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August 12, 1988, Vol 260, No. 6 >
ARTICLE | August 12, 1988

Physicians and the Organizational Evolution of Medicine FREE

R. Clay Burchell, MD; Robert E. White, MD; Howard L. Smith, PhD; Neill F. Piland, DrPH
[+] Author Affiliations

Reprint requests to Department of Obstetrics and Gynecology, Lovelace Medical Center Inc, 5400 Gibson Blvd SE, Albuquerque, NM 87108 (Dr Burchell).


JAMA. 1988;260(6):826-831. doi:10.1001/jama.1988.03410060096035
Text Size: A A A
Published online
Article
References

Within medicine there is growing uneasiness and debate about changes in medical care delivery. Much of this concern centers on the evolution of organizations and the role of physicians. The emergence of multi-institutional organizations, the rise of investor-owned health care corporations, and the expansion of group medical practice illustrate the increasing organizational influence in medicine. Added to these trends are new financial incentives confronting both physicians and organizations so that the environment increasingly favors conflict. This article reviews the primary strategies for resolving physician-organization conflicts, including cooperation between physicians and organizations, having physician representatives in governance and management, restructuring incentives, and restructuring organizations. Although these strategies have various merits, we suggest that every physician has a personal responsibility to become more involved in organization and management issues. Physicians can play an important role in guiding the evolution of medicine.

(JAMA 1988;260:826-831)

REFERENCES

1 +
Fuchs VR:  The battle for control of health care . Health Aff , (Summer) 1982;, pp 5-13.
2 +
Relman AS:  The new medicine-industrial complex . N Engl J Med 1980;;303:963-970.
3 +
Glandon GL, Morrisey MA:  Redefining the hospital-physician relationship under prospective payment . Inquiry 1986;;23:166-175.
4 +
Kralewski JE, Dowd B, Feldman R, et al:  The physician rebellion . N Engl J Med 1987;;316:339-342.
5 +
Ottensmeyer DJ, Smith HL:  A new agenda for the practice of medicine . Front Health Serv Manage , (August) 1986;, pp 3-29.
6 +
Spivey BE:  The relation between hospital management and medical staff under a prospective-payment system . N Engl J Med 1984;;310:984-986.
7 +
Guncheon KF:  New battles, partnerships emerge for administrators, physicians . Hosp Med Staff , (March) 1984;, pp 24-27.
8 +
Friedman E:  Conflict or partnership? Matherlee looks at physicians and hospitals . Hosp Med Staff , October 1982;, pp 18-22.
9 +
Goldsmith JC:  MDs and hospitals: Conflict or partnership . Hosp Med Staff , (May) 1983;, pp 3-12.
10 +
Friedson E: Profession of Medicine . New York, Dodd Mead & Co Inc, 1970;.
11 +
Eisenburg JM, Williams SV:  Cost containment and changing physicians' practice behavior . JAMA 1981;;246:2195-2201.
12 +
Young DW, Saltman RB:  Medical practice, case mix, and cost containment . JAMA 1982;; 247:801-805.
13 +
Rothman RA, Schwartzbaum AM, McGrath JH:  Physicians and a hospital merger: Patterns of resistance to organizational change . J Health Soc Behav 1971;;12:46-55.
14 +
Hofer CW:  Toward a contingency theory of business strategy . Acad Manage J 1975;;18:784-810.
15 +
Kimberly JR, Miles RH (eds): The Organizational Life-Cycle . San Francisco, Jossey-Bass Inc Publishers, 1980;.
16 +
Quinn RE, Cameron K:  Organizational life-cycles and shifting criteria of effectiveness: Some preliminary evidence . Manage Sci 1983;;29:33-51.
17 +
Gray B, Ariss SS:  Politics and strategic change across organizational life cycles . Acad Manage Rev 1985;;10:707-723.
18 +
Kimberly JR, Zajac EJ:  Strategic adaptation in health care organizations: Implications for theory and research . Med Care Rev 1985;;42:267-302.
19 +
Scott WR:  Managing professional work: three models of control for health organizations . Health Serv Res 1982;;17:213-240.
20 +
Harris JE:  Regulation and internal control of hospitals . Bull NYAcad Med 1979;;55:88-103.
