Doctor's Orders: Shifting Power Relations in the Practice of Medicine in a US Hospital

Aim/research question “Every shift in power brings a change in our ideas and ideals. The connection between shift of power and revaluation of interests must be carefully studied. Society should be so organized that standards... [ view full abstract ]

Aim/research question

“Every shift in power brings a change in our ideas and ideals. The connection between shift of power and revaluation of interests must be carefully studied. Society should be so organized that standards and power evolve together; social tragedy comes when they are in different hands”. (Follett, 1924, p. 194)

            Dramatic shifts in the way health care and related health care services are delivered and managed in the United States are unfolding at an unrelenting pace. Concurrent with ongoing changes in United States’ delivery of medicine, some argue that traditional notions of power are undergoing an equally transformative shift (Mintzberg, 2015; Naím, 2013). The confluence of the emerging reconsideration of the role of power in our society and organizations along with the dramatic changes in the American healthcare system provided a fertile backdrop and context for this study of power.

At the center of this transformation, the physician maintains a unique and “very special position” in the hospital setting (Freidson, 1970). In light of the dramatic changes that have occurred in the delivery of medicine in the United States over the last several decades, the purpose of this study was to investigate the nature of physician power within the context of the practice of medicine. Specifically, we explicated how exogenous and endogenous factors, such as deprofessionalization and the corporatization and proletarianization of medicine and the ACA, altered physician conceptualizations of power and the exercise of such power in the ongoing practice of medicine. The study addressed one primary research question:

RQ:      How do physicians conceptualize their exercise of power, autonomy, and control in their day-to-day interactions in the practice of medicine?             

Design/methodology/approach  

Grounded theory forms the methodology for this study. We employed a specific form of grounded theory research, the constructivist form, which emerged in the 1990s as a reaction to the heavily positivist influence of Glaser, Strauss, and Corbin (Charmaz, 2015).

We used purposeful sampling to identify 24 physicians from a single independent, nonaffiliated, private, community-based hospital located in the mid-Atlantic region of the United States. Working collaboratively with the chief medical officer of the hospital and hospital leadership, we identified potential participants who had experience with the phenomenon of power and occupied roles in the hospital that could contribute in meaningful ways to our research. We sought a diverse sample both demographically and professionally.

We interviewed participants using an intensive interview approach, following a semi-structured interview protocol with open-ended questions.  Interviews were audio recorded and transcribed, and coded with ATLAS.ti

Data were analyzed through both memo writing and coding. Memo writing allowed exploration and investigation of ideas throughout the research process. Both initial and focused coding were completed, involving constant comparative methods. Techniques to ensure trustworthiness included prolonged engagement, member checking, and triangulation.

Findings  

We find physicians at MedHealth chose to conceptualize their exercise of their power, autonomy and control unitarily. Physicians in all three participant groups at MedHealth (surgeons, pediatricians and others) conceptualized a significant loss of power, autonomy, and control, in the practice of medicine. Additionally, physician conceptualizations of their exercise of power, autonomy, and control in the practice of medicine are shaped and fashioned by micro, meso, and macro level interactions.

            We present a theoretical model in an effort to gain a richer appreciation of how physicians at MedHealth conceptualize their power, autonomy, and control (PAC). We argue a reconceptualization of their PAC is necessary given the transformative changes to the US healthcare model. Last, we offer numerous recommendations spanning theoretical, practice, policy issues, and areas for future research that emerged from this research project.   

Research limitations/implications

One fact that contributes to the limited generalizability of this study is the nature of the research site. MedHealth is an independent, nonaffiliated, private, community-based hospital located in the mid-Atlantic region of the United States. It is a 350-bed facility serving a diverse range of communities in a large metropolitan area with a large staff of hospital-based physicians (hospitalists) and private physicians who practice medicine. There are four additional characteristics of MedHealth that may differentiate it from other hospital settings.

