Image and perception of physicians as barriers to inter-disciplinary cooperation? – the example of German occupational health physicians in the rehabilitation process: a qualitative study
In the German rehabilitation system, primary care physicians (PCPs), occupational health physicians (OPs), and rehabilitation physicians (RPs) fulfill different distinct functions and roles. While effective cooperation can improve outcomes of rehabilitation, the cooperation between these groups of stakeholders has been criticized as lacking or insufficient. This article proposes an approach to understand the low levels of cooperation by examining the role of group perception and group identity in intra-professional cooperation as a barrier to cooperation between physicians in different roles. Group perception was evaluated in terms of (1) negative views about another group of medical specialists and (2) differences between the perception of members and non-members of a medical specialty group. To examine this issue, we focused on the role of OPs in the German rehabilitation process.
We implemented a qualitative study design with eight focus group discussions with PCPs, OPs, RPs, and patients (two focus group discussions per stakeholder group; 4–10 participants) and qualitative content analysis. We used the Social Identity Approach by Tajfel and Turner as a theoretical underpinning.
While all protagonists reported a positive perception of their own professional group, we found numerous negative perceptions about other groups, especially regarding OPs. Negative perceptions of OPs included 1) apparent conflict of interest between employer and employee, 2) lack of commitment to patient outcomes, 3) lack of useful specialized knowledge which could have a bearing on rehabilitation outcomes, and 4) distrust on the part of their patients. We also found divergent perceptions regarding roles, responsibilities, and capabilities among the specialist groups. Both negative and conflicting perceptions about roles were characterized as barriers to cooperation by study participants.
This example of cooperation between RPs, OPs, and PCPs suggests that negative and diverging perceptions about an out-group could create barriers in intra-professional and inter-disciplinary cooperation between physicians. These perspectives might also be useful in explaining problems at intersections between different specialties. We suggest examining the inter-group dimension of perception-based barriers to cooperation in future interventions to overcome problems caused by intra-professional and inter-disciplinary conflicts in addition to other barriers (i.e. organizational hurdles).
KeywordsOccupational health physicians Primary care physicians General practitioners Rehabilitation Interface Health services research Social identity approach Conflicts Cooperation Inter-disciplinary
Focus group discussion
Intractable identity-based conflicts
Occupational health physician
Primary care physician
Social categorization theory
Social identity approach
Social identity theory
The complex and highly segmented German health care system is based on the cooperation of numerous specialized stakeholders with various professional competencies, organizational responsibilities, and goals. It is essential that these stakeholders are linked effectively through intersections, at which information is transformed, translated, and provided to the recipient. Intersections are points of transition in complex social systems. At these intersections specific professional expertise and skill levels, organizational responsibilities as well as the reach provided services end, which creates the need of continuation and supplementation in a cooperative manner . While segmented health care systems can facilitate higher quality of services through specialization, they come with the risk of malfunctioning intersections leading to information loss or discontinuation of care pathways.
In the German rehabilitation process of working persons, the most important intersections between medical protagonists are those between primary care physicians (PCPs), occupational health physicians (OPs), and rehabilitation physicians (RPs). The focus of this study is on OPs. Every company in Germany is obliged to employ or work together with an OP, whose functions regarding rehabilitation include screening employees, initiating or supporting the process of applying for rehabilitation, providing RPs with information about the workplace, as well as assessing, preparing, and discussing occupational reintegration. This includes providing work accommodations (e.g. standing desks, supporting devices) and determining the need for retraining and job rotation. No referral by other physicians is needed. The role of this stakeholder is explained in more detail in our study protocol .
Absent or insufficient cooperation and communication at these intersections have been criticized for many years [3, 4]; in particular an insufficient flow of information from and to OPs [5, 6]. Surveys from Germany and other European countries found a low intensity of communication and cooperation between OPs and RPs [7, 8, 9, 10, 11, 12, 13]. German OPs in particular felt excluded from the rehabilitation process [10, 11, 12, 13]. Although not focused on rehabilitation, insufficient cooperation between OPs and PCPs was reported in a literature review from Germany , as well as surveys from Germany , France , and Italy [17, 18].
All medical protagonists agree that improvements are needed [7, 8, 9, 10, 12, 15, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28]. Several interventional studies from Germany indicated that improved cooperation could be beneficial in improving the occupational health of patients [29, 30, 31, 32, 33, 34, 35, 36, 37]. Furthermore, international literature reviews have identified several promising interventions, which cover the areas for which OPs are responsible in Germany [38, 39, 40, 41, 42, 43, 44, 45, 46].
