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Time clock requirements for hospital physicians
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Health Policy journal homepage: www.elsevier.com/locate/healthpol
Time clock requirements for hospital physicians Chen Shapira a,1 , Iris Vilnai-Yavetz b,∗ , Anat Rafaeli c,2 , Moran Zemel c,3 a b c
Carmel Medical Center, Haifa, Israel Department of Business Administration, Ruppin Academic Center, Emek Hefer 4025000, Israel Faculty of Industrial Engineering and Management, Technion Institute of Technology, Haifa, Israel
a r t i c l e
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Article history: Received 12 August 2014 Received in revised form 17 April 2016 Accepted 19 April 2016 Keywords: Clocking in Time clocks Hospital physicians Sense of calling Quit intentions
a b s t r a c t An agreement negotiated following a doctors’ strike in 2011 introduced a requirement that physicians in Israel’s public hospitals clock in and out when starting and leaving work. The press reported strong negative reactions to this policy and predicted doctors deserting hospitals en masse. This study examines physicians’ reactions toward the clock-in/clock-out policy 6 months after its implementation, and assesses the relationship between these reactions and aspects of their employment context. 676 physicians in 42 hospitals responded to a survey assessing doctor’s reactions toward the clock, hospital policy makers, and aspects of their work. Reactions to the clock were generally negative. Sense of calling correlated positively with negative reactions to the clock, and the latter correlated positively with quit intentions. However, overall, respondents reported a high sense of calling and low quit intentions. We suggest that sense of calling buffers and protects physicians from quit intentions. Differences in reactions to the clock were associated with different employment characteristics, but sense of calling did not vary by hospital size or type or by physicians’ specialty. The findings offer insights into how physicians’ working environment affects their reactions to regulatory interventions, and highlight medical professionalism as buffering reactions to unpopular regulatory policies. © 2016 Elsevier Ireland Ltd. All rights reserved.
1. Introduction “Everyone clocks-in. I can’t complain about the principle cause the agreement signed improved our salary substantially. But along with my huge workload, the need to punch in a clock when everyone sees – my staff and my patients – is difficult. It is humiliating and does not
∗ Corresponding author. Tel.: +972 9 8983033; fax: +972 9 8981317. E-mail addresses: [email protected] (C. Shapira), [email protected] (I. Vilnai-Yavetz), [email protected] (A. Rafaeli), [email protected] (M. Zemel). 1 Tel.: +972 4 8250301; fax: +972 4 8559940. 2 Tel.: +972 4 8294421; fax: +972 4 8295688. 3 Tel.: +972 4 8235713; fax: +972 4 9555315.
respect our profession. Usually it is production line staff who punch in a clock.” (A senior physician, a clinic manager, March, 2016) This opening quote, voiced recently by a hospital physician in a large Israeli hospital, is an authentic reaction to a requirement imposed on all hospital physicians in Israel to clock-in and out of their hospital work. The requirement was introduced in 2011, and the Israeli medical system is until today living with its ramifications. The current study uses this situation to study the reactions and implications of requiring hospital physicians to clock in and out of work. Health care in Israel, governed by a 1995 National Health Insurance Law, provides a basic benefits package that covers diagnosis, treatment, preventive medicine, all forms of hospitalization, and medication. The standards of Israel’s public medical system are very high, as evidenced by the
http://dx.doi.org/10.1016/j.healthpol.2016.04.013 0168-8510/© 2016 Elsevier Ireland Ltd. All rights reserved.
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country’s high life expectancy (the 9th highest in the world in 2012 [1]). Most hospitals in Israel are general hospitals owned and run either by the government or by the largest of Israel’s public health maintenance organizations (HMOs); these are all considered public-sector hospitals. Only a few hospitals are privately owned. In 2012, about 23,500 doctors were actively working in Israel, of whom 42% were female, 47% were up to 45 years of age, and 40% were employed by a hospital [2]. Sixty percent of the latter (i.e., 24% of all physicians) were pure “hospitalists,” working only in hospitals, not in other public clinics or in private practice [2]. Given that, as noted, most of Israel’s hospitals are public-sector institutions, in this paper terms such as “hospital” and “hospitalist” refer to public-sector hospitals unless otherwise specified. Salaries and contractual obligations of hospital and other public-sector doctors in Israel are set through negotiations between the government and the physicians’ professional organization (the Israeli Medical Association [IMA], http://www.ima.org.il/ENG/Default.aspx). However, in general, salaries paid by Israel’s public health system are relatively low, especially compared to the rest of the Western world, and physician salaries are the subject of continuous dispute. Many physicians work several health care jobs, and in particular, combine employment in public and private institutions to improve their income. Meanwhile, physicians have often been accused of abusing the public system, devoting extra time to their private practices at the expense of their public-sector commitments. In 2011, a 158-day physicians’ strike ended with a new contract that increased the average pay of public-sector physicians by 49% while introducing several new provisions (details about the strike and contract can be found in [3]). One critical condition of the contract was a move to curtail perceived abuses of the system by requiring hospital physicians to clock in and out, thus enabling their pay to be linked directly with the hours they were in the hospital. Prior to the strike, and until the clock-in/clockout requirement was introduced, there was no formal or systematic monitoring of the hours that physicians were present in hospitals. The new policy was therefore based on perceptions rather than objective data. Time clocks are rarely used for monitoring hospital physicians, and where they are used (in some hospitals in the USA, UK and France), this is primarily for insurance purposes, or to verify compliance with regulations regarding hours worked (cf. http://www.hopkinsmedicine. org/hmn/W06/feature2.cfm). Thus, to our knowledge, the Israeli case is the first example of a Western nation where clocking in and out is connected to physician compensation. The clock-in4 policy in Israel thus provides a unique opportunity to examine factors that relate to physicians’ reactions to time monitoring policies. In particular, clock-in policies are generally associated with lower-skilled workers, whose compensation is often explicitly linked with hours worked, as opposed to highly skilled professionals such as medical doctors, who expect remuneration in
