The Role of Well-Being on the Impact of High Performance Work Systems on Physicians’ Job Burnout

This is a theoretical paper which examines the role of physicians’ well-being in the relationship between utilization of High Performance Work Systems (HPWS) and Physicians’ job burnout. The research is aimed at recommending a new model which should be adopted when researchers are identifying gaps that exist in theory and methodology on the link between HPWS and employee outcomes. The paper adopts among other theories a Critical Theory perspective which calls for Axel Honneth’s three spheres of relationships in the communication between employees and employers. The paper starts by mapping key concepts on HPWS, physicians’ well-being and physicians’ burnout. The paper also identifies types of evidence that link HPWS with physicians’ well-being and physicians’ burnout. It ends with synthesizing existing knowledge on reducing physicians’ burnout and improving physicians’ well-being. Overall, the study proposes that in order to improve employee well-being and get away with the ‘pessimistic perspective’ which claims that HR practices are harmful to the employees’ well-being, employers are obligated to examine operations which are based on ‘personal relationships’ which are either contractual or non-contractual, but still legally binding. In this way, workplaces which are using HPWS will reduce physicians’ burnout and improve their well-being. Discussion, recommendation for future research and conclusion are made.


Introduction
Much as researchers claim that there is neither a commonly accepted definition nor a gold standard for measuring quality of life (Katschnig, 2006:139), however, in measuring people's well-being, there is a universal agreement that quality of life is a multi-dimensional construct integrating physical, emotional, and social well-being and functioning as perceived by the individual (Lutz et al., 2007). The definition by Lutz et al. (2007) derives from the World Health Organization Quality of Life Assessment (WHOQOL), which states that quality of life (QoL) is an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. (European Commission, 2010), the future prosperity of European workers is not based on low wages but on the high quality of working life. This makes it clear that the issue of employees' well-being and quality of life is not only an organizational or academic issue but also a political issue. Thus, improving quality of work has a potential benefit in raising worker well-being and lowering the social costs of ill-health (Felstead, Gallie, Green & Henseke, 2019).
Physicians are employees whose well-being is an issue of importance for several reasons besides the political and academic grounds mentioned above. These include: a. That Medicine is a unique organizational environment in which the health of physicians may be a significant risk factor for inadequate patient safety and suboptimal care. Likewise, globally, physicians are reporting increasing levels of job burnout, especially among younger physicians in training (Montgomery, 2014). b. Studies suggest that quality of healthcare systems is also dependent on the physicians' well-being (Wallace, Lemaire & Ghali, 2009). In surgical literature links have been established between patients' safety, medical errors, quality of life and burnout (Shanafelt, Balch, Bechamps, Russell, et al., 2010). c. Ethically, constant changes in the workplace context make employees' concerns secondary and neglected which erode work-related well-being which may result into negative consequences to both employees and organizations (Guest, 2017;Beer, Boselie, & Brewster, 2015).
Besides views in Strategic HRM on the negativity of HRM practices on physicians' well-being, the current concern in HRM literature is that while globally physicians are at risk of leaving their jobs and engage in different specialties; in some countries, physicians have been leaving their countries to other countries to seek for better employment environment than their own. Notwithstanding, studies are conscious of unethical trend in workplaces which encourages HRM practices which promote productivity and performance at the expense of employee wellbeing (Guest, 2017).
Several studies suggest that HRM practices and the so-called High-Performance Work Systems (HPWS) are associated with higher performance and higher organizational commitment, however outcomes for employees' health-related well-being are less clear-cut with some indication that HRM practices can be associated with higher stress (Guest, 2017:24; see also Van de Voorde, Paauwe, & Veldhoven, 2012;Peccei, van de Voorde & van Veldhoven, 2013). There is relatively dearth of research which links HPWS with physicians' well-being. However, for the past three decades, the literature on Strategic Human Resource Management and performance shows that researchers have focused much on organizational and performance-related outcomes and less on the health of the employees per se (Montgomery, 2016). This has led some researchers to claim that if there is any positive outcome of HRM practices to the employee well-being, then the outcome is a 'by-product' and not the intended target (Appelbaum Bailey, Berg, & Kalleberg, 2000;Guest, 2017). Studies show that individual as well as organizational work characteristics such as job monitoring, job control, effort-reward balance, organizational justice, and support at work, have predicted health-related outcomes at work (i.e., sickness, absence, and minor psychiatric morbidity (North, Syme, Feeney Head, Shipley, & Marmot, 1993;Kivimaki, Elovainio, Vahtera, & Ferrie, 2003;and Head, Kivimaki, Siegrist, et al., 2007).
Burnout is an aspect of employee health at work which is concerned with his or her physiological and psychological well-being (Danna & Griffin, 1999). Burnout among physicians is a problem which must not be ignored by any country. Estimates show that burnout levels among physicians is between 25% and 60% and can reach as high as 75% (Goehring, Bouvier, Kunzi & Bovier, 2005;Goitein, Shanafelt, Wipf, Slatore & Back, 2005). Burnout has also been associated with performance among physicians where major findings include burnout and depression being main sources of major medical errors among surgeons (Shanafelt et al., 2010). In this regard, there is great likelihood that physicians' burnout is an aspect of employees' well-being which puts their work and life at risk. If not well studied, physicians' work conditions may lead into poor policy decisions. This study is set to examine how organizations can reduce physicians' burnout and improve physicians' well-being. In this regard, the study explores the role of well-being in the relationship between the use of HPWS and physicians' job burnout.

