Calling and Comradeship

Patient safety heavily relies on doctors performing to the best of their abilities, delivering high quality of patientcare. However, changing market forces and increasing bureaucracy challenge physicians in their performance. Despite the dynamic conditions they experience, the majority performs on a high level. What exactly drives these doctors? Answering this question will shed light on how to best support doctors to be the engaged healthcare professionals that society wants and needs them to be. So patients are ensured safe and high quality of care. This chapter dips deeper into what primarily drives doctors, thus we turned to doctors themselves for answers. Being interested in their perceptions, feelings, behaviour, relations to, and interactions with, each other, this chapter relies heavily on qualitative research involving around 1000 hospital-based physicians. Conclusively, doctors can only truly blossom in an environment that stimulates their calling and that breathes a comradeship mindset, where sharing is about caring and peer-support is felt. It’s alarming that these essential humanistic and relational values are supressed by today’s more business-like climate in healthcare. Curtailing what primarily inspires doctors will eventually lead to doctors no longer having the time, energy and motivation to deliver the best possible patientcare. To restore the balance, we provide recommendations on the individual-, group-, and organizational level.


Introduction
In a field as complex, dynamic, resource-intensive and with such high stakes as healthcare, physician performance is vital for delivering safe and high quality patient care. However, physicians today encounter increasing demands related to the care they feel they should give to their patients. Knowledge about what drives doctors will be helpful in optimal supporting them. So they can continue being the engaged healthcare professionals that patients need, and ensure safe and high quality of care. In this chapter we thus focus on the essence of physician performance. We share our knowledge, which is based on a thesis containing six research projects regarding this topic [1]. We unravel what drives the individual physician as well as the impact of peer-interaction on performance, motivation and well-being of the individual physician. In that context, we introduce the concepts of calling and comradeship, the essential elements of physician performance. We point out how these core values are currently threatened and provide directions of what can be done to restore the balance.
As stated above, physicians are faced with challenging tasks these days. Changing healthcare systems, changing market forces, societal pressure and increasing bureaucracy are some of these challenges [2][3][4][5]. In current literature addressing physician performance, this topic is mostly discussed on the individual level. The discourse covering performance-related aspects such as wellbeing, burnout [5][6][7] and poor performance [8][9][10] tend to be described from an individual physician perspective. We would like to point out that, in this chapter, we specifically focus on the discourse of engagement and calling, whereas we view these themes the positive counterpart of burnout. Thus, all content that is targeted at stimulating calling could therefore be framed as preventive for burnout.
Despite a focus on the individual when addressing performance, the work context, and especially peer interaction, is a known driving force for individual performance [11]. Teamwork and a collaborative mindset have increasingly become cornerstones in modern modern healthcare, with physicians increasingly performing in teams rather than individually. On top of this, effective teamwork has been explicitly linked to patient safety [12]. Thus, good interpersonal peer-relationships are essential in facilitating teamwork and the quality and safety of patientcare [11][12][13].
The abovementioned highlights physicians' crucial role in patient safety and the current challenges doctors face in performing to the best of their abilities. It also raises attention to performance being increasingly about teamwork, in which interpersonal connection becomes essential in the sphere of patient safety. In our overall aim to unravel the essence of physician performance, we thus explored what drives the individual physician as well as the impact of peer-interaction on performance, motivation and well-being of the individual physician. Through exploring these issues, we intended to enhance understanding of the essence of physician performance, of what makes doctors tick. Our findings indicated two overarching themes expressing the essence of physician performance: on the individual level, doctors deem calling vital to bloom. On the peer-interaction level, comradeship arose as necessary to flourish. We will briefly introduce these two concepts in this introduction and elaborate upon them in more detail in the paragraphs two and three below.
Calling, i.e. a career that provides a sense of meaning or purpose and is used to help others, emerged as an essential element. We found physicians to be highly committed and dedicated professionals with humanistic practice at the heart of their performance. A profession so strongly rooted in the fundaments of human values paves the road for a work-related sense of meaning and purpose, in turn leading to high levels of commitment, motivation and inspiration. Thus, having a calling emerged as a key component. This finding indicates that individuals only truly flourish when they feel committed and dedicated.
Comradeship, i.e. an environment were doctors feel connected, psychological safe and responsible for each other, arose as the second essential element. We found comradeship to reflect a broad feeling of a supportive group atmosphere. This indicates that relational values are essential to be at your best as an individual doctor. The findings indicate that individuals can only truly blossom in an environment that breathes a collaborative mindset, where sharing is about caring and mutual trust, and cohesion and peer-support are felt.
In paragraph four, we will outline our alarming outcome, indicating the increasing clerical burden threatening these essential values. As a result, it negatively affect doctors' motivation, empathy, well-being and performance. DOI: http://dx.doi.org /10.5772/intechopen.97065 Which, in turn potentially leads to a decline in the quality and safety of patientcare. This knowledge can provide us with directions in how to put physicians' core values in the spotlight, support them in their performance and thus ultimately, contribute to the safety and quality of the patient care they provide. We will point those directions out on the individual-, group-, and organizational level in more detail in paragraph five.
Before discussing these aspects, we will briefly highlight the methodological rationale of this chapter and the practical setting in which our research has taken place.

