Supporting ‘Paperwork Compliance’: The Ideological Factor
Although of clear importance, it may well be that the ‘ideological’ factor is most important in comparison to the structural one. For the ‘structural factor’ reinforces the ‘ritual quality’ of doctors ‘bureaucratic accountability’ to medical elites. In doing so, it contributes to the adoption of ‘paperwork compliance’ by ‘rank and file’ doctors. Nevertheless, the concept of ‘paperwork compliance’ is grounded firmly in the epistemological makeup of medical expertise and therefore remains at the ideological root of the occupational culture of the medical profession (Stacey 1992 2000). The empirical findings discussed here illustrate how attempts to enhance accountability within the medical club utilising a rationalistic-bureaucratic discourse of outcome based standard setting and performance appraisal will encounter inevitably a certain amount of resistance ‘on the shop floor’ (that is at the level of the individual practitioner) due in no small measure to that ‘ineffable’ and ‘charismatic’ quality known as ‘clinical acumen’ (Bosk 1979). The formal ‘technicality’ of the rules and procedures linked with medicine’s new governing tools such as portfolio based performance appraisal are designed to ensure quality control and accountability. These are being ‘trumped’ by the ‘indeterminacy’ that lies at the basis of modern medical expertise. This state of affairs reflects what Armstrong (2002) found in his study. He noted that doctors are now required to record their clinical decisions and the reasons for them in order to ensure compliance with the ‘technicality’ of evidenced based guidelines (Grey and Harrison 2004). However, he also noted that they ‘trump’ the clinical protocols of the medical elite operating within in the ‘guideline industry’. Furthermore, they do this by reaffirming at the level of everyday clinical practice the inherent ‘indeterminacy’ that lies at the basis of much of medical work.
It has been noted by sociologists that a cloud of uncertainty surrounds much of medical work to the extent that ‘training for uncertainty’ became long ago a defining characteristic of the occupational culture and internal social organisation of the medical profession (Fox 1975, Atkinson 1981, Stacey 1992, Gladstone 2000). Freidson (1970, 1994, 2001) argues that because of this a thoroughgoing ‘epistemological individualism’ lies at the basis of the ‘clinical mentality’. This is due to the need for doctors to exercise personal judgment and discretion because of the inherently specialist nature of their work. The faith of the ‘clinical mentality’ in firsthand perception and personal experience is so entrenched within the medical club that, as Armstrong (1980: 167) notes, ‘whether this skill is described as ‘clinical sense’, ‘clinical ability’ or the ‘art of diagnosis’ the (individual) doctor is ranked according to his facility with the technique’.
Yet two interrelated issues have been recognised amongst sociologists since the 1970s about the ‘indeterminate’ foundations of modern medical expertise. First, as medical practice and technology develops today’s ‘indeterminacy’ becomes tomorrows ‘technicality’. The general public becomes increasingly aware of the possibilities and limitations of modern medical practice as this process unfolds. Therefore, they demand ever more say over their treatment and care (Haug 1973). While also increasingly requiring doctor’s account for their actions and how they organise members training, practice and discipline to ensure quality control. Second, the indeterminate foundations of modern medical expertise have reinforce a propensity within the medical club to justify exclusory, paternalistic and elitist attitudes concerning who controls the governance of medical training, practice and discipline. The doctors interviewed for this research certainly possessed paternalistic and elitist attitudes concerning the issue of doctor appraisal and the reporting of underperformance. Such attitudes are typically hidden by doctors behind the ‘service ideal’ of their professionalism (i.e. that it is in the best interests of patients that they be left alone to manage their own affairs).Modern medicine may still be treated with awe and respect, and its members possess considerable status and influence within society, but the medical club has to come to terms with the fact that it no longer commands as much unquestioning respect as it used to (Lupton 1997, Elston 2004, Allsop 2006). Certainly, in the last three decades critical social commentators have argued that many occupations possess ‘formal’ and ‘tacit’ dimensions to their expertise; but they do not demand the same degree of exclusive collegiate control over members training, practice and discipline that the medical profession typically has done (Polanyi 1967, Jamous and Peloille 1970, Allsop and Mulcahy 1996).