As part of a larger research project aimed at identifying barriers and solutions in the cooperation between OPs, PCPs, and RPs , previous studies based on the same data set have outlined various barriers to cooperation  and compiled suggestions of the participants for how the cooperation could be improved . Although problems at the intersections of different medical disciplines clearly constitute an intergroup issue, the role of group-identity and group-perceptions is often ignored . Therefore, the present study aims to provide a meta-level assessment to understand and explain barriers by focusing on the group dimension of cooperation.
This study is based on an explorative, qualitative research design using the Social Identity Approach (SIA) by Tajfel and Turner [50, 51, 52, 53, 54, 55, 56] as the theoretical underpinning, eight focus group discussions (FGDs) for data collection, and qualitative content analysis  for data analysis. A more detailed outline of methods and research questions is provided in the study protocol  and the preceding publications [47, 48].
Social Identity Theory (SIT) adresses intergroup behavior and perception, and was developed to describe social factors in the development of perceptions, which lead to prejudice and discrimination [50, 51, 52, 53]. It states that social categories (i.e. being an OP) provide a definition of who one is in terms of being part of a self-concept. In a specific context (i.e. the health care system), one of those categories may gain relative importance within the self-concept and form the social identity of the person. Thereby, individuals categorize themselves as members of a social group and relate to other protagonists in the system based on this affiliation (seeing others as part of the in or out-group). A positive social identity is based extensively on favorable comparisons, in which the in-group is positively distinct from the relevant out-group. The identity content is thereby comprised of specific value-laden attributes and characteristics, which members of the in-group attribute to themselves and use to compare themselves with members of the out-group. As a result, the out-group perception may become stereotypical and pejorative, and inter-group interaction is based on group identities and may become competitive and discriminatory [51, 55, 56]. The process of group categorization is further elaborated in the Social Categorization Theory (SCT), which was developed based on SIT. In this theory, the social identity groups are cognitively represented in terms of prototypes. These prototypes are simplified, stereotypical, or idealized members of the in-group or out-group, which are based on an identity content attributed to the group. The prototypes may be actual members of the groups or non-existing idealized versions of them [51, 56]. SIT and SCT together form the concept of the Social Identity Approach (SIA).
Characteristics of focus group participants
Primary Care Physicians
n = 22
n = 9
n = 12
n = 15
Age Average [Median/(Range)]
57 / (40–67) Years
55 / (45–65) Years
48 / (34–58) Years
53 / (22–63) Years
Age [Median / (Range)]
Sex: nbr. Female
n = 9
n = 5
n = 6
n = 8
Sex: nbr- fem.
Work experience as physician
27 / (13–40) Years
29 / (12–39) Years
13 / (6–30) Years
One: n = 4
Two: n = 1
Three: n = 1
Previous rehabilitation therapies
Work experience in specialization [Median/(Range)]
21 / (7–33) Years
20 / (1–32) Years
11 / (3–31) Years
Type of employment
Solo practice: n = 13
Group practice: n = 9
Employed at enterprise n = 1 Employed in occupational health service: n = 4
Freelance: n = 4
all employed at the rehabilitation clinics
21 days: n = 4
28 days: n = 3
35 days: n = 5
> 35 days: n = 3
Planned duration of rehabilitation (days)
Urban: n = 2
Rural: n = 10
Mixed: n = 10
Urban: n = 5
Rural: n = 0
Mixed: n = 4
Mental health n = 5
Musculoskeletal n = 5
Reason for rehabilitation
Practice size (patients per 3 months)
< 700: n = 2
700–1400: n = 14
> 1400: n = 5
Responsible for SME: n = 8
Office work: n = 5
Industrial production: n = 3
Rehabilitation applications [Median/(Range)]
35 / (5–50) per Year
Construction work: n = 1
Logistic sector: n = 1
Nursing care: n = 2
Pedagogue: n = 1
Cleaner: n = 1
Small or medium enterprises: n = 7
Type of employer
Business has OP: n = 8 Patient knows OP: n = 7
Relationship to OP (responses by patients)
Setting of data collection
Meeting room in University Hospital Tübingen or in our institute in Tübingen
Meeting room in our institute in Tübingen & Conference room in Stuttgart
Meeting room in rehabilitation clinics
Meeting room in rehabilitation clinics
Setting of data collection
The semi-structured FGDs lasted between 85 and 99 min and were conducted between February and May 2015. The interviews were conducted by one of two female researchers working for the Institute of Occupational and Social Medicine and Health Services Research at the University Hospital Tübingen (an occupational safety engineer and an associate professor for occupational, social, and environmental medicine (author SVM)). Both have previous experience in conducting qualitative research and received theoretical training in our institute. We informed the participants prior to the FGD about the professional background of the interviewer and the aim of the research project. One of the interviewers was already acquainted with three OPs and one GP. A research assistant was present in one of the interviews. The FGD guide was developed by an interdisciplinary team of content and methods experts based on previous literature reviews [6, 14], and our main research questions were pilot-tested before use. It focused on the topics: (1) attitudes towards rehabilitation therapy (warm-up question), (2) the perceived role and function of OPs, GPs, and RPs in the rehabilitation process, (3) the informational need of patients and medical stakeholders, and (4) the perceived quality and intensity of cooperation and communication at the interfaces between the different groups. The full interview guide can be provided upon request.
