Beyond Binaries: Reflections and a Suggestion on the Subject of Medical Professional Satisfaction

Beyond binaries—incorporating exploration of different types of medical work

In a recent study my colleagues and I compared doctors’ responses in areas of activity that were the subject of “top down” reforms with those which were not (McDonald, Cheraghi-Sohi, Bayes, Morriss, & Kai, 2013). The former, the Quality and Outcomes Framework (QOF), involved guideline driven care underpinned by financial incentives (Roland, 2004). In terms of the latter, the focus was on patients with medically unexplained symptoms (MUS) and the study found that doctors continued to practise as they had always done in this area. Whereas the introduction of guideline driven care appeared to embed new ways of working and thinking, with patients as groups to be managed as part of the organisational processes established for doing this, the organisational dimension with regard to MUS patients was largely absent from doctors’ accounts. For patients with QOF-related conditions proactive call and recall systems were developed and facilitated by disease registers and customized software. For MUS patients, doctors described reacting to patients who consumed large amounts of their time. Often doctors felt unhappy with the process and unsure of their impact. No attempt was made by the doctors to work together as a group practice to identify patients who attended too frequently and/or to meet to discuss strategies for managing this group of patients. This contrasted sharply with QOF-related areas of activity, where doctors and other members of the practice team worked closely together to ensure that targets were met.

Whereas QOF resulted in standardised approaches to care, accounts of MUS patients were characterized by variations and individual and idiosyncratic practice. Doctors’ accounts suggested that variations between approaches were seen as a “taken for granted” aspect of practice life, rather than something to be minimized in the pursuit of standardisation. Doctors gained little satisfaction from dealing with MUS patients. The absence of attempts to tackle this patient population could be attributed in part to the more complex nature of guidance and lack of computerized protocols for this group of patients compared to the various mechanisms which support QOF target delivery. However, it can also be interpreted in the context of the persistence of a logic (Scott, 2001) of medical professionalism, which involves doctors coping with whatever presents and focusing on interactions with individual patients, as opposed to conceptualizing this in terms of organizations and the populations they serve (McDonald et al., 2013). This example highlights that it is important not to approach DS from an “either/or” perspective, but to recognise the complexity of the context in which doctors are working. Examining different types of medical work undertaken by the same individuals helps to provide a more nuanced understanding.

McKinlay and Marceau (2011) view clinical guidelines as undermining clinical autonomy and contributing to physician dissatisfaction. Yet studies demonstrate that this is not necessarily the case and physician satisfaction has been shown to be positively associated with guidelines (Kerr et al., 2000). This suggests that doctors do not always view such guidance as unhelpful or overly managerial. Doctors did not express high levels of dissatisfaction in relation to guidelines in our study (McDonald et al., 2013). Furthermore, as Timmermans (2008) explains, in the US and elsewhere the growth in clinical practice guidelines depends to a great extent on the collaboration of medical professional organisations. Guidelines have been part of the landscape of English primary medical care for some years and GPs as generalists do not necessarily see guidelines as threatening their professional autonomy (Checkland, 2004). In our study (McDonald et al., 2013) the doctors actively engaged with processes of organizational redesign and changes to ways of working. They welcomed being able to practise in a “well organized” environment and new structures did not undermine business ownership, which remained in the hands of the medical partners. Rather than viewing the reforms as running roughshod over traditional general medical practice, they can be seen as an attempt to build on and accelerate trends which were emerging pre-QOF, which may explain doctors’ willingness to embrace them.

In a context where much of the sociological literature is concerned with powerful medical professionals and their ability to resist change (e.g. Currie, Lockett, Finn, Martin, & Waring, 2012) our findings were relatively unusual. The state of affairs described with regard to MUS patients is less attributable to the power of medical professionals than to feelings of powerlessness experienced by many of the doctors in our study. Whilst maintaining the status quo is often characterised in terms of the “political efforts of actors to accomplish their ends” (DiMaggio, 1988, p. 33), it can also involve less conscious, iterative, routine-based and routine-reproducing activities (Scott, 2008). These routinised behaviours continue in the context of MUS patients, where the logic of medical professionalism endures, despite the dissatisfactions of doctors in this area. At the same time, QOF activities were viewed in a relatively positive light, although some aspects (i.e. the potential to lose sight of the patient’s agenda) were seen in more negative terms.

Beyond binaries—comparing different dimensions of autonomy/discretion

Various studies from the physician satisfaction literature make links between autonomy and satisfaction. However, autonomy is often measured and defined differently in different studies. Acknowledging developments over time which mean that nowadays professionals are much more likely to be located in employing organisations than was previously the case, Julia Evetts (2002) suggests that rather than using the concept of autonomy, the term professional discretion is more appropriate and highly relevant to modern professional organisational contexts. Professional discretion,

This conceptualisation raises questions about the extent to which doctors are comfortable with a remit to “take all factors and requirements into account,” as well as the relationship between discretion and satisfaction. It also suggests a more complex and multi-dimensional concept than the view of “autonomy,” which features in much of the DS literature.

