Factors That Affect Job Satisfaction
Contents
TOC o “1-3” h z u HYPERLINK l “_Toc376933490” Introduction PAGEREF _Toc376933490 h 1
HYPERLINK l “_Toc376933491” Database and literature PAGEREF _Toc376933491 h 2
HYPERLINK l “_Toc376933492” Job Satisfaction PAGEREF _Toc376933492 h 3
HYPERLINK l “_Toc376933493” Factors that Influence Job Satisfaction PAGEREF _Toc376933493 h 4
HYPERLINK l “_Toc376933494” Job Satisfaction and Medical Oncologists PAGEREF _Toc376933494 h 7
HYPERLINK l “_Toc376933495” Factors Contributing to Job Satisfaction in Oncology PAGEREF _Toc376933495 h 7
HYPERLINK l “_Toc376933496” Medicare Reimbursement PAGEREF _Toc376933496 h 11
HYPERLINK l “_Toc376933497” Ppsa From The Standpoint Of The Stakeholder PAGEREF _Toc376933497 h 13
HYPERLINK l “_Toc376933498” Areas Of Spending Being Recorded PAGEREF _Toc376933498 h 14
HYPERLINK l “_Toc376933499” The Physician Payment Sunshine Act PAGEREF _Toc376933499 h 14
HYPERLINK l “_Toc376933500” Medicare Reimbursement Scheduled Cuts For Cancer Care PAGEREF _Toc376933500 h 16
HYPERLINK l “_Toc376933501” Theoretical Framework PAGEREF _Toc376933501 h 17
HYPERLINK l “_Toc376933502” Research Design PAGEREF _Toc376933502 h 23
HYPERLINK l “_Toc376933503” References PAGEREF _Toc376933503 h 25
HYPERLINK l “_Toc376933504” Manage, 47-51. PAGEREF _Toc376933504 h 26
IntroductionThe current study is an investigation of factors that affect job satisfaction, or attitudes that affect the work of oncologists in Wisconsin, Illinois and Michigan. Previous literature has indicated a decline in the satisfaction of oncologists over the past several years (Almenarez, et al., 2009). Since job satisfaction influences the performance of job functions, it is important for physicians to have a high profile of job satisfaction. The lower the level of job satisfaction of physicians, and in this case oncologists, the less efficient the delivery of patient care and the lower the patient satisfaction. Although there have been incentives offered to physicians in the past decades, such as rewards and improved working conditions, literature has indicated that there is still a decline in job satisfaction. In addition, it has been noted that there is a lack of interest in repeating job satisfaction studies for physicians. (Burke, 2004).
There are several factors that are contributing to the decline in job satisfaction of physicians, as well as several changes occurring in the market place and legislature that have lowered costs of care yet the physicians are required to maintain a high quality of care. In addition, there are financial stresses and pressures that are forced upon physicians due to health care cuts in re-imbursements and increases in oncology drugs. Furthermore, physicians are exposed to constant stress from the suffering of their patients and loss of their patients.
The above factors can ultimately affect the job satisfaction of oncologists. The purpose of the literature review, therefore, is to evaluate job satisfaction factors by first looking at the overall job satisfaction factors of every type of profession and then looking specifically at job satisfaction factors in regard to medical oncologists.
Database and literatureThe databases that were used were the E-library through the University of Phoenix, Baker College online library database and basic Google search engines looking for case studies and research papers in regard to job satisfaction studies in all professions and specifically related to the medical field and oncology. (key words – Job satisfaction, oncology, oncologists, burnout, Medicare reimbursement, Physician Payment Sunshine Act, cancer care, Maslow’s Hierarchy of Needs, Herzberg’s Two Factor Theory, qualitative case study.) Several journals were used to evaluate different case studies and research, such as the African Journal of Business Management, Journal of Counseling Psychology, Journal of Applied Psychology, Annuals of Internal Medicine, International Journal of Business and Social Science, Radiology Management, Journal of Oncology Practice, American Academy of Physician and Patients, Lancent, Journal of Medical Oncology, Journal of Physicians, Proceedings of the National Academy of Sciences, and the Journal of General Internal Medicine. In addition, books and encyclopedias were used in the review, such as the Encyclopedia of Business and Finance EPEC-O, Participant’s Handbook and Sloan Work and Family Encyclopedia.