The discussions were digitally recorded on video and audio files. No field notes were taken. We used the methodological orientation of content analysis, the method of qualitative content analysis , and the software MAXQDA 11 (VERBI GmbH; Berlin, Germany) to assess the transcribed and pseudonymized interviews. The coding frame was developed inductively from the text while keeping the main research questions in mind. After we assumed saturation to be reached after three transcripts, we revised the coding frame and applied the categories deductively to all transcripts based on the research questions. To control for subjective blurring and to achieve intersubjective creditability, two to three persons applied the categories to the transcripts, in part independently and in close discussion . The category system is provided in Additional file 1. We conducted a workshop for content validation in January 2015. Representatives of all participating groups were invited, and a total of 16 GPs and OPs participated.
First, we describe how the cooperation with OPs is perceived by the protagonists. Next, we outline the perception by OPs, PCPs, and RPs of their own professional group (in-group perspective), followed by a description of how the professional groups are perceived by other protagonists (out-group perspective). Then we focus on the process of group distinction, and finally we outline how the negative perceptions about other groups, as well as diverging perceptions between the groups relate to cooperation deficits.
Cooperation with OPs in the rehabilitative health care system
Excerpt from PCP-FGD-I: Interviewer: “[When thinking about OPs], where do you see their position, their relevancy [in the rehabilitation process]?” PCP: “We don’t know, as we do not know what they are doing at the moment. In the past 18 years, I never been in touch with an OP. Other than sometimes patients coming to my practice […] and telling me that their OP had told them that their cholesterol or liver enzymes were elevated. But beyond that, I don’t hear anything. There really is no communication with OPs.”
Self-perception of medical protagonists
We found that all medical protagonists in the rehabilitation process tried to establish and maintain a positive social identity that was based on specific functions and characteristics that also made them essential for the rehabilitation process (e.g. OPs: profound knowledge of workplace). We found aspects of an idealized prototype of the own profession in all groups. For example, the image of the highly committed OP who actively guides his patients through the rehabilitation process like a lighthouse, or the RP who enables their patients to rejoin social and working life.
In-group perception of OPs
Excerpt from OP-FGD-II: “OP1: […] I do believe we provide a valuable contribution. Who really knows the work on site and can link health to occupation, and occupational burden to health?” OP2: “Yes, precisely” OP1: “That’s the OP!” OP2: “Yes, definitely” OP3: “He/She is the lighthouse!”
In-group perception of PCPs
One central identity content of PCPs in the rehabilitation process was the role of patient advocate. PCPs constructed a self-image of physicians with strong and trustful doctor-patient-relationships. Many PCPs perceived their professional group as the protagonist with the most profound knowledge about their patients. PCPs described themselves as committed to improving their patients’ health and to defend it from harmful influences, such as arbitrary decision-making by the pension insurances or exposure to work-related hazards. PCPs portrayed themselves as having a high workload and little time to spare. In the rehabilitation process, they regarded themselves as door openers, enabling the right patients to receive the necessary rehabilitative treatment. For these reasons, PCPs described themselves as best-suited for the role of coordinator or case manager in the rehabilitation process.
In-group perception of RPs
Excerpt from RP-FGD-I: “What is health? Being able to live and work – according to Freud. And this is exactly what we [as RPs] do here”.