4 In the rest of this paper, we use the term clock-in to refer to a clockin/clock-out policy.
keeping with their education and training [4,5]. Indeed, the identity of medical doctors is tightly bound up with an ethos of medical work as a mission or calling [6–8], and physicians are presumed to be motivated by internal goals rather than by the promise of extrinsic rewards [9]. The current project used an electronic survey to assess physicians’ reactions to the clock-in requirement after it had been in place for several months, and the relationship between those reactions and two variables: physicians’ sense of calling and intentions to quit. Over 650 physicians in 42 hospitals around the country responded to a set of questions designed to elicit their attitudes and intentions as well as professional characteristics. Our goals were (a) to examine whether and how the introduction of the clock tested the potency of the sense of calling in which medical professionalism takes pride, and (b) to elucidate whether and how features of the doctor’s professional life and employment setting (e.g., hospital size and type, medical specialty, and whether or not the physician also worked outside the hospital) affect the tested relationships. Below, we first develop our predictions regarding the intersection of professional sense of calling and reactions to the time clock. We then describe our study and empirical findings. We conclude by discussing limitations of the current study and implications of the results. 1.1. Research hypotheses Our first two hypotheses relate to physicians’ status as high-skilled professionals and their well-established sense of calling [6–8]. As noted above, a clock-in requirement implies a one-to-one relationship between hours worked and compensation – a relationship typically associated with less-skilled work [4,5]. We therefore expected that physicians would respond negatively to the clock-in policy, viewing it as an affront to their professional status. Further, we expected that negative reactions to the new policy would be highest among those physicians with the strongest sense of calling, on the grounds that those individuals would be most sensitive to the offensive symbolism of the clock. Formally we propose: H1. Physicians’ sense of calling to the medical profession will be (positively) related to negative reactions to the clock-in requirement. The requirement to clock in and out also means a loss of personal control. Along with the offensive symbolism of the clock-in policy, we expected this loss of control to engender negative emotions that would induce in doctors a desire to quit their jobs [10]. We therefore expect a positive relationship between negative reactions to the clock and reported intentions to quit: H2. Physicians’ negative reactions to the clock-in requirement will be (positively) related to intentions to quit. Taken together, our first two hypotheses suggest that we expect greater sense of calling to produce more-negative reactions, and more-negative reactions to produce greater intentions to quit. However, the sense of calling, as a central aspect of physicians’ identity and source of self-respect [6–8], can also be expected to serve as a
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shield that buffers intentions to quit, despite the negative implications of the clock-in policy. We thus expect to find a generally high sense of calling, and generally low rates of quit intentions, despite any negative reactions to the clock. H3. Physicians will report a generally high sense of calling and low intentions to quit. Our next three hypotheses examine how a physician’s work setting and professional life might relate to reactions to the clock and quit intentions. First, we presume that physicians employed in clinical contexts with a more demanding workload and daily routine are likely to have more-negative reactions to the clock. Therefore, we expect doctors working in larger hospitals and/or in major trauma centers – i.e., in more demanding, high-stress settings – to report more-negative reactions to the clock than physicians working in less-demanding contexts. H4. Physicians working in larger hospitals and/or in major trauma centers will report stronger negative reactions to the clock. By the same reasoning, we expect doctors working in more-stressful hospitals to report a higher sense of calling, which – following the reasoning employed above – should provide a shield to the challenges presented by the clock. Thus, we expect such physicians to report less drastic intentions to quit following their negative reactions to the clock than doctors working in less-stressful hospitals: H5. Physicians working in larger hospitals and/or in major trauma centers will report lower intentions to quit. Finally, the clock-in policy was designed as a way of structuring the hours physicians spend in the hospital and limiting their ability to use hospital time for private practice. As such, we expected physicians with additional work outside the hospital (e.g., in another clinic or in private practice) to see the clock as a greater constraint, and to react to the clock more negatively, than others who worked only in the hospital. Hence our fifth hypothesis: H6. Reactions to the clock of pure “hospitalists” will be less negative than those of physicians with additional work outside the hospital. 2. Method 2.1. Data collection and sample Data were collected approximately 6 months after the introduction of the clock-in requirement, using an electronic survey comprising 38 Likert-scale type questions along with questions eliciting details about the respondent’s work context. We emailed the full population of public hospital physicians in Israel a link to the study survey (the survey is described in Section 2.2.2). Physicians were assured that participation was voluntary and that their responses would be fully anonymous. To ensure anonymity, responses were forwarded directly to the researchers by the data collection tool with no means of identifying the specific respondent. As an incentive to respond, we informed the physicians that a summary of the
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survey results would be made available to all respondents. In addition, following Magro et al. [11], we sent recipients of the original email two reminders, one 7 days after the initial distribution of the survey and the second a week later (i.e., two weeks after the initial distribution). Privately owned hospitals either did not implement the clock-in policy or did so only for medical residents, and are therefore not included in this study. 2.2. Research variables 2.2.1. Independent variables As summarized in Table 1, we collected data on five variables for each responding physician. Three of these related to characteristics of the physician, and two to characteristics of the hospital where the respondent reported working: Professional rank. There were four groups of respondents: residents (medical school graduates undergoing specialty training); young specialists (residency graduates who have been working in their specialty for less than 3 years); senior specialists (doctors who have been working in their specialty for at least 3 years); and heads of department. For the analyses, respondents were categorized into two levels: “junior” (residents and young specialists) and “senior” (senior specialists and department heads). Specialization. This measure originally included 28 options (e.g., neurology, pediatrics, cardiology, nephrology, etc.). For the analyses, these were collapsed into five groups: internal medicine; surgery; pediatrics and obstetrics/gynecology; geriatrics, psychiatry, and rehabilitative medicine; and other. Size of hospital (number of beds) was based on information obtained from the Israeli Ministry of Health, which divides hospitals into four size categories (see Table 1). For the analyses these were reduced to two groups: “small” (up to 500 beds) and “large” (501 beds and up). Function of hospital. Hospitals were defined based on their main function: trauma center (trauma level 1), general hospital (including trauma levels 2 and 3), or long-term care center, based on the Ministry of Health classification. Additional work was assessed via three yes/no survey items asking respondents whether they also worked outside the public hospital in which they were employed. The three items elicited information on additional work in (1) an HMO, (2) a private clinic, and/or (3) a private hospital. 2.2.2. Dependent variables The 38 items in the main survey assessed six constructs capturing physician emotions toward and perceptions of the time clock, their emotions toward the policy makers responsible for introducing the clock, their sense of calling, and their intentions to quit. All responses were on a 5-point Likert scale, with 1 = “strongly disagree” and 5 = “strongly agree”. The full list of items is given in Table 2. Negative emotions toward the clock were measured via four items adapted from Watson et al. [12]. A sample item: “Having to punch the clock frustrates me.”
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Table 1 Characteristics of physicians in the research sample (N = 676). Variable
Frequencies in the research sample
Frequencies in physicians’ population
Professional rank Junior (resident or young specialist) Senior (specialist or department head)
30% 70%
34% 66%
Specialization Internal medicine Surgery Pediatrics and ob/gyn Geriatrics, psychiatry, rehabilitative med. Other
30% 24% 16% 10% 20%
36% 13% 20% 8% 23%
Hospital size Small (up to 500 beds) Large (over 500 beds)
42% 58%
48% 52%
Main function of the hospital Long-term care (geriatric, psychiatric, rehabilitative) Trauma center (trauma level 1) General hospital (trauma levels 2 and 3)
11% 49% 40%
12% 54% 34%
Additional work No additional work outside hospital Additional work outside hospital
69% 31%
62% 38%
Gender Female Male
32% 68%
41% 59%
Negative emotions toward policy makers were also measured via four items adapted from Watson et al. [12]. A sample item: “I am angry with the policy makers’ decision regarding the requirement to punch the clock.” Perceptions of the clock as a symbol of status impingement were measured based on six items adapted from VilnaiYavetz et al. [13]. A sample item: “Making doctors punch the clock reduces their status.” Perceptions of the clock as a symbol of estrangement and aggression were also measured via six items adapted from Vilnai-Yavetz et al. [13]. A sample item: “The clock is an expression of policy makers’ aggression.” Sense of calling was measured using 15 items adapted from Wrzesniewski et al. [6]. Sample items include “The main reason I work as a doctor is to support my family financially and for the quality of life” (reverse coded) and “Working as a doctor is one of the most important things in my life.” Intentions to quit were measured using three items adapted from Mowday et al. [14]. A sample item: “During the past few months, I have thought about a career change.”
2.3. Data analysis We first calculated descriptive statistics for the dependent variables (physicians’ reactions to the clock, sense of calling, and quit intentions). We then calculated Pearson correlation coefficients to verify the expected relationships between these variables. We also calculated 2 coefficients to compare proportion of respondents in different categories (responding with high, moderate, or low sense of calling and intentions to quit). Finally, we used independent samples t-tests and analysis of variance (ANOVA) to
test for the predicted differences between groups of physicians with different employment contexts (e.g., different hospital sizes or work outside the hospital).
3. Results We received 676 responses (68% men, 32% women), which represents 16% of the full relevant population of physicians. Indeed, our study is unusual in that our data collection outreach was to the full population of relevant individuals rather than a selected sample. Hence, to assess the representativeness of our respondents, following Cook et al. [15] (p. 821), we compared the profile of our respondents to that of the full population, namely all public-sector hospital physicians in Israel [2]. As Table 1 shows, the 676 respondents are largely representative of the full population. We also note that hospital physicians comprise what Leslie [16] defined as a “relatively homogeneous population” (i.e., people with a strong group identity). In such cases, survey results regarding issues of concern to the group are unlikely to be strongly affected by response-rate bias [16], meaning that results can be considered highly credible even with seemingly low response rates. Respondents to the survey worked in 42 hospitals owned by the government or by the largest HMO, with no apparent effect of employment by the HMO vs. the government. Respondents represented 28 medical specialties and the full organizational hierarchy, from resident to department head (see Table 1). As expected, and as evident in Table 2, the results suggest generally negative emotions toward the clock and toward hospital policy makers (mean = 3.76 and 3.56, respectively, on a 5-point scale). In addition, the results show that physicians generally regard the clock as
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Table 2 Descriptive statistics and questionnaire items for dependent variables. SD
Cronbach’s ˛
1. Negative emotion toward the clock 676 3.76 4.00 5.00 Having to punch the clock frustrates me. Having to punch the clock irritates me. I am angry at having to punch the clock. Making doctors punch the clock creates tensions in the relationship between the hospital management and doctors.
1.28
0.85
655 3.55 3.75 2. Negative emotion toward policy makers I am angry with the policy makers’ decision regarding the requirement to punch the clock. The policy makers’ decision makes it hard for me to perform my job. The policy makers have humiliated me. The policy makers’ decision regarding the clock hurts my professional pride.