Chapter Two:
Section 1 Define Job Satisfaction
Section 2 Legislation Affecting Oncologists (Medicare reimbursement)
Section 3 PPSA (Physician Payment Sunshine Act) Legislation
Section 4 Theoretical Framework
Section 5 Methodology
Key words
Job satisfaction, oncology, oncologists, burnout, Medicare reimbursement, Physician Payment Sunshine Act, cancer care, Maslow’s Hierarchy of Needs, Herzberg’s Two Factor Theory, qualitative case study.
Job SatisfactionJob satisfaction can be defined as the extent to which an individual is content with his work. If a person enjoys most aspects of his career, he is likely to find his job to be highly satisfying. Conversely, an employee who feels discontent with many aspects of his job will experience job dissatisfaction. According to experts, job satisfaction is simply the collection of attitudes that workers have about their jobs (Johns, 1996). Job satisfaction can be high or low, but it reflects the feelings one holds towards his work.
Attaining high job satisfaction is significant at the individual level because an employee who perceives his job as enjoyable, rewarding, and fulfilling will embody enthusiasm for his work and generally associate a measure of happiness over his professional responsibilities. In general, employees who are satisfied in their occupation are more productive and able to contribute more to their field than those who are unhappy or disgruntled at work. Furthermore, an employee who thrives in his career is more likely to experience satisfaction in other areas of life. Research has confirmed that the sense of achievement and success gained from satisfying work is directly connected to an individual’s general feeling of fulfillment in life (Marion & Ceengage, 2001). This research shows that the level of contentment a person experiences through his job will impact his overall well-being in life.
Job satisfaction, however, is different from the motivation to work. Concepts of job satisfaction and motivation have, in many situations, been used interchangeably. Yet, job satisfaction is an individual’s emotional response to his current job conditions, and motivation functions as the driving force that pushes a person to pursue and satisfy his needs (Alshallah, 2004). An individual may be motivated to work and not feel satisfied with the job. In the work environment, motivation can be understood as boosting the morale of employees–encouraging them to willingly give their best in accomplishing assigned tasks (Itoje, 2011). Satisfaction with one’s work is determined by how he feels about his job—regardless of his motivation for working.
Studies of workers in the US have shown that the majority of people are satisfied with their jobs (Fritzsche & Parns, 2005). According to a 1999 Gallop Poll, ninety percent of employed Americans were generally satisfied with jobs, and researchers report that data from 2001 “indicated that one third of American’s reported that they ‘loved’ their job” (Fritzsche & Parns, 2005, p. 1880). Research has affirmed that high job satisfaction is attainable for most people in the United States.
Factors that Influence Job SatisfactionResearchers are able to assess levels of job satisfaction in employees by studying how individuals feel about different aspects of their profession. Ultimately, a person’s satisfaction level with his job is based upon how the individual perceives a variety of factors connected to his employment. Researchers approach job satisfaction assessments as “an attitudinal variable” (Spector, 1997, p. 2) and typically use interviews, questions, and surveys to measure employee job satisfaction levels.
Notable factors that influence a person’s satisfaction with his job include: salary and benefits, working conditions and supervision, and the nature of the work (Williams, 2004). While the value of the individual factors vary from person to person, the culmination of these areas work to affect a person’s overall sense of well-being in the workplace. One expert explains, “Job satisfaction is to some extent a reflection of good treatment” (Spector, 1997, p.2). Thus, employees who feel they are treated well at work will report higher levels of contentment and enjoyment in their occupation than those who perceive mistreatment.
Salary has the potential to be a significant factor in a person’s level of job satisfaction. Research has shown that increased earnings, individual and group performance pay, as well as ownership of company shares, can all create high job satisfaction in employees (Artz, 2008). Yet, while income proves to be a significant factor for some individuals, salary does not always raise the level of job satisfaction a person feels. Findings in another study has suggested that in high paying professions, such as in the medical profession, salary and benefits become a less significant factor in overall job satisfaction. In fact, according to a recent study in the “Proceedings of the National Academy of Sciences”, when a US household income reaches $75,000 a year, money “does nothing for happiness, enjoyment, sadness or stress,” (Korkki, 2010, p 1). Researcher and Professor of Psychology at Princeton University, Dr. Kahneman has confirmed that, “The lack of money no longer hurts you after $75,000” (Korkki, 2010, p1 ). Therefore, aspects besides pay and benefits must influence levels of job satisfaction in many American workers.
