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|Title: ||Een vertrouwenskwestie? Over het samenwerken van huisartsen en bedrijfsartsen|
|Authors: ||Nauta, Noks|
Occupational health physicians
Sociaal Medische Begeleiding
|Issue Date: ||2004|
|Publisher: ||Delft: A.P. Nauta|
Introduction (chapter 1)
In the Netherlands in1999 there were about 7000 general practitioners (GPs) and about 2000 occupational health physicians (OHPs), in 2003 there were almost 10.000 GPs and about 3000 OHPs. An employee on sick leave related to the work has to do with his or her GP and OHP GPs and OHPs want to collaborate better, but in reality this collaboration is poor.
From social psychology it is known that representatives from several groups do not collaborate well because, when they identify with their own group, they feel distinct form the other group. Other factors that explain problems of collaboration are the division of responsibility, the mutual dependency and trust in the other. These concepts will be made clear in chapter 3.
The problem which is worked on in this thesis is twofold:
1 Which social-psychological factors explain why the collaboration of general practitioners and occupational health physicians, in the meaning of exchanging information on patients, is not optimal?
2 To what extent do courses and projects (a joint course in the vocational training of GPS and OHPs and regional activities) add to changes in social-psychological factors?
To answer the problem three empirical studies were carried out. Study 1 is a cross-sectional questionnaire-study, carried out in 1999 among 338 GPs and 209 OHPs in the south west of the Netherlands. Study 2 is a case study, carried out in 2000 among 34 GP-trainees and 20 OHP-trainees who followed the course ‘Learning to collaborate during social-medical management’. The case study consisted of questionnaires on several moments and oral interviews with two GPs and two OHPs one and a half year after the course. Study 3 is a part of a bigger questionnaire study, carried out in the period 2001 to 2003 to evaluate projects to enhance collaboration of GPs and OHPs in ten regions. Before and after the projects questionnaires were filled out and data of 575 GPs and 398 OHPs of whom two measurements where available where used in the study.
General practitioners and occupational health physicians (chapter 2)
In the first part the concept ‘collaboration’ is described. In the literature possible effects of collaboration by GPs and OHPs were looked for. This was done by an exploring, narrative literature search. Collaboration can enhance efficiency (less double work), there can be measurable effects like less sick leave, the quality of professional action can improve and the well-being of the patient can improve. There has not been any effect study in this field. The barriers in the collaboration of GPs and OHPs mentioned in literature can be divided in four group: legal-ethical barriers, structural barriers, practical barriers and social-psychological barriers. An essential barriers in the collaboration is in the social-psychological field. That is the theme of this thesis. The following factors will be examined: occupational identity, relative position with regard to the other, mutual dependency, division of responsibility and mutual trust. These concepts will be further explained in chapter 3.
In the second part it is made plausible that in the case GPs and OHP there are indeed two distinctive groups with an own occupational identity. Although both are medical doctors, the two groups can be seen as distinctive ‘professions’. Literature on this subject says that ‘professions’ are occupational groups with their own values and norms. Historically in the Netherlands a choice was made for a distinct division between doctors for treatment and doctors for social-medical work (‘control’). The thesis gives a description of the two groups with their history of ‘professionalising’ and some characteristics (demographic, education and registration, and content of the disciplines).
Hypotheses and questions (chapter 3)
In this chapter the theoretical basis is given. First the hypotheses and questions of study 1, the cross-sectional study among GPs and OHPs. The Social Identity Theory is first elaborated on. Based on that hypotheses are given on occupational identification and relative position. The measure occupational identification questions are asked about how the doctors feel in their own profession. For relative position the questions were to what extent one needs knowledge and competencies in more fields than the other profession. Th expectation is that both professions find themselves better than the other, but that GPs have a stronger tendency to do so than OHPs. GPs will identify themselves more with their discipline. OHPs with experience in the other discipline will have a more equal position compared to GPs. We expect GPs with experience as an OHP will feel a more equal position to OHPs (which is lower than GPs without experience as an OHP).
The hypothesis is that GPs will feel more responsibility than OHPs and feel less dependent from OHPs than the reverse. Experience in the other discipline will lead to a more equal division of responsibility and dependence.
