title: From the doctor's workshop to the iron cage? Evolving modes of physician control in US health systems.
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.
authors.affiliation: Department of Social and Behavioral Sciences, University of California, San Francisco, 3333 California Street, Suite 455, San Francisco, CA 94118, USA. martink@itsa.ucsf.edu
authors.forename: Martin
authors.initials: M
authors.lastname: Kitchener
authors.forename: Carol A
authors.initials: CA
authors.lastname: Caronna
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Shortell
mesh_terms: D032982:Contracts; D003659:Decision Making, Organizational; D006279:Health Maintenance Organizations / Q000458:organization & administration; D006302:Health Services Research; D006608:Hierarchy, Social; D018578:Hospital-Physician Relations; D006788:Hospitals, Voluntary / Q000458:organization & administration*; D006801:Humans; D007325:Institutional Practice / Q000458:organization & administration*; D007857:Leadership; D008505:Medical Staff, Hospital / Q000458:organization & administration*; D019982:Organizational Case Studies; D011243:Preferred Provider Organizations / Q000458:organization & administration; D017009:Professional Autonomy; D011785:Quality Assurance, Health Care; D012962:Sociology, Medical / Q000639:trends*; D014481:United States