Study Outline
This study is organized in the following manner: i. Introduction which covers study outline, study objectives and research questions ii.
Theoretical concepts and arguments related to the topic iii.
Identifying gaps that exist in theory and methodology iv.
Mapping key concepts on HPWS, physicians' well-being and physicians' burnout v.
Identifying types of evidence that link HPWS with physicians' well-being and physicians' burnout vi.
Synthesizing existing knowledge on reducing physicians' burnout and improving physicians' well-being vii.
Recommendation on a new model for future research viii. Conclusion

Study Objectives
This research seeks: i.
To identify factors which show that physicians well-being is at risk ii.
Examine the extent to which utilization of HPWS is related to the burnout problem iii.
Suggest alternative ways to resolve the problem that exists between utilization of HRM practices (HPWS) and physicians' well-being

Research Questions
i.
To what extent is physicians' well-being at risk? ii.
How is utilization of HPWS related to physicians' burnout and well-being? iii.
What model is recommended to resolve the so called 'dark side of HPWS' and physician's well-being agenda?

Theoretical Constructs and Arguments
Theoretically, this study is informed by several theoretical perspectives. It is informed by Critical Theory -not much on its critique to capitalism, but on the way Max Horkheimer (from the Frankfurt Institute for Social Research, 1930s) conceived the possibility of rational organization of society where there is progress in the human domination of nature and emancipation of individuals. Unlike other traditional forms of critical theory, this theory conceives of itself as part of a struggle for an "association of liberated human beings, in which everybody would have an equal chance of self-development" (Wellmer, 2014:706).
The study likewise adopts Axel Honneth's perspective of critical theory where he proposes three relational systems, i.e., the three 'spheres of action' in modern society, namely the sphere of personal relationships, the sphere of the market economy, and the sphere of the political public (Honneth, 2014:131). The 'sphere of personal relationships' explains and enriches our understanding of the potential mechanism behind the relationship between the employer and the employee. The understanding is based on the principles of legitimation such as 'social freedom' in this particular sphere of action (Wellmer, 2014). The theory also highlights the importance of examining contractual and non-contractual roles and obligations in relational systems since they are based on legal systems (Honneth, 2014).
Another perspective which is used in this study is the Job Demand Control Theory (Karasek 1979). This theory explains the mechanism behind potential negative relationship between HR practices, the so called HPWS and employee well-being, and thus increased physicians' burnout. The 'demand-control' model of stress, for example, predicts that jobs with higher demands combined with low employee discretion or control will create the most strain (Gallie, 2005;Karasek, 1979). This theory therefore, calls for increased job control and autonomy which must lead employees to positive health effects since "malleable features of the work environment are associated with perceived effects of work on health" (Ettner & Crzywacz, 2001:101). Work pressure and increased job demands especially long working hours have been linked to ill-being, i.e., negative indicators in employee wellbeing (Gallie, 2008), and increased work-life conflict (Gallie & Russell, 2009). The rationale behind these findings is a common perception that there is an increase in work intensity due to increased international competition. On the other hand, some researchers claim that despite an increase in skills development, job pressure can also be increased by additional responsibilities at work and decision making pressure (Gallie & Russell, 2009).
Organizations are constantly competing to improve their productivity and performance based on the need for speed innovation. This has necessitated organizations to adopt just in time management processes, speed information transmission and decentralized decision making as organizational design methods. The blend between new technologies and new HR practices has led to the so called 'time-based competition' (Askenazy, Thesmar, Thoening, 2006) which puts more decision making pressure on employees.
Lastly, the study adopts Christophe Dejours' Psychodynamics Theory of Work (Dashtipour & Vidaillet, 2017) which highlights situations in which workers should be supported by organizations to work well. With this theory, Dejours suggests that in the experience of working, based on unconscious dynamics, an encounter of the subject with the 'real of work' there is an affect of suffering which can or cannot be overcome or sublimated depending on circumstances. In this way, work is viewed as a field of exploitation for instrumental reasons. The theory, however, calls for collective organizational action or cooperation to transforming such affect into pleasure or good health (Dashtipour & Vidaillet, 2017). In this regard, this research is informed by Dejours concern in the process of work as described below: Dejours' work is concerned with identifying the conditions that turn the experience of work either into one of pleasure, subjective expansion, and freedom or one of pathological suffering. …work is central to subjectivity and health, to the relationship between men and women, to the community, and finally to the theory of knowledge (Dashtipour & Vidaillet, 2017:19).
These theories explain potential mechanism behind the suggestion that based on the nature of their profession, physicians' well-being is at risk in their working environment. Traditionally, the Labor Process Theorists posit that there are different and fundamentally opposite interests between employers and employees. According to Godard (2004Godard ( , 2010 the need for profit overrides employees' well-being in organizations. In this regard, should one take the Labor Process Theory perspective, HRM practices are considered as means through which employees are exploited. The practices are conceived to be managerial tools of control and monitoring resulting into employee compliance and performance (Grant, Christianson & Price, 2007).

