Findings from the focus groups. The findings suggest that after the launch of the P4P system, the participating residents have become more estranged toward their professions, their professional environment, their patients, and themselves. Less motivation to practice ethical codes in the wards and loss of hope regarding their future are assumed to reinforce this tendency as well as the anxiety and burnout that they experience.
Thematic analysis revealed several dynamics functioning as either an underlying factor or an essential dimension of physicians’ perceived estrangement. Therefore, we present the results in two groups as follows: 1) factors leading to estrangement, and 2) manifestations of estrangement.
Factors leading to estrangement
Participants thought that P4P affected various aspects of their professional and private lives, which we consider contributed to their estrangement. Relationships at work, family, and social relationships, working conditions, quality of the specialty training, quality of healthcare services, and healthcare system-related consequences of P4P are among them. They also pose the contexts where their critical experiences occur.
1) Relationships at work
Our analysis revealed that P4P affected physicians’ relationships both with their patients and their relatives, and with their colleagues and superiors negatively. It impaired their communication with the former and they were subjected to inappropriate behavior by them more often. They also thought they had become less reputable in patients’ and their relatives’ eyes.
“. . . at our department, anti-depressants are ordered very often; other departments do the same thing too. But an anti-depressant isn’t effective in the first three weeks and in the first week it has only adverse effects. Thus, the patient takes the drug, after two days it interrupts his sleeps; he has vivid dreams. Then, he sees another doctor thinking that the drug prescribed by the previous one isn’t good; there 26 of 28 tablets are wasted. He gets a second drug; he experiences the same until somebody finds an opportunity to explain this to him.” [FG-I/P-6/Ln. 899-904] [3]
Similarly, the participants either regarded their superiors less and/or felt angry with them since they either witnessed or were subjected to unethical behavior such as being treated merely as an instrument by them.
“Our professor, he shows up in every council and says, ‘this has this many points, that has that much, points are important, bla bla…’ (Laughing). They were doing bone marrow transplantations non-stop, and I think there is this thing underlying most such decisions, points. Because, well, once a patient with a transplantation decision became ex [died]. I mean, even receiving chemotherapy was impossible [for her], let alone transplantation. . .” [FG-I/P-4/Ln. 378-383]
Lastly, P4P diminished or disturbed peace at work and impaired solidarity among healthcare professionals since it worsened the relationships between physicians, teams, and departments.
“Say, you need to go somewhere. First, you are supposed to talk to your resident fellow. Then you speak with the specialists. Then, you go to your chief. That ritual is life draining. Because all say ‘sure, just go, but we are just a couple of people here.’ Once a person leaves that dirty wheel, his duties will be loaded onto someone else’s shoulder. . . [FG-III/P-5/Ln. 1172-1178]
These experiences might have led to negative feelings such as anger, anxiety, intolerance, timidity, loneliness, distrust, lack of safety and diminished professional satisfaction.
2) Family and social relationships
The participants all agreed that P4P had negative influence on their family relationships and narrowed their social network, which might have resulted in receiving limited or no social support. In fact, some participants mentioned that they needed to be understood and backed up by their partners and/or parents as they had started working harder than they had used to do.
“We were just married when my husband started his residency. Before that, we had been dating for six something years. The man I had known for six years turned into an utterly different person in the very first month of our marriage. It was like a nightmare . . . although you can barely keep up your own life, suddenly there is someone in need of care next to you. [FG-III/P-2/Ln. 1140-1146]”
Besides, some added that they felt worried or guilty for not being there whenever their family members needed them.
I realized that I’ve started to live more intolerantly. I don't call my parents as often as I used to, but they don't bother me too much with such trifles at home anymore, they know maybe I won't shake it too much. My head is tired; I'm done listening to trouble all day. I'm like, "Okay okay . . . Well, now they saw that there is not much good from me. They don't involve me much in their family matters and things anymore. [FG-I/P-5/Ln. 1204-1209]
3) Working conditions
The participants observed an increase in patient numbers, medical interventions, and bureaucracy with the introduction of P4P. Additionally, they mentioned that hospitals were run with insufficient personnel numbers. As they were concerned about collecting as many performance points as possible, they were more likely to waive their right to vacation/leave. Moreover, they frequently had to deal with stuff that fall outside their job description such as secretarial tasks. Some also stated that they worked off-the-clock to keep up with the quality measures of the medical care they provided. All these factors eventually led to an increase in the overall workload the residents had to shoulder. In addition, fear of losing performance points due to duty-offs urge residents to work almost non-stop and spare less time for rest.
