Introduction

Diabetes is a challenging disease not only for patients and their relatives but also for those responsible for their care. To provide the most effective care and successfully address the needs of patients, physicians are often exposed to fatigue as well as both mental and physical problems [1]. Most of all, patient nonadherence constitutes a pervasive threat to health and clinical outcomes, thus making diabetes care a “relational challenge” in motivating patients to self-care.

In this regard, a recent study showed 47% of endocrinologists were emotionally exhausted and reported burnout symptoms [2]. Although only a few studies investigated health status in physicians working in diabetic settings, it has been showed that diabetes and pre-diabetes care are associated with worse mental health and higher levels of burnout [3, 4]. Burnout syndrome consequences include stress, depression and suicide risk [5] as well as physician dropout rate and reduced empathy with patients, leading to clinical errors, worse medical outcomes and care dissatisfaction [2, 6, 7].

Qualitative research focusing on diabetologists’ subjective experience highlighted feelings of frustration connected to patient nonadherence, worries about failure to achieve clinical outcomes and an overinvolvement with patient accompanied by the fear to be overwhelmed [8–11]. Moreover, physicians working in diabetic settings reported the sensation of not having enough psychological resources to address patients’ needs [12] and tolerate emotional labor in healthcare relationships [9, 13]. Environmental factors also emerged (e.g. time constraints, lack of specialized personnel) as barriers to personalized care [9, 10, 12].

These pieces of research demonstrate that care relationships in diabetes can represent an emotional burden for physicians. Recently, Craven et al. [8] proposed the term “diabetes distress”–usually referring to patient distress connected with diabetes–to indicate a specific feature of diabetes professional experience that needs to be more deeply explored and consequently addressed by specific interventions to improve quality of care. Although–as yet highlighted–there are some studies addressing the subjective experience of physicians working in diabetic settings, none of them has examined the relationship with patients with diabetes from a psychodynamic point of view [14]. In this perspective, interpersonal experiences (e.g. relation with patients with diabetes) are internalized as symbolic representations involving feelings, images, sensations, expectations and beliefs about the relationship with the other that drive–often in an implicit way–interpersonal interactions. In line with this, emotions experienced within relationships are derived from “affective symbolizations” [15], which can be shared from people who live or work in the same context (e.g. physician working in diabetic settings). Affective symbolizations can emerge through narratives and discourses, looking at language and words as social vehicles for communicating the internal world. On this premise, it is important to investigate how physicians unconsciously symbolize patients with diabetes to more deeply understand critical issues and potential relational skills that can be further promoted in such a medical setting.

The purpose of the present study was to explore the subjective experience of physicians working in diabetic settings about their care relationships as to grasp their affective symbolizations. This may allow the detection of relational issues that can be crucial for promoting professional health of physicians working in diabetic settings, with fruitful advantages for patient adherence to treatment. In this way, the study aims at finding some unique clues contributing to physician capacities to manage patient adherence and elaborate on the emotional labor of clinical care of persons with diabetes.

Research design and methods

Results

Cluster analysis has detected six thematic domains. In Table 1, the percentage of sentences grouped in each cluster as well as the most characteristic keywords and some examples of participants’ extracts are reported.

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Table 1. Clusters.

https://doi.org/10.1371/journal.pone.0263226.t001

Latent factors

The first three latent dimensions emerging from MCA have been taken into account, which overall explain 69.20% of data variance. The absolute contributions of clusters to the factorial axes are presented in Table 2.

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Table 2. Absolute contributions of clusters to each factor.

https://doi.org/10.1371/journal.pone.0263226.t002

Conclusions

Six thematic domains have been detected, which shape affective symbolizations about caring for patients with diabetes and respectively referred to concern (8.43%), control (14.42%), avoidance (22.08%), devotion (22.49%), guilt (19.29%), and strive for achievement (13.30%). Such domains are conceived along three latent dimensions synthesizing the physicians’ subjective experience.

