The influence of gender of the medical specialist on the use of management control systems in hospitals

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The influence of gender of the medical specialist on the use of

management control systems in hospitals

Gert-Jan Doornbos

Master Thesis

University of Groningen Faculty of Economics and Business

MSc Business Administration

Specialization: Organizational and Management Control

August 2011 Gert-Jan Doornbos Address: Reitemakersrijge 5 Postal Code: 9711 HT City: Groningen Mobile: +31 6 54967965 MSc Business Administration

Specialization: Organizational & Management Control S1654772

August 2011

Supervisor: Dr. B. Crom

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Preface

During the process of writing my master thesis, I have realized that my time as a student is coming to an end. Looking back I have realized that I have developed myself both professionally as well as personally. The experiences and skills that I have learned and possessed during my studies give me great confidence to look brightly into the future.

I began working on my thesis early 2011 and finished in august 2011. The study was mainly a literature study with some interviews which helped me gain new insights or to get things clear.

The thesis in front of you is being written by an explorer with very little experience in the health care industry, yet this journey has proven itself to be both interesting as well as being quite insightful. It has also given me the opportunity to speak and meet with various interesting people.

A first meeting with Dr. Ben Crom, assistant professor, produced possibilities for a master thesis. I was here that the idea for a gender research thesis was born. Together we deliberated on an interesting subject and came up with the research at hand.

During the entire research process Ben Crom has proven his self to be a great mentor and provided me with a lot of new ideas, insights and constructive criticism. I would therefore like to take this opportunity to thank Ben Crom for his great cooperation and inspiration. Thank you for being a positive mentor and a pleasant person to work with.

Furthermore, I would like to thank several other people. Firstly, I would like to thank my second supervisor Dr. M.P. Van der Steen for co-reading my master thesis in the short time he was given. Secondly, I would thank my girlfriend Marly, my friends and family for guiding me in the right direction and supporting me throughout the whole process.

Hopefully my results can inspire others to search for further answers in this interesting field.

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Abstract

This research at hand deploys examines a possible difference in gender of medical specialists on the use of management control systems in hospitals

This research has the form of a literature study in which academic literature is used to answer the research question. In addition, nine interviews were conducted to gain a better understanding of the profession of medical specialists and the relation between the hospital and medical specialists.

Furthermore, a few interviews have focussed on the gender aspect to acquire a better understanding on female and their characteristics.

The central research question in this research is:

Which changes in the use of management control systems in hospitals are needed to cope with the change in gender of medical specialists?

The research has shown that female medical specialists have different preferences in the way they would like to be managed than male medical specialists. Results suggest that females prefer a less tight management control system and a more transformal style of management.

Male medical specialists, generally look at concrete results and eccentric rewards, whereas female medical specialists are more interested in intrinsic rewards and their personal working environment. When management should decide to follow a more female ‗friendly‘ control system, management could focus on trying to involve female specialists in the decision making process. Besides this, management should try to focus more attention on personal development opportunities and not only look at hard financial results. In addition, the working environment could be built more around the social and domestic life which seem to be of importance to female workers.

The social benefit of this research is evident. Because of the aging Dutch society, healthcare costs are constantly rising. Medical specialists are among the professionals who answer this demand for healthcare. Data in this field shows that the ‗new generation‘ of medical specialists consists largely out of women, whereas earlier this group mainly consisted out of males.

As this group of medical specialists is important for the future delivery of healthcare such a development cannot be ignored. With the idea that managing and leading is looking forward, the results of this thesis can help managers to customize their management control systems used in hospitals due to this demographic development.

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Examples of different, but related subjects are females in accountancy or females in law.

Keywords

Management control system, gender, professionals, medical specialists, female.

Supervisor Dr. B.Com Co-Supervisor

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Chapter 1 Introduction

The first chapter of this thesis will start of with a general introduction. Furthermore it will shed a light on prior research that has been done in this field. Moreover, it introduces figures and developments that are important for this research, e.g. gender developments in the medical world with respect to medical specialists. Additionally, the goal of the thesis will be explained and general information about the relation between medical specialists and managers will be presented. Finally, a practical case on the gender of medical specialists will be outlined.

1.1 Thesis introduction

Like most countries, life expectancy rate in the Netherlands is increasing due to amongst others an improving healthcare sector (CBS). This implies that more people will come to rely on the healthcare sector and more medical specialists are required to meet this increased demand for healthcare (Capaciteitsplan, 2010). Thus, one could conclude that medical students are being trained to become medical specialists to ensure that this increasing demand can be met. It is interesting to see that there is a new development in the training of medical specialists in the Netherlands: increasingly more females are studying medicine than men (Capaciteitsplan, 2010). The logical consequence of this trend is that the distribution of medical specialists will be skewered more towards females rather than males. To illustrate the extent of this development one can look at the following statistics. At the beginning of this century eighty percent of medical specialists were male, and only twenty percent were said to be female. Looking at the situation on January 1, 2010, a shift can already be detected; sixty-six percent are male and already thirty-four percent are female.

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When looking at figure 1.1, one can clearly see that the amount of female medical specialists (yellow line) has doubled since 2000, while male specialists (pink line) show an increase of only ten percent.

This development has an impact on the age distribution between male and female medical specialists. An interesting note is that, when looking at figure 1.2 one can see that only in the age bracket of fifty years and older, the percentage of male specialists is higher than the number of female medical specialists

(Table 1.1: Age distribution between males and females among medical specialists)

Additionally, in the next ten to twenty years most of these older medical specialists will already have retired and if the development of increasing female students for medical specialists will continue, the profession of medical specialist will become a more female dominated profession instead of a traditionally male dominated occupation.

