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Assessing the relation between career satisfaction in psychiatry with lifelong learning and scientific activity Pedro Afonso, Maria Rosário Ramos, Sérgio Saraiva, Cátia Alves Moreira, Maria Luísa Figueira

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Received date: 10 November 2013 Revised date: 11 March 2014 Accepted date: 29 March 2014 Cite this article as: Pedro Afonso, Maria Rosário Ramos, Sérgio Saraiva, Cátia Alves Moreira, Maria Luísa Figueira, Assessing the relation between career satisfaction in psychiatry with lifelong learning and scientific activity, Psychiatry Research, http://dx.doi.org/10.1016/j.psychres.2014.03.044 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Assessing the relation between career satisfaction in psychiatry with lifelong learning and scientific activity Pedro Afonsoa*, Maria Rosário Ramosb, Sérgio Saraivac, Cátia Alves Moreirac, Maria Luísa Figueiraa a

Department of Psychiatry, Faculty of Medicine, University of Lisbon, Portugal.

b

Center of Mathematics and Fundamental Applications, University of Lisbon and

Universidade Aberta (Distance learning University, Portugal). c

Psychiatric Hospital Centre of Lisbon, Lisbon, Portugal.

*First author’s address: Department of Psychiatry, Faculty of Medicine, University of Lisbon Av. Prof. Egas Moniz 1640-035 Lisboa, Portugal Telephone: + 351 21 799 95 57 Fax: +351 21 799 06 12 E-mail: [email protected]

Abstract: Lifelong learning (LLL) is an essential feature for the doctor to keep clinically updated and has been described as an indicator of competence and professionalism. The aim of this study was to evaluate the association between career satisfaction in psychiatry, lifelong learning, and commitment in scientific activities, taking into account other personal and professional effects. The survey was sent to 453 national psychiatrists and 190 surveys (41.9%) were completed online and validated. The Jefferson Scale of Physician Lifelong Learning (JSPLL) was used to assess the level of LLL for each doctor. The results of the analysis of JSPLL showed that participants more satisfied with their career have greater motivation and invest more in the LLL. Furthermore, participants 1

who were more satisfied with their career had a higher percentage of scientific activity in the last year. Multiple linear regression with these two effects in the model revealed a positive association between career satisfaction in psychiatry, LLL and the publication of scientific papers, leading to the main conclusion that satisfaction with a career in psychiatry has a significant correlation with LLL and with involvement in scientific activities. Keywords: career satisfaction, Jefferson scale of physician lifelong learning, lifelong learning, psychiatry. 1. Introduction Research on satisfaction with a career in medicine is important because career satisfaction is a key factor in a physician’s physical, psychological, and social wellbeing. Therefore, this has a positive impact on the quality of the health care provided to patients. Despite the importance and consequences of career satisfaction in psychiatry, it has received little attention in research. Dissatisfaction with one’s professional life is related to burnout (Govardhan et al., 2012; Kumar, 2011; Rossler, 2012), and can harm the doctor–patient relationship, leading to worse treatment outcomes (Lasalvia, 2009; Priebe, 2004). In psychiatry, the physician must make a sustained effort to keep up-to-date with medical and scientific developments in the relevant area of expertise (Lewis, 1998; Panda and Desbiens, 2010). Thus, physicians must be lifelong learners throughout their professional careers, taking time to keep abreast of advancement in their specialty. This task is increasingly difficult in a society where scientific, technological, and social changes occur quickly. The need for continuing professional development is recognized by several national and international medical organizations, as well as by some documents that highlight the importance of continuing medical education (Association of American Medical Colleges (AAMC), 1999; Epstein and Hundert, 2002; Gonnella et al., 2004). Lifelong learning (LLL) is extremely valued in the medical practice, and has been described as an indicator of competence and professionalism (Arnold, 2002; Duff, 2002; Nelson, 1998). Thereby, medical associations, scientific societies, medical schools, and various 2

medical institutions promote initiatives that aim to impart knowledge and provide professional development training for physicians. However, the relation between career satisfaction and continuing professional development has received little attention. Therefore, the aim of this paper was to investigate this link in the field of psychiatry. In summary, this study evaluates the association between career satisfaction in psychiatry, LLL in the field of medicine, and involvement in scholarly and scientific activities (i.e. publication and review of scientific papers, participation in research projects, organization of conferences or scientific meetings). In addition, we also focus the relation between career satisfaction in psychiatry and gender, age, length of practice, and overall grade achieved in medicine.

