Doctors: Clinician, Entrepreneur or both?

A move away from our traditional style of content this week, I stumbled across this academic journal research paper about one of Doctology's favourite topics, Doctors as Entrepreneurs - but are they mutually exclusive? And how do they cope with being both?


The authors of this piece kindly gave me permission to post in full, with the original accessed here.


Sit back, grab a big cup of coffee and dive deep into Reconciling doctor as clinician and doctor as entrepreneur: the information practices and identity work of early career surgeons.


*****


IRinformationresearch.

published quarterly by the university of borås, sweden.


vol. 24 no. 3, September, 2019.


Proceedings of RAILS - Research Applications, Information and Library Studies, 2018:

Faculty of Information Technology, Monash University, Australia, 28-30 November 2018.


Reconciling doctor as clinician and doctor as entrepreneur: the information practices and identity work of early career surgeons.


By Shona Gallagher and Michael Olsson.


Introduction. The study examines the information practices of early career surgeons. Methodologically, it uses critical discourse analysis in conjunction with two social constructivist theories, Lloyd's information practices and Alvesson and Willmott's identity regulation and identity work.

Method. In-depth, semi-structured interviews were conducted with early career surgical specialists transitioning from accredited training to private practice. Participants were asked how they navigated two professional contexts in constant tension: doctor as clinician and doctor as entrepreneur.

Analysis. Interview transcripts were reviewed by an inductive process approach of constant comparison.

Results. Participants engaged in different information practices whilst functioning in different professional contexts. They described the difficulty of being caught between two worlds and revealed encounters with taboo subjects surrounding surgical fees. The information practices of participants not only involve problem solving or information acquisition but are also inextricably linked to the construction of their professional identity.

Conclusions. The findings suggest that critical discourse analysis is a useful tool for exploring the organisational control of professions. It suggests a strongly entwined relationship between information and identity practices and raises questions about the value of everyday life as a library and information science research concept.


Introduction

This article reports the findings of a study of the information practices of early career surgeons transitioning from training to working in private practice. In particular it focuses on the information practices participants use when trying to make sense of their role as business managers. Findings show that the information practices of early career surgeons prompt them to review what it means to be a good doctor.


The study is based on in-depth interviews conducted with six early career surgeons. Australia has a two tier health system offering public and private care. Surgeons work in both these environments. There is professional prestige attached to a public teaching hospital appointment which traditionally translates to a business advantage. These positions are usually held for the duration of a surgeon’s career. Hence, there is fierce competition among early career surgeons for a public hospital appointment, particularly a public teaching hospital appointment. Competition is further fuelled by a decreasing number of public teaching hospital positions, an increasing number of medical graduates, and lengthier training periods. Only a small number of surgeons derive 100% of their income from the public sector. The majority earn most of their income in the private sector and are effectively self-employed (Royal Australasian College of Surgeons, 2016). Australia is the only country in the Organisation for Economic Co-operation and Development (OECD) that allows doctors complete price freedom (Paris, Devaux, and Wei, 2010).


When working in private practice, surgeons are simultaneously engaged in two roles in constant tension: doctor as clinician and doctor as entrepreneur. Of particular interest to this study is the contrast in the training surgeons receive for these two roles. To qualify as a clinician they engage in an average of twelve years of training, must pass fellowship exams in order to be admitted to the surgical college which trains and regulates their specialty, and must demonstrate continuous engagement in professional development throughout their career. In their role as doctor as entrepreneur they receive no formal training and are only offered limited, optional workshops from their governing professional colleges. The Australian Competition and Consumer Commission (ACCC) Act of 2010 prohibits surgeons from discussing fees with one another unless they practise through the same legal entity (Australian Competition and Consumer Commission, n.d.).


Participants in this study described encountering taboos when they tried to approach senior colleagues for guidance and information about setting fees and running a private practice. Participants also described great difficulty in navigating the tension between the two roles of doctor as clinician and doctor as entrepreneur. Reflecting upon these tensions led many participants to question what it means to be a good doctor and to review the type of doctor they wanted to be. This indicated that participants reviewed their professional identity as a result of their information practices.


