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Volgograd State Medical University, Volgograd, Russia
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Improvement of medical care is the topical issue of the health care system; its solution requires significant economic investment, based on the results of sociological research. In this regard, the author conducted a comprehensive study of the social and psychological parameters of the doctor’s professional role with a view to explicate its possible deviations. The study was conducted within the sociology of medicine, using its qualitative and quantitative methods, as well as a number of psycho-diagnostic tests. The results showed that the discrepancy between the level of the neuro-emotional and physical stress of medical practice and the institutional and professional valuation parameters leads to deviations in the professional role of the doctor, which is explicated as professional deformations of two types: general professional and special.
Professional team of doctors, Professional deformations, The professional role of the doctor, Professional stagnation.
The problem of the healthcare industry optimization is closely connected with the problem of its human resources (Leonova, 2013). In particular, the results of the expert survey conducted within the framework of the Foresight Research (2010-2015) showed that regardless of the planned growth of health care costs, one should not expect a breakthrough in the application of new technologies and in bridging the gap between treatment methods in Russia and in the developed countries. One of the factors of stagnation medical innovation is the low qualification level of doctors. In addition, the qualification criteria include not only narrow professional competence, but also personal and social-psychological characteristics that define this professional group in general.
The increased interest in the sociology of professions and professional groups in general, is a modern international trend, which determines the subject of international sociological conferences and for a (Abramson, 2015). One of the examples of such discussions is the conference "Challenges to professionalism: the limitations and advantages of a professional model" held by the Research Committee of Sociology of Professions and Professional groups of the International Sociological Association, in Oslo in 2008 (The committee itself was established in 1992, it works closely with research network, which deals with the sociology of the professions within the European Sociological Association, founded in 1999). The main topic of discussion at that conference was associated with the phenomenon of professionalism as a specific system of values system at work, defining specific form of social control over the employment organization and the status of certain highly professional groups in the labor market.
Proceedings of the conference demonstrate the persistence of significant differences between the Anglo-American and the continental (European) approach to the concept of professions and professionalism. The first approach, besides professions, considers occupations, in terms of their transformation into professions, on the one hand, and on the other - the privileged position of professionals in the labor market through professional closure. The second approach,which is being developed in France and continental Europe, provides wider definition of profession, and largely studies professional identity, career growth, professional training and competence.
In particular, the report delivered by D. Sciulli (University of Texas, USA) "Structural and institutional invariance in the professions and professionalism" is built on the historical approach to the study of the Anglo-American phenomenon, being consistently developed in 4 areas - medicine, law, science and engineering. The author emphasizes the institutional role of professions in the development of monopoly in the labor market, based on professional competence, collegiality and responsibility. The opposing point of view was expressed in the report delivered by E. Erikson (Oslo, Norway) on the controversial role of professional expertise in the context of the democratic foundations of civil society. Modern trends in studying the professionalization phenomenon have interdisciplinary character and define the area of scientific research in the field of theoretical and applied sociology, psychology, pedagogy, psychology. One interesting approach was described in the lecture delivered by Professor M. Sax (UK) "Challenges to professionalism: professional zoo" in the description of the profession management modes as privileged classes by the example of health care: rethinking the relationship between professions, government and citizens and their regulation was seen through the analogous relationship and regulation in the zoo. This analogy derives from comes from the neo-Weber perspective, which considers professions as the privileged groups in the field of employment, pursuing their own interests in the market, protecting their interests by using social closure tools (evaluation, monitoring, payment, etc.), sometimes having "predator" interests.
The conference proceedings reflect current trends in the field of professional management as the ways used to organize and control workers in their own interests. Thus, J. Evetts (UK) explicated new features of professionalism:
- Management principles, justifying power (as opposed to relations of authority, based on the professional credibility of the expert);
- Administration / management (as opposed to relying on legitimacy);
- Planned targets and indicators of their performance (suppressing the freedom of professionals in difficult situations related to their competences), standardization of work and financial control, competition in the individualistic spirit (as opposed to collegiality in the interaction), control over priorities on the part of the organization.