Research Gap (Theory and Methodology)
Literature on the linkage between work and health show inconsistencies in findings across studies which could be due to methodological differences or theoretical biases (Ettner & Crzywacz, 2001) or dataset employed and specification tested (Godard, 2010). Another aspect that might be related to inconsistent findings might be geographical or national differences of the study areas (Godard, 2010). Notwithstanding, for about three decades, studies have shown that implementation of HRM practices the so called HPWS lead into positive employee behavioral outcomes such as discretionary efforts and extra role behaviors in the workplace (Huselid, 1995;Berg, Kalleberg, & Appelbaum, 2003;Elorza, Harris, Aritzeta & Balluerka, 2016). These practices have also been termed HR enhancing practices in the sense of enhancing skills, motivation and empowerment among employees (Subramony, 2009;Rauch & Hatak, 2016). HPWS have also been associated with reduced employee turnover (Huselid, 1995;Fabi, Lacoursiere & Raymond, 2015;Sikora, Ferris, & van Iddekinge, 2015). However, studies have also shown mixed results to the same research questions. Bryson & Forth (2015) for example have shown that increases in workload (worker output per hour/employees working harder) alongside static wages, has reduced fairness and threatened well-being but no evidence of improved productivity.
Notwithstanding, we are observing a movement of physicians from one country to another. These movements of physicians suggest that our understanding of the work conditions among physicians or the relationship between Electronic copy available at: https://ssrn.com/abstract=3527427 them as employees and their employers is still limited. This gap of knowledge necessitates further research on the factors behind this process or the reasons behind this phenomenon. Another gap is on the way research is carried out in this HRM practices-well-being relationship. Several studies have used HR officers to ask questions about employee well-being instead of asking employees themselves. This has led to having unrealistic research procedures (e.g., common method variance) and unreliable findings since employees themselves are the best knowledgeable people of their own work conditions and their psychological or physical well-being. It is good to cite here what Kinnie, Hutchinson, Purcell, Rayton & Swart (2005:11) highlighted on this point noting that, 'the fulcrum of the HRM-performance causal chain is the employees' reactions to HR practices as experienced by them.' In this regard, our proposition is that physicians' well-being must have a role in mediating the impact of HPWS and employee work-related outcomes (these outcomes can be attitudinal or behavioral).