“There is a screen in between, I type there. She tells you something behind the screen. Without raising your head, you say ‘come on in, lie down’. Meanwhile, you try finishing your typing. . . . Then, you look at her out of the corner of your eye and understand what it is. You run there right away and, you know, make a quick examination, then you return to your seat and slip her hand a piece of paper. You don’t really see the patient’s face, you are jammed.” [FG-I/P-5/Ln. 675-679]
Moreover, the participants complained about having to work under direct or indirect pressure either coming from administrators, superiors, or colleagues, or of catching up with the performance measures originating from the harsh competition between different hospitals and/or departments.
“You must increase your turnovers, he said. Gosh! Is here an enterprise? What is it with the turnovers? In psychiatry, patients stay at the hospital longer. Because it is necessary, I mean, a longer stay is necessary, they already hardly collect themselves. I mean, you pull a ruined disoriented schizophrenic patient together barely in three-five weeks. But we are told to discharge them quickly in about one week! Pardon me? The effects of the drugs you give to them don’t even start in less than a week.” [FG-I/P-1/Ln. 745-749]
These elements mark the deterioration of the working conditions, which might presumably lead to physician burnout, anxiety, exposure to mobbing, feelings of being under threat, and inability to refresh oneself.
“. . . in pediatrics residents are warned by their professor not to get pregnant. ‘If you want to conceive, show a valid reason for that, something like I am getting old (people laughing).’ I am serious, there is such a thing. ‘I can arrange no night-duties for you, but just so you know, if you give birth, you will have night-duties.’ Normally, legally, you cannot be asked to do that in the first year after giving birth, but there is no such thing.” [FG-III/P-4/Ln. 1233-1239]
4) Quality of the residency training
According to the participants, the compromised quality of the residency training was another important consequence of P4P. Due to the increased workload, the time spared for training-related activities diminished, case-based training was hampered, and physicians did not have the opportunity to develop themselves professionally by seeing various medical interventions and by attending courses and conferences. These factors might make physicians deprived of their seniors’ mentorship and eventually obstruct their professional competence.
“We can’t attend courses, for example. Because when somebody goes to a course, congress, or something else, the rest must do her job. That is why we are disinclined to do that. I mean, you might have to say ‘well, anyway, let me not go then.’ Then, all joking aside, four years have already been passed. Or, I don’t know, for example you want to learn something. A patient comes in. There are two treatment methodologies; one lasts one hour and the other, say, only fifteen minutes. You cannot learn the one that takes an hour.” [FG-I/P-5/Ln. 1136-1142]
5) Quality of healthcare services
The participants stated that under P4P, they could not exercise due care and attentiveness toward their patients.
“I did an outpatient clinic in oncology for two months. The professor limited the number of patients back then. Twenty-five patients a day, it was a wonderful period. . . . I communicated with them very nicely; I could also consult with the professor. I mean, it was also good for my training, besides that the patients received an efficient treatment. . . . However, here, for example, I did gastroenterology for a short time and saw 60 patients a day. . . . I could not establish any communication with anybody. All I mind was to finish all the patients immediately, . . . I used to adopt the approach that ‘let her get a new appointment in a month [for ultrasound], and then I will not be here anyway.’” [FG-I/P-4/Ln. 950-961]
They also added that they could not perform their profession properly due to lack of time, tendency to commit more medical errors, and automation. It is assumed that this process might induce feelings of professional incompetence and lower self-esteem in physicians.
“For example, recently they offered a new setup; the quotation for surgery’s package program has become 41.50 lira. . . When you order MRI and colonoscopy for a patient, the package hits 120 lira. You fear that they will cut the 80 lira-difference from your revenue. . . As you are afraid, you don’t order the necessary tests . . . I mean, here especially in surgery, we will skip many diagnoses.” [FG-II/P-3/Ln. 445-449]
Besides, they thought that P4P negatively affected patients’ health status due to multiple disruptions it caused in the provision of healthcare services. This, in turn, might make the physician feel responsible to or embarrassed of such undeserved consequences.
“Somehow, she ([the patient]) doesn’t have any other time. . . She wants to be seen even if she is the hundredth patient that day. She says, ‘I can never come again in the morning’. They ([the patients]) don’t even have the luxury to complain about this because when the quality of our lives decreases, theirs get even worse. If we consider ourselves as a compass, we always talk about how bad our lives are, but citizens’ conditions get much poorer.” [FG-III/P-7/Ln. 1051-1056]
Lastly, a few participants mentioned that patients might have been pleased thinking that physicians care for them better than they used to do earlier.