2. Methods For the purposes of this study a questionnaire was designed in order to collect the following demographic data: final grade achieved in medicine (from 10 to 20, national scale), time of clinical practice and scientific activity in the last year. The assessment of overall satisfaction with a career in psychiatry was measured with a single question as follows: How would you rate your overall satisfaction with your medical career? Participants answered to this question using a Likert scale, ranging between 1 (not at all satisfied) and 10 (totally satisfied). In order to assess the physician’s LLL, we used the Jefferson Scale of Physician Lifelong Learning (JSPLL) (Hojat et al., 2003; Hojat et al., 2009a; Hojat et al., 2009b; Hojat et al., 2006).This is a self-report scale consisting of 19 items that evaluate motivation and investment in LLL. The answers were classified in a Likert type scale ranging from 1 (strongly disagree) to 4 (strongly agree). The scale of 19 items measures four subscales (or dimensions) with explicit meaning. The first subscale relates to professionalism, motivation and beliefs related to learning (items 1, 2, 3, 4, 8, 11, 12, 13 and 14). The second subscale relates to academic activities (items 5, 9, 10 and 15). The third subscale concerns the attention given to learning opportunities (items 6, 14, 17 and 18). Finally, the fourth subscale relates to technical skills for finding information (items 7 and 19). Overall scores were calculated by the sum of respective items. Higher scores means greater participation in LLL. This scale has been validated for the Portuguese medical population (Salgueira et al., 2009). 3

2.1.Participants An e-mail invitation to participate in this survey, with unique hyperlink, was sent to all 453 psychiatrists members of the Portuguese Society of Psychiatry and Mental Health. Participation in the study was voluntary, and the questionnaire was confidential and anonymous. 190 surveys (41.9%) were returned completed and validated and form the base of our analysis. To simplify the identification and interpretation of the relationship between satisfaction and other variables, the data was divided into three groups based on levels of career satisfaction. Participants were categorized as “least satisfied” (scores 2–6), “moderately satisfied” (score of 7), and “very satisfied” (scores 8–10) with their careers (Hojat et al., 2010). 2.2.Statistical Analysis Statistical analysis included descriptive statistics, statistical modeling and tests for groups in order to investigate the hypotheses of the research. The methods were chosen as they were the most suitable to the different types of response scales of the survey, correlation analysis, stepwise regression and ANOVA were considered. Nonparametric approaches were used whenever the assumptions of the parametric tests failed. Although most of the scales had already been validated in the Portuguese population, a preliminary analysis of the internal consistency was conducted (Salgueira et al., 2009). For the 19-items of the Jefferson Scale, the Cronbach’s (α) reliability coefficient of 0.842 was obtained, which corresponds to a high internal consistency of the scale. The chi-square (χ2) test was used to test the association between all the categorical variables, while linear correlation coefficients, Pearson and Spearman, were applied for variables in the interval and ratio scales. An exploratory factor analysis was performed using the Jefferson scale to assess how well the four subscales are reflected by this sample. Oneway analysis of variance (ANOVA) was conducted on the independent variable (factor) satisfaction (low, moderate, and high) with all of the previous variables entered as dependent variables, namely the total JSPLL and the four sub-scales. Subsequent posthoc tests (Tukey and Duncan) were performed (Table 1). Finally, multiple regression was used to identify variables that best predicted the career satisfaction and scholarly