21 +
Ermann D, Gabel J:  Multihospital systems: Issues and empirical findings . Health Aff , (Spring) 1984;, pp 50-64.
22 +
Frederick L:  How you'll feel the money squeeze on hospitals . Med Econ , (Feb 4) , 1985;, pp 117-126.
23 +
Henderson SR, Odem RJ, Ginsburg KM: Medical Groups in the US 1980 . Chicago, American Medical Association, 1982;.
24 +
Morrisey MA, Brooks DC:  Hospital-physician joint venture: Who's doing what? Hospitals , (May 1) , 1985;, pp 74-78.
25 +
Richards G:  How do joint ventures affect relations with physicians? Hospitals , (Dec 1) , 1984;, pp 68-74.
26 +
Peters TJ, Waterman RH: In Search of Excellence: Lessons From America's Best-Run Companies . New York, Harper & Row Publishers Inc, 1982;.
27 +
Quintana JB, Duncan WJ, Houser HW:  Hospital governance and the corporate revolution . Health Care Manage Rev 1985;;10:63-71.
28 +
Chazan JA:  Institutional prerogatives and the private practicing physician: A changing partnership or the development of adversarial roles? RI Med J 1983;;66:285-287.
29 +
Mamana JP:  Corporate management model eroding physician influence in hospitals . Hosp Med Staff , (July) 1981;, pp 16-18.
30 +
Starr P: The Social Transformation of American Medicine . New York, Basic Books Inc Publishers, 1982;.
31 +
Friedson E:  The organization of medical practice , in Freeman HE, Levine S, Reeder LG (eds): Handbook of Medical Sociology . Englewood Cliffs, NJ, Prentice-Hall International Inc, 1972;, pp 343-358.
32 +
Moffit EM:  What's ahead for physicians? Am Med News , Oct 12, 1984;, p 4.
33 +
Tarlov A:  Shattuck lecture: The increasing supply of physicians, the changing structure of the health-services system, and the future practice of medicine . N Engl J Med 1983;;308:1235-1244.
34 +
Feldstein PJ: Health Care Economies . New York, John Wiley & Sons Inc, 1979;.
35 +
Rushmer FR:  Technological resources for health , in Williams SJ, Torrens PR (eds): Introduction to Health Services . New York, John Wiley & Sons Inc, 1980;, pp 227-255.
36 +
Shortell SM:  The medical staff of the future: Replanting the garden . Front Health Serv Manage , (February) 1986;, pp 3-48.
37 +
Relman AS:  The changing climate of medical practice . N Engl J Med 1987;;316:333-334.
38 +
Colombotos J:  Social origins and ideology of physicians: A study of the effects of early socialization . J Health Soc Behav 1969;;10:16-29.
39 +
Argyris C: Integrating the Individual and the Organization . New York, John Wiley & Sons Inc, 1964;.
40 +
Mowday RT, Porter LW, Steers RM: Employee-Organization Linkages: The Psychology of Commitment, Absenteeism and Turnove r. Orlando, Fla, Academic Press Inc, 1982;.
41 +
Barnard CI: The Function of the Executive . Cambridge, Mass, Harvard University Press, 1938;.
42 +
Culbert SA, McDonough JJ: The Invisible War: Pursuing Self Interests at Work . New York, John Wiley & Sons Inc, 1980;.
43 +
Katz D, Kahn RL: The Social Psychology of Organizations . New York, John Wiley & Sons Inc, 1966;.
44 +
Scott WG, Hart DK: Organizational America . Boston, Houghton Mifflin Co, 1979;.
45 +
Whyte WH: The Organization Man . New York, Simon & Schuster Inc Publishers, 1956;.
46 +
Simendinger EA, Pasmore W:  Developing partnerships between physicians and health care executives . Hosp Health Serv Admin Q , (November) -December 1984;, pp 21-35.
47 +
Regan TG:  Some limits to the hospital as a negotiated order . Soc Sci Med 1984;;18:243-249.
48 +
Hillman AL, Nash DB, Kissick WL, et al:  Managing the medical-industrial complex . N Engl J Med 1986;;315:511-513.
