Role stress among physician executives.

Standard sociology texts define "role" as a set of expectations applied to an incumbent of a particular position both inside and outside one's organization.(2) Role stress includes two constructs: role conflict and role ambiguity.

Komarovsky described role conflict as the psychological experience of being pulled in opposite directions.(3) The incumbent, caught in the middle, experiences a state of strain. This stress of "being caught in the middle" is role conflict. Rizzo et al. defined role conflict as having the following components.

* Individuals experience conflict between time resources or their capabilities and the defined role behavior.

* Individuals find the role requires different or incompatible behaviors for different constituencies.(4)

The shifting of gears between administrative and clinical responsibilities would appear to generate role conflict. Role conflict also can take the form of conflict between the conflicting demands of work and personal life. Physicians have long experience with this conflict.(5)

Role ambiguity occurs when the requirements of the job are not clearly expressed. Sometimes the requirements are unstated. Sometimes the unstated requirements differ from those that are stated. In either case, incumbents do not know how their performance will be measured. Rizzo et al. found a relationship between role conflict and role ambiguity.(4) The result of role conflict and role ambiguity is a state of stress.

Background Research

Various researchers have studied and reported on physician roles.(6-8) Betson studied and described the role of the physician manager.(9) She found that policy development and program management occupied physician executives' time more than resource management tasks. At this writing, her study is the most recent and authoritative on the role of physician managers. There is no study on the subject of role stress among physician executives.

Identification of role stress, its causes, and possible correctives importance to those in the roles, to others in the organization, and to those under the care of such persons. Several studies across various occupations show the relationship of role conflict and role ambiguity to organizationally dysfunctional results. Negative outcomes of role conflict include job dissatisfaction, unsatisfactory work relationships, and lower commitment to the organization.(10-17) Role ambiguity is related to job dissatisfaction, increased tension, job turnover, and other dysfunctional outcomes.(18,19) Rizzo et al. reported only a slight correlation of role conflict and role ambiguity with demographic variables of age, educational level, and tenure in the organization.(4)

In a study of nurse executives, Scalzi found a relationship between role conflict and increased depression and decreased job satisfaction.(20) She also reported that role overload, a specific form of role conflict, was a particular concern. In a study of hospital executives, Burke found several relationships.

* Role conflict was associated with job dissatisfaction.

* Job dissatisfaction varied with level in the organization.

* Role overload contributed significantly to role conflict.(21)

Study Methods

The sample for this survey was 300 randomly selected members of the American College of Physician Executives. We conducted the study from May through July of 1990. The American College of Physician Executives mailed a questionnaire to each of the participants, including a cover letter explaining the study's purpose. If the respondent had no medico-administrative responsibilities, we asked him or her to return the questionnaire without responses. Out of 300 questionnaires mailed, 130 were completed and returned, a 43 percent response rate. Nine questionnaires were excluded because respondents indicated "no medico-administrative responsibilities."

We used the instrument developed by Rizzo et al.(4) to measure role conflict and role ambiguity. Previous studies found the instrument valid and reliable.(22) Use of this instrument enabled us to make general comparisons of results with those in previous studies across various occupations. In addition to the 14 items from the Rizzo et al. instrument, we developed seven questions to specifically address role stress among physicians. (We urge caution in extrapolation of results from those questions. Researchers have not used those questions before, nor have we verified their validity or reliability.) The 21 survey items, which are shown in table 1, page 10, required a range of responses from "1" to "7" along a continuum from "strongly disagree" to "strongly agree."

We analyzed the data using the Statistical Package for the Social Sciences (SPSS-X). Several definitions deserve mention.

* We calculated a Role Conflict Score for seven questions that addressed role conflict. We calculated a mean score for each of the items.

* We averaged the role conflict scores to obtain the Overall Mean Conflict Score. This produces a mean score for the entire group of questions addressed to role conflict.

* Using the same procedure, we derived the Role Ambiguity Score for each of the six questions that addressed role ambiguity.

* Likewise, we established the Overall Mean Ambiguity Score to represent all subjects' role ambiguity scores. As before, this is the average of the six means calculated for each of the questions in this group.

We did not include the seven questions developed specifically for physician executives in the Overall Mean Conflict or Role Ambiguity scores. Nonetheless, we shall present some tentative findings.

Profile of the Physician Executive Respondents

We collected background demographic and organizational characteristics to facilitate analysis (table 2, right). The respondents were predominantly male, married, and over 40 years old and had maintained their current positions for less than five years. The most frequently named setting for the type of position was not-for-profit hospitals. Most executives supervised fewer than 50 employees. The majority of the executives were not CEOs but reported directly to CEOs.

