Pieter Degeling

Medicine, management, and modernisation: a “danse macabre”?

To break their destructive antagonism over issues of health service modernisation, doctors and managers should engage more directly with nursing and allied health professionals when responding to reform initiatives

'It's an Interesting Conversation I'm Hearing': The Doctor as Manager

The aim of this article is to outline in discursive-linguistic terms how doctor-managers (or ‘physician-executives’ as they are termed in the USA) manage the incommensurate dimensions of their boundary position between profession and organization. In order to achieve this we undertook a discourse analytical study of both recorded, situated talk and open interview data focusing on one doctor-manager navigating between profession and organization. The doctor-manager at the centre of this study locates himself on the boundary of at least three discourses which, in many respects, are incommensurate. These are the profession-specific discourse of clinical medicine, the resource-efficiency and systematization discourse of management, and an interpersonalizing discourse devoted to hedging and mitigating contradictions. While this multi-vocality in itself is not surprising, data show that the doctor-manager positions himself across these discourses and manages their inherent incommensurabilities before a heterogeneous audience and on occasions even within the one utterance. In this particular case, boundary management is achieved by weaving incommensurable positions together into the social and linguistic dynamics of a single, heteroglossic stream of talk. This highly complex and dialogic strategy enables the doctor-manager to dissimulate the disjunction between his reluctance to impose organizational rules on his medical colleagues and his perception that such rules, in the future (to some extent at least), will be the appropriate means for managing the clinical work, and through that the organization.

Making clinical governance work

The current focus on quality and safety means most doctors have negative views about clinical governance. But done properly, clinical governance has the power to improve NHS performance

The professional subcultures of students entering medicine, nursing and pharmacy programmes

This study sought to determine the attitudes, beliefs and values towards clinical work organization of students entering undergraduate medicine, nursing and pharmacy programmes in order to frame questions for a wider study. In the Faculty of Medical and Health Sciences, The University of Auckland students entering medicine, nursing and pharmacy programmes completed a questionnaire based on that used by Degeling et al. in studies of the professional subcultures working in the health system in Australia, New Zealand, England and elsewhere. Findings indicate that before students commence their education and training medical, nursing and pharmacy students as groups or sub-cultures differ in how they believe clinical work should be organized. Medical students believe that clinical work should be the responsibility of individuals in contrast to nursing students who have a collective view and believe that work should be systemized. Pharmacy students are at a mid-point in this continuum. There are many challenges for undergraduate programmes preparing graduates for modern healthcare practice where the emphasis is on systemized work and team based approaches. These include issues of professional socialization which begins before students enter programmes, selection of students, attitudinal shifts and interprofessional education.

How important are quality and safety for clinician managers? Evidence from triangulated studies

Aims to discover the work hospital clinician managers think they do and observe them in practice. A total of 14 managerial interests and concerns were identified in focus group discussions. Clinician managers’ jobs are pressurised, and are more about negotiation and persuasion than command and control. Their work is of considerable complexity, pace and responsibility and it is predicated more on managing inputs (e.g. money and people) than care processes, systems, outputs and outcomes. Thus the capacity of clinicians in these roles to respond to reforms such as those envisaged in the Bristol Inquiry may be problematic. Qualitative studies are re‐affirmed as important in providing grounded insights into not only clinical activities, but also organisational behaviour and processes.

Medical Education and Curriculum Reform: Putting Reform Proposals in Context

Abstract: The purpose of this paper is to elaborate criteria by which the principles of curriculum reform can be judged. To this end, the paper presents an overview of standard critiques of medical education and examines the ways medical curriculum reforms have responded to these critiques. The paper then sets out our assessment of these curriculum reforms along three parameters: pedagogy, educational context, and knowledge status. Following on from this evaluation of recent curriculum reforms, the paper puts forward four criteria with which to gauge the adequacy medical curriculum reform. These criteria enable us to question the extent to which new curricula incorporate methods and approaches for ensuring that its substance: overcomes the traditional opposition between clinical and resource dimensions of care; emphasizes that the clinical work needs to be systematized in so far as that it feasible; promotes multi-disciplinary team work, and balances clinical autonomy with accountability to non-clinical stakeholders. Keywords: Curriculum reform, evaluation criteria, systematization, multi-disciplinary teamwork, responsible autonomy

Changing Health Care Systems

Health care reform continues to be an international preoccupation as countries seek to square the circle of rising demand and limited resources. In the UK, and building on changes already in hand, the National Health Service (NHS) Plan is the latest attempt to engineer a new delivery system that is both patient-centred and based around the NHS as a ‘high trust’ organisation . Central to the NHS modernisation project is fashioning a new relationship between centre and periphery. The government has eschewed both the command-and-control and market models in favour of a ‘third way’ which combines centrally determined targets and monitoring with ‘earned autonomy’ for those NHS organisations able to demonstrate improved performance. As the Plan states, ‘there will be progressively less central control and progressively more devolution as standards improve and modernisation takes hold” (paragraph 6.6). A system of ‘traffic lights’ will classi@ NHS organisations each year as ‘green’, ‘yellow’ or ‘red’, with the criteria set nationally. In the words of the Plan:

The negotiated order of health care.

It is forty years since Anselm Strauss and his colleagues published this seminal paper. In the present day it can be read at two levels. First, for proponents of reform, it provides a benchmark for measuring progress. Second, for students and researchers, it is an enduring contribution to organisation studies. The discussion that follows is in three parts. We open with Strauss’s depiction of clinical work organisation and examine its benchmarking potential. We then canvas the paper’s contribution to organisation studies. We conclude by examining the paper’s implications for current efforts on reform.