5.00
1.23
0.86
633 3.78 4.12 5.00 3. Perceptions of clock as symbol of status impingement Making doctors punch the clock reduces their status. Making doctors punch the clock equates their status to that of administrative staff and maintenance personnel. It’s not fitting for professional and educated workers to have to punch the clock. Making doctors punch the clock is humiliating. Making doctors punch the clock is damaging to their professional pride. Making doctors punch the clock is a show of contempt for their work.
1.21
0.94
615 3.57 4. Perceptions of the clock as symbol of aggression and estrangement between policy makers and hospital doctors The clock represents the estrangement of hospital management from doctors. The clock represents the estrangement of hospital policy makers from doctors. The clock represents the estrangement between the IMA and doctors. The clock is an expression of hospital managers’ aggression. The clock enables policy makers to express their aggression. The clock is an expression of IMA’s aggression.
1.15
0.92
574 4.14 4.19 4.38 5. Sense of calling The main reason I work as a doctor is to support my family financially and for the quality of life. (Reverse coded.) I am compelled to waste time on things which are not important. (Reverse coded.) Working as a doctor is one of the most important things in my life. I enjoy talking to other people about my work as a doctor. I would continue to work as a doctor even if I did not have financial security and could not make a good living. Working as a doctor makes the world a better place. If I had a second chance, I would choose to work as a doctor again. Working as a doctor rewards me internally. I believe that working as a doctor requires a high trust relationship. I am proud of my work as a doctor. I work out of ideology. I am dedicated to my work as a doctor. People perceive a doctor’s work as important. I perceive my work as a mission. In the framework of my job, I am able to bestow on my patients the highest quality medical treatment.
0.37
0.78
576 6. Intentions to quit 2.01 During the past few months, I have thought about a career change. During the past few months, I have considered leaving my work at the hospital. I expect that I will still be working as a doctor 5 years from now. (Reverse coded.)
0.97
0.74
Variables
N
impinging on their professional status (mean = 3.78) and as reflecting an attitude of aggression and estrangement on the part of hospital policy makers (mean = 3.57).
3.1. Relationships between sense of calling, quit intentions, and reactions to the clock Our findings confirm H1, showing the expected relationship between physicians’ sense of calling and reactions to the clock. More committed physicians were also more likely to express more negative feelings about the clock and about the policy makers who imposed it, as evident in a positive correlation between physicians’ reported sense of calling and negative emotions toward the clock (r = .24, p < .001) and toward policy makers (r = .22, p < .001). A sense of calling was also related to perceived impingement of
Mean
Median
3.83
2.00
Mode
5.00
1.00
the clock on physicians’ status (r = .28, p < .001) and to perceptions of the clock as symbolizing aggression by policy makers and estrangement between the policy makers and hospital doctors (r = .23, p < .001). These findings confirm that the more committed physicians were more offended by the clock and more likely to view it in a negative light.5 The findings also support H2, confirming a link between negative reactions to the clock and quit intentions. Positive correlations were found between quit intentions and negative emotions both toward the clock (r = .15, p < .001) and toward policy makers (r = .25, p < .001). Quit intentions were also related to perceived impingement of the clock on
5 See [17] for a review of expected correlation effect sizes in studies of relationships between attitudes and other attitudes or behavioral intentions.
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physicians’ status (r = .15, p < .001) and to perceptions of the clock as symbolizing aggression and estrangement (r = .26, p < .001). At the same time, and in support of H3, the physicians continued to report a high sense of calling (mean = 4.14) and very low intentions to quit their hospital work (mean = 2.01 on a 5-point scale). We do not have information on these variables before the introduction of the clock, so we could compare these responses. Therefore, to test H3 we used 2 to test the distribution of responses on the sense of calling index; we compared the proportion of respondents who reported high values (agree or strongly agree, 4 or 5, 67.8% of respondents; SR = 191.36 ), proportion who reported moderate values (somewhat agree, 3, 32%; SR = −7.7), and proportion who reported low values (disagree or strongly disagree, 1 or 2, 0.2%; SR = −183.7). The chi-square test (2 = 381.2, p < .000) and the SR values supported the prediction of H3. Similarly, we employed 2 to test the distribution of responses on the intentions to quit index; we compared the proportion of respondents who reported high intentions to quit (values 4 or 5, 5.9% of respondents; SR = −158.0), proportion who reported moderate values (3, 31.9%; SR = −8.0), and proportion who reported low intentions to quit (1 or 2, 62.2%; SR = 166.0). The chi-square test (2 = 273.9, p < .000) and the SR values confirmed the prediction of H3. Unrelated to the clock implementation, yet interesting and not surprising, the correlation between sense of calling and intentions to quit was negative (r = −0.20, p < .000). 3.2. Differences between groups of physicians Hypotheses 4 and 5 dealt with the relationship between physicians’ professional lives and work context, on the one hand, and their reactions to the clock and quit intentions on the other. Supporting H4, a comparison of responses by hospital size shows that physicians in larger hospitals reported stronger negative emotions toward policy makers than physicians in smaller hospitals (mean = 3.69 in larger hospitals vs. 3.38 in smaller hospitals, p < .01). Physicians in larger hospitals also viewed the clock as a stronger symbol of aggression and estrangement on the part of policy makers than physicians in smaller hospitals (mean = 3.66 in larger hospitals vs. 3.47 in smaller hospitals, p < .05). However, hospital type (long-term care vs. trauma centers) was not related to physicians’ negative reactions. Supporting H5, physicians in long-term care hospitals reported greater intentions to quit than physicians in trauma centers and general hospitals (mean intentions to quit = 1.99 and 1.89 for trauma centers and general hospitals respectively, vs. a mean of 2.27 for long-term care centers, p < .05). However, there were no significant differences between physicians in small vs. large hospitals in reported intentions to quit.
6 SR = standardized residuals. An |SR| larger than 1.96 indicates that the number of cases in that cell is significantly different from the expected if the null hypothesis were true (p < .05). The sign of the SR (±) shows the direction to which it exceeds the expected proportion (high/low).
