Calling: Never seen before or heard of – A survey among Swiss physicians

1 Introduction

Since the 1961 publication of Boys in White by Howard Becker et al. [1], describing an ethnographic study of students at a US medical school, times have changed. If the study has to be replicated in 2020, the book should be entitled Women in White [2]; however, more importantly, we not only know more about how medical students live, but we have also gained knowledge about what it means to be a physician today. What is striking in the literature on the working experience of physicians is the alarming observation of their physical and psychological health (e.g., substance abuse, burnout), commitment to work (e.g., dissatisfaction with medical practice, demoralization, and loss of meaning), and work environment (e.g., economic pressures, physician shortage, loss of autonomy, malpractice claims, and complaints) [3–10]. A “diagnosis” of a collapse of morale among hospital physicians has even been made [11].

On the other hand, a prominent physician, Siddharta Mukherjee, in a recent New York Times article entitled “For doctors, delving deeper as a way to avoid burnout,” made the case for an alternative look [12]. He states that avoiding burnout is possible “only, perhaps, by finding personal, often deeply specialized purpose in our work,” and concludes as follows: “We [our group] didn’t burn out, perhaps, by burning a little more [12].” While Mukherjee remains prudent, as shown using “perhaps” in both quotes, he refers to the deeper motivation of becoming and being a physician as a means to resist the constraints, which apparently have invaded the field.

What makes physicians burn a little more? Mukherjee describes not only external factors that determine the choice of a medical career and the joyful aspects of the profession, but an inner deep rooted motivation, which may be referred to as the concept of a calling. Indeed, research on calling shows a link between perceiving a calling and greater career maturity, career commitment, work and life meaning, and job and life satisfaction [13–18]. However, the definition of a calling varies from author to author and changes over time, and is the subject of ongoing debate [19, 20]. Particular emphasis is placed on different or even opposite facets of a calling, which is related to either an inner requiredness of passion and enjoyment or an outer requiredness of duty and destiny [21].

Duffy and Dik (2013), whose conceptualization has served as a basis for many studies, described a calling as a combination of three components: an external summons, meaning/purpose, and prosocial motivation [20]. With this three-component definition, they made a distinction between calling and constructs such as work centrality, work commitment, or work engagement [20].

The starting point of the present study was a statement from a physician about the non-reality of a calling in those who choose medicine as a career (see methods below), contrary to what Mukherjee seems to assume. To gain further insights into calling as an approach to work in a population sample of physicians, we designed an online survey. We decided to mainly rely on how the participants understand the term calling and aimed to determine whether they consider themselves and physicians in general to have a calling. Additionally, we linked the issue of calling with career choice and professional consistency.

The authors of a recent review reported that the concept of work as a calling is likely to provide key findings about how individuals relate to their work and organizations [21]. With respect to medicine, few studies have explored the issue of career calling among physicians. These studies tended to examine whether a calling was associated with a variety of markers such as well-being or burnout [22–24] or focused on intrinsic factors that motivate to be physicians and the meaning of medical work [25]. A qualitative study by Bott et al. explored career calling experience of 17 physicians and provided insights into how calling fits with a medical career, is maintained over time or is expected to evolve in the physicians’ future career trajectories [26].

Our study aimed to investigate a complementary perspective by assessing the potential link between experience of a calling, career choice, and professional consistency in a population of physicians of all specialties.

2 Methods

This study was designed as an online survey questionnaire addressing career choice and career calling among physicians working in French-speaking Switzerland.

3 Results

Two hundred and eighty-three physicians completed the survey (144 were female). Medical specialties with the highest number of respondents were general internal medicine (n = 118), adult and child-adolescent psychiatry (n = 43), anesthesiology (n = 31), and surgery (n = 22). Specialties with fewer respondents, such as medical oncology (n = 15), physical medicine and rehabilitation (n = 12), pediatrics (n = 11) were classified in an “Others” category. Respondents from hospitals were chief residents (n = 96), residents (n = 84), senior staff members (n = 54), and chiefs of service (n = 14); 35 respondents were physicians in private practices. Nearly three-quarters of the participants worked in a university hospital. The median year of graduation from medical school was 2008 (range: 1974 –2018).

In the following, we present the results by distinguishing between physicians who had experienced or experienced a calling and physicians who had chosen medicine for other reasons.

This study aimed to investigate a potential link between physicians’ subjective experience of a calling, career choice, and professional consistency.

A sense of calling was associated with greater professional consistency. To put it differently, physicians who reported experiencing a calling, among other career motivators, seem “to find what they were and are looking for.” This assumption is supported by the finding that these physicians defined a calling significantly more often as “being in the right place.” One might thus consider that there is a “give-and-take” or resonance [35] between the physicians and their tasks and work environment. This somehow undermines the assumption that a calling is a kind of altruistic “give-without-take” and thus more in line with the usual exchange individuals undertake with each other. It remains unanswered whether it is a calling, which makes a difference or if these physicians have a general disposition to relate to the world in a way that allows them to feel adequate (in the right place), responding (internal summons), and to experience passion as these responses are significantly more often reported in the questionnaire survey. It is of note that the prevailing definition provided by the physicians of Bott and al.s’ study rather indicated a sense of feeling drawn or guided to pursue a career [26]. As stressed by the authors, this definition corresponds to that of Dick and Duffy highlighting the external summoning nature of a calling [36]. Variant definitions indicating that calling has an external source (external summons), is a sacrifice or predisposition or provides a sense of purpose in life were shared by the participants of our study, regardless of whether or not they declared having a calling.

