Presentation to the Discipline of Medical Education 'Research Rap' at The University of Queensland Medical School on 7 August

1. 'Medical Dominance' and the
continuing robustness of
professional cultures in healthcare.
Dr Mark Bahnisch
7 August 2012
CMEDRS/DME ‘Research Rap’

2. Contexts
FRENK, J., CHEN, L., BHUTTA, Z., COHEN, J., CRISP, N., EVANS, T.,
FINEBERG, H., GARCIA, P., KE, Y., KELLEY, P., KISTNASAMY, B., MELEIS,
A., NAYLOR, D., PABLOS-MENDEZ, A., REDDY, S., SCRIMSHAW, S.,
SEPULVEDA, J., SERWADDA, D. & ZURAYK, H. 2010. Health
professionals for a new century: transforming education to strengthen
health systems in an interdependent world. The Lancet, 376, 1923-58.
“100 years ago, a series of studies about the education
of health professionals, led by the 1910 Flexner report,
sparked groundbreaking reforms. Through integration
of modern science into the curricula at university-based
schools, the reforms equipped health professionals
with the knowledge that contributed to the doubling of
life span during the 20th century.

3. “By the beginning of the 21st century, however, all
is not well. Glaring gaps and inequities in health
persist both within and between countries,
underscoring our collective failure to share the
dramatic health advances equitably. At the same
time, fresh health challenges loom. New infectious,
environmental, and behavioural risks, at a time of
rapid demographic and epidemiological transitions,
threaten health security of all. Health systems
worldwide are struggling to keep up, as they
become more complex and costly, placing
additional demands on health workers.”

4. “Professional education has not kept pace with these challenges,
largely because of fragmented, outdated, and static curricula that
produce ill-equipped graduates. The problems are systemic: mismatch
of competencies to patient and population needs; poor teamwork;
persistent gender stratification of professional status; narrow technical
focus without broader contextual understanding; episodic encounters
rather than continuous care; predominant hospital orientation at the
expense of primary care; quantitative and qualitative imbalances in the
professional labour market; and weak leadership to improve health-
system performance. Laudable efforts to address these deficiencies
have mostly floundered, partly because of the so-called tribalism of
the professions—ie, the tendency of the various professions to act in
isolation from or even in competition with each other.”
[Emphasis mine]

5. Caveats and comments
• Research I am doing, and am hoping to do rather
than research I have done
• But note potential to re-analyse data from
completed study
• Literature has been approached systematically
but not yet comprehensively
• Ability to realise research design would be
dependent on funding, opportunity – choices
framed to take this into account
• I am presenting to discuss ideas, research design,
methods, get feedback

6. Medicine and the sociology of
professions and of medical education
• An ideal-typical case
• Structural-functionalism and Parsonian sociology – searching for
what typifies a profession, expert knowledge and the professional
hierarchy and division of labour (Emile Durkheim, Max Weber)
• Normative assumptions
• Eliot Friedson (1970) Profession of Medicine – closure theory
– But did Friedson really say what he has been said to say?
• Studies of ‘negotiated order’ (notable is STRAUSS, A., SCHATZMAN,
L., BUCHER, R., EHRLICH, D. & SABSHIN, M. 1963. The hospital and
its negotiated order. FRIEDSON, E. (ed.) The Hospital in Modern
Society. New York: Free Press.
• Studies of the formation and reproduction of student professional
cultures (Merton et al 1957 The Student-Physician from a Parsonian
perspective, Becker et al 1961 Boys in White: Student Culture in
Medical School from a symbolic-interactionist perspective)

7. ‘Medical Dominance’
• Evan Willis – 1983, 1989; Revisited in 2006 special issue of the Health
Sociology Review (cf particularly COBURN, D. Medical dominance then and
now: critical reflections. Health Sociology Review, 15, 432-433.)
• Willis (1989:2-3) posited three axes of ‘medical dominance’
– Autonomy (“over its own work”)
– Authority (“over other health professions”)
– Sovereignty (“dominant in relations between the health sector and the wider
society”)
• Willis’ method – historical case studies (midwifery, optometry, chiropractic
– subordination, limitation, exclusion)
• Implicit but not really theorised here was a dynamic and more complex
historical and social interaction than the simple exercise of power or
authority (different concepts)
• Too much structure, too little agency?
• Problems of typification?

8. Research problem
• Institutional and cultural resilience and
embeddedness may not have been given
adequate weight in shifting educational,
organisational and policy agendas towards
‘interprofessional practice’.

9. Why is this important?
• There often seems to be an assumption that
‘medical dominance’ is a ‘bad thing’
• Some sociological insights about the individual
focus or orientation of medical work as compared
to ‘shaping’ institutions may have a lot to tell us
about the circumstances under which IPP is or is
not desirable and is or is not realisable
• Do we really know that much about ‘the hidden
curriculum’? And/or how professional cultures
are reproduced?

10. Research questions
• How are the dynamic boundaries of medical
authority reproduced in educational,
institutional and organisational cultures?
• What implications are there of the cultural
reproduction of medical authority for
education and public policy?