Finally, H6 was supported. Physicians who worked outside the hospital in addition to their hospital job reported substantially more-negative reactions to the clock (mean = 3.90 vs. 3.62, p < .01) and toward hospital policy makers (mean = 3.68 vs. 3.41, p < .01) compared with physicians who did not work outside the hospital. Those with additional jobs also viewed the clock as a stronger symbol of status impingement (mean = 3.95 vs. 3.59, p < .001) and of aggression and estrangement on the part of policy makers (mean = 3.71 vs. 3.41, p < .01) relative to the pure hospitalists. Interestingly, comparisons between junior and senior physicians showed no differences in reactions to the clock, although there were differences in sense of calling and quit intentions: junior physicians reported a lower sense of calling (mean = 4.07 vs. 4.16, p < .05) and significantly higher intentions to quit (mean = 2.24 vs. 1.92, p < .01). The comparison of responses by specialty showed no systematic variations in sense of calling, quit intentions, or reactions to the clock. 4. Discussion Our point of departure for this study was the introduction of time clocks to monitor hospital physicians. We examined the implications of this policy on physicians’ emotions and attitudes early in the implementation of the policy, about 6 months after its introduction. This means that the physicians had had time to register the impact of the new policy but had not yet become habituated or oblivious to its effects. Our findings confirm that the reactions of the physicians affected were highly negative, and physicians view the requirement to clock as demeaning and unprofessional. We believe that the context of these attitudes is that other professionals in hospitals that are often required to clock in, including nurses, administrators, and paramedical personnel are all professions that require fewer years of training and, arguably, entail less-skilled or less-demanding work. Other professions are perceived by the doctors as having less responsibility regarding “patients’ life” than the physicians. Thus, physicians’ negative reactions to the clock may relate in large part to the disrespect it communicates. Our data show a relationship between physicians’ negative reactions and sense of calling, with more-committed physicians reporting significantly stronger reactions. Negative reactions were associated with greater intentions to quit. At the same time, the physicians overall report included both a high sense of calling and very low intentions to quit. These findings convey the powerful effects of medical professionalism in overcoming challenges that be engendered by regulatory policies. These results highlight the power of high moral standards associated with medical professionalism in securing doctors’ commitment toward patients. Our findings highlight the role that a sense of calling can play in helping keep physicians on an even keel in the face of non-medical challenges. The question of whether, when, and how to monitor the hours that professionals spend at work is of general social concern, both because of extensive recent changes in the organization of work time [18] and a trend of
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increasing time demands in the normative work day and work week [19]. Work-time dynamics can influence people’s health [20,21], including implications of overwork, stress and fatigue for individuals working more than one job [22], typical to many of the physicians surveyed in the present study. These issues are beyond the scope of the current study and should be examined in future research. Also beyond the scope of the present effort are the broader implications of the clock-in policy for Israel’s healthcare system, and implication for other healthcare systems that might implement such a policy. The physicians at the center of the present study had to accept time clocks because many were working in both the public and private sectors; this situation is linked to disparities in remuneration and conditions between the two systems. Payments to doctors (and consequently costs for patients) are substantially higher in the private sector. Whether the new contract and clock-in requirement will limit private medical practice during hospital employment hours is not discernable from our data. However, a follow-up of the implications of the clock at the time of writing this article illuminates the negative ramifications of the clock policy. The contract that introduced the clock-in requirement, also enabled overtime payments, which is generally one of the presumed positive outcomes of clocking-in [23], and makes our analyses relevant to any hospital (public or private sector) that may consider clocking as a control policy. Our informal follow up with directors of Israel’s hospitals shows that the negative effects of the clock outweigh the enforcement of working hours. The clock policy altered the commitment of hospital doctors, and induced a spirit that one can follow the clock and feel comfortable leaving the hospital exactly according to formal working hours. Teaching and research activities are now implicitly included in “formal working hours,” and doctors expect payment for any time they stay longer than formally defined. The clock challenges a major aspect of effective medical work, of teamwork, because this may mean work outside scheduled working hours. Some hospital directors suggest that since the clock policy was introduced, physicians’ actual working hours have been compromised by up to 30%! Moreover, the clock cannot address the major issue of the salary disparities between the private and public sector. Our study showed that respondents employed outside the hospital held stronger negative reactions to the policy than pure “hospitalists,” which seems to confirm the concerns that lead to the clocking requirement in the first place. Yet the costs of the clock solution seem to outweigh its presumed benefits. A measure that the Ministry of Health is currently considering, incentivizing physicians to engage full-time in hospital work [24] may be more effective. A program that encourages physicians to work in only one place (a hospital), removing the competing attraction of private work, could potentially also remove the need for the time clock. 4.1. Limitations and suggestions for future research An angle that our analyses could not cover is the implications of the clock-in policy for health delivery, continuity of patient care, and the concern that physicians may leave
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when their “shift” is over because a clock says so. We do have informal evidence from hospital directors that this has not happened – a result that, if true, is consistent with our analyses that doctors continue to maintain a strong sense of calling, which clearly precludes deserting patients. However, our analyses cannot identify the long-term implications for hospitals of the clocking policy, in terms of the loss of physician training and team-work. 4.2. Conclusions All the physicians we surveyed felt the negative symbolism of the time clock, regardless of whether or not they worked outside the hospital. Obviously abuse of hospital hours by physicians should be reprimanded. However, our data and analyses suggest that, although clocking may seem to control and reduce such abuse, it may actually be counterproductive. Its symbolism is demeaning and demoralizing to physicians and its implementation can introduce important costs. Acknowledgements We are grateful to Valeria Mastantuono, Yael Shababo, and Meira Ben-Gad for their assistance with the preparation of this manuscript. Funding in support of the research was provided by the Yigal Alon Chair for the Study of People at Work, an endowed chair at the Technion – Israel Institute of Technology currently held by Prof. Rafaeli; by the research authority of the Ruppin Academic Center; and by the Carmel Hospital. We hereby state that these are the sole sources of support for the research, and that there is no potential conflict of interest for any of these institutions or for any of the authors for the past 3 years. References [1] OECD. Health at a Glance 2013: OECD indicators. Available at http://dx.doi.org/10.1787/health glance-2013-en [accessed 20.04.14]. [2] Shemesh A, Rotem N, Haklai Z, Gorgi M, Horev T. Employment characteristics of physicians in Israel. In: The 5th International Jerusalem Conference of Health Policy. 2012. [3] Weil LG, Bin Nun G, McKee M. Recent physician strike in Israel: a health system under stress? Israel Journal of Health Policy Research 2013;2:33, http://dx.doi.org/10.1186/2045-4015-2-33. [4] Freidson E. The changing nature of professional control. Annual Review of Sociology 1984;10:1–20 http://www.jstor.org/stable/ 2083165. [5] Abbott A. The system of professions: an essay on the division of expert labor. Chicago: University of Chicago Press; 1988. [6] Wrzesniewski A, McCauley C, Rozin P, Schwartz B. Jobs, careers and callings: people’s relations to their work. Journal of Research in Personality 1997;31:21–33, http://dx.doi.org/10.1006/jrpe.1997.2162. [7] Frank E, Brownstein M, Ephgrave K, Neumayer L. Characteristics of women surgeons in the United States. American Journal of Surgery 1998;176:244–50, http://dx.doi.org/10.1016/S00029610(98)00152-4. [8] Hinami K, Whelan CT, Miller JA, Wolosin RJ, Wetterneck TB, Society of Hospital Medicine Career Satisfaction Task Force. Job characteristics, satisfaction, and burnout across hospitalist practice models. Journal of Hospital Medicine 2012;7:402–10, http://dx.doi.org/10.1002/jhm.1907. [9] Williams GC, Saizow RB, Ryan RM. The importance of selfdetermination theory for medical education. Academic Medicine 1999;74:992–5.
Please cite this article in press as: Shapira C, et al. Time clock requirements for hospital physicians. Health Policy (2016), http://dx.doi.org/10.1016/j.healthpol.2016.04.013
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ARTICLE IN PRESS C. Shapira et al. / Health Policy xxx (2016) xxx–xxx
[10] Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Services Research 2009;9:166–74, http://dx.doi.org/10.1186/1472-6963-9-166. [11] Magro MJ, Prybutok VR, Ryan SD. How survey administration can affect response in electronic surveys. Quality & Quan2015;49(5):2145–54, http://dx.doi.org/10.1007/s11135tity 014-0098-4. [12] Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. Journal of Personality and Social Psychology 1988;54:1063–70, http://dx.doi.org/10.1037/0022-3514.54.6.1063. [13] Vilnai-Yavetz I, Rafaeli A, Schneider-Yaacov C. Instrumentality, aesthetics and symbolism of office design. Environment and Behavior 2005;37(4):533–51, http://dx.doi.org/10.1177/0013916504270695. [14] Mowday RT, Koberg CS, McArthur AW. The psychology of the withdrawal process: a cross-validational test of Mobley’s intermediate linkages model of turnover in two samples. Academy of Management Journal 1984;27(1):79–94, http://dx.doi.org/10.2307/255958. [15] Cook C, Heath F, Thompson RL. A meta-analysis of response rates in web-or internet-based surveys. Educational and Psychological Measurement 2000;60(6):821–36.
[16] Leslie LL. Are high response rates essential to valid surveys? Social Science Research 1972;1(3):323–34. [17] Bosco FA, Aguinis H, Singh K, Field JG, Pierce CA. Correlational effect size benchmarks. Journal of Applied Psychology 2015;100(2):431–49, http://dx.doi.org/10.1037/a0038047. [18] Jacobs JA, Gerson K. The time divide. Harvard University Press; 2004. [19] Hamermesh DS, Stancanelli E. Long workweeks and strange hours. Industrial and Labor Relations Review 2015;68(5):1007–18. [20] Kleiner S, Pavalko EK. Clocking in: the organization of work time and health in the United States. Social Forces 2010;88(3):1463–86, http://dx.doi.org/10.1353/sof.0.0301. [21] Ross CE, Mirowsky J. Does employment affect health? Journal of Health and Social Behavior 1995;36(3):230–43 http://www.jstor. org/stable/2137340. [22] Baker DB. The study of stress at work. Annual Review of Public Health 1985;6(1):367–81, http://dx.doi.org/10.1146/annurev.pu.06. 050185.002055. [23] Moses LN. Income, leisure, and wage pressure. Economic Journal 1962;72(286):320–34. [24] Doctors only (Aug 6, 2015). http://doctorsonly.co.il/2015/ 08/100520/ [retrieved 10.12.15].