Physicians, who did not have a calling among their motivations, indicated less professional consistency. Particularly alarming was the high proportion of them who questioned their career choice –45% indicated at not being sure about their choices. Even if ultimately only around one in ten Swiss physicians actually decide not to stay in medicine and to quit their job [37], any form of work dissatisfaction is negative for physicians, patients, and society, and may lead to a diminished quality of care. While the reasons for these disappointments may be multiple, the question arises if a sense of calling may serve as a buffer against adversity associated with work.

If this later assumption is true, addressing early motivators to study medicine and become a physician is a major issue in order to prevent later deceptions. In this regard, physicians who declared having a calling tended to be inspired by a certain idealism when choosing the profession compared with those who did not experience a calling and who considered the scientific aspects of work more relevant for career choice. While medicine is certainly a scientifically grounded discipline, it is also an applied discipline that consists of relational aspects and human encounters. These relational aspects of medicine might be experienced in different ways, and some physicians may even feel threatened or otherwise distressed by patient encounters, and the associated perception of suffering. Idealism, together with an increased number of motivations by physicians with a calling –which may reflect different facets of medicine and lead to increased satisfaction –may again be an asset to maintain professional consistency. Scientific skills, along with a lesser number of motivations and, for some physicians, a feeling of not knowing why they had chosen medicine, may be, on the other hand, a cause of dissatisfaction. In addition, it has been shown that hospital users’ complaints are more often related to clinical communication and interpersonal relationships with physicians and other health care professionals [38]. An unbalanced interest in the technical and scientific aspects of medicine may thus result in negative feedback from patients and lower job satisfaction. Addressing the issue of career motivators in under- and postgraduate medical education may be of direct clinical and practical relevance as well as a way to reflect on the professional aspects of becoming and being a physician. Example of such interventions are reflexivity training for medical students [39] or Osler groups [40], which aim to raise awareness about physicians’ identity formation [41]. The same holds true for the meanings attributed to the term “calling”. These meanings could be a starting point to reflect on how physicians situate themselves in the medical field and the representations they are subjected to, be they from their own experience, based on deep-rooted values or dominant discourses. Representations and associated subjective experiences have clinical implications and influence the way in which physicians grow in their profession.

Last, life events were also more frequently a motivator for career choice among physicians experiencing a calling. This finding has also been reported in a large study, where career choice of women psychiatrists appeared to be significantly related to physical or psychiatric disturbances in their families (in comparison with women with a university degree who chose other professions) [42]. While own life events may increase sensitivity for suffering, and thus a sense of calling, and may contribute to increased empathy –based on experiential knowledge –it may also be a double-edged sword, especially when the life events have not been worked through. Indeed, if the reason for choosing a caring profession is an attempt to fulfil unmet needs of the past or to turn a passive and dependent experience into an active one, the past will still be unresolved and fuel the adopted attitude, with a potential risk of disappointment. In addition, a constant and rigid attitude motivated by denied needs makes the career selection not a choice but a necessity and may lead in the long run to dissatisfaction and/or burnout. This last issue also prompts the question of whether those participants who declared having a calling remain over time in the profession, a question only a longitudinal cohort can answer. Non-significant results between physicians with and without a calling with regard to motivations to choose medicine as a career may indicate that certain motivators such as a need to be useful, an interest for the sick, family influences or social recognition operate at a generic level; this might also have an effect on career stability.

The lack of a longitudinal approach also points to other limitations of this study, which cannot access the more subtle subjective experiences associated with a calling. Moreover, culture and language also produce different approaches to a calling. For instance, in French (the language of our study), a calling exists only as one word (“la vocation”), while English has at least two words, “calling” and “vocation.” We have also utilized a somewhat static definition but a calling might also be acquired or lost over time, as stressed above.

Finally, only an infinitely small number of physicians viewed a calling as the sole reason for choosing medicine. This result may be related to the evolution of the profession, being increasingly regarded as a job similar to others –an evolution already observed in the nursing profession, which desired to gain some distance from its religious background associated with a sacrificial attitude [43] –, and to the call for a good life (gutes Leben) [35]. This last finding may also explain why a calling as a co-motivator was experienced only by a minority of participants.

5 Conclusion

Our study reveals that a calling is considered only by a minority of physicians as a driving force of their career choice. This result, however, does not mean that physicians do not need a certain drive to work and that they rely on it in daily clinical work despite their often deplored professional context. A sense of calling influences career choice and professional stability, and might thus play a protective role with regard to feelings of exhaustion or dissatisfaction with work.

In times of change –increased use of technology, administrative burden, loss of prestige, and so on –, research is needed to gain a deeper understanding of what motivates physicians to do their work and maintains them in the profession. Introducing the issue of professional consistency in this study can be considered a strength and innovative dimension. Our results invite further investigation of possible links between a calling, job satisfaction, career choice and stability, and the production or loss of meaning in the professional life of physicians.