The Wal-Marting of American psychiatry: an ethnography of psychiatric practice in the late 20th century.
OBJECTIVE
U.S. psychiatry has been radically reorganized by changes in the way the psychiatric hospital, the asylum, is funded. The imposition and internalization of cost control measures are major elements of this reorganization. This paper traces the ways in which cost control methods associated with managed care have produced new ways of organizing and patterning clinical work and clinical knowledge.


METHODS
Participant observation, used in qualitative sociological research, was undertaken in three settings: a public hospital, a private hospital with roots in the history of the asylum, and a for-profit hospital chain. The research consisted of observation of usual clinic practices and interviews with clinicians and ancillary staff, such as utilization reviewers, concerning their construction of and understandings about their work experience. In addition, interviews with personnel at a number of managed care companies was arranged although actual ethnographic experience was not performed in these companies due to declined permission. Interviews included clinicians whose experiences bridged the pre- and post-managed care eras.


RESULTS
This paper argues that the widespread adoption of Quality Assurance and Utilization Management procedures has created new standards of evaluation and treatment. These standards grow out of a transition from a person-centered to a population-based data base. They are justified by a conviction on the part of managed care proponents that good clinical treatment is equivalent to efficient cost control. This epistemological change results in the development of a clinical knowledge patterned along algorithmic pathways rather than subjective understanding. An increased and more rapid rationalization of psychiatry is the result. This rationalization process has produced moral dilemmas for practicing clinicians as they struggle to redefine their professional purposes and identities within a new order.


CONCLUSIONS
The rise of the 'Quality Movement' has led to the reconstruction of clinical knowledge as a result of the imposition of social practices influenced by the cultural consequences of capitalism. A peculiarly American psychiatry is the result.
Donald
A
A
Harvard University, USA.
D000465:Algorithms; D000884:Anthropology, Cultural; D001291:Attitude of Health Personnel; D001294:Attitude to Health / Q000208:ethnology; D004345:Drug Industry; D017598:Efficiency, Organizational; D006778:Hospitals, Psychiatric / Q000639:trends; D006801:Humans; D008329:Managed Care Programs / Q000191:economics / Q000458:organization & administration* / Q000592:standards; D008605:Mental Health Services / Q000191:economics / Q000592:standards / Q000639:trends*; D011570:Psychiatry / Q000191:economics / Q000592:standards / Q000639:trends*; D017749:Total Quality Management; D014481:United States