The influence of a market-oriented primary care reform on family physicians' working conditions: A qualitative study in Turkey

Background: Turkey has undergone a 'Health transformation programme' putting emphasis on the reorganization of primary care (PC) services towards a more market-oriented system. Objectives: To obtain a deep understanding of how family physicians (FPs) experienced the process of the reforms by focusing on working conditions. Methods: This phenomenological and qualitative research used maximum variation sampling and 51 FPs were interviewed in 36 in-depth and four focus-group interviews. Results: Thematic analysis of interviews provided seven themes: (1) change in the professional identity of PC physicians (physician as businessperson); (2) transformation of the physician-patient relationship in PC (into a provider-customer relationship); (3) job description and workload; (4) interpersonal relationships; (5) remuneration of FPs, (6) uncertainty about the future and (7) exhaustion. Most FPs felt that the Family medicine model (FMM) placed more emphasis on the business function of family practice and this conflicted with their professional characteristics as physicians. FPs complained that some of their patients behaved as extremely demanding consumers. Continuously increasing responsibilities and extremely high workload were commonly reported problems. Most participants described the negative incentives in the performance scheme as a degrading method of punishment. The main factor was job insecurity caused by contract-based employment. FPs described the point at which they are with terms such as exhaustion. Conclusion: By increasing workload and creating uncertainty about the future and about income, the PC reforms have led to working conditions, which has led to changes in the professional attitudes of physicians and their practice of medicine.