Medical Dominance and the continuing robustness ofprofessional cultures in healthcare. Dr Mark Bahnisch 7 August 2012 CMEDRS/DME ‘Research Rap’
ContextsFRENK, J., CHEN, L., BHUTTA, Z., COHEN, J., CRISP, N., EVANS, T.,FINEBERG, H., GARCIA, P., KE, Y., KELLEY, P., KISTNASAMY, B., MELEIS,A., NAYLOR, D., PABLOS-MENDEZ, A., REDDY, S., SCRIMSHAW, S.,SEPULVEDA, J., SERWADDA, D. & ZURAYK, H. 2010. Healthprofessionals for a new century: transforming education to strengthenhealth systems in an interdependent world. The Lancet, 376, 1923-58.“100 years ago, a series of studies about the educationof health professionals, led by the 1910 Flexner report,sparked groundbreaking reforms. Through integrationof modern science into the curricula at university-basedschools, the reforms equipped health professionalswith the knowledge that contributed to the doubling oflife span during the 20th century.
“By the beginning of the 21st century, however, allis not well. Glaring gaps and inequities in healthpersist both within and between countries,underscoring our collective failure to share thedramatic health advances equitably. At the sametime, fresh health challenges loom. New infectious,environmental, and behavioural risks, at a time ofrapid demographic and epidemiological transitions,threaten health security of all. Health systemsworldwide are struggling to keep up, as theybecome more complex and costly, placingadditional demands on health workers.”
“Professional education has not kept pace with these challenges,largely because of fragmented, outdated, and static curricula thatproduce ill-equipped graduates. The problems are systemic: mismatchof competencies to patient and population needs; poor teamwork;persistent gender stratification of professional status; narrow technicalfocus without broader contextual understanding; episodic encountersrather than continuous care; predominant hospital orientation at theexpense of primary care; quantitative and qualitative imbalances in theprofessional labour market; and weak leadership to improve health-system performance. Laudable efforts to address these deficiencieshave mostly floundered, partly because of the so-called tribalism ofthe professions—ie, the tendency of the various professions to act inisolation from or even in competition with each other.”[Emphasis mine]
Caveats and comments• Research I am doing, and am hoping to do rather than research I have done• But note potential to re-analyse data from completed study• Literature has been approached systematically but not yet comprehensively• Ability to realise research design would be dependent on funding, opportunity – choices framed to take this into account• I am presenting to discuss ideas, research design, methods, get feedback
Medicine and the sociology of professions and of medical education• An ideal-typical case• Structural-functionalism and Parsonian sociology – searching for what typifies a profession, expert knowledge and the professional hierarchy and division of labour (Emile Durkheim, Max Weber)• Normative assumptions• Eliot Friedson (1970) Profession of Medicine – closure theory – But did Friedson really say what he has been said to say?• Studies of ‘negotiated order’ (notable is STRAUSS, A., SCHATZMAN, L., BUCHER, R., EHRLICH, D. & SABSHIN, M. 1963. The hospital and its negotiated order. FRIEDSON, E. (ed.) The Hospital in Modern Society. New York: Free Press.• Studies of the formation and reproduction of student professional cultures (Merton et al 1957 The Student-Physician from a Parsonian perspective, Becker et al 1961 Boys in White: Student Culture in Medical School from a symbolic-interactionist perspective)
‘Medical Dominance’• Evan Willis – 1983, 1989; Revisited in 2006 special issue of the Health Sociology Review (cf particularly COBURN, D. Medical dominance then and now: critical reflections. Health Sociology Review, 15, 432-433.)• Willis (1989:2-3) posited three axes of ‘medical dominance’ – Autonomy (“over its own work”) – Authority (“over other health professions”) – Sovereignty (“dominant in relations between the health sector and the wider society”)• Willis’ method – historical case studies (midwifery, optometry, chiropractic – subordination, limitation, exclusion)• Implicit but not really theorised here was a dynamic and more complex historical and social interaction than the simple exercise of power or authority (different concepts)• Too much structure, too little agency?• Problems of typification?
Research problem• Institutional and cultural resilience and embeddedness may not have been given adequate weight in shifting educational, organisational and policy agendas towards ‘interprofessional practice’.
Why is this important?• There often seems to be an assumption that ‘medical dominance’ is a ‘bad thing’• Some sociological insights about the individual focus or orientation of medical work as compared to ‘shaping’ institutions may have a lot to tell us about the circumstances under which IPP is or is not desirable and is or is not realisable• Do we really know that much about ‘the hidden curriculum’? And/or how professional cultures are reproduced?
Research questions• How are the dynamic boundaries of medical authority reproduced in educational, institutional and organisational cultures?• What implications are there of the cultural reproduction of medical authority for education and public policy?
