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From the doctor's workshop to the iron cage? Evolving modes of physician control in US health systems

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  • Kitchener, Martin
  • Caronna, Carol A.
  • Shortell, Stephen M.

Abstract

As national health systems pursue the common goals of containing expenditure growth and improving quality, many have sought to replace autonomous modes (systems) of physician control that rely on initial professional training and subsequent peer review. A common approach has involved extending bureaucratic modes of physician control that employ techniques such as hierarchical coordination and salaried positions. This paper applies concepts from studies of professional work to frame an empirical analysis of emergent bureaucratic modes of physician control in US hospital-based systems. Conceptually, we draw from recent studies to update Scott's (Health Services Res. 17(3) (1982) 213) typology to specify three bureaucratic modes of physician control: heteronomous, conjoint, and custodial. Empirically, we use case study evidence from eight US hospital-based systems to illustrate the heterogeneity of bureaucratic modes of physician control that span each of the ideal types. The findings indicate that some influential analysts perpetuate a caricature of bureaucratic organization which underplays its capacity to provide multiple modes of physician control that maintain professional autonomy over the content of work, and present opportunities for aligning practice with social goals.

Suggested Citation

  • Kitchener, Martin & Caronna, Carol A. & Shortell, Stephen M., 2005. "From the doctor's workshop to the iron cage? Evolving modes of physician control in US health systems," Social Science & Medicine, Elsevier, vol. 60(6), pages 1311-1322, March.
  • Handle: RePEc:eee:socmed:v:60:y:2005:i:6:p:1311-1322
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    References listed on IDEAS

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    1. Exworthy, M. & Wilkinson, E. K. & McColl, A. & Moore, M. & Roderick, P. & Smith, H. & Gabbay, J., 2003. "The role of performance indicators in changing the autonomy of the general practice profession in the UK," Social Science & Medicine, Elsevier, vol. 56(7), pages 1493-1504, April.
    2. Stephen Ackroyd & John A. Hughes & Keith Soothill, 1989. "Public Sector Services And Their Management," Journal of Management Studies, Wiley Blackwell, vol. 26(6), pages 603-619, November.
    3. Pauly, Mark V & Redisch, Michael, 1973. "The Not-For-Profit Hospital as a Physicians' Cooperative," American Economic Review, American Economic Association, vol. 63(1), pages 87-99, March.
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    Cited by:

    1. Waring, Justin & Bishop, Simon, 2013. "McDonaldization or Commercial Re-stratification: Corporatization and the multimodal organisation of English doctors," Social Science & Medicine, Elsevier, vol. 82(C), pages 147-155.
    2. Reilley, Jacob & Pflueger, Dane & Huber, Christian, 2024. "A typology of evaluative health platforms: Commercial interests and their implications for patient voice," Social Science & Medicine, Elsevier, vol. 350(C).
    3. Sally Gunz & Hugh Gunz, 2008. "Ethical Decision Making and the Employed Lawyer," Journal of Business Ethics, Springer, vol. 81(4), pages 927-944, September.
    4. Forrest Briscoe, 2007. "From Iron Cage to Iron Shield? How Bureaucracy Enables Temporal Flexibility for Professional Service Workers," Organization Science, INFORMS, vol. 18(2), pages 297-314, April.
    5. Racko, Girts, 2017. "Bureaucratization and medical professionals’ values: A cross-national analysis," Social Science & Medicine, Elsevier, vol. 180(C), pages 76-84.

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