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

特别是临床决策已日益合理化在今天快速发展的医疗保健系统。临床决策合理化是指对医生的核心活动即诊断和治疗进行规范化和正规化的措施；例子包括正式的实践指南、专家系统和计算机化的决策支持工具。传统上，临床决策一直是医学界的专属领域；临床自主是专业优势的基础。那么，医生对这种合理化过程的反应是什么呢？影响他们态度的因素是什么？本项目拟在医师群体实践的背景下调查这些问题。它提出了三个具体问题：(1)医生是否认为临床决策的合理化会破坏专业知识或使其应用更有效？(2)医生的专业工作观念如何影响他们对临床决策合理化的态度？(3)合理化措施的特点和医疗集团的组织背景如何影响医生对合理化过程的态度？我将采访来自加州和中西部12家大中型医疗集团的36名医生。本研究有三个贡献：(1)临床决策合理化的实证研究很少，尽管有大量的推测和相互矛盾的预测，即合理化过程是否会降低或赋予医疗行业权力。这个项目可能会通过调查个别从业者是否认为合理化措施是提高还是降低他们的工作来阐明这一争论。(2)理论文献对理性化和规范化对职业地位的影响存在矛盾；此外，这些文献主要关注作为集体的职业。这个项目试图构建和测试一个影响个体从业者对其工作合理化反应的因素模型。(3)医疗集团可以说是管理式医疗环境下最重要的医师组织形式，但对医疗集团医师的研究较少。本研究将增加对医生专业精神和工作环境的相互作用的理解在这种研究不足的类型的组织设置。本研究的更广泛影响包括以下几点。本研究将对学者、学生和政策制定者感兴趣，了解医疗行业的转型和专家劳动组织的变化。此外，从卫生政策的角度来看，临床决策的合理化被认为对提高质量和降低成本具有相当大的希望。拟议的活动将在一定程度上确定医生专业精神的因素，以及合理化措施和组织环境中构成实施合理化措施障碍的因素。这项研究有可能有助于努力寻求改革医生文化和改善措施的实施，使临床决策合理化。

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.