Paper info

A Study of the Relationships among Medical Practitioners in Commercial and Conventional Medical Practices: A Qualitative Comparison

Brian Jonmundsson and Ken Miller

The paper was published at the 19th IMP-conference in Lugano, Switzerland in 2003.

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Medical practice in Australia is changing. Medical practitioners in small to middle size ?conventional? family practices are being given large financial incentives to join ?one-stop? commercial medical practices. The enticements are attractive. They involve giving up a large part of the work that is associated with the administration of their own practices, to have that work taken over by clerks, receptionists, and other assistants. Staff is rostered so that medical practitioners are able to take time off from work, and plan their holidays. Higher levels of medical specialisation are often available in such practices, and inward referral is quick and easy. Other facilities are often in close proximity, such as a pharmacy and pathology. Trained nurses are on hand to take over routine, but relatively, minor medical procedures. And the use of sophisticated procedures such as CAT scans and, through referral to an in-house specialist, MRIs can, depending on the size of the commercial practice, be done within the company.In a series of continuing focus groups, it was evident that one of the main attractions for medical practitioners of joining a commercial practice was the fact that the administrative burden of running a conventional family practice was taken off their shoulders. Other attractions have already been alluded to, but expressed in another way, amounted to a greater degree of personal independence, time with family and friends, financial security in the form of an attractive and steady income, with on some occasion's additional financial incentives, and membership of a superannuation scheme. In addition, in some commercial practices, the holding company offers on-going, in-house education that gives medical practitioners credit points that they must collect for continuing registration.However relationships have changed for these doctors who have been acquired by larger medical corporations. As relationships mature, they might tend to be characterised by increasing and symmetrical levels of commitment and mutual adaptations. However, relational evolution does not necessarily follow this path (Ford, 1980; Dwyer, Shurr and Oh, 1987), with some mature relationships being distinguished by asymmetrical distributions of dependence and commitment. As Wilkinson and Young (1994) have found, there are many different kinds of relationships that have varying degrees of competition and co-operation that may be classed as successful. So far, in a series of six focus groups, it was apparent that there was a substantial divide and difference between medical practitioners who had joined commercial organisations, and those that had stayed in the more conventional setting of the family practice. The criticisms levelled at those that had joined the commercial medical organisations were concerned with a number of issues, the main ones being listed below:o The concern with profit rather than patient care: It was clearly pointed out by those who were opposed to commercial medical practices that the job of a medical practitioner in such an organisation was contribution to profit (somewhat) at the expense of patient care, although this was not qualified sufficiently, and needs to be explored further.o The loss of community: The conventional medical practice was, and continues to be, in many cases, the centre piece of the community, particularly, in rural Australia, with medical practitioners and their staff knowing patients on first name terms. The argument was made that commercial medical practices had lost such a standing in the community, and were nothing more or less than one-stop-shops, with little if any in the way of a personal relationship between the patient and the medical practitioner.o Loss of collegiality: The critics of medical practitioners who had been 'seduced? into joining commercial medical practices had lost their sense of collegiality; that, in fact, such medical practitioners were ?in it for themselves?, and were not ?interested? in working to advance the wellbeing and professional satisfaction that arose from working as a team. o The Machine Organisation: Mintzberg (1996) talks about the ?Machine Organisation?, one that is set up to process inputs into outputs quickly and efficiently. Although, opponents did not use that term, there was an insinuation among medical practitioners in family medical practices that commercial medical practices were set up to process patients as quickly as possible. The relationships among medical practitioners in the commercial setting appears to be, on the face of it a informal, loosely-structured relationship, to the extent that a practitioner has less professional, and non-professional (friendship) contacts with colleagues than medical practitioners in the more conventional medical, family practices. The infrastructure of the commercial organisations appears to make the medical practitioner less dependent on his colleagues; and where there are cases beyond his/her capabilities, he/she is able to refer, often, internally, to a specialist who can relieve him/her of the responsibility. And this, it seems, can be done relatively quickly, without going outside the organisation. Specialised facilities are available to medical practitioners, such as CAT scans, and via a referral from a specialist, most likely a practitioner in the practice, MRIs can be ordered as required.The situation in the commercial medical practice is not all negative with respect to fostering relationships. Facilities such as medical workshops and ongoing medical education are provided by some companies, and are certainly made available in different ways by the pharmaceutical companies. Medical practitioners from commercial operations are able to meet their colleagues at such events, as well as meeting medical practitioners who work in the more ?conventional? family practice setting. Restrooms and other facilities exist, as they do in family medical practices, where medical practitioners can rub shoulders with their colleagues in an informal setting.When medical practitioners join a commercial medical organisation, they must know that they join a practice in which profit is a significant driver. In some commercial medical practices, inward referrals are encouraged, which tends to increase the income to the firm. The relationships that are formed in commercial medical practices appear to be more superficial than those that are formed in conventional family type practices where the infrastructure is less, and there appears to be more dependence on colleagues, and a greater formation of medical networks via referrals outside the practice, as well as (in the case of medical practitioners in the commercial setting) attendance at in-house as well as external conference, and meetings with sales people from pharmaceutical companies.. Commercial organisations in Australia are continuing to aggressively recruit independent doctors to join their medical practices.Further data will be obtained through the conduct of an additional six focus groups utilising medical practitioners. Three focus groups will be comprised of independent family medical practitioners and three will comprise corporatised medical practitioners. The transcripts from these interviews will be analysed using both NVIVO and Leximancer(2003). Leximancer is a data-mining tool that can be used to analyse the content of collections of textual documents and to visually display the extracted information. Desision systems analysis (DSA) will also be used through ?direct research? (Mintzberg 1979) to uncover the nuances in the streams of conversations, behaviours, and decisions occurring in the textual data. These qualitative analysis techniques will provide insights into medical practitioner and patient relationships under differing corporate governance conditions.