The concept ‘trust’ is studied in literature and based on that two types of trust were chosen for this study: knowledge-based trust (KBT) en identification-based trust (IBT). KBT is trust in the work of the other (for instance diagnostic abilities) IBT is trust in the more communicative aspects of the other (openness, clearness in communication). Trust has to do with risks: do you dare to give confidential information to the other doctor? Or are you afraid that he or she uses it for other purposes and will damage the patient. Trust has to grow in a relation, it needs positive experiences. It is expected that KBT will generally be higher than IBT, because there is poor collaboration until now. For OHPs KBT and IBT will be higher than for GPs. Experience in the other profession will lead to more trust. A more equal position will also go with more trust.
OHPs will be expected to more often take the in initiative in the contact. It will be explored how many contacts the doctors have on average with the other. More contacts will lead to more trust and to a more positive evaluation of the contacts. The practical barriers in the contact are divided into controllable (internal) and uncontrollable (external) barriers. Expectation is that GPS experience more barriers than OHPs. The hypotheses will be tested in study 1 and in part also in study 3.
Exploring questions in study 1 were: how many contacts have GPs and OHPs on average with each other and which factors predict the evaluation of the contacts and the experience of the barriers?
For study 2 the questions were: how are relative position, occupational identification and dependence of GP-trainees and OHP-trainees, before and after a joint course? How is trust in the other discipline before and after the course, how many contacts do they have with the other and how is their evaluation of the contacts? How do they describe after the course the division of responsibilities and trust? Which arguments do they give to get into contact with the other and what are the benefits of the contact?
For study 3 the question was: what are the changes when comparing measurements before and after regional projects? This was about changes in relative position, occupational identification, responsibility, dependence, trust, frequency of contacts, initiative for contact, barriers and evaluation of the contacts.
Methods of research (chapter 4)
The characteristics of the group of study 1 shows that GPs and OHPs differ from each other on several demographic characteristics: age, type of employment and number of hours working. The questionnaire was constructed by the author, but ideas were used from several studies with comparable questions. There were closed questions (Likert-type), statements and there was room for remarks. Some questions were linked to daily activities of the doctors like diagnosing and referring. The procedure of the study is described. Internal consistency of the scales is sufficient to good. The study group of GPs is representative for the total group. For OHPs there are not enough data to state that. Validity and reliability are found sufficient. For the statistical process some controls were done and no adaptations were necessary.
The study group of study 2 is described, with the demographic characteristics of the four interviewees. The questionnaire and the list of items for the interviews is described, also the procedure of the study. Because of loss to follow-up the effects on longer term could not be studied.
For study 3 the demographic variables of the study group are given. After that a description of the questionnaire which is for a great deal similar to study 1.
Results and discussion (chapters 5 and 6)
The results are presented here thematically.
All doctors in study 1 and in study 3 think they need knowledge and capacities in more fields than the other discipline, but for GPs this is a stronger tendency than for OHPs. This supports the Social Identity Theory.
GP-trainees in study 2 also think they need knowledge and capacities in more fields than OHPs but OHP-trainees think they are equal to GPs. This can be explained by selection in vocational choice or selection in group of the course.
OHPs with experience as GP feel themselves more equal to GPs (study 1). This is not the case for GPs with experience as OHP. It is possible that GPs with experience as OHP feel themselves permanently ‘better’ than OHPs. It is possible that the duration of the experience plays a role.
There were no changes in relative position after the course for GP-trainees and OHP-trainees (study 2) or after the regional projects (study 3). Apparently these type of interventions do not work on these variables.
GPs identify themselves, as expected, stronger with their discipline than OHPs (studies 1 and 3). Experience in the other discipline (study 1) leads to less identification with the own profession. This can be explained by an effect of the experience on the occupational identification or (for GPS) a selection of people that choose the experience of being an OHP.
GP-trainees (study 2) have (like GPs) a stronger occupational identification than OHP-trainees. OHP-trainees have a negative score on occupational identification (score below 3) (they do not feel positive in their work). This can be explained by a general discontentment in the profession and the negative image of the occupation.
After the course for GP-trainees and OHP-trainees (study 2) and after the regional projects (study 3) no changes were found in occupational identification. It is questionable whether these changes could be expected from these type of interventions.
GPs in study 1 and in study 3 feel they have more responsibilities than OHPs in respect to for instance diagnosing and referring employees with work-relevant disorders. This was expected. The feeling of having more responsibilities is correlated to the higher relative position (study 1). Experience in the other discipline is not correlated to the feeling of having more responsibilities. It is possible that GPs as an occupational group feel a strong autonomy and freedom.
GPs and OHPs in study 2 (interviews) do more or less agree on the mutual division of responsibilities. These could be socially desirable answers.