The author shares the view of most modern scholars that achieving balance between these trends and traditional values is an important problem of modern theory and practice (Edwards, Rowson & Piachaud, 2011).
The empirical base of the study is presented by the results of 15,636 studies conducted on the model, which involved 311 doctors of medical institutions and 120 respondents in the control group. The rules of confidentiality and respect for autonomy were observed in working with respondents.
The program of field study was developed by the laboratory of ethical, legal and sociological expertise in medicine of the State-Financed Institution "Volgograd Medical Research Center"; the resolution of the Ethics Committee was not required because the study was sociological in nature, and not a clinical research study.
Comparative analysis of the basic professionally significant qualities was held on model groups of doctors with regard to: a) therapeutic profiles, b) non-therapeutic profile, c) medical leaders and non-medical professionals (N = 311 people, including 151 men, 160 women, the average age made 38,4 ± 1,4 years).
The examination of medical professionals was carried out in accordance with the following analytical tasks:
Diagnostics of the Social and Psychological Attitudes of the Individual in Motivation-Interest Area
This task was solved using the method by O.F. Potemkina, which gave the possibility to identify the degree of the social and psychological attitudes, conventionally called "altruism-egoism", "process-outcome".
Definition of Nervous and Mental Stability, the Risk of Deadaptation Under Stress
This definition was conducted by the “Forecast” method, developed by the S.M. Kirov St. Petersburg Military Medical Academy for the selection of persons suitable for work in emergencies.
Diagnostics of the Alert Level Degree (Risk-Reflection)
Solution of this task was carried out by the Schubert method, which gave the possibility to define three categories of persons: "too cautious", "average values", "risk loving"
Diagnostics of Communicative Qualities
This diagnostics was carried out by using:
- The method of organizational and communicative aptitudes (OCA) definition, introduced by V.V. Sinyavskiy and B.A. Fedorishin. The valuation coefficients of communicative (Cc) and organizational (Co) aptitudes were calculated as follows: Cc = Cx / 20 and Co = Ox / 20 (where x - number of responses matching the scale) corresponded to the gradation level estimates of the considered aptitudes: 1 - low, 2 - below average, 3 - average, 4 - high, 5 - above average.
- The technique Self-control diagnostics in communication by M.Snider, according to which three levels of communicative control were identified: low (0-3 points), moderate (4-6 points), high (7-10 points).
- The test "Do you know how to listen?". The low level - up to 55 points, the average - 55 – 61 points, more than 62 points – the high level.
- The technique “Diagnostics of "interference" in establishing emotional contacts. This technique identifies four levels of emotional problems in communication: 0 - absence of interference, 1 - slight interference 2 - interference, which complicates communication, 3 - interference that hinders communication (disruptive state). The technique division "communication noise" into 5 etiological groups: 1 - the inability to manage emotions; 2 - inadequate display of emotion, 3 - inflexibility, underdevelopment of emotions, 4 - the dominance of negative emotions, 5 - emotional reluctance to get closer to other people.
Diagnosis of the emotional burnout level
Was conducted by using the technique introduced by V.V.Boyko. This technique gives the possibility to identify the stage of phase development and the formation of the main symptoms of professional burnout syndrome (PBS): in the first phase ("tension") – the symptoms of "experiencing stressful situations" "dissatisfaction with oneself", "up against the ropes", "anxiety and depression" , in the second phase ("resistance phase") – the symptoms of "inadequate selective response", "emotional and moral disorientation", "expanding the economy of emotions" and "reduction of professional emotions"; in the third phase ("exhaustion") – the symptoms of "emotional deficit", "emotional detachment", "personal detachment" (depersonalization), along with psychosomatic and psycho-vegetative disorders. The severity index of each symptom is determined by the number of points: 9 points (or less) – the symptom has not developed, 10-15 points - the emerging symptom, 16 points or more – the developed symptom. The extent of PBS phase development is determined by the number of points corresponding to its symptoms: 36 or less points – the phase is not formed, 37-60 points – the formation stage, 61 points or more – the formed phase.
Mathematical processing of data was carried out by methods of variation statistics with the calculation of parametric (t-criterion by Student) and nonparametric (χ-square) criteria of differences and correlation coefficients, using the software package Excell for Windows Statistica 10,0.