Role Conflict

The frequency distribution for responses to the role conflict items are presented in table 3, below. Three of the items exceeded one standard deviation from the mean. This indicates significant importance relative to the other questions. Not surprisingly, physician executives work extensively with two or more groups that operate quite differently (item 4). In this environment, physician executives find it commonplace that one group accepts activities that another will not (item 9). We did not expect the response to item 12.

Physician executives report an exceedingly low percentage of their time spent on unnecessary activities. A plausible explanation is that physician executives understand the significance of their varying, even conflicting, activities. Perhaps physician executives are not expected to spend time in activities that many managers find unnecessary. We compared the response items here to other studies that provided individual item information.

The highest scoring item for physician executives was item 4. That score (5.32) is comparable to that reported by Burke for hospital executives on the same item (5.63).(21) In spite of higher scores for this item for hospital executives, physician executives posted a higher overall mean for role conflict.

Of the health care executives examined, physician executives report the highest level of role conflict. Nurse executives scored a close second.(20) Both physicians and nurses who become executives have clinical backgrounds and moved from there into management roles. These roles require the individual to balance the conflicting demands of individualized patient care and the requirements to think and to act to benefit aggregate outcomes. We believe this explains the higher role conflict scores for executives with clinical backgrounds when compared to health care executives without such a background.

Role Ambiguity

Table 4, page 12, shows the frequency of response to each of the role ambiguity items. The overall role ambiguity mean score for the respondents of the present study was somewhat higher than that for CEO respondents in Burke's 1986 study of urban hospital executives.(21)

Questions Specific to Physician Executives

Our study included items specific to the role of physician executives. Table 5, page 12, shows the responses to the supplemental questions. Items 15, 19, and 21 are negative statements, whereas the other items are positive. Thus, a simple comparison of means is not appropriate. In response to the negative questions, the physician executives said their duties as managers did not conflict with their duties as physicians. Nor did many of them seriously consider returning exclusively to clinical practice. However, a sizable number of respondents noted that their positions prevented them from giving their families the time they deserve. Some physicians drop clinical practice altogether in the transition to physician executives. Others stay in both worlds. We did not collect data on these differences.

Examination of the positive statements shows a high level of agreement. The highest level of agreement for any question was seen with item 20, regarding the ability of the physician executive to have a positive influence on the organization. Physician executives clearly believe that what they do makes a difference. An interesting study would question the CEOs and representative physicians of these organizations to see the extent to which their answers agree with what the physician executives have said.

The physician executives indicated the second highest level of agreement when asked about the extent to which they had maintained the respect of other physicians. The lower scores in this group indicate that the physicians perceive that it is difficult to obtain respect as a manager from other physicians. The physicians indicated that they receive more respect from other managers than from physicians. Several plausible explanations for this finding exist. A number of clinicians tend to lack high levels of respect for managers in general. We also found higher levels of respect correlated with larger numbers of employees under the control of the manager. Many physician managers lack large numbers of employees to supervise. In any case, these responses were quite positive.

How Do Physician Executives Succeed?

The overall mean role conflict score of physician executives exceeded that of hospital executives and nurse executives. Yet, physician executives perceive themselves as effective and respected. What type of person takes such a position?

Kibbe has described physicians as a clan managed by the "tendency to use socialization and acceptance of traditions and values, rather than prices or regulations, to mediate exchanges."(23) As physicians progress from medical school to residency to private practice, they learn the values and habits of the clan. This type of organizational structure is useful in dealing with complex problems with uncertain outcomes, a description that undeniably applies to modern clinical medicine.

Neither medical school nor residency training expose physicians to the basics of bureaucratic organizations and the values and culture of business managers. Nor are managers routinely taught the value systems of physicians. As managers and physicians increasingly interact over the control and use of limited medical resources, there is a greater need for both parties to understand conflicting management styles and goals. Physician executives jump into this role, or get pushed into it, because of their ability to handle conflict and ambiguity.

Covey says "seeking to understand requires consideration; seeking to be understood takes courage." (24) The increased interdependence of physicians and managers creates a powerful role for those physicians capable of learning the business culture. In turn, physician executives pass on their understanding of the physician value system and clan management style. Physician executives may not perceive severe role stress because they quickly learn to understand the views of both managers and physicians and can speak to each in their own language. The primary value system of health care organizations finds its roots in the healing ethic espoused by physicians and other clinicians. When executives fail to honor, follow, or communicate from that tradition, their actions will be suspect, and they will never gain even honorary admission to the clan of the clinicians.(25)

Successful physician executives deal with role stress routinely. Physicians capable of handling conflict and ambiguity may gravitate naturally into these positions. The physician executive's insight into the values and culture of both managers and physicians may be an important factor in a successful and satisfying career. This insight may also contribute to the effectiveness of the organization.