Methodological rationale
This chapter has the essence of physician performance at its heart. In an era that breathes personalized healthcare, we believe that a personalized approach fits scientific research regarding this topic. Capturing physicians' stories and exploring opinions and reflections is the foundation in understanding the essence of physician performance. Thus, we turned to doctors themselves for answers. Being interested in their perceptions, feelings, behavior, relations to, and interactions with, each other, this chapter relies heavily on qualitative research involving hospital-based physicians. We split our main goal, unravelling the essence of physician performance, into two challenges to gain a more detailed understanding of physician performance. The first challenge, containing four research projects, focusses on peer-interaction and how this interaction shapes the performance of the individual physician. Since physicians increasingly perform in teams, rather than individually, where interpersonal connection is an essential element in performing well, we argue that, in order to unravel the essence of physician performance, it is important to focus in on the peer-interaction aspect. This challenge unravels how the individual doctor is influenced (either stimulated or discouraged) by peers. The concept of comradeship arose from these research projects. The second challenge involved two research projects exploring physicians' perceptions of performance. As we were interested in the essence of physician performance, we considered it essential to explicitly bring in physicians' perceptions and experiences on this topic. This exploration exposed the concept of calling as essential element.

Methods
We used various methodological and analytical methods to address our challenges including: literature review of poor physician performance, review of disciplinary law verdicts, expert interviews regarding the topic poor performance, in-depth interviews addressing soft signals, surveys handling psychological safety and performance feedback, observation and in-depth interviews with a focus on the impact of peer group reflections, written reflections regarding physicians' views on their own performance and in-depth interviews unravelling physicians' perceptions on high performance. Literature search strategies followed the topics of the research projects, i.e. poor performance, soft-weak signals and performance concerns, psychological safety, reflection, professional development and multisource feedback, physician performance, high performance and professional culture. In aligning the research projects, we specifically added literature targeted at teamwork, motivation and calling. The outline below provides further information on the methodological an analytical approaches we employed, see Figure 1.
Contemporary Topics in Patient Safety -Volume 1 4

Setting the stage
This chapter is based on research taking place in the Dutch hospital setting. A characteristic in the Netherlands is the variety in physicians' employment status within the same hospital organisation. Physicians may be either employed by the hospital or organised in independent entrepreneurships. Most hospitals have both employed physician groups on the hospital's payroll and various independent entrepreneurships autonomously responsible for their "mini enterprises" within hospitals. Within a hospital, all the hospital-based physicians come under a medical board as a counterpart to the hospital board. The role of the medical board is to stand up for and maintain the interests of all physicians in their hospital, regardless of their employment status. For example, quality and performance issues are regulated by the medical board on behalf of all physicians.

Calling amidst physician performance
'Seeing patients and their families at their worst and most vulnerable moments strongly motivates me to be as emphatic and humanistic as I can be; that doesn't feel damnatory, on the contrary, it gives the uttermost satisfaction and appreciation' This quote from a participating physicians of the thesis reflects how doctors feel an intense dedication to their patients and consider humanistic practice at the heart of being a doctor. The overall conclusion from our findings show that physicians view the medical profession as one that provides a deep sense of meaning and purpose, where motivation and inspiration derive from their dedication to helping their patients. Figure 2 presents a concise overview of the findings regarding calling.
In clarifying how we moved from performance, via motivation to calling, we will first briefly share existing knowledge on physician performance and how motivation forms a crucial element in high performance. Subsequently we will dip into motivation theories, how they differ from calling and explain the concept of having a calling.