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activity in the context of LLL. For all statistical analyses, we used Statistical Package for the Social Sciences (SPSS Inc., Chicago, Illinois, USA), version 20.0. 3. Results The 190 completed answers to the survey (valid response rate of 41.9%) are divided into men (46.8%) and women (53.2%), aged between 25 and 73 years old (M = 39.5, SD = 12.2 years). The mean time completed in medical practice was 14.35 years (SD = 12.13). The Final mean grade in the degree in medicine was 15.03 (SD = 1.3), meaning a rating on the border of Very Good (in a 20 point maximum). The mean level of satisfaction with the medical profession was 6.69 (SD = 1.7). While 3 subjects showed the minimum level of satisfaction observed (2), 5 subjects revealed the maximum of the scale (10). As mentioned before, the criterion used by Hojat was adopted (Hojat, 2010) to define three groups of satisfaction. The number of participants included in each career satisfaction group was as follows: 73 participants (38.4%) were placed into the less satisfied group (LS); 58 (30.5%) into the moderately satisfied group (MS); and 59 (31.1%) into the very satisfied group (VS). Note that even though the MS group registered a score of 7, this was two points above the midpoint of the scale (5), suggesting that members of this group were satisfied with their careers. Table 1 (post here) Table 2 (post here) Regarding participation in scientific activities (Table 2), it appears that MS participants participated in the least scientific activity in the last year. In the case of scientific paper publication, the differences between the MS group and the LS and VS (see Table 2) were significant (p = 0.042). In order to investigate LLL variables significantly correlated with satisfaction with medical career, a multiple linear regression was conducted, using different methods of variable selection (trying all variables and sequential methods) The full model has the following predictor variables: age, final grade in medicine (degree), total time of clinical practice, overall JSPLL score, all five JSPLL subscales, and gender (as a dummy variable). 5

The overall model was significant and explains 5.9% (adjusted R2) of the variability in satisfaction. The total JSPLL score was the only significant predictor of satisfaction (b=0.066, p = 0.000). Considering these results, a new model was tested with the four JSPLL subscales as predictors in order to identify which dimension contributes most for the satisfaction. In order to limit problems of collinearity in the model and to identify, if possible, which subscales are determinant for career satisfaction, the total JSPLL score was omitted from the model. In this second analysis, the only significant variable for career satisfaction was the "active participation in academic research activities" (second subscale of JSPLL scale), (b = 0.094, p= 0.054 < 0.10). Active participation in academic research explained about 4.8% of the variance in the model. As mentioned earlier, the second subscale consists of four items, including "I publish articles in peer-reviewed journals." Moreover, in the survey, the VS group had published the most scientific articles in the last year (39.3%), which is consistent with the results of the JSPLL subscale. As we can observe, although this influential variable was identified, the model based in the JSPLL total explains more of the variability of career satisfaction than the second model. The score JSPLL contains the information of all subscales, and we can take into account the effect of age, graduation final grade, and total time of clinical practice. The first model is more parsimonious, has greater explanatory power, and meets more conditions for validity; therefore, this model was referred in the present study. Thus, the authors demonstrate that LLL correlates positively with the degree of career satisfaction. 4. Discussion Understanding career satisfaction in psychiatry is a complex issue involving numerous factors. The professional satisfaction of physicians has been studied in several countries, along with the socio-cultural aspects related to health policies (Van Ham et al., 2006). Some characteristics that influence job satisfaction have been reported, such as satisfaction with available resources, working hours, opportunity to apply technical skills, autonomy, relationships with patients, professional relationships with colleagues, and the social status and remuneration of other health professionals (Ben-David, 1958; Mechanic, 1975; Nylenna et al., 2005; Qian and Lim, 2008; Sibbald et al., 2003). Despite the complexity of factors that influence job satisfaction, the medical profession 6