In addition to salary, working conditions generally have an affect on job satisfaction levels in employees. Management style and supervision can create either positive or negative working conditions for staff. For example, managers who use the participatory style give employees tasks to complete from start to finish, and in most settings, this gives employees a sense of empowerment and responsibility and increases job satisfaction rates. Organizational leaders can create favorable working conditions by giving employees a sense of control simply by adjusting their structure, routine, and culture, which will accommodate increased worker autonomy at the workplace (Millet & Sandberg, 2005). Effective management styles also help solve common organizational problems, such as communication, thereby contributing to a positive working environment and improving employee satisfaction.
An organization, business, or institution can benefit from high employee satisfaction in significant ways. High employee job satisfaction reduces complaints and grievances, absenteeism, turnover, and termination, and it can improve punctuality and worker morale (Marion & Cengage, 2001). Job satisfaction is also linked to a productive work force, and it is commonly understood to be a good indicator of employee longevity.
However, not all employers are equipped to make employee job satisfaction a priority. In some settings, how a person feels about his work is not addressed by the employer in any capacity. This may be due the employer failing to realize how satisfied employees benefit the organization as a whole. Notably, research has shown that discontent workers will exhibit negative characteristics in the workplace. Employers whose workers are dissatisfied will find decreased job performance, withdrawal, burnout, counterproductive behavior, and issues with physical and psychological well-being in their employees (Spector, 1997). A discontent worker may actually be a negative asset to an organization.
Job Satisfaction and Medical OncologistsA clinical oncologist is a medical doctor whose patients are diagnosed and treated for various forms of cancer. Oncologists have different areas for specialization, such as: radiation, pediatric, surgical, or gynecological oncology. These specialists have invested years into their education and training and enter a field that demands exceptional expertise and emotional empathy for suffering patients. With the number of cancer diagnosis increasing and the demand for qualified and talented oncologists climbing, the level of job satisfaction of physicians in the practice of oncology is important to examine.
Factors Contributing to Job Satisfaction in OncologyThe nature of this profession predisposes it to be both rewarding and stressful work. Research from the Mayo Clinic College of Medicine asserts that “Although many oncologists experience burnout, depression, and dissatisfaction with work, others experience tremendous career satisfaction and achieve a high overall quality of life” (Shanafelt, Chung, White, Lyckholm, 2006, p 4020). While much of the literature focuses on distress in the practice of Oncology, researching coming from the North Central Cancer Treatment Group found that out of 241 responding oncologists, 50% reported high overall well-being (Shanafelt et al., 2005). This study goes on to say that “Oncologists with high overall well-being also reported greater career satisfaction” (p.1). While the percentage of oncologists who feel satisfied with their jobs appears to be evenly divided, it is still considerably lower then the satisfaction rate in the general public as reported through the previously referenced 1999 Gallop Poll.
Despite the recognized value and importance of oncology as a profession, a body of literature reports that physicians in general are experiencing increased personal distress and decreased satisfaction with the medical practice (Spickard, 2002).While an oncologist may be satisfied with one or more aspects of his work, a given individual may find that career-specific demands create discontentment for the job.
Low job satisfaction rates among oncologists can be attributed to two main factors—stress and burnout. First, financial pressure and litigation contribute to stress in most medical specialties, and especially for the oncologist. It is well documented that doctors are sued often (Novack, 1997), and the stress from litigation can negatively effect one’s sense of job satisfaction. As one practicing oncologist sates, “Any physician who has been sued for malpractice is familiar with the unpleasant, visceral reaction generated by a malpractice suit. Whatever the outcome, a claim takes such a financial and emotional toll that the physician hopes never to experience one again” (Legant, 2006, p. 164). Oncologists, whose patients do not have an overwhelming recovery rate, have reason to be concerned about accusations of negligence and subsequent litigation.
In addition, reimbursement for medical services continues to decrease for the oncologist and fewer options for care are available for this specialist to use. Cancer costs account for approximately five percent of US health care spending (Marsland & Marks & Robbins, 2010) and yet, physician reimbursement for treatment is declining. A seven percent cut in payments to Johnson & Johnson’s drug, Remicade, contributed to these reductions in reimbursements as did Medicare payments for Taxol, which had an eighty one percent reduction, and Aredia, with a seventy two percent reduction, and also Navelbine, which took a twenty one percent reduction (Lueck, 2004). This loss in revenue combined with limited treatment options for care may be a source of stress and dissatisfaction among practicing oncologists.
