It therefore represents the first attempt to analyse doctors educational autonomy in the context of contemporary sociological debate concerning ‘the decline and fall’ of medical autonomy and the future of the principle of professional self-regulation.
The research findings provide direct empirical evidence to support the central argument of the ‘restratification thesis’. Namely that medical elites are seeking to maintain collective rights and freedoms in the form of collegiate control over training, practice and discipline. Furthermore, to achieve this goal they are introducing administrative and managerial strategies, which not only place the ‘rank and file’ under greater collegiate surveillance, but also subject them to a rationalistic-bureaucratic discourse of outcomes based standing setting and performance appraisal. The empirical findings certainly do indicate that ‘rank and file’ practitioners are becoming more ‘bureaucratically accountable’ to ‘medical elites’, in the sense that they are required to record their decisions and the reasons for them (Harrison and Dowswell, 2002). As in the clinical arena, doctor’s activities within the educational domain are becoming subject to greater peer surveillance and control. Yet the empirical evidence also shows that this ‘bureaucratic accountability’ possesses a ‘ritual quality’, and furthermore, this state of affairs is due to a mixture of structural and ideological factors, with doctors adopting a stance of ‘paperwork compliance’ towards portfolio based performance appraisal as a consequence. This finding has significant consequences. Particularly given that portfolio based performance appraisal fills an important function as a ‘signifier of quality control’ under the more open and accountable governing regimes advocated by medical elites.
In particular, given that this is the first empirical study to examine specifically the introduction of portfolio based performance appraisal within the medical club, it is necessary to undertake comparative research in other medical schools to identify if regional variation exists. Factors such as variations in curricula design, as well as trainer and trainee characteristics, need to be taken into account when undertaking comparative research between ‘Blue School’ and other medical schools and postgraduate training providers.Identifying this is important because they are part of the medical elite and will play a significant role in Revalidation. Furthermore, it is important to specifically focus upon exploring the issue of ‘paperwork compliance’ from the perspective of trainees themselves, including how it interacts with key factors that could be involved in shaping their experience of medical education and performance appraisal, such as their gender, ethnicity, age or personal career aspirations. But perhaps most importantly, the findings reinforce the need to look at reforms in medical education from a long-term perspective. It is necessary to conduct longitudinally based research to develop further the concept of ‘paperwork compliance’. Finally, given its conceptual grounding within the restratification thesis and the neo-Weberian and Governmentality theoretical perspectives, the concept of ‘paperwork compliance’ could also be applied other similar occupational contexts, such as in nursing, law, accountancy or dentistry for example.
The Restratification Thesis
In spite of possessing clear theoretical and empirical relevance to the contemporary regulatory policy context, the restratification thesis has not received a great deal of attention from sociologists since its initial formation by Freidson in the 1980s (Harrison 2004). Rather, they have focused upon exploring contemporary challenges to professional autonomy through the respective lenses of the deprofessionalization and proletarianization theses (Elston 2004).The growth of media coverage of gross medical malpractice cases like Harold Shipman is a good example.It focuses upon the fact that attitudes to traditional forms of authority are changing and highlights that the public increasingly expects their governing institutions to operate in a transparent and accountable manner (Moran 1999). In contrast, the proletarianization thesis highlights the existence of the potential for expert work in general, and medical work in particular, to become subject to rationalisation and routinization.Today’s ‘indeterminacy’ becoming tomorrows ‘technicality’. It focuses upon how this causes medical work to become subject to managerial bureaucratic control in the name of controlling costs and promoting consumer choice.
It is undoubtedly the case that the proletarianization and deprofessionalization theses possess a great deal of descriptive value. They illustrate that two broad general trends – the rise of heath care managerialism and the growth of consumer power – are actively challenging internationally traditional professional freedoms. Including the historical right of occupations classified as professions in the Anglo-American context to manage their own affairs and so possess monopolistic occupational control over members training, practice and discipline (Gladstone 2000). Nevertheless, the deprofessionalization and proletarianization theses do not fully encapsulate the nature of the contemporary situation faced by professions such as medicine, law, nursing, dentistry, teaching and social work (Allsop and Saks 2002). It is not a simple case where professional autonomy is in long-term decline due to the rise of health care managerialism and a more critically aware and demanding general public. Rather, two key points need to be noted.
First, the applicability of the deprofessionalization and proletarianization theses inside and outside of their point of origin, the United State of America, is open to serious question (Elston 2004). Certainly, critical commentators within the UK context, such as Elston (1991), have argued convincingly that neither the proletarianization thesis nor the deprofessionalization thesis fully reflect the nature of the contemporary professional training and practice context. Additionally, even the most ardent advocate of the proletarianization or deprofessionalization theses must acknowledge that there is a distinct lack of empirical evidence to support their claims (Harrison and Ahmed 2000).
Second, the proletarianization and deprofessionalization theses focus solely upon external factors held to be acting upon the professions, such as the growth of a more informed and demanding general public. They do not consider the internal changes professions such as medicine are currently undergoing, as professional elites response to challenges to professional privileges by subjecting ‘rank and file’ practitioners to greater peer surveillance and control. The dominance of the deprofessionalization and proletarianization theses within the sociological literature, regarding current trends in the governance of professional expertise, belies the fact that sociologists are guilty of paying little attention to internal reforms within the professions, when analysing current changes in how professional expertise is regulated.