From physician performance to motivation
'I'd rather not mention performance. To me, that means that you work according to an pattern or schedule. I feel that I work from engagement, not just 'perform" Participating physician The high stakes in healthcare ensure that many stakeholders become involved with, and have opinions on, the topic of 'physician performance' . These implicit ideas are made explicit in numerous charters and guidelines, all having roots extending back to the classic and oldest of all codes of conduct: the Hippocratic Oath [14,15]. Despite the remarkable changes in medical science, the Hippocratic Oath has survived as an ideal for almost 2500 years, inspiring physicians to reinvent and uphold valued ethical principles regarding their performance [2]. It captures the core values of the medical profession, centring on the duty to help sick people and avoid harm [16].
Since healthcare is a human activity, these professional values are still considered fundamental to compassionate, ethical and patient-centred care and thus to a physician's performance [17][18][19][20][21]. Many documents translate these values into more hands-on guidelines and formulate good medical practice in concrete terms of knowledge, skills, communication, teamwork and maintaining trust and safety [22][23][24]. At the most practical level, competence frameworks describe the actual knowledge, skills and abilities that physicians should have in order to provide high quality patient care [25,26].
Defining physician performance is complex since it encompasses all the aforementioned perspectives ranging from values to actual competences. Incorporating all these elements leads to definitions of professional performance as 'a physician committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour' [27]. From a more practical perspective, physician performance can be viewed as that what physicians are actually seen to do in practice, being a reflection of their adherence to values and the necessary skills and competences [28]. These definitions encompass a wide variety of aspects, ranging from values, commitment, behaviour to actual medical-technical expertise. Reflecting on knowledge of high performance in general, individual-related elements as intrinsic motivation and engagement are identified the most critical. The latter corresponds with the deep-seated dedication to their patients that physicians in our research projects exposed. Therefore we followed the path from performance to motivation in our aim to unravel the essence of physician performance.

From motivation to calling
'Getting to know the person behind the patient creates understanding, a deeper relationship and motivation to meet the goal for the patient' Participating physician Human motivation as a driving force of behavior and performance has been extensively studied, extending out from the realm of philosophy to the psychological, behavioral and management domains [29]. As a result, a rich variety of theories have been presented, all with their own specific angle. Well-known theories include Maslow's [30] need hierarchy theory (individual human motives are related to work), Herzberg's [31] motivation hygiene theory (hygiene factors in the context surrounding a job predict satisfaction and future motivation), Porter and Lawler's [32] expectancy theory (individual differences in abilities and skills plus role clarity link job effort to actual job performance), Locke and Latham's [33] goal setting theory (task performance is enhanced by specifying targets to achieve) and Bandura's [34] selfefficacy theory (self-confidence lies at the heart of an individual's incentive to act or to be proactive). We will briefly discuss two other theories (Self Determination Theory and Job Demands Resources Theory) in a little more detail as examples to explain how, in our research, calling was identified as the best-fitting concept for driving physician performance [35][36][37][38]. Self Determination Theory, although one of the older theories, was chosen because of its frequent citations (Ryan and Deci's [35] article has 35,697 citations according to Google Scholar) and the Job Demands Resources Theory because it is well established in the medical domain and referred to in the Vison Document of the Federation of Medical Specialists in the Netherlands [39]. DOI: http://dx.doi.org /10.5772/intechopen.97065 According to Self Determination Theory, the nature of motivation predicts many important outcomes such as psychological health, wellbeing, deep learning and effective performance [35,36]. Psychological health and performance benefit most from a high level of intrinsic motivation. This theory posits that three basic psychological needs (i.e. autonomy, competence and belongingness) need to be fulfilled in order to perform at one's best. In Bakker and Demerouti's Job Demands Resources Model (JD-R model), performance predictors are classified into job resources (e.g. autonomy, harmony, colleague support) and job demands such as perceived pressure, emotional demands, work-home conflict) [37,38]. In this model, performance will blossom when the motivational process dominates, when job resources are widely available and when job demands are minimal. Where the JD-R model emphasises work-related characteristics, the Self Determination Theory puts basic psychological needs central. As this quote from a participating physician expresses, none of the abovementioned motivation concepts truly fits the deep-seated dedication to their patients that doctors expressed in our research. We found that physicians' motivation and inspiration derive primarily from their dedication, and from the meaningfulness of the doctor-patient relationship [1]. An analysis of nearly 800 written reflections, targeted at physician performance, indicated that physicians experience being a humanistic practitioner at the heart of their performance. They feel that all other activities build on this humanistic practice, translated into daily practice by striving to do the best for their patients. Gaining and sharing knowledge and competences, being accountable and being transparent are means that can contribute to the best patient care. Interviewing 28 physicians and 7 HR professionals underlined the perception of a doctor as a deeply dedicated and committed professional, going that extra mile for their patients. That extra mile was even demonstrated by doctors participating in interviews after working hours, wanting to contribute to improvements, giving up their time to talk to us, despite their heavy workloads and time restraints. Their strong dedication to their patients resulted in their opinion that dedication is more than just an antecedent of high performance, as it is described in most research. They viewed dedication an essential component of high performance. We found that passion and ambition are incorporated in physicians' culture and thus shape their view of high performance. Dedication, passion, commitment and intrinsic motivation thus shape physicians' sense of meaning and purpose and drives them to perform at their best. Concepts that are all intertwined and positively related to high performance. Putting humanistic care, meaningfulness and dedication central, the concept of having a calling, i.e. having a career that provides a sense of meaning or purpose and is used to help others, best fitted the deep-seated dedication and arose as one of the two essential elements in physicians' performance [40].

