Entering practice : the experiences of junior doctors in two health care systems : an immersion within the experiences of Dutch and French Swiss Junior doctors

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ENTERING

PRACTICE:

THE EXPERIENCES OF JUNIOR DOCTORS

IN TWO HEALTH CARE SYSTEMS

An immersion within the experiences of Dutch and French Swiss Junior doctors

Amsterdam, 2nd_{of July 2015}

Master of Medical anthropology and Sociology Mia Gisselbaek, 10862072, theredbee@gmail.com

Under the supervision of Stuart Blume Second reader: Patrick Brown

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ACKNOWLEDGEMENTS

I wish to express my most sincere and thoughtful thanks to my supervisor and friend, Professor Stuart Blume. He managed to guide me, a junior doctor entering the sociological world thinking in terms of quantitative evidence, through an anthropological and sociological thesis. He wisely opened my eyes into a new type of knowledge and was able to criticize me sensibly. I could not have wished for a more present, reassuring and supportive supervisor.

“Mia: I really don’t know how I will be able to do this, I am not an anthropologist, I never learnt to think that way, neither to write.

Stuart: That’s why I am there. You just have to trust me.”

Moreover, I would like to thank him for the strong friendship I now share with him that I hope we will maintain through the years. I would also like to thank Patrick Brown for asking to be my second reader, as well as all the interest he showed in my topic.

I am really grateful to all of my informants, for their precious time, openness and trust. Indeed, I was able to immerge myself in their experiences as they showed interest in my thesis and took the time to answer my questions. I hope this thesis will render them justice. I would like to thank all the people that encouraged me in this undertaking along the way. My special regards go to Patricia Hudelson, my medical anthropology teacher at the faculty of medicine of Geneva’s university, as well as my long time mentor, Jerome Pugin. Finally, this thesis would not have been possible without the emotional support of my friends and family. I would like to mention here Camilla, Sophie and Arno. Thank you for reassuring me and being there especially in times of doubts and crisis.

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PREFACE

Reflecting on my past experiences as a junior doctor in a Swiss university hospital made me aware of the tensions inherent in the experience of the years of medical practice immediately following graduation. Indeed, as a junior doctor working in a ward you have the particular task to synchronize the care and to be the main referent for your patients. Therefore, you are at the crossroad between multiplicities of actors, the main one being the patient in need of care. However, in hospitals this multiplicity further complicates the already complex doctor-patient relationship: complicated by the patient’s family searching for answers and checking taken initiatives, by the health care workers linked to the case such as nurses, specialists and, last but not least, your superior checking your work. To give an illustrative instance of such statements, I will recount briefly the story of one of my oncology ward patients.

A sixty-year-old patient entered our hospital with breathing difficulties he had never encountered before. After excluding an infection, the option of a potential lung cancer naturally came to our minds. Indeed, the patient was a heavy smoker and had lost about seven pounds during the last few months. Therefore, we decided to investigate this hypothesis with radiology imaging and were struck by our findings. The patient was not only suffering a simple lung cancer, he was actually in a final stage and the cancer was already spreading through his whole body as well as his brain. A biopsy of the masses was still required to be formally diagnosed as a lung cancer. However, the clinical picture was crystal-clear. The brain metastasis location could even explain the lack of motivation reported by the patient these past few months. As it was my first months in what I will call the real doctor world, my superior came with me to announce that difficult diagnosis and to support me. We were just entering the room when the wife of the patient intercepted us and asked for the diagnosis before her husband to support him and his potential reactions. To my astonishment my chief told her the diagnosis without noticing the patient. That was the first of many incidents that obscured my definition of ideal care, as for me the patient is the core centre. The wife reacted by telling us that her husband was in a depressive state, he would take it as a death sentence, and would attempt suicide. She directly asked us to hide the information from the patient. When we entered the room, my chief told the patient that we found masses but never mentioned a cancer and I got the feeling that my patient was not aware of the gravity of his situation. When we found ourselves alone I told my superior I thought it was not right and that we should tell the patient clearly. He forbade me to tell the patient for the sake of his mental sanity. I could not fall asleep that night as I

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felt a mix of frustration, anger and incomprehension. What had happened also discredited the medical ethics that are taught in medical school. Indeed, my patient was not informed properly of what was going on. I was torn between my thoughts and my superior’s order. Moreover, I could not resist projecting the situation on myself: I would like to know as soon as possible if I was going to die a few months later. I am well aware that my subjectivity was then, and will be, influencing my interpretation of the medical cases I will encounter and of my clinical decisions. However, this might be a part of the human competence required to doctor and care. The next morning I went to the hospital and immediately called the oncology specialist to tell her that I had a patient with a cancer that he did not know he had and recounted her the story. She explained everything to the patient and my chief never knew that I was at the origin of this scheme. This is the way I coped with orders which were not right for me, nor in line with how I want to practice medicine. This is one of the many instances of ‘fateful moments’ (Giddens, 1991:113) that lead me to question the hospital hierarchy and the experiences as well as coping mechanisms of young doctors at the beginning of their clinical years.

Based on my own experience and on what I have heard from my colleagues ‘off the record’, it seems to me that junior doctors in the first years of practice experience tensions between their expectations and ideals and the organizational reality encountered in hospital clinical practice.

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CHAPTER 1: INTRODUCTION

W

HO ARE JUNIOR DOCTORS

?

Medical clinical training

Renée Fox (1980) suggests that medical training encompasses a great deal of uncertainty. Indeed, an important part of becoming a doctor involves learning how to deal with the uncertainties encountered in medical practice. Light (1979) sustains that medical socialization is about training for control of such uncertainty. For example, a form of control can be acquired through clinical experience or a focus on mastering techniques. Indeed, learning to work as a clinician is about learning to cope with patients’ uncertainties and concerns by using experiential knowledge. According to Light (1979) it is more difficult for medical students to learn in specialities with weak paradigms (such as psychology) than in surgery where the meanings of a positive outcome are strongly agreed on. Following Light, Atkinson (1984) calls for a rethinking of uncertainties in the light of advances and the rise of Evidence based medicine (EBM)1_{. He advocates that the direct} experiences of the clinical years should allow for a practical knowledge that includes ‘bracketing out’ of uncertainties via certitudes. For him, medical education is about learning how to become pragmatic and certain. He further describes a ‘reductionist model’ practitioners might learn to overcome limits brought by overcrowded medical studies (Atkinson, 1984:952). Nevertheless, “The goal in professional training should be to learn tempered control, that is, sufficient control to overcome the uncertainties of practice so that decisions can be made, but tempered by the continued acknowledgment of those uncertainties and human error.” (Light, 1979:320). Perhaps a great part of becoming a doctor is about ‘dogmatic’ personal knowledge acquired through experience and learnt from superiors. This raises a potential epistemological tension between experiential knowledge and the EBM-based knowledge used in the formulation of clinical guidelines2_.