Conclusion: An Invaluable Baseline
As this last point illustrates, the empirical work of this research takes place against a socio-political backdrop which since the re-emergence of liberalism in the last three decades has seen an intensification in the external and internal governance of expertise across the public and private spheres, the health and social service sector, as well as the higher education system (Stacey 1992, Taylor 1997, Hanlon 1998, Biggs 1999, Allsop and Saks 2002). Power (1997) and Rose (1999) note that a key facet of advanced liberal society is its central concern with disciplining the population without recourse to direct or oppressive intervention. Yet it also sees the encroachment of demands for standardisation and transparent accountability associated with Audit into all aspects of social life (Burchell, Gordon and Miller 1991). Rose (1999) argues that Audit is a key large-scale activity for governing the activities of experts ‘at a distance’ in order to minimise the costs and risks associated with the application of specialist expertise. Is it a surprise, therefore, that the rationalistic-bureaucratic discourse of outcomes based standard setting and performance appraisal is also found within occupations other than medicine, such as accountancy, law and education for example (Slater 2000, Allsop 2002)? Indeed, elite collegiate training and regulatory bodies in occupational groups concerned with teaching, social work and nursing (to name but a few) are increasingly subjecting the practices of their members to surveillance and standardisation. The changes underway in medicine can be found in other occupations and other contexts, and research into the changing nature of the governance of medical expertise should keep this comparative issue in mind.
The findings of this research may not indicate an intractable situation whereby the tacit foundation stones of professional expertise will always be used to ‘trump’ measures that seem to act to survey and curtail professional autonomy. Its interviewees belong to a different generation than ones who will experience the full affect of recent changes in medical training and regulation. Will it be different for the next generation of doctors: those whose training, practice and disciplinary arrangements will increasingly operate under a different set of cultural expectations concerning the appropriate limits of professional autonomy, as one generation of doctors gives away to the next? Indeed, it is arguable that the research bears witness to the fact that we are standing at the beginning of a long-term process of change and reform within medical training, practice and regulation. What is more, it is also arguable that the full affects of this process will gradually unfold over the coming decades as the political renewal of liberalism continues to bring with it a fundamental shift in the grounds upon which ‘good governance’ is practiced. Interviewee’s accounts did reveal that a process of restructuring is underway in medicine and that they do feel that over time this will increasingly formalise and standardise clinical education. What is more, they felt this process is placing them under more and more surveillance. It is making them ever more accountable to medical elites for their decisions and the reasons behind them. Aren’t we then talking about a process of organisational and cultural change that actually is just beginning?
It needs to be remembered that this research was conducted on the cusp of recent changes in undergraduate and postgraduate medical education (GMC 1992 2002 2003). It is just five years since the first ‘new curriculum’ medical students began to graduate nationally. It is only three years since the new junior doctor-training program began (BMA 2005). Additionally, Annual Appraisal for senior doctors has also only been in operation for a relatively short period of time (Black 2002). Given these three facts, it is arguable that this research reports what is happening at the beginning of a process of far reaching changes in medical training and regulation, whose full affects will not be known for another generation of doctors. Could it be that these findings have provided an invaluable ‘baseline’ from which the affect of subsequent changes in the governance of medical expertise can be compared longitudinally? This conclusion seems appropriate given that at the time of writing we are still waiting for revalidation to be implemented nationally in 2010, and furthermore, it will be at least a decade more before the full effects of revalidation’s implementation are known. However, at this time we can be confident of two things. First, revalidation will bring about far reaching changes in medical training and regulation. Second, the state will continue to move away from emphasising ‘professional autonomy’ and towards emphasising ‘professional accountability’ within the health and social care arena. Additionally, it will continue to rely upon a rationalistic-bureaucratic discourse of standard setting and performance appraisal to achieve this goal. Given these circumstance it is best for the moment to conclude that these findings reinforce that a process of change has only just begun within the medical club. Consequently, it is perhaps most appropriate to allow Dr Blue (Surgeon) to have the final say on what he thinks the future may bring:
‘I don’t know what will exactly happen in medical education over the next few years…I do think we will look back and say that this was when the big changes were starting to occur. But having said that, going on what is happening at the moment I expect whatever does happen will in some way involve me having to fill out more paperwork. It generally does’.