Within the framework of modern sociology, various professionalization aspects are studied by using attributive, phenomenological and anthropological methods. The first method is characterized by the assessment of features or characteristics inherent to a particular type of employment according to a predetermined scale, which determines the profession status.
Many researchers for a long time tried to elaborate universal criteria of profession. Attempts were made to formulate modalities of professionalism (Greenwood, 1965), which could give the possibility to assess subsequent approximation of a particular activity to the ideal type of profession (Millerson, 1964). The mentioned approaches reflect different aspects of professionalization; their integration into the transformation processes of the social system determines their modification. Therefore, the professionalization phenomenon cannot be isolated from the social context.
Cognitive problems of the medical profession are reflected in the papers devoted to specific features of professional medical thinking and the search for the synthesis of medical theory and practice. The development of evidence-based medicine determined the appearance of works devoted to the principles of organization and operation of medical knowledge and relevant information.
Ethical regulators related to professional activities of doctors are considered as the agents of socialization in modern deontological.
Legal regulation of the doctor professional work, as well as the ratio of ethical and legal standards are reflected in the papers by Bulanova et al.
Generally, the analysis of recent studies in this area gives the possibility to determine the main research areas in the context of the three aspects of professionalization, considering it as:
- Social phenomenon, reflecting globalization of modern society;
- The process of mastering a particular professional activity, as a process of human inclusion into the professional sphere, and, as a consequence, - subsequent acquisition of the required professional skills – the individual professionalization;
- The system of social institutions regulating the process of gaining professional role by the person, which in turn enable effective use of his/her potential.
The study of modern professional role of the doctor in the context of its social characteristics interpretation by T. Parsons: scale, obtainment method, the level of emotion, formalization and motivation, is interrelated with sociology of medicine, which gives the possibility to reveal social, psychological and somatic determinants of professional development of the individual in their integrative unity (Parsons, 1939).
Modern researchers consider professional deformations as the destructive changes of personality resulting from professional occupation. The development of professional deformations is determined by many factors: various ontogenetic changes, age dynamics, profession content, social environment, vital events and random moments.
Modern researchers consider the main socio-psychological determinants of professional destruction of personality, as professional activity stereotypes, psychological protection mechanisms, professional development stagnation, psycho-physiological changes beyond professional development and accentuation of personality traits.
The objective of this study was to explicate socially significant deviations in the professional role of the doctor in the context of various medical specialties.
Research object: Individual professionalization of medicine.
Research subject: Professional deformation of doctors.
The comprehensive examination of doctors was carried out in model groups, which included therapists, surgeons, doctors having non-therapeutic profile and medical managers by using quantitative (questionnaires, survey, content analysis) and qualitative (observation, case studies) sociological methods and techniques of psychological testing and social diagnostics. This gave the possibility to explicate the number of professional deformations of the considered professional activity:
The noted dominance of organizational qualities in the dichotomy of "communicative-organizational qualities" among therapists, against the background of low level of communication skills, can be interpreted as dominance, expressed in partial satisfaction of the need for affiliation, self-affirmation by means of others.
According to the obtained results, the average index value of communicative qualities in model groups of surgeons and doctors having non-therapeutic profile corresponds to the gradation "average level" (Table 1). It should be noted that the average value of this indicator for therapeutists refers to graduation "below average" and it is significantly less than in other medical groups (p < 0.05). The average value of organizational qualities of doctors of all groups (Table 1) corresponds to the gradation "below average" (p > 0.05). Analysis of the average values suggests that communicative properties of surgeons and doctors having non-therapeutic profile are better developed than the organizational ones. The organizational skills of therapists from the model group, on the contrary, are more developed, their average index value is higher as compared with the communication skills (p < 0.05).
|Мodel group of doctors||Communication skills||Organizational skills||р|
|М±m||Level gradation||М±m||Level gradation|
|Therapeutists||8.9±0.98*||Below average||12.0±0.99**||Below average||<0.05|
|Doctors having non-therapeutic profile||12.6±0.85*||Average||11.7±0.95**||Below average||>0.05|
Тable 1: Average index values of communication and organizational skills development of the doctors
According to the distribution analysis, half of subjects (49.8%) in the group of surgeons had communicative properties marked as "low" and "below average" in another half of subjects - "high" and "very high". Thus, persons with "very high" gradation rates constituted a significant part of the model group of surgeons (41.9%), which was significantly greater than in the group of therapeutists and the number of surgeons with low index values was less than therapeutists (p < 0, 05). At the same time, it should be noted that almost every third surgeon (33.2%) had "low" index of communicative qualities.