49 +
Campbell JP, Dunnette MD, Lawler EE, et al: Managerial Behavior, Performance and Effectiveness . New York, McGraw-Hill International Book Co, 1970;.
50 +
Randall DM:  Commitment and the organization: The organization man revisited . Acad Manage Rev 1987;;12:460-471.
51 +
Smircich L:  Concepts of culture and organizational analysis . Admin Sci Q 1983;;28:339-358.
52 +
ames LR, Jones AP:  Organizational climate: A review of theory and research . Psychol Bull 1974;;81:1096-1112.
53 +
Blanton WB:  Understanding differences between medical staff and administration . Hosp Med Staff , (December) 1981;, pp 15-21.
54 +
Landgarten S:  Cooperation will conquer competition . Hosp Med Staff , (September) 1983;, p 31.
55 +
Jacobs MO:  Administrators, boards, physicians must help change health system . Hospitals , (Aug 1) , 1978;, pp 78-80.
56 +
Fried BJ:  Collaboration, not co-optation . Can Med Assoc J 1986;;135:733-736.
57 +
Johnson RL:  CEO must have authority to coordinate governance, management, medical staff . Hosp Prog , (April) 1984;, pp 49-53.
58 +
Hofmann PB:  Physician-administrator collaboration slows hospital cost increases . Hosp Prog, (July) 1983;, pp 60-72.
59 +
Shortell SM:  Ten guidelines for success of hospital-physician partnerships . Mod Healthcare 1984;;14:132-136.
60 +
Wright S, Wright A:  A cooperative organizational form for hospitals . Health Care Manage Rev 1984;;9:7-19.
61 +
Shortell SM, Morrisey MA, Conrad DA:  Economic regulation and hospital behavior: The effects on medical staff organization and hospital-physician relationships . Health Serv Res 1985;;20:597-628.
62 +
Bragg JE, Andrews IR:  Participative decision-making: An experimental study in a hospital . J Appl Behav Sci 1973;;9:727-735.
63 +
Mitchell TR:  Motivation and participation: An integration . Acad Manage J 1973;;16:670-679.
64 +
Shull FA, Delbecq AL, Cummings LL: Organizational Decision Making . New York, McGraw-Hill International Book Co, 1970;.
65 +
Khandwalla PN: The Design of Organizations . New York, Harcourt Brace Jovanovich Publishers, 1977;.
66 +
Miller KI, Morge PR:  Participation, satisfaction and productivity: A meta-analytic review . Acad Manage J 1986;;29:727-753.
67 +
Tucker SL:  Does your hospital really care what you think? Med Econ , (July 19) , 1982;, pp 111-118.
68 +
Shortell SM:  Determinants of physician referral rates: An exchange theory approach . Med Care , (January) 1974;, pp 13-31.
69 +
Ottensmeyer DJ:  The prototype physician organization . Group Pract , (January) -February 1984;, pp 10-12.
70 +
Morrisey MA, Brooks DC:  Physician influence in hospitals: An update . Hospitals , (Sept 1) , 1985;, pp 86-89.
71 +
Schultz R:  How effective is physician participation in hospital management? Hosp Med Staff , January 1972;, pp 4-10.
72 +
Ferguson G:  Where's the credibility in hospital administrators? Can Med Assoc J 1985;;132:286-287.
73 +
Wallace C:  Physicians leaving their practices for hospital jobs . Mod Healthcare , (May) 1987;, pp 40-57.
74 +
Harris JE:  Regulation and internal control in hospitals . Bull NY Acad Med 1979;;55:88-103.
75 +
Young DW: Financial Control in Health Care: A Managerial Perspective . Homewood, Ill, Dow Jones-Irwin, 1984;.
76 +
Slater C:  Challenges of the physician manager's role , in Schenke R (ed): The Physician in Management . Falls Church, Va, American Academy of Medical Directors, 1980;, pp 71-78.
77 +
Royer J:  The dual role dilemma: A perspective in medicine , in Schenke R (ed): The Physician in Management . Falls Church, Va, American Academy of Medical Directors, 1980;, pp 79-82.
78 +
Chapman CB:  Doctors and their autonomy: Past events and future prospects . Science 1978;; 200:851-856.