Summarizing, one can observe the increase of women in the area of medical professionals and the fact that more medical professionals will be needed in the near future to ensure the provision of adequate healthcare for a growing population.

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As this research shows, female medical specialists are already a significant group, one which will only increase in significance in the near future. Here, an important challenge can be pointed out for management in hospitals; a new management system should be set up that monitors the developments and changes in medical specialists and can help management to act accordingly.

Caution is advised however, as there is a tense relationship between medical specialists and management of hospitals because of, in general, the different goals of medical specialists and hospital managers.

Put simply, medical specialists want the best possible care for their patients and the costs of treatment is not their highest priority. The hospital managers on the other hand, will be more likely to be focussed on the long term continuity goals and maintaining a cost-effective healthcare service (Klopper-Kes, 2010). There appears to be an ‗us versus them‘ mentality in the hospital between management on the one hand and medical specialists on the other hand. Aside from this, there is a so-called double monopoly of production. This means that there is a monopoly on surgery and a monopoly on evaluation. Only professionals can judge each other with regard to the position of medical specialists. This gives the medical specialists a unique position of supremacy through their knowledge with respect to their management

(Petterson, 1995).

There is an enormous knowledge/information gap between managers and professionals. This gap will not disappear any time soon, as hospital managers are not likely to be able to be knowledgeable about the medical specialisms in their hospitals, likewise medical professionals cannot be expected to be knowledgeable about the management‘s goals. Thus in the meantime, knowledge/information gap will remain. There are no indications that indicate that because of the fact that more women are going to be medical specialists this tense relationship will improve; both groups will still have their same opposing targets (Pas, 2011).

In my research I want to research the gender development of medical specialists and the consequences for the use of management control systems of hospitals. My goal with this research is to make a first step towards elucidating the issue of control. I plan to accomplish this by investigating whether a difference in gender requires a change in management control types. That this issue is socially relevant, is evident due to the fact that in the near future the Netherlands will need more medical specialists than that there will be available (Capaciteitsorgaan, 2010).

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This is important because research from the UMCG shows that somewhere in the process a lot of female medical talent is lost (Sebille, 2010), meaning that many assistant medical specialists do not become medical specialists or quickly drop out once they have become a medical specialist. One can conclude from this that the UMCG understands the need that all potential medical professionals will be required to meet the future demand of care. The amount of attention this group receives is hardly surprising in light of the increased demand scenario. Figures1 indicate that female medical specialists will likely become the dominant group in circa 2025.

However, the data shows that this group is highly susceptible to leaving in either their training phase or once they have become medical specialists. It is thus interesting to investigate if the management control system for medical specialists has an influence on this outflow of female medical specialists and if it outcomes of this research can be used to positively reducing this outflow.

1

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Chapter 2 Research design & Outline thesis

In this chapter, the research design will be further clarified. Firstly, the goals of the research will be described; subsequently the main research question will be presented which will be followed by the various sub questions. Secondly, the conceptual model and the research methods will be outlined. After that, the restrictions and limitations of this research will be explained. Lastly, the last paragraph will include the outline for the following chapters.

2.1 Goals of the thesis

The objective of this research is to investigate if the change in gender of medical specialists has a consequence for the use of management control systems in healthcare

2.2 Main research question

Which changes in the use of management control systems in hospitals are needed to cope with the change in gender of medical specialists?

2.3 Sub research questions

 How is the management control system structure in hospitals organised?

 Which management control systems are theoretically available and which can be applied to the control of medical specialists?

 What are the differences between male and female medical specialists in their preferred management control systems?

The first sub research question is to find out who nowadays is in control of the medical specialists in hospitals, e.g. what does the current hierarchy look like. This will give a clear overview on how the organizational structure is arranged in hospitals. The next issue is to find out which theoretical models are available for management control systems and how management control takes place in practice.

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are between male and female medical specialists and what can be said about their preferred management control system.

The last step in the research is to combine both the knowledge of the current management control system for medical specialists and the knowledge of the appropriate management control system for female medical specialists. One can then clearly draw conclusions and answer the main research question and see whether the current management control system is the most suitable for female medical specialists.

Aside from the issue stated in the main research question, this thesis also provides information on the preferred female management style. This can be seen as a new addition adding to this thesis. These new results do not directly concern the theme of a specific management control system or the tightness of a management control system, but are certainly important in the total management approach. In several related study outcomes on a preferred management approach, the management style is indicated as important, thus in this research about management control systems this could not be ignored.

2.4 Conceptual model

Fig 2.1: Conceptual model of the research

2.5 Method of Research

To ensure that one obtains the most reliable information, it is sensible to get information from different and independent sources that are relevant for the research. This proved to be quite difficult. For this literature thesis multiple parties were approached and involved in the gathering of information. Sometimes these parties were personally visited for interviews or approached by mail or in some other cases they were interviewed by telephone. Aside from individuals and organisations, books and scientific articles were collected and read. Despite the amount of sources available, the useful information they produced was limited in the light of this specific topic. Especially the part of the research which concerns the role of gender and the use of a suitable management control systems to control medical specialists was limited.