Most subjects from the group of therapeutists (71.6%) showed indicators of properties corresponding to "low" and "below average" gradation level, p < 0.05. Few persons showed "high" and "very high" gradations (21.3%) and this quantity significantly lower than among other medical groups (p < 0.05). Consequently, only a third of the examined therapeutists (28.4%) has adequate communication properties.
Medical practice specificity that requires professional expertise and skills can be considered as objective reason, which causes development of this deformation. Professionalism is inherently characterized by a hierarchy of competences (T. Parsons) in the expert-client relationship, which determines the superiority of professional (expert) over the recipient of professional services.
The low level of communicative control among doctors of all model groups (Table 2) allows explicating authoritarianism, which is displayed in the intolerance for criticism, reduced reflection, excessive straightforwardness, arrogance.
|Мodel groups of doctors||Number of persons (%) with regard to gradation of communication control index:|
|Doctors having non-therapeutic profile||22.7||45.4||31.9*|
Тable 2: Distribution of doctors with regard to gradation of communication control index (%)
According to Snyder’s interpretation, persons with average level of communicative control are characterized by sincerity in dialogue, restraint in expressing their emotions, respect for the opinion expressed by other people. Most of these individuals were found in a group of therapists. Individuals with high level of communicative control that were outnumbered in this study, could easily cope with communicative roles, flexibly respond to changes in the situation, can foresee the impression they make on others. However, they are characterized by impeded self-expression spontaneity; they do not like unpredictable situations. Persons with low communicative control (about one third of all examined persons) are characterized by excessive straightforwardness; they do not consider it necessary to adjust their behavior with regard to the situation, which obviously does not meet the requirements of the considered professional role.
This deformation is especially pronounced in the model group of surgeons and doctors having non-therapeutic profile, which demonstrate low levels of communication skill "to listen to the interlocutor." According to the obtained data, the average value (M ± m) of this index for therapists and doctors having non-therapeutic profile corresponds to the gradation "above average" (respectively: 64,9 ± 2,56; 64,7 ± 2,56). In the group of surgeons, this value is less than in other groups of doctors (61,27 ± 3,66, p <0.05) and corresponds to the "average" gradation.
According to the distribution analysis, most doctors demonstrated high and average values of the studied phenomenon. The largest number of persons with high values was observed in the group of therapists (61.5%) and in the group of doctors having non-therapeutic medical profile (68.2%) (p < 0.05, as compared with the surgeons). In this regard, it should be noted that the number of persons with low rates is insignificant among therapists (7.6%) and less than in other model groups (p < 0.001).
The authors believe that, prerequisites for the development of authoritarianism are also determined by the paternalistic model of interaction between doctor and patient. The doctor superiority is especially typical for surgeons, keeping in mind the fact that not only health, but also the patient's life may actually depend on the doctor’s skill.
The considered deformations are largely determined by emotional problems in communication, such as rigidity, improper display of emotions, inability to manage emotions (especially pronounced in the model group of doctors having non-therapeutic profile, which are marked by communication interference of the third level (Table 3). Disturbances in communication against the background of emotional problems could be conditionally called as communicative complex.
|Мodel groups of doctors||Number of persons (%) with different levels of “interference”|
|Nointerference Zero level||Insignificant interference Level 1||Interferencethat complicate communication Level 2||Interference that hinder communication Level 3|
|Doctors having non-therapeutic profile||31.7||40.8*||9.0**||18.4***|
Тable 3: Distribution of doctors pursuant to the results of “interference” diagnostics in the establishment of emotional contacts, according to V.V. Boyko.