In fact, some oncologists can no longer afford to supply medication to their Medicare patients, and this may influence overall job satisfaction in the field. According to one report, only doctors who buy drugs in large quantities can afford to treat Medicare patients (Johnson & Won Tesoriero, 2007). Under a new Medicare program, known as The Competitive Acquisition Program, doctors are only paid to administer drugs. This program has been called “impractical and unworkable” by oncologists who can not longer afford to treat all the Medicare patients in their care (Johnson & Won Tesoriero, 2007 ). Issues and restrictions on medication can be a significant source of stress for the physician who is working with cancer patients. Many of these professionals find themselves in a position where they must align with a hospital and academic medical center to gain financial support and stability (Barkley & Guidi, 2011). The diminishing options for care may negatively impact job satisfaction rates among oncologists.
In addition to stress stemming from unique financial pressures in oncology, burnout is another factor in low job satisfaction rates among these physicians. Burnout can be described as a depleted emotional state characterized by a number of physical and behavioral signs and symptoms, such as: physical and mental exhaustion, perceived ineffectiveness, impaired job performance, poor health, anxiety, and depression (Gunderson, 2001). Burnout can easily develop in employees who work under constant pressure and stress. According to one recent survey, the rate of burnout among oncologists in the US exceeds sixty percent (Allegra, 2004). When physicians experience burnout, not only are their job satisfaction rates likely to plummet, but poor patient care and increased medical errors can result.
Given the potential human costs of medical mistakes, the emotional impact of burnout and job dissatisfaction can be detrimental for oncologists and devastating for cancer patients. One expert attributes burnout, and ultimately dissatisfaction in the profession, to the fact that the number of cancer cases has steadily increased (up to1, 372,910 in the US in 2005), yet cuts in funding have forced some health care facilities to downsize their staff (Moss, 2005). Consequently, a smaller number of doctors must keep up with an increase in demand for services. Burnout among physicians is the result.
The potentially overwhelming needs of cancer patients combined with limited resources for care can contribute to stress and low job satisfaction in oncologists. As one researcher explains “The increasing demand for oncology care has not been consistently matched with an increase in human and material resources, or improvements in systems of care delivery. The imbalance between patient need and available resources to meet the need is considered to be a significant source of stress and burnout for physicians working in oncology” (Ramirez et al., 1995, 1996). Burnout may not only make it harder to work with patients diagnosed with terminal illnesses, but it can also lead to job satisfaction in cancer workers. If the professional expectations are too high the oncologists could develop negative feelings that produce undesirable outcomes. The potential for burnout to negatively affect quality of care has clearly been raised in literature (Whippen, 1991). Burnout may make it harder to work with patients diagnosed with terminal illnesses because it creates stress for cancer workers.
In conclusion, job satisfaction is understood to be an individual’s feelings and attitudes towards his work. Rates, or levels, of satisfaction in the work environment can be measured through surveys and questions that prompt an employee’s response to factors connected to his job. Identifiable factors, such as pay and working conditions, influence job satisfaction and issues of stress and burnout have the potential to decrease job satisfaction rates, specifically for oncologists. Research has shown that most workers in the US are satisfied with their jobs, yet the job satisfaction rate among oncologists is lower then the national average. An oncologist is likely to experience stress and burnout—both of which have the potential to create dissatisfaction at the individual level for the practitioner in his work.
Research emphasizes the negative factors that contribute to job satisfaction and offers little for the individual seeking to raise his level of contentment on the job. The connection between job satisfaction and benefit to the employer has been clearly affirmed; research in the area of how the practicing oncologist can promote his well-being through high job satisfaction has not been well established in literature.
Medicare ReimbursementThe past few years, the cancer care environment has been strained by cuts in Medicare reimbursement for drugs and services. The cuts are concerning because almost half of cancer patients are receiving Medicare. Based on data from community oncology practices across the nation, the Community Oncology Alliance (COA) estimates that the new cuts will result in a staggering 38% annual average reduction in Medicare reimbursement for chemotherapy infusion services alone (News-Medical.Net). This means that cancer patients will experience delays in diagnosis and treatment. The cuts could cause local access to care to be limited and that means more travel for patients.