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Contents lists available at ScienceDirect
Health Policy journal homepage: www.elsevier.com/locate/healthpol
Time clock requirements for hospital physicians Chen Shapira a,1 , Iris Vilnai-Yavetz b,∗ , Anat Rafaeli c,2 , Moran Zemel c,3 a b c
Carmel Medical Center, Haifa, Israel Department of Business Administration, Ruppin Academic Center, Emek Hefer 4025000, Israel Faculty of Industrial Engineering and Management, Technion Institute of Technology, Haifa, Israel
a r t i c l e
i n f o
Article history: Received 12 August 2014 Received in revised form 17 April 2016 Accepted 19 April 2016 Keywords: Clocking in Time clocks Hospital physicians Sense of calling Quit intentions
a b s t r a c t An agreement negotiated following a doctors’ strike in 2011 introduced a requirement that physicians in Israel’s public hospitals clock in and out when starting and leaving work. The press reported strong negative reactions to this policy and predicted doctors deserting hospitals en masse. This study examines physicians’ reactions toward the clock-in/clock-out policy 6 months after its implementation, and assesses the relationship between these reactions and aspects of their employment context. 676 physicians in 42 hospitals responded to a survey assessing doctor’s reactions toward the clock, hospital policy makers, and aspects of their work. Reactions to the clock were generally negative. Sense of calling correlated positively with negative reactions to the clock, and the latter correlated positively with quit intentions. However, overall, respondents reported a high sense of calling and low quit intentions. We suggest that sense of calling buffers and protects physicians from quit intentions. Differences in reactions to the clock were associated with different employment characteristics, but sense of calling did not vary by hospital size or type or by physicians’ specialty. The findings offer insights into how physicians’ working environment affects their reactions to regulatory interventions, and highlight medical professionalism as buffering reactions to unpopular regulatory policies. © 2016 Elsevier Ireland Ltd. All rights reserved.
1. Introduction “Everyone clocks-in. I can’t complain about the principle cause the agreement signed improved our salary substantially. But along with my huge workload, the need to punch in a clock when everyone sees – my staff and my patients – is difficult. It is humiliating and does not
∗ Corresponding author. Tel.: +972 9 8983033; fax: +972 9 8981317. E-mail addresses: [email protected] (C. Shapira), [email protected] (I. Vilnai-Yavetz), [email protected] (A. Rafaeli), [email protected] (M. Zemel). 1 Tel.: +972 4 8250301; fax: +972 4 8559940. 2 Tel.: +972 4 8294421; fax: +972 4 8295688. 3 Tel.: +972 4 8235713; fax: +972 4 9555315.
respect our profession. Usually it is production line staff who punch in a clock.” (A senior physician, a clinic manager, March, 2016) This opening quote, voiced recently by a hospital physician in a large Israeli hospital, is an authentic reaction to a requirement imposed on all hospital physicians in Israel to clock-in and out of their hospital work. The requirement was introduced in 2011, and the Israeli medical system is until today living with its ramifications. The current study uses this situation to study the reactions and implications of requiring hospital physicians to clock in and out of work. Health care in Israel, governed by a 1995 National Health Insurance Law, provides a basic benefits package that covers diagnosis, treatment, preventive medicine, all forms of hospitalization, and medication. The standards of Israel’s public medical system are very high, as evidenced by the
http://dx.doi.org/10.1016/j.healthpol.2016.04.013 0168-8510/© 2016 Elsevier Ireland Ltd. All rights reserved.
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country’s high life expectancy (the 9th highest in the world in 2012 [1]). Most hospitals in Israel are general hospitals owned and run either by the government or by the largest of Israel’s public health maintenance organizations (HMOs); these are all considered public-sector hospitals. Only a few hospitals are privately owned. In 2012, about 23,500 doctors were actively working in Israel, of whom 42% were female, 47% were up to 45 years of age, and 40% were employed by a hospital [2]. Sixty percent of the latter (i.e., 24% of all physicians) were pure “hospitalists,” working only in hospitals, not in other public clinics or in private practice [2]. Given that, as noted, most of Israel’s hospitals are public-sector institutions, in this paper terms such as “hospital” and “hospitalist” refer to public-sector hospitals unless otherwise specified. Salaries and contractual obligations of hospital and other public-sector doctors in Israel are set through negotiations between the government and the physicians’ professional organization (the Israeli Medical Association [IMA], http://www.ima.org.il/ENG/Default.aspx). However, in general, salaries paid by Israel’s public health system are relatively low, especially compared to the rest of the Western world, and physician salaries are the subject of continuous dispute. Many physicians work several health care jobs, and in particular, combine employment in public and private institutions to improve their income. Meanwhile, physicians have often been accused of abusing the public system, devoting extra time to their private practices at the expense of their public-sector commitments. In 2011, a 158-day physicians’ strike ended with a new contract that increased the average pay of public-sector physicians by 49% while introducing several new provisions (details about the strike and contract can be found in [3]). One critical condition of the contract was a move to curtail perceived abuses of the system by requiring hospital physicians to clock in and out, thus enabling their pay to be linked directly with the hours they were in the hospital. Prior to the strike, and until the clock-in/clockout requirement was introduced, there was no formal or systematic monitoring of the hours that physicians were present in hospitals. The new policy was therefore based on perceptions rather than objective data. Time clocks are rarely used for monitoring hospital physicians, and where they are used (in some hospitals in the USA, UK and France), this is primarily for insurance purposes, or to verify compliance with regulations regarding hours worked (cf. http://www.hopkinsmedicine. org/hmn/W06/feature2.cfm). Thus, to our knowledge, the Israeli case is the first example of a Western nation where clocking in and out is connected to physician compensation. The clock-in4 policy in Israel thus provides a unique opportunity to examine factors that relate to physicians’ reactions to time monitoring policies. In particular, clock-in policies are generally associated with lower-skilled workers, whose compensation is often explicitly linked with hours worked, as opposed to highly skilled professionals such as medical doctors, who expect remuneration in