Communicative disturbances, such as reluctance to associate with people on an emotional basis, emotional and personal detachment (symptoms of emotional burnout syndrome), selfish social orientation, marked among doctors of model groups, cause professional indifference.
The prevalence of resistance phase symptoms determines compensation of neuro-emotional burnout, which mechanisms reflect dominant symptoms of this phase. Thus, the comparative analysis of indices related to model group of doctors having therapeutic profile showed that the symptom of "emotional deficit", typical for the exhaustion phase, is significantly more often registered in therapists than in surgeons (13.7 and 5.6%, p <0.01) At the same time, surgeons in this phase are often characterized by the symptom of "psychosomatic and psychovegetative disorders" (16.6 and 0%, p < 0.01), and in the resistance phase – by the symptom of "emotional and moral disorientation" (respectively 3.4 and 16.6%, p < 0.01).
Consequently, compensatory mechanisms for therapists are presented by emotional detachment, i.e., indifferent attitude to patients, for surgeons – by replacement of moral imperatives.
In general, the distribution analysis gave the possibility to make a graphical profile of PBS for the representatives of the medical profession. It is an M-shaped profile, with two distinct peaks, formed due to the high prevalence of "inadequate selective response" symptom in doctors and (to a lesser extent) – due to the symptom of "reduction of professional duties "(Figure 1). Probably, the first peak of this profile is determined by the PBS protection mechanisms in medical profession. At the same time, the second peak, in the author’s opinion, provides the overall negative assessment of PBS for doctors, because it shows the negative impact of PBS on the social interaction effectiveness in this professional field.
Figure 1: Prevalence rate of PBS symptoms in doctors of different profile. (X-direction - PBS symptoms: 1- experiencing stressful situations; 2 – self-dissatisfaction, 3 – “up against the ropes”, 4 – anxiety and depression, 5 – inadequate selective response, 6 – emotional-moral disorientation, 7 – expansion of emotion economy, 8 – reduction of professional duties, 9 - emotional deficit, 10- emotional detachment, 11 – personal detachment (depersonalization), 12 – psychosomatic and psychovegetative disorders. (Translation of the Russian elements: терапевты – therapists; хирурги – surgeons; ВНП - doctors having non-therapeutic profile)
Non-typical PBS formation along with predominant symptoms of resistance phase at immature stress stage is typical for protective reactions of professional stress.
Expressed in high self-esteem and self-confidence, is found in low levels of reflection, especially in relation to the socially important and professionally significant qualities, ambiguous attitude of doctors towards a healthy lifestyle.
The model groups of therapists and doctors having non-therapeutic profile is marked by a low level of risk-reflection interpreted as personal orientation on the set course of behavior and stereotypes, which gives the possibility to determine conservatism as professional deformation.
The doctors’ focus on social selfishness (especially typical for doctors having non-therapeutic profile, 31.5%) as well as the PBS symptoms as a reduction of professional responsibility and the emotional and moral disorientation, cause the loss of empathy, psychological indifference of doctors, whose professional actions, socially revealed in caring about the patient (anamnesis, complaints) are transformed into social hypocrisy.
The low level of communicative control, psychosocial orientation toward selfishness registered in the model group of medical leaders suggest the development of role expansionism as a type of professional deformation, which is revealed in the hard line of behavior, unwillingness to understand other people, categorical judgments.
In general, such factors of inefficient management risk as the low level of communicative control, the dominance of negative emotions, low empathy, egocentric installation (15-25% of managers) complicate the implementation of leadership roles in medicine and leads to tensions in social interactions.
Specificity of the profession genesis stages and multifaceted character of medical specialties determine the creation of a continuous sociological support of medical activities, which main tasks are the following:
• rational choice of professional area, including the medical practice profile;
• timely social diagnostics of professional deformations and the development of personalized reorientation program;
• assessment of professional and personal qualities of doctors along with their performance review;
• self-assessment skills, the development of professional reflection and strengthening of corporate imperatives of the profession.