1_{EBM represents a medical practice guided by the best available knowledge gathered through good}

empirical scientific outcome-research methods. It seeks to improve clinical practice and assure the quality of evidence-based care (Sackett et al., 1996). It embodies an empiricist mode of thinking in medicine in a systematized pattern regarding randomized-controlled trials (RCT) as the pinnacle of a ‘hierarchy of evidence’ that is represented, particularly, in the Cochrane library (Cochrane Library, 2014).

2_{Practice guidelines are "systematically developed statements to assist practitioner and patient}

decisions about appropriate health care for specific clinical circumstances". In other words, practice guidelines focus on assisting patients and practitioners in making decisions (IOM, 1990, p.8)

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Nevertheless, guidelines and hierarchy within hospital can be seen as ways of coping with the unavoidable uncertainties encountered in the practice of medicine. Yet, experienced doctors have been shown to struggle in guidelines application because of their experience and wish for authority (Spyridonidis & Calnan, 2011). From my own experience, medical students today are highly aware of the important place doctoring will have in their personal lives, making them very aware of things that will influence their professional practice. Moreover, medical studies and bioethics nowadays problematize what one ought to do (Fox, 1980:15), and young doctors might struggle with their ideals of good care. The expectations of junior doctors toward medicine, what they consider ‘good care’, their own values, their ideals and their commitments may not fit easily with the rules, guidelines, hierarchy and institutionalized expectations they find in the university hospital.

The ‘hidden curriculum’ is a concept that depicts the informal learning process, which results from exposure to the professional culture. It allows capturing the enculturation process that is going on throughout apprenticeship. From a Bourdieusan perspective, the hidden curriculum could be paralleled to the formation of habitus3_{(Bourdieu, 1972).} Hafferty (1998) described three distinct processes in medical education, focusing on what is learnt rather than what is taught. First, is the formal curriculum that includes every conventional aspect of the medical education and what is said to be taught. Second, is the informal curriculum: “an unscripted, predominantly ad hoc, and highly interpersonal form of teaching and learning that take place among and between faculty and students” (Hafferty, 1998:404), emphasizing the importance of role models in medical education. Third, is the anthropologically relevant hidden curriculum, that encompasses “a set of influences that function at the level of organizational structure and culture” (Hafferty, 1998:404). Lempp et al. (2004) define the hidden curriculum as “the set of influences that function at the level of organizational structure and culture including, for example, implicit rules to survive the institution such as customs, rituals, and taken for granted aspects” (Lempp et al., 2004:770). Multiple processes have been described as inherent parts of this curriculum and they include a loss of idealism, an acceptance of hierarchy and the formation of a professional identity. Formal and informal curricula differ between countries. For instance, in the UK, learning about hierarchy is said to rely on humiliation and critique of doctors-to-be (Lempp, 2004). This process might extend through the first

3_{Habitus: A system of “dispositions durables, structures structurées prédisposées à fonctionner comme}

structures structurantes, c’est à dire en tant que principe de génération et de structuration de pratiques et de représentations qui peuvent être objectivement réglées et régulières (...) collectivement orchestrée sans être le produit de l’action organisatrice d’un chef d’orchestre.“ (Bourdieu, 1972 : 256).

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clinical years if the hierarchy has not yet been accepted or if the habitus is not perfectly fitting (Bourdieu, 1972). Moreover, students in the UK reported a competitive rather than cooperative atmosphere (Lempp et al., 2004). Lately, medical education has been re-focused on the importance of internships and students are spending more time learning within clinical wards. This might have increased the importance of the hidden curriculum and of interpersonal relationships. This informal learning process continues to affect junior doctors as their teaching is based on in-ward learning.

Medical education in Francophone Switzerland

Enrolment in the first year of the bachelor’s degree is open to every student in possession of a maturity diploma (having successfully graduated high-school). This year is particular in two ways. First, the ex-cathedra lectures are given in overcrowded rooms. Second, selection (un-told numerus clausus) takes place at the end of the first year, based on theoretical knowledge tested in an 8-hour long multiple question examination. These two particular facts lead to a feeling of insecurity and competition in the first year of medicine that potentially marks the student for the rest of her or his education and medical career. During three more years, the student (with the particularity of Geneva’s university hospital) undergoes several thematic study blocs that are designed as problem-based learning in small students groups. Those thematic blocs are enriched by clinical events that prepare the student for the last years of clinical internships. A noticeable part of the studies are dedicated to social science based disciplines and ethics, and are designed to develop interpersonal competence. Moreover, the doctors-to-be are sensitized to evidence-based medicine and opportunities for research experience are regularly presented to them. During the Master years, the first two years are dedicated to mandatory internships and rotations and the last year is composed of 10 months of internships in the specialty of choice (Etudes de médecine, 2015). The future career informally depends on performance during those internships in the chosen specialty. Supposedly the interns or junior doctors are chosen on their CVs but in reality selection depends more on performance during the interview and the rapport one had previously with its interviewer. To recount a personal example, my interview was highly informal and was more of a relaxed conversation than about my CV, as they already knew me. The FMH (specialist diploma) is delivered after the necessary years in the different wards have been completed as junior doctor and the exam is passed. Thus once through the competition and stress of the first years, doctors-to-be are formatted to doctors-to-be competitors, and their habitus (Bourdieu, 1972) adjusts to the hierarchical competitive medical culture they will be immersed in. Moreover, the prioritization of internships in the specialization of their choice can be seen as an

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immersion in the hidden curriculum and a necessary enculturation in the characteristics of the specialty. In Switzerland, doctors are welcome to make their own decisions regarding their career paths as residents. The specializations are not framed by strict curriculum and flexibility is available. Junior doctors usually perform for one to two years in secondary hospitals before beginning their academic specialist training. PhD’s are not required and the position is mainly assured through personal connections and performance during the last year of internships as a student.