has some specific requirements. For example, it requires that professionals keep up-todate throughout their practice, in order to provide the best care to their patients. Moreover, some studies evaluating physician’s satisfaction with their career indicate that the opportunity to conduct research while working in a university hospital or in a hospital where research is possible, along with the opportunity to combine clinical activity with teaching, are factors that increase satisfaction with medical career (Kitai et al., 1999; Skolnik et al.,1993; Sobreques et al., 2003). The results obtained with the JSPLL scale (total score and subscales results) were higher in the VS group (Table 1). The results obtained with the JSPLL scale (total score and subscales results) were higher in the VS group (Table 1). This means that the Score in LLL is positively and significantly associated with higher levels of satisfaction with medical career. Our results are further supported by a U.S. study (Hojat et al., 2010) that used the same assessment tool. Participants in the VS group reported higher scores on all five items assessing scholarly activity in the last year (Table 2) than did the MS group. The linear regression model demonstrated that career satisfaction is correlated with physician’s LLL and scholarly activity, specifically with the publication of scientific articles. Therefore, this study indicates that ongoing active learning is associated with the satisfaction of psychiatrists with their medical career. Similarly, regular participation in scholarly activities is also positively associated with satisfaction levels. LLL and scholarly activity are interconnected, and both provide benefits since doctors cannot practice high quality medicine without constantly updating their medical knowledge. Continuing professional development is often used to advance a medical career; for example, one can give greater importance to a candidate involved with research activity, since this would be a way to encourage not only updating clinical knowledge and skills, but also to stimulate research activity in psychiatry. Physicians are lifelong learners because scientific advances in medicine are constant, which leads to the need to continuously update knowledge. Using LLL, there are ways to enhance and stimulate learning throughout doctors’ careers. The results of this study provide evidence suggesting that career satisfaction is directly linked to LLL. Therefore, increased levels of satisfaction with a career in psychiatry

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promote greater understanding and practice within psychiatry, ultimately leading to an improvement in mental health care. Interestingly, final grade achieved in medical school was not correlated with medical career satisfaction, research activity, or JSPLL scores. Although academic success is linked to the intelligence of graduates (Fergunson et al., 2002), postgraduate training and scholarly activity are linked to other aspects such as personality (Mcmanus et al., 2003). In other words, intelligence itself is not a predicting factor of a satisfying medical career since it also does not correlate with the number of scientific publications (Mechanic, 1975). As such, satisfaction with the medical profession is likely related to factors beyond the scope of this study (Smith, 2001). Age and length of time spent in medical practice were also not correlated with career satisfaction. It would be difficult to make a more detailed analysis with these variables, given that physicians are at different career stages and may consider some factors related to satisfaction more important than others. For example, salary may be a quite significant incentive for professionals in management positions (Kontodimopoulos et al., 2009), while burnout is perhaps more salient for younger doctors (Winefield and Anstey, 1991). This study has some limitations. One limitation of this study includes the 41,9 % response rate which is not as high as studies done in other developed countries (which typically range around 60%) (Hojat et al., 2010; Sibbald et al., 2003; Skolnik et al., 1993). This may be due to differences in the culture of cooperation and disclosure. Therefore, we have to admit that 41.9% response rate could hinder generalization of the findings from this study. Despite that, response representativeness is more important than response rate in survey research (Cook et al., 2000). For that reason, we compared respondents (n=199) and non respondents (n=263) to assure representativeness of the sample and no significant differences were observed for the variables of interest. Notably, satisfaction with a medical career involves several dimensions not evaluated in this study (e.g., working conditions, salary, and career progression). Thus, we recognize that our methods do not allow us to evaluate other factors that may explain the satisfaction with the medical profession.

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Our study shows that medical career satisfaction in psychiatry is related to the extent to which a physician participates in continuing professional development (e.g., scholarly activities). The results indicate the need to strengthen medical education, ensuring provisions for physicians to update their clinical knowledge. Still, it is important to increase scholarly activity throughout one’s career in psychiatry to ensure that physicians keep up-to-date with developments in the field and continue to contribute to research in psychiatry. Together, these two measures have a positive impact not only on the physician’s career satisfaction in psychiatry, but also on the level of health care provided to patients. Acknowledgments: The authors would like to thank the Portuguese Society of Psychiatry and Mental Health for the support given in this study. They would also like to thank to Ana Fernandes from the Medical School of Lisbon for the secretarial support. Conflict of interest: The authors declare having no conflicts of interest regarding this article. Sources of funding: There were no external sources of funding to implement this article. The second author was partially supported by FCT- Fundação para a Ciência e a Tecnologia, Portugal, within the project PEst-OE/MAT/UI0209/2011. References Association of American Medical Colleges (AAMC), 1999. Contemporary issues in medicine—medical informatics and population health: report II of the Medical School Objectives Project. Academic Medicine 74, 130–141. Arnold L., 2002. Assessing professional behavior: yesterday, today, and tomorrow. Academic Medicine 77, 28–37. Ben-David J., 1958. The professional role of the physician in bureaucratized medicine: a study in role-conflict. Human Relations 4, 255–274.