79 +
Davis LL:  Professional collaboration in health care administration . Nurs Admin Q , (Summer) 1983;, pp 45-51.
80 +
Devereaux PM:  Does joint practice work? J Nurs Admin , (June 11) , 1981;, pp 39-43.
81 +
Gilliss CL:  Collaborative practice in the hospital: What's in it for nursing? Nurs Admin Q , (Summer) 1983;, pp 37-43.
82 +
Ritter RA:  Collaborative practice: What's in it for medicine? Nurs Admin Q , (Summer) 1983;, pp 31-
83 +
Gray BH:  Overview: Origins and trends . Bull NY Acad Med 1985;;61:7-22.
84 +
Rubin I:  Organizations have to grow up . Phys Exec , (March) -April 1987;, pp 2-6.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Fuchs VR:  The battle for control of health care . Health Aff , (Summer) 1982;, pp 5-13.
2 +
Relman AS:  The new medicine-industrial complex . N Engl J Med 1980;;303:963-970.
3 +
Glandon GL, Morrisey MA:  Redefining the hospital-physician relationship under prospective payment . Inquiry 1986;;23:166-175.
4 +
Kralewski JE, Dowd B, Feldman R, et al:  The physician rebellion . N Engl J Med 1987;;316:339-342.
5 +
Ottensmeyer DJ, Smith HL:  A new agenda for the practice of medicine . Front Health Serv Manage , (August) 1986;, pp 3-29.
6 +
Spivey BE:  The relation between hospital management and medical staff under a prospective-payment system . N Engl J Med 1984;;310:984-986.
7 +
Guncheon KF:  New battles, partnerships emerge for administrators, physicians . Hosp Med Staff , (March) 1984;, pp 24-27.
8 +
Friedman E:  Conflict or partnership? Matherlee looks at physicians and hospitals . Hosp Med Staff , October 1982;, pp 18-22.
9 +
Goldsmith JC:  MDs and hospitals: Conflict or partnership . Hosp Med Staff , (May) 1983;, pp 3-12.
10 +
Friedson E: Profession of Medicine . New York, Dodd Mead & Co Inc, 1970;.
11 +
Eisenburg JM, Williams SV:  Cost containment and changing physicians' practice behavior . JAMA 1981;;246:2195-2201.
12 +
Young DW, Saltman RB:  Medical practice, case mix, and cost containment . JAMA 1982;; 247:801-805.
13 +
Rothman RA, Schwartzbaum AM, McGrath JH:  Physicians and a hospital merger: Patterns of resistance to organizational change . J Health Soc Behav 1971;;12:46-55.
14 +
Hofer CW:  Toward a contingency theory of business strategy . Acad Manage J 1975;;18:784-810.
15 +
Kimberly JR, Miles RH (eds): The Organizational Life-Cycle . San Francisco, Jossey-Bass Inc Publishers, 1980;.
16 +
Quinn RE, Cameron K:  Organizational life-cycles and shifting criteria of effectiveness: Some preliminary evidence . Manage Sci 1983;;29:33-51.
17 +
Gray B, Ariss SS:  Politics and strategic change across organizational life cycles . Acad Manage Rev 1985;;10:707-723.
18 +
Kimberly JR, Zajac EJ:  Strategic adaptation in health care organizations: Implications for theory and research . Med Care Rev 1985;;42:267-302.
19 +
Scott WR:  Managing professional work: three models of control for health organizations . Health Serv Res 1982;;17:213-240.
20 +
Harris JE:  Regulation and internal control of hospitals . Bull NYAcad Med 1979;;55:88-103.
21 +
Ermann D, Gabel J:  Multihospital systems: Issues and empirical findings . Health Aff , (Spring) 1984;, pp 50-64.
22 +
Frederick L:  How you'll feel the money squeeze on hospitals . Med Econ , (Feb 4) , 1985;, pp 117-126.
23 +
Henderson SR, Odem RJ, Ginsburg KM: Medical Groups in the US 1980 . Chicago, American Medical Association, 1982;.
24 +
Morrisey MA, Brooks DC:  Hospital-physician joint venture: Who's doing what? Hospitals , (May 1) , 1985;, pp 74-78.
25 +
Richards G:  How do joint ventures affect relations with physicians? Hospitals , (Dec 1) , 1984;, pp 68-74.
