The Doctor’s Heart: A Qualitative Study Exploring Physicians’ Views on Their Professional Performance in Light of Excellence, Humanistic Practice and Accountability

Background In a field as high-stakes as health care, professional values have long been recognized as an essential mediating force for good medical practice. In the current era of changing market forces, anchoring these values in the professional performance of daily practice can be challenging. In this study we explored how physicians reflect upon their own professional performance and whether they feel they are performing to their best ability in light of excellence, humanistic practice and accountability. Methods We conducted a thematic analysis of written reflections from 786 hospital-based physicians, representing 35 specialties and 18 hospitals. Results When reflecting on their professional performance, physicians differentiated between (i) their calling for being a doctor, (ii) the translation of this calling into daily practice, and (iii) threats to their performance. Reflecting on humanistic practice triggered thoughts about the essence of being a physician in terms of calling, meaning and purpose. Physicians described concrete actions regarding pursuit of excellence and accountability. Furthermore, they suggested that their ability to perform optimally was put under pressure, mainly by heavy workloads and collaboration issues. This pressure negatively affected their calling for being a doctor and hampered the ability to be a humanistic practitioner. Conclusions In large inventory reflections, the core value However, feel high performance and the ability to act as heavy and collaboration issues. Decreasing the clinical burden and relational aspects could foster an environment where physicians can perform optimally.

physician in terms of calling, meaning and purpose. Physicians described concrete actions regarding pursuit of excellence and accountability. Furthermore, they suggested that their ability to perform optimally was put under pressure, mainly by heavy workloads and collaboration issues. This pressure negatively affected their calling for being a doctor and hampered the ability to be a humanistic practitioner.

Conclusions
In this large inventory of reflections, humanistic practice was recognized as the core value of being a physician. However, physicians feel high performance and the ability to act as a humanistic practitioner is hindered by heavy workloads and collaboration issues. Decreasing the clinical burden and reinforcing humanistic and relational aspects of care could foster an environment where physicians can perform optimally.

Background
In a field as complex and as high-stakes as health care, professional values have long been recognized as an essential mediating force in patient care [1,2]. The often implicit ideas about physicians' performance are made explicit in a variety of charters and guidelines, all having roots extending back to the classic and oldest of all codes of conduct: the Hippocratic Oath [3,4,]. The increased administrative workloads may result in less face-to-face time with patients [17,18,19].
These aspects often result in physicians lacking time, energy or inspiration, and can translate into the diminished commitment to essential professional values and of professional performance. In light of these and many other challenges to physicians' performance, it is in the interest of patients and society that physicians are able and are enabled to act according to their professional values. In this study, we were interested in hearing first-hand from hospital-based physicians about whether they felt they were performing to the best of their ability.
Therefore, the aim of our study was to gain insight into physicians' perspectives on their own professional performance. This multicentre study used written reflections of nearly 800 physicians of multiple specialties. Our research question was: how do physicians reflect upon their professional performance in terms of the pursuit of excellence, humanistic practice, and accountability?

Setting and participants
We conducted this study in the Netherlands, where physicians are either employed by hospitals or organized in independent entrepreneur partnerships. All licensed physicians must periodically demonstrate that they are up to date and fit to practice for recertification as a physician, being the equivalent of revalidation in the United Kingdom or maintenance of certification in the USA [9,20,21].
In this mandatory process in The Netherlands, physicians gather feedback from multiple colleagues and also self-assess and reflect on their performance. To guide the assessment and reflection, an assessment tool including a few reflective questions based on the three performance pillars as described in the introduction was provided [22]. The reflections were for personal use only and were not shared with colleagues, managers or the revalidation authority. For this study, we used physicians' reflections on their performance, as written in the context of their recertification process.
Participants were all hospital-based physicians, representing various specialties from several (academic and non-academic) hospitals.