Having a calling
'You have to be extremely motivated, to do your utmost best if patients need your care. To earn and redeem the trust that people confide in you ' Participating physician Being a doctor is primarily a people business, helping others in their most vulnerable hour of need. In a profession so strongly rooted in in the fundaments of human Contemporary Topics in Patient Safety -Volume 1 values, a work-related sense of meaning and purpose seems self-evident. Having a meaning is assumed to influence important work-related outcomes, therefore we turn to what is known about the concept of calling [40]. Despite the growing popularity of this topic in everyday life, the literature on 'calling' is still in its infancy and only recently been seen in the medical domain [41][42][43]. A variety of definitions exist for 'calling' to a vocation. Dik and Duffy's seems to well reflect the general tone in defining a calling as a career that (i) involves an external summons, (ii) provides a sense of meaning or purpose, and (iii) is used to help others in some capacity [40]. The first component states that motivation comes from an external source, intentionally leaving the source undefined since this may range from God to the needs of society to serendipitous fate. The second aspect posits that one's efforts should fit into a broader framework of purpose and meaning in life; a process that is believed to help people find stability and coherence in life. The third element draws on the historic interpretation that the purpose and meaningfulness should contribute (directly or indirectly) in some positive way to "the common good" or wellbeing of society.
Freely translated from Dik & Duffy's definition, we portray calling as the sweet spot, the coinciding centre of a Venn-diagram, consisting of the following three elements: Doing what one is meant to do, Sense of purpose and meaning, and Helping others, see Figure 3. In an extended overview, Duffy and Dik conclude that, between 2007 and 2017, approximately 40 studies have been completed examining how a sense of calling links to work-related and general wellbeing outcomes, including increased career maturity, academic satisfaction, job satisfaction, career commitment, life meaning and life satisfaction [42,44,45]. Research in the medical domain has been limited to medical students, and indicates that first-year students feel strongly that medicine is the career they are called to, and that students interested in primary care most strongly express the presence of a calling [41]. Having a calling also bolsters medical students who have lower levels of self-efficacy and it is positively correlated with career commitment [43]. If, and how, physicians perceive this calling after graduation is still unknown. In terms of living out a calling, it is suggested that individuals actively craft their job to make it more meaningful or prosocial [46]. Despite these positive outcomes, over-investing in one's work has a potential dark side so it is advisable to ensure a healthy pursuit of any calling [42,47]. Given the often extreme working hours and workloads of physicians, this could be a dark side to take seriously.

Comradeship amidst physician performance
'I did not expect to get emotional during the session, but it happened anyway. In my colleagues' reactions, I felt genuine interest, concern and empathy. I mean, patient contact is very important, but so is working with a group of colleagues you feel comfortable and safe with; that makes up three-quarters of your job satisfaction'.
This statement from one of the participating physicians in the thesis, describes in a nutshell how 'comradeship' arose as one of the two overarching themes. The overall conclusion of our findings indicates that physicians perceive a safe work environment, with peers that you can trust and rely on, not only as one of the most important drivers, but as a vital dimension of optimum individual performance. Figure 4 illustrates our findings regarding comradeship. Building on these findings, we portray comradeship as the coinciding centre of a Venn-diagram consisting of the following three elements: Feeling responsible, Feeling connected and Feeling psychological safe, as illustrated by Figure 5.
We will further elaborate on these three elements of comradeship below. Since comradeship emerges from team-performance, we will start by briefly setting the context of knowledge on team-performance.

