University of Groningen
Through the physician’s lens. A micro-level perspective on the structural adaptation of professional work
Gifford, Rachel
DOI:
10.33612/diss.172180526
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Publication date: 2021
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Gifford, R. (2021). Through the physician’s lens. A micro-level perspective on the structural adaptation of professional work. University of Groningen, SOM research school. https://doi.org/10.33612/diss.172180526
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171 Summary
In recent years, due to increasing pressures on already strained healthcare systems, many western countries have initiated further system reforms, increasingly introducing market forces into healthcare in order to control costs and create incentives for greater quality. The policy agenda has focused primarily on reforms in the areas of payment and system delivery in order to achieve the goals of efficiency, transparency, quality and cost effectiveness. Yet, the question of how can we best organize and incentivize healthcare professionals to achieve health system goals remains an open empirical question that is often difficult to answer in practice.
Our3 micro-level approach to the study of structural adaptation brings forward an often-overlooked perspective, that of clinicians themselves, in response to ongoing
environmental pressures. This approach has helped us to reveal important micro dynamics that influence the way in which physicians perceive, interpret and subsequently act upon these pressures and in response to adaptations in their work. In particular, we examine ongoing pressures towards physician payment reform and the reorganization of care delivery and examine three empirical cases where these pressures manifested in structural adaptations in the organization of physicians’ work.
In each chapter we showcase potentially negative, and unintended, effects of these structural adaptations that result from a lack of attention to the micro-level dynamics at play, such as sensemaking processes (Ch. 2), the expression of professional values (Ch. 3),
intergroup relations (Ch. 2, 3, 4) and the formation, maintenance, and policing of
intra-professional boundaries (e.g., across physicians from different specialties) (Ch. 4). All studies included in this dissertation explore complex and nuanced phenomenon that required an
3 While this thesis is my original, work, all empirical chapters are the product of teamwork and I therefore
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exploratory and in-depth approach. This has allowed us to offer a more granular view to ongoing reform efforts, and can offer nuanced insights to the issue of physician and secondary care organization. The use of a wide range of in-depth qualitative interviews with key
stakeholders in healthcare (Ch. 2, 3, 4), document analysis (Ch. 2, 4), and a mixed method design (Ch. 3) has allowed us to approached our core research question in a rigorous way that helps to instill confidence in our findings.
Scientific foundation
The three studies presented in this thesis offer an important micro-level view of how professionals respond to environmental pressures and disruptions in their daily work. We have opened up our theorizing to help understand how, and why, physicians respond to structural adaptations in their work in particular ways. First, in chapter 2 and 3, we explore the
increasing pressures on payment reform and the pursuance of tighter forms of hospital-physician integration. Secondly, in chapter 4 we explore how hospital-physicians respond to
integration efforts and the reorganization of their work. Here we zoom in on the professional level of integration between interdependent but segregated professionals to unveil the unique barriers that exist to integration in care delivery processes. We uncover the existence of structural, interpersonal and cultural boundaries and demonstrate how these boundaries are created, reinforced, and overcome in daily practice. We also find that these barriers all uniquely influence care delivery processes, for example by delaying patient flow and speed.
The institutional context influences how providers respond to reform
In chapter 2, we examine the responses of medical specialists to a budgetary reform that resulted in the creation of new organizational forms and modes of hospital-physician governance. The reform was initiated by the government (2015) and aimed at aligning the interests of physicians and hospitals, as well as economically integrating them with the
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organization. We carried out an exploratory case study in two large general hospitals in the Netherlands to gain in-depth insights into the process and outcome of this reform. We employ a sensemaking frame to examine the process of medical specialists in responding to pressures towards employment and show how institutional tensions play a core role in the way in which medical professionals interpret and ultimately respond to governmental targets. By examining the sensemaking process of professionals in response to this reform, we uncover how traditional ways of organizing have become connected to core professional values and dominant institutional logics. The dominant logics in the field include medical professionalism, and what has been described as a managerial or business-like logic, with increasing managerial oversight and control, and a focus on cost targets and efficiency.