Instrument
As part of performance assessment in the context of the above mentioned recertification process, multisource feedback tools are used to facilitate the reflective process. Physicians collect feedback from multiple colleagues and also self-assess their performance. Physicians reflect on the obtained feedback and formulate professional development goals, often in consultation with a trained facilitator [23,24]. In The Netherlands, one such assessment tool is the Inviting Co-workers to Evaluate Physicians -Tool (INCEPT) [22]. This tool is designed to capture various respondent groups' perspectives on physicians' professional performance and also includes a physician self-assessment questionnaire. The information is collected digitally and anonymously. The self-assessment questionnaire contains performance items to be rated as well as reflective open-ended questions to stimulate introspection. Although it could be argued that, in general, the rating of self-assessment questionnaires can differ from the ratings of respondent groups, this study only targets at the written reflections of the self-assessment and does not take the ratings of the questionnaire into account, The framework of these open ended questions is based on Lombarts' pillars of professional performance: (i) the pursuit of excellent care, (ii) humanistic practice, and (iii) accountability (see supplementary file 1). In this study, we were interested in physicians' perceptions and reflections on their own performance and improvement needs, including a reflection of their adherence to values and the necessary skills and competences. We therefore used physicians' written reflections on the following two open-ended questions: (i) what aspect(s) need(s) your (extra) attention in order to maintain or improve your performance, and (ii) when reflecting on your own performance, how do you perceive the balance between the three pillars of professional performance. These open ended questions suited our purpose in stimulating thoughts on a more practice-based level (what aspect(s) need(s) your (extra) attention in order to maintain or improve your performance?) and on a reflective level (when reflecting on your own performance, how do you perceive the balance between the three pillars of professional performance?). These two questions were preceded by a definition of professional performance and some sample key words for each of the three pillars, as described in Appendix 1. Physicians were not obliged to answer these questions and their answers did not need to be discussed with a facilitator or anyone else; the written reflections would be added to their personal portfolio for themselves to read and ponder upon.

Data collection
Data used for this study consist of physicians' written reflections on their own performance. We included all available written reflections -786 in total -from hospital-based physicians that used the INCEPT tool between January 2016 and January 2017.

Data analysis
For the purposes of data analysis, we used a thematic analysis approach, a qualitative, independent and descriptive method particularly useful for large sets of written data [25]. It can be described as 'a method for identifying, analysing and reporting patterns (themes) within the data' [26]. The analytical process is characterized by description and interpretation, integration of manifest and latent contents and by drawing a thematic map that consists of the major themes and topics emerging from the data [25]. Following this approach, we focused on the content of the text, on 'what' is said more than 'how' it is said [27]. Since researchers bring their own backgrounds to the analytical process, practicing reflexivity is critical. In this reflective spirit, we provide the following contextual information: the lead author (MvdG), is currently working as CEO and management consultant, guiding physicians on performance, reflection and collaboration and also worked as a general practitioner for many years; her collaborators for this research represent various backgrounds including health sciences, education and methodology (BB), art history and clinical neuropsychology (EB), medicine and member of hospital board of directors (MH), and health service research and medical professionalism (KL). The first author (re)coded all reflections and a total of 300 reflections were independently double-coded by a second researcher (BB). All aspects of coding were discussed until consensus was reached in order to establish trustworthiness in the interpretation of the data [28]. The lead author started with an overall inspection of all reflections to formulate a first understanding, in line with the thematic analysis approach [26]. After this orientation, the research team chose to translate the two reflective questions into a pre-defined coding template. Four themes thus originated as top-level codes: related to the first question: (i) pursuit of excellence, (ii) humanistic practice, (iii) accountability, and related to the second question, (iv) threats to optimal performance. Further analysis outlined a higher order level emerging from the theme of humanistic practice; this level was defined as the 'calling for being a doctor'. The theme 'threats' could be divided into individual aspects and work related aspects. This resulted in minimal adjustment of the initial coding template into the following topics: (i) the calling for being a doctor, (ii) translation of the calling into daily practice (comprising pursuit of excellent care, humanistic practice, and accountability of care) and (iii) threats to optimal performance (containing individual-and work-related aspects). The first author recoded previous reflections into the new template and subsequent original reflections were coded accordingly. The themes coded in the final template are shown in Table 1, including exemplar quotations. We used the qualitative data analysis software Dedoose to support the thematic analysis. We collected reflections of 786 physicians (56% female), aged 32 to 66 years, representing 35 different (sub-)specialties at 18 hospitals. A total of 737 physicians (94%) completed the reflective questions, which we subsequently analysed; 38 physicians (5%) used 'not applicable' or comparable short statements of less than 50 characters. Most physicians, however, reflected more extensively.
The mean reflection length was 503 characters, ranging from 83 to 2963 characters.

Overall findings
The majority of physicians reflected on all three pillars of professional performance. . Physicians also experienced that their ability to perform well is under pressure, and there is a palpable threat to their ability to live up to their calling and to act as a genuinely caring practitioner. We will now describe these findings in more detail.