From team-performance to comradeship
'The assurance that we have each others back, gives an enormous amount of work pleasure' Participating physician Physicians increasingly perform in teams rather than individually. When addressing team or teamwork, the general consensus in the research literature is that a team consists of two or more individuals who have specific roles, perform interdependent tasks, are adaptable and share a common goal [48]. Teamwork is the ongoing process of interaction between team members as they work together to provide care to the patients [49]. When referring to teams, we specifically mean teams of physicians. Turning to the teamwork literature, a plethora of studies highlight the benefits and importance of teamwork, and specifically in healthcare. Teamwork has been associated with a higher level of job satisfaction [50,51], a higher quality of care [52][53][54], an increase in patient safety [55,56] and greater patient satisfaction [57]. The extensive literature on healthcare teams has identified interpersonal-related topics including mutual respect and trust, collaboration, conflict resolution, participation and cohesion as required underpinning conditions for staff satisfaction and team effectiveness [58,59]. Given the highly interdependent nature of physician teams, high quality peer-relationships are even more crucial in achieving high quality physician performance, both on the individual and the group level.
Turning to the current knowledge and discourses on teamwork and team performance, prior research has increasingly recognized the significance and benefits of effective teamwork in modern healthcare. Effective teamwork is linked to quality and safety of patient care because teams make fewer mistakes than individuals do [12,60,61]. Teamwork is also an important predictor of individual aspects such as wellbeing and job satisfaction [52]. The knowledge, skills and attitudes needed for effective teamwork include mutual performance monitoring, backup behavior, adaptability, team leadership and a team orientation [48,60]. Psychological safety, i.e. the safety within the team to take interpersonal risks, is reported in the literature as an important aspect of high performing healthcare teams [62][63][64]. The importance of effective teamwork in healthcare is undisputable, affecting patient safety as well as the individual healthcare professional himself. Prior research points to a variety of conditions for effective teamwork. However, physicians in our research portray how they -ideally-work together as more than teamwork. Thus comradeship taps into a deeper level than 'just working together' to achieve a common goal. Physicians need to feel connected to one another, feel responsible for each other and psychological safe. In such a comradeship situation, individuals can bloom and deliver the best care to their patients.

Feeling connected; sharing is caring 'I didn't expect to get emotional, but it happened anyway. I felt a genuine interest, care and empathy in my colleagues' reactions. I mean, contact with my patients is very important, but being a member of a group were I feel comfortable makes up three quarters of my work pleasure' Participating physician
Sharing builds connection within teams, whether you share knowledge, stories or reflections. Connecting fuels constructive peer-relationships, which are known to be fertile ground for the professional development and performance improvement [11]. Social support within a team increases individual well-being and even 'work-happiness' [65]. Individuals bloom in an environment were feedback can be openly shared with each other [66]. We dug deeper into this topic and investigated the potential power of sharing reflections in an peer-group setting and its effect on the individual physician [67]. We found that sharing is definitely caring. The process of sharing, self-disclosure and active participation encourages groupcohesion and also enhances individuals' self-knowledge. It offers the possibility to discuss and compare one's own and others' perceptions, gaining a nuanced insights into one's professional performance. Sharing reflections was experienced as a source of social support and deepened communal relationships on a group level. On the individual level, sharing reflections was helpful in realising actual change and creating a sense of urgency for improvement. These findings thus point to a positive effect on the team as well as the individual performance level, indicating a close correlation. Thus we conclude that performance should not be viewed on an individual level, it should always incorporate the context of this individual. As Groysberg et al. [68] observed: when a top performer leaves a company, their achievement levels fall sharply, and may still be depressed even up to five years later. It thus seems that, still too often, it is ignored that relationships shape performance alongside personal knowledge and skills. As expressed by Ramani and colleagues [69,70], it is not about following recipes, but about investing in relationships in order to disclose, discuss, reflect on and learn from feedback.

Feeling responsible 'in that difficult time, I just stood by him, letting hm know that I was there for him" Participating physician
Physicians express a strong sense of responsibility towards their peers, to take care of one another and look after each other. They consider it their responsibility to pick up an act on soft signals, i.e. observable deviances from a colleague's normal behaviour, appearance or communication style [65]. Physicians even consider soft signals as personal related concerns, within the sphere of well-being. As a colleague, they feel co-responsible for their peers' wellbeing: a striking example of comradeship. Prior research underscores this finding, stating that well-functioning DOI: http://dx.doi.org /10.5772/intechopen.97065 teams can actually protect their members from the negative effects of work-related stress by enhancing occupational wellbeing indicators such as better physical and mental health [71,72]. Our findings showed that physicians feel the need to take care of each other by actively picking up on signals or concerns and then offering a helping hand.
We considered that a situation where relations are likely to be strained, such as having a poorly performing colleague, would provide us with valuable information on how peers act and interact with one another [73]. On the interaction level, this research showed that low levels of responsibility, reflected in insufficient collaboration and a lack of addressing and speaking up amongst peers, provide fertile ground for individual performance issues to flourish and potentially develop into poor performance. This finding underscores the need to show responsibility and create a culture of speaking up and blame-free discussion of performance concerns. This echoes the literature stating that a supportive environment is necessary for effective teamwork and high team performance; an environment showing 'backup-behavior' , where feedback is regularly given, poor performers are dealt with, and tough issues can be brought up [48,75].