The introduction of sociological monitoring of professional activities of doctors in a legal society requires compliance with regulations and ethical standards, providing its humanistic orientation. Development of these standards is part of the social diagnostics methodology developed by the author.
E.F. Zeer believes that each profession is characterized by its own realm of deformations (Rudenko, 2011). Hence, numerous studies of professional development of teachers revealed the following deformations: authoritarianism, dogmatic teaching, indifference, conservatism, role expansionism, social hypocrisy, behavioral transfer.
Most researchers consider professional deformations as a negative phenomenon, which reduces individual adaptation possibilities. At the same time, a number of researchers believe that broadly defined development of the mindset deformations, as well as deformations of dynamic stereotypes, thinking strategies, cognitive schemes, professionally oriented semantic structures of a professional – could be regarded as natural phenomena, which character depends on the depth of professional expertise and the degree of labor tasks specificity.
E.I. Rogov suggests allocating several types of professional deformations:
General professional – determined by invariant features of professional tasks, forms of communication, mindset. In a number of other studies, they are called "professional accentuation of personality" (Klimov, 1995). K. Marx in his “Capital" called such gross violations of personality as "professional idiocy";
typological - formed by the fusion of personality characteristics and the functional structure features of professional activity (among teachers E.I. Rogov differentiates teachers-organizers and subject teachers);
individual – determined primarily by personal orientation; profession only creates favorable conditions for the development of those personal traits, which occurred before professionalization started (for example, among the teachers of primary school one could often encounter people who remained in the profession because they have strongly expressed need to have power, repression, control over other people) (Noskova, 2004) .
According to current views, deformations of doctors identified in this paper could be divided into the following groups:
1. General professional: authoritarianism, communicative complex, professional indifference, professional dogmatism, social hypocrisy.
2. Special: dominance and conservatism - for therapists, role expansionism - for medical leaders.
The explicated professional deformation on the one hand, undoubtedly cause inefficiency in some cases of social interaction in the system doctor-patient, because, as shown by the results of sociological research, Russia is characterized by a paternalistic model of the medical profession, which provides a high empathy level of a doctor as a social actor. On the other hand, contributing to the development of non-compliance in patients, professional destructions impede practical implementation of innovative medical practices as they cause distrust among consumers of health services.
Besides, such professional deformations as professional dogmatism and conservatism indicate low creativity level of doctors, which complicates implementation of innovations into medical practice (Donika, 2015).
Modern social and economic realities characterized by relentless competition in the health care market and the permanent upgrading of health care services, highlights the issue of professional competence assessment of the medical specialists, the forecast of their professional growth and career, with a view to raise their competitiveness and professional mobility. The explication of modern internalization trends related to the professional role of doctors at various stages of profession genesis gives the possibility to develop a program of sociological monitoring of professional activities to provide timely diagnostics of possible deviations in the professional role, leading to a decrease in the efficiency of social interaction in this professional area.
The study of contemporary patterns of doctor professionalization was carried out in an interdisciplinary environment, by using quantitative (questionnaires, survey, content analysis) and qualitative (observation, case studies) sociological methods as well as anthropometric techniques and psycho-diagnostic instruments. The analysis of the socio-psychological determinants of the doctor’s professional role internalization was carried out in the context of interrelation between relevant personal qualities of doctors included into model groups and the socially relevant professional competences, which present invariant professional qualities. Explicate requirements related to personal medical properties have been used as a diagnostic tool to assess social and psychological competence of doctors from model groups: a) therapists; b) surgeons; c) doctors having non-therapeutic medical profile; d) medical leaders.
The incompatibility of neuro-emotional and physical stress of medical practice and institutional status and professional valuation parameters leads to deviations in the professional role of doctors, explicated as professional deformations, which can be divided into two groups: general professional (authoritarian, communicative complex, professional indifference, professional dogmatism, social hypocrisy) and special (dominance and conservatism - for therapists, role expansionism - for medical leaders).
This study provided explication of the factors that reduce social effectiveness of innovations in medical practice and determine the need for a system of sociological monitoring of professional activities of doctors with a view to develop measures aimed at the development of their creativity in particular, and at the improvement of medical care quality in general.
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