Medical education in the Netherlands

In the Netherlands, all medical schools have a similar study plan synchronized at a national level by the KNMG (Royal Dutch Medical Association). The numerus clausus is applied during the selection process for the first year of medicine, which means that places are already secured if the student doesn’t fail his exams. After high school the students have access to two different selection processes. They can apply through the central lottery (with a maximum of three attempts), which access ¾ of the places, though good high school grades improves the chances that one is picked. The remaining quarter are attributed through decentralized process by applying directly to a particular university (UvA medicine website). The latter is based on grades, motivation, CVs and the result of a multiple choice question examination. The learning process is then thematically based as in Geneva’s university hospital during the Bachelors’ years. The Master program is quite similar to the Swiss one, though there are more opportunities to broaden the knowledge via research or parallel disciplines. Indeed, the students have 6 month (or more) dedicated to the master thesis in the discipline of their choice. There too, the last year is highly relevant for securing a future place in a specialization. However, the doctors are strongly advised to complete a PhD if they wish to enter a competitive specialisation (a strict number of places are allowed to each specialisation each year), which results in a delayed entrance in practice and additional experience. Most commonly, the interns have to go through two years clinical experiences as ANIOS (Arts niet in opleiding tot specialist) before entering the specialty of their choice and becoming AIOS (Arts in opleiding tot specialist). Moreover, they will sometimes have completed a PhD in the discipline of their choice, so entering the specialization after several years of work. Junior doctors in the Netherlands are thus highly sensitized to research and evidence-based practice and the performance in theoretical studies is not a pressure at the bachelor level.

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Junior doctors’ role

Entering practice, the junior doctors have gone through six overcrowded years of competition and fast learning (Atkinson, 1984). They enter a post-graduate training process and must choose a specialization. This choice can depend on both intrinsic attributes, such as opportunities for procedural or intellectual work and continuity of care, or on quality of life (salary and schedule). The final choice often results from a long decision process weighing, analysing and mixing every variable (Sivey et al., 2011). A study conducted in Germany showed that role model identification was correlated with a positive emotional development and that role models might be easier to access by men since academic doctors are mostly masculine figures (Ochsmann, 2012). Women, lacking mentorship, were more inclined to judge themselves negatively. The strongest predicator (gender-independent) for considering leaving the profession was shown to be an experience of lack of support (Ochsmann, 2012). For the choice of specialization, the junior doctor might naturally choose the specialization he or she most positively experienced during his internship as a student. This positive experience might be linked to the one where his habitus is fitting the best or to the felt support and identification of role model. Studies have shown the transition from medical universities to practice is particularly difficult, involving learning to deal with new responsibilities and to work and perform in a stressful and hierarchical culture (Teunissen & Westerman, 2011). This process might be more than many individuals can cope with, since as many as 25% of junior doctors appear to fit the diagnosis of burnout (Teunissen & Westerman, 2011).

The junior doctor, in specialization or not, has the job of coordinating or synchronizing the care of patients and works under the supervision of a resident or senior doctor (superior) who checks his or her work. He or she should respect the latters orders and the constraints imposed by the institutional setting. He is not yet considered able to work independently, is still in a learning process, and must gain experience and the trust of his (often changing) superiors and other professionals. He is at the crossroads: between different consultants, his superior’s wishes, and the nursing team that care daily for the patient. He is a member of multiple inter-professional teams and needs to translate it into a consistent care.

“(...) Sometimes you’re at the crossroad between the consultant and superiors that decide and the nurses that have to apply and you need to justify every behaviour from one

to the other one. That’s not easy!” {Emilie, Swiss junior doctor}

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divergent discourses (Weller et al., 2011). In these situations it is often hard for new doctors to gain the trust of older nurses or other professionals. Indeed, trust is highly interpersonal and depends on experience and prejudices.

“I think toward the nurses it’s hard to get to the point where they see you as a real doctor” {Isa, Dutch junior doctor}

For Junior doctors deeply immersed in medical culture during their last years as medical students, competence, competiveness and invulnerability might be deeply rooted principles (Fox et al., 2011). Strong medical hierarchy is considered as a barrier in seeking for help. Indeed, a fear to be blamed and to not achieve to meet up with superiors’ expectations can inhibit them from seeking needed help. To add to these perceived expectations, junior doctors apparently delay turning to superiors for advice because of wanting to fit their own standards of what being a doctor means (Tallentire, 2011).

H

EALTH CARE ORGANIZATION

Health care organization varies greatly from country to country as policies are issued at a national level. It seems that the hospital cultures also differ, both within countries (Kuhlmann & Burau, 2008) and over time. Medicine has been taken from its high pedestal: reflecting the general decline in the status, and previously unquestioned authority, of the professions (Freidson, 1973). Indeed, the hero-status and autonomy doctors once had are daily challenged by managers promoting health care efficiency. Moreover, an increase in public scrutiny over healthcare has led to new forms of control that are aiming to increase accountability and safety (Kuhlmann & Burau, 2008). Those forms of control are expressed at the local level of practice in for example clinical guidelines. Some countries are further than others in this managerial revolution, which demystifies doctors’ status and might affect the will to compete as well as the medical hierarchy. State and public scrutiny in health care has increased and monitoring systems have multiplied. Learning in a master-apprentice relationship is increasingly replaced by ruled guidelines and protocols in junior doctors’ education. Interestingly, when I inquired about his direct thoughts towards hierarchy, Peter, a Dutch surgeon in his fifth year of practical training after completing a PhD, told me that a certain level of hierarchy was needed but that it should always include a two-way communication. He stated that he would not do something he doesn’t agree with. Yet, this never happened to him. Peter also described how medicine changed lately. He exemplified it with the evolution of the master-trainee relationship. Formerly, the trainee would shadow his master and never

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question anything. He would just replicate the conduct of his master until he could fly on his own.