Feeling psychological safe 'hearing colleagues' struggles in an open and safe atmosphere, that offers the opportunity to be more open yourself '
Participating physician The concept of psychological safety has extensively be expounded upon by Amy Edmondson and identified as the most important aspect of high performing teams [62][63][64]74]. Organizational research has identified psychological safety as a critical factor in understanding phenomena such as voice, teamwork and team learning. Edmondson defines psychological safety as 'the shared beliefs that a team is safe for interpersonal risk taking and such environment exudes a sense of confidence that the team will not embarrass, reject, or punish someone for speaking up' [62]. Translated to daily practice, interpersonal risk-taking means the willingness to bring up tough issues, ask questions, seek help, admit errors, back each other or simply say 'I'm not sure, I don't know' within your team. Teams whose members feel comfortable speaking honestly with each other, even when expressing contrarian perspectives, are the teams most likely to try new things and outperform others. Specifically, a dynamic, contact-intensive and interdependent environment, such as healthcare, is likely to benefit from physicians feeling psychologically safe within their teams. Every interpersonal encounter contains a possibility to either build or destroy psychological safety, since it is really about what happens every time at that micro-level. It is in essence about questioning yourself: if I do or say this here, will I be hurt, embarrassed or criticised? A negative response indicates psychological safety and so you can proceed. This also means that actions unthinkable in one setting, can be readily taken in another owing to different beliefs about the probable interpersonal consequences. This phenomenon is called 'tacit calculus': 'the assessment of interpersonal risk associated with a given behaviour against the particular interpersonal climate' [75].
In a more tangible form, individual supportive behaviour encompasses being accessible and approachable, admitting when you do not know something, willing to show fallibility, being inclusive instead of punishing, encouraging the embracing of error and, when others cross boundaries, set in advance, and fail to perform up to these standards, holding them accountable fairly and consistently [76]. It can be argued that this interpersonal risk taking is especially important in the field of physician performance since this is a field of frequent peer-interaction under often limited time and resources combined with heavy workloads.
Physicians in our research underscore the importance of feeling psychological safe. Creating a psychologically safe environment encourages speaking up in terms of giving and receiving performance feedback [1,66]. Performance feedback is more positively perceived by physicians who experience a higher level of psychological safety within their team. High levels of psychological safety and performance feedback are not only crucial for professional development and improving the performance of the individual physician, they also result in fewer errors and better patient outcomes [63,77].