Mapping key concepts of HPWS
There are different approaches to understanding HRM and in particular understanding the utilization of the 'progressive' or 'high-road' HRM practices the so called HPWS (Peccei et al., 2013:16). Concepts which have been used to connote HPWS (Huselid, 1995;Appelbaum et al., 2000) include High Involvement Practices (Batt, 2000;Guthrie et al., 2001), HR enhancing practices (Sabramony, 2009), and high commitment practices (Arthur, 1994;Pfeffer, 1998). These HRM practices are characterized by the relationship between employers and employees whereby employers provide to employees the following: a. Opportunities for worker involvement and participation b. Intensive training and development, and c. Incentives (Wood & de Menezes, 2011) d. Other provisions such as providing employees with skills, knowledge and abilities, motivation and opportunities to perform their primary role task (Appelbaum et al., 2000). These approaches are meant to elicit employees' discretionary behaviors and discretionary efforts (Berg, Kalleberg, & Appelbaum, 2003;Shin & Konrad, 2017).
Besides the 'high-road' or 'progressive' HR practices, HRM is also related to 'exploitative' or 'low-road' HRM practices in employer-employee relationships (Peccei et al. 2013;Ramsay, Scholaris & Harley, 2000). These exploitative practices are a source of concern to HRM researchers and practitioners since they contribute to the 'dark side of HRM-performance' linkages. As transactional HRM systems, they include practices such as low pay, long hours, tight monitoring, low discretion, and job insecurity (Peccei et al., 2013:17).
While many studies over the past three decades have shown that High Performance Work Systems (HPWS) may benefit employers since they increase organizational performance by eliciting employee discretionary behaviors and employees in turn exhibit discretionary efforts (e.g., Berg, Kalleberg, & Appelbaum, 2003;Takeuchi, Chen & Lepak, 2009;Zatzick & Iverson, 2011;Elorza, Harris, Aritzeta, & Balluerka, 2016;Shin & Konrad, 2017), there are claims that HPWS can also (adversely) work at the cost of employee outcomes. The rationale behind this suggestion is that by their very nature HPWS could push employees to work harder to raise productivity at the cost of their well-being (e.g., Ramsay, Scholaris & Harley, 2000;Wood & De Menezes, 2011;Jensen, Patel & Messersmith, 2013, Van De Voorde & Jensen, 2016Misra, 2018). Another view which is based on the AMO Model (Appelbaum et al., 2000) suggests that when employees are encouraged to use their Abilities when given Opportunities to do so, and when they are Motivated, their performance outcome is not an end to their benefit, rather they are used for the benefit of the organization and not for their well-being (Boxall, Guthrie & Paauwe, 2016;Guest, 2017). In this regard, under this perspective, it is claimed that HPWS has failed to service the goal of employee well-being. Overall, these scholars present what has been called the 'dark side' of High-Performance Work Practices (Van De Voorde & Jensen, 2016; Misra, 2018). Grant, Christianson & Price (2007:52) define employee well-being as 'the overall quality of an employee's experience and functioning at work.' Literature shows that there are different aspects of employee well-being. These include mental or psychological well-being, work-related well-being such as job satisfaction, and "general"

Mapping Key Concepts of Employee Well-being
Electronic copy available at: https://ssrn.com/abstract=3527427 well-being, like depression and anxiety. Well-being can also be "context-free well-being" or "domain-specific" (e.g., work-related) well-being (Warr, 2007;De Witte, Pienaar & De Cuyper, 2016). Psychologists and sociologists have also developed a well-being index which includes psychological, physical and social parameters in order to capture a person's general well-being (Diener & Seligman, 2004;Grant, Christianson & Price, 2007).
Research has demonstrated that employee well-being is an important concern for organizations. Studies indicate that employee well-being has a significant impact on the performance and survival of organizations by affecting costs which are related to illness and health care (Danna & Griffin, 1999). The changing work environment suggests that there is increased work demands, work overload, and pressures at work which negatively affect employee work-related well-being (Guest, 2017;Derks & Bakker, 2010). A study by Felstead et al. (2019), for example, found that in the UK, in low skilled jobs, average levels of autonomy have declined, and work demands have increased. In similar manner, job insecurity is another aspect which affects employee work-related well-being (De Witte et al., 2016).