The first factor deals with a dynamic of affect repression suggesting a defensive minimization of potential perceived distress in care relationships by resorting to intellectualization and rationalization. Several studies have demonstrated that physicians tend to develop emotional detachment when dealing with stressful situations as to maintain scientific and medical objectivity [26–28]. Indeed, diabetes care can progressively lead to burnout because of several care challenges involving frustration about patients’ nonadherence to recommendations and emotional fatigue about the redundancy of treatment topics [3, 4, 8]. In order to protect oneself, such overwhelming emotions are handled by focusing on more technical and biomedical aspects concerning the disease [29], seen as something separated from patients in line with the “phallocentric function” of medical intervention proposed by Fornari [20]. The use of mature defenses allows alleviating discomfort and anxiety, as found in other studies about healthcare professionals [18, 30], as to reassure oneself and avoid feelings of powerlessness. In our results, this is expressed through abstract self-serving explanations about the value of professional mission or hypervigilant and controlling behaviors in diabetes management. However, some authors suggest that such strategies may reinforce depersonalization and reduce job satisfaction over time [27, 31].

The second factor deals with the tendency to repair patients’ integrity as “persons” since diabetes is a chronic and disabling condition involving ongoing psychological adjustment due to the impossibility to restore a completely healthy state [32]. Healthcare providers are thus faced with a potential empathic identification with care recipients, which may lead to a continuous effort to repair patients’ damaged self in symbolic terms [33–35]. Moreover, since diabetes care consists in a challenging step-by-step path involving monitoring and adherence to medical treatment, patients may enact denial strategies to handle disease related burden that prevent them from adopting self-care behaviors [10, 32]. This in turn affects care relationships, potentially engendering feelings of guilt and inadequateness in physicians and consequently the urge to address patients’ needs [36]. Indeed, previous studies have found a strong perceived responsibility in dealing with the emotional sufferance of patients with diabetes [8, 12] as well as a sense of deficiency and personal failure [9, 35] that can be overcome by using active listening and relational skills [13, 29, 37]. In this sense, both the fear of failure and the strive for achievement are strongly intertwined and underlie a motivation to derive satisfaction from the mastery of challenging tasks and effective care relationships [38].

The third factor deals with an anxiety pattern shaping the physician-patient interaction, characterized by insecure-ambivalent attachments. As reported by several pieces of research, physicians treating patients with diabetes experience feelings of anxiety [8, 9, 12, 37], with specific regard to worries about patients’ outcomes, fears of losing control over treatment and time constraints limiting individualized care. This may lead to feeling overwhelmed by social needs of patients as well as confused about one’s professional role because of the risk of an excessively symbiotic relation with patients [8]. As a consequence, physicians strive to maintain professional boundaries and try to get less involved in patients’ emotional concerns [29], for instance adopting an assertive attitude and paternalistic communication with patients within an asymmetrical relationship [8].

The limitations of the present study include the convenience nature of the sample and its reduced size that prevent from any generalization of the findings. Besides, the lack of secondary subgroup analyses by participants’ characteristics (e.g., gender, professional tenure, psychological status) does not allow considering some potential variability in the subjective experience of physicians working in diabetic settings. From this perspective, this study should be considered as explorative and preliminary, providing some qualitative clues that contribute to the understanding of care relationships. Enrolling a larger sample of physicians working in hospitals and/or GPs outpatient clinics throughout the country could make the present findings more robust and of impact in scientific literature. Overall, our results confirm the challenging nature of diabetes care [39]. Indeed, the ongoing effort to restore patients’ psychological integrity in such a chronic condition may lead to distress and professional fatigue. In this regard, physicians’ potential feelings of guilt concerning the impossibility to completely achieve healing—as a novel finding compared to previous studies—could be further explored in future research. In sum, the study highlights the need for emotional labour regarding physician-patient interaction to avoid maladaptive strategies in managing care relationships. On the one hand, the overuse of defensive mechanisms aimed at affect repression may involve the risk of depersonalization and detachment in relating to patients. This requires the development of affective and relational skills in physicians’ education and training. On the other hand, perceived uncertainty in care relationships could imply the enactment of paternalistic or conflictual behaviors, assuming a monopoly on decision-making about care. Therefore, reflective practices and clinical supervision should be promoted to adopt an integrative function in physician–patient relationship, intended as the capacity to activate a shared-decision making. This could make patients more prone to participate in and adhere to treatment as well as activate their personal resources for self-care [40–42].

Supporting information

Acknowledgments

The authors thank all the physicians who participated to the study.