Physician Autonomy and the Paradox of Rationalization

Abstract

Tools meant to standardize and rationalize clinical practice have been widely used in healthcare institutions. One tool in particular, clinical pathways, has been a key component of the recent public hospital reform in China. Clinical pathways regulate how the core activities of the medical professional should be performed. Examining pathway implementation and physicians’ attitude toward them may shed light on the extent of discretion and autonomy physicians have in their core activities. Therefore, this study takes clinical pathways as a lens through which to study Chinese physicians’ work and autonomy and asks three questions: First, what is the attitude of physicians toward clinical pathways? Second, how are pathways implemented in physicians’ practice? And third, what are the determinants of physicians’ attitude? Both quantitative and qualitative data are used to explore the research questions. The quantitative data come from a survey of 158 physicians in three tertiary hospitals in two provincial capitals. The qualitative data are from all online discussions about clinical pathways on one of the most popular social networking websites for physicians and hospital administrators. The findings are consistent with the prediction based on sociological theorization of rationalization in professional work. Namely, there are two distinct dimensions in physicians’ attitude toward clinical pathways: physicians felt that pathways made their practice more scientific, but they also felt that the pathways were burdensome and restrictive. Physicians were in general heavily involved in the process of pathway implementation, and restrictive monitoring and sanctioning practices were relatively uncommon. Factors associated with pathway implementation were important predictors of physicians’ attitude, whereas professional orientation and concerns with the status of the profession had limited effect. Taken together, the findings from this exploratory study suggest that although physicians in China's public hospitals are dependent on their organizations, they retain considerable discretion in the implementation and use of clinical pathways. On the other hand, physicians’ views of clinical pathways are more prominently shaped by organizational factors than by their professional orientation.