  Table 1. Question Items Used in Study
  1. I know what my responsibilities are.
  2. I receive assignments with manpower to complete them.
  3. I have clear, planned goals for my job.
  4. I work with two or more groups that operate quite
differently.
  5. I know that I have divided my time properly.
  6. I have to buck a rule or policy in order to carry out
an assignment.
  7. I receive incompatible requests from two or more people.
  8. I feel certain about how much authority I have.
  9. I do things that are apt to be accepted by one person and
not accepted by others.
  10. I know exactly what is expected of me.

  11. I have to do things that should be done differently.
  12. I work on unnecessary things.
  13. Explanations are clear of what has to be done.

  14. I receive assignments without adequate resources and
materials to execute them.
  15. My duty as a manager directly conflicts with my duty as
a physician.
  16. Other physicians respect me as a manager.
  17. Other physicians respect me as a physician.
  18. Non-physician managers respect me as a manager.
  19. I often consider giving up my managerial duties and
returning to full-time clinical practice.
  20. I am able to have a positive influence on the quality of
medical care in my organization.
  21. Time demands prevent me from giving my family the
attention it deserves.

[TABULAR DATA OMITTED]

References

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3. Komarovsky, M. "Presidential Address: Some Problems in Role Analysis." American Sociological Review 38(6):649-62, Dec. 1973.

4. Rizzo, J., and others. "Role Conflict and Ambiguity in Complex Organizations." Administrative Science Quarterly 15(2):150-63, June 1970.

5. Howell, J., and Schroeder, D. Physician Stress: A Handbook for Coping. Baltimore, Md.: University Park Press, 1984, p. 72.

6. Slater, C. "The Physician Manager's Role: Results of a Survey" in The Physician in Management, Schenke, R. (Ed). Washington, D.C.: American Academy of Medical Directors, 1980, pp. 57-82.

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11. Brief, A., and Aldag, R. "Correlates of Role Indices." Journal of Applied Psychology 61(4):468-72, Aug. 1976.

12. Brief, A., and others. "Anticipatory Socialization and Role Stress among Registered Nurses." journal of Health and Social Behavior 20(2): 161-6, June 1979.

13. Gross, N., and others. Explorations in Role Analysis: Studies of the School Superintendency Role. New York, N.Y.: John Wiley and Sons, Inc., 1958.

14. House, R., and Rizzo, J. "Role Conflict and Ambiguity as Critical Variables in a Model of Organizational Behavior." Organizational Behavior and Human Performance 7(3):467-505, June 1972.

15. Miles, R. "A Comparison of the Relative Impacts of Role Perceptions of Ambiguity and Conflict by Role." Academy of Management Journal 19(1):25-35, March 1976.

16. Oliver, R., and Brief, A. "Determinants and Consequences of Role Conflict and Ambiguity among Retail Sales Managers." Journal of Retailing 53(4):47-58,90, Winter 1977-8.

17. Liddell, W., and Slocum, J. "The Effects of Individual-Role Compatibility upon Group Performance: An Extension of Schutz's FIRO Theory. Academy of Management Journal 19(3):413-26, Sept. 1976.

18. Caplan, R., and Jones, K. "Effects of Work Load, Role Ambiguity, and Type A Personality on Anxiety, Depression, and Heart Rate. Journal of Applied Psychology 60(6):713-9, Dec. 1975.

19. Johnson, T., and Graen, G. "Organizational Assimilation and Role Rejection." Organizational Behavior and Human Performance 10(1):72-87, Aug. 1973.

20. Scalzi, C. "An Exploratory Study of the Relationship between Role Conflict and Ambiguity and Depressive Symptoms in Top Level Nursing Administrators." Doctoral dissertation, University of California, Los Angeles, 1984.

21. Burke, G. "Understanding the Dynamic Role of the Hospital Executive: The View Is Better from the Top. Hospital and Health Services Administration 34(1):99-112, Spring 1989.

22. Van Sell, M., and others. "Role Conflict and Role Ambiguity: Integration of the Literature and Directions for Future Research. Human Relations 34(1):43-71, Jan. 1981.

23. Kibbe, D. "Markets, Bureaucracies, and Clans--The Domains of Management in Health Care Organizations." Presentation at American College of Physician Executives meeting, Toronto, Ontario, Canada, May 1991.

24. Covey, S. The Seven Habits of Highly Effective People. New York, N.Y.: Simon and Schuster, Inc., 1989.

25. Summers, J. "Doing Good and Doing Well: Ethics, Professionalism, and Success." Hospital and Health Services Administration 29(2):84-100, March-April 1984.

George Burke III, DrPH, FACHE, is Associate Professor, Lynda Tompkins, PhD, is Assistant Professor, and Jim Summers, PhD, is Assistant Professor, Department of Health Administration, Southwest Texas State University, San Marcos, Chris Jagmin, MD, is Medical Director, Pacificare of Texas, San Antonio.