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"A manager in the minds of doctors" : a comparison of new modes of control in European hospitals
(2013)
Background: Hospital governance increasingly combines management and professional self-governance. This article maps the new emergent modes of control in a comparative perspective and aims to better understand the relationship between medicine and management as hybrid and context-dependent. Theoretically, we critically review approaches into the managerialism-professionalism relationship; methodologically, we expand cross-country comparison towards the meso-level of organisations; and empirically, the focus is on processes and actors in a range of European hospitals.
Methods: The research is explorative and was carried out as part of the FP7 COST action IS0903 Medicine and Management, Working Group 2. Comprising seven European countries, the focus is on doctors and public hospitals. We use a comparative case study design that primarily draws on expert information and document analysis as well as other secondary sources.
Results: The findings reveal that managerial control is not simply an external force but increasingly integrated in medical professionalism. These processes of change are relevant in all countries but shaped by organisational settings, and therefore create different patterns of control: (1) ‘integrated’ control with high levels of coordination and coherent patterns for cost and quality controls; (2) ‘partly integrated’ control with diversity of coordination on hospital and department level and between cost and quality controls; and (3) ‘fragmented’ control with limited coordination and gaps between quality control more strongly dominated by medicine, and cost control by management.
Conclusions: Our comparison highlights how organisations matter and brings the crucial relevance of ‘coordination’ of medicine and management across the levels (hospital/department) and the substance (cost/quality-safety) of control into perspective. Consequently, coordination may serve as a taxonomy of emergent modes of control, thus bringing new directions for cost-efficient and quality-effective hospital governance into perspective.
In cancer medicine, particularly in drug research and development, structural changes in professionalism can be observed as examples. This field is characterized by a strong tension between social expectations concerning the control of existential risks to health, on the one hand, and strong commercial interests of a shareholder value-driven industry, on the other hand. Based on a qualitative empirical analysis, two subfields within the field of cancer medicine are reconstructed. One of these subfields—colon cancer therapy—could be interpreted as representing a renewal of the knowledge-power nexus. The pattern of the other subfield—brain tumour research—refers to a much more vulnerable professionalism. Both fields are characterized by development in professional work, which could be described with the hybridization concept. Therefore, the contrast between the two empirical examples presented still challenges the theoretical interpretation of contemporary professionalism.