Academic journal article Health Sociology Review

The (Im)possibilities of Clinical Democracy

Academic journal article Health Sociology Review

The (Im)possibilities of Clinical Democracy

Article excerpt


The idea that all health care professionals medical, nursing and allied health - could be respected for their specific area of professional expertise and have equal voice in care-management decisions according to that expertise, remains, for most health care workers, an impossible dream. Medical dominance, as relevant in Australia in 2006 as it was when first described by Willis (1983) over two decades ago, works against multi-vocality in decision making within multidisciplinary clinical teams. The challenges to implementing clinically democratic modes of decision making appear to be no less complex and multifaceted now than they were twenty years ago.

Willis' original medical dominance thesis (1983, 1989) belongs to a body of work that regards the medical profession as mobilising selected means to restrict and exclude other professions from gaining legitimacy in the field of health care (Freidson 1970; Illich 1976; Larson 1977). Willis' historical analysis of medicine's professional relationship with neighbouring professions highlighted three specific modes of domination: subordination, which ensures other professionals conduct their work under direct control« from doctors; limitation, which restricts other professionals' access to important institutions; and exclusion, in which formal licensing processes deny official legitimacy. Since the book's appearance in 1983, analyses of medicine and its relationships with other professions and the state have appeared that have illustrated tendencies away from medical dominance, including proletarianisation (McKinlay and Stoekle 1988; White 2000), deprofessionalisation (Haug 1973), and a loss of public trust (Daniel 1994). More recently still, shifts in interprofessional boundaries (Freidson 1994), arising from the contemporary 'climate of workforce change' (Nancarrow and Borthwick 2005:914), have been interpreted as important challenges to medicine s original means of control (Nancarrow and Borthwick 2005).

Challenges to medical dominance have now been extensively documented (e.g., Boyce 2001; Braithwaite and Westbrook 2005; De Voe and Short 2003; Flynn 2002; Germov 2002; McKinlay and Marceau 2002). McKinlay and Marceau make a claim for the 'decline of the golden age of doctoring' (2002:379) in the USA on the basis of, among other things, increasing corporatisation and market control over doctors' practices (McKinlay and Arches 1985; McKinlay and Marceau 2002; McKinlay and Stoekle 1988). In the UK, changes in government regulation and health system governance are credited with diminishing clinical autonomy and increasing the visibility of what doctors do (Britten 2001:492).

In Australia, challenges to medical dominance have arisen through patient safety concerns (Germov 2002:293; Iedema et al. 2006b:1605) and increased health consumerism (Germov 2002:294; Iedema et al. 2006b:1606). According to Germov, it is: '[m]anagerialism in its general and clinical modes', as formulated in the introduction of Australia's clinical governance policies, which 'may represent the most effective challenge to medical dominance to date' (Germov 2002:300). Clinicians are increasingly expected to undertake administrative-managerial and organisational roles, and to engage in practice measurement and improvement and clinical error investigations (Boyce 2001; Braithwaite and Westbrook 2005; Iedema et al. 2006b). These organizational reforms have resulted in a 'reduced dominance of the previously universal medical model' (Boyce 2001:22) and shifted doctors' 'power vis-a-vis nurses and allied health professions' (Braithwaite and Westbrook 2005:11). This shift has not been even: although medical and nursing voices are now often well represented in management structures within Australian hospitals, allied health is less well represented at key decision making levels (Braithwaite and Westbrook 2005; Rowe et al. 2004:17).

This unequal representation has particular implications for the dynamics of multi-disciplinary health care teams, which are increasingly needed to provide complex, multi-factorial care to chronically-ill patients (Colombo et al. …

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