analyzed the interviews from 28 physicians in Sweden by discursive psychology. Results: The interpretative repertoires showed how COVID-19 created an experience of knowledge vacuum in medical logic and how physicians dealt with clinical patient dilemmas. They had to find unorthodox ways to rebuild a sense of medical evidence while still being responsible for clinical decision-making for patients with critical care needs. Discussion: In the knowledge vacuum occurring during the first wave of COVID-19, physicians could not use their common medical knowledge nor rely on published evidence or their clinical judgment. They were thus challenged in their norm of being the “good doctor”. One practical implication of this research is that it provides a rich empirical account where physicians are allowed to mirror, make sense, and normalize their own individual and sometimes painful struggle to uphold the professional role and related medical responsibility in the early phases of the COVID-19 pandemic. It will be important to follow how the tremendous challenge of COVID-19 to medical logic plays out over time in the community of physicians. There are many dimensions to study, with sick leave, burnout, and attrition being some interesting areas

Organizational logics in time of crises : How physicians narrate the healthcare response to the Covid-19 pandemic in Swedish hospitals

Background: The COVID-19 pandemic has challenged healthcare organizations and puts focus on risk management in many ways. Both medical staff and leaders at various levels have been forced to find solutions to problems they had not previously encountered. This study aimed to explore how physicians in Sweden narrated the changes in organizational logic in response to the Covid-19 pandemic using neo-institutional theory and discursive psychology. In specific, we aimed to explore how physicians articulated their understanding of if and, in that case, how the organizational logic has changed during this crisis response. Methods: The empirical material stems from interviews with 29 physicians in Sweden in the summer and autumn of 2020. They were asked to reflect on the organizational response to the pandemic focusing on leadership, support, working conditions, and patient care. Results: The analysis revealed that the organizational logic in Swedish healthcare changed and that the physicians came in troubled positions as leaders. With management, workload, and risk repertoires, the physicians expressed that the organizational logic, to a large extent, was changed based on local contextual circumstances in the 21 self-governing regions. The organizational logic was being altered based upon how the two powerbases (physicians and managers) were interacting over time. Conclusions: Given that healthcare probably will deal with future unforeseen crises, it seems essential that healthcare leaders discuss what can be a sustainable organizational logic. There should be more explicit regulatory elements about who is responsible for what in similar situations. The normative elements have probably been stretched during the ongoing crisis, given that physicians have gained practical experience and that there is now also, at least some evidence-based knowledge about this particular pandemic. But the question is what knowledge they need in their education when it comes to dealing with new unknown risks

Duty to treat and perceived risk of contagion during the COVID-19 pandemic: Norwegian physicians’ perspectives and experiences—a questionnaire survey

Abstract Background The COVID-19 pandemic actualised the dilemma of how to balance physicians´ obligation to treat patients and their own perceived risk of being infected. To discuss this in a constructive way we need empirical studies of physicians´ views of this obligation. Methods A postal questionnaire survey was sent to a representative sample of Norwegian physicians in December 2020. We measured their perceived obligation to expose themselves to infection, when necessary, in order to provide care, concerns about being infected themselves, for spreading the virus to patients or to their families. We used descriptive statistics, chi-square tests and logistic regression analyses. Results The response rate was 1639/2316 (70.9%), 54% women. Of doctors < 70, 60,2% (95% CI 57.7–62.7) acknowledged to some or a large degree an obligation to expose themselves to risk of infection, and 42.0% (39.5–44.5) held this view despite a scarcity of personal protective equipment (PPE). Concern about being infected oneself to some or to a large extent was reported by 42.8% (40.3–45.3), 47.8% (45.3–50.3) reported concern about spreading the virus to patients, and 63.9% (61.5–66.3) indicated worry about spreading it to their families. Being older increased the odds of feeling obligated (ExpB = 1.02 p < 0.001), while experiencing scarcity of PPE decreased the odds (ExpB = 0.74, p = 0.01). The odds of concern about spreading virus to one´s family decreased with higher age (Exp B = 0.97, p < 0.001), increased with being female (Exp B = 1.44, p = 0.004), and perceived lack of PPE (Exp B = 2.25, p < 0.001). Although more physicians working in COVID-exposed specialties experienced scarcity of PPE and reported perceived increased risks for health personnel, the odds of concern about being infected themselves or spreading the virus to their families were not higher than for other doctors. Conclusion These empirical findings lead to the question if fewer physicians in the future will consider the duty to treat their top priority. This underscores the need to revisit and revitalise existing ethical codes to handle the dilemma between physicians´ duty to treat versus the duty to protect physicians and their families. This is important for the ability to provide good care for the patient and the provider in a future pandemic situation