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Table 1. Comparison of mean scores on the scales in the three groups of career satisfaction ANOVA. Variable

Less satisfied (LS)

Moderately satisfied (MS)

Very satisfied (VS)

F

p

Difference between groups (posthoc tests or multiple comparisons)

57.9

59.5

62.7

8.76

0.00**

VS > MS = LS

I. Professionalism, motivation, and beliefs related to learning

30.8

31.8

32.3

4.74

0.010*

VS > LS

II. Active participation in academic research activities

9.8

9.7

11.1

6.75

0.001**

VS> MS = LS

III. Active behavior in updating professional knowledge and skills

11.5

11.9

12.8

3.13

0.045*

VS> MS = LS

IV. Technical skills for information search

5.8

6.1

6.4

8.76

0.00**

VS >LS

JSPLL (total)

JSPLL Subscales

*

p< 0.05

**

p < 0.01

13

Table 2: Frequencies of participants who participate in scholarly activity within each group of career satisfaction Level of career satisfaction χ2(2)

Less satisfied (LS), n=73

Moderately satisfied (MS), n=58

Very satisfied (VS), n=59

%

%

%

Published a scientific article

44%

33%

56%

6.36

0.042*

Reviewed a scientific article

21%

21%

24%

0.21

0.90

Presented oral communication

52%

47%

61%

2.52

0.284

29%

28%

37%

61.1%

63.8%

Organization of a scientific event Participated in a research project

75%

p

1.51

0.47

2.83

0.243

* p< 0.05. Table 3. Mean scores and standard deviations for the 19 items of the JSPLL scale (N=190). Variable/item

Mean

Standard Deviation

1. Searching for the answer to a question is, in and by itself rewarding.

3.3

0.55

2. Lifelong learning is a professional responsibility of all physicians.

3.82

0.38

3. I enjoy reading articles in which issues of my professional interest are discussed.

3.58

0.49

4. I routinely attend annual meetings of professional medical organizations.

3.27

0.66

5. I routinely Exchange e-mail with colleagues.

2.92

0.74

6. I read professional journals at least once every week.

2.77

0.74

14

7. I routinely search computer databases to find out about new developments in my specialty.

3.13

0.71

8. I believe that I would fall behind if I stopped learning about new developments in my profession.

3.59

0.55

9. I give on average at least one presentation per year at a professional meeting.

2.73

0.95

10. I conduct research as a principal investigator or a coinvestigator.

2.34

1.05

11. I attend educational programs whether or not CME credit is offered.

3.44

0.64

12. One of the important goals of medical school is to develop students’ lifelong learning skills.

3.44

0.65

13. Rapid changes in medical science require constant updating of knowledge and development of new professional skills.

3.63

0.54

14. I always make time for self-directed learning, even when I have a busy practice Schedule and other professional and family obligations.

2.79

0.78

15. I publish articles in peer-reviewed journals.

2.21

0.92

16. I recognize my need to constantly acquire new professional knowledge.

3.55

0.51

17. I routinely attend continuing medical education programs to improve patient care.

3.19

0.66

18. I take every opportunity to gain new knowledge/skills that are important to my profession.

3.29

0.62

19. My preferred approach in finding an answer to a question is to search the appropriate computer databases.

2.94

0.74

15

Assessing the relation between career satisfaction in psychiatry with lifelong learning and scientific activity.

Lifelong learning (LLL) is an essential feature for the doctor to keep clinically updated and has been described as an indicator of competence and pro...
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