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Doctor's Orders Specialists' Day to Day Work and their Jurisdictional Claims in Dutch Hospitals Table of Contents Part 1 The Study and its Context, Concepts and Methods 1 1.1 1.2 1.3 1.4 1.5 1.6 The study Introduction Relevance National policy for jurisdiction in hospital: integration and participation Jurisdiction in specialist work: concepts Aim and central question: finding jurisdictional daims Research questions References Chapter 1 12 12 12 13 14 15 16 18 2 2.1 2.2 2.3 2.4 2.5 Specialists' work in history, at present, and in other countries Introduction The rise and development of speciatities The rise and development of modern hospitals Relationships between hospitals and specialists in a national context The present context of specialist work 2.5.1 Legislation 2.5.2 The health care system 2.5.3 Hospital - specialists relationships The international context Conclusion References Chapter 2 20 20 20 21 22 26 27 28 29 32 34 35 2.6 2.7 3 3.1 3.2 3.3 3.4 3.5 3.6 The research framework Introduction A journey through theories and concepts Professional work Professions and professionals in their context Negotiated order and jurisdiction The research framework 3.6.1 Studying the nature of specialists' day to day work in patient care 3.6.2 Studying specialists' day to day negotiations 3.6.3 Studying the 'structural context' of negotiations Conclusion References Chapter 3 40 40 40 42 44 48 49 49 51 54 55 57 3.7 4 4.1 4.2 Methods Introduction The case studies: 51 specialists 4.2.1 Selection of the peer groups 4.2.2 Case study design 4.2.3 Semi-structured observations and conversations 4.2.4 Processing, analysing and reporting data: four steps 4.2.5 The researcher in the case studies The surveys: 819 specialists 4.3 Themes in the surveys 4.3.2 Local surveys: pilots 4.3.3 The national survey Strengths and weaknesses of this study References Chapter 4 60 60 62 62 64 68 68 70 72 72 74 74 76 78 4.3 4.4 Part 2 Results Empirical prologue Introduction A working day in a medical speciality A working day in a surgical speciality A working day in a supporting speciality References 82 82 82 84 87 91 5 5.1 5.2 The nature of specialist work in patient care Introduction The nature of specialist work in patient care in medical specialities 5.2.1 Reasoning about individual patients 5.2.2 OPD and ward define times and places 5.2.3 Persons: patient 'ownership' and joint reasoning 5.2.4 Logistics: organising patient contacts The nature of specialist work in patient care in surgical specialities 5.3.1 Decision making about surgery on individual patients 5.3.2 OR, OPD and ward define times and places 5.3.3 Persans: focus on facts and joint decision making 5.3.4 Logistics: patient flows and availability of capacity The nature of specialist work in patient care in supporting specialities 5.4.1 Connecting the acts of inference about individual patients 5.4.2 Equipment defines times and places 5.4.3 Persans: short patient contacts and joint service 5.4.4 Logistics: synchronisation with other specialities Specialist work: results from the questionnaire Conclusion: the nature of speciatist work in patient care References Chapter 5 92 92 93 93 93 95 97 98 98 98 100 101 102 102 103 105 106 106 111 116 5.3 5.4 5.5 5.6 6 6.1 6.2 Negotiations in day to day patient care Introduction Negotiations in day to day patient care in medicat specialities 6.2.1 Entrance control at the pigeonhote for patients and probtems 6.2.2 Negotiations about logistics 6.2.3 Jurisdictional daims on content and contacts Negotiations in day to day patient care in surgical speciatities 6.3.1 Traffic control in patient care togistics 6.3.2 Negotiations about patient care 6.3.3 Jurisdictional daims on flows and decisions Negotiations in day to day patient care in supporting specialities 6.4.1 Position contrat in retationships with other specialities 6.4.2 Negotiations about togistics 6.4.3 Jurisdictional daims on professionat position and synchronisation Patient care: results from the questionnaire 6.5.1 Professional primacy and autonomy 6.5.2 Involvement in decision making