“It used to be a lot like you have a master and a trainee and basically you learn everything that the mentor does... but now (...) if I don’t agree with something we always

discuss it” {Peter, Dutch junior doctor}

As concluded by Kilminster et al. (2011) while comparing hospitals within the UK, “practice, performance and learning are so interlinked that they are inseparable and dependent on the specific setting” (Kilminster et al., 2011:1014). Mattick et al. (2014) interviewing junior doctors’ in the UK about their antimicrobial prescribing experiences, found out that a feeling of pressure was associated with health-care culture, including Hafferty’s ‘hidden curriculum’ (Hafferty, 1998:404)) and out-of-hour working. They also reported mostly negative comments about hierarchy that were linked to poor inter-professional relationships. Moreover doctors in strong hierarchical systems felt themselves left out of a team. Feedback and supervision were valued but were often variable or lacking. A three level teaching was applicable to those young doctors: the formal curriculum, the informal ward-based curriculum and the hidden curriculum which can be seen as fitting the young doctor into the health care culture (Mattick et al., 2014). I turn now to two different organizational systems and culture represented by Swiss and Dutch health-care systems.

In Switzerland (a federation) health care is managed at two different levels: the national and cantonal levels. At the national level big broad policies are issued. However, the cantonal one matters much. For instance, paediatric guidelines are issued both from Geneva’s university hospital and Lausanne’s, though the two cities are only sixty kilometres apart. The two hospitals are competing for their recognition and prestige and neither of them wants to let go of its power. This problematic is reflected in small hospitals, which are very independent from government’s scrutiny. Moreover, a silent war of power is going on between different linguistic regions of Switzerland, which leads to a deep breach between cultures. Nowadays, efforts are being made to reconcile health care and ensure a national continuity but they meet resistance. Hierarchy is still strong and professional claims powerful. In contrast, one of the particularities of the Dutch institutional context is the strong role of government in terms of policies and guidelines (Lugtenberg et al., 2009). Indeed, to limit health cost expansion, the Dutch government (for the sake of the ethical principle of ‘justice’), is going through strong reforms to limit consumer choice. In 2006, the insurance reform led to a need for health care providers to

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document the quality of care and to link it to evidence-based baseline and performance indicators (Knottnerus & ten Velden, 2007). Considering the differences between the two systems my hypothesis is that the practical experience of junior doctors starting to work in Swiss French and Dutch hospitals after graduation will differ.

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CHAPTER 2: METHODOLOGY AND THEORY

M

ETHODOLOGY

After constructing a draft of the questions I proposed to ask I carried out a pilot interview with one of my colleagues in Switzerland. I was struck by the similarity between our experiences of the first months of practice, even though she had worked in a surgical ward and I had worked in a medical one. Then, I began to search for junior doctors in the Netherlands who were willing to be interviewed, mostly through old acquaintances and social networks such as Facebook. It was more difficult than I expected to gather enough volunteers. Especially in their first months of practice doctors have busy schedules and would rather spend their few free hours a day enjoying social life than answering questions about their work. However with a bit of flexibility, persuasion and perseverance I managed to succeed. I interviewed seven doctors in total, six of whom were working in secondary hospitals of the approximate same size within the Netherlands4_{. The interviews} were all recorded and took place in cafes, bars and homes, as well as on Skype. They lasted between 30 and 80 minutes and were held in English.

At first the interviews were stressful for me and I could not really let the questions flow naturally. I was too attached to my question framework and was constantly afraid to forget one of the relevant topics. With practice, I adapted to interviews better and remained more open to the inputs of the interviewees and included my previous analysis as a basis for further interviews. As my data extended and the analysis advanced, I was able to perfect my interview framework. My expectation was that they would tell about the difficulties they had encountered during the first months in practice as a result of constraints imposed by superiors or of clinical guidelines.

However, I was struck by the lack of constraints they seemed to have experienced, and the similarity between their experiences, even though they worked in different hospitals and specialities. It seemed very different from my own experiences. Indeed, almost no one encountered difficult situations with superiors, whilst guidelines were almost never experienced as constraining. To the contrary, guidelines were more experienced as a useful resource and all agreed that medicine needs a kind of evidence base. They felt supported by open superiors wanting to teach them. This made me question the particularity of my

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own experiences, whilst recollecting that I’d heard similar experiences to mine discussed ‘off the record’ in Switzerland. It led me to refine my primary hypothesis; experience or not of tensions in the first year of practice might depend on hospital organization and culture. For instance, I know that there is a strong feeling of belonging in the Netherlands that is not to be found in a federation such as Switzerland where every Canton has its own guidelines and competes with its neighbours. This is why I decided to interview Swiss doctors as well with the aim to compare countries with a different health care organisation. I recorded 4 interviews with Swiss doctors on Skype that lasted from 30 to 60 minutes. The languages used were both French and English and all of these doctors were working in secondary hospitals similar in size to the Dutch ones.

In total between February and April 2015 I interviewed 7 Dutch junior doctors within 1 month to 5 years of practice and 4 Swiss junior doctors within 1 month to 1 year of practice (see characteristics in annexe). The interviews covered background, experiences prior to medical studies, the experience of medical studies, career choices, ambitions, difficult experiences encountered during practice as a junior doctor, hurdles, difficulties in relationships with other health-care workers, conflicts with direct hierarchy and practical meaning of guidelines. I also aimed to understand the coping strategies they use to deal with the hurdles they encounter.

S

UBJECTIVITY

My perspective and own experience place me as an insider when I interview young doctors. This particularity of my research helps me understand the complexity of the experiences reported by my interviewees. The benefits of this particularity of my experience that helps me understand junior doctor’s stories overcome the possible disadvantages in terms of bias, as I try to remain fully aware of my own subjectivity. However my thesis first aimed to investigate the experience of Dutch junior doctors and I have never practiced medicine in the Netherlands. Nevertheless, I had already been living in this country as I studied at the LUMC in Leiden during my bachelor of medicine. The organisation of health care differs between the countries and, as a result, so do the practices and experiences. I am also aware that my own experience shapes my understanding of the data and the way I ask questions and conduct interviews with other junior doctors. For this particular reason I remained silent about the core questions of my research before interviewing them and tried to remain as open as possible to their insights.

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Doctors have been trained to conduct interviews with patient and to get essential information by asking directed question within a defined timeline. As I interviewed them, they asked themselves for directed questions and immediately discarded my open questions by asking me for precisions; “But what is really your question?”, “What do you

want to know?”, “Can you be more precise?”. Moreover, having undergone the same

studies, I am also trained to ask sharp and direct questions and to lead an interview. This was something I had to bear in mind whilst interviewing in a more anthropological way.