“President Obama recommitted in his speech last night to building on what works and fixing what does not work,” said Patrick Cobb, M.D., president of COA and managing partner of Oncology Centers of the Northern Rockies in Billings, Montana. “But the cancer care system is already broken after a steady series of cuts to Medicare reimbursement for drugs and services each year over the past five years. The Medicare reimbursement cuts planned by CMS will kill cancer care as we know it. Community cancer clinics have already had to close satellite facilities and cut staff. Smaller clinics are struggling to operate and more will close.” (News-Medical.Net)
Some oncologists have been proactive and started making changes to accommodate the cuts by eliminating staff, reducing staff hours, eliminating overtime, and sending Medicare patients to hospital inpatient infusion centers for treatment instead of to the clinic.
“The patients do not receive the same level of care in hospital infusion centers, often waiting longer for lab tests and the preparation of their treatments for each chemotherapy visit, and the cancer care is ultimately at a higher financial cost than we can provide in the community oncology setting,” Dr. Thompson said. (News-Medical.Net)
Another area impacting oncologist job satisfaction is the new laws passed by Congress. The Sunshine Act was passed into law and will take effect in the near future. The law requires medical manufacturers to report payments to U.S. physicians. Anything over ten dollars must be reported. There are significant penalties for violations, ranging from $1,000 to $100,000. This Act imposes stricter reporting and a regime of compliance by in-house lawyers. The law goes into effect on January 1, 2012. All reporting must be submitted to the U.S. Department of Health & Human Services by March 2013, and the Act requires that all of the data be available online by September 2013. The website will be maintained by HHS in a manner that it is searchable and understandable to the public. The law will create public transparency for all payments by manufacturers. Consequently, the impact of this law may negatively affect oncologists’ job satisfaction.
Ppsa From The Standpoint Of The StakeholderStarting from the individual physician, a doctor attending a speaker program with dinner provided will trigger a record on the Physician Payment Sunshine Act (PPSA) website that states the doctor received a $100 dinner paid for by a pharmaceutical company. The information can be viewed by the public to search how much money has been accepted from all biopharmaceutical companies in 2012. Data shows that in the past physicians felt the meals and amenities from pharmaceutical companies were acceptable and appropriate. However, in today’s environment there is a great amount of mistrust by pharmaceutical companies. The general consensus now is that few physicians want free meals and other “gifts” to be publicly accessed. Group practices and national medical societies want to avoid the perception of influence by pharmaceutical companies. Those protesting voices have quieted over the past year, however, largely because of a number of high-profile cases where physicians appear to have put lucrative consulting agreements ahead of patient safety. One of the most glaring examples came to light last March when Baystate Medical Center in Springfield, Massachusetts revealed it had discovered that Scott Reuben, an anesthesiologist with the 653-bed hospital, fabricated results in 21 painkiller studies, many appearing in the journal Anesthesia & Analgesia (Rhea, 2010).
Two of the pain relievers—Celebrex and the since-recalled Bextra—that Reuben published favorable findings on were from Pfizer, which paid him a still-undisclosed amount in speaker fees and gave him five research grants between 2002 and 2007. During that period, both Celebrex and Bextra were linked to heart attacks in patients using the drugs, and in January 2008 Pfizer reached an agreement with federal prosecutors to pay $2.3 billion in fines to settle charges that it illegally marketed Bextra. Many of Reuben’s studies on these and other drugs have been used by clinicians as guidelines for prescribing pain treatment regimens (Rhea, 2010). Many institutions are restricting the access of pharmaceutical representatives to physicians because of this perceived influence. The law is motivating practices to eliminate TOV completely.
This has impacted pharmaceutical companies dramatically. All biotech, pharmaceutical, and medical product companies will be required to submit TOV data. The PPSA website will reveal which companies are spending tens of millions of dollars on free meals for doctors each year. This spending might be negatively perceived by the public.
Areas Of Spending Being RecordedIn order to understand how the PPSA will impact the industry and physicians, it is important to understand which TOVs the law will cover and the scale at which they will be measured. All dinner meetings, lunches, and destination meetings will have to be recorded. Most pharmaceutical companies employ physicians to speak at local dinner meetings in order to provide dinner and product education to prescribers. Currently, pharmaceutical companies do not have to record the amount spent annually on speaker programs, but it is estimated that companies spend approximately $15-25 million a year on meals associated with speaker programs (Rhea, 2009).