Management control systems used by the hospital management Gender of the medical

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The first sub research question could be answered with scientific articles and reports which were all available and well documented. The second research question required some more research effort. When answering this sub research question scientific articles offered the most suitable information but were unfortunately not complete. The problem being that most articles focussed on the strained relationships between hospital management and medical specialists instead of the use of management control systems and medical specialists. For this part of the research books were read and interviews were conducted. For example, the director of the so-called ‗Orde van de Medische Raad‘ in Utrecht and a senior advisor of the so called Capaciteitorgaan were interviewed to get a clear picture of the tightness of management control systems in hospitals.

The last research question was by far the most difficult question to answer. Whereas the previous sub research question was already a bit more difficult to find out, the final research question proved even more difficult as there was no direct information whatsoever at hand. Therefore, research was needed to find out what specific management control systems seem to fit with female specialists. During this phase different related subjects where included to get a better idea of the female context. Here, one can think of female lawyers and female students. It may be clear that there is a difference between these groups; however one needs a starting point. Throughout this report, this information is also used to get a more global feel into this subject

2.6 Limitations

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2.7 Outline of the thesis

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Chapter 3 Management control in hospitals

This chapter is constructed as follows; section 3.1 will be a clarification of which management level medical specialists are being controlled by in practice. This section will answer sub research question one. The focus in section 3.2 is on the research of Mintzberg (1993) with specific attention to the professional bureaucracy and how this relates to the world of controlling medical specialists. This offers a first introduction into the issue of management control and professionals. Section 3.3 will theoretically research management control systems and will give advice on how to practically implement this system in hospitals and answer sub research question two. Section 3.4 will present a variable of the discussed management control system; namely the tightness of a management control system. The following section, section 3.5, will discuss the style of leadership/ management. The last paragraph contains a short chapter conclusion.

The goal of this thesis is to determine which influence the gender of medical specialists has on the management performed by hospitals. Hence before researching the actual goal of this thesis, the gender component, it is imperative to observe the current management control systems and related issues.

3.1 The organizational structure of hospitals

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Management in Dutch hospitals has several administrative levels (Crom, 2005). The top layer is the top management also known as the Board of directors. Generally each member of this board is responsible for one portfolio or division. This is followed by the division level. This level is of the organizational units of medical professions that belong together. Under the division level there are the departments. These are the medical specialities with their department management. It concerns the organizational units of the hospital. The department management is often threefold.

 The department head is mostly a medical specialist and primus inter pares. The main focus lies on the medical content policy and depending on the type of hospital the focus is sometimes on research;

 Manager business with finance and personnel in portfolio;

 Care manager, responsible for the daily routine on the care provision.

Under the departments one can find the partnerships. In these partnerships the medical specialists are united. The last level is the sub-department or care units which are subservient to the departments and sometimes are organised into sub departments or can sometimes be a combination of the two. The head is mostly called a unit manager or head care unit.

For this research, management is not specified as the board of directors but as the department management. The latter is therefore the focus of the research. On the department level management decisions include performance management of the employers of the hospital.

3.2 Professional bureaucracy

According to Mintzberg (1993) the organization of medical specialists meets the characteristics of what he describes as a ‗professional bureaucracy‘. The medical specialists are given long and intensive training before performing operations and are given considerable control over their own work. The professional bureaucracy stresses the authority of a professional and that the performance of this individual (i.e. the medical specialist) is the key part.

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medical specialists for the management is that they do not have the knowledge required to judge if the medical specialist is doing his or her work adequately and efficiently. The logical consequence is that managers do not judge and control their medical professionals on behaviour but on factors they can understand themselves. Examples include financial results and amounts of operations performed. Mintzberg names the following methods used for controlling the problems associated with the professional bureaucracy: Direct supervision, standardization of work processes or standardization of outputs. Direct supervision can work if the medical professional displays tardiness and he or she can be reprimanded. However, is does not work well enough to ensure that the medical specialist is working as efficiently as possible for the hospital. Also, some specific work cannot be standardized. The manager cannot judge the quality of work of the medical professional so instead of this the manager will focus on controlling financial results as the manager can understand this part. The conclusion so far is that the medical professional is controlled on his predetermined result within a framework that the manager understands like amounts of operations and cost control of the total operations or treatments.

3.3 Management control systems

Traditionally literature on the medical professionals‘ healthcare world is dominated by male and male culture (masculinity). Hofstede (1983) offers clarification on the concept of masculinity. He describes it as to what extent the traditional distribution between male and female qualities is taking place. With typical strong male qualities, i.e. high masculinity, there is a higher emphasis on traits such as assertiveness, ambition and an orientation on rewards. In a situation of low masculinity, i.e. a more feminine approach, a more people orientated culture exists, which results in a sentiment that there should not be a difference in sexes. In the feminine approach the quality of life and environment is important, whilst in a highly masculine approach the focus lies primarily on performance and growth. This typical masculine behaviour is something that is still present in the medical world.

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(Fig 3.1: Forms of management control)

One control system is result control, this implies that the employee is expected to deliver certain results, e.g. customer satisfaction or returns on investment that the employee needs to achieve. These results are being measured by management with the help of predetermined targets that are shaped for employees to strive for. To make sure that the employee is challenged, incentives are used to encourage the employee (Merchant & Van de Stede, 2007).

Medical specialists have to perform a certain type of operation in a predetermined time within a certain budget. A specific example would be that of a surgeon who has to perform fifty stomach reductions in 2011 and has a budget available of two million euro‘s. This form of control can and is applied by managers in hospitals. Result control is especially useful when there is no other good source of information available (e.g. input or same knowledge level). Due to the gap of knowledge and information, managers cannot exactly judge medical professionals on effort and input resulting in a shift towards accountability in terms of financial results and amounts of operations (Pettersen, 1995).