R

EFLECTIONS AND LIMITATIONS

Direct situational observation was not possible. The stories I collected were thus inherently subjective and linked to individual`s understanding of his or her experiences. Following Berger and Luckmann (1989), I think that the interpretation people make of their experience allows to enter their reality and the meaning they give to it. I was mostly aiming to hear about difficulties, thus my question framework was mostly designed to investigate these and not the happy-good-times of practice. Thus a bias is inherent and it should not be forgotten. Indeed, young interns have bad times, but they also do experience good times not reported to me. Moreover, I am seen as a stranger in Dutch doctors’ eyes. This particular fact might have biased the experiences they were willing to share. Out of speculation, it might be easier to present an image of open teamwork than to share the bad sides of practice that one might want to hide. Along these lines, Anna, the only non-Dutch interviewee working within a Dutch hospital reported to me that:

“Dutch people always have those like... this image of being very open and tolerant but once you live here I think it’s a lot different story doors are not open for you.” {Anna}

My position as a doctor as well as a researcher likely led my respondents to trust me, and also influenced my understanding of the data. It was particularly helpful to share my own experience to bring more depth to my interviews. Sharing my experiences enhanced the trust they felt towards me. Yet, it also framed the interviews. No new friendships developed on the basis of my interviews, and the old ones remained unchanged. Finally, I hope my interviews helped them to discharge a bit of their accumulated frustrations and to increase reflexivity on their practice. Anonymity has been assured to all participants, names have been changed, exact places are not mentioned and I offered to let interviewees read the final thesis. No ethical clearance is required in this study. I would also like to mention that due to time-constraints, the small number of participant did not allow me to look at possible variation between (for example) specialities or genders.

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T

HEORY

In order to understand the experiences of junior doctors, the theoretical perspective I use revolves around Bourdieu’s concept of habitus. To enable labelling of the coping strategies junior doctors use when faced with structural constraints I read my data in light of Hirschman’s (1970) ‘Voice’, ‘Exit’ and ‘Loyalty’ framework. Finally, by comparing two different settings that are the Netherlands and Switzerland I have the purpose of linking the practical experiences to the differing institutional cultures.

A Bourdieusian perspective on doctors’ experiences

First, I aim to understand the junior doctors’ accounts of their experiences from a Bourdieusan perspective (Bourdieu, 1972). Junior doctors enter practice with values and ideas of good medicine, and career expectations, which are likely to depend on their social backgrounds and the experiences they have encountered during their previous education. I want to understand how new doctors become aware of the hierarchy in their practice and how they experience the unavoidable interactions with their direct superiors. I use the concept of habitus in terms of dispositions that orient their choices and position in the field that is the institution as well as the coping strategies they choose. Hence for understanding how they negotiate their entrance in their new roles. Luke (2003) insightfully analysed the accounts of junior doctors linked to the unconscious and structuring habitus developed through codes of conducts issued from the institutional setting, highlighting the weight of the medical culture in constructing the professional. Indeed, junior doctors likely reproduce the values and norms of the institutional setting they enter. The habitus is according to Bourdieu’s original work: A system of “dispositions durables, structures structurées prédisposées à fonctionner comme structures structurantes, c’est à dire en tant que principe de génération et de structuration de pratiques et de représentations qui peuvent être objectivement réglées et régulières (...) collectivement orchestrée sans être le produit de l’action organisatrice d’un chef d’orchestre.” (Bourdieu, 1972:256).

Therefore, the habitus allows for particular ways of acting and negotiating interactions within the social structure of practice. It also accounts for understanding how medical profession is reproducing particular conducts in junior doctors through, notably, the ‘informal’ and ‘hidden curriculum’ (Hafferty, 1998).

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Coping strategies framework

Second, I would like to look at the ways in which junior doctors negotiate and cope with the reality of clinical practice. This reality encompasses potentially conflicting orders from their superiors that constrain the autonomy and practice of young doctors. Hirschman’s framework helps classify the coping strategies they use. It allows understanding how they negotiate the constraints when faced with situations of discordance. The coping mechanisms in Hirschman’s framework are named: ‘Exit’, ‘Voice’ and ‘Loyalty’ (Hirschman, 1970). It allows describing different kinds of coping strategies in regard to disagreements and doubts about a situation. Some junior doctors might choose to ‘Voice’ their concerns: if so, how will they show them? In the Netherlands, for instance, will they rely directly on their superiors? Some might choose ‘Exit’ strategies (physically or metaphorically) and detach themselves from the clinical practice. Finally, ‘Loyalty’ refers to accepting what the institution recommends without making a stand.This framework has been used in an insightful study of nursing students’ compliance. Indeed, the authors study how students are gradually empowered in clinical practice and the strategies adopted in conflicting clinical cases (Bradbury-Jones et al., 2011). Moreover, I will link this framework to the concept of habitus as a way to understand what lead them to engage a particular coping strategy based on the characteristics issued from the country (Bourdieu, 1972).

Institutional hierarchies structuring practice

I want to understand the institutional settings’ role in shaping experience of hierarchy and guidelines. Cost-containments and structure of health care as well as the traditions and practices of the profession depend on the country (though even within a country the organization of medical care might differ between hospitals). Comparing the Netherlands and French-speaking Switzerland will allow me to explore how junior doctors’ different habitus experience hierarchy and guidelines in these different settings.

P

RIMARY RESEARCH QUESTIONS

In the particular context of European biomedicine, where strong hierarchies might still exist and where health-care reforms have led to an increase in regulatory practices such as guidelines (Armstrong, 2002, Berg, 1997), my hypothesis is that Junior doctors experience tensions between their expectations and ideals, and the organizational reality (linked to working environment and culture) they encounter in their first years of practice. Specifically the questions to be addressed here are:

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• Do junior doctors experience uncertainties and conflicting expectations during their

first years of clinical practice, whilst gaining insights into their responsibilities as professional, and if so how?

• What coping strategies are available to them?

• How does hospital organizational culture influence the way a junior doctor

experiences the potentially conflicting situations of his or her practice, as well as the coping strategies he or she chooses?

