his article presents results from two surveys that illustrate changes in the physician's work between 1992 and 2010. There are several indications that the physician's working conditions have deteriorated in recent decades. The Work Environment and SCB's studies, doctors have identified as an occupational group with health and safety problems [1, 2]. The Work Environment Authority's report on the negative stress at work was a doctor - along with dentists, primary school teachers and cashiers - those occupations where there was most common with the work under high tension, ie, low self-monitoring, and insufficient support from managers and colleagues [2]. These studies, which in time is between our two data points indicate that there has been a continuous change during the period. In this direction also points to some other studies that focused on doctors working in Sweden [3, 4]. The phenomenon is not only Swedish, there are similarities with developments in several other countries [5, 6].

 

The issues addressed in this analysis are: How has the doctor's position and responsibilities of the position changed? Have there been changes in time for skills development and training? How has medical situation in terms of requirements, influence, support and feedback changed? Finally, we try to understand the results in relation to the change in the professional work that takes place not only among physicians but also among other professions in much of the western world.

Methods

Some 20 questions about work environment were included in a survey of physicians 1992nd These questions were asked verbatim also in a survey in 2010. Here, these two cohorts are referred to as "the 1992 doctors 'and' The 2010 physicians."

Survey questions

In both surveys are included, in addition to background questions on sex, age, position and specialty questions on hours worked per week and number of hours on average spent on training / reading and research per week. In a couple of questions are asked doctors to assess their own managerial responsibility: if they have any staff management or verksamhets-/samordningsansvar. Nine questions refers to areas in other studies been shown to have an impact on individuals' health: questions about the requirements, supervision and support in the work [7]. Two of these questions is about influence, three and four on the requirements for support in the work. There are also two issues of providing support that is directed to managers only.

The study also includes questions of competence, the supervisor has expertise in the subject area, if one may use for its highest standard and if you feel it is a pressure to try and keep pace with the development of knowledge. One issue is about resources in relation to the effort. Also included is an analysis of a case of fatigue after work.

1992 doctors

The material from 1992 is part of a large study by academics working conditions made at the National Institute under the direction of Gunnela Westlander [8, 9]. All the then 24 Saco-union included. The survey was sent to an unbound, random sample of about 2 percent of the members of the Swedish Medical Association: 508 physicians, 350 men and 158 women. The response rate was 71 percent for men and 70 percent for women.

The 2010 doctors

A questionnaire was sent to an unbound, random sample of 10 percent of the Swedish Medical Association's members (where about 83 percent of the medical profession are members): 3000 persons, 1564 men and 1436 women. The number of answered questionnaires was, after several reminders and new mailing, 1 937th After adjusting for a declared shortfall of 109 individuals were response rate was 67 (62 percent for men and 69 percent for women).

Failure analysis showed that there were differences in response rate between different specialties (response rate for the specialties in which more than 100 questionnaires were answered: general 64 percent, anesthesia / critical care 79 percent, Pediatrics, 81 percent, internal medicine 48 percent, surgery 61 per cent, Psychiatry 73 percent, Radiology 81 percent). As for age distribution and geographical distribution was very good correlation between those who responded to the survey and those who were part of the loss.The study has been approved in the regional ethics committee. The study is based on a large sample from two independent samples.Statistical analysis of differences between the two years indicated were performed using χ2-and t-test SPSS version 19 for all assays.To check the differences and possible interaction effects for age and sex were used independent analysis of variance.

Result

The doctors were age becomes more evenly distributed in 2010 than 1992, when there were few doctors in the older age groups.The analysis also shows that today there is a higher proportion of doctors from outside the Nordic region. The proportion of women in the medical profession has increased substantially over the period.From having been less than a third of the 1992 physicians are slightly more than half of the 2010 women doctors. For the 2010 physicians are the younger age group (25-34 years) to 61 percent of women, while women in the older group (55-64 years) is 46 percent.

Hours of work, training and research

In 1992, a large proportion of doctors more than 40 hours per week. It did not in 2010, and among the 2010 physicians was also a higher proportion working part time. The time spent on skills development and advancement has been reduced, among the 1992 physicians were 10 percent who do not put any time on training and reading. The corresponding percentage among the 2010 physicians was 19 percent. Regarding research, the proportion who did not engage in this increase, from 55 percent 1992 to 71 percent in 2010.

