S ociety's increasing expectations and the transition from traditional to regional bureaucracies, combined with advances in medicine, pressure physicians into increasing their teaching and research commitments and into becoming more involved in administrative functions. In addition to their clinical duties, many physicians have taken on varying amounts of teaching, research, and administrative duties (1-4). Further, the practice of medicine has always intruded on physicians' personal lives, particularly in rural areas and where there are few specialists. Consequently, the organization of medical practice has shifted toward group practice and clinical decision making has evolved from highly independent consultations to the sharing of expertise (5,6).

Objective: Existing measures of stress either focus on burnout or frustration and fatigue factors, often referred to as job strain. The objectives of this study were to: establish a reliable measure of distress that is sensitive enough to identify job strain at lower levels of distress and risk of burnout at higher levels of distress; and document levels of distress among the major medical specialties and across varying patterns of clinical practice. Methods:A stratified cross-sectional survey of physicians in Canada was conducted in 2004. Among the eligible population, 2810 physicians (56.7%) responded. Response bias was negligible. Responding physicians completed a 13-item measure of distress. Confirmatory factor analysis was used to establish the measure. Scheffe tests were used to document differences in the levels of distress among specializations and by clinical practice profile.Results: Factor analysis revealed reliable dimensions of: fatigue (á = 0.75) and reaction (á = 0.73). The distress measure was reliable (á = 0.82). Emergency physicians (n = 4.51), surgeons (n = 4.35), and general practitioners (n = 4.33) reported the highest levels of distress, while administrative physicians (n = 3.30), community health (n = 3.35), and clinical specialists (n = 3.46) reported the lowest levels of distress. Physicians with clinical and administrative responsibilities reported the highest levels of distress (n = 4.40), compared with purely clinical physicians (n = 3.94) and clinician-academics (n = 3.98). Conclusions:Some specializations are associated with more distress than others. Administrative duties appear to add to distress for all physicians. Counterintuitively, adding academic as well as administrative responsibilities appears to add less distress than adding administrative duties alone. Academic duties are viewed as advancing medicine. Can J Psychiatry. 2009;54(3):170-180. Clinical Implications· Mentorship by senior colleagues may prevent physicians from becoming too absorbed in career responsibilities. · Community support is important to patients and physicians to ensure proper follow-up care. · Effective organization of clinical work and recognition of accomplishments by colleagues and administrators may provide psychological protection against excessive stress. Limitations· The study was cross-sectional. · The data were self-reported. · The number of specific specialists within each practice pattern was small.

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T he health status of First Nations people in Canada is well below the national average. [1][2][3] Contact with Europeans brought outbreaks of infectious diseases (e.g., influenza, measles and smallpox) to which First Nations people had no immunity. 4 First Nations people lost traditional lands to settlements for trade relationships based on harvesting furs. 5 The shift from a seasonal economy based on traditional food gathering to the fur trade led to exploitation of wildlife and land. 5,6 Locating reserve lands in remote areas served to isolate First Nations, impoverishing their communities by limiting access to traditional resources. 6,7 The British North America Act of 1867 8 allowed Canada to pass laws that subjugated all First Nations people and their land, replacing their traditional governments and taking control of valuable resources on reserve lands. 7 It also disrupted First Nations culture and families by imposing European concepts of marriage, parenting and land ownership 7 in the belief that First Nations people were "savage" and less than human. 7,9,10 The Indian Act 11 restricted First Nations people from leaving reserve lands and prohibited outsiders from doing business with First Nations people, thus marginalizing them. 7 It also disrupted the transmission of culture from generation to generation, reinforcing learned helplessness among First Nations people in Canada by making participation in traditional cultural events (e.g., the potlatch and sun dance) a criminal offence. 7,11 The residential school system was designed to assimilate First Nations people into the culture of the white majority. 7,12 The needs of First Nations children were neglected, and many were physically, sexually and emotionally abused in the schools. 13,14 Over 500 years of domination, displacement and assimilation have prevented First Nations from nurturing a model of health determinants congruent with their culture. 12 Although Health Canada has selected the key determinants of health, developed by the Agency (Table 1), as the benchmark model to address the health status of all Canadians, a growing body of work suggests that these determinants of health are not suitable for most First Nations peoples. 9,[15][16][17] In response, the Four Worlds Institute developed 14 determinants of well-being and health (14 health determinants) (Table 1) relevant to First Nations people using their guiding principles: Development Comes from Within; No Vision, No Development; Individual and Community Transformations Must Go Hand in Hand; and Holistic Learning is the Key to Deep and Lasting Change. 9,18 To improve the overall health status of First Nations people in Canada, it is vital that Health Canada adopt a model of health determinants that incorporates the worldview of Indigenous peoples. 9,[19][20][21][22]

The study demonstrated that variance associated with career satisfaction can be explained using various factors reported directly by physicians. The study also confirmed that relative differences in the importance of these factors do occur among specialties. Surgeons prefer to delegate more responsibility in the management of their practices on an informal basis, whereas psychiatrists prefer to be more involved in the management of their practices and use more formal structures.