For Cheraghi-Sohi and Calnan (2013) it is important to recognise the multi-dimensional nature of discretion when exploring doctors’ responses to changing work environments. The authors draw on Evetts’ (2002) views to examine changes in English primary medical care and define various aspects of discretion (i.e. bureaucratic, social, organizational, economic and political). To some extent this resonates with McKinlay and Marceau’s (2011) call to “change the approach to research on physician discontent […] to an organizational approach” (p. 322). But Cheraghi-Sohi and Calnan (2013) go beyond this to examine how changes in each of these dimensions are perceived by the doctors involved. As their paper illustrates, conducting analyses on changes to discretion from a uni-dimensional perspective leads to, at best, a partial and at worse, an erroneous view of the situation. The authors find support for Evetts’ (2011) assertion that modern professionalism is changing and “modern professional discretion is embedded in an organizational context and can only be understood on those terms with individual medical freedoms and latitude being tempered by increased collegiality, accountability and performance management” (Cheraghi-Sohi and Calnan, 2013 p. 59). This resonates with other studies which report the emergence of new forms of professionalism and an acceptance by medical professionals of such changes (e.g. Kuhlmann, 2008).

Beyond binaries—collapsing the medicine versus management divide

My final example is drawn from a recent study which I undertook with colleagues (McDonald et al., 2012) examining responses of hospital doctors to financial incentives which reward hospitals (as opposed to individuals) for providing care which is in accordance with a “best practice” pathway. As outlined above, guideline driven care has often been depicted as constraining clinical freedom. Furthermore, mechanisms such as financial incentives might be construed as part of the toolkit of management in a context where traditional notions of medical professionalism differ sharply in terms of ethics and orientation from the imperatives of management (Schlesinger, Gray, & Perreira, 1997; McDonald 2009). Many studies describe how managers and medical doctors inhabit different subcultures each with their own beliefs and practices (Morgan & Ogbonna, 2008; McDonald, Waring, & Harrison, 2006) languages and communication habits (Holtman, 2011). Numerato et al. (2012) describe how a whole raft of techniques and initiatives (e.g. New Public Management, governmentality) have been seen as part of a process whereby the tentacles of managerialism extend to control medical professionals. They conclude that:

In our study, doctors were generally in agreement with the “best practice pathways” rather than seeing them as a mechanism of control. This is hardly surprising since the national pathway development was for the most part underpinned by medical knowledge and input. Some doctors described working with local managers to exploit the potential of the incentive initiative in order to improve care. At the same time, different levels of “management” were reported as being more or less amenable to collaborative working on the issue depending on a range of factors including proximity to the service and history of working relationships. This reminds us that “management” is not a unified monolithic entity but a collection of managers at different levels of the organisation characterised by collaborative and competing objectives and impulses. Additionally, doctors reported using what might be seen as management tools in order to deliver “best practice” care as part of a process of persuading senior managers to allocate resources to their service. In the area of renal “best practice tariffs” (BPTs) this BPT is intended to encourage vascular access for haemodialysis. There are wide variations in vascular access use within Europe, which do not appear to be explained by differences in population characteristics (Pisoni et al., 2002) and rates in the UK are low. Consultant nephrologists identified a key issue for pathway compliance was access to surgeons and this could be problematic. Different doctors responded in different ways to this as illustrated below:

In contrast, as the following quote illustrates, some nephrologists wanted to increase vascular access, but felt frustrated at their inability to influence factors which they saw as beyond their control:

It does not seem helpful to categorise these response using a control/resistance or medicine/management framework. The doctor in the second quote feels powerless and frustrated rather than actively resisting control. In the first case, the adoption of “management” tools and close working with local level managers has resulted in what the nephrologist sees as a positive outcome for patients. He does not appear to see this as threatening his medical identity, nor is it used to shore up medical power to defend against controlling managers. There is a literature describing how medical professionals attempt to maintain their clinical autonomy by selectively using “management” measures. However, my point here is that this is less about defending against encroachments on clinical autonomy than joining up aspects of care in a way that solves the sorts of problems that can leave doctors feeling powerless and dissatisfied. Furthermore, the example illustrates how differences and divisions between different types of doctors (in this case nephrologists and vascular surgeons) can be more important than divisions between doctors and managers.

In this example we can see how some doctors can incorporate what might be seen as management techniques and practices in ways which challenges static ideas about what constitutes doctors’ roles. Sociologists have written much on the subject of identity (Jenkins, 2008) as a fluid and dynamic concept involving multiple identities (e.g. mother, doctor, wife etc.). Applying this perspective and locating individual accounts in a wider social and historic context, can help to understand doctors’ views and actions and avoid simplistic assumptions about the relationship between medicine and management.