4 In the rest of this paper, we use the term clock-in to refer to a clockin/clock-out policy.
keeping with their education and training [4,5]. Indeed, the identity of medical doctors is tightly bound up with an ethos of medical work as a mission or calling [6–8], and physicians are presumed to be motivated by internal goals rather than by the promise of extrinsic rewards [9]. The current project used an electronic survey to assess physicians’ reactions to the clock-in requirement after it had been in place for several months, and the relationship between those reactions and two variables: physicians’ sense of calling and intentions to quit. Over 650 physicians in 42 hospitals around the country responded to a set of questions designed to elicit their attitudes and intentions as well as professional characteristics. Our goals were (a) to examine whether and how the introduction of the clock tested the potency of the sense of calling in which medical professionalism takes pride, and (b) to elucidate whether and how features of the doctor’s professional life and employment setting (e.g., hospital size and type, medical specialty, and whether or not the physician also worked outside the hospital) affect the tested relationships. Below, we first develop our predictions regarding the intersection of professional sense of calling and reactions to the time clock. We then describe our study and empirical findings. We conclude by discussing limitations of the current study and implications of the results. 1.1. Research hypotheses Our first two hypotheses relate to physicians’ status as high-skilled professionals and their well-established sense of calling [6–8]. As noted above, a clock-in requirement implies a one-to-one relationship between hours worked and compensation – a relationship typically associated with less-skilled work [4,5]. We therefore expected that physicians would respond negatively to the clock-in policy, viewing it as an affront to their professional status. Further, we expected that negative reactions to the new policy would be highest among those physicians with the strongest sense of calling, on the grounds that those individuals would be most sensitive to the offensive symbolism of the clock. Formally we propose: H1. Physicians’ sense of calling to the medical profession will be (positively) related to negative reactions to the clock-in requirement. The requirement to clock in and out also means a loss of personal control. Along with the offensive symbolism of the clock-in policy, we expected this loss of control to engender negative emotions that would induce in doctors a desire to quit their jobs [10]. We therefore expect a positive relationship between negative reactions to the clock and reported intentions to quit: H2. Physicians’ negative reactions to the clock-in requirement will be (positively) related to intentions to quit. Taken together, our first two hypotheses suggest that we expect greater sense of calling to produce more-negative reactions, and more-negative reactions to produce greater intentions to quit. However, the sense of calling, as a central aspect of physicians’ identity and source of self-respect [6–8], can also be expected to serve as a
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shield that buffers intentions to quit, despite the negative implications of the clock-in policy. We thus expect to find a generally high sense of calling, and generally low rates of quit intentions, despite any negative reactions to the clock. H3. Physicians will report a generally high sense of calling and low intentions to quit. Our next three hypotheses examine how a physician’s work setting and professional life might relate to reactions to the clock and quit intentions. First, we presume that physicians employed in clinical contexts with a more demanding workload and daily routine are likely to have more-negative reactions to the clock. Therefore, we expect doctors working in larger hospitals and/or in major trauma centers – i.e., in more demanding, high-stress settings – to report more-negative reactions to the clock than physicians working in less-demanding contexts. H4. Physicians working in larger hospitals and/or in major trauma centers will report stronger negative reactions to the clock. By the same reasoning, we expect doctors working in more-stressful hospitals to report a higher sense of calling, which – following the reasoning employed above – should provide a shield to the challenges presented by the clock. Thus, we expect such physicians to report less drastic intentions to quit following their negative reactions to the clock than doctors working in less-stressful hospitals: H5. Physicians working in larger hospitals and/or in major trauma centers will report lower intentions to quit. Finally, the clock-in policy was designed as a way of structuring the hours physicians spend in the hospital and limiting their ability to use hospital time for private practice. As such, we expected physicians with additional work outside the hospital (e.g., in another clinic or in private practice) to see the clock as a greater constraint, and to react to the clock more negatively, than others who worked only in the hospital. Hence our fifth hypothesis: H6. Reactions to the clock of pure “hospitalists” will be less negative than those of physicians with additional work outside the hospital. 2. Method 2.1. Data collection and sample Data were collected approximately 6 months after the introduction of the clock-in requirement, using an electronic survey comprising 38 Likert-scale type questions along with questions eliciting details about the respondent’s work context. We emailed the full population of public hospital physicians in Israel a link to the study survey (the survey is described in Section 2.2.2). Physicians were assured that participation was voluntary and that their responses would be fully anonymous. To ensure anonymity, responses were forwarded directly to the researchers by the data collection tool with no means of identifying the specific respondent. As an incentive to respond, we informed the physicians that a summary of the
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survey results would be made available to all respondents. In addition, following Magro et al. [11], we sent recipients of the original email two reminders, one 7 days after the initial distribution of the survey and the second a week later (i.e., two weeks after the initial distribution). Privately owned hospitals either did not implement the clock-in policy or did so only for medical residents, and are therefore not included in this study. 2.2. Research variables 2.2.1. Independent variables As summarized in Table 1, we collected data on five variables for each responding physician. Three of these related to characteristics of the physician, and two to characteristics of the hospital where the respondent reported working: Professional rank. There were four groups of respondents: residents (medical school graduates undergoing specialty training); young specialists (residency graduates who have been working in their specialty for less than 3 years); senior specialists (doctors who have been working in their specialty for at least 3 years); and heads of department. For the analyses, respondents were categorized into two levels: “junior” (residents and young specialists) and “senior” (senior specialists and department heads). Specialization. This measure originally included 28 options (e.g., neurology, pediatrics, cardiology, nephrology, etc.). For the analyses, these were collapsed into five groups: internal medicine; surgery; pediatrics and obstetrics/gynecology; geriatrics, psychiatry, and rehabilitative medicine; and other. Size of hospital (number of beds) was based on information obtained from the Israeli Ministry of Health, which divides hospitals into four size categories (see Table 1). For the analyses these were reduced to two groups: “small” (up to 500 beds) and “large” (501 beds and up). Function of hospital. Hospitals were defined based on their main function: trauma center (trauma level 1), general hospital (including trauma levels 2 and 3), or long-term care center, based on the Ministry of Health classification. Additional work was assessed via three yes/no survey items asking respondents whether they also worked outside the public hospital in which they were employed. The three items elicited information on additional work in (1) an HMO, (2) a private clinic, and/or (3) a private hospital. 2.2.2. Dependent variables The 38 items in the main survey assessed six constructs capturing physician emotions toward and perceptions of the time clock, their emotions toward the policy makers responsible for introducing the clock, their sense of calling, and their intentions to quit. All responses were on a 5-point Likert scale, with 1 = “strongly disagree” and 5 = “strongly agree”. The full list of items is given in Table 2. Negative emotions toward the clock were measured via four items adapted from Watson et al. [12]. A sample item: “Having to punch the clock frustrates me.”
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Table 1 Characteristics of physicians in the research sample (N = 676). Variable
Frequencies in the research sample
Frequencies in physicians’ population
Professional rank Junior (resident or young specialist) Senior (specialist or department head)
30% 70%
34% 66%
Specialization Internal medicine Surgery Pediatrics and ob/gyn Geriatrics, psychiatry, rehabilitative med. Other
30% 24% 16% 10% 20%
36% 13% 20% 8% 23%
Hospital size Small (up to 500 beds) Large (over 500 beds)
42% 58%
48% 52%
Main function of the hospital Long-term care (geriatric, psychiatric, rehabilitative) Trauma center (trauma level 1) General hospital (trauma levels 2 and 3)
11% 49% 40%
12% 54% 34%
Additional work No additional work outside hospital Additional work outside hospital
69% 31%
62% 38%
Gender Female Male
32% 68%
41% 59%
Negative emotions toward policy makers were also measured via four items adapted from Watson et al. [12]. A sample item: “I am angry with the policy makers’ decision regarding the requirement to punch the clock.” Perceptions of the clock as a symbol of status impingement were measured based on six items adapted from VilnaiYavetz et al. [13]. A sample item: “Making doctors punch the clock reduces their status.” Perceptions of the clock as a symbol of estrangement and aggression were also measured via six items adapted from Vilnai-Yavetz et al. [13]. A sample item: “The clock is an expression of policy makers’ aggression.” Sense of calling was measured using 15 items adapted from Wrzesniewski et al. [6]. Sample items include “The main reason I work as a doctor is to support my family financially and for the quality of life” (reverse coded) and “Working as a doctor is one of the most important things in my life.” Intentions to quit were measured using three items adapted from Mowday et al. [14]. A sample item: “During the past few months, I have thought about a career change.”
2.3. Data analysis We first calculated descriptive statistics for the dependent variables (physicians’ reactions to the clock, sense of calling, and quit intentions). We then calculated Pearson correlation coefficients to verify the expected relationships between these variables. We also calculated 2 coefficients to compare proportion of respondents in different categories (responding with high, moderate, or low sense of calling and intentions to quit). Finally, we used independent samples t-tests and analysis of variance (ANOVA) to
test for the predicted differences between groups of physicians with different employment contexts (e.g., different hospital sizes or work outside the hospital).
3. Results We received 676 responses (68% men, 32% women), which represents 16% of the full relevant population of physicians. Indeed, our study is unusual in that our data collection outreach was to the full population of relevant individuals rather than a selected sample. Hence, to assess the representativeness of our respondents, following Cook et al. [15] (p. 821), we compared the profile of our respondents to that of the full population, namely all public-sector hospital physicians in Israel [2]. As Table 1 shows, the 676 respondents are largely representative of the full population. We also note that hospital physicians comprise what Leslie [16] defined as a “relatively homogeneous population” (i.e., people with a strong group identity). In such cases, survey results regarding issues of concern to the group are unlikely to be strongly affected by response-rate bias [16], meaning that results can be considered highly credible even with seemingly low response rates. Respondents to the survey worked in 42 hospitals owned by the government or by the largest HMO, with no apparent effect of employment by the HMO vs. the government. Respondents represented 28 medical specialties and the full organizational hierarchy, from resident to department head (see Table 1). As expected, and as evident in Table 2, the results suggest generally negative emotions toward the clock and toward hospital policy makers (mean = 3.76 and 3.56, respectively, on a 5-point scale). In addition, the results show that physicians generally regard the clock as
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Table 2 Descriptive statistics and questionnaire items for dependent variables. SD
Cronbach’s ˛
1. Negative emotion toward the clock 676 3.76 4.00 5.00 Having to punch the clock frustrates me. Having to punch the clock irritates me. I am angry at having to punch the clock. Making doctors punch the clock creates tensions in the relationship between the hospital management and doctors.
1.28
0.85
655 3.55 3.75 2. Negative emotion toward policy makers I am angry with the policy makers’ decision regarding the requirement to punch the clock. The policy makers’ decision makes it hard for me to perform my job. The policy makers have humiliated me. The policy makers’ decision regarding the clock hurts my professional pride.