The erosion of medical dominance?• General erosion of professional autonomy vis a vis control or monopoly over knowledge• ‘Neo-liberal’ governance – CURRIE, G., FINN, R., MARTIN, G. 2009. Professional competition and modernizing the clinical workforce in the NHS. Work, Employment & Society, 23, 267-284.• Agendas such as ‘patient centred care’, ‘interprofessional practice’
But…• Erosion of professional autonomy over knowledge – The other side of micro-studies about ‘dominance’ in consultations. – Macro-social theorising – meta-observation or the received wisdom of liberal academic elites? – ‘Dynamic professional boundaries in the healthcare workforce’ NANCARROW, S. A. & BORTHWICK, A. M. 2005. Dynamic professional boundaries in the healthcare workforce. Sociology of Health & Illness, 27, 897-919. – Negotiated orders as such are not new.
• ‘Neo-liberal’ governance – How strong is the state and how to what degree is state power if not authority contested through inertia, folkways, ‘how things are done here’ ie – professional and institutional cultures? – Following on from this, how about the power of interest groups and the field of policy interaction? We could look for instance at the journey of the National Health and Hospital Reform Plan through inception to ‘local hospital boards’ under the LNP government in Queensland. – NATIONAL HEALTH AND HOSPITALS REFORM COMMISSION 2009. A healthier future for all Australians: Final report of the national health and hospitals reform commission. Canberra, ACT: National Health and Hospitals Reform Commission. – Additionally, can the evidence that ‘managerialism’ and ‘teamwork’ are subverted in some contexts by professionally-bound cultural strategies be generalised? – FINN, R., LEARMONTH, M. & REEDY, P. 2010. Some unintended effects of teamwork in healthcare. Social Science & Medicine, 78, 1148-1154.
• Patient-centred care/IPP – The continued resilience of professional cultures, and particularly how these are reproduced and lived institutionally. – HALL, P. 2005. Interprofessional teamwork: Professional cultures as barriers. Journal of Interprofessional Care, May 2005, 188- 196. – The sustainability of IPP initiatives and their sustainability in the absence of a ‘good’ doctor – WHITEHEAD, C. 2007. The doctor dilemma in interprofessional education and care: how and why will physicians collaborate? Medical Education, 41, 1010-1016.
Then or now?• STRAUSS, A. 1971 ‘Psychiatrists in a Private Hospital’ and ‘The Nurses at PPI’ in Professions, Work and Careers. San Francisco: The Sociology Press.• FINN, R. 2008. The language of teamwork: Reproducing professional divisions in the operating theatre. Human Relations, 61, 103- 130.
Hypothesis• The relative failure of many IPP initiatives is caused in part by the resilience of professional medical culture in institutions. – BOURGEAULT, I. & MULVALE, G. 2006. Collaborative health care teams in Canada and the USA: Confronting the structural embeddedness of medical dominance. Health Sociology Review, 15, 481-495.
Research design: How would we measure this?• RIPLS – MCFADYEN, A., WEBSTER, V. & MACLAREN, W. 2006. The test-retest reliability of a revised version of the Readiness for Interprofessional Learning Scale (RILPS). Journal of Interprofessional Care, 20, 633-639. – Critique in THANNHAUSER, J., RUSSELL-MAYHEW, S. & SCOTT, C. 2010. Measures of interprofessional education and collaboration. Journal of Interprofessional Care, 24, 336-349.• What is the independent variable?• What is the dependent variable?
Another way of measuring/conceptualising• Not what has happened but what has not happened – GREENFIELD, D., NUGUS, P., TRAVAGLIA, J. & BRAITHWAITE, J. 2011. Factors that shape the development of interprofessional improvement initiatives in health organizations. BMJ Quality and Safety, 20:332-337. – NUGUS, P., GREENFIELD, D., TRAVAGLIA, J., WESTBROOK, J. & BRAITHWAITE, J. 2010. How and where clinicians exercise power: interprofessional relations in health care. Social Science & Medicine, 71, 898-909.• Continuities rather than fractures• Ie – findings from – ACT IPE/IPL Study – NUGUS, P., GREENFIELD, D., TRAVAGLIA, J. & BRAITHWAITE, J. 2011. Action research for interprofessional learning and interprofessional practice in ACT Health. Paper presented to the University of Queensland Centre for Clinical Research. – Wide Bay IPE/IPP Study
Case studies…• Case selection• Within case variation• Ethnography• Phenomenology• Discourse analysis
Replication and a longitudinal or cross- sectional study…• The American and UK literature contains rich studies of the reproduction of professional cultures in medical education• Recency?• Cross-national replication and/or longitudinal or cross-sectional study• Mixed methods
Implications for sociological theory• Back to the foundations – ie ‘Rules of Sociological Method’; grounding macro-theory• Questioning some of the normative or ideological assumptions underpinning sociological theory which may themselves be reflections in part of contests over/within social facts• Incorporating historical sociology into health/medical sociology and public policy studies – contribution to method
Implications for medical education and public policy• ‘Barriers’ to IPP/Patient-centred care may be much more rigid than thought – the lack of malleability might lie in culture/s• A better evidence base for ‘the informal curriculum’• An ability to assess ‘what works’ – under what conditions is ‘medical dominance’ a good or a bad thing? Or is this a poorly framed question? (Ie professional expertise/specialisation and clinical reasoning within particular contexts of care) – links into the competency agenda