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CHAPTER 3: ORGANIZATION, HIERARCHY

I

NTRODUCTION

To understand the concept of hierarchy within medicine it is important to look back into medical sociology’s history. According to Freidson’s (1973) definition of the formal characteristic of a profession, a form of occupation – “a group of people who perform a set of activities which provide them with the major source of their subsistence” (Freidson, 1973:71) – medicine can be seen as an epitome. Specifically, a profession has achieved deliberately granted autonomy with the right to determine admission to the profession, the knowledge required of the practitioner and how the work is to be done (ibid). To be able to maintain its’ professional status, medicine has to make sure that the latter principle is respected. Hierarchy can be understood as the way to sustain the order within the profession and to ensure that new professionals are maintaining principles. Until quite recently, the Hippocratic Oath was rehearsed during the graduation ceremony of medical students. The oath stipulates “To hold him who has taught me this art as equal to my parents and to live my life in partnership with him (...) To give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.” (Antoniou et al., 2010:3076). This gives a particular kind of order and hierarchy of knowledge to medical training as young doctors must learn their art from old ones, as well as respect them. The sermon also highlights the never-ending acquisition of knowledge that has to be done by doctors, as young doctors mature and have to take new ones under their wings. Finally, it requires respect for masters from apprentices as their knowledge acquisition highly depends on what the former want to teach. In sum, hierarchy can be seen as a way to self-regulate the profession and ensure that professionals are correctly formed before being granted the right to practice independently.

Hierarchy reflects, or at least should reflect, the amount of clinical experience, that results from dealing with patient and disease. The clinical experience can be contrasted with the scientific expertise linked to quantitative test results. Together the ‘art’ and ‘science’ regarding a patient’s case shape the decisions a doctor makes. Medical hierarchy can also be seen as a classification of levels of responsibilities (Becker, 1976). Hence, hospital hierarchies should represent levels both of responsibility and of knowledge. The rigidity of the hierarchy and the profession suffers nowadays from external constraints on the content of the clinical work. Health care managers impose economic and

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organizational constraints ‘in the public interest’: professional autonomy cannot be complete, certainly not when third parties (state, insurance companies) have to meet the costs of care. In his end-call, Freidson (1973) concedes that to minimize the rigidity of the profession, by “recruitment from all population, other perspectives also represented will improve profession’s integrity and adjust its mission to the needs of society” (ibid:376). Hierarchy defines the teaching system within hospitals and junior doctors are learning mainly from practicing medicine and embodying senior doctors conduct. The years that have to be spent in hospital allow junior doctors to learn theoretically and technically to care for their patients. However, the ‘hidden curriculum’ (Hafferty, 1998) is a way to ensure that new professionals have embodied the principles and distinctions of the hierarchy. Five years are generally completed to function as an independent doctor, this allows time for the hidden curriculum to mould junior doctors’ habitus (Bourdieu, 1972) to the particular requirements of their newly found status.

While studying the organizational cultures that promote patient safety in the US, Singer et al. (2009) described different types of organizational cultures present on different levels in hospitals. Two types are relevant in regard to this study: a ‘hierarchical culture’ that aims to achieve predictable operations via strong structure and rules with a reward system according to rank; and a ‘group culture’ that values cohesion, mentorship, participation and teamwork. The former can be beneficial but can decrease expertise, as some actors are no longer directly in contact with patient. Junior doctors are lacking experiential knowledge and are often afraid to speak up when they encounter issues of safety (Singer, 2009). Hence it can give rise to an unsafe climate in health care through fear of shame or blame. The group culture seemed more easily experienced by all the actors and strongly linked to a safety climate (ibid). The importance of these two cultures will likely differ between French-speaking Switzerland and the Netherlands.

E

MPIRICAL FINDINGS

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S

WITZERLAND

My French Swiss informants reported multiple sources of stress in their daily experiences, the main ones being uncertainties that can refer to the clinical and theoretical knowledge. They can also stem from the lack of confidence towards their own skills and their knowledge applied to concrete medical cases. Young doctors leaving medical schools prioritize patients’ safety and feel lost when presented with uncertainties that they judge as risky and cannot overcome alone. Junior doctors’ uncertainties as well as lack of clinical experience are justifications for the existence of hierarchy. When this kind of formal

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support is lacking junior doctors find the experience of responsibilities particularly difficult.

Having superiors to turn to is reassuring. My interviewees acknowledged the fact that having a superior to turn to during day shifts was relieving and they labelled the relationship as ‘generally good’. Yet, ‘good’ has to be understood in the context of their daily normality, a concept that I will explain later on. My interviewees seemed to fear having to carry the full responsibility for patients and liked the feeling of being supervised. They felt that having someone to share the responsibility with was:

“(...) The good thing about it (their jobs)” {Clara}

For instance, acute experience in the emergency ward could be experienced favourably when feedback was given, as it seems to allow for reduced stresses and lessened the guilt some doctors seemed to feel. Hence this voicing opportunity is particularly influential on the lives of young doctors:

“At the beginning you feel like you’ve done everything wrong and you were not good enough and after you notice that you could not have done it better with your knowledge. When my superior asked me how I was the next morning, I asked him to talk about what

happened” {Emilie}

Nevertheless, superiors are not always available. Lack of support, development of a blame and shame culture and lack of teaching could be identified. Generally, junior doctors reported that support was often lacking:

“I think it’s rather good until now (...) but I did not feel supported in my beginnings as a junior doctor. They never asked how I was or proposed help spontaneously with things I had never done (...) if you don’t ask for help you don’t get it.... and perhaps it’s normal but

at the same time I would really have liked them to support me without having to call them...” {Emilie}

At night, superiors seem to be particularly absent; hence nights are stressful because of the lack of supervision, support and the weight of responsibilities doctors have to bear. Indeed, Swiss doctors felt abandoned at night by their on-call supervisor that they did not feel free to wake up:

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“(...) You have to make a lot of decisions on your own and you can’t be calling your chief all night long to ask him single questions and the responsibility of the decision to

make is very hard.” {Clara}

This lack of support is particularly well highlighted by the experience of Clara, a surgeon in training. During a night shift she was screamed at and felt particularly lonely, which feeds on the fear of blame interns seem to experience:

“So I spent 3 hours trying with it not working, hesitating to call my boss, to call him, thinking about it, going back to see the patient, and finally I decided to call him and it was

one of the senior chiefs who was on call that night and he basically spent 15 minutes screaming at me on the phone because I had woken him at 3 am for a catheter and then he

said... he... so he yelled at me because he thought it was inadmissible that I was calling him and then he just said okay just ‘démerde toi’5_{(...) and I was all alone I really didn’t}

know what to do so I just... I tried...” {Clara}

Still, Clara carried out what was asked from her. She mentioned that it was particularly hard to cope with her feelings of devaluation and shame, which were emphasized by her perfectionism. This situation added to Clara’s anxieties and scared her off from calling. It was also emotionally notably hard because she was still uncertain of how to handle the case. Moreover, she had no alternative support in this situation. This kind of experience can be particularly harmful as there is no place for apprenticeship in such a relation. The lack of support seems to lead Swiss French junior doctors to take responsibilities that they should perhaps not take. Indeed, the hierarchy within hospitals is aimed at preventing inexperienced doctors’ errors but the relationship can affect the safety environment:

“I’m not sure, sometimes you have no idea, and you just have to try (...) I am a danger, I have 3 days of experience. I feel it’s insane to do that and don’t think we should do that.”