First, the hospital is situated in a wealthy suburban area. This may have an impact on a number of the findings of the study. Other hospitals may not have the same level of community support and perhaps more importantly access to the same level of resources. Another factor worth considering is the composition of the physicians who have chosen to work at a hospital such as MedHealth. The training and experience levels of the physicians who work at MedHealth was quite extraordinary and may not be representative of other hospitals. MedHealth’s ability to recruit highly qualified and accomplished physicians may be greater than other hospitals. Additionally, MedHealth was recently recognized as a teaching hospital. Physician composition at teaching hospitals may be significantly different from those at non-teaching hospitals. Together these limitations may impact the generalizability of the interpretations and conclusions of this study but do not diminish their importance.  

Practical implications 

There are three areas of practice that our findings suggest may be helpful for hospitals and those directly involved in healthcare to consider.              

• Hospital healthcare administrators should seek to improve the ways they integrate technology into the delivery of healthcare with the goal of enhancing rather than disrupting physician and provider relationships and quality of service.
• Hospital leadership teams should expand their efforts to assure the voice of the physician at all levels of the organization is sought out, valued, and clearly heard on all matters related to the delivery of patient care.
• Medical school curricula and ongoing physician training and development programs should continue to be revised to include additional leadership, communication, change management and team management training for physicians, reflecting those skills demanded by new healthcare delivery models.

Social implications

Research and theory development to determine how positive or coactive power is exercised in the modern organization, and especially in hospitals, is important for several reasons. First, as noted, there is a dearth of literature and theories that specifically address this question. Additional research has the potential to provide a significant contribution to the body of knowledge on organizational power. This is particularly true in terms of research on physicians and their understanding and exercise of power in the day-to-day interactions of their workplaces (Collin, Sintonen, Paloniemi, & Auvinen, 2011).

            Second, and perhaps most importantly, Naím’s (2013) treatise provided fertile ground for a reemphasis on power and, especially, the positive effects of power in organizations. The longstanding view that power is inseparable from politics, and politics is merely an inappropriate use of power, must be contested. Power can be a positive force in modern organizations if organizations and their leaders learn the nuances of exercising it in a positive manner and if they can conceptualize power in a manner that is “not the organization’s last dirty secret” but rather “the secret of success for both individuals and their organizations. Innovation and change in almost any arena requires the skill to develop power and the willingness to employ it to get things accomplished” (Pfeffer, 1992, p. 49).

            Third, situating this study in the context of a hospital is timely and significant. The recent passage of the ACA has altered and changed the landscape of the delivery of health care in the United States (Blank, 2012; Doonan & Katz, 2015; Lanford & Quadagno, 2015). The way physicians respond to these changes is critical to the ultimate outcome and success of the ACA, a macro institutional event that has altered the face of medicine and specifically impacted the professional identity, autonomy, and power of physicians. Karagiannis et al. (2014) argued, “With little empirical evidence suggesting otherwise, we feel policy makers are underestimating the magnitude of physician acceptance as a barrier to practice transformation” (p. 94). A better understanding of how physicians choose to respond to and exercise their power, autonomy, and control in managing the evolving relations with health care administrators, other physicians, nurses, insurance companies, and their patients can provide valuable physician insights into the changing practice of medicine.

Originality/value  

Freidson (1970/1988), recognized that “virtually all types of medical practice in industrialized societies include within them systematic accommodations to hospitals” (p. 110). Twenty-five years later, Turner (1995) noted that the role of hospitals in the delivery of American medicine had expanded. “The hospital is a crucial institution within modern systems of health care, but it is also symbolic of the social power of the medical profession, representing the institutionalization of specialized medical knowledge” (Turner, 1995, p. 153). The confluence of the emerging reconsideration of the role of power in our society and organizations along with the dramatic changes in the American healthcare system provides a fertile backdrop and context for the study of power. Most importantly, the voice of the physician, which has gone largely unheard in this transformation, is given voice in this study.