Archives
The (Im)Possibilities of Clinical Democracy
Katherine Carroll
Centre for Clinical Governance Research, University of New South Wales, Australia
Rowena Forsyth
Centre for Clinical Governance Research, University of New South Wales, Australia
Rick Iedema
Centre for Clinical Governance Research, University of New South Wales, Australia
Debbie Long
Centre for Clinical Governance Research, University of New South Wales, Australia
Abstract
In this article, we argue that homogenising discussions of medical dominance on the meta-level of professions do not fully capture the complexity that characterises current clinical care in multidisciplinary health care teams.
We illustrate this through an empirical study of a multidisciplinary team attempting to enact their work in a clinically democratic way. The challenges that arose in putting this into practice highlight the depth and complexity of enculturated medical dominance in Australian hospital practice.
Our study shows that effective facilitation of clinician reflexivity has the potential to challenge and change deeply embedded structures and behaviours.
Keywords
medical dominance, clinical democracy, sociology, hospital ethnography, multidisciplinary clinical team, reflexivity
References
Ardener E (1975) Belief and the problem of women. In S Ardener (ed) Perceiving Women. London: Dent.
Boyce RA (2001) Organisational governance in allied health services: a decade of change. Australian Health Review 24(1):22-35.
Braithwaite J and Westbrook MT (2005) Rethinking clinical organisational structures: an attitude survey of doctors, nurses and allied health staff in clinical directorates. Journal of Health Services Research & Policy 10(1):10-17.
Britten N (2001) Prescribing and the defence of clinical autonomy. Sociology of Health and Illness 23(4):478-496.
Carmel S (2006) Boundaries obscured and boundaries reinforced: incorporation as a strategy of occupational enhancement for intensive care. Sociology of Health and Illness 28(2):154-177.
Colombo A, Bendelow G, Fulford B and Williams S (2003) Evaluating the influence of implicit models of mental disorder on processes of shared decision making within community-based multi-disciplinary teams. Social Science & Medicine 56:1557-70.
Cott C (1997) 'We decide, you carry it out': A social network analysis of multidisciplinary long-term care teams. Social Science & Medicine 45(9):1411-1421.
Daniel A (1994) Medicine, state and people: a failure of trust? In C Waddell and AR Petersen (eds) Just Health: Inequality in Illness, Care and Prevention. Melbourne: Churchill Livingstone, pp.191-205.
De Voe JE and Short SD (2003) A shift in the historical trajectory of medical dominance: the case of Medibank and the Australian doctors' lobby. Social Science & Medicine 57:343-353.
Degeling P, Iedema R, Winters M, Maxwell S, Coyle B, Kennedy J and Hunter D (2003) Leadership in the context of health reform: an Australian case study. In S Dopson and AL Mark (eds) Leading Health Care Organisations. Basingstoke: Palgrave.
Dzur E (2002) Democratizing the hospital: deliberative-democratic bioethics. Journal of Health Politics, Policy and Law 27(2):177-211.
Elston MA (1991) The politics of professional power: medicine in a changing health service. In J Gabe, M Calnan and M Bury (eds) The Sociology of the Health Service. London: Routledge.
Evetts J (2003) The sociological analysis of professionalism: occupational change in the modern world. International Sociology 18(2):395-415.
Flynn R (2002) Clinicial governance and governmentality. Health, Risk & Society 4(2):155-173.
Fox NJ, Ward KJ and O'Rourke AJ (2005) The 'expert patient': empowerment of medical dominance? The case of weight loss, pharmaceutical drugs and the internet. Social Science & Medicine 60:1299-1309.
Freidson E (1970) Professional Dominance: The Social Structure of Medical Care. New York: Atherton Press.
Freidson E (1994) Professionalism Reborn: Theory, Prophesy and Policy. Cambridge: Polity Press.
Gair G and Hartery T (2001) Medical dominance in multidisciplinary teamwork: a case study of discharge decision-making in a geriatric assessment unit. Journal of Nursing Management 9:3-11.
Germov J (2002) Challenges to medical dominance. In J Germov (ed) Second Opinion (2nd ed) Melbourne: Oxford University Press.
Griffiths L (1998) Humour as resistance to professional dominance in community mental health teams. Sociology of Health and illness 20(6):874-895.
Ham C and Alberti KGMM (2002) The medical profession, the public and the government. BMJ:324, 838-842.
Hardt M and Negri A (2000) Empire. Cambridge: Harvard University Press.
Haug MR (1973) Deprofessionalisation: an alternative hypothesis for the future. Sociological Review Monograph 20:195-211.
Hegel GWF (1977) Phenomenology of Spirit. Oxford: Oxford University Press.
Iedema R, Long D, Carroll K, Stenglin M and Braithwaite J (2005a) Corridor work: how 'liminal' space can be a focal resource for handling complexities of multi-disciplinary health care. Apros 11: Asia Pacific Researchers in Organization Studies. Melbourne, Australia.
Iedema R, Rhodes C and Scheeres H (2005b) Presencing identity: organizational change and immaterial labor. Journal of Organizational Change Management 18(4):327-337.