Why: the calling for being a doctor
Physicians perceive the doctor-patient relationship as the heart of being a physician. They describe earning a patient's trust as an important foundation for this relationship. As pointed out by the following physicians, respect, engagement, and genuine interest in the patient as a person are key components in order to earn such trust:

Threats to optimal performance
When reflecting on their performance, many physicians describe situations that hinder them to perform to the best of their abilities. These situations either hamper their pursuit for excellence or put their purpose of being a physician under pressure. They perceive that such individual-and work related situations obstruct, and thus pose a threat to, optimal performance.

Individual aspects; physical and mental wellbeing
Physicians acknowledge the potential negative effect of low levels of vitality on their professional performance. They detect the impact of insufficient mental energy in lacking time and attention for oneself as resulting in loss of attention, inspiration, and enthusiasm during their contact with patients and colleagues. Physical inabilities are also mentioned as posing a potential threat to optimal performance.

Work related aspects; workload and collaboration issues
The majority of physicians appoint work related factors as threats to optimal performance. They describe the negative effects of their heavy workload, and more specifically the increasing administrative tasks due to accountability and national or local policies. This leads to a lack of time for their patients, creating frustration and diminishing motivation. In particular, the purpose of being a physician and of humanistic practice is described as being under pressure by a heavy work-and administrative load.

Discussion
Main findings defined as excellence, humanistic practice, and accountability. Humanistic practice was found to emerge as physicians' 'why,' that is, the heart of being a physician. Excellence and accountability were depicted as 'how'; a means to translate the essence of being a physician in daily practice.
Humanistic practice was considered both a means as well as a state of being. Physicians report their ability to optimal performance is put under pressure by heavy workloads and collaboration issues.
These threats to high performance in particular affect their ability to live up to their calling for being a genuinely caring physician.

Explanation of the findings
Our findings illustrate that physicians nowadays still sense the significance of their calling and that their motivation and inspiration primarily originates from this calling. Reflecting on their performance, they extensively reflect upon their essence -the heart -of being a physician. Physicians consider caring about patients and their families, putting patients' interests and concerns first, and gaining and deserving the patient's trust, as this essence. This is consistent with the humanistic realm of actually being with patients when they are suffering, exactly what many patients want and expect from their physician [29]. These findings confirm what has long been recognized, that is motivation is a driving force of behaviour and performance, extending out from the realm of philosophy to the psychological, behavioural and management domains [30]. The rich variety of motivation theories range form defined by Dik & Duffy as a sense of purpose and meaning that this is the work that one was meant to do, reflecting the belief that the career is central part of a broader purpose in life and is used to help others [37].
Our findings underscore that physician performance still primary seems to originate from values and that the universal values of medical professionalism are deeply imbibed by physicians in their views on their profession and performance [7]. This may soften the view often put forward in health services and economic contribution, that money is regarded a motivator priority for physicians [38]. To the contrast, in this study, none of the physicians mentioned in their reflections 'money', 'income' or 'financial incentives' in relation to performance. This is in line with literature emphasizing non financial motivators like mastery and social purpose for changing physician behaviour [39]. This may be considered a reassuring finding, since professional values have long been recognized as fundamental for good patient care [1,2], and in our view still are.
In order to live up to their professional performance, physicians cultivate certain professional practices. They attend courses to stay afresh of the latest knowledge, introduce new techniques, participate in consultation and discussion with colleagues, share their knowledge, maintain transparency about choices they make and keep an adequate registration in the patients' interest, including managing electronic patient records and participating in quality assurance registries.
However, our results also indicate that physicians experience threats in actually accomplishing these actions in practice. They mention that collaboration issues such as disturbed relationships, feelings of being hold back, insufficient space to voice their opinions and a lack of openness within their peer group negatively influence their performance. This is a disturbing finding, since effective teamwork is linked to quality and safety of patientcare [40,41], and indicative for wellbeing and job satisfaction [42,43]. Additionally, psychological safety and speaking up behaviour are known to be driving forces for a safe and stimulating learning environment where performance can flourish [44,45,46].
Physicians furthermore express that they spend time on administration at the cost of (being with) their patients. This is consistent with international research indicating that increasing clerical burden is leading to limited face-to-face time with patients and that for every clinical hour spent on face-toface interactions with patients, physicians spend an additional two hours on administrative tasks [17,19]. This worrisome finding seems to reflect the current era of marketisation in healthcare, shifting from people to processes, productivity and efficiency [16]. Physicians consider administrative tasks to be a serious threat to their performance, while time and attention for patients are known to be powerful drivers of physician satisfaction and the ability to provide high quality care [18,47].
Curtailing what primarily inspires physicians might eventually lead to physicians no longer having the time, energy and motivation to deliver the best possible care. Thus, a high clerical burden is challenging high performance not only by taking time from patients but also by potentially disconnecting physicians from their purpose of caring for patients [48]. Fortunately, multiple healthcare stakeholders now seem to take the adverse events of too much administration seriously.
In the Netherlands, for example, the Department of Health and Welfare, the Health Care Inspectorate, and the Dutch Federation of Physicians joined hands and published a manifest to de-regulate healthcare [49].