{Clara}

This kind of experience is not in line with her ideals of good care or the practice she has been taught at medical school. Emilie, similarly reported feeling abandoned and having to take “crazy” responsibilities especially at night: responsibilities that she did not feel up to.

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Stresses can ensue from the working environment doctors are embedded in. My interviewees reported a fear of shame and blame stemming from their encounters with superiors. The shame feeling did not always come from direct experiences but probably from the conduct they embodied during their student’s internships. As a student, you can sometimes see junior doctors being blamed for not knowing facts or procedures. The resented shame could sometimes stop them seeking help from their direct superiors:

“When you’re not sure about a clinical fact and you find it silly to ask them {superiors} you can ask older junior doctors and if they tell you it’s weird you then feel less ashamed

of calling them.” {Emilie}

Public blaming has also been experienced by some of my informants. This negative feedback reinforced their lack of confidence and their scared conduct. For instance, after a nightshift, Joëlle felt tricked by her on-call superior whom she had awakened during the night:

“It disgusted me, I felt let down, unrecognized, she humiliated me in front of everybody. I had the impression she told me I was lazy.” {Joëlle}

Yet, Joëlle never voiced her feelings, and did not claim her right to dignity.

Two of my Swiss informants also experienced conflicting situations when they were asked by their superiors to hide information from their patients. This tore apart their principles of good practice as learned in medical school: a patient should always be informed.

Though the hierarchy remains, individuals change. Changing supervisors with different habits add to the stresses experienced by my informants, as they sometimes have to justify the choice of a patients’ treatment to a new superior that would have chosen another one. Hence they get the feeling of being scapegoats:

“And one chief tells you to do something and you do it and then another chief tells you ‘why did you do such a stupid thing’... yeah but I mean he told me to.” {Clara}

The lack of continuity between the orders of different superiors highlights the underlying issues of power and competitiveness between the older doctors that rub off on junior doctors who do not necessarily understand why they are doing what they are doing. Junior doctors encounter the problematic of the discontinuity of care, while they have to assure continuity and synchronized care for their patients:

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“Sometimes they {superiors} give you a lot of orders. Suddenly during a ward round they ask you a lot of complementary exams without justifying in front of the parents and sometimes you’re not necessarily okay with it and then you have to justify it in front of the people.. (...) When I don’t get it and I have to justify.... I kind of sew on it... you can always

say it’s better for the security and that you don’t want to miss an infection. Even if I am not convinced of what I am saying” {Emilie}

My interviewees generally coped with the conflicts encountered by staying ‘Loyal’ (Hirschman, 1970) to their superiors. I was able to label and classify different loyal conducts. Clara stayed ‘Loyal’ to her superior even tough required tasks were not conforming to her ideals of good care. She coped with the stresses stemming from her work by voicing and discussing the difficult situations with her relatives and colleagues, such as nurses, that she looks up to. Having their approval on her side of the story, in this case, relieved her. Seeking approval is a conduct reproduced by most of my informants. Still, even though junior doctors feel a lack of support, they never voice it to their superiors mostly due to their lack of confidence and the fact that they think that their feelings are normal. Even though junior doctors do not necessarily understand why they are completing tasks they still do. This loyalty is maintained even when junior doctors ideals’ are not in line. Junior doctors encounter the problematic of the discontinuity of care, while they have to assure continuity and synchronized care for their patients. Emilie, for instance, also stayed ‘Loyal’ to her superiors’ expectations. However she transferred her needs and built her own safety net by asking more experienced junior doctors for help:

“I felt supported when I asked for but never spontaneously.... more from my colleagues a bit more advanced than from my superiors...”{Emilie}

Another coping mechanism I noted in my informants is hope, as they hoped for a better future and convinced themselves that the difficulties were only temporary. Hope is highlighted by the quote of Chloé, an internist:

“Since I began to work I noticed that I do love my job but that it doesn’t allow me to be happy on its own (...) At the moment it parasitize my private life but I accept it only

because it’s temporary.” {Chloé}

Nevertheless, unsuccessful attempts to voice seemed to appear in the comportment of young doctors that experienced opportunities to communicate. However, it often ended in disappointment, as the voices of junior doctors were not heard:

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“I try to tell them but after one attempt, if they still want their suggestion to be completed I let it go. You don’t discuss what the chief wants. But I don’t have the

impression that they give orders” {Chloé}

Another phenomenon Chloé highlights is the reframing of orders as suggestions. This allows for a feeling of freedom and agency, while working under a strong structure. People are more willing to complete tasks if they feel empowered. Still, the fact that junior doctors should not discuss orders or chiefs’ opinion is particularly undermining for junior doctors’ agency. Hence Chloé copes with her difficulties, such as doing complementary exams for patients without any justification or explanation from the superior, by staying ‘Loyal’. Yet, she coped by telling herself that there’s always two way around a case thus allowing the supervisor some credit, a particular kind of empathy:

“(...) Then there’s also a need to accept that others might see the case otherwise and that sometimes you have the feeling that it’s for the wrong reasons but that those reasons are perhaps not known by us {junior doctors} yet. Perhaps we don’t understand yet. I am

not in their position after all.” {Chloé}

My interviewees seemed to have embodied the kind of conduct that is expected of them, their habitus fitting to the required work. This leads them to normalize the difficulties encountered, allowing them to cope. Indeed, they reported that it is normal for them to shut down, as they are not supposed to be the ones deciding. This embodiment of conducts can be seen as a part of the ‘hidden curriculum’, the deeply enrooted culture playing out loud:

“At the same time you’re not the chief, you don’t decide (...) yeah... it’s your role as a junior doctor.” {Emilie}

“ (...) When your chief gives you an order you’re not really allowed to say no even if you have a different opinion, the hierarchy is really (...)“ {Clara}

Even though they seemingly stayed ‘Loyal’, junior doctors found it harder to respect superiors whose conduct was not in line with their ideals. This lead to a fracture in the training relationship, as they lost respect in hierarchy, so no longer had a trusted mentor. Moreover, staying ‘Loyal’ to their superiors and understanding their experiences as normal allowed junior doctors to maintain continuity. Adapting to expectations of the hospital structure with its inherent hierarchy is easier than exiting, as an exit of any kind could terminate their careers.