In order to better understand professional taboo topics and identity construction, the original research question exploring the information practices of early career surgeons navigating the two contexts of doctor as clinician and doctor as entrepreneur was expanded to the following;


1. How does the surgical profession shape the information practices of surgeons?

2. What is the role of identity construction in the shaping of their information practices?


Conceptual framework

The present study builds upon information practice research which focuses on the role of social practices in shaping the behaviour of individuals (Lloyd, 2010; McKenzie, 2003; Savolainen, 2007). Lloyd defines information practices as:


An array of information-related activities and skills, constituted, justified and organized through the arrangements of social site, and mediated socially and materially with the aim of producing shared understanding and mutual agreement about ways of knowing and recognizing how performance is enacted, enabled and constrained in collective situated action (Lloyd, 2011, p. 285).


The present study also joins other library and information research which engages with critical discourse analysis as both a methodology and a theory in the Foucauldian tradition (Johannisson and Sundin, 2007; Olsson and Heizmann, 2015). Critical discourse analysis has been described as the link between power and discourse (Clegg, 1989; Grant, Iedema, and Oswick, 2009; Talja, 1999). It draws upon the work of poststructuralist theorists such as Bourdieu, Derrida, Foucault and Lyotard to argue that the actor-agent is simultaneously influenced by and plays a central role in power relations (Fairclough and Wodak, 1997). To illuminate these power relations, critical discourse analysis uses various forms of textual analysis (Fairclough, 1992).


Foucault's work has been most influential on informing critical discourse analysis. For Foucault, language in the form of discourses constitutes object and subjects. Discourses arrange the social world in ways that inform social practices. These social practices constitute forms of subjectivity in which human subjects are given what is perceived to be a rational, self-evident form that manages who they are and what they do (Foucault, 1976, 1980; Grant et al., 2009).


The manner in which Foucault influences critical discourse analysis acknowledges the importance of the relationship between discourse and power and makes it an attractive proposition for information practice researchers. Information practice researchers Heizmann and Olsson (2015, p. 757) note that 'Collaborative ways of interacting among peers are as much the product of specific power relations as excessive knowledge hoarding and influencing tactics.'


The present study focuses attention on the relationship between information practices and professional identity. Academic definitions of profession and professionalism have been debated in recent decades among management, organisation, sociology and medical education scholars (Birden et al., 2014; Saks, 2012). Traditionally, professions are seen as institutional entities governed by codes of ethics and professing commitment to competence, integrity, morality, altruism and the promotion of the public good within their expert domain.


Foucault (1973, 1979) adopts a more critical approach centred on governmentality. In this view, the professions are seen as social constructions of power/knowledge involving the 'institutionalisation of expertise', in which professional bodies, teaching institutions, hospitals etc. become central actors in the discursive landscapes of the professions with which they engage. Individual members of a profession must construct their own professional knowledge and identity in the context of the rules and norms defined and policed by these institutions. This discourse analytic way of constructing the nature of the professions has strongly influenced the present study.


Previous information science studies have explored the information behaviour and information practices of medical professionals when participants are functioning in the role of doctor as clinician. Information behaviour studies have typically focused on the information seeking behaviour of surgeons and physicians (Booth, Carroll, Papaioannou, Sutton, and Wong, 2009; Clarke et al., 2013; Grant, 2017; Ward, Stevens, Brentnall, and Briddon, 2008). Discursive studies involving doctor-patient relationships have been conducted by information practice researchers; however, the focus of these studies has been on the information practices of patients rather than those of medical practitioners (Andsager and Powers, 2001; Dervin, Harpring and Foreman-Wernet, 1999; Godbold, 2012; McKenzie, 2002, 2003; Tuominen, 2004). Bonner and Lloyd (2011) studied the information practices of renal nurses performing clinical responsibilities and Johannisson and Sundin (2007) explored discourses at work in the nursing profession which shape knowledge claims.


