The need for physician-centered research:
results of a bi-national study
Stiefel F, Bourquin C, Orsini S,
Stiefel Fa, Terui T, Machino T, Ishitani K
Psychiatric Liaison Service, University Hospital Lausanne,
Switzerland and Higashi Sapporo Hospital, Japan

Fondation Leenaards, Association Suisse des Sciences Médicales

The need for physician-centered research
It is important to care about and for patients, but it
is also important to care about and for clinicians- Clinicians are affected by their « outer » (context) and their« inner » world (psychic) and they deserve attention- Clinicians lived experience of their profession impacts onpatients, the practice of medecine and the health caresystemStiefel F. Bourquin C: The lived experience ofphysicians: A call for research.
Cancer Research Switzerland 2015: 69-73

What kind of influences (from the outerand inner world) are clinicians subjected to?
 Societye.g., dominant discourses on medecine, death and dying; expectations,judiciarization, modification of the patient-clinician relationship, etc.

 Institutional context and environmente.g., institutional constraints (efficacy, administrative work), changes ofpractice (fragmentation and stadardization of care), physician shortage, etc.

 Socialization and relational ties of clinicianse.g., hidden curriculum of medicine, hierarchical systems, conformisme,infighting, competition, corporatisme, etc.

 Clinicians’ emotions and psychological healthe.g., fears, burn-out, cognitive dissonance (cynicism, frustration, substanceabuse), lack of engagement, interferences of biography with care, etc.

A few clinical examples: the influences formthe « outer » and the « inner » world• Outer world:– Society: from shared decisions to a shift of responsability– Institutional context: side effects of a complaint center– Socialization: an oncologist and his ambivalent patient• Inner world– When biography interferes with medical care
Bourquin C, Stiefel F, Panese F, Schaad B: « What was
the hardest to endure for the patient was me »: how physicians
experience patient complaints. Pat Edu Couns (submitted)

What do we know
about clinicians’
lived experience ?

1)

The literature focuses on burnout,
psychopathology and job dissatisfaction2) The lived experience of physicians (N = 28) and nurses(N = 30) [Focus Groups (N = 8) of different hospitals(N = 9) and different disciplines (N = 4)] in EoL care
*Results: unvoiced topics

Physician-centered research: a bi-national study

Methodology• Swiss physicians (N = 33, 20 men) and Japanesephysicians (N = 18, 12 men) of different hierarchicallevels and various disciplines• Outer world– Photo-elicitation methods (sociology)– Purpose-designed techniques (quotes)• Inner world– Projective methods (psychology)

Narrative facilitators

 Society

Reactions of physicians facing
discourses about medicine ?

Some examples / Swiss physicians
I think our profession has changed …there are more
and more demands put on the physician … we areloosing our identity …we are not anymore infallible(change of identity, status and role)
The human side is put between parentheses…(cognitive dissonance)
The public is fascinated and on the same time
fearful of medicine…(ambivalence of society) Institutional context,
work environmentReactions of physicians facing a clinician’s day of work ?

Some examples (Japanese physicians)
This physician seem to fill in forms, he is forcedto do this, he seems bored ... he looks at the PC
for a holiday location…(institutional constraints)
The people seem to be alone, everyone in hisbubble… (lack of relationships)
In the meeting, they all look up to theboss…(hierarchy)
He is happy work is done, he will now have adrink…(stress-related behaviour) Socialization

Reactions of physicians facing
quotes from peers ?
Quotes from qualitative studies (Japan) or books(Switzerland) on different aspects of medicine:
Such as the way clinical work is conceived,
hierarchy, gender differences, medical knowledge
and attitudes, role models and relationship withpeers

Examples (Swiss physicians)
A physician has to do everything and to know
everything…(physician-hood)I think it’s essential to have some distance towards thepatients… (rules in clincics)
I’ve got used to things, I even consider that I lackcompassion… (physician fatigue)
I have the impression physicians have difficulties to talkabout themselves …(lack of communication)

 Clinicians’ emotions andpsychological healthReactions of physicians facing scenes of a clinician whoworks, encounters a patient and peers, and is alone ?

Stiefel F, Nakamura K, Terui T, Ishitani K: Collusions Between Patients andClinicians: Why Clarity Matters. J Pain Symptom Manage 2017; 53: 776-782

An illustration of a sequence,
blurred and without soundExamples (Japanese physicians)
Ahh, professor’s round, all are following him
blindly…(conformisme)
This physican turns in circles, he has to announce
bad news to his patient …(anxiety)

He is afraid to has to go see his boss … (hierarchyrelated anxiety)
He is not in a good condition, I would like to ask him
what’s the matter …(physician’s suffering)Analyses• Different perspectives and methods can be used
to analyse the data, first results• Thematic analysis of the narratives’ contents,
reactions towards the narrative facilitators, etc.
• Directions of narratives as a whole, individual
narratives and typologies of physicians, minority
discourses, etc.

Narratives of Japanese physicians I
A physician with a tough and stressfull job, a kind of« lonely fighter », who feels torn between his ideal ofpatient-centered care and a harsh clinical reality withtime pressure.

Patients are generally considered as preoccupied« consumers » and he fears to deceive them. He
deplores a lack of understanding of andcommunication with patients, but also with peers.
The health care system is perceived as excellent forthe patients, but less for physicians.

Narratives of Japanese physicians II
Despite the harsh reality, no complaints are voiced andrules of conduct guide him in a somehow constraining
and not supportive environment and a society which
delegates some of its problems to medicine …
While difficulties with communication runs like a red
thread throughout the narratives and the joyful sides ofthe profession remain unvoiced, no indication exists ofwhat has been called the collapse of morale amonghospital physicians. Yasunaga H: The catastrophic collapse of morale
among hospital physicians in Japan, Risk Manage Healthcare Pol 2008; 1:
1-6
Stiefel F, Stiefel F, Machino T, Terui T, Ishitani T, Bourquin C:
Spotlight on Japanese physicians: an exploratoration of theirprofessional experience by means of stimulated narratives(submitted)

Narratives of Swiss physicians
A physician who face a practise under transformationand on the way to be increasingly dominated bytechnics, affected by a identity crisis and a loss ofprestige in an environment, which shows considerable
ambivalence towards medicine.
A physician who has a positive outlook on the developments,fascinated by medical progress and increased possibilities.
A lonely fighter, only understood by peers, with his work andlife are almost collapsed.

A last general comment
In the past, health and medicine have played alimited role within society and physicians wereoften entirely devoted to their profession, andhighly respected. While today health and medicine
have become very important issue within society quoting Foucault: health has replaced salvation -,physicians seem to less value their professions
and immigrate into an inner insulation
Foucault M: Naissance de la clinique, PUF
1963. The Birth of the Clinic, Routledge
Classics edition, 2003

Conclusions• Physicians somehow endure their destiny, some of them
reported difficulties to « see the whole picture » in which
medicine in practised.
• I hardly ever use this part of my brain !
 We need to know more about the physicians Training: Conscientization, Reflexivity, Introspection

Stiefel F, Saraga M, Bourquin C: Clinicalcommunication: don’t forget the physician !
Med Educ 2017; DOI 10.1111/medu.13279

And a final word …