A second form of management control is cultural control. This is achieved by creating an organizational culture where employees share company values and perform their job in line with the company‘s culture. This culture is created by a mission statement or a code of conduct (Merchant & Van de Stede, 2007). This kind of management control is more difficult to apply for managers of medical specialists. This is because medical specialists can differ in opinion in what they find what is actually important (Klopper-Kes et al., 2010). Evidently, the ideal situation would be to demand that both sides have basic knowledge of each other‘s field, i.e. medical specialists have a basic understanding of the financial interests at play, whereas managers adopt a view that transcends mere accounting. In practice however, this approach is very difficult to achieve because of the long education time. As a result, cultural control does not have the preference of managers, and so management tries to achieve their goals by using result control.

Cultural Control Result Control

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A third option for management control is personal control. The reasoning behind this type of management control is that employees control and motivate themselves. With personal control it is the management‘s function to hire the right and most qualified personnel. Next, it is important to ensure that the new employee is at the right place in the organization and is subsequently trained to make sure that the employee has the required facilities so he or she can do his work well (Merchant & Van de Stede, 2007).

If personal control is applied in healthcare, it gives the medical professional too much freedom according to hospital management and is therefore not suitable. This mode of control is simply not suitable because medical specialist are probably not interested in financial results, but they will try to give the best possible healthcare for patients which does not correspond with the goals formulated by management.

The fourth form of management control is action control. There are multiple ways to perform action control. An example of action control is pre-action reviews, which means implies that before a specific action is executed, it must be approved by a reviewer. A well-known characteristic of action control is that the organization can determine what actions are (un)desirable. This implies that the knowledge of the controller needs to be more or less the same as the knowledge of the professional (Merchant & Van de Stede, 2007). In the context of the hospital management and the medical specialist this is impossible because managers do not have the required knowledge available (Pettersen, 1995), hence action control would not be an appropriate form of control in their fundamental form.

3.4 Tightness of a management control system

In addition to the four basic types of management control, there is the variable

tightness of a chosen management control system. A management control system

can be tightly or loosely applied. The article of Van der Stede (2001) states that tightness of a management control system can be described as to which degree the performance of a subordinate is evaluated primary on the ability to meet his of her objectives in a certain period.

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According to the interview with Meegdes (2011) in hospitals there is a tight management control system applied in hospitals.

3.5 Leadership/management styles

The last part of this thesis will focus on the style of leadership/management that can be applied. While there are overlaps with management control systems, the leadership/management style is something different. The style of leadership is the outer shell in this research. From the research performed in chapter four it became clear that the style of management is important for females when discussing the gender management. Four general types of leadership can be identified. According to meta research (Pearce et al., 2003) the four styles have their own characteristics.

Leadership Style Directive leadership style Transactional leadership style Transformational leadership style Empowering leadership style Idea of subordinates Subordinates are among others lazy and not willing to work and they dislike responsibilities. Also subordinates are preferred to lead by others and they are resistant to change. Subordinates measure what they get for certain effort and make their consideration.

Subordinates are valuable assets and need a vision and inspiration in their work.

Let

subordinates make their own targets and let them become self-managed Type of leadership style needed Tight control mechanism and compulsory power Contingent material reward Stimulation and inspiration, vision and idealism Delegating, supporting and mentoring Behaviour of leader Decisive, coordinating and defines how work should be done without consultation. Motivating subordinates by appropriate rewarding for appropriate effort. For example higher income by higher effort Motivates subordinates by getting them to a higher level of self-actualization so not only looking at the basic reward but also other development possibilities Encouraging subordinates to become self-managed

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One cannot assume that a certain type of management control system is perfectly matched by a certain type of leadership/management style by comparing the attributes of both. In addition, one can also not infer that tight control is the same as a decisive leadership/management style or that loose control is the same as empowering leadership/management.

However, said it can be stated (cautiously) that a very tight control provides the most suitable fit with the properties of directive leadership style if one has to choose one of the four leadership /management styles. The same applies for loose control and empowering leadership. But in this research management control system, tightness and style of management are three different objectives and all three important for a total management control system.

3.6 Short chapter conclusion

It may be clear that although managers and medical professionals work in the same organisation their goals are generally misaligned. Managers act in the belief that the hospital is a business that they have to run with community funds. Their emphasis on sound financial results is therefore a logical consequence. Medical professionals on the other hand, act in the belief that the patient is the priority and every form of treatment should be pursued regardless of the financial implications. To overcome these different interests managers use a certain type of management control system, result control, to make sure medical specialists act in a desirable way. Choosing a certain degree of tightness to manage the medical specialists in their chosen management control system is a second decision managers have to make. Aside from the chosen management control system and degree of tightness of the chosen management control system, the style of the manager is an influencing factor on the desired behaviour of the medical specialists. Chapter four will investigate among others which style is suitable for female medical specialists. To illustrate these connections between these three variables figure 3.3 can provide some clarity:

Fig 3.3: Circles of management control systems in this research

Management Style Tightness

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Chapter 4 Gender management

Chapter four concerns the gender issue. In this chapter the last sub research question will be investigated. Because there was no literature available which could answer the research question directly, the so-called ‗sprokkel strategy‘ has been used. This ‗sprokkel strategy‘ means that articles are used which come closest to the research subject.

When searching for facts that could imply if female medical specialists do or do not want a different management control system eight related subjects were researched. However, none of these subjects directly compare female medical specialists with male medical specialists on preferred management control systems. The eight points of comparable research subjects are:

(1) female versus male (2) female leadership

(3) female students and control (4) female professionals

(5) female lawyers (6) female accountants (7) nurses and control (8) medical female control.