6) Healthcare system-related consequences of P4P
In all groups, the participants highlighted multiple negative healthcare system-related consequences of P4P, while they mentioned only a few of its positive effects. The themes of the latter are as follows: increased efficiency of services, growth in physicians’ income, and patients’ increased access to physicians. Nevertheless, the former largely involves a wide range of themes such as problematic diagnostic standardization measures, adverse effects on teamwork, disruptions in the organization of services, corruption, and encouragement of inappropriate behavior.
“With the diagnosis I make, this patient can’t be hospitalized. So, we change the diagnostic records. It ([the P4P regulation]) says the patient can be admitted only on that certain diagnosis. . . . We must add made-up mentions to the patient reports. We constantly play with our operation notes (Sighs).” [FG-II/P-3/Ln. 424-429]
“They say ‘do something that hasn’t been done before.’ . . . The government really encourages this; it has incredible points, I mean, it brings incredible income. Furthermore, it urges us to do something novel. For example, . . . they try atrial fibrillation ablation; they applied it to three patients and two of them died. When viewed from this angel, we should question how right the implementations done with an itching palm are.” [FG-I/P-3/Ln. 888-894]
The participants also touched upon system malfunction, increased healthcare costs, injustice in the income delivery among healthcare professionals, physician exploitation, physicians becoming disreputable, violence against physicians, and commercialization of the healthcare system.
“ . . . I think they are trying to finish the preventative healthcare thing. Because there you protect the patient, and she doesn’t get sick. But there is no need to protect, let them become all ill, so that they come ([to the hospital]) and make the system run. The aim is, I mean, may money circulate, and may some people get rich.” [FG-I/P-1/Ln. 583-586]
Having witnessed, been subject to or had to be a part of multiple inappropriate, improper, or even clearly wrong practices and attitudes, the residents might have lost their faith in their profession due to stigmatization, feelings of depreciation, insecurity and/or meaninglessness.
Manifestations of estrangement
In their accounts, the participants specified certain dimensions of their multifaceted estrangement as a central consequence of P4P. One of them, the estrangement of the physician, involves the core codes that mark the immediate manifestations of estrangement. Others concerning the damaging effects on physician’s psychology, physician’s perception of their future life and physician as a moral agent display it less directly, though still strongly.
1) Estrangement of the physician
According to the statements of our participants, P4P-related implementations majorly caused physicians to feel estranged from not only their profession but patients, other people, and themselves as a human being and a professional. Firstly, they declared that they were losing their faith in and respect for the medical profession, they could get less or no professional satisfaction, and they had been gradually losing their control over their vocational practices. Besides, they also mentioned that they were pessimistic about the future of the profession, and they would have been unwilling to choose medicine as a profession if they had been given a chance to start their career again.
“For example, [I say] ‘give me your hand, let’s have a look. Tongue out. Ok, done’ (Participants laughing). Because we can’t fulfill any medical need. I mean, maybe not no part of the training we had, but we can apply only a little portion of it. We see the patient (Participants laughing). Sometimes she’s walking, we see her walking, or sometimes we see her lying on the stretcher.” [FG-III/P-7/Ln. 860-864]
“We perform a profession. This is not a sacred thing. Our hand is not God’s hand. All in all, it’s a profession. A job, which we do for money and use as a means of living. But it’s more than that. Why is it more than that? Because . . . we have a profession for which we finished a university, we got training on. Okay, we do it for earning a living but it’s a profession of honor, it’s one of kind of morality. We perform a profession that all scientists performed a long time ago. . . . But when we come to today, they [(physicians]) have been becoming a professional group whose only work is to make money.” [FG-III/P-67/Ln. 353-362]
Secondly, our analysis revealed that the residents usually felt angry with their patients and were mostly nervous and intolerant while dealing with them. Moreover, they tended to ascribe this feeling to the public as well. Most of them stated that they did not rely on people anymore.
“A patient’s relative, you ask him to leave the room because he quarrels with the nurse, and he disturbs other patients. The security guy comes to take him out. The relative says ‘Now what? Should I go now and call the media?’ The crud he displays is immeasurable. He swears at everybody, he swears at the healthcare personnel and the nurse. You cannot get rid of him. Then when the head doctor, or the chief physician, whatever, comes, ‘Oh, please, show a bit of tolerance!’ Why tolerance?!” [FG-III/P-6/Ln. 206-210]
Thirdly, they stated that they abstained from people, sought silence and solitude whenever possible. Very often residents expressed that they would have liked to travel somewhere where nobody lives for some time. Similarly, they could not stand to talk, listen to or see anybody after a workday. They also added that their desire to meet friends diminished day by day.