Positions of responsibility and competence

The proportion of physicians who are specialists and physician has increased slightly, while the proportion who are managers or the like has been halved, from 12 to 6 percent between 1992 and 2010. A variable that measures the activity responsibility shows how doctors themselves consider their position of responsibility. In 1992, indicated 19 percent of the doctors that they had business responsibility at a higher level of organization, 2010 was this for just under 4 percent. The proportion who said they had no business liability whatsoever has rose from 31 to 77 percent of the medical profession during the period examined (Table I). The same change is related to staff management (t = 22.27, df = 2112, P <0.001).

Among the 2010 physicians, fewer who believed that their immediate supervisor "fully" with competence in the candidate's subject area than among the 1992 physicians, the proportion of 70 percent in 1992 has fallen to 49 percent in 2010 (Table I). The doctors also reported that the much less get used to its highest excellence in their work. Among the 2010 physicians, the proportion who used their highest competence "full working" 8 percent compared to 24 percent among the 1992 physicians. The question of whether one perceives it as a pressure to keep up with the development of knowledge were significantly fewer who experienced such pressure in 2010 than in 1992.

Overall, doctors use their skills to a lesser extent in 2010 and also experience a weaker pressure to keep up with developments. A question of resources in relation to the effort showed more clearly such a relationship in 1992 than in 2010. While 44 percent felt that there was a positive thing when in 1992 the figure was 23 percent in 2010.

Influence, requirements and support at work

Physicians' influence over decisions at departmental level has decreased between 1992 and 2010. While 28 percent of the 1992 doctors reported that they "usually" had enough influence on the department's decision, the corresponding share 18 percent in 2010 (Table II). The question of influence over their own work was the change over time were not significantly. The answers to three questions, which covers the requirements of the work, only in an area of ​​physicians reported a deterioration over time, namely the answers to the number of tasks impair the ability to work effectively (Table II). If the number of jobs actually increased or if they are more prohibitive today than before, one can not deduce the answers.

The answers to four questions on the support and encouragement from the immediate supervisor shows doctors a big difference over time, for example, if one can speak of difficulties in the work of his immediate chef.Andelen who argue that this is "completely" or "very good" fell from 70 percent from 1992 to 40 percent in 2010. The proportion who answered that they receive the support and encouragement they need from the next line (line "completely" or "very good") has fallen from 52 per cent in 1992 to 32 percent in 2010 (Table III).

Variance Analysis of responses to questions about requirements, influence and support shows that there are interaction effects between age and study year or between sex and year. Women did have a major problem with the demands and influence at work, but change over time between 1992 and 2010 were the same for male and female doctors.

Physicians with some form of employment or coordination responsibilities (1992: n = 238, 2010 n = 414) responded to the claim that they could "share the work so that time is to give staff the attention needed." The analysis showed that 37 percent of the 1992 physicians with operational responsibility replied that this was in "quite" or "very well", while the corresponding figure in 2010 was only 15 percent (5-point scale, 1992 M = 2.89, SD 1.09; 2010 M = 3.43 SD 1.09, t = -5.35, P <0.001). Meanwhile, the proportion who agreed that they had "some sort of intermediate position which is difficult to manage in my managerial" dropped from 41 per cent in 1992 to 28 percent in 2010 (five-point scale, 1992: M = 3.13, SD 1.37; 2010: M = 3.34, SD 1.37, t = -2.44, P = 0.015).

Thus, the 2010 physicians with leadership less time for their staff, but they also experienced a lesser extent that they had a difficult middle position, which is likely to be associated with a change of direction in their management.

Tired after work

Three issues of fatigue was included in both studies. With regard to physical and mental fatigue after work, there were no significant differences between the two studies. The answers to the question of how often "you are so tired after work that you have difficulty taking you for something, such as exercise, engage in any hobbies, make friends and acquaintances" were, however, significant deterioration; 1992 was the 10 percent who reported that they "often" was so tired after work, compared to 18 percent in 2010 (five-point scale, 1992: M = 2.89, SD 1.03; 2010: M = 2.72, SD 1.15, t = 2.72, P = 0.007). 

The 1992 study was a single weak but significant correlation between fatigue after work and the four questions on support from immediate supervisor (the claim ", the encouragement and support I need" r = -0.11, P = 0.029). The 2010 data were however clearly significant correlations between fatigue and all four questions on the support (r = -0.20 to -0.26, P <0.001). According to our variance analysis does not explain the increased proportion of physicians who report that they are often too tired after work to make something of his free time of demographic change in gender composition or age.

Discussion

Taken together, the physicians' responses in the two surveys are signs of deterioration in some of the work environment key dimensions in the period 1992-2010. In the case of support and feedback in the work, the changes are little short of dramatic, as with the sharp decrease in the proportion of physicians who report that they have a verksamhets-/samordningsansvar or personnel.