Thus the answer to this last question is collected out of multiple related sources which all have an overlap with the research subject of this thesis. These assumptions will help answer the research question. Figure 4.1 displays the different studies:

(Fig 4.1: Figure of method of research gender issue)

Female leadership versus male leadership

Female students versus male students

Female professionals versus male professionals

in general

Female lawyers

Female accountants

Nurses and control

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This paragraph will attempt to ensure clarity on the definitions of task-oriented leadership/management and relation-transformal leadership/management which are used often in the studies that follow. The general idea of task-oriented leadership/ management is to give a definition and explanation on work requirements, to be exact about plans that need to be followed, and to give clear instructions and plans. This can also be viewed as what Van der Stede (2001) describes as directive style of leadership/management. For ease of reading this style will be named directive leadership/management style. The general idea about relation-transformal leadership/management is: to show regards for the subordinates as individuals, to be considerate, to rely on subordinates, to be just in treating subordinates and allowing subordinates to decide. (Ekvall and Arvonen, 1991), which matches the description of transformal style of leadership/management by Van der Stede (2001) so that it can keep the same name. Looking at the situation in the hospital sector, as described in chapter three, one can say that the first style is applied by the managers because they set the (financial) targets without consultation and not being an inspiration for their medical specialists.

4.1 Female versus male in general

Morgen (1986) made a list of male and female characteristics:

Male Female Forceful Intuitive Independent Spontaneous Logical Caring Manipulative Cooperative Competitive Flexible Resilient Emotional Decisive Thorough

(Table 4.2: difference between women and men characteristics)

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4.2 Female leadership versus male leadership

According to the Handbook of Leadership (Bass, 1990) female leaders are more relational oriented and involved than their male counterparts who are more focused on results. Eagly (2003) states that female leaders adopt a more democratic style or participative style and a less autocratic or direct style than male managers. It can thus be said that females would opt for a more relation-transformal control system if they are in the position to choose, instead of the directive style which is often used in hospitals for controlling medical specialists.

Moreover, according to research conducted by University of Utrecht (1988) there are specific differences between male and female managers. Female managers prefer to understand their employees and try to motivate them. They stimulate a working environment of cooperation with their employees. Male managers however, are focussed on control, aggression and analytic thinking. This research endorses the assumption about the female preference for a more transformal management style and the male preference for oriented-task management style. Hence with the restriction those female managers are not the same as female medical specialists one could say that if there is any difference, it is that female managers are more supporting and people-oriented than their male colleagues who primarily concentrate on results and control.

4.3 Female students and control

Now that a clear distinction has been made between the differences in preferences between males and females on management control styles, it is interesting to see what has been researched on males and females who have actually undergone the different controlling styles.

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that women think that a more democratic decision making style is the style in which they would like to be managed, while men think that a more autocratic decision making style is appropriate. The clear restriction here is that students are not the same as medical specialists but again this shows that females seem to have a preference for a more democratic management style and are more focussed on intrinsic rewards as opposed to their male colleagues, who are more focussed on extrinsic rewards and prefer a directive management style.

4.4 Female versus male professionals

Another interesting issue to research is to see if there are any differences in preferences when females and males are working, as opposed to studying. A study (Peterson, 2004) held under 1123 fulltime employees in organizations with more than 1000 employees‘ shows what males and females value when they are working. For males, money and benefits are important, followed by results, power, authority and status. Females however, value other things as important. Women think of relationships and friends to be more are important, followed by recognition, respect and collaboration. An optimal work environment for females is one in which work is done in collaboration with other people. Also, women value human relationships and communication as important within an organization. Working benefits do not have to materialize in financial compensation, women value personal relations and the balance between working and their domestic situation as being more important. Men on the other hand, do think of work as being done for achievement and financial compensation. This study is in line with the proposition that has been put forward earlier: females focus more on intrinsic values and the working environment, whereas males rate traditional results like financial targets and status and influence as being most important.

4.5 Female lawyers

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commitment to the law firm and to their clients, which creates a conflict of roles between the female professional job-role and domestic-role. Basick (2006) confirms these findings when investigating what female lawyers want to improve about their working environment. Provisions for childcare or substituting facilities were rated as most important. Additionally, the possibility to work fewer hours and the opportunity to take two years off for personal development or childcare were also rated as important. From the results of studies concerning the legal sector it seems that female lawyers have corresponding wishes to female medical specialists.

4.6 Female accountants

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4.7 Nurses and control

This section concerns nursing professionals and their preferences about control and motivations. A study conducted by Cowden, Cummings and Profetto-Mcgrath (2011) on whether the style of management can persuade staff nurses to resign offers some interesting insights. Note that as with medical specialists, a shortage of nurses is expected for the coming years. From the research it can be concluded that the behaviour and style of management influences the decision of nurses whether to stay or to leave the organization. A transformational leadership style was more positive, in that it made the nurses have a greater intention to stay in the organization while on the other hand, task-focused leadership styles, e.g. management by exception, made the nurses more likely to leave the organization. A focus on the personal needs of the staff nurses will improve the probability that the staff nurse is likely to stay. Also important is a work environment in which nurses feel supported by their manager and peers, that they have autonomy in their work and that the staff nurse is recognized and valued for their effort. Moreover, the staff nurse needs to be encouraged to participate in the decision making process. In cases where these conditions were met the probability of the nurse willing to stay at the organization was higher. Once again it seems that females do prefer the transformal management style instead of the more directive style which fits more with the masculine medical specialist‘s world. This again illustrates and makes clear that females appreciate the intrinsic rewards more than financial compensation.

