A Tale of Two Hospitals: When Managerial Logic Faces Medical Profession

In recent decades, there has been a profound transformation in the realm of professional work, including its medical variant. A key component of this transformation has been the implementation of managerial logic into the field of healthcare across the world with the avowed aim of a more efficient and effective service provision and improved healthcare accountability and transparency through the use of tools such as clinical guidelines, consumer-driven supervision over medical work, output control methods, incentive schemes, and knowledge management systems. A large body of literature focused on the dynamics between professional practice and managerial logic in organizational settings and showed that the results of this encounter fall on a continuum between resistance to and compliance with managerialism. Nevertheless, this body of literature is marked by a triple limitation. First, most work in this tradition remains within the confines of hegemony/resistance framework, by assuming an inherent conflict between professional and managerial logics and by not paying enough attention to cases where they cooperate or coevolve. Second, there is a dominance of single-case studies and a lack of analyses that are based on comparative and multi-sited ethnographies. Third, there is a gap regarding how managerial policies affect organizational performance, and their impacts on the quality and accessibility of patient care. My paper aims at addressing these three limitations by comparing the diffusion of management principles, its interplay with professional identity and practice, and its effects on healthcare provision in two large public hospitals (I call as “Fortune” and “Grand” hospitals) in Istanbul, Turkey. It draws on data from a 10-months field research involving seventy-two in-depth interviews with physicians, administrators, and other health care workers as well as over 150 hours ethnographic observation. I find that although being under similar environmental pressures on the way they traditionally operate through the healthcare reform process, these two organizations respond to policy changes differently with different organizational outcomes. In Fortune Hospital, managerial and professional logics coevolve in compatibility as economic objectives are integrated into professional behavior, whereas in Grand Hospital they coexist in tension with a misalignment between managerial goals and physicians’ interests and motivations. I show that two key factors explain the different trajectories the two hospitals follow: Fortune Hospital managers’ successful intervention into moral economies and informal culture prevailing in the organization by alleviating status hierarchies among physicians and their mobilization of physicians around organizational goals while simultaneously fostering their clinical autonomy and patient-centered approach. I also discuss the impacts of the interplay of managerial and professional logics on organizational outcomes and nature of clinical practice as while compatibility of logics brings organizational efficiency and financial sustainability, there are indications of both under- and overtreatment and diagnosis in different realms of patient care.  This study contributes to medical and institutional/organizational sociology literatures by emphasizing that a successful managerial reform may rely on altering the informal structure in a given hospital and enabling physicians to relate to the moral content of their work, while also warning against unintended consequences on quality of patient care.