“I am worn-out, sometimes I don’t want to go out from home. Let me just sit at home in the weekend, let me stand still, not go anywhere, not speak with anybody. Let me not listen to anybody’s problem. You know, we constantly have to listen to people and speak with them. I feel daunted because of that. I am tired of talking and speaking and I long for silence. May nobody start on me for one day.” [FG-I/P-1/Ln. 1215-1219]
Fourthly, prominent emphases were that the residents lose their self-confidence, they cannot protect their professional integrity and their self-esteem decreases, as P4P leaves no room to develop informed clinical decisions due to the increased speed and intensity of the healthcare services.
“This situation ([P4P]) . . . suppresses everything, my self-sufficiency, my self-confidence. You pull yourself back. You withdraw yourself from normal life. . . This, for example, is something very troubling for surgery. I mean, as a surgeon, you need to be self-confident. However, because of this unnecessary workload, plus this, I mean, the oppression due to the hierarchy amongst us, and the redundant work, and so on, you gradually become nonassertive surgeons. Such a surgeon is zero, I mean, nothing!” [FG-III/P-5/Ln. 1178-1184]
Lastly, they suffer from not being able to be effective in their private life. Some mentioned feeling of being detached from real life and that they were not the same person they had used to be in the past. They also touched upon losing ability to comprehend or interpret what they had been through due to work overload.
“For the first year, it is not too abnormal that you devote all your concentration there ([the hospital]), that you endeavor to learn, that you try to live all your days fully. But for later it turns out to be a real torture. Because then you realize that everything starts to disassociate from you, you begin to live in another world and are becoming somebody else. I mean, you begin grasping more or less the place where you have come. You will get lonely, you will be left all alone, I mean, soon the only thing you have got will be this hospital.” [FG-I/P-5/Ln. 1228-1233]
2) Damaging effects on physician’s psychology
Almost all participants remarked that P4P affected their mental well-being negatively in various ways. Due to exposure to heavy workload, perceived injustice and intensifying competition, the residents are likely to suffer from anxiety, depressive mood, anger, disappointment, frustration, and burnout. In consequence, the physician’s quality of life would be impaired. P4P also leads to indifference to wrongdoings or hopelessness about a possibility of change, which can be considered the indicators of cynicism.
“I get very demoralized when I see that the satisfaction, I get from saving a patient’s life by sweating blood can in no sense be measured, I mean, determined by the adversary, or rather in terms of points. Perhaps, I would have earned the same number of points by merely prescribing to flu patients during that time. In total, I would have seen twenty-thirty flu patients and thus showed that I work more. While you think that you really went over big, suddenly you realize that you have achieved nothing in terms of points. This causes a big disappointment.” [FG-I/P-5/Ln. 136-142]
3) Physician’s perception of their life in the future
Few participants stated they were still hopeful about their future professional life. However, after P4P most of them started viewing it with pessimistic eyes. Expectation that the further changes would not be positive, and feelings of despair seem to underlay this tendency. Besides, they mentioned not being able to make long-term plans, as they could not foresee what is ahead of them and felt a constant urge to improve themselves to prevent the perceived risk of unemployment.
“If I can be a specialist, if I can finish [the residency], I think it will be better than this. I mean, I hope for that; but I think I’d be constantly worried, I mean I can’t look into the future comfortably. Always, I’ll wonder… Each and every craze of gossip, I mean, expressions such as ‘it’d be like this, like that’ make me anxious. I think it’ll never change for the better. It’s as if each upcoming day would make the running of things worse for us. After all I’ve developed anxiety of getting fresh news. I don’t want to hear anything new.” [FG-II/P-4/Ln. 1203-1208]
4) Physician as a moral subject
According to the participants’ statements, the system inclines the physician to performing and/or overlooking unethical practices, such as picking patients who would bring more performance points. Similarly, under P4P the residents tend comply with performance measures while evaluating the treatment indications rather than with the scientific algorithms.