The Physician Payment Sunshine ActAnother large area of spending by the pharmaceutical companies is lunches. Meals brought into physician offices are estimated at a range of $10-20 million per year. The lunches provide a meal for the office during the clinical presentation of the products provided by the pharmaceutical company. Finally, destination meetings, such as advisory boards, consultant meetings, honoraria, and speaker training will have to be recorded. Some companies have already started to disclose payments to physicians. Now all payments including travel costs, hotels, and meals must be disclosed as well. The level of transparency exposing all the payments and “gifts” given to healthcare providers will most likely alienate pharmaceutical companies. It is possible that healthcare providers will not engage in industry interactions that include any TOVs. This could negatively impact the pharmaceutical industry in many ways. Access to physicians would be significantly limited, and future grants and funding for research at institutions could be cut off. Ultimately, the patient is the one who loses the most. Pharmaceutical companies will not continue to invest millions of dollars in new drug research if they have no access to the prescriber. There needs to be a relationship between the two parties in order for research to continue. The oncologist’s job satisfaction is affected due to the high transparency of their activities. Basically, it will be as if they are practicing in a glass house for everyone to see. The law would address a growing demand to eliminate medical-product manufacturers’ influence on doctors’ treatment decisions, and help curb spending on physician-preference items. But critics say the bill could also threaten industry’s funding of medical innovation if the disclosure requirements are so stringent that they would reveal trade secrets about certain kinds of research and development projects. Such a move could ultimately place a heavier burden on government to finance research, and have a negative effect on healthcare reform’s cost containment efforts (Rhea, 2010).
Medicare Reimbursement Scheduled Cuts For Cancer CareAnother area of concern for oncologists is the cuts being made in Medicare reimbursement for cancer centers by the Centers for Medicare and Medicaid Services (CMS). In the past, oncologists were making a significant amount of money billing Medicare for cancer services, but the new cuts will drastically decrease the reimbursement amounts. As of January 1, 2010 CMS scheduled an additional 21.5% decrease in all physician-related services by Medicare. The cuts include reductions for diagnostic imaging, medical oncology, and radiation oncology. The Community Oncology Alliance (COA) estimates that the cuts will result in a staggering 38% annual reduction in Medicare reimbursement for chemotherapy infusion services alone (News-Medical.Net). Reimbursement cuts to oncologists for cancer drug administration have already occurred every year since 2003, with a total decrease in reimbursement from 2003 to 2009 of 68%. This means that if an oncologist was reimbursed $100 in 2003 for the net profit or loss on a drug plus its administration, in 2009 he or she is being reimbursed $32 (News-Medical.net). Oncologists simply are not being paid enough money for their services, and many are going out of business. Areas of underpayment for services include chemotherapy infusion, treatment planning, treatment evaluation, testing, palliative care, and counseling. For as many as 40% of cancer drugs, the Medicare reimbursement is already less than the acquisition cost (News-medical.Net). Many oncologists feel the changes made to improve Medicare reimbursement might have made the situation worse. Due to the changes, Medicare no longer covers many of the necessities in cancer care. In recent years, oncology has moved from inpatient treatment to community-based outpatient care. Unfortunately, with the reimbursement changes many the community-based centers are closing. Oncologists cannot afford to purchase chemotherapy drugs and be reimbursed at such a low rate. This has caused significant stress to the oncologist and oncology staff. A community cancer center must outlay a large amount of money to purchase chemotherapeutic agents. As a result, a number of oncologists are refusing to accept new Medicare patients. This is a very sad situation for patients and for physicians.
Theoretical FrameworkThis theoretical framework builds on the works of two leading management theorists, Abraham Maslow and Frederick Herzberg. Abraham Maslow offered a theory known as Maslow’s Hierarchy of Needs. The theory proposes that employees’ needs can be classified into different levels and most employees take a sequential path to fulfilling these needs. According to the theory, most of the employees’ needs can be put into one of the five levels which are Physiological Needs, Safety Needs, Social Needs, Esteem Needs, and Self Actualization. Physiological Needs include most basic needs such as food and w