Other research (Tourangeau et al., 2009) stresses the importance of a good relation between nurses and their managers in the nurses‘ decision to stay or leave the organization. The nurses in this study expect that their manager is supportive and possesses strong interpersonal skills. Furthermore, the manager needs to be fair and respectful. Again, this is evidence that supports the fact that a more transformal style is appreciated. In a Swedish study (Sellgren, Ekvall and Tomson, 2006) it was investigated how nurses would like to be managed. The research focussed on what leadership style was preferred and what the nurses perceived. It is important to note that in this study the two highest valued leadership styles were the basis of transformational leadership style. The least appreciated management style was the task oriented style.

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with the motivation for working not being the pursuit of status and financial fees but more for intrinsic rewards.

4.8 Female medical specialist versus male medical specialists

There are differences between male and female medical specialists in performing their professional activities and their demands related to working conditions. Female medical specialists are more focussed on the patient. This manifests itself in the form of an open attitude for negotiation with the patient about their treatment, spending longer overall time in direct communication with the patient and facilitating greater levels of continuity of care and responding to them as equals. Male medical specialists however, are more focussed on the technical side of treating a patient (Brooks, 1998). This implies that female medical specialists are more open for communication while male medical specialists focus on producing results by treating their patient. Historically women are more communicative then men. This result in female medical specialists choosing specializations that is more people-oriented like pediatrics and male medical specialists choosing more technology-oriented specializations like surgery (Ku, 2011).

It appears that female physicians have multiple sources that can provoke stress (Robinson, 2003). These factors can be categorized as follows: (1) lack of role models, mentors, or sponsors, (2) minority status and discrimination and (3) role strain. Note that these sources are not all exclusively for females, but they are important factors that female physicians face. A short explanation about these factors is necessary. Despite the fact that the percentage of female medical specialists has been increasing over the last years and the amount of female students starting with a study in medicine is higher than the amount of men starting a study in medicine, there still exists a form of discrimination and a minority status for females. For example, despite the high percentage of women entering medical school only a very small percentage is an associate or holds the title of professor. Even taken into account the fact of motherhood or that women have less publications women are not well represented in this group. Also, women tend to earn less than their male colleagues and are less likely to advance as quickly as their male colleagues.

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feeling that they spend insufficient time on their professional or on their domestic situation. Although male medical professionals are mostly also married and have children, society accepts more or less that males are more focussed on their professional career.

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4.9 Short chapter conclusion

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Chapter 5 Analysis

This chapter combines the results that are found above and will focus on the current and desired situation.

5.1 Current situation and desired situation

Chapter three clearly establishes that managers incrementally gain more power and influence with regard to medical specialists. The medical specialist is free to perform his profession but peripheral issues like planning and controlling the budget are the responsibilities of the manager. Consequently, only medical professionals can mutually control each other in terms of job content.

Managers can only control and manage medical specialists on matters that they understand and are able to measure. Out of the four basic management controls systems, managers in the hospital setting use the result control to manage and control medical specialists. With result control medical specialists are controlled on financial targets (Pettersen, 2004). For example, medical specialists have to perform fifty stomach reductions in one year with an available budget of two million euros. Managers use a tight form of control in this situation. Which implies that the agreed objectives need to be met by the medical specialist otherwise his manager will reprimand him of her. The style of management with respect to the medical specialist is a directive style. Managers set out goals and do this primarily in a mind-set focused on obtaining financial results. As a result, these managers do not enquire about the best possible practice with every medical specialist involved. It can be stated that the medical specialist holds a key player position within the hospital setting, nevertheless their position is severely decreasing in influence.

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Also, there is a difference between female leadership and male leadership. Female leaders are more relational oriented and adopt a more transformal leadership style (Bass, 1990). Moreover, females want to be a motivator for their employees, while male leaders are more focused on results and competition, thus using a more autocratic style when determining the goals (Eagly, 2003). Assuming that if one manages their subordinates in the same way as they would like to be managed themselves, this provides a clear signal. The management style should not be directive but much more a transformal style. It is important to note that when managing females, it is important to know that females are working better when they are inspired and motivated instead of having to work competitively with their colleagues.

Studies conducted under students also measure a difference between males and females. It seems (Marini, 1996) that female students are more interested in intrinsic rewards and appreciate their work environment and congenial associates more, while male students attach more value to extrinsic rewards and responsibilities. Female students think that a democratic style works better for them, while male students think a more autocratic (directive) style suits them better (Kushel et al., 1986). This again shows that females are motivated more when their working environment is adjusted on good cooperation. The challenge for managers therefore is that they need to create a female friendly environment. Thus a hospital that manages their medical specialists purely on financial results in combination with a tight control and a manager that decides which objective needs to be met does not match with the above mentioned female preferred working conditions. The challenge will be to involve females in the decision process and offer intrinsic rewards rather than monetary incentives. Also a working environment needs to be shaped where collaboration is encouraged and fostered.

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A group of professionals which are closely related to medical professionals are lawyers. This is because the legal world can be characterized as somewhat similar with regard to gender and female professionals as the medical world. Research (Wald, 2010; Kay, 2008) in this setting also shows a difference between male and female professionals. Female lawyers state that it is hard to find the right female mentors who can guide them. Moreover, finding a balance between work and private time is difficult. Factors which need to be improved according to this group are more part-time jobs and better arrangements for childcare, allowing for better mediation between work and private-role conflict (Basick, 2006).

