The primary goals of a health system are generally regarded as the advancement, restoration, and maintenance of health through efforts to ensure coordinated, sustainable delivery of effective, safe, and people-centred healthcare that involves promotion, prevention, treatment, rehabilitation, and palliation.1 High-quality services delivered by motivated healthcare providers are essential for the achievement of effective universal health coverage in countries at all income levels. However, factors that contribute to the quality of healthcare services are multivariate, complex, and interrelated; they cover a wide spectrum of patient-, provider-, organisation-, and system-level enablers and barriers. A previous systematic review demonstrated the negative consequences of physician unwellness on healthcare system outcomes, including but not limited to worse recruitment and retention, reduced productivity and efficiency, suboptimal patient care quality, higher rates of patient nonadherence and dissatisfaction, and increased risk of medical errors.2

In this issue of the Hong Kong Medical Journal, Gao et al3 used standardised patients and questionnaire interviews to examine the extent to which healthcare quality could be attributed to work motivation among village clinicians in 21 rural counties across three provinces in China. The research demonstrated a positive relationship between village clinicians’ internal work motivation and their clinical performance; this association was stronger with incentives and lighter workload (eg, number of patients per month).3 The study adds to a body of previous work published in our section ‘Healthcare in Mainland China’4 by identifying factors associated with healthcare quality in remote and rural areas in China. It also highlights the contribution of physician work motivation to the delivery of high-quality care.

Physicians have a responsibility to meet the needs of people throughout the healthcare system; they also have a responsibility to make evidence-based, sound clinical decisions. Physicians also make substantial contributions to the advancement of medical knowledge and practical skills by conducting well-designed scientific research. For example, research studies focused on coronavirus disease 2019 (COVID-19) are increasingly led by frontline physicians who seek to gain insights regarding disease transmission, risk factors, screening, clinical diagnosis, immune responses, treatment and pharmaceutical prophylaxis, and vaccines.5 The various high-value functions performed by physicians inevitably require continuous dedication, commitment, and passion. Therefore, work motivation and career satisfaction among physicians have received increasing attention over the years, considering their close relationships with healthcare quality.6 There is increasing empirical evidence regarding the multidimensional factors, context, and processes that may influence a physician’s motivation for work; these aspects exert complex effects on the risks of burnout, turnover intention, and job satisfaction.7

Rapid progress in strengthening health systems and service capacity has led to increased clinical responsibilities and job demands on physicians because of increased patient volume, expanded key performance metric indicator targets, and decreased autonomy. Additionally, physician workloads can substantially increase during public health emergencies. For example, the COVID-19 pandemic has presented new challenges that require novel solutions with respect to infection prevention, early recognition, rapid identification, disease control, rehabilitation, and resilience.8 9 10 11 12 These changes have been addressed by research conducted in Hong Kong. A recent territory-wide cross-sectional survey revealed a high prevalence of burnout among physicians who had completed specialist registration within the past 10 years and among residents-in-training, as well as a high level of depression among junior physicians who reported substantial dissatisfaction with their current job positions.13 A review of international literature highlighted the prevalences of sleep deprivation and circadian disorders related to prolonged working hours; these problems affect physician health, leaving physicians vulnerable to significant work-life imbalance, psychological stress, and burnout.14

In remote and rural areas where limited healthcare resource availability remains a recurring key challenge, the achievement of desired health outcomes is dependent on whether physicians can deliver a broad spectrum of person- and family-centred care in the community. Rural physicians play an important role in the delivery of community-based disease prevention and health promotion in response to community healthcare needs. Observational evidence from China suggests that rural physicians with higher workloads tend to deliver less frequent follow-up care; this phenomenon may be explained by reduced initiative and motivation related to the perception of an increased daily clinical workload, particularly among physicians who have not yet achieved clinical proficiency in managing complex encounters.15 The results of a nationally representative survey of physicians in the United States also led to speculation regarding the associations of intrinsic motivation factors with physicians’ career enjoyment, life satisfaction, and clinical commitment.16

Physician attitudes and behaviours with respect to following clinical guideline recommendations are presumed to strongly influence healthcare outcomes. The inability or failure of physicians to initiate or intensify therapy when indicated, despite clear recognition of the problem (ie, ‘clinical inertia’), represents a common and major barrier to efficiency and effectiveness in disease management.17 18 A recent observational study indicated that efforts solely focused on increasing the proportion of tertiary educational attainment among Chinese rural physicians may not directly translate into strong motivation and active commitment to the provision of clinical services, considering the potential for concurrent clinical inertia and workload-related factors.15 Thus, there may be a need for a systematic approach that incorporates the use of facilitators (eg, computerised decision support systems and standardised clinical management protocols), provision of carefully and appropriately designed incentives, and implementation of CME/CPD (continuing medical education/continuous professional development) programmes throughout each physician’s career,18 in addition to the initial medical training.

There remains a vast array of factors to consider when attempting to improve healthcare sustainability and enhance physician satisfaction over time. For instance, practice structure and ownership; relationships with colleagues within and outside the practice; and the content, quantity, and speed of work have been identified as factors that influence physician career satisfaction.19 Some conceptual frameworks may provide useful perspectives, such as the Knowledge-Attitude-Behaviour-Result model, Awareness-Agreement-Adoption-Adherence model, Physician Guideline Compliance model, and Regulatory Focus Theory.18 These frameworks may help to guide interventions that overcome barriers to physician motivation and satisfaction. Multiple randomised clinical trials have been conducted to explore innovative approaches that promote physician well-being. A study at the Mayo Clinic in the United States demonstrated that self-facilitated physician small-group meetings involving reflection, shared experience, and small-group learning produced significant improvements in burnout, depressive symptoms, and job satisfaction.20 As noted in a previous systematic review, physicians with higher levels of career satisfaction are more likely to dedicate their full attention to patients’ healthcare needs and provide better patient care.6

The current findings emphasise the importance of promoting physical, emotional, and spiritual well-being among physicians to ensure empathy and compassion in patient care, while minimising and preventing medical errors and malpractice. Further research concerning the extent to which relationships of physician motivation and satisfaction with healthcare quality vary across levels of healthcare and among medical specialists will be of interest to the readers of the Hong Kong Medical Journal. We also look forward to receiving additional evidence from pragmatic implementation studies that can provide insights regarding optimal strategies for improving physician motivation and satisfaction, particularly in the post–COVID-19 era.

The authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.

The authors have declared no conflict of interest.

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