26 +
Peters TJ, Waterman RH: In Search of Excellence: Lessons From America's Best-Run Companies . New York, Harper & Row Publishers Inc, 1982;.
27 +
Quintana JB, Duncan WJ, Houser HW:  Hospital governance and the corporate revolution . Health Care Manage Rev 1985;;10:63-71.
28 +
Chazan JA:  Institutional prerogatives and the private practicing physician: A changing partnership or the development of adversarial roles? RI Med J 1983;;66:285-287.
29 +
Mamana JP:  Corporate management model eroding physician influence in hospitals . Hosp Med Staff , (July) 1981;, pp 16-18.
30 +
Starr P: The Social Transformation of American Medicine . New York, Basic Books Inc Publishers, 1982;.
31 +
Friedson E:  The organization of medical practice , in Freeman HE, Levine S, Reeder LG (eds): Handbook of Medical Sociology . Englewood Cliffs, NJ, Prentice-Hall International Inc, 1972;, pp 343-358.
32 +
Moffit EM:  What's ahead for physicians? Am Med News , Oct 12, 1984;, p 4.
33 +
Tarlov A:  Shattuck lecture: The increasing supply of physicians, the changing structure of the health-services system, and the future practice of medicine . N Engl J Med 1983;;308:1235-1244.
34 +
Feldstein PJ: Health Care Economies . New York, John Wiley & Sons Inc, 1979;.
35 +
Rushmer FR:  Technological resources for health , in Williams SJ, Torrens PR (eds): Introduction to Health Services . New York, John Wiley & Sons Inc, 1980;, pp 227-255.
36 +
Shortell SM:  The medical staff of the future: Replanting the garden . Front Health Serv Manage , (February) 1986;, pp 3-48.
37 +
Relman AS:  The changing climate of medical practice . N Engl J Med 1987;;316:333-334.
38 +
Colombotos J:  Social origins and ideology of physicians: A study of the effects of early socialization . J Health Soc Behav 1969;;10:16-29.
39 +
Argyris C: Integrating the Individual and the Organization . New York, John Wiley & Sons Inc, 1964;.
40 +
Mowday RT, Porter LW, Steers RM: Employee-Organization Linkages: The Psychology of Commitment, Absenteeism and Turnove r. Orlando, Fla, Academic Press Inc, 1982;.
41 +
Barnard CI: The Function of the Executive . Cambridge, Mass, Harvard University Press, 1938;.
42 +
Culbert SA, McDonough JJ: The Invisible War: Pursuing Self Interests at Work . New York, John Wiley & Sons Inc, 1980;.
43 +
Katz D, Kahn RL: The Social Psychology of Organizations . New York, John Wiley & Sons Inc, 1966;.
44 +
Scott WG, Hart DK: Organizational America . Boston, Houghton Mifflin Co, 1979;.
45 +
Whyte WH: The Organization Man . New York, Simon & Schuster Inc Publishers, 1956;.
46 +
Simendinger EA, Pasmore W:  Developing partnerships between physicians and health care executives . Hosp Health Serv Admin Q , (November) -December 1984;, pp 21-35.
47 +
Regan TG:  Some limits to the hospital as a negotiated order . Soc Sci Med 1984;;18:243-249.
48 +
Hillman AL, Nash DB, Kissick WL, et al:  Managing the medical-industrial complex . N Engl J Med 1986;;315:511-513.
49 +
Campbell JP, Dunnette MD, Lawler EE, et al: Managerial Behavior, Performance and Effectiveness . New York, McGraw-Hill International Book Co, 1970;.
50 +
Randall DM:  Commitment and the organization: The organization man revisited . Acad Manage Rev 1987;;12:460-471.
51 +
Smircich L:  Concepts of culture and organizational analysis . Admin Sci Q 1983;;28:339-358.
52 +
ames LR, Jones AP:  Organizational climate: A review of theory and research . Psychol Bull 1974;;81:1096-1112.
53 +
Blanton WB:  Understanding differences between medical staff and administration . Hosp Med Staff , (December) 1981;, pp 15-21.
54 +
Landgarten S:  Cooperation will conquer competition . Hosp Med Staff , (September) 1983;, p 31.