A second group of related professionals are the female accountants. The developments in the medical sector are not unique. Females in the accountancy world face similar difficulties. Working fewer hours is difficult to realise, also because this group prefers to work part-time to have the opportunity to take care of their households (Lyonette, 2008). A lack of female role models and the so-called old boy‘s network generate further difficulties for female accountants (Crompton and Lyonette, 2011).

A manager of female medical specialists should draw conclusions from the research in both related branches. Management should be more focussed on creating a female friendly working environment which was mentioned before. This implies also that women get more possibilities to work part-time in the hospital and that part of the management‘s task is to take care of some the specific challenges with which females are faced. Practical examples could be the employer taking care of childcare or the facilitation of more female role models. The style of management should thus be more transformal or include some elements of empowerment instead of directive management.

Research held under nurses has also produced some interesting results. Nurses are also professionals working in the medical sector and are generally female. By using a transformal style of management, nurses are willing to stay longer in hospitals than when a task-focused leadership style is applied (Crowden, Cummings and Profetto-Mcgrath, 2011). Aside from the style of leadership, the environment in which nurse‘s work is also seen as important. An environment where nurses are supported by their manager and peers is highly appreciated. Moreover, the possibility to be a part of the decision process is seen as important.

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Chapter 6 Conclusions and recommendations

This chapter will draw the conclusion and after this there will be recommendations based on the conclusions.

6.1 Conclusion

 Males and females differ in working motivations.

Throughout the whole research it becomes clear that males and females despite working in the same organisation and working in the same occupation do vary in their motivation to work. Males work primarily for status and income. Females on the other hand work for more intrinsic motivations. Females appreciate good social relationships between colleagues and their manager and look for challenges within their profession. Furthermore, females want to be more involved in the decision process concerning their profession and the organisation. However the current management control systems and tightness of the system combined with the style of management does not fit with these working motivations.

 Females face specific problems while working that males do not face.

When females are working, they face challenges that are gender specific. Firstly they feel the pressure between their domestic role and their working role. This role-conflict forces females to divide their time being at work and taking care of their domestic situation without the idea that one of these roles falls short. Females like to work fewer hours which is not always accepted and the childcare arrangements are in general not optimal. In addition to this, females lack a female mentor when working, which can guide them and introduce her to her mentor‘s network. Also, females indicate that the old boy‘s network still exists and that the working environment is still based on traditional ‗male‘ values.

 The management control system used in hospitals is not appropriate for female medical specialists

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not appropriate to control females because the assumptions that underlie this management style are a complete misfit with the working motivations of women. Consequently, the transformal style fits the female medical specialists more.

6.2 Recommendations

 Be aware of the growing need for female medical specialists in the near future From the data which was presented throughout this report it becomes clear that at least two developments are going to rapidly change the medical environment. Firstly, the demand for healthcare will increase in the coming years. Secondly, the gender distribution of medical specialists will skewer towards women, changing it into a more female profession. It is therefore important for the management in hospitals to look forward and to take the necessary steps to deal with both developments.

 Create a more female friendly working environment by changing the management control systems

The above mentioned developments demand action. Importance should be given to adjusting the management control system to manage the medical specialists. One can still use a result control management system, but the results need to be adjusted to widen the focus, i.e. include expected results other than financial targets. Additionally, results need to be determined in consultation with the medical specialists. Furthermore, tightness of the management control should be changed. Currently, within the medical healthcare branch, the focus is on the end financial result which determines whether the medical specialist has performed satisfactory or not, this will have to change.

Objectives need to be determined in consultation with the medical specialist. Moreover, an open environment needs to be created in which communication between managers, medical specialists and eventually patients determine policy. The style of management should therefore change. Currently there is a very directive style of management, however a more transformal style or even a more empowerment style is preferred. These three changes imply that the working environment needs to be redesigned to make female medical specialists feel they work in a female friendly working place. To create such a female friendly environment one the following practical issues should be considered.

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Chapter 7 Further Research

It should be evident that some assumptions concerning the wishes of female medical specialists and their preferred management control systems were made throughout this thesis. This has been done with the intention of filling the gap of academic information and also present modest practical advice for the medical world. A logical follow-up to this research is the development of a questionnaire for medical specialists to ascertain if the assumptions in this thesis are correct. For example, medical specialists from two different departments could be interviewed. One department with primarily female medical specialists like the paediatrics and the other department with primarily male medical specialists like surgery. Other hospitals should be included to increase reliability and accuracy. The results can then be compared to the assumptions developed in this thesis.

Another idea is to develop a ‗best-practice‘ model for females in the medical world. A best practice can be explained as follows; a guideline to help organizations to adjust themselves to a recent development, like for example female professionals in this case. Nowadays, best-practice for female professionals are available for female professionals in the ICT sector or in the legal sector but not yet for the medical world. This best practice gives managers a manual to check if their organization is female friendly and also practical suggestions on how to achieve this goal. Of course this manual needs to be made in cooperation with all involved parties but specifically with female interest organisations and their members. To ensure this manual is actually used it would be wise to persuade hospitals and other medical institutions to sign it, thus proving their commitment.

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Appendix 1. Reflection

After completing my master thesis I look back at my research and it give me a feeling of accomplishment. A difficulty I encountered during my research was the lack of specific academic literature which forced me to research related subjects. I should mention that the medical world was unfamiliar territory for me and I needed some time to understand the relations between the different parties.

