Surgeons’ motivation for choice of workplace

The private market for health care services has increased substantially in recent years as a result of current reforms in the Danish healthcare system (HCS) and changes in the legal framework of healthcare system. An example of such a reform is the extended free-choice of hospital which was introduced in 2002. This reform gives patients the right to choose treatment at a private facility at no cost for the patient if the public hospitals cannot offer treatment within 2 months (reduced to one month in 2007) [1, 2]. Before 2002, there were only a few private hospitals in Denmark, but the private hospitals’ share of somatic treatments increased from 2.5% in 2007 to 3.9% in 2008 partially as a result of the previously mentioned reforms [3]. Along with this increase in activity, the number of privately employed physicians, mainly orthopaedic surgeons and anaesthesiologists, also rose [3, 4] (Figure 1). The emergence of private hospitals in combination with a shortage of specialized physicians in general has resulted in competition between the public and the private HCS for both patients and health care professionals (HCP). Since competent staff is a prerequisite for the provision of quality health care, it is of great importance that health care planners are aware of the employment characteristics that attract physicians. Research is scarce on what attracts physicians to certain positions, but the few existing studies suggest that factors such as collegial network as well as variation in and influence on the job are crucial factors [6, 7]. In recent years, a consolidation of public hospitals into larger units has emerged, which further differentiates public and private hospitals. They already differ from one another on crucial points such as organizational structure, number of employees and patients, and types of activities [2, 5]. The primary goal of this study was to examine what attracts physicians to employment in either a public or private hospital or a combination of both. Furthermore, we examined the potential influence of organizational structure on motivation (Figure 1).

MATERIAL AND METHODS

Design

Eight qualitative interviews were performed with physicians employed at public or private hospitals, or both. Data were collected by means of a semi-structured interview guide, which allowed the informants to elaborate openly on their perceived motives for choice of employment.

Data sampling

It was difficult to establish contact with relevant informants, and only few physicians had time to participate in the study. For this reason, the physicians included were recruited using the snowball method [8]; a method by which informants identify potential other informants. In this process, variation among participants was sought by actively seeking participants with different opinions. Since private hospitals in Denmark mainly employ surgeons [9], only surgeons were included in the study. The participants included were either plastic or orthopaedic surgeons employed at hospitals in Copenhagen. The interviews were conducted in the spring of 2011 (Table 1).

Analysis

Phenomenology

Phenomenological analysis was used to analyze the collected data. The method focuses on the study participant’s perspective [10], and the interviewer thus strives to disregard previous knowledge and opinions on the interview topic and attempts to remain as open-minded as possible. Phenomenological analysis includes four steps: 1) transcription and thorough reading of the interviews, 2) exploration of meaningful passages, 3) pooling of meaningful passages to identify themes and 4) synthesization of themes across interviews.

Theory

Due to the scarce literature on the topic, an organizational model was used to enhance the understanding of surgeons’ work preferences. The model can be used to visually understand the link between e.g. organizational size and type of work tasks, as presented later in this article.

Trial registration: not relevant.

RESULTS

Motivational factors

Five overall themes associated with motivation emerged from the analysis; patient-centred care (I), personal influence on the job (II), challenging work tasks (III), colleagues (IV) and ideological reasons (V).

Patient-centred care

The possibility to provide optimal patient care and to have more influence on the job were primarily identified as factors motivating employment at private hospitals. Patient-centred care was linked to better access to resources and more time with patients, as illustrated in the quote below from a privately employed surgeon describing his previous job at a public hospital.

"In the end I didn’t have time to be with my patients. I had to use all my time registering (...), and then some patients walked away being really unhappy, I simply couldn’t stand it anymore" (A, privately employed).

Personal influence on the job

Personal influence on the job was considered important by both publicly and privately employed surgeons. Publicly employed surgeons divided their influence into 1) influence on own tasks, e.g. in the physician-patient relationship, and 2) organizational influence in a wider perspective, concerning their ward or the hospital.

"One has more influence on working conditions at a private hospital. In general, I choose entirely how I wish to organize my day, how I deal with my patients and at what time" (F, combined employment).

Publicly employed surgeons were generally satisfied with their influence on their encounters with patients, but expressed substantial dissatisfaction regarding their over-all influence. The privately employed surgeons, on the other hand, generally felt that they had a high level of influence over-all, for example as illustrated by the quote above by a surgeon working both in the public and private sector.

Challenging work tasks

Publicly employed surgeons primarily identified challenging work tasks, colleagues and ideological reasons as the factors motivating employment in the public HCS. In Denmark, the National Board of Health and Medicines decides where specialized interventions may be performed [12] and so far highly specialized interventions have solely been performed at larger, public hospitals. Furthermore, private hospitals admit only elective and often less burdened patients [16]. This has implications for the tasks performed at public hospitals, as illustrated by the below quote.

"The public sector is the most interesting place to work; for one thing, there is a wider spectrum of patients, and it is the public hospitals which perform the complicated procedures and revisions" (F, combined employment).

Colleagues

Fulfilling relationships with colleagues, both professionally and socially, was identified as an important reason for public employment.

"When you work at a public hospital, you have colleagues who you can ask, and if you have a bad case, it’s natural to talk to one of your colleagues, whom you know to have a good knowledge on the specific topic" (P, combined employment).