Perception of professional groups by others
Out-group perception of OPs
One prominent narrative among PCPs and rehabilitation patients about OPs was that they were not primarily working in the interest of their patients but were rather “henchmen” of the employers. One PCP stated that contacting OPs about occupational health risks would never lead to any change in the patient’s workplace situation, which he thought was due to OPs being corrupted by the employer. Rehabilitation patients were especially concerned regarding information being passed on by OPs to the employer. RPs reported these concerns to be prevalent among their patients. This aligns with a prominent narrative among RPs and PCPs regarding the doctor-patient relationship between OPs and patients, which was dominated by unfamiliarity and distrust. Most patients reported either not knowing their OP at all or having little to no contact. This was confirmed by RPs in their FGD. In contrast, two participants had a positive perception of OPs: They described the relationship as good and trustful. OPs were aware of these negative perceptions and strongly rejected them. They stated that OPs were sometimes perceived as opponents in the struggle for the patients’ health and well-being by PCPs. While most PCPs shared this negative perception, two PCPs held a more positive view about OPs and portrayed them as cooperative and willing to improve patient health. One PCP who reported having had positive experiences with OPs in the past stated that although friendly and willing to help, OPs were limited in their capacities by rules set by the employers. In both FGDs involving PCPs, OPs were described as having a weak work ethic, showing little commitment to the patient’s health and well-being, and having a well-paid job with short working hours. This was often mentioned in the context of OPs not being interested in cooperation, as PCPs had seldom experienced OPs trying to communicate with them. One OP stated that these kinds of perceptions were prevalent among PCPs.
Excerpt from PCP-FGD-I: “In most cases communication is established through our [PCP] initiative and is mostly a negative experience. […] [PCP gives an example of a patient he provided with a certificate of incapacity for a certain task]. This has never been successful, never! Instead, the patient returns to his workplace and the OP says: someone must do this job. This is why we get little joy from [cooperating] with them [OPs]. Because they just don’t care at all about our recommendations. […] They should be obliged to report why they can’t implement it. And they should be obligated to prove that they were not bought by the company and do not primarily work in the interest of the employer […].”
Out-group perception of PCPs
OPs and RPs acknowledged the depth of the doctor-patient relationship between PCPs and their patients, and also shared the in-group perception of PCPs as being busy and having little spare time. One RP felt as if he was perceived as a disturbance when trying to communicate directly with PCPs. RPs and OPs both stated that PCPs had limited knowledge of their patient’s occupation and workplace. They assumed his was due to PCPs not assigning much value to this aspect of the patient’s life and not having insights into the working world. According to RPs, some PCPs did not properly understand the concept of “ability to work”. This was in part due to PCPs not reading the rehabilitation report, not being familiar with legal definitions, or not being sufficiently familiar with the patient’s occupation. OPs believed that some PCPs saw the employer as an antagonist in the struggle for improving patient health.
Out-group perception of RPs
Excerpt from OP-FGD-I: “One has to ask oneself: who becomes an RP? […] Are these the ones who are most dynamic? Who want to achieve something? Or rather those who tell themselves: it is quite comfortable being in this position”
Group-based comparisons and distinctions
To a large degree, group distinctions were made by contrasting the goals and functions of the own group in the rehabilitation process with those of the other groups. In these comparisons, the participants highlighted how essential or important their own role was, or they created a distinction based on value-laden attributes.
An example for the distinctions through devaluing based on value-laden attributes is the clear, dichotomous distinction made by PCPs between themselves, the highly committed and diligent PCP working to help and protect their patients, and the well-paid OPs with short working hours and little commitment to the patient’s well-being. A similar distinction was made regarding RPs, who according to PCPs worked few hours and had low levels of occupational stress, while PCPs portrayed themselves as having a high workload and little time to spare.
Excerpt from OP-FGD-I: OP1: “ [It is good that the PCP takes on the role of coordinator in the rehabilitation process]. But the [coordination] within the workplace, that is in good hands with us. Because, with a positive patient image, a positive scope of performance levels, and [knowledge of] the workplace requirements, we are much better-suited to evaluate what is possible and sensible.” OP2: “Yes, because the PCPs don’t have any insights. It would be presumptuous if they asserted they could do this.”