Calling and comradeship threatened.
'I feel that nowadays, registration rules in the hospital. That goes at the expense of my engagement and empathy and that really frustrates me' Participating physician We conclude calling and comradeship shape the essence of physician performance. That is what makes doctors tick and go that extra mile for their patients. Neuroscientific research sheds an extra light on this, explaining how the production of the happy hormone oxytocine appears to be important when it comes to connection, social contact and pleasure [78][79][80]. The production of oxytocine is stimulated when one has a feeling of purpose or meaningfulness. It is also stimulated in an environment of high trust. It seems that also from a neuroscientific point of view, calling and comradeship fuel work-related happiness.
That brings us to the alarming finding in our research: calling and comradeship are threatened especially by an increasing clerical burden. Although humanistic practice arises from dedication, passion and ambition, forming the heart of being a doctor, this humanistic care seems to be suppressed by today's more business-like climate in healthcare. Our findings show that increasing and heavy administrative workloads are perceived as an alarming threat to physicians' performance. This worrisome finding reflects the current era of marketisation in healthcare, shifting from people to processes, productivity and efficiency [3]. Aspects that have gained popularity in an era of declining societal trust in the medical profession due to critical incidents [81] and modern society's demands for greater transparency, accountability and measurable outcomes [82]. The doctors in our research confirmed findings elsewhere that the increasing clerical burden is leading to limited face-toface time with patients [83]. Curtailing what primarily inspires doctors will eventually lead to doctors no longer having the time, energy and motivation to deliver the best possible care. Where humanistic care is at the heart of physician performance, dedication evolves around human values such as caring, compassion and respect [21]. Doctors' dedication will therefore only flourish if the same humanity-related aspects receive adequate attention. Where Rider et al. [85] advocate reinforcing humanistic and relational aspects of care on the organizational level, we feel this should be the focus of attention on all levels, from the individual physician through to policy and society as a whole.
To place the above-mentioned call in a broader theoretical and philosophical perspective, we draw on Habermas's theory of communicative action and the parallel of the perceived discrepancy between values on one side of the spectrum and commercialization on the other side. Habermas discriminates 'lifeworld' from 'system' [86]. The 'system' consists of administrative, economic and political responsibilities and focuses on rules, checklists and costs -it is the world of money DOI: http://dx.doi.org /10.5772/intechopen.97065 and power. Conversely, the 'lifeworld' builds on experience, everyday encounters between people, shared meaning, understanding and values -the world of shared knowledge [86,87]. As illustrated by Figure 6.
Ideally, the values of the 'lifeworld' are conditioning, and the 'system' depends on, and follows, the 'lifeworld' with supporting rules and regulations. However, the 'system' sometimes becomes parasitic as it tends to colonize the 'lifeworld' , creating a world of checklists and regulations, where values and relationships are subordinate, and regulations can become meaningless. Habermas argues that this leads to social instability since it may lead people to overlook significance or meaning. This social instability can be recognized in the healthcare arena, where the growing commercialization has resulted in a decline in medical values [20].
Related to our findings, the increasing clerical burden of the 'system' is threatening meaning and humanistic practice in the 'lifeworld' . Given that significance, meaning and purpose are all vital to physician performance, we hope that our findings contribute to the societal call for change and plea for voice to be given to physicians' 'lifeworld' [87].

The way forward
Based on our findings, we strongly advocate countering the climate of commercialisation by putting people in the spotlight ahead of process and productivity. By stimulating calling and comradeship. The results of our research represent a scientific argument for a broader societal call for change to 'soften' the current business-like environment that healthcare has become. Giving voice to physicians' lifeworld can and should be executed on the individual, department or group and organizational level. We will thus describe the implications and recommendations on these levels, targeted at supporting 'calling' and 'comradeship' . This appears necessary if we, as a society, want to secure dedicated professionals going that extra mile in our own hours of need when we ourselves become patients and are in need of safe care. To be a dedicated doctor and colleague, it is crucial to take care of oneself and those around. Physicians' self-care thus should be viewed as an element of professional behaviour. As Jean Wallace described in the Lancet some years ago: "Physician wellness; the missing quality indicator [5]." Taking care of one's own physical and mental wellbeing should be a number one priority of every physician.

Leadership skills
'Professionally, we are highly trained, but we lack expertise in leadership and communications skills, those skills are simply lacking' Participating physician Our findings identified a desire in doctors for improved leadership and collaboration skills. This could be realised on an individual level in post-academic training programmes. From a leadership perspective, we found that inclusive leadership behaviour is beneficial in improving the quality of interpersonal relationships. Meaning: invite your colleagues to speak, explicitly show your appreciation, proactively ask for other opinions, offer a helping hand, reflect on an d give feedback, share and self-disclose. This can, and should, be enacted by all physicians, whether or not they have a 'formal' leadership position. Individuals can only blossom within a culture of trust and safety, and therefore investing in developing such a culture seems essential, especially since the absence of psychological safety often contributes to breakdowns in collaboration [88]. Peer groups or departments can invest in comradeship by periodically collectively discuss and reflect on individual and group performance. Group reflection encourages professional development and performance, lowers the threshold for speaking up and creates an opportunity to help and advise each other. Invest as a group in discussions regarding medical topics or teambuilding activities. In addition to the work context, social activities are also important in optimising interpersonal connections. Groups and departments should in general invest in optimising group cohesion since this is known to build trust within a team.

Take care of each another 'if I have a gut feeling that something is going on, I just ask my colleague what's up and what I can do to help. Sometimes jus a cup of coffee and listening can be enough, that's what you do for each other'
Participating physician Cohesion can be built through various activities especially when things did not work out as expected. Discuss adverse events, complaints or disciplinary rulings and support each other in such circumstances. Helping a colleague when they are facing an adverse event or medical error, builds fruitful relationships [89]. The impact of adverse events is intense and support form colleagues of great value [90]. When confronted with soft signals, pick up and act on them.