Link between HPWS and Well-being
Traditionally, the mainstream HRM scholars argue that there is a positive relationship between perceptions of HRM and employee well-being (Peccei, 2004). However, several studies have attempted to link HPWS and employee outcomes such as job-related well-being with different results including negative correlations and mixed results findings (Ramsay, Scholarios, & Harley, 2000;Godard, 2004;Guest, 2017). The positive side of HPWS or also called the 'high-road approach to management' (Ramsay, Scholarios, & Harley, 2000) has been and is still demonstrated by studies which link HPWS with organizational and employee outcomes across different sectors and contexts. According to some of the studies, these HR practices are associated with higher levels of well-being (Alfes, Shantz & Truss, 2012) and lower levels of stress and emotional exhaustion (Kalmi & Kauhanen, 2008). On the other hand, the critical HRM research has focused on the negative aspects of HRM practices in the sense of viewing performance management practices as coercive or inequitable management device (De Witte, 2016). This is the so called 'exploitative' or 'low-road' HRM systems (Peccei et al., 2013;Batt, 2000). These two distinct approaches to the problem always call for further research on resolving the debate on whether HRM practices in particular the HPWS are positive to employees' well-being or not.  (64) and 130 from quaternary services i.e., (knowledge-intensive).
There is a need for alignment of employees' attributions and employers' intentions of WBIs in implementing strategic businesses. Shared strategic intentionality shaped employees' perceptions of the WBIs packages they were offered by the employers. Effective WBIs in organizations depend on alignment of employers' intentions and employees' attributions of the initiatives made. Assessing the extent enriched job design and HIM practices influence employee well-being by testing two aspects of wellbeing (job satisfaction and job-related anxiety-comfort) UK's Workplace Employment Relations Survey 2004. Workplace data -data from managers -face to face interview with senior person -2295 workplaces. Response rate was 64%. Employee data -survey of employees, selfcompletion questionnaire, 22,451 employees, response rate was 61%. Findings are based on the sample of 14,127 employees and 1177 workplaces.
Mixed results: Highinvolvement management practices were negatively associated with well-being but had a positive association with performance.

Mapping Key Concepts of Employee Burnout
Burnout is a work-related stress disorder which affects many people in working age which results from a combination of many factors both work-related and individual-related (Salminen, Andreou, Holma, Pekkonen, & Mäkikangas, 2017). The term burnout has been used to describe different realities of people's experiences at work from fatigue, stress, loss of idealism and passion for one's work to psychological syndrome as response to chronic stressors in the job (Maslach, Schaufeli & Leiter, 2001). Three dimensions of burnout have been identified; overwhelming exhaustion, feeling of detachment from one's job and lack of accomplishment (Maslach, Schaufeli & Leiter, 2001). Some of identified factors which contribute to burnout include; time demands, lack of control, work planning, work organization, difficult job situations and interpersonal relations (Montgomery, 2014). In assessing employee well-being, burnout has been considered as an individual problem, however, literature shows an increase in the evidence of factors that link burnout to organizational problems which are related to working environment and organizational culture (Montgomery, Todorova, Baban & Panagopoulou, 2013). Burnout, for example, is associated with patients' mortality and morbidity (Montgomery, 2014).

The Link between HPWS and Employee Burnout
McMurray, Linzer, Konrad, Douglas, Shugerman & Nelson (2000) carried a Physician Work Life Study. It was a survey which contained 150 items assessing career satisfaction and gender differences among multiple aspects of work life. The study adopted a nationally representative random stratified sample of 5,704 physicians in primary and specialty nonsurgical care (N = 2,326 respondents; 32% female, adjusted response rate = 52%). Their findings included that women had 1.6 times the odds of reporting burnout compared with men (P< .05), with the odds of burnout by women increasing by 12% to 15% for each additional 5 hours worked per week over 40 hours (P < .05). Lack of workplace control predicted burnout in women but not in men. Likewise, female physicians were more likely to report satisfaction with their specialty and with patient and colleague relationships (P < .05), but less likely to be satisfied with autonomy, relationships with community, pay, and resources (P < .05).
Likewise, a study by Dekker & Schaufeli (1995) examined the relationship between psychological distress and burnout. The findings included that job insecurity and exhaustion increased job burnout. Shanafelt et al. (2010) carried out a study on self-assessment of major medical errors, and standardized assessments of burnout and quality of life. The study was a cross-sectional survey in June 2008 with a sample of 7905 surgeons who are members of American College of Surgeons. The results showed that major medical errors reported by surgeons are strongly related to a surgeon's degree of burnout and their mental quality of life. In short, burnout was major predictor of medical errors.
Vander Elst, Van den Broeck, De Cuyper & De Witte (2014) carried a study on the links between job insecurity, job control and mental exhaustion. The study findings showed evidence of causation of loss of job control, mental exhaustion and its effect on well-being through control. Likewise, Mäkikangas & Kinnunen (2003) studied the relationship between job satisfaction and mental distress. Their findings included that job insecurity was related to ratings of emotional exhaustion and mental distress overtime. However, the study showed no effects for physical symptoms.