Excerpt from PCP-FGD-I: PCP1: “[…] I never felt the need or had particular interest [in cooperating with OPs]. Because we will talk to them over the phone for an eternity, and nothing comes out of it” […] PCP2: “Those OPs have an unsavory taste. […] It is a relaxed occupation: they start at 8 in the morning, are at home at 4 PM, and are well-paid for that by the company. They don’t have any responsibility; don’t need to spring into action during the night. [..] Maybe there is a little envy talking from our side.”
Excerpt from PCP-FGD-I: “The level of contact is close to nil. They sit around somewhere and have an easy job in my view. You can see that from their (lack of) availability in the morning at half past seven or in the afternoon after four PM. We have close to no points of contact”
Perception-based barriers to cooperation with OPs in the rehabilitation process reported by protagonists
In this section, we contextualize the diverging and negative group-based perceptions in the context of barriers to cooperation.
Henchmen of employer
Excerpt from OP-FGD-I: “I am a doctor for internal medicine by training and have worked in the hospital for many years. Do you believe I would have taken an OP seriously? Not at all! […] What do they want? That is actually the employer! I won’t tell them anything!”
Excerpt from RP-FGD-I: “But to the company physicians, there’s hardly any contact, if any. And that has a lot to do, speaking from my own experience here, a lot to do with prejudices and fears [of the rehabilitants] that confidentiality will be neglected regarding their employers, etc.”
OPs as optional protagonists
The in-group perspective of OPs and the out-group perspective by PCPs and RPs diverged considerably regarding roles in the rehabilitation process. OPs perceived themselves as having information and knowledge that was important and not available to PCPs and RPs, which made their contribution essential. By contrast, the role of the OP was considered optional or irrelevant by some PCPs and RPs. Some OPs had experienced that this perception was prevalent among PCPs and RPs. In one FGD with RPs, one RP stated that they were not aware of the potential function of OPs in the rehabilitation process. RPs argued that in practice, the delivery of workplace information and occupational reintegration was rarely needed. OPs in both interviews stated that cooperation deficits might be caused by insufficient knowledge of PCPs and RPs about OPs’ functions and potential role in the rehabilitation process.
Less dedicated & limited agency
Excerpt from OP-FGD-I: “At the times when we have the time to call them, you cannot reach anyone, because it is lunch break again or after 7 PM”. “Actually, they [OPs] should be the ones responsible for trying to get in touch with us”
Reported self-perception of protagonists and perception of these groups by other medical protagonists
● Working in the interest of patients
● Profound knowledge of workplace; which others were lacking
● Experts on interface between occupation and health
● Well-suited to be coordinators in rehabilitation process
● Good relationship with their patients
● Role in rehabilitation process not known and adequately valued
● Important for successful rehabilitation process
● Dedicated to patients
● Advocates for their patients
● Important for successful rehabilitation process
● Good and intensive relationship with patients
● Profound knowledge of patients workplace
● High workload and unjustified demand from patients
● Dedicated to cooperation with other protagonists
● Promoting patients’ physical health, social well-being, and occupational participation
● Henchman of the employer
● Limited agency
● Not hardworking
● Not working in the interest of patients
● Patients don’t know them
● Role and function in rehabilitation process unclear
● Not interested in cooperation
● PCPs and OPs are competitors
● Not interested in cooperation
● Not interested in cooperation
● Insincere concerning reported rehabilitation outcomes
● Not interested in the patients’ health after end of rehabilitation
● Not hardworking
● Not very ambitious
Identity and perception as roots of cooperation deficits
A negative image or stereotype of a group may be derived from real world events (e.g. negative experience of an individual OP). The problem can occur when, facilitated through group identity processes, the interaction with individual members of a group (e.g. OPs) are based on, or influenced by the stereotypical characteristics of the group, which are then ascribed to every individual (e.g. OPs are henchmen of the employers). This can pose a direct barrier to cooperation, for example when patients refuse to pass on information due to confidentiality concerns. Furthermore, they can shape how objective obstacles (e.g. structural barriers) limit cooperation. For example, PCPs not being able to be reached because of (objectively) different working hours, and PCPs not trying to contact OPs because they have the mental image of OPs having a weak work ethic and therefore assume OPs are difficult to reach. While it is not possible to distinguish these aspects based on the subjective accounts of our participants, we believe it is important to explore the extent to which structural barriers mask additional group perception-based hindering factors.