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However, a particular form of ‘Exit’ (Hirschman, 1970) was also identifiable in the experiences of junior doctors. Exiting can mean physically leaving medicine or changing specialisation but it can also be emotional or metaphorical. For instance, Joëlle and Emilie coped with conflicts with ideals of good care by re-assessing their personal priorities. Indeed, by giving more space to their personal life, disappointment stemming from work experiences could be reduced. This way of coping with the difficulties allows them to stay ‘Loyal’ while emotionally (and metaphorically) exiting. Finally, they also re-assessed career goals in order to ‘Exit’ sooner the hierarchy of hospitals:

“I am no more willing to sacrifice my whole life for my career. I want to blossom on the side” {Joëlle}

“Since I began to work, I noticed that I love my job and that it is an important part of my life but that it’s not sufficient for my happiness... so that I am less willing to sacrifice

everything for it.”{Emilie}

Junior doctors in Swiss French hospitals seem aware of the hierarchical structure of their daily practice. They feel that the constraints are not wisely used around them. However, despite forms of resistance that can be observed they lack the strong voice that collective resistance could bring them. Indeed, Swiss doctors were mostly cynical when I asked them about their roles. They felt that to endorse the role was difficult but necessary. Moreover, all of the Swiss doctors, sometimes jokingly, reported that they thought about leaving their jobs all the time.

Finally, Joëlle gave me an insightful critique of hierarchy. She reported a lack of clarity and transparency in the orders junior doctors receive. Indeed, stresses are added when she resents having to do what she’s told even when there’s no explanation:

“It lacks transparency, it’s a bit like the chief are doing things between them and then they tell us what we have to do but it’s not egalitarian and it’s very formal. They have this

“Us we know” side (...) and they tell us we never do nothing” {Joëlle}

The feeling of conspiracy evoked anxiety and exhaustion in Joëlle. She even reported suffering from anxiety crisis during difficult times. Some of my informants felt left apart from the cases, which sometimes led them to complete tasks that they did not really understand. The lack of egalitarianism Joëlle refers to contrasts greatly to the Netherlands, which I will now introduce.

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E

MPIRICAL FINDINGS

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N

ETHERLANDS

During my interviews, Dutch junior doctors spontaneously mentioned the great support they received from their superiors when I inquired about their positions. They confirmed this feeling when I questioned about the relationships they hold with their superiors, which were described as informal and open. My Dutch informants did not genuinely suffer from hierarchy, and authority issues were not mentioned. Indeed, they never felt forced to complete tasks, as they were often included in the decision process regarding patients’ care. They got the feeling of being valued and having freedom of choice. Dutch junior doctors felt that the ultimate responsibility of their superior was relieving, which led them to easily complete required tasks. Working climate is important in shaping experiences and if one feels safe and empowered in a team culture, one might be more inclined to complete asked procedures.

My Dutch informants described the workload and the business of the emergency room (including acute cases) as the two big daily stressors they encountered. They were constrained by time, which had them minimize social interactions with patients. Patient-centred care is the current approach of medical schools but often lacks concreteness. The increasing responsibilities and uncertainties of their practice also brought about a large amount of stress. Though here too nightshifts were stressful, unlike their Swiss counterparts they felt well supported by their superiors and that they had the:

“(...) Safety net of being able to call our bosses all the time if you believe something is not right.” {Peter}

“As a General Practitioner in training it’s the best because there is not a hierarchy as in hospitals and we are really supported and the situation is created so that we can learn

the best way” {Eva}

My informants acknowledged that the workload was hard to balance with their personal life but the positivity of their experiences made it more bearable. Indeed the team culture and supportive hierarchy seemed to help them cope with the daily difficulties. They willingly make sacrifices that lead to positive feedback and teaching from their supervisors.

During the nightshifts, junior doctors that seemed to feel in control were not afraid. Indeed, they were encouraged to call their superiors all the time. Moreover, if the call ended up in a disagreement about admitting or not a patient, the superiors would always

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give the possibility to junior doctors to follow their instincts and safely admit the patient. It generally resulted in a teaching period the next morning where the case would be discussed again to understand what could have been improved in the handling of the case:

“You can always ask them, or you call them at home... (...) They don’t really tell me to do stuff (....) it’s more of I have a question and I’m asking what we should do and then we talk about it and we agree on something, like what to do. They don’t really boss around in

that way” {Tim}

“I have a lot of freedom and I want that responsibility.... I have the feeling we do it together and not that they tell me to do stuff”{Daan}

This safety net leads to positive experiences of freedom, as Dutch doctors did not report frustration or abandonment. The teaching relationship seemed to be strong and maintained through the years. Moreover, junior doctors told me that they privileged their workplaces because of the known teaching qualities.

Direct experiences and personal interactions with superiors and hierarchy are essential in shaping experiences and orientating career choices. Moreover, doctors showed flexibility by adapting easily to opportunities, hence highlighting the importance of mentorship. Jasper, for instance reported having no idea of what to do until he met a paediatrician that took him along during his internships as a medical student and became his mentor.

My interviewees’ sometimes felt themselves lacking in knowledge, which they did not expect. The never-ending learning process required in the medical profession can explain these uncertainties that suddenly stumble upon their minds. Indeed, junior doctors lack confidence in their practice as well as their own skills, which can sometimes lead to difficulties when asked to perform tasks:

“I’m a doctor for a few months now (...) but I still feel like I’m so little, you know a bit like, there’s so much you can still learn. When I started med-school I expected that when

you become a doctor you would be more able to really work on your own.” {Tim} “It made me feel really uncomfortable because I didn’t feel that I had enough

experience” {Anna}

Anna here, found herself in disagreement with her superior’s order when for the first time she was asked to perform as the main paediatrician in the C-section room without