11. The erosion of medical dominance?
• General erosion of professional autonomy vis
a vis control or monopoly over knowledge
• ‘Neo-liberal’ governance
– CURRIE, G., FINN, R., MARTIN, G. 2009. Professional competition and
modernizing the clinical workforce in the NHS. Work, Employment &
Society, 23, 267-284.
• Agendas such as ‘patient centred care’,
‘interprofessional practice’

12. But…
• Erosion of professional autonomy over
knowledge
– The other side of micro-studies about ‘dominance’
in consultations.
– Macro-social theorising – meta-observation or the
received wisdom of liberal academic elites?
– ‘Dynamic professional boundaries in the healthcare workforce’
NANCARROW, S. A. & BORTHWICK, A. M. 2005. Dynamic
professional boundaries in the healthcare workforce. Sociology
of Health & Illness, 27, 897-919.
– Negotiated orders as such are not new.

13. • ‘Neo-liberal’ governance
– How strong is the state and how to what degree is state power if not authority
contested through inertia, folkways, ‘how things are done here’ ie –
professional and institutional cultures?
– Following on from this, how about the power of interest groups and the field
of policy interaction? We could look for instance at the journey of the National
Health and Hospital Reform Plan through inception to ‘local hospital boards’
under the LNP government in Queensland.
– NATIONAL HEALTH AND HOSPITALS REFORM COMMISSION 2009. A healthier
future for all Australians: Final report of the national health and hospitals
reform commission. Canberra, ACT: National Health and Hospitals Reform
Commission.
– Additionally, can the evidence that ‘managerialism’ and ‘teamwork’ are
subverted in some contexts by professionally-bound cultural strategies be
generalised?
– FINN, R., LEARMONTH, M. & REEDY, P. 2010. Some unintended effects of
teamwork in healthcare. Social Science & Medicine, 78, 1148-1154.

14. • Patient-centred care/IPP
– The continued resilience of professional cultures, and
particularly how these are reproduced and lived
institutionally.
– HALL, P. 2005. Interprofessional teamwork: Professional cultures
as barriers. Journal of Interprofessional Care, May 2005, 188-
196.
– The sustainability of IPP initiatives and their
sustainability in the absence of a ‘good’ doctor
– WHITEHEAD, C. 2007. The doctor dilemma in interprofessional
education and care: how and why will physicians collaborate? Medical
Education, 41, 1010-1016.

15. Then or now?
• STRAUSS, A. 1971 ‘Psychiatrists in a Private
Hospital’ and ‘The Nurses at PPI’ in
Professions, Work and Careers. San Francisco:
The Sociology Press.
• FINN, R. 2008. The language of teamwork:
Reproducing professional divisions in the
operating theatre. Human Relations, 61, 103-
130.

16. Hypothesis
• The relative failure of many IPP initiatives is
caused in part by the resilience of professional
medical culture in institutions.
– BOURGEAULT, I. & MULVALE, G. 2006. Collaborative health care teams
in Canada and the USA: Confronting the structural embeddedness of
medical dominance. Health Sociology Review, 15, 481-495.

17. Research design: How would we
measure this?
• RIPLS
– MCFADYEN, A., WEBSTER, V. & MACLAREN, W. 2006. The test-retest
reliability of a revised version of the Readiness for Interprofessional
Learning Scale (RILPS). Journal of Interprofessional Care, 20, 633-639.
– Critique in THANNHAUSER, J., RUSSELL-MAYHEW, S. & SCOTT, C. 2010.
Measures of interprofessional education and collaboration. Journal of
Interprofessional Care, 24, 336-349.
• What is the independent variable?
• What is the dependent variable?

18. Another way of
measuring/conceptualising
• Not what has happened but what has not happened
– GREENFIELD, D., NUGUS, P., TRAVAGLIA, J. & BRAITHWAITE, J. 2011.
Factors that shape the development of interprofessional improvement
initiatives in health organizations. BMJ Quality and Safety, 20:332-337.
– NUGUS, P., GREENFIELD, D., TRAVAGLIA, J., WESTBROOK, J. &
BRAITHWAITE, J. 2010. How and where clinicians exercise power:
interprofessional relations in health care. Social Science & Medicine,
71, 898-909.
• Continuities rather than fractures
• Ie – findings from
– ACT IPE/IPL Study
– NUGUS, P., GREENFIELD, D., TRAVAGLIA, J. & BRAITHWAITE, J. 2011.
Action research for interprofessional learning and interprofessional
practice in ACT Health. Paper presented to the University of
Queensland Centre for Clinical Research.
– Wide Bay IPE/IPP Study

19. Case studies…
• Case selection
• Within case variation
• Ethnography
• Phenomenology
• Discourse analysis

20. Replication and a longitudinal or cross-
sectional study…
• The American and UK literature contains rich
studies of the reproduction of professional
cultures in medical education
• Recency?
• Cross-national replication and/or longitudinal
or cross-sectional study
• Mixed methods

21. Or… meta-analysis?

22. Implications for sociological theory
• Back to the foundations – ie ‘Rules of Sociological
Method’; grounding macro-theory
• Questioning some of the normative or ideological
assumptions underpinning sociological theory
which may themselves be reflections in part of
contests over/within social facts
• Incorporating historical sociology into
health/medical sociology and public policy
studies – contribution to method

23. Implications for medical education and
public policy
• ‘Barriers’ to IPP/Patient-centred care may be
much more rigid than thought – the lack of
malleability might lie in culture/s
• A better evidence base for ‘the informal
curriculum’
• An ability to assess ‘what works’ – under what
conditions is ‘medical dominance’ a good or a
bad thing? Or is this a poorly framed question?
(Ie professional expertise/specialisation and
clinical reasoning within particular contexts of
care) – links into the competency agenda