Less of self-improvement and research

One troubling finding is that the 2010 physicians are experiencing weaker pressure to keep up with the development of knowledge than 1992 doctors, and they also have less time than before for this. Possibly the result may be interpreted against a background of the shift in responsibilities, reduced liability for the business so you are no longer "public face" and the press at his own advancement decreases. Another explanation could be that complete care plans and schedules meant a form of standardization, which has become a substitute for himself to read and learn.

Research is not only the pressures of business throughout the Swedish health care system, it has also had a significantly lower merit [10]. A smaller proportion of managers have the same professional background as physicians, in the 2010 survey were questions about whether the line manager and operations manager was a doctor or not, and almost 30 percent responded that they did not belong to the profession. But clinic directors, regardless of background, to measure the clinical research less important than other aspects of the business [10].

Fewer have leadership responsibility

That significantly fewer among the 2010 physicians than among the 1992 physicians felt that they had managerial needs of each individual case is not at all mean poorer health, or even less influence over their own work. But the medical profession declining representation in leadership positions resulting loss of opportunity to influence developments in health care. If the change is rooted in the organization become flatter and a large part of management jobs are lost can not be inferred from this study, but an analysis of age structure shows that a large proportion of the 2010 physicians are over 50 years, why the reduction in managerial positions can hardly be due to shortage of experienced candidates.

Causation, reform and influence

Our material consists of cross-sectional data from the two occasions, which means that the direct causal link can not be confirmed. The loss is about 30 percent, but failure analysis show good agreement with the respondents, except that men were slightly less likely to answer the questionnaire. There are differences in response rates between specialties, but with some caution, the study can still be regarded as representative for the Swedish medical profession working in 2010/2011.

Trying to capture what reforms and organizational changes at the macro level this means for the working environment is a complex task that is best solved by a combination of qualitative and quantitative studies. Unfortunately, there is a gap between qualitative social science research that highlights institutional change and new forms of governance at the national level and on the other hand, quantitative studies on the safety of individual and group experiences of change [11]. Bringing these two areas is an important step in further research on the Swedish public sector, especially health care.

An attempt in this direction in an article on notifications [12] based on the same material as the present study. It is shown that structural factors such as reorganizations and senior physician's influence on the activities related to the number of notifications.Preliminary analysis shows that these factors also have impact on support from immediate supervisor. We intend to come back with analysis on this.

Public sector production of goods

Over the past two decades, the wave of change in the public sector has been particularly strong in Scandinavia, Britain, Holland, Australia and New Zealand have been analyzed in hundreds of scientific papers. The scientists who analyze and critique these reforms from the outside using the collection name new public management (NPM). Knowledge of NPM provides a background that puts the changes in working conditions in a broader context.

In short, these changes are based in the public sector on the belief that public services can be rationalized continuously, just as commodity production, and reforms are also marked by deep distrust of professions' demands for autonomy [13]. Changes have often included both savings and new ways to manage and control the professional occupational groups [14-19].

Do we see a profession in free fall?

New public management challenges the professional logic that has been dominant since the birth of modern medical care [20] with a "new logic" which honors the standardization, measurement, control and productivity. Our results point in this direction, not least in terms of things that usually considered typical of professional organizations, such as collegiate leadership, the research and development are integrated into the daily work tasks and a sense of responsibility for the operation. In light of these facts and the current study, we believe that it is justified to ask whether we see a profession in free fall.

*

The study was supported by research grants from the AFA and Vinnova. Swedish Medical Association has contributed both financially and with the knowledge and support from the Working Group. Mats Gautam was a research assistant for data collection, and Joakim Westerlund, Department of Psychology, Stockholm University, have examined the statistics.

 

This comparative study demonstrates the change in physicians’ perception of work environment in 1992 compared to 2010. In both studies a random sample was drawn from the Swedish Medical Association’s membership directory. In the 1992 study, 362 physicians responded (response rate 70 %) whereas 1937 responded to the questionnaire in 2010/2011 (response rate 67 %). The results show that the work environment has become significantly worse over time; this applies to some extent to influence and the demands at work. However, the largest change is found in the diminishing support from the immediate superior. Doctors use less time to comply with the development of knowledge in 2010/2011 compared to 1992 and a large drop in the percentage of physicians with a sense of managerial responsibility was found.

Eva Bejerot, Gunnar Aronsson, Hans Hassel Bladh, Susanne Bejerot

Correspondence: Eva Bejerot, Department of Psychology, Stockholm University, SE-106 91 Stockholm,

Sweden

eva.bejerot @ psychology.su.se