Differences in well-being between GPs, medical specialists, and private physicians: the role of psychosocial factors.

In Finland, health care is mainly publicly funded and responsibility for running health care is devolved to the municipalities (local government). The public health care system provides the largest share of primary and secondary health care services: 71 percent of outpatient physician visits and 95 percent of inpatient care periods (Vuorenkoski 2008). Public primary health care is provided by district health centers employing general practitioners (GPs) who provide most of the day-to-day medical services. Public secondary care is provided by 20 hospital districts employing medical specialists. The hospital district organizes and provides specialist medical services for the population of their member municipalities. Private health care provides both primary and secondary health care services, accounting for 16 percent of outpatient physician visits and 5 percent of hospital inpatient care. In addition to public and private health services, occupational health services provide preventive and day-to-day primary health care for their employees. In addition, occupational health services provide about 13 percent of outpatient physician visits, which are mainly organized by private sector firms (Vuorenkoski 2008). Each health care system (public, private, and occupational health services) receives some public funding, although the financing mechanisms differ. Municipalities fund public health care services and National Health Insurance (NHI) funds a share of private and occupational health care (the NHI reimburses on average 30 percent of the costs of using private health services). Patients can choose between these three health care systems, but substantial user fees can be a barrier to accessing the private sector, and occupational health care is available only to employed people. The Finnish health care system faces many challenges, including a shortage of GPs (Kokko 2009), rising health care costs, and high physician turnover from the public to private sectors (Kankaanranta et al. 2007). Within the last 10 years, a lack of GPs has led to a new trend of leasing the GPs to health centers from private firms. In 2010, 7 percent of GP posts were managed by private firms and 5 percent of health centers had their staffing arranged entirely by private firms (Parmanne 2010). A recent study of Finnish physicians showed that private physicians were more satisfied and committed to their job, and had less psychosocial disorders and sleep problems than public sector physicians. This was partly explained by higher organizational justice and job control in the private sector (Heponiemi et al. 2010a). Private physicians in Sweden had better experiences of their work environment than public sector physicians (Hellgren et al. 2006). In New Zealand, radiologists in the private sector reported less work-related stress and they had less burnout compared with secondary care radiologists (Lim and Pinto 2009). A previous study found that GPs were less committed to their organizations than other physicians (Kuusio et al. 2010). In addition, the same study found that work-related psychosocial stressors such as high job demands, low job control, and poor colleague consultation decreased organizational commitment among GPs. It has repeatedly been shown that a negative psychosocial work environment is associated with health problems such as cardiovascular diseases and symptoms of depression (Umehara et al. 2007; Couser 2008; Nieuwenhuijsen, Bruinvels, and Frings-Dresen 2010). In most theories on stress it has been argued that experienced stress is an outcome of long-term and interactional processes between environmental demands and a physician's ability to meet those demands (Lazarus and Folkman 1984; Selye 1985; McEwen 1998). Thus, it is suggested that environmental factors affect the perception of stress through the appraisal process and this appraisal (perceived psychosocial stressors) may affect psychological and physiological outcomes, such as psychological distress, self-rated health, and work ability (Karasek 1979; Karasek and Theorell 1990). These outcomes can be seen as a continuum. In this study, we expected long-term psychosocial distress to increase physical and mental health problems, and in the long run that may cause deterioration in work ability among physicians. Psychosocial distress, self-rated health, and work ability have been used repeatedly as measures of the different stages of the psychological stress process (Lundberg 1996; Elovainio et al. 2005; von Thiele, Lindfors, and Lundberg 2006). Possible differences in work-related stress across health care sectors may offer one explanation for differences in physician well-being between sectors. The role of psychosocial factors has been widely tested using the established Job Demand-Control-Support (JDC-S) model of Karasek (1979), which has shown that low job control and high demands predict health risks and lower well-being among physicians (Rodriguez et al. 2001; Elovainio et al. 2005; Heponiemi et al. 2008). Previous studies also show the importance of psychosocial stress factors as mediators. For example, an increase in job control acted as the mechanism by which improvements in mental health and sickness absence rates came about after a work reorganization intervention (Bond and Bunce 2001). Less is known about the effects of specific psychosocial work-related factors on physician well-being, such as patient-related issues, role ambiguity, or problems with teamwork. However, some studies show that patient-related stress and role ambiguity may be associated with well-being outcomes and that complex patient information systems increase the workload of physicians (Firth-Cozens 1998, 2003; Coomber et al. 2002; Likourezos et al. 2004; Couser 2008; Boonstra and Broekhuis 2010; Karsh, Beasley, and Brown 2010). In addition, a lack of social support and problems with teamwork has previously been suggested to decrease well-being and work ability among physicians working in hospitals (Kivimaki et al. 2001; Elovainio et al. 2002; Nieuwenhuijsen, Bruinvels, and Frings-Dresen 2010). Even less is known about the differences in these specific psychosocial stressors between physicians working in different health care sectors, such as primary and secondary care and private sectors, and the role they play in well-being differences among physicians. This is despite the fact that they may serve as a basis for appropriate interventions for enhancing well-being, such as decreasing psychosocial distress and health problems and increasing work ability among physicians. This study aimed at extending both theoretically and methodologically on previous studies. One aim was to produce a more detailed description of the specific factors accounting for the differences in well-being of physicians working with patients in different health care sectors. The objective of this study was to explore the role of specific psychosocial stressors that are not usually included in the established stress models/methods (e.g., Rodriguez et al. 2001; Elovainio et al. 2005; Couser 2008; Heponiemi et al. 2010a, b). Thus, we examined the association between working in different health care sectors and well-being indicators (psychosocial distress [GHQ], self-rated health, and work ability) among physicians. In addition, we tested whether specific psychosocial stressors at work (patient-related stress, stresses related to teamwork, stresses related to role ambiguity, and stresses related to patient information systems), in addition to high demands and job control would mediate the potential well-being differences in different health care sectors.