When modes of practice become connected to core values of the profession (such as autonomy and self-regulation) and institutional logics, policies aimed at reforming these practices can function as a significant disruption, bringing tensions to the surface and
triggering threat perceptions. By not accounting for the institutional context and the embedded norms, values and practices that existed within the field, policymakers initiated a reform that fundamentally altered the relations between physicians and organizations. The reform triggered the creation of new organizational forms (medical specialist companies, MSBs) which resulted in the concentration of power of self-employed medical specialists. As a result, the field has now been transformed in new and unexpected ways, with significant
consequences at both the organizational and field level. Although the reform aimed at
bringing medical specialists and the hospital organization closer to each other, the final result was opposite to this. Our findings offer insights into how professionals respond to disruption in more complex fields and highlights the centrality and importance of interpretive and relational processes for both field stability and successful change.
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In chapter 3 we expand upon our first study and alternatively consider the process and outcomes of medical specialists becoming employees of a hospital organization. The
employment of physicians has been debated in recent years, with increased pressure on further [economically] integrating clinicians into the hospital. Trends towards the economic integration of physicians and physician practices into hospital systems has been growing and physician employment is seen as a way to further address the issue of rising costs and
improve quality. With increasing pressure on eliminating production incentives and increasing numbers of physicians becoming employees of hospital systems, it is important to consider the effects of moving physicians to employment contracts. In this chapter we conducted a mixed-method study at one medium sized hospital in the Netherlands. We employed an exploratory sequential design, beginning with 21 qualitative interviews with medical specialists. Building upon the emergent insights, we then designed a small online survey to further explore emergent insights within the organization. Here we consider what the effects are of moving physicians away from production incentives and towards more bureaucratic modes of control (e.g., salaried employment) by economically integrating them with the hospital.
We examine effects of employment on physicians in three domains: patient care (physicians treatment behaviors and approach to care delivery), the individual domain (professional values, job satisfaction) and the organizational domain (hospital-physician relations including organizational identification and trust). Focusing on core professional values and broader institutional tensions, we add important empirical evidence to the ongoing debate regarding physician payment and governance and shed light on the mixed-results that currently plague the literature on physician employment. Our findings indicate the importance of reconsidering our current approaches to payment reform by putting more emphasis on the distinction between employment status (e.g., self-employed or employed) and payment
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method (financial incentives). We again unveil, and emphasize, the importance of considering the effects of organizational models on core professional values and professional relations.
Rethinking professional integration
Due to clinical and technological advances, healthcare delivery has become increasingly differentiated, creating boundaries not only across different professions and professional groups (e.g., nurses and doctors, social care and clinical care) but also within the same professional group (e.g. physicians across different specialties ). This can create
challenges to care delivery processes, particularly when multiple professionals are involved and share responsibility for optimizing patient flow. However, it is not clear how boundaries come to directly influence integration efforts or care processes and performance. In chapter 4 we carried out a case study to explore how physicians respond to internal reorganization and integration efforts. We examine a case of emergency care reorganization, focusing on uncovering the unique barriers to integration between professionals in emergency care delivery.
In our case organization, medical specialists [partially] responsible for emergency care delivery were physically co-located on the emergency department during peak hours. We conducted on-site observations and interviewed 28 emergency physicians and medical specialists over an 18-month period (beginning, middle and post reorganization). Here we focus on revealing barriers to intra-professional integration (between members of the same profession), offering insights into the mechanisms that inhibit integration within hospital care. We also explore how these mechanisms come to impact care delivery processes, namely patient flow and speed. We combine the professional literature on boundaries with the literature on supply chain integration to understand how integration functions at this level. Our findings reveal the existence of structural, interpersonal and cultural boundaries between physicians across different specialties. We see that integration between professionals requires
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strategies to overcome interpersonal and cultural barriers, such as approaches to work, competence-based trust, and status hierarchies. We also unveil why integration efforts fail or may result in backlash and offer important insights for organizations in their implementation of integration efforts.
Conclusion
The three studies presented in this thesis have helped us to open up the way in which we think about the [re]organization of professional work, and in particular have helped us to understand the responses of physicians to structural adaptations in their work. By taking a micro-level view, we have offered insights into how physicians perceive, interpret and attach meaning to these adaptations and how these meanings ultimately spur action that has
important consequences for the field more generally. Our studies indicate the need for more attention to the relational and cultural dynamics when considering the organization of work. While structural adaptations may serve as an initial catalyst for further progress, in and of itself, structural adaptation fails to address the need for real behavioral change.