. . . especially in surgery, there are not many opportunities to collect points; we can’t get enough points over clinical examinations . . . Because we can only get them over surgical operations, indications have started to change, our treatments and follow-ups too. . . and that situation increases the number of complications and the surgeon’s liability. . . Science already set the standards for that, but the performance system has started to contravene science . . . But insomuch the points sign in your eyes that you become unable to settle the matter.” [FG-II/P-3/Ln. 362-376]
Besides, the residents often exhibit inappropriate behaviors while tackling with extensive workload such as turning their duties over subordinates or seeing more than one patient at a time. Moreover, they blamed P4P for transforming their values and priorities, as well as their behaviors and attitudes. Approaching patients as a shopkeeper pleasing their customers and minding quantity rather than quality exemplify this turn.
“Before coming here, I had worked as a general practitioner. Back then I used to rejoice when the weather is cold, when there is a flu outbreak. That meant simple patients, making easy money. You could increase your points fabulously. For instance, while we normally had seventy patients in 24 hours, at times of the epidemic the number hit one hundred and forty. The money, the revenue that I’d get at the end of the month used to increase one and a half times or double in all aspects. Normally I should think of such things: May nobody got sick. Whereas I should aim for people’s health, I rub my hands expecting them to get sick so that I can earn more money.” [FG-II/P-6/Ln. 915-926]
“I started residency when I was 25, spent 6 years there and I’ve always continued by losing a part of myself on the way. Perhaps I have gained important knowledge during the plastic surgery training, but I can enunciate that I have always eaten my humanity out, I’ve lost it. I mean, having no work peace with your colleagues, negative relationships with patients… all these things eroded my humanity. . . . I started with different ideas; such things never crossed my mind. I have always been interested and known that it would have led us somewhere, but I have never dreamt that to end up in such a situation, both socially and scientifically.” [FG-III/P-5/Ln. 1524-1531]
Habitual repetition of such coping mechanisms might lead to erosion of the physician’s morals. They suffer from moral distress, as they cannot do what they believe is the professionally right thing to do.
“You have no strength left to examine another patient. It’s five to five. The one in front of you is the eightieth patient. I mean, the eightieth! Interruptions for showing results have been incalculable. The inappropriate disturbance by personnel too. Then, you had to do other things meantime, the senior professor called you over and lectured you, came down on you, etc. Now, it’s five to five. Would you examine that patient? She brought her mammography test results. There are growths, which ultrasound and mammography cannot catch. I mean, you skip them unless you examine the patient. Right at that moment the conscience starts to speak; should I send this patient away, or not? You feel suffocated. If I examine her, the work will linger.” [FG-III/P-3/Ln. 843-850]
Findings from the survey. Analysis of Section 1 demonstrated the demographic attributes of the participants. 612 females (44.4%) and 766 males (55.6%) validly took part in the survey. Participants’ age varies from 21 to 70 years, 38.6 being the average. Although the majority of the participants were from some major metropoles such as Ankara (n:450, 32.7%), İstanbul (n:175, 12.7%), İzmir (n:103, 7.5%), and Antalya (n:92, 6.7%), responses were received from every city in Turkey (n:81). Specialist doctors (SDs) comprised the biggest group of participants; yet data from a considerable number of general practitioners and family physicians (GPs+FPs), physicians in training (residents), and faculty members (FMs) were collected as well. Participants affiliated with various institutions, most of whom worked at training and research hospitals (TRHs), public hospitals (PubHs), and university hospitals (UHs) (Table 2).
Table 2
Frequency of participants’ professional title and affiliation
|
|
Frequency
|
%
|
Professional title
|
General practitioners and family physicians (GPs+FPs)
|
232
|
16.8
|
Residents
|
236
|
17.1
|
Specialist doctors (SDs)
|
689
|
50.0
|
Physicians who are faculty members (FMs)
|
221
|
16.0
|
Total
|
1378
|
100
|
Affiliation
|
Training and research hospitals (TRHs)
|
396
|
28.7
|
University hospitals (UHs)
|
290
|
21.0
|
Private university hospitals (PUHs)
|
17
|
1.2
|
Public hospitals (PubHs)
|
385
|
27.9
|
Private hospitals (PriHs)
|
85
|
6.2
|
Family health centers (FHCs)
|
132
|
9.6
|
Public health centers (PHCs)
|
17
|
1.2
|
Other
|
56
|
4.1
|
Total
|
1378
|
100
|
The specialties of the participants showed great diversity, including all clinical and basic branches of medicine. General practitioners and family physicians (n=242, 17.6%), psychiatrists (n=135, 9.8%), internal disease specialists (n=80, 5.8%) comprised the three biggest groups. As for marital status, 330 (23.9%) declared to be single, while 988 (77.7%) were married and 60 (4.4%) were divorced. 751 (59%) had children.