5.00
1.23
0.86
633 3.78 4.12 5.00 3. Perceptions of clock as symbol of status impingement Making doctors punch the clock reduces their status. Making doctors punch the clock equates their status to that of administrative staff and maintenance personnel. It’s not fitting for professional and educated workers to have to punch the clock. Making doctors punch the clock is humiliating. Making doctors punch the clock is damaging to their professional pride. Making doctors punch the clock is a show of contempt for their work.
1.21
0.94
615 3.57 4. Perceptions of the clock as symbol of aggression and estrangement between policy makers and hospital doctors The clock represents the estrangement of hospital management from doctors. The clock represents the estrangement of hospital policy makers from doctors. The clock represents the estrangement between the IMA and doctors. The clock is an expression of hospital managers’ aggression. The clock enables policy makers to express their aggression. The clock is an expression of IMA’s aggression.
1.15
0.92
574 4.14 4.19 4.38 5. Sense of calling The main reason I work as a doctor is to support my family financially and for the quality of life. (Reverse coded.) I am compelled to waste time on things which are not important. (Reverse coded.) Working as a doctor is one of the most important things in my life. I enjoy talking to other people about my work as a doctor. I would continue to work as a doctor even if I did not have financial security and could not make a good living. Working as a doctor makes the world a better place. If I had a second chance, I would choose to work as a doctor again. Working as a doctor rewards me internally. I believe that working as a doctor requires a high trust relationship. I am proud of my work as a doctor. I work out of ideology. I am dedicated to my work as a doctor. People perceive a doctor’s work as important. I perceive my work as a mission. In the framework of my job, I am able to bestow on my patients the highest quality medical treatment.
0.37
0.78
576 6. Intentions to quit 2.01 During the past few months, I have thought about a career change. During the past few months, I have considered leaving my work at the hospital. I expect that I will still be working as a doctor 5 years from now. (Reverse coded.)
0.97
0.74
Variables
N
impinging on their professional status (mean = 3.78) and as reflecting an attitude of aggression and estrangement on the part of hospital policy makers (mean = 3.57).
3.1. Relationships between sense of calling, quit intentions, and reactions to the clock Our findings confirm H1, showing the expected relationship between physicians’ sense of calling and reactions to the clock. More committed physicians were also more likely to express more negative feelings about the clock and about the policy makers who imposed it, as evident in a positive correlation between physicians’ reported sense of calling and negative emotions toward the clock (r = .24, p < .001) and toward policy makers (r = .22, p < .001). A sense of calling was also related to perceived impingement of
Mean
Median
3.83
2.00
Mode
5.00
1.00
the clock on physicians’ status (r = .28, p < .001) and to perceptions of the clock as symbolizing aggression by policy makers and estrangement between the policy makers and hospital doctors (r = .23, p < .001). These findings confirm that the more committed physicians were more offended by the clock and more likely to view it in a negative light.5 The findings also support H2, confirming a link between negative reactions to the clock and quit intentions. Positive correlations were found between quit intentions and negative emotions both toward the clock (r = .15, p < .001) and toward policy makers (r = .25, p < .001). Quit intentions were also related to perceived impingement of the clock on
5 See [17] for a review of expected correlation effect sizes in studies of relationships between attitudes and other attitudes or behavioral intentions.
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physicians’ status (r = .15, p < .001) and to perceptions of the clock as symbolizing aggression and estrangement (r = .26, p < .001). At the same time, and in support of H3, the physicians continued to report a high sense of calling (mean = 4.14) and very low intentions to quit their hospital work (mean = 2.01 on a 5-point scale). We do not have information on these variables before the introduction of the clock, so we could compare these responses. Therefore, to test H3 we used 2 to test the distribution of responses on the sense of calling index; we compared the proportion of respondents who reported high values (agree or strongly agree, 4 or 5, 67.8% of respondents; SR = 191.36 ), proportion who reported moderate values (somewhat agree, 3, 32%; SR = −7.7), and proportion who reported low values (disagree or strongly disagree, 1 or 2, 0.2%; SR = −183.7). The chi-square test (2 = 381.2, p < .000) and the SR values supported the prediction of H3. Similarly, we employed 2 to test the distribution of responses on the intentions to quit index; we compared the proportion of respondents who reported high intentions to quit (values 4 or 5, 5.9% of respondents; SR = −158.0), proportion who reported moderate values (3, 31.9%; SR = −8.0), and proportion who reported low intentions to quit (1 or 2, 62.2%; SR = 166.0). The chi-square test (2 = 273.9, p < .000) and the SR values confirmed the prediction of H3. Unrelated to the clock implementation, yet interesting and not surprising, the correlation between sense of calling and intentions to quit was negative (r = −0.20, p < .000). 3.2. Differences between groups of physicians Hypotheses 4 and 5 dealt with the relationship between physicians’ professional lives and work context, on the one hand, and their reactions to the clock and quit intentions on the other. Supporting H4, a comparison of responses by hospital size shows that physicians in larger hospitals reported stronger negative emotions toward policy makers than physicians in smaller hospitals (mean = 3.69 in larger hospitals vs. 3.38 in smaller hospitals, p < .01). Physicians in larger hospitals also viewed the clock as a stronger symbol of aggression and estrangement on the part of policy makers than physicians in smaller hospitals (mean = 3.66 in larger hospitals vs. 3.47 in smaller hospitals, p < .05). However, hospital type (long-term care vs. trauma centers) was not related to physicians’ negative reactions. Supporting H5, physicians in long-term care hospitals reported greater intentions to quit than physicians in trauma centers and general hospitals (mean intentions to quit = 1.99 and 1.89 for trauma centers and general hospitals respectively, vs. a mean of 2.27 for long-term care centers, p < .05). However, there were no significant differences between physicians in small vs. large hospitals in reported intentions to quit.
6 SR = standardized residuals. An |SR| larger than 1.96 indicates that the number of cases in that cell is significantly different from the expected if the null hypothesis were true (p < .05). The sign of the SR (±) shows the direction to which it exceeds the expected proportion (high/low).