Strengths and Limitations
This study provided us with the opportunity to analyse a substantial sample of written reflections from a representative group of hospital-based physicians. Our data were collected in a pre-defined format, coming with the limitation that this method could have potentially narrowed the focus and depth of the reflection process. Another point of consideration is the setting in which the study was conducted.
Since the participants were all hospital-based physicians in The Netherlands, the findings reported may not be transferable to practices and physicians outside the hospital environment and/or the Dutch healthcare system. Lastly, researchers bring their own backgrounds to the analytical process, therefore this study might have been influenced by the medical and consultancy background of the principal author, being both a potential limitation and a strength. To strengthen data analysis and interpretation, we sought diversity within the background profiles of the research collaborators.

Implications/ recommendations
Since humanistic practice is considered to be at the heart of being a physician and indispensable for high quality care in the future, humanism should be at the top of physicians' priority list when practicing medicine. Because the lack in research on supporting and increasing humanistic practice in healthcare professionals, there is a need for more research on this topic [50]. In practice, physicians should pay attention to their personal well-being, since research indicates a relationship between physician well-being and the quality of patient care [51,52]. Given their strong links to quality of care and patient safety, having an engaged physician workforce that experiences a sense of meaning is critical for healthcare organisations [53,54]. Organizational interventions directed at enabling physicians to focus on their core tasks in patient care could enhance physicians' experience of meaningful work. Best practices like the Mayo Clinics could be followed, where the creation of dedicated meeting spaces for physicians boosted engagement and dedication [55] and where funding of small groups of physicians to have a meal together and discuss topics that explored the virtues and challenges of being a physician, led to improvements in both meaning in work and burnout for participants [53]. Since peer support has always been part of how physicians deal with intense circumstances, this could be enhanced on the organizational level by formal peer support or coaching programmes [55,56]. Furthermore, investments could be made to create a psychologically safe environment by facilitating (peer) reflection and discussion regarding engagement, vitality, and

Conclusion
This large inventory of physicians' reflections indicates that being a humanistic practitioner is at the heart of professional performance, referred to in terms such as calling, meaning or purpose.
Physicians translate this calling further into everyday practice by explicit focus on striving for excellence, humanistic practice and accountability. They feel their high performance is hindered by threats deriving from a perceived extensive administrative workload as well as collaboration issues.
These threats negatively affect the calling for being a doctor and hamper the ability to be a humanistic practitioner. informational meeting was held per institution, to inform all physicians about the tool an about the anonymized usage of the data for scientific purposes and research for any -including the currentstudy. The leading author was involved in this process in order to answer any questions. All physicians were subsequently part of the decision-making process to actually continue with the INCEPT tool in their hospital.

Consent to publish
Not applicable.

Availability of data and materials
Due to the sensitive nature of the raw data on which the conclusions of the manuscript rely, it is not publicly available. Please contact the authors for further information. The raw data were digitally collected and encrypted in accordance with the General Data Protection Regulation Implementing Law. The data-administrator granted the leading author permission to use the encrypted data for the current study.
design. MG led the process of analysis and interpretation of the data. BB participated in the analysis through additional coding. BB, EB, MH and KL additionally contributed to interpretation of the data through discussion of and reflection on the analysis. MG wrote all the drafts, which were revised with input from all authors. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors approved the final manuscript for publication. CodingTemplatewithexamplarQuotations.pdf ProfessionalPerformanceModel.pdf Appendix1.pdf