Doctoral Dissertation Research: Physician Professionalism and Rationalization of Clinical Decision-Making

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Clinical decision-making in particular have been increasingly rationalized in today's rapidly evolving healthcare system. Rationalization of clinical decision-making refers to measures that standardize and formalize the core activities of the physician, i.e. diagnosis and treatment; examples include formal practice guidelines, expert systems, and computerized decision-support tools. Clinical decision-making has traditionally been the exclusive domain of the medical profession; clinical autonomy forms the foundation for professional dominance. What, then, is physicians' reaction toward this rationalizing process? What are the factors that influence their attitudes? This project proposes to investigate these issues in the context of physician group practices. It asks three specific questions: (1) Do physicians perceive rationalization of clinical decision-making as undermining professional expertise or making its application more efficient? (2) How does physicians' conception of professional work influence their attitudes toward rationalization of clinical decision-making? (3) How do the characteristics of rationalizing measures and the organizational context of medical groups contribute to physicians' attitudes toward the rationalization process? I will interview 36 physicians from 12 medium to large-sized medical groups located in California and the Midwest. This research makes three contributions: (1) Empirical studies of rationalization of clinical decision-making are rare, despite abundant speculative and conflicting predictions on whether the rationalizing process degrades or empowers the medical profession. This project may shed some light on this debate by investigating whether individual practitioners regard rationalizing measures as enhancing or degrading their work. (2) Theoretical literature is ambivalent on the effects of rationalization and standardization on professional status; moreover, this body of literature focuses mainly on professions as collectivities. This project seeks to construct and test a model of factors that affect individual practitioners' reaction toward the rationalization of their work. (3) Medical groups are arguably the most important form of physician organizations in the managed care environment, but research on physicians in medical groups is scarce. This study will add to the understanding of interaction of physician professionalism and work environment in this under-studied type of organizational setting. The broader impacts of this study include the following. This study will be of interest to scholars, students, and policymakers interested in understanding the transformation of the medical profession and the changing organization of expert labor. In addition, from a health policy point of view, rationalization of clinical decision-making is seen as holding considerable promise to improving quality and reducing costs. The proposed activity will be to identify to an extent the elements of physician professionalism, and those of rationalization measures and organizational context that pose as barriers to the implementation of rationalization measures. This research has the potential to contribute to the efforts that seek to reform physician culture and improve the implementation of measures that rationalize clinical decision-making.