Doctors in study 3 do not change in score on division of responsibilities after the projects compared to before.
OHPs feel, as expected more dependent on the information of GPs than GPs feel of the information of OHPs (study 1). Experience in the other profession has no correlation with this outcome (study 1). In study 3 there was no difference between the disciplines in dependence. It is possible that feelings of dependence have changed over time.
GP-trainees feel less dependent on the information of OHPs than OHPs feel dependent on the information of GPs (study 2).
After the course for GP-trainees and OHP-trainees (study 2) and after the regional projects (study 3) no changes were found in dependence.
Scores for knowlede-based trust (KBT) are for both professions together higher than for identification-based trust (IBT) (studies 1 and 3). Doctors have in general more trust in capacities of the other profession than in communication. This follows the hypothesis and is explained by the theory that states that KBT comes before IBT.
OHPs have higher KBT than GPs but lower IBT (studies 1 and 3). This is not according to the hypothesis. It might be that GPs do not make a difference between the two types of trust whereas OHPs do.
Doctors with experience in the other discipline have less trust in the other (KBT and IBT), this is contrary to the hypothesis (study 1). Doctors who know what happens in the other group may better know what goes wrong.
OHPs who feel equal in position to GPs have more KBT; GPs who feel in a lower relative position from OHPs also have more KBT; there are no correlations between relative position and IBT (study 1). A possible explanation is that relative position was asked for by more cognitive aspects. In study 3 doctors with a lower relative position feel more KBT an more IBT, with a higher relative position they feel less trust. It is possible that there are more factors working together in this phenomenon.
OHP-trainees in study 2 have more trust in the quality of the information of GPs than GP-trainees have in the quality of the information of OHPs. This is the same outcome as the results of studies 1 and 3 in respect to KBT.
Just after the course for GP- and OHP-trainees trust of GP-trainees in OHPs rises significantly but it drops later on (study 2). Apparently the course leads to a (short-lasting) rise in trust.
In GPs of study 3 KBT and IBT are higher after the projects compared to before. In OHPs there is a trend that IBT has become higher. These results may be an effect of the attention on collaboration.
In the interviews of study 2 there were questions on trust and the content of trust. GPs tell that they have more trust in OHPs. Trust is connected to what they think the OHP will do with the information given by the GP and whether this in the interest of the employee. They have a more positive image of OHPs, but this can be more improved. Negative experiences with OHPs are demotivating for the collaboration. OHPs say they trusted the GPs already before the course, a positive change could not really be expected for them.
OHPs have significantly more often contact with a GP than the reverse, more than twice (studies 1 and 3). OHPs say they have more than 20 contacts a year with a GP about a patient, GPs have almost 10 times a year a contact with an OHP. The number of referrals from OHPs to a GP (56 times a year) is significantly more than the reverse (more than 23 times, which is about twice a month).
OHP-trainees in study 2 had 4.1 contacts with a GP in the previous three months, GP-trainees 0.6 contacts with an OHP. OHP-trainees gave 0.8 times a note to the patient for the GP, GP-trainees gave a note for the OHP 0.2 times in the previous three months. Differences between the professions are significant. OHP-trainees gave on the average 19.1 times the advice to go to the GP, GP-trainees 3.0 times. The difference is not significant.
OHP-trainees and GP-trainees did not have more contact with the other profession after the course, this counts for the three forms of.
In study 3 there were no significant differences after the projects in frequency of contacts. It is assumed that visible changes in behaviour need more time.
Motives of GPs in study 2 to contact an OHP are: assuming factors in the working situation as cause of the complaint; be the advocate for the patient in the case of discourteous behaviour of the OHP. Motives of the OHPs to contact a GP are: giving information to the GP; asking for a referral by the GP; consultation with the GP about referral (who does what?), consultation about management (in the possible case of disagreement). The GPs mention the following benefits of consultation with an OHP: positive effect of being the advocate of the client; more understanding based on more information (mutual); adaptations in the workplace; adaptations in the type of work. But also a negative reaction. OHPs mention the following benefits of consultation with a GP: management that is tuned in; clear division of tasks; information of the GP as base for own management.
Doctors with more contacts with the other discipline have significant more IBT (study 1 and study 3 when tested separately for each moment). This was expected based on the affective character of IBT. Such a correlation was not found for KBT.
OHPs in study 1 with more contacts have significantly less KBT. When one has more knowledge of the other discipline (in this case by more contacts), may better know what goes wrong. This effect was not found in study 3.