The extent to which the participants reported having colleagues with whom they could discuss social and professional matters was found to be closely tied to the size of the hospital: thus, the large organization present at public hospitals ensures a large group of colleagues with different specialties. This matter was appreciated by a majority of the publicly employed surgeons.

Ideological reasons

Ideological reasons were mentioned as the primary reason why the publicly employed surgeons could not imagine seeking employment in the private HCS. Furthermore, surgeons with combined employment also voiced an ideological standpoint.

"I believe in public healthcare. I have no doubt that my heart primarily belongs to public healthcare. I believe we should have free and public healthcare for all, and it should be good" (G, combined employment).

Matters related to organizational structure

Of the five overall themes emerging from the analysis, four may be traced back to organizational structure. These themes are: achieving patient-centred care, personal influence on the job, collegial relationships and challenging work tasks. The interviews revealed that the size of the organization was of much greater importance than whether the organization was public or private:

"I don’t think it is so much about public or not-public, I think what matters is the size of the unit you’re working in. The bigger the unit, the more wards working together, the more ineffective it becomes" (E, publicly employed).

Organizational size was also addressed indirectly by two of the surgeons who explained how their respective work places had changed in character due to changes in organizational size. A publicly employed surgeon explained how he once worked in a small, public hospital where he experienced many of the positive characteristics associated with private hospitals. Adjectives such as "influence", "transparency" and "short distance from idea to action" were used to describe the small unit. Conversely, a privately employed surgeon explained how she experienced a decrease in influence due to centralization when the private hospital where she was employed expanded:

"There is no doubt that there has been a change from when it was just one hospital to now when there are x hospitals, an organizational difference definitely emerged, where one used to be close to the decisions being made, all of a sudden you were a lot further away" (C, privately employed).

The surgeons’ statements regarding (dis)advantages of large and small units, as well as their experiences with public and private hospitals losing their "advantages" due to changes in organizational structure contributed to the hypothesis that organizational size rather than public/private ownership is important when surgeons choose employment.

Reasons for combined employment

Motivational factors for a mixed position in both public and private health care did not differ from the factors mentioned by the surgeons working solely in one of the systems. Surgeons holding a position in both the public and private sector seemed to strive for the benefits of both sectors and therefore chose a combined position.

DISCUSSION

The key findings of this study were that organizational size rather than public or private ownership seemed to matter when surgeons choose HCS employment. The effect of organizational structure on various other components in an organization has already been addressed in the existing literature, e.g. Leavitt’s diamond [11] (Figure 2), as introduced in the beginning of this article. The "structure" component (e.g. a small organisation) may affect the "work task component" (e.g. more time with patients), which in turn affects the "individual component" (e.g. more satisfied surgeons). Further research is needed to determine if the results of this study may be generalised to other medical specialties. The organizational trend of consolidating wards into fewer and larger units is seen in other specialities, too [15], which makes the results of this study relevant for other specialities as well. Extensive media attention on the higher wages earned at private hospitals could lead one to believe that the salary would be mentioned as a motivational factor; however only very few of the surgeons did, and never as a primary reason for their choice of employment.

Though the amount of literature on the topic of the physician’s choice of position is scarce, the motivational factors revealed in this study are supported by existing literature. A Japanese study from 2008 reported similar motivational factors for physicians [7], and a Danish study on the topic from 2009 came to similar conclusions regarding the effect of organizational size on motivation. As illustrated in the analysis, both small and large organizations have advantages, and surgeons are therefore forced into a trade-off of advantages. The personal dilemma consists in striving to provide the optimal health care to patients, but having the feeling of being restrained from doing so due to organizational structures. Differences in motivational factors according to sex were investigated, but male and female surgeons did not differ. A reason for this may be that sex influences which speciality the physician chooses [13]. The importance of sex will therefore appear more in the selection of specialty and less in the subsequent choice employment.

Methodological considerations

A qualitative method was used since the aim was to gain in-depth understanding of how the study participants perceived and expressed their motivation for choosing their respective positions. By examining the topic using quantitative methods, e.g. questionnaires, conclusions could have been generalized to a larger group of physicians; however, due to the scarce literature on the topic, qualitative interviews were considered expedient. The results of the study are highly time-sensitive: The HCS and its structures are constantly in transition and, naturally, the opinions expressed on these matters may be equally dynamic. Furthermore, the conclusions of this study may be sensitive to geographical setting. Hospitals in the area of Copenhagen are mainly large university hospitals where physicians are facing considerable time-consuming teaching and training obligations [14] which may affect the importance of different motivational factors among surgeons. Further research on the topic of factors shaping physicians’ motivations is needed, e.g. by means of questionnaires, to further explore what attracts physicians to certain positions.

CONCLUSION

Perspectives for Danish health care

The study revealed that factors affecting surgeons’ motivation for choice of employment are multi-dimensional, complex and internally linked. They are rooted in organizational structure: size rather than whether the organization is public or private is thus crucial. Taking advantage of this knowledge in future health care planning may prevent surgeons from feeling restrained in their medical work due to organizational structures. Healthcare planners may benefit from this knowledge, e.g. by establishing smaller units within large organizations. This may ensure some of the benefits associated with working in a small organization in a larger hospital setting.

Correspondence: Lena Kähler, , Department of Public Health, University of Copenhagen, 1014 Copenhagen K, Denmark. E-mail: lena_kahler@yahoo.com

Accepted: 10 July 2012

Conflicts of interest:Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dk.