[The analysis of physicians' work: announcing the end of attempts at in vitro fertilization].Encephale 2003 Jul-Aug; 29(4 Pt 1):293-305E
The purpose of this empirical study is to analyze modalities of announcing the end of attempts at in vitro ferti-lization to women who, for various reasons, were not able to have a child after several trials. What are the problems physicians face when, in the course of their work, they make these announcements? How do they give (or not give) support to these women who have placed so much hope in this technique? These are some of the questions that led the authors to conduct this empirical study within the framework of a clinical and qualitative approach to work psychology. Within this framework, work is conceptualised as a complex activity that involves the subject, both bodily and through his various modes of socialisation. The field of clinical and quali-tative approach to work psychology situations focuses on different ways of expressing distress related to contradictory work demands, as the activity is being performed; it also focuses on those creative processes used by the subject to cope with those internal and external conflicts that hinder task performance. A review of the literature and preliminary observations led us to postulate that the problems physicians are faced with when they announce the end of attempts at in vitro fertilisation (IVF) are linked to several conflicts between work values (that are specific to the medical world) and the recognition of work failure: termination of attempts at IVF. The popu-lation that participated in this research project belongs to a network of private practitioners who work with the in-house team of a Parisian clinic. But the group is not uniform and some physicians perform IVFs more frequently than others. Our qualitative study involved 10 semi-directive interviews of approximately 1 1/2 hours each, which were recorded and transcribed. Initial instructions focused on a concrete description of situations of abandonment of attempts at IVF, in terms of their preparation, development, and the way they are experienced . Interviews therefore centred on specific and limited practitioner activity. Each transcription was submitted to a Qualitative Analysis of Discourse, followed by a comparative analysis of the 10 transcriptions. We propose an original method of Qualitative Analysis of Discourse, to be applied to semi-structured clinical interviews. This method seeks to analyse the structure of the resulting egocentric monologue in research si-tuations of semi-directive interviewing. The method of Quali-tative Analysis of Discourse involves three steps, but only the first two were applied in this work: a) identification of sequences of discourse; b) analysis of relationships between statements; c) stylistic analysis of figures of speech. Our first set of analyses showed that seve-ral markers increase in physicians' discourse when they describe difficult and/or conflict-laden consultation situations: logical connectors, impersonal pronouns, reported discourse, anti-cipations regarding the interviewer's judgement. The logical balance of the discourse therefore appears threatened when pro-blems inherent in the work demands involved in ending IVF attempts are mentioned. As a whole, these markers underscore the importance of the implicit dimension of discourse (inferences, presuppositions, hints, allusions, etc.), thus reflecting complex speech that attempts to negotiate between subjective positions and shared cultural values. A comparative analysis of the markers identified in the 10 interviews revealed four areas, each involving nervous tension poles, that are suggestive of cognitive-emotional dissonance in the task to be performed. Some factors increase professional distress while others temper it. They act upon the work situation itself on the one hand, and on the working relationship between physician and patient on the other. 1. Areas of tension relating to the task to be performed. The first area contrasts individual with collective decision-making. The independent status which characterises private medical practice increases self-esteem in cases of success but weakens it when IVF attempts fail. In addition, it goes against collective involvement in the work situation, yet such involvement may act as a strong moderating factor for the experience of distress. The second area contrasts work that is well done with recognition by peers. Indeed, in the hierarchy of medical values, recognition by peers that work has been well performed is anchored in successful healing (in the broad sense of the term), whereas in situations of abandonment of IVF attempts, ending the attempt is considered by everyone to be a failure, even if it has been well conducted . The third area opposes objective medical practice to a necessarily subjective medical involvement. The scientific and ideal values which characterise medicine reflect its objective and scientific orientation, but IVF situations are a reminder that medicine is not an exact science and that it can make mistakes. There are numerous special individual cases which reduce certainty that a decision to terminate IVF is well-founded. The fourth area distinguishes between work that is considered to be well done and work considered to be well conducted . Personal estimation of work that is well done is based on the impression that the maximum feasible has been done . But in IVF situations, constant uncertainty leads to professional over-involvement (examinations, verifications, changes of protocols). Work that is poorly done is work that does not cure or that brings no relief. As a result, work that consists in ending IVF attempts, even if it is well conducted , remains a subjective failure for everyone since it does not bring a cure (pregnancy). 2. Areas of tension in the physician-patient relationship. The first area contrasts women's irrational desire with possible support from their husbands, when the time has come to announce the end of the attempts. But this voice/presence of husbands is consi-dered desirable and important only when attempts have failed, so that husbands are not encouraged to participate in the protocols except to help restrain their wives' over reactions . The second area opposes respect for the patient role with demands made by women. Lack of respect for the patient role, by making demands or by refusing to follow advice, particularly when IVF attempts are abandoned, crystallises all the resentment experienced by physicians in difficult work situations. Two cognitive-emotional worlds, more or less tuned to one another over the course of the IVF, start to clash and lose all mutual understanding: the medical world and the patient's subjective world. The third area results from the second one. It contrasts a listening physician with a powerful one. Physicians are very concerned that their relationship with their patients be one of partnership. But this (idealised) equilibrium is abruptly disrupted by the end of the attempts, inasmuch as it is the physician who has the power to stop these attempts and who decides to do so. The unveiling of this reality of a power relationship becomes a source of suffering and contradicts expressed surface values. The fourth area contrasts an attitude of ongoing patient support based on a belief in success with an attitude of patient support based on the prediction of a possible failure. Indeed, for a patient to be supported in a way physicians would consider right and adequate , the abandonment of IVF attempts should be anticipated in advance so that the physician can prepare both himself and the patients for the high risk of failure. But physicians insist on the fact that medical work can only succeed if they believe in it . As a result, the more energy the physician puts into launching the initial phase of IVF, the greater the feeling of self-accomplishment during the first phase of IVF; but conversely, the weaker the efficacy of the process of seeing the patient through the end of the attempts, the stronger the fee-ling of subjective distress at work will be. Overall, it is a para-doxical work situation for physicians to have to anticipate the interruption of IVF attempts and to have to prepare for seeing the patient through this abandonment. This situation creates conflicts of representations and values within their very practice and generates distress at work. It is worth noting that some moderating factors could alleviate their sense of suffering and contribute to improving their work experience: a) the deve-lopment of a protocol for seeing patients through the end of IVF attempts, which would make abandonment part of a job well done for physicians; b) regular participation by the spouse in these protocols; c) making all decisions to end IVF attempts a collective process, in order to avoid placing exclusive responsibility on the treating physician. The limitations of this study are inherent both in the qualitative nature of the data that involve a small number of physicians, and in the specificity of this population that works within a poorly structured network. On the other hand, our method of Qualitative Analysis of Discourse can be applied to all types of discourse obtained in research situations, provided the discourse is produced through semi-directive or non-directive interviews.