Build on the talents in your team
'right now it's more or less: it's your turn now, you're next. Even if that person is not really the best equipped colleague for that task. We should change this ' Participating physician Teams should build on the unique talents and motivations of the individual physicians within the group since such a strength-based climate is a prerequisite for numerous positive effects and well-being [91,92]. If a team manages to go further and ensure that members can spend at least 20% of their professional effort focused on the dimensions of work that they find most meaningful, this will dramatically lower the risk of burnout since it directly fuels ones calling [93,94].

Put calling and comradeship on the agenda
'I'm working with these colleagues for a long time, but we never talk about our passion or how to improve as a team, that is really strange when I think about it now ' Participating physician Physicians deem calling and comradeship their core values. It is astonishing that simultaneously, these values are hardly explicitly discussed within groups or departments. Meetings predominantly evolve around organizational-, patient-related-, financial-, or productivity aspects. How to stay engaged and what every team member can do to contribute to an open and safe environment deserves at least the same attention.

Recommendations for the organizational level
Given their strong links to quality of care, patient safety and patient satisfaction, having an engaged and collaborative physician workforce is critical for healthcare organisations [95,96]. To foster dedicated doctors working in dedicated teams, healthcare organisations should invest in a collaborative mindset.

Facilitate groups and departments to foster calling and comradeship 'It would be helpful if our organization would encourage teams to reflect on individual and team-performance' Participating physician
Facilitating groups and departments to optimise their group cohesion is helpful in achieving a collaborative mindset. Since the hospital board and the medical board are jointly responsible for the quality and wellbeing of their physicians, facilitating groups to spend time together and invest in their team and the individual team members should not be optional and solely a group's responsibility. On top of that, organizations could actively engage in the discourse regarding calling and comradeship; by proactively discussing these themes in team-meetings organization-wide or by organising a training or workshop.

Implement guidance and support
'you notice that people in multidisciplinary teams are very dedicated and passionate, they have a lot of knowledge and they really complement each other ' Participating physician Comradeship can be enhanced by formal support or coaching programmes, investing in multidisciplinary collaboration and performance evaluations on a team level, followed by guiding and support. Physicians deal with unique challenges (such as medical errors and malpractice suits) and have a professional identity and role that is distinct from other disciplines. Because of this, fruitful peer interaction and peer support have always been part of how physicians deal with these circumstances [97]. The topic of peer support is gaining popularity and formal peer support programmes are implemented in many institutions [89]. However, the informal support aspects and interactions have become difficult given a more productivity-driven-, time-and resource effective mindset. This mindset has led to an erosion of peer support and a greater sense of isolation for many physicians [97]. In an attempt to counterbalance these eroding forces, the Mayo Clinic created dedicated meeting spaces for physicians and scientists with free fruit and beverages, computers and lunch tables. These spaces were successful in generating a sense of community and comradeship [97]. To promote engagement and satisfaction within their staff, they further funded small groups of physicians to have a meal together every other week and discuss topics that explored the virtues and challenges of being a physician. These sessions led to improvements in both meaning in work and burnout for participants [98]. DOI: http://dx.doi.org/10.5772/intechopen.97065

Author details
Myra van den Goor 1 * and Tanya Bondarouk 2 1 Q3 BV, 's Hertogenbosch, The Netherlands 2 University of Twente, Enschede, The Netherlands *Address all correspondence to: m.vandengoor@q3consult.nl 5.3.3 Restore the possibility to organically spend time. 'We used to have a room for our entire group, so we would discuss stuff very easily between patients or so. Right now we hardly see each other ' Participating physician Nowadays, it is believed that every encounter should be as 'efficient' as possible. With this side-effect of the current commercialisation of healthcare, the benefits of organically spending time together, sharing with and helping colleagues seem to be becoming overshadowed. In order to restore a healthy balance, such encounters should be re-enabled, if not organically, then through institutionalisation.

Conclusion
Engaged physicians working constructively in teams are prerequisite for patient safety and high quality of care. However, increasing clerical burden and limited face-to-face time with patients due to the current marketization climate in healthcare, are challenging physicians to perform to the best of their ability. Restoring the balance from processes and productivity towards people seems essential. Exploring what drives doctors fuels knowledge on how to best support these professionals. In this chapter, we explain how doctors deem two drivers essential regarding their performance: calling, i.e. a career that provides a sense of meaning or purpose and is used to help others, and comradeship, i.e. an environment were doctors feel connected, psychological safe and responsible for each other. Putting these human-and relational values in the spotlight is an active assignment for the individual physician, the group or department and the organization.
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