Scientific literature on perception-based barriers to cooperation
Negative and/or sterotypical group perecptions have been reported in other studies: For example RPs being unaware of the OP’s role and function in rehabilitation [7, 8, 10, 13, 59]; patient unawareness of of the existence of OPs or their function, as well as patient mistrust of OPs as barriers to cooperation in the rehabilitation process [4, 7, 12, 27, 60, 61, 62]; or a lack of understanding of the OP’s role among physicians [19, 61, 63]. Several studies mention PCPs [14, 15, 16, 17, 18, 20, 59, 64, 65] or RPs [8, 9] mistrusting OPs (e.g. in terms of OPs not working in the interest of the patient or breaching confidentiality regulations).
Despite awareness about these barriers, the approach to understand them as perception-based barriers to cooperation at intersections resulting from inter-group processes has rarely been applied, either to examine interference in the cooperation of physicians in Germany, or in the rehabilitative health care setting. We only identified one Dutch study in which this concept was partially applied (without referencing SIA). The study found a correlation between trust of PCPs in OPs and the perceived relative status of the groups: PCPs who perceived their relative social status as higher reported having more professional trust in OPs .
While few studies examined the role of group perception and group identity in intra-professional cooperation between physicians, these issues were addressed in a number of studies focusing on inter-professional cooperation. For example, Kreindler et al. proposed SIA as a framework to understand inter-professional cooperation, i.e. between nursing staff and physicians .
Facilitators and perquisites for successful cooperation
Several studies, including systematic reviews, identified facilitators and perquisites for successful inter-professional cooperation in the health care setting; especially concerning the cooperation of doctors and nurses [66, 67, 68, 69, 70, 71, 72, 73, 74]. These facilitators and perquisites included, i.e.: mutual trust [75, 76, 77, 78, 79, 80, 81, 82], mutual respect [75, 76, 77, 79, 80, 83, 84], collegial partnerships [69, 75, 83, 85], understanding the practice of the other group’s profession [69, 75, 77, 86], awareness and valorization of other professionals’ contribution [76, 80, 85, 87], as well as perceived benefits of cooperation [85, 88, 89]. Conflicts were reported following a redistribution of power and functions of nurses, which was experienced as an erosion of roles by GPs [88, 89, 90]. A lack of clear understanding of the cooperation partner’s professional role and responsibility was mentioned as a barrier to cooperation and as promoting professional conflicts [66, 91, 92].
Despite a number of distinct differences, we believe that the intra-professional, inter-disciplinary conflicts in our study have some resemblance to inter-professional perception-based conflicts reported on in this study. We therefore argue that well-developed strategies to overcome barriers to inter-professional cooperation could also be useful in overcoming intra-professional cooperation deficits between different specialist groups of physicians.
Approaches to overcome negative and prejudicial attitudes
One of these strategies identified by reviews on inter-professional is clearly-stated and shared goals as facilitators of successful cooperation in teams [66, 68, 69]. For the German rehabilitative health care system, an intervention to test this approach could focus on the development of shared goals in meetings with different disciplines (e.g. GP, RP, and OP), professions (e.g. physical therapists), and patients for the field as a whole or for circumscribed geographical regions.
Another approach to overcome inter-disciplinary group-based conflicts through facilitation of communication and relationship-building is joint educational programs . These were suggested by participants in our study, as well as by the participants of other studies from Germany and the Netherlands [7, 9, 28, 65, 92]. One reason why participants in our study suggested introducing these programs was to overcome negative perceptions and attitudes through contact. The underlying theory is the contact hypothesis by Allport , which has been proven to effectively reduce prejudice and negative-attitudes . While this approach was successfully applied in inter-professional cooperation, two studies on joint educational programs between OPs and PCPs did not show lasting positive impact [96, 97].
As a third approach, interventions building on the model to resolve intractable identity-based conflicts (IIC) could be used, which itself is based on the social-identity approach . This model states that a de-escalation of identity-based conflicts drawing on negative perceptions about an out-group must go through stages of interaction. These stages are a (1) readiness and willingness to solve existing conflicts, (2) a decoupling of situation and conflict from inter-group identities, which may be achieved through the promotion of mindfulness about the situation. Thirdly, (3) establishing an secure identity within the subgroups can then be supported through promoting positive in-group distinctiveness, which does not draw on the devaluation of out-groups. Followed by a stage of (4) promoting cooperation around specific objectives while maintaining separate, distinct groups, and an (5) enduring intergroup harmony may be achieved through further promoting integrative goals and structures between the former conflicting identity groups . We could not identify suitable interventional studies, which were based on the IIC-model.