These studies have helped us to open up the way in which we view professional resistance to employment by allowing us to reveal the true meaning of self-employment for independent physicians. In chapter 2 we show how this practice has become institutionalized and connected to local notions of professionalism for physicians who have traditionally operated in their own private practices. While salaried physicians continue to exercise considerable levels of clinical autonomy, for many self-employed physicians it became clear that employment practices were seen as a means to protecting their clinical autonomy and service the common good, preserving their commitment to society by providing the best care to patients without external control. Creating a shield against what was perceived as the increasing power of banks, insurers and organizations over the way in which physicians structure and carry out their work, self-employment symbolically became seen as ‘the last
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bastion’ against an increasingly dominant business-like logic, where care quality is assessed by cost and non-medical experts dictate how to provide patient care. When a governmental reform threatened this practice, it disturbed the former institutional settlement between medical professionalism and the business-like logic. We show how the way in which
physicians perceived and attached meaning to the reform was influenced by the institutional complexity in the field, and how their interpretations led to the creation of new organizational forms (MSBs) that ultimately had significant consequences for the field. These outcomes are, at least partly, the opposite of those the reform aimed at.
Opening up our understanding of how physicians construct meaning and attach it to practices allows us to provide a clearer picture of issues, from the ground up. In particular, our findings in chapter 2 led us also to a second key insight in chapter 3, about the importance of disentangling employment status from payment reform. With trends and increasing pressure to (economically) integrate physicians and hospitals, and with increasing administrative pressures and burdens on physicians, there are more and more physicians becoming
employees of hospital systems. However, our study in chapter 3 revealed the importance of parsing out the move away from production-based incentives and the move to employment. We revealed primarily positive effects for physicians in terms of moving away from
production incentives, but negative effects of the move into hospital employment. To understand how negative effects can be minimized, we must also consider the source of negative effects. Conflating these dimensions may overshadow important dynamics and effects in different domains, and may also explain the continued mixed results found in the current literature. Our study offers a foundation for future research to continue to explore this issue and account for effects in multiple domains across more diverse organizational and cultural settings.
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Lastly, our study in chapter 4 has helped us to reveal the influence of relational and cultural dynamics on care delivery processes and integration efforts. We have revealed the existence of professional boundaries between physicians who share mutual responsibility for care delivery, and show how these boundaries are perceived to directly and indirectly
influence processes of care, influencing patient flow and reducing speed. Our findings have helped us to highlight the importance of studying supply chain integration at the level of individual professionals and point to the unique nature of professional service contexts and other settings where professionals hold unique knowledge and play a central role in the supply chain. Despite a structural adaptation that attempted to achieve better integration in the
emergency care chain, integration at the level of professionals (e.g., between medical specialists and emergency physicians), remained difficult, and in some cases became more challenging. This highlights the importance of considering the impact of integration at various levels (cultural, relational), potentially expanding our current notions of supply chain
integration.
Taking a micro-level view and incorporating scientific insights from multiple fields (healthcare management, psychology, sociology, supply chain management) we believe our study has helped to further our understanding of the issues currently facing healthcare reform. We have offered unique insights into how physicians interpret, respond to and the effect of environmental pressures, and believe that the findings presented here can help policymakers and researchers alike to continue to unpack the complex issue of secondary care organization. In particular, we raise critical questions about the need to further tease out the effects of payment and employment status when enacting payment reforms. As we have shown, professionals may be willing to move away from production-based incentives, but threat responses may be triggered when their employment status is challenged by reforms. Further research can help to unpack the effects of reform and consider alternative models by
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separating these. Secondly, we also highlight the need for a more system level approach to payment reform; while most attention has been on reforming physicians’ incentives,
incentives at a higher level (organizational funding, insurance contracts) remain largely based on volume and cost rather than quality. Reforming physicians’ payment may do little to meet health system goals unless incentives at these other levels are also reformed. Lastly, our research has indicated that integration at the level of professionals [and in professional service firms more generally] requires more attention to relational and cultural dynamics. While supply chain integration includes considerations of relational dynamics such as trust and commitment, this is often theorized at the firm or subunit level, and overlooks the unique boundaries and antecedents that exist at the level of individual supply chain actors. We show here how unique boundaries at the level of professionals restrict supply chain performance, and how structural adaptations are only a stepping-stone for the more intensive work of relational and cultural change needed to achieve true integration at this level. This thesis therefore highlights the importance of taking a micro-level view when designing,
implementing and assessing structural reforms, and uncovers important micro-dynamics that influence how physicians perceive, interpret and ultimately respond to environmental