Frequency of contact does not add to the variance of the change in IBT (study 3). It might be too early to see this effect.
OHPs take more often the initiative to contact a GP than the reverse; GPs agree in this (studies 1 and 3). Explanation could be that OHPs have more need for the information of GPs than the reverse.
After the project (study 3) GPs state they more often take the initiative to contact an OHP than before.
Barriers in the contact
GPs (studies 1 and 3) say they experience more often internal (controllable) barriers in the contact than OHPs. This is in agreement with the hypothesis.
OHPs experience more often than GPs two of the three external (uncontrollable) barriers. Perhaps they experience these barriers more often because they have more need for consultation.
Doctors with experience in the other discipline in study 1 less often experience both types of barriers (internal and external) when their trust (KBT) is higher. For IBT this correlation is there too but only for external barriers and only for doctors without experience in the other discipline. Apparently a combination of experience in the other discipline and KBT is needed to feel less barriers. IBT may be a stronger factor working independent of experience in the other discipline.
Experiencing internal barriers is significantly explained by discipline and IBT (study 1). Experiencing external barriers is also explained by IBT, but this effect is much smaller. More factors interact in the experience of barriers.
In study 3 IBT and KBT add significantly to the variance of experiencing external barriers. More trust lead to less experiencing of those barriers. In univariate analysis IBT also adds to the variance of internal barriers.
Evaluation of the contacts
Having more contacts correlates with a more positive evaluation of the contacts (studies 1 and 3). This supports the ‘contact hypothesis’.
Evaluation of the contacts is largely explained by both types of trust, discipline and frequency of contacts and not by the other social-psychological factors relative position, dependence, responsibility (study 1). This supports the choice of this thesis to study social-psychological factors in the collaboration.
GP-trainees and OHP-trainees (study 2) do not differ in their evaluation of the contacts with the other discipline. Especially GP-trainees had very few contacts. After the course and after the projects (studies 2 and 3) there was no difference in evaluation of the contacts compared to before.
Discussion (chapter 6)
In the discussion explanations for the results are given (see above), limitations of the studies and implications.
Limitations of the studies
These are: problems of non-response, selective response, validity of the scales, problems in the relation of attitude and behaviour, ‘common-method variance’, possible selective results of study 2, and the choice for an exploring, narrative literature review.
Theoretical and practical implications
In the studies it is found that GPs and OHPs are two separate groups, who apparently do not feel enough that they are both medical doctors. They do not feel to belong to one group of doctors working together to solve a problem. Insights from Social Identity Theory can thus apply to the problem of collaboration. This is important because based on this practical advice can be given. Relative position and trust prove to be important aspects. The nature of the relationship between trust and relative position has not become clear.
Educational experience could be used to initiate more focussed interventions.
Practical suggestions to improve collaboration:
- Talk on differences in status during meetings and in publications
- Make doctors conscious of mutual dependence, for instance by talking about cases or by an OHP consultant in GP-practices
- Clarify the division of responsibility and talk about this in meetings around cases and in telephonic consultations
- Stimulate many contacts between the professional groups (formal and informal) to build trust
- Remove practical barriers and improve the way to get in touch with each other
- Give a course on occupational health for GP-trainers.
The results can also be used for other relations where professionals collaborate.
Although there are indications that trust has grown after a course (study 2) and after regional projects (study 3) the number of contacts has not. The question is if we can expect effects on the level of patients (sick leave and disability pension). Changing attitudes and behaviour is a slow process. Showing positive effects of collaboration (for instance by experiencing a higher quality of own work) can be a stimulating factor for professionals who do not collaborate to start doing it. The rising of trust (studies 2 and 3) can be seen as a hopeful development.|
|Description: ||Academisch Proefschrift. Verdedigd 9 juli 2004 aan de Open Universiteit.
Promotor: Prof. dr. J. von Grumbkow, Open Universiteit Nederland
Leden van de beoordelingscommissie:
Prof. dr. M.C.E. van Dam-Mieras, Open Universiteit Nederland
Prof. dr. F. J. H. van Dijk, Universiteit van Amsterdam
Prof. dr. J. W. Groothoff, Rijksuniversiteit Groningen
Prof. dr. R.W.J.V. van Hezewijk, Open Universiteit Nederland
Dr. J.E.M.M. Syroit, Open Universiteit Nederland|
|Appears in Collections:||PhD School of Psychology|
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