55 +
Jacobs MO:  Administrators, boards, physicians must help change health system . Hospitals , (Aug 1) , 1978;, pp 78-80.
56 +
Fried BJ:  Collaboration, not co-optation . Can Med Assoc J 1986;;135:733-736.
57 +
Johnson RL:  CEO must have authority to coordinate governance, management, medical staff . Hosp Prog , (April) 1984;, pp 49-53.
58 +
Hofmann PB:  Physician-administrator collaboration slows hospital cost increases . Hosp Prog, (July) 1983;, pp 60-72.
59 +
Shortell SM:  Ten guidelines for success of hospital-physician partnerships . Mod Healthcare 1984;;14:132-136.
60 +
Wright S, Wright A:  A cooperative organizational form for hospitals . Health Care Manage Rev 1984;;9:7-19.
61 +
Shortell SM, Morrisey MA, Conrad DA:  Economic regulation and hospital behavior: The effects on medical staff organization and hospital-physician relationships . Health Serv Res 1985;;20:597-628.
62 +
Bragg JE, Andrews IR:  Participative decision-making: An experimental study in a hospital . J Appl Behav Sci 1973;;9:727-735.
63 +
Mitchell TR:  Motivation and participation: An integration . Acad Manage J 1973;;16:670-679.
64 +
Shull FA, Delbecq AL, Cummings LL: Organizational Decision Making . New York, McGraw-Hill International Book Co, 1970;.
65 +
Khandwalla PN: The Design of Organizations . New York, Harcourt Brace Jovanovich Publishers, 1977;.
66 +
Miller KI, Morge PR:  Participation, satisfaction and productivity: A meta-analytic review . Acad Manage J 1986;;29:727-753.
67 +
Tucker SL:  Does your hospital really care what you think? Med Econ , (July 19) , 1982;, pp 111-118.
68 +
Shortell SM:  Determinants of physician referral rates: An exchange theory approach . Med Care , (January) 1974;, pp 13-31.
69 +
Ottensmeyer DJ:  The prototype physician organization . Group Pract , (January) -February 1984;, pp 10-12.
70 +
Morrisey MA, Brooks DC:  Physician influence in hospitals: An update . Hospitals , (Sept 1) , 1985;, pp 86-89.
71 +
Schultz R:  How effective is physician participation in hospital management? Hosp Med Staff , January 1972;, pp 4-10.
72 +
Ferguson G:  Where's the credibility in hospital administrators? Can Med Assoc J 1985;;132:286-287.
73 +
Wallace C:  Physicians leaving their practices for hospital jobs . Mod Healthcare , (May) 1987;, pp 40-57.
74 +
Harris JE:  Regulation and internal control in hospitals . Bull NY Acad Med 1979;;55:88-103.
75 +
Young DW: Financial Control in Health Care: A Managerial Perspective . Homewood, Ill, Dow Jones-Irwin, 1984;.
76 +
Slater C:  Challenges of the physician manager's role , in Schenke R (ed): The Physician in Management . Falls Church, Va, American Academy of Medical Directors, 1980;, pp 71-78.
77 +
Royer J:  The dual role dilemma: A perspective in medicine , in Schenke R (ed): The Physician in Management . Falls Church, Va, American Academy of Medical Directors, 1980;, pp 79-82.
78 +
Chapman CB:  Doctors and their autonomy: Past events and future prospects . Science 1978;; 200:851-856.
79 +
Davis LL:  Professional collaboration in health care administration . Nurs Admin Q , (Summer) 1983;, pp 45-51.
80 +
Devereaux PM:  Does joint practice work? J Nurs Admin , (June 11) , 1981;, pp 39-43.
81 +
Gilliss CL:  Collaborative practice in the hospital: What's in it for nursing? Nurs Admin Q , (Summer) 1983;, pp 37-43.
82 +
Ritter RA:  Collaborative practice: What's in it for medicine? Nurs Admin Q , (Summer) 1983;, pp 31-
83 +
Gray BH:  Overview: Origins and trends . Bull NY Acad Med 1985;;61:7-22.
84 +
Rubin I:  Organizations have to grow up . Phys Exec , (March) -April 1987;, pp 2-6.

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