Discussion and Recommendation of a New Model
The discussion in this paper is based on the following question: how can this existing body of knowledge on the field help researchers suggest new models to reducing physicians' burnout and improving physicians' well-being? There is a connection between work conditions and health of employees. However, "multiple features of employment arrangements and workers' health is not well understood" (Ettner & Grzywacz, 2001:101) and that is why it needs to be studied. Considerable research in Strategic HRM has addressed this problem of the link between HRM practices and employee outcomes. Overall, researchers tend to agree that the conduit through which this problem can be resolved is "people." Peccei et al. (2013) for example, highlight that employee psychological, attitudinal and behavioral outcomes at work, including employee well-being, are hypothesized to play a key role in understanding the impact of HR practices on organizational and employee outcomes. In this regard, it is important to examine the mediating role of employee well-being in the impact of HR practices (i.e., HPWS) on individual or employee outcomes. By doing so, such research will be contributing to the debate on understanding the 'black box' problem which needs a critical review and empirical evidence in the SHRM literature.
There is an 'optimistic perspective' which claims that utilization of HRM practices is beneficial to the employees and that generally it improves employee attitudes, behaviors and their well-being (Peccei, 2004;Peccei et al., 2013). The basis and rationale behind this optimistic perspective is the social exchange theory (Blau, 1964;Gouldner, 1960) which asserts that employees will pay back favorably to the employers if they are treated well. In this regard, these HR practices are expected to increase employees' discretionary behaviors such as commitment, and combined with employee empowerment and rewarding work environment, employees get quality work life (Peccei et al., 2013). Despite this optimistic perspective, however, researchers are cautious of the misuse of this perspective since it amounts to Pollyanna Fallacy which claims that people will always be looking at the positive aspects of things and thus will be grateful to those who have been good to them. This assertion is based on the norm of reciprocity theory (Gouldner 1960), which makes two minimal demands that "(1) people should help those who have helped them, and (2) people should not injure those who have helped them" (Gouldner, 1960:171).
David Guest (2017) suggests a configuration of employee and employer terms in resolving the problem of unequal gains between employers who extensively and intensively utilize HR practices (HPWS) at the expense of employees who are considered to be subjects or losers in this tension. While this study acknowledges this great suggestion, this study goes further than Guest's suggestion in proposing the Critical Theory perspective which has been adopted in this study. Honneth's three spheres of relationships have a bearing in what employees as individuals have to say in order to maintain their social freedom and configure their contractual and noncontractual obligations to the employer (2014:131). It is important to note what Kinnie et al. (2005:11) highlighted on this point noting that, 'the fulcrum of the HRM-performance causal chain is the employees' reactions to HR practices as experienced by them.' In this regard, a new model which this study proposes is based on the Social Critical Theory. This study proposes that in order to get away with the 'pessimistic perspective' which claims that HR practices are harmful to the employees' well-being, employers are obligated to examine operations which are based on 'personal relationships' which are either contractual or non-contractual, but still legally binding. In this regard, at personal level relationships, employers have to consider employees' individual needs and properties, and at the market level they have to consider employees' particular interests and abilities, and at political public sphere, they have to consider employee individual aims and self-determination (Honneth, 2014:131). By doing so, employees will be involved fully and will be exercising their individual and social freedom in the workplace.

Conclusion
The mediating role of physicians' well-being in analysing the relationship between HPWS and physicians' burnout is based on lack of (divergence from) policy emphasis on improving work conditions which is likely to have major leverage in reducing even other work-related problems such as work family conflict (Gallie & Russell, 2009). In this regard, in order to reduce physicians' burnout in a HPWS workplace, policies on improving physicians' wellbeing have to be aligned with employee interests. It should be remembered that research on burnout has its roots in care-giving and service occupations where the core business was the relationship between the provider and the recipient rather than a stress response to an individual (Maslach, Schaufeli & Leiter, 2001). So, establishing interpersonal relationships in the workplace might be the right thing to do in order to mitigate other symptoms of burnout such as psychological and physical ailments including mental health.'