BACKGROUND: Pay-for-performance system (P4P) has been in operation in the Turkish healthcare sector since 2004. While the government defended that it encouraged healthcare professionals' job motivation, and improved patient satisfaction by increasing efficiency and service quality, healthcare professionals have emphasized the system's negative effects on working conditions, physicians' trustworthiness, and cost-quality outcomes. In this study, we investigated physicians' accounts of current working conditions, their status as a moral agent, and their professional attitudes in the context of P4P's perceived effects on their professional, social, private, and future lives. METHODS: First, we held 3 focus groups with 19 residents and 1 specialist regarding their lived experiences under P4P and thematically analyzed the transcripts. Second, we developed a questionnaire to assess how generalizable the qualitative findings are for a broader group of physicians. The tool has three parts questioning 1) demographic information, 2) working conditions, and 3) perceived consequences and effects of P4P. 2136 physicians responded to the survey. After refining the data, we conducted the statistical analysis over 1378 responses by using Spearman's correlation coefficient, exploratory factor analysis (EFA) for categorical data, and Kruskal-Wallis variance analysis. RESULTS: Thematic analysis revealed two dimensions: 1) factors leading to estrangement, and 2) manifestations of estrangement. As for the initial, participants thought that P4P affected relationships at work
family and social relationships
working conditions
quality of the specialty training
quality of healthcare services
and it caused healthcare system-related consequences. Concerning the latter, the following themes emerged: Estrangement of the physician
damaging effects on physician's psychology
physician's perception of their future life
and physician as a moral agent. According to EFA, a 5-factor structure was appropriate: F1) Estrangement
F2) adverse effects on the physician's quality of life
F3) favorable consequences
F4) physicians becoming disreputable
F5) unfavorable consequences. CONCLUSIONS: The findings suggest that under P4P, physicians have become more estranged towards their profession, their patients, and themselves. They suffer from deteriorating working conditions, lack of motivation, lack of work-related satisfaction, and hopelessness regarding their future. Furthermore, P4P impairs their ability to realize themselves as moral subjects practicing in alignment with professional values and principles.