Besides these challenges I found it very interesting to do a research which was relevant due to the gender demographic development and the increasing demand in the future for medical specialists.

What I learned during my thesis research is that it is extremely important to keep track of all the results that I collected during my research. Fortunately I archived all the articles, search terms, mails, reports I used in my research so when I was writing my thesis this gave me a lot of time advantage.

I was already well-aware of the stress that can occur when trying to combine full time research with a demanding job. However with the time available I look back with a feeling of satisfaction.

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Appendix 2: Information sources

As mentioned in the thesis, it was difficult to obtain information about the research subject with regard to the gender aspect. The sources consulted during the investigation are documented and can now be viewed.

The sources can be roughly split up into nine separate groups. This information overview is certainly not intended to impress or to brag about it but gives an idea of the different persons and organisations that were approached.

14 Books:

 Bass, B.M. & Stogdill‘s. (1990). Handbook of leadership, theory Research & Managerial Applications. New-York. Free Press.  Chafetz, J.Z. (1990).Gender Equity, An Integrated Theory of

Stability and Change. Sage publications. 1990.

 Crom, B. (2005). De invloed van externe budgetparameters op de interne budgettering van academische ziekenhuizen, verklaringen voor verschillen in budgetteringssystemen en hun effecten. Ridderkerk. Uitgever Labyrint Publication.

 Demenint, M.I. & Disselen, C.E. (1992). Vrouwen, leiderschap en management. Utrecht. Uitgeverij Lemma BV.

 Due Billing, Y. & Alvesson, M. (1994). Gender, managers, and organizations. Berlin; New York: De Gruyter

 Fine, C. (2011). Waarom we allemaal van mars komen. Hoe neurosksisme aan de basis ligt van de verschillen tussen man en vrouw. Tielt. Uitgeverij Lannoo.

 Kimmel, M.S. (2004) The gendered Society. Oxford. Oxford University press.

 Hofstede, G. & Hofstede, G.J. (2007). Allemaal

andersdenkenden, omgaan met cultuurverschillen. Geert Hofstede en Gert Jan Hofstede. Amsterdam / Antwerpen Uitgeverij Contact.

 Ledwith, S. & Colgan, F. (1996). Women in organizations, challenging gender politics. Macmillan Business.

 Mediforum. (2010). Medisch Specialistische zorg 2010. Mediforum te Alkmaar.

 Merchant, K.A. & Stede, W.A. van der. (2007). Management Control Systems, performance measurement, evaluation and incentives. London. Prentice Hall.

 Meijer, G.R. & Heesen, B.J. Medisch specialist in perspectief, een visie op de toekomst van de medisch-specialistische zorg  Mintzberg, H. (1993) Structure in fives, Designing effective

organizations. Upper Saddle River, N.J, Prentice Hall.  Orde van Medisch specialisten. (2008). Individueel

Functioneren van Medisch Specialisten, persoonlijk beter. Utrecht.

Approached organizations who had no further information

 Aletta, Instituut voor vrouwengeschiedenis;  Centre for Gender and

Diversity.

 KNMG;

 Nederlands Genootschap Vrouwenstudies;

 Research department from UMCG;

Approached persons who had no further information  Besnschop, Y. (Ru Nijmegen)

specialised in gender and organisations

 Broekhuis, M. (RUG), specialised in among other management and health care  Engen, M.L. van. (Tilburg

University), specialized in gender and organizations  Klinge, I. (Maastricht

University), specialised in Gender Medicine  Largo-Janssen, T. (Ru

Nijmegen), specialised in gender studies medicine  Meer, P. van der. (RUG),

specialized in labour market and HRM

 Ryan, M.K. (Exeter, UK), specialised in HRM & OB  J. Stoker (RUG), specialised in

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Appendix 1: Information sources (2)

The interviews, both personal and by telephone, were very interesting. Despite their background and position none of the interviewees had any idea if the change of gender influences the management control system. In fact, almost no one had even thought about the idea that a different gender wants a different management control system. Without almost any exception, every interviewee thought the research was very interesting and I had to promise to send a copy of the thesis when it was finished. The reports and websites were interesting but did not answer the research question.

Telephonic interviews:

 Heiligers, expert in work & women and gender

 Pas, PhD candidate on subject women in organizations  Vogelpoel, medical

professional and chair member of VNVA

 Winants, Med Doctor and Phd expert in gender studies

Personal interviews:

 Heesen, B. Director of Orde van Medisch Specialisten.  Meegdes, J. Senior advisor at

Capaciteitsorgaan  Molleman, E.H.B.M.

Specialized in HRM and Organization Behavior (RUG)  Sebille, M. van. HRM at

UMCG

 Quispel, C. Specialised in gender and leadership (RUG)

Reports:  Deelrapport 1 Medisch

Specialisten from the Capaciteitsorgaan about 2010.  Dissertation from Phd Winants

Articles:

Used the following seven search machines: Scopius, Web of Science,

Picarta, Scopius, Purple Search, Science Direct and Google Scholar. Search on 30 search terms. Scanned about more than 400 articles and actually useful articles for this thesis

were 27 articles.

Fully read journals:

 Gender, work and organization  International journal of health

planning and management  Journal Gender in Management  Journal of health, organization

and management  Journal of work and

occupations

 National Health support  Vakblad Nederlands Tijdschrift

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Brooks, F. (1998). Women in general practice: responding to the sexual division of labour? Social Science Medicine. Vol. 47, No. 2, pp 181-193.

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The influence of gender of the medical specialist on the use of management control systems in hospitals