Section 2 concerns participants’ perceptions about their working conditions. As mentioned earlier, items in this section were grouped into five thematic parts (See Methods/Questionnaire Survey, and Table 3) for each of which a mean value was calculated. Findings demonstrated that the participants think that the time spared for the following is moderately inadequate: Patient examination, medical interventions apart from outpatient clinic tasks, professional education, resting and relaxation, family and social life, and their income. According to the results, the perceived workload over physicians is redundant, off-label medical interventions do exist and are practiced to a moderate degree, negative feelings about one’s own professional practices are considerably high, and the perceived quality of one’s communication with different parties in daily professional life is slightly below moderate (Table 3).
Table 3
Frequency of participants’ perceived evaluation of their working conditions
Part
|
Content (Section 2)
|
Items
|
Valid
|
Missing
|
±SD
|
Median (Min-Max)
|
1
|
Amount of income, and the time spared for patient examination, medical interventions apart from policlinic tasks, professional development, professional education, resting and relaxation, family, and social life
|
1-11
|
1378
|
0
|
1.68±0.44
|
1.64 (1-3)
|
2
|
Workload
|
12-15
|
1378
|
0
|
3.66±0.90
|
3.75 (0-5)
|
3
|
Number of off-label medical practices
|
16-18
|
1345
|
33
|
2.24±1.44
|
2.00 (0-5)
|
4
|
Negative feelings about one’s own professional practices
|
19-21
|
1371
|
7
|
4.17±1.03
|
4.67 (0-5)
|
5
|
Quality of one’s communication with different parties in daily professional life
|
22-24
|
1367
|
11
|
2.28±1.12
|
2.33 (0-5)
|
In Section 3 the 4-Likert picks about the effects of P4P were scored respectively as follows: “I totally disagree” 0; “I disagree” 1; “I agree” 2; and “I totally agree” 3. According to EFA, the six-factor solution was considered most appropriate (RMSEA= 0.046, CFI= 0.949, TLI= 0.935). Factor loadings are given in Table 4.
Table 4
Factor Loadings
Item
|
F1
|
F2
|
F3
|
F4
|
F5
|
F6 (Neglected)
|
U1
|
0.419
|
|
|
|
|
|
U11
|
0.548
|
|
|
|
|
|
U12
|
0.792
|
|
|
|
|
|
U13
|
0.488
|
|
|
|
|
|
U14
|
0.667
|
|
|
|
|
|
U15
|
0.800
|
|
|
|
|
|
U16
|
0.591
|
|
|
|
|
|
U17
|
0.596
|
|
|
|
|
|
U21
|
0.424
|
|
|
|
|
|
U37
|
0.335
|
|
|
|
|
|
U2
|
|
0.454
|
|
|
|
|
U18
|
|
0.638
|
|
|
|
|
U19
|
|
0.598
|
|
|
|
|
U20
|
|
0.540
|
|
|
|
|
U41
|
|
0.491
|
|
|
|
|
U43
|
|
0.527
|
|
|
|
|
U51
|
|
0.321
|
|
|
|
|
U52
|
|
0.796
|
|
|
|
|
U53
|
|
0.833
|
|
|
|
|
U54
|
|
0.705
|
|
|
|
|
U55
|
|
0.584
|
|
|
|
|
U7
|
|
|
0.514
|
|
|
|
U10
|
|
|
0.498
|
|
|
|
U22
|
|
|
0.476
|
|
|
|
U23
|
|
|
0.626
|
|
|
|
U24
|
|
|
0.698
|
|
|
|
U25
|
|
|
0.493
|
|
|
|
U26
|
|
|
0.647
|
|
|
|
U27
|
|
|
0.322
|
|
|
|
U28
|
|
|
0.781
|
|
|
|
U29
|
|
|
0.828
|
|
|
|
U30
|
|
|
0.819
|
|
|
|
U31
|
|
|
0.909
|
|
|
|
U32
|
|
|
0.877
|
|
|
|
U33
|
|
|
0.690
|
|
|
|
U34
|
|
|
0.813
|
|
|
|
U35
|
|
|
0.850
|
|
|
|
U36
|
|
|
0.810
|
|
|
|
U39
|
|
|
0.477
|
|
|
|
U40
|
|
|
0.366
|
|
|
|
U48
|
|
|
0.677
|
|
|
|
U49
|
|
|
0.703
|
|
|
|
U50
|
|
|
0.671
|
|
|
|
U3
|
|
|
|
0.342
|
|
|
U4
|
|
|
|
0.860
|
|
|
U5
|
|
|
|
0.853
|
|
|
U6
|
|
|
|
0.521
|
|
|
U38
|
|
|
|
|
0.441
|
|
U42
|
|
|
|
|
0.572
|
|
U44
|
|
|
|
|
0.445
|
|
U45
|
|
|
|
|
0.654
|
|
U46
|
|
|
|
|
0.681
|
|
U47
|
|
|
|
|
0.597
|
|
U8
|
|
|
|
|
|
0.590
|
U9
|
|
|
|
|
|
0.563
|
A factor was neglected completely since only two items were loaded on it. Cronbach’s alphas for F1, F2, F3, F4, and F5 were 0.807, 0.881, 0.918, 0.779, and 0.733, respectively. Eventually Section 3 is composed of 53 items and 5 factors as follows: F1) Estrangement toward the profession; F2) P4P’s adverse effects on the physician’s quality of life; F3) Favorable consequences of P4P; F4) Becoming disreputable in the eyes of patients/patient relatives; and F5) Unfavorable consequences of P4P (Table 5).