Finally, H6 was supported. Physicians who worked outside the hospital in addition to their hospital job reported substantially more-negative reactions to the clock (mean = 3.90 vs. 3.62, p < .01) and toward hospital policy makers (mean = 3.68 vs. 3.41, p < .01) compared with physicians who did not work outside the hospital. Those with additional jobs also viewed the clock as a stronger symbol of status impingement (mean = 3.95 vs. 3.59, p < .001) and of aggression and estrangement on the part of policy makers (mean = 3.71 vs. 3.41, p < .01) relative to the pure hospitalists. Interestingly, comparisons between junior and senior physicians showed no differences in reactions to the clock, although there were differences in sense of calling and quit intentions: junior physicians reported a lower sense of calling (mean = 4.07 vs. 4.16, p < .05) and significantly higher intentions to quit (mean = 2.24 vs. 1.92, p < .01). The comparison of responses by specialty showed no systematic variations in sense of calling, quit intentions, or reactions to the clock. 4. Discussion Our point of departure for this study was the introduction of time clocks to monitor hospital physicians. We examined the implications of this policy on physicians’ emotions and attitudes early in the implementation of the policy, about 6 months after its introduction. This means that the physicians had had time to register the impact of the new policy but had not yet become habituated or oblivious to its effects. Our findings confirm that the reactions of the physicians affected were highly negative, and physicians view the requirement to clock as demeaning and unprofessional. We believe that the context of these attitudes is that other professionals in hospitals that are often required to clock in, including nurses, administrators, and paramedical personnel are all professions that require fewer years of training and, arguably, entail less-skilled or less-demanding work. Other professions are perceived by the doctors as having less responsibility regarding “patients’ life” than the physicians. Thus, physicians’ negative reactions to the clock may relate in large part to the disrespect it communicates. Our data show a relationship between physicians’ negative reactions and sense of calling, with more-committed physicians reporting significantly stronger reactions. Negative reactions were associated with greater intentions to quit. At the same time, the physicians overall report included both a high sense of calling and very low intentions to quit. These findings convey the powerful effects of medical professionalism in overcoming challenges that be engendered by regulatory policies. These results highlight the power of high moral standards associated with medical professionalism in securing doctors’ commitment toward patients. Our findings highlight the role that a sense of calling can play in helping keep physicians on an even keel in the face of non-medical challenges. The question of whether, when, and how to monitor the hours that professionals spend at work is of general social concern, both because of extensive recent changes in the organization of work time [18] and a trend of
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increasing time demands in the normative work day and work week [19]. Work-time dynamics can influence people’s health [20,21], including implications of overwork, stress and fatigue for individuals working more than one job [22], typical to many of the physicians surveyed in the present study. These issues are beyond the scope of the current study and should be examined in future research. Also beyond the scope of the present effort are the broader implications of the clock-in policy for Israel’s healthcare system, and implication for other healthcare systems that might implement such a policy. The physicians at the center of the present study had to accept time clocks because many were working in both the public and private sectors; this situation is linked to disparities in remuneration and conditions between the two systems. Payments to doctors (and consequently costs for patients) are substantially higher in the private sector. Whether the new contract and clock-in requirement will limit private medical practice during hospital employment hours is not discernable from our data. However, a follow-up of the implications of the clock at the time of writing this article illuminates the negative ramifications of the clock policy. The contract that introduced the clock-in requirement, also enabled overtime payments, which is generally one of the presumed positive outcomes of clocking-in [23], and makes our analyses relevant to any hospital (public or private sector) that may consider clocking as a control policy. Our informal follow up with directors of Israel’s hospitals shows that the negative effects of the clock outweigh the enforcement of working hours. The clock policy altered the commitment of hospital doctors, and induced a spirit that one can follow the clock and feel comfortable leaving the hospital exactly according to formal working hours. Teaching and research activities are now implicitly included in “formal working hours,” and doctors expect payment for any time they stay longer than formally defined. The clock challenges a major aspect of effective medical work, of teamwork, because this may mean work outside scheduled working hours. Some hospital directors suggest that since the clock policy was introduced, physicians’ actual working hours have been compromised by up to 30%! Moreover, the clock cannot address the major issue of the salary disparities between the private and public sector. Our study showed that respondents employed outside the hospital held stronger negative reactions to the policy than pure “hospitalists,” which seems to confirm the concerns that lead to the clocking requirement in the first place. Yet the costs of the clock solution seem to outweigh its presumed benefits. A measure that the Ministry of Health is currently considering, incentivizing physicians to engage full-time in hospital work [24] may be more effective. A program that encourages physicians to work in only one place (a hospital), removing the competing attraction of private work, could potentially also remove the need for the time clock. 4.1. Limitations and suggestions for future research An angle that our analyses could not cover is the implications of the clock-in policy for health delivery, continuity of patient care, and the concern that physicians may leave
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when their “shift” is over because a clock says so. We do have informal evidence from hospital directors that this has not happened – a result that, if true, is consistent with our analyses that doctors continue to maintain a strong sense of calling, which clearly precludes deserting patients. However, our analyses cannot identify the long-term implications for hospitals of the clocking policy, in terms of the loss of physician training and team-work. 4.2. Conclusions All the physicians we surveyed felt the negative symbolism of the time clock, regardless of whether or not they worked outside the hospital. Obviously abuse of hospital hours by physicians should be reprimanded. However, our data and analyses suggest that, although clocking may seem to control and reduce such abuse, it may actually be counterproductive. Its symbolism is demeaning and demoralizing to physicians and its implementation can introduce important costs. Acknowledgements We are grateful to Valeria Mastantuono, Yael Shababo, and Meira Ben-Gad for their assistance with the preparation of this manuscript. Funding in support of the research was provided by the Yigal Alon Chair for the Study of People at Work, an endowed chair at the Technion – Israel Institute of Technology currently held by Prof. Rafaeli; by the research authority of the Ruppin Academic Center; and by the Carmel Hospital. We hereby state that these are the sole sources of support for the research, and that there is no potential conflict of interest for any of these institutions or for any of the authors for the past 3 years. References [1] OECD. Health at a Glance 2013: OECD indicators. Available at http://dx.doi.org/10.1787/health glance-2013-en [accessed 20.04.14]. [2] Shemesh A, Rotem N, Haklai Z, Gorgi M, Horev T. Employment characteristics of physicians in Israel. In: The 5th International Jerusalem Conference of Health Policy. 2012. [3] Weil LG, Bin Nun G, McKee M. Recent physician strike in Israel: a health system under stress? Israel Journal of Health Policy Research 2013;2:33, http://dx.doi.org/10.1186/2045-4015-2-33. [4] Freidson E. The changing nature of professional control. Annual Review of Sociology 1984;10:1–20 http://www.jstor.org/stable/ 2083165. [5] Abbott A. The system of professions: an essay on the division of expert labor. Chicago: University of Chicago Press; 1988. [6] Wrzesniewski A, McCauley C, Rozin P, Schwartz B. Jobs, careers and callings: people’s relations to their work. Journal of Research in Personality 1997;31:21–33, http://dx.doi.org/10.1006/jrpe.1997.2162. [7] Frank E, Brownstein M, Ephgrave K, Neumayer L. Characteristics of women surgeons in the United States. American Journal of Surgery 1998;176:244–50, http://dx.doi.org/10.1016/S00029610(98)00152-4. [8] Hinami K, Whelan CT, Miller JA, Wolosin RJ, Wetterneck TB, Society of Hospital Medicine Career Satisfaction Task Force. Job characteristics, satisfaction, and burnout across hospitalist practice models. Journal of Hospital Medicine 2012;7:402–10, http://dx.doi.org/10.1002/jhm.1907. [9] Williams GC, Saizow RB, Ryan RM. The importance of selfdetermination theory for medical education. Academic Medicine 1999;74:992–5.
Please cite this article in press as: Shapira C, et al. Time clock requirements for hospital physicians. Health Policy (2016), http://dx.doi.org/10.1016/j.healthpol.2016.04.013
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ARTICLE IN PRESS C. Shapira et al. / Health Policy xxx (2016) xxx–xxx
[10] Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Services Research 2009;9:166–74, http://dx.doi.org/10.1186/1472-6963-9-166. [11] Magro MJ, Prybutok VR, Ryan SD. How survey administration can affect response in electronic surveys. Quality & Quan2015;49(5):2145–54, http://dx.doi.org/10.1007/s11135tity 014-0098-4. [12] Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. Journal of Personality and Social Psychology 1988;54:1063–70, http://dx.doi.org/10.1037/0022-3514.54.6.1063. [13] Vilnai-Yavetz I, Rafaeli A, Schneider-Yaacov C. Instrumentality, aesthetics and symbolism of office design. Environment and Behavior 2005;37(4):533–51, http://dx.doi.org/10.1177/0013916504270695. [14] Mowday RT, Koberg CS, McArthur AW. The psychology of the withdrawal process: a cross-validational test of Mobley’s intermediate linkages model of turnover in two samples. Academy of Management Journal 1984;27(1):79–94, http://dx.doi.org/10.2307/255958. [15] Cook C, Heath F, Thompson RL. A meta-analysis of response rates in web-or internet-based surveys. Educational and Psychological Measurement 2000;60(6):821–36.
[16] Leslie LL. Are high response rates essential to valid surveys? Social Science Research 1972;1(3):323–34. [17] Bosco FA, Aguinis H, Singh K, Field JG, Pierce CA. Correlational effect size benchmarks. Journal of Applied Psychology 2015;100(2):431–49, http://dx.doi.org/10.1037/a0038047. [18] Jacobs JA, Gerson K. The time divide. Harvard University Press; 2004. [19] Hamermesh DS, Stancanelli E. Long workweeks and strange hours. Industrial and Labor Relations Review 2015;68(5):1007–18. [20] Kleiner S, Pavalko EK. Clocking in: the organization of work time and health in the United States. Social Forces 2010;88(3):1463–86, http://dx.doi.org/10.1353/sof.0.0301. [21] Ross CE, Mirowsky J. Does employment affect health? Journal of Health and Social Behavior 1995;36(3):230–43 http://www.jstor. org/stable/2137340. [22] Baker DB. The study of stress at work. Annual Review of Public Health 1985;6(1):367–81, http://dx.doi.org/10.1146/annurev.pu.06. 050185.002055. [23] Moses LN. Income, leisure, and wage pressure. Economic Journal 1962;72(286):320–34. [24] Doctors only (Aug 6, 2015). http://doctorsonly.co.il/2015/ 08/100520/ [retrieved 10.12.15].
Please cite this article in press as: Shapira C, et al. Time clock requirements for hospital physicians. Health Policy (2016), http://dx.doi.org/10.1016/j.healthpol.2016.04.013