Strengths & Limitations
A strength of this study is the novelty of our approach, in which we looked at the low intensities of inter-disciplinary cooperation between GPs, OPs, and RPs in the German rehabilitation process by taking group perception and group-identity into account. Furthermore, we achieved high levels of heterogeneity in the composition of FGD-participants (e.g. working experience, disease profiles, company sizes) and included FGDs with patients.
Two limitations of our study result from the complicated recruitment process of OPs: a selective sample of OPs with a strong interest in the topic cannot be ruled out, and the composition of our FGDs deviated from the planned composition. As RPs and rehabilitants were recruited from two rehabilitation institutions, unwanted group effects cannot be excluded. Especially as studies indicate a pronounced heterogeneity of rehabilitation clinics regarding quality and interest in cooperation . As the study was conducted by experts in the field of occupational health, biased responses due to social desirability are possible.
We conducted FGDs with homogenous professional groups to enable participants to have less constrained discussions and to allow them talk more freely about negative or possibly prejudicial attitudes. While we consider this approach successful, it would have strengthened the study if additional FGDs would have been conducted with mixed groups. This was partly achieved in the validation workshop held in January 2015, where both OPs and PCPs participated.
Our explorative, qualitative study indicates that the deficits in cooperation between RPs, OPs, and PCPs in the German health care system could result from, or be influenced by perception- or group identity-based conflicts. A divergence between how group members (in-group) and other disciplines (out-group) perceive a group of specialists, as well as negative perceptions of one group could lead to conflicts and barriers to cooperation. We found these barriers especially pronounced regarding OPs. While this does not devalue the importance of other barriers to cooperation , we believe this group perspective could help understand and reduce these barriers. Lessons learned from interventions to improve inter-professional cooperation as circumscribed in this study might be useful to improve cooperation between physicians of different specialty groups.
Future quantitative research is required to assess the relative weight of the findings and to further explore our hypothesis. High-quality interventional studies incorporating models to overcome inter-group conflicts could advance this field.
The authors would like to thank all focus group and workshop participants, the Department of General Medicine at the University of Tübingen, the Therapy Center Federsee - Bad Buchau, and the Rehabilitation Center Bad Duerrheim - Klinik Huettenbuehl. Moreover, we would like to thank the student assistants René Markovits Hoopi, Maira Schobert, Sigrid Emerich, Stefanie Klein, and Natalia Radionova for contributing to data analysis, Dipl.-Ing. Nicole Blomberg for conducting one focus-group discussion, Dr. Martina Michaelis and Christine Preiser for their assistance in developing the interview guide, Dr. Rainer Kaluscha for supporting the recruiting process, Peter von Philipsborn for language checks and Lisa Peterson for translation services and language check.
This study was conducted as part of the young scientist program of the network Health Services Research Baden-Wuerttemberg (‘Versorgungsforschung Baden-Wuerttemberg), which is funded by the Ministry for Science, Research and Art and the Ministry for Work and Social Welfare, Family, Women and Senior Citizens of the federal state of Baden-Wuerttemberg, Germany. The work of the Institute of Occupational and Social Medicine and Health Services Research is supported by an unrestricted grant of the Employers’ Association of the Metal and Electric Industry Baden-Württemberg (Südwestmetall).
Availability of data and materials
The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.
The authors Stratil (JS), Voelter-Mahlknecht (SVM), and Rieger (MAR) contributed to the publication as follows: Development of the study design as a whole: SVM, MAR; Development of the theoretical background and review of literature: JS; Selections and invitation of participants: SVM, JS; Conducting interviews and preparation of transcripts: SVM, JS; Data analysis: JS; Drafting the manuscript: JS; Critical Revision of the manuscript; SVM, MAR. Final approval of the version and agreement to be accountable for all aspects of the work: JS, SVM, MAR.
Ethics approval and consent to participate
The ethics committee of the Faculty of Medicine at the University of Tübingen approved the study protocol. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The participation of the study participants was voluntary. They were informed that the consent could be withdrawn at any given time without a statement of reasons and without detriment in medical care. The nature and scope of the research was explained to the study participants in written and oral form before onset of the study and their written consent was a perquisite for participation.
Consent for publication
The authors declare that they have no competing interests
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