The frequency analysis of the factors demonstrated that in general the participants think P4P has affected their professional and private lives negatively and caused unfavorable consequences in general for both the healthcare professionals and the organization of healthcare system. Scores of F1 revealed that they have distanced from their patients, tend to prefer easy and/or higher-scored medical interventions, have been gradually losing their faith in their profession and are becoming less self-confident as a physician. They also esteem that P4P has caused competition among colleagues. According to the results of F2, participants think that P4P has influenced their quality of life, health, and psychology negatively. They have found themselves in uncertainty, are less tolerant of their patients and cannot get professional satisfaction. F3 scores demonstrated participants strongly disagree with the perspective that the model has led to positive consequences in terms of income justice, professional security, career guarantee, peace at work, healthy physician-patient relationship, efficient and quality conduct of healthcare services, and solidarity among colleagues. Results concerning F4 showed that physicians think that there is a relation between P4P and their perception of being behaved disrespectfully by patients and their relatives. They also feel to be dealing with the emerging problems in the healthcare system on their own. Lastly, according to the scores of F5 participants mostly agree with that P4P causes physicians to view patients as money or points, harms professional ethics and the physician’s independence, and devaluates the physician labor (Table 5).
Table 5
Distribution of items (Section 3) to the factors and frequency of factor points
Factor
|
Content (Section 3)
|
Items
|
±SD
|
Median (IQR)
|
1
|
Estrangement toward the profession
|
1, 11-17, 21, 37
|
2.95±0.56
|
3.00 (1-4)
|
2
|
P4P’s adverse effects on the physician’s quality of life
|
2, 18-20, 41, 43, 51-55
|
3.32±0.56
|
3.36 (1-4)
|
3
|
Favorable consequences of P4P
|
7, 10*, 22, (23-26) *, 27, (28-36) *, 39, 40*, (48-50)*
|
3.60±0.41
|
3.73 (1-4)
|
4
|
Becoming disreputable in the eyes of patients/patient relatives
|
3-6
|
3.49±0.53
|
3.50 (1-4)
|
5
|
Unfavorable consequences of P4P
|
38, 42, 44-47
|
3.30±0.54
|
3.33 (1-4)
|
6
(Neglected)
|
None
|
8, 9
|
-
|
-
|
*: Items coded inversely
Next, differences between the scores of each factor according to the participants’ affiliation and title were inquired. Concerning F2 and F4, the results showed no distinction between the scores of those working at different healthcare institutions. As for F1, however, physicians working at PubHs agree more strongly with the expressions suggesting that P4P causes professional estrangement compared to those working at UHs and TRHs. In F3 physicians working at UHs have significantly higher points than those from FPCs. This indicates that the former objects more strongly to the claims that P4P has positively affected the overall organization of the healthcare setting, quality of relationships among different parties, and the distribution of wages to physicians. Similarly, relating to F5 physicians working at UHs more strongly agree that P4P has impaired moral values and ethical practices intrinsic to the profession than those working at FPCs (Table 6).