about specialist patient care Conclusion: the negotiations and jurisdictional daims in patient care References Chapter 6 118 118 119 119 119 120 122 122 124 125 125 125 126 128 128 128 131 133 136 6.3 6.4 6.5 6.6 7 7.1 7.2 Specialist roles defined by relationships in the hospital Introduction The rote of peer 7.2.1 Pats and partners 7.2.2 Working the retationship network 7.2.3 The organisation of work: finances and output 7.2.4 The rote of peer: results from the questionnaire 7.2.5 Jurisdictional daims retated to the rote of peer The rote of department member 7.3.1 Department structures 7.3.2 Work itself 7.3.3 Space to work in, materials and equipment to work with 7.3.4 Being a lellow member' at the department 7.3.5 Positioning in retationships beyond department borders 7.3.6 The rote of department member: results from the questionnaire 7.3.7 Jurisdictionat daims related to the rote of department member The rote of staff member 7.4.1 The staff as a forum of positions 7.4.2 The staff as a starting point for organising work 7.4.3 The rote of staff member: results from the questionnaire 7.4.4 Jurisdictional daims related to the rote of staff member The rote of hospital member 7.5.1 The hospital as a forum of positions 7.5.2 The hospital as a starting point for organising work 7.5.3 The rote of hospital member: results from the questionnaire 7.5.4 Jurisdictional daims related to the role of hospital member 138 138 138 139 142 145 146 149 150 151 152 153 157 160 161 164 165 166 167 168 170 170 171 172 173 178 7.3 7.4 7.5 7.6 Specialist managers 7.6.1 The position of the speciatist manager 7.6.2 The manager-role in organising work 7.6.3 Non-managers about specialist-managers 7.6.4 The rote of specialist manager: results from the questionnaire 7.6.5 Jurisdictional daims related to the rote of speciatist manager Conclusion: specialist rotes defined by relationships in the hospital References Chapter 7 178 179 180 181 181 182 186 190 192 192 192 192 195 195 196 199 199 200 201 202 203 205 206 209 7.7 8 8.1 8.2 Specialist rotes defined by retationships outside the hospital Introduction The rote of individual 8.2.1 Individual specialists in intrapersonal negotiations 8.2.2 Retationships with peers 8.2.3 Taking care of career 8.2.4 The rote of individual: results from the questionnaire 8.2.5 Jurisdictional ctaims connected with the rote of individual The rote of professionat 8.3.1 Being an employee of the health care sector: worries about finances 8.3.2 Being a member of the profession: relationship with society 8.3.3 Being a member of a speciatity: shifts in speciatist care 8.3.4 The rote of professional: results from the questionnaire 8.3.5 Jurisdictional daims connected with the rote of professionat Conclusion: specialist rotes defined by relationships outside the hospital References Chapter 8 8.3 8.4 Empirical epitogue Introduction Contesting combinations in the medical specialities Contesting combinations in the surgical specialities Contesting combinations in the supporting specialities 210 210 210 211 211 Part 3 Conclusions and Discussion 9 9.1 9.2 Conclusions and discussion Introduction Conclusions 9.2.1 The nature of specialist work in patient care 9.2.2 Negotiations in day to day patient care 9.2.3 Specialist rotes defined by relationships in the hospitat 9.2.4 Specialist rotes defined by retationships outside the hospital 9.2.5 Specialists' negotiations and their jurisdictional daims 9.2.6 Validity 216 216 216 216 218 220 223 224 228 9.3 Discussion 9.3.1 Research issues 9.3.2 Discussion about specialists' day to day work 9.3.3 Recommendations and further discussion 9.3.4 Conclusion References Chapter 9 230 230 234 235 240 241 Appendices 1. 2. 3. Codes for the analysis of the nature of specialist work in patient care Codes for the analysis of negotiations and jurisdictionat daims Quotations concerning the researcher 244 244 248 253 Enquêteformulier The survey (in Dutch) 254 Dokterspraktijken Summary Dutch( Deel 1 Het onderzoek: achtergrond, theorieën en methodes Deel 2 Resultaten Deel 3 Conclusie en discussie Dankwoord 271 272 277 282 286 Curriculum Vitae 288