Iedema R, Long D, Forsyth R and Lee BB (2006a) Visibilising clinical work: video ethnography in the contemporary hospital. Health Sociology Review 15(2).
Iedema RAM, Jorm C, Long D, Braithwaite J, Travaglia J and Westbrook M (2006b) Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error. Social Science & Medicine 62:1605-1615.
Illich I (1976) Limits to Medicine. London: Marion Boyars.
Kippax S and Race K (2003) Sustaining safe practice: twenty years on. Social Science & Medicine 57:1-12.
Larson MS (1977) The Rise of Professionalism: A Sociological Analysis. Berkeley: University of California Press.
Latham L, Freeman T, Walshe K, Spurgeon P and Wallace L (2000) Clinical governance in the west midlands and south west regions: early progress in NHS trusts. Clinician in Management 9:83-91.
Lee B, Iedema R, Long D, Marial O and Braithwaite J (2005) Spinal pressure care initiatives in POW 'Looking in the mirror' from research to clinical practice (and back again). Prince of Wales Hospital Grand Round. Randwick.
Long D (2005) Code switching as immaterial labour in multidisciplinary healthcare work. COMET-VELIM Communication, Medicine and Ethics Conference Sydney: University of Sydney.
Long D, Clezy K, Lee BB, Pontivivo G and Iedema R (2006) Preventing Health Care Associated Infections: An Ethnographic Approach. Australasian Society for Infectious Diseases Incorporated Annual Scientific Meeting Wellington Convention Centre, Wellington, New Zealand.
Long D, Iedema R and Lee BB (forthcoming-a) Corridor conversations: clinical communication in casual spaces. In R Iedema (ed) The Discourse of Hospital Communication. Tracing Complexity in Contemporary Health Organizations. Basingstoke: Palgrave-Macmillan.
Long D, Iedema R, Lee BB and Braithwaite J (forthcoming-b) Attempting clinical democracy: enhancing multivocality in a multidisciplinary clinical team. In CR Caldas-Coulthard and R Iedema (eds) Identity Trouble: Discursive Constructions. Basingstoke: Palgrave -Macmillan.
Lupton D (1997) Consumerism, reflexivity and the medical encounter. Social Science & Medicine 45:373-381.
McKinlay JB and Arches J (1985) Towards the proletarianization of physicians. International Journal of Health Services 15:161-195.
McKinlay JB and Stoekle JD (1988) Corporatization and the social transformation of doctoring. International Journal of Health Services 18:191-205.
McKinlay JB and Marceau LD (2002) The end of the golden age of doctoring. International Journal of Health Services 32(2):379-416.
Morrison EW and Milliken FJ (2003) Speaking up, remaining silent: the dynamics of voice and silence in organizations. Journal of Management Studies 40(6):1353-1358.
Nancarrow SA and Borthwick AM (2005) Dynamic professional boundaries in the healthcare workforce. Sociology of Health and Illness 27(7):897-919.
Piercy M (1973) ‘Unlearning Not to Speak' To Be Of Use. New York: Doubleday.
Pontivivo G and Long D (2006) Turning surveillance into self-surveillance: using video ethnography and feedback sessions to assist clinicians in taking responsibility for infection control. ‘Coughs and harbouring colds - what's come through the door'. 29th Annual Conference of the Infection Control Association, NSW Coffs Harbour, NSW.
Roter D (2000) The medical visit context of treatment decision-making and the therapeutic relationship. Health Expectations 3:17-25.
Rowe PA, Boyce RA, Boyle MV and O'Rielly K (2004) A comparative analysis of entrepreneurial approaches within public healthcare organisations. Australian Journal of Public Administration 63(2).
Senge PM (1990) The Fifth Discipline: The Art and Practice of the Learning Organisation. New York: Doubleday.
Sherer R, Stieglitz K, Narra J, Jasek J, Green L, Moore B, Shott S and Cohen M (2002) HIV multidisciplinary teams work: support services improve access to and retention in HIV primary care. AIDS Care 14(1):531-544.
Wagner EH (2000) The role of patient care teams in chronic disease management. BMJ 320:569-572.
Wailoo K (2004) Sovereignty and science: revisiting the role of science in the construction and erosion of medical dominance. Journal of Health Politics, Policy and Law 29(4-5):643-659.
Wearing M (1999) Medical dominance and the division of labour in the health professions. In C Grbich (ed) Health in Australia. Sociological Concepts and Issues. Sydney: Longman.
Weiss M and Fitzpatrick R (1997) Challenges to medicine: the case of prescribing. Sociology of Health and Illness 19(3):297-327.
White K (2000) The state, the market, and general practice: the Australian case. International Journal of Health Services 30(2):285-308.
Williams L (2002) In search of profession: a sociology of allied health. In J Germov (ed) Second Opinion (2nd ed) Melbourne: Oxford University Press.
Willis E (1983) Medical Dominance: The Division of Labour in Australian Healthcare. Sydney: Allen & Unwin.
Willis E (1989) Medical Dominance (revised edition) Sydney: Allen & Unwin.
Zadoroznyj M (2001) Birth and the 'reflexive consumer': trust, risk and medical dominance in obstetric encounters. Journal of Sociology 37(2):117-139.
eContent Home