***Table 6 here***
Comparison according to titles showed no difference among GPs and FPs, residents, SDs, and FMs in F5. Their individual scores indicate that they all think P4P has had negative moral consequences. Results of F1 and F2 demonstrated that GPs and FPs, residents, and SDs more strongly concur compared to FMs with the statements implying a relation between professional estrangement and P4P, and that the model has diminished the quality of physicians’ lives. Although residents’ scores from F3 are significantly higher than the rest of the groups, they all disapprove that P4P has contributed to improving the conduct of the healthcare system. The F4 scores revealed GPs and FPs, residents, and SDs more strongly agree with the claim that P4P has caused physicians to be discredited in the eyes of patients and their relatives than FMs do, even though FMs also agree with this phenomenon. (Table 7).
***Table 7 here***
Lastly, a Spearman correlation coefficient was calculated among Section 2 (perceptions about working conditions) and Section 3 (consequences and effects of P4P). Cohen’s standard was used to evaluate the strength of the relationships, where coefficients between .10 and .29 represent a small association, coefficients between .30 and .49 represent a moderate association, and coefficients above .50 indicate a large association. The results demonstrated a significant association between each part (P) of Section 2 and each factor (F) of Section 3 as follows. There is a significant negative correlation between P1 (the adequacy of time spared for certain aspects of work, and income) and F1 (r=-0.33, p<.001), F2 (r=-0.51, p<.001), F3 (r=-0.41, p<.001), F4 (r=-0.41, p<.001), and F5 (r=-0.31, p<.001). The correlation coefficient between P1 and F2 is -0.51, indicating a larger relationship than those between P1 and other factors do. This finding indicates that the greater the adverse effects of P4P on physicians’ lives are, they perceive to have less adequate time spared for certain aspects of work and earn less income. There is a significant positive correlation between P2 (perceived workload) and F1 (r=0.19, p<.001), F2 (r=0.38, p<.001), F3 (r=0.27, p<.001), F4 (r=0.31, p<.001), and F5 (r=0.14, p<.001). The correlation coefficients between P2 and F2, and between P2 and F4 are 0.38 and 0.31 respectively both indicating a moderate relationship. This finding indicates that the heavier the perceived workload is, the more physicians think that they are affected by P4P adversely. There is a significant positive correlation between P3 (off-label medical practices) and F1 (r=0.27, p<.001), F2 (r=0.18, p<.001), F3 (r=0.14, p<.001), F4 (r=0.21, p<.001), and F5 (r=0.17, p<.001), even though the association is small. There is a significant positive correlation between P4 (negative feelings about professional practices) and F1 (r=0.39, p<.001), F2 (r=0.59, p<.001), F3 (r=0.39, p<.001), F4 (r=0.42, p<.001), and F5 (r=0.30, p<.001). The correlation coefficient between P4 and F2 is 0.59, indicating a large relationship. This finding demonstrates a coexistence of physicians’ negative feelings about their professional practices, and their tendency to think that P4P affects their lives adversely. There is a moderate association between P4 and other factors, which is worth mentioning as well. Lastly, there is a significant negative correlation between P5 (quality communication in professional life) and F1 (r=-0.33, p<.001), F2 (r=-0.32, p<.001), F3 (r=-0.30, p<.001), F4 (r=-0.33, p<.001), and F5 (r=-0.24, p<.001). There is a moderate association between P5 and the first four factors, and a small association between P5 and F5, which indicates overall that when physicians’ perception of P4P’s negative consequences increases, the quality of their communication with their colleagues, patients and other parties deteriorates. Table 8 presents the results of this analysis.
Table 8
Results of the Spearman correlation coefficient between Section 2 and Section 3
|
Section 3
|
Section 2 / Parts
|
N
|
|
F1
|
F2
|
F3
|
F4
|
F5
|
1
|
1378
|
r
|
-.331
|
-.506
|
-.414
|
-.412
|
-.310
|
p
|
<0.001
|
<0.001
|
<0.001
|
<0.001
|
<0.001
|
2
|
1378
|
r
|
.185
|
.378
|
.267
|
.314
|
.136
|
p
|
<0.001
|
<0.001
|
<0.001
|
<0.001
|
<0.001
|
3
|
1345
|
r
|
.274
|
.181
|
.142
|
.212
|
.171
|
p
|
<0.001
|
<0.001
|
<0.001
|
<0.001
|
<0.001
|
4
|
1371
|
r
|
.388
|
.594
|
.386
|
.427
|
.303
|
p
|
<0.001
|
<0.001
|
<0.001
|
<0.001
|
<0.001
|
5
|
1367
|
r
|
-.333
|
-.323
|
-.302
|
-.331
|
-.238
|
p
|
<0.001
|
<0.001
|
<0.001
|
<0.001
|
<0.001
|