It is certainly arguable that sociologists have paid little attention to how professions such as medicine are reforming their training and regulatory arrangements as they respond to calls to become more open and accountable for how they manage their affairs (Davies 2004). By focusing mainly upon external threats to professional autonomy, through their advocacy of the deprofessionalization and proletarianization theses, sociologists have only considered half of the picture in relation to the changing position of professions within contemporary society. The restratification thesis redresses this imbalance by firmly refocusing sociological analysis so it also considers internal reforms occurring within professions such as medicine. There can be no doubt that in advocating a ‘new medical professionalism’, medical elites are seeking to maintain collective rights and freedoms, in the form of collegiate control over training, practice and discipline (Catto 2006 2007).
Debate exists between neo-Weberian commentators (i.e. Freidson 1985 1994 2000, Elston 1991 2004) and neo-Marxist commentators (i.e. McKinley and Stoeckle 1988, Coburn 1997, Barnett 1998) over whether the process of restratification signifies a further decline in professional autonomy (the neo-Marxist viewpoint) or the retention of profession prerogatives (the neo-Weberian viewpoint). Yet the fact of the matter is that unlike their neo-Weberian counterparts, neo-Marxists fail to recognise that professional prerogatives do not rest solely upon the control of occupational work tasks. Control over educational credentials plays an important role in ensuring the legitimacy of occupational control over regulatory and disciplinary arrangements surrounding group members activities. Certainly, neo-Marxist commentators are guilty of neglecting the fact that the restratification thesis argues occupational control over members training arrangements is vital to maintaining professional privileges (Freidson 1994).
By directing the attentions of sociologists to the important role played by control over training arrangements in maintaining professional borders and privileges, the restratification thesis opens up an important area for empirical inquiry, which the research detailed here has only begun to address. There certainly is a need to conduct empirical research into how doctor’s educational activities are changing over time as they become more ‘bureaucratically accountable’ to medical elites for what they do. There is a clear need for sociologists to analyse changes in the nature and extent of the educational autonomy possessed by ‘rank and file’ medical practitioners, in order to more fully understand the consequences of the restratification process currently occurring within the medical profession.
Here it needs to be acknowledged that the empirical work discussed here relies solely upon doctors own accounts of their educational activities. It was not able to provide an independent report of what actually happened between appraisers and appraisees during appraisal meetings. Nor does it explore in depth with doctors themselves the reasons why they approached portfolio based performance appraisal as they did.Preferably using a mixture of methods, including direct observation of portfolio based performance appraisal events. Additionally, comparative research with other professions needs to be undertaken. Medicine is not alone in becoming subject to a process of restratification as a result of the state acting to open up the previously ‘closed shop’ field of professional regulation (Slater 2007). Comparative research, concerned with the strategies by which different professional elites are reacting to contemporary challenges to the principle of professional self-regulation, would enable sociologists to obtain a clearer picture of what the future may bring, in regards to how the experts who provide us with much valued public services are regulated to ensure the welfare of the general public.
The Neo-Weberian and Governmentality Viewpoints
Finally, it needs to be noted that an additional advantage of the restratification thesis is that it reinforces the value of synthesising the neo-Weberian and Governmentality perspectives when analysing the governance of professional expertise.In addition to the important insights the neo-Weberian standpoint offers into the fundamentally exclusory nature of ‘club governance’, it encapsulates the socio-legal and political realities of the regulatory context with regards to the professions in general and medicine in particular. Yet the fact is the dominance of the neo-Weberian perspective has led social scientists to somewhat neglect the symbiotic nature of the development of professional expertise and the modern liberal democratic state.In contrast, the Governmentality perspective focuses upon the productive affects of the close relationship that exists between the professions and the state. It does this by highlighting how professionals enable the state to govern legitimately the population in such a way that an individual’s capacity for self-determination is enhanced, while simultaneously being brought into line with overarching governing objectives.
The Governmentality perspective highlights the key role professions, such as medicine, have played in the governance of the population. In doing so, it adopts a similar critical view of the emergence of professionalism as a form of regulatory control as the neo-Marxist and neo-Weberian perspectives. Importantly, it reinforces the need for current debate surrounding recent challenges to the principle of professional self-regulation, to also consider the changing nature of the relationship between subject-citizens and the state, as a result of the political and economic re-emergence of liberalism since the mid to late-1970s. For the Governmentality perspective notes the ascendancy of the concept of the ‘enterprise self’ into all spheres of contemporary life. In doing so it highlights how challenges to the principle of professional self regulation and concurrent calls to reform elite regulatory bodies such as the GMC can be seen to be directed towards the object of Governmentality – the population in general and the individual subject-citizen in particular – as much as they are the medical profession. For medicine (and indeed the health and social care professions as a whole) form but one part of a complex array of governing calculations, strategies and tactics which seek to promote the security, wealth, health and happiness of the population. It is important for social scientists interested the study of the professions and professional regulation to recognise this fact. For changes in the conditions under which ‘good governance’ can be practiced within previously closed off public institutions such as the GMC highlight how society as a whole is currently undergoing a period of far reaching transformation. This in turn reinforces the fact that study of the professions and the principle of professional self-regulation must always remain grounded within broader sociological theorising concerning the nature of modern world in which we live.
