Curtail Our Assertions That Hospital Physicians Are Not Engaged

The term ‘physician engagement’ has become overused and all encompassing. A physician that does not participate in leadership or administrative activities can still be highly engaged in patient care and have high work engagement. The reasons provided by physicians for not participating in work outside of patient care can often be addressed at little cost.


Introduction
Physicians and hospitals have a unique privileging relationship -hospitals are responsible for granting annual privileges to physicians who in turn are responsible for providing a suite of services for the hospital. What's unique is while the hospital retains responsibility for managing this relationship, they do not retain the possibility for payment. The traditional carrot and stick approach to managing and engaging employees simply doesn't work.
In a hospital environment, you've likely heard from medical leadership or hospital administration that "our physicians are not engaged" or "we need to focus on improving physician engagement at our hospital". Engaged in what? By whom? How? Understanding the root of engagement as a concept may be the key to improving that engagement over time.
The Ontario Hospital Association has spent the last five years undertaking several initiatives to investigate, understand and define physician engagement. These initiatives include literature searches, publications, regional sessions, collaborations with system partners, and physician surveys. Here is a snapshot of what we discovered.

Work engagement-What is it?
A review of the literature and publications to date has created a distinction between the general concept of "engagement" and "work" engagement. Work engagement is a well-established construct in the work psychology and organizational behavior literature. It refers more to a mindset and how one approaches their work. It is defined as a positive, fulfilling work-related state of mind, which is characterized by vigor, dedication, and absorption. Individuals with high work engagement have high energy and mental resilience. They take pride in their work, are persistent, enthusiastic, inspired, fully engrossed in what they are doing, and have difficulty detaching oneself from work. [1] For hospitals, ensuring physicians have work engagement, or engagement in the clinical work that they do is rarely a challenge. Engaging in the practice of medicine is a commitment and a dedication to patients -when hospitals are talking about "engagement" of physicians they are most often referring to something else.

Physician Engagement-What Do We Really Mean?
While much of the literature references the concept of physician engagement, there weren't any sources that defined it explicitly. We conducted a conceptual analysis of the term "physician engagement" and were surprised to find that it was not synonymous with "work engagement." In fact, instead, physician engagement often referred to deciding how work was done, suggesting improvements, goal setting, self-monitoring of performance and strategic planning for the organization.
Understanding what defines engagement has been a springboard to being able to pinpoint in what specific areas physicians are engaged and identify strategies that might lead to improvement. Our conceptual analysis helped us understand why and how a physician who had high levels of work engagement might score low on overall engagement at their workplace.
After looking at data from our 2019 survey of 1096 hospital physicians immediately prior to the COVID pandemic, and then our 2021 survey of 488 hospital physicians, we identified that physicians can be engaged in their work, but not necessarily their workplace. We affirmed that physicians had high work engagement -they were engaged in their clinical practice, enthusiastic, dedicated to and absorbed in their day-to-day activities. Yet many physicians referred to themselves as being burned out and disengaged. It was this nuance that needed better understanding.
Survey results indicated that for those physicians who did get involved, they were primarily involved in 'decisionmaking.' Very few participated in 'strategic planning.' Even fewer in 'setting goals and suggesting improvements' with least involvement in 'self-monitoring performance.' In line with our results, the literature suggests that physicians can be engaged in their clinical practice but not engaged with the organization and it's administration. [3] Findings also support the health care literature on work engagement [4,5] and burnout. [6] While physicians demonstrate high engagement in their work, burnout remains a significant concern. Distinguishing burnout from engagement is critical -the terms cannot be used synonymously as physicians can be both highly engaged and highly burned out at the same time.

Top Reasons Given for Not Participating at an Organizational Level
When we asked physicians why they weren't engaged at an organizational level, the results intrigued us. The top five reasons included: not being asked to participate; too much bureaucracy; lack of opportunity; no leadership support; and fear of negative consequences from leadership. Virtually no where did the results of our survey suggest that not being engaged was a result of lack of desire. Perhaps most surprising was that most physicians reported that they didn't trust their organization's senior leadership team, nor did they feel that the organization's senior leadership team treated them with respect.

How Can Hospitals Use This Knowledge Effectively?
Hospitals that are contemplating how to direct organizational resources to improve engagement may consider that solutions are more than likely relationship-driven -low cost, simple strategies that involve two-way communication and building trust. Hospitals that have been successful at engaging and sustaining engagement of physicians at the organizational level have reported that much of their success comes from providing ongoing opportunities to suggest improvements and participate in decision-making. Providing growth opportunities such as education and training have also been beneficial. Some organizations have suggested and implemented a physician compact-A joint agreement between an organization and its physicians, which explicitly outlines expect from you and, in turn, what you may expect from your physicians [7]. If there is ample budget, incentives and pay packages could also be considered. It is important these opportunities be communicated through various means, while emphasizing leadership support.

Conclusion
There is no doubt that physicians are and will continue to be engaged at the clinical level -the last two years of the COVID-19 pandemic are a testament to the dedication and engagement of our physicians to patient care. We know from our work that physicians can and want to be engaged in leadership opportunities at the organizational level, and that there is work to be done to improve the relationship between physicians and hospital administration specifically. As we continue this research, understanding the concept of engagement and what contributes to engagement success (or failure) has never been more important.