In their study of health care and other types of professionals, Leckie, Pettigrew and Sylvain (1996) acknowledge different roles, associated tasks and information behaviour among professionals but do not take a discursive approach. Their definition of a health care system does not include the business, financial, policy development, governance or regulatory elements of the system. The Leckie et al. study, and others previously mentioned here, note that medical professionals use a variety of information sources when addressing their information needs. These sources are multi-faceted and range from authorised guidelines and academic journals to seeking the opinion of more experienced colleagues (Leckie, et al., 1996).


Iedema, Degeling, Braithwaite, and White's 2004 study of doctor-managers explores how doctors navigate the tensions between their profession and organisation, specifically the public hospital and area health service that employs them. They conceptualise doctors as functioning in the roles of doctor as clinician and doctor-manager. The study explores language within interview data as a means of identifying discursive boundaries used by doctor-managers to mitigate their reluctance to impose organizational rules upon fellow clinicians. Iedema et al.'s study engages with one doctor-manager participant in each of three formal management settings of similar context. In each of these settings the doctor-manager is a senior member of their profession, functioning as an employee of the broader hospital research site. The researchers acknowledge that 'despite these differences, each setting induced sacred, front-stage talk, rather than profane, off-the-record talk' (Iedema et al., 2004, p. 28). In contrast to that study, the interview data collected in the present study includes candid talk, direct acknowledgement of the difficulty of navigating between the two worlds of clinical and entrepreneurial work, and more detailed descriptions of how participant information practices are shaped by their profession.


Shunning discussion of particular subjects is a form of information avoidance and is the result of negative emotions giving rise to anxiety and fear (Chatman, 1992; Savolainen, 2014). Sociologists broadly agree that taboo subjects and activities current in any society tend to be significant to the social order. They are usually avoided in order to avoid causing embarrassment or offence. Within library and information science, the topics of shame, secrecy and stigma have been most thoroughly explored by Chatman in her studies of information poverty. Findings in our study suggest similarities between the information landscape of early career surgeons searching for information relating to the business side of their practice and Chatman's information poor participants. This raises the surprising possibility that early career surgeons are similar to Chatman's elderly retirees, janitors and single mothers in regard to being made and kept information poor by the accepted discursive practices and social norms operating within their profession. Chatman (1996) claims that information poverty is reinforced among information poor groups who identify as outsiders 'by neglecting to accept sources of information not created by themselves' (p. 193). The social nature of taboos and the means by which they are enforced demonstrate the importance of exploring the social aspects of information practices in order to understand the context of any individual's actions.


Identity and professional identity have previously been studied by information science researchers. Given (2003) used social positioning theory to explore the social construction of stereotypical student identities and the ways that mature students interact with available discourses and the implications for their information behaviour. Hicks (2014, 2016) studied the professional identities of librarians with a focus on professional identity construction surrounding library advocacy and the value of exploring professional identity to provide insight into why professionals behave the way they do. Both studies acknowledge the interconnection between identity construction and information practices. The present study continues this exploration.


Identity research is now considered 'a critical cornerstone' (Brown, 2015, p. 22; Cerulo, 1997, p. 385) in contemporary sociological and social psychological theorising (Elliot, 2001; Gleason, 1983). The identity theory enlisted in this study is Alvesson and Willmott's (2002) concepts of identity regulation and identity work, jointly referred to here as identity practices. Alvesson and Willmott describe identity regulation as a form of organisational control which incorporates the intentional and unintentional action of management to influence employees' self-constructions of identity. One of the nine key modes of discourse listed in their theory of identity regulation is 'knowledge and skills'; 'knowledge defines the knower: what one is capable of doing (or expected to be able to do) frames who one "is". Education and professional affiliation are powerful media of identity construction' (Alvesson and Willmott, 2002, p. 630). Identity work is the fluid and continuous process of accepting or rejecting identity regulation (see Figure 1).



Figure 1: Identity regulation, identity work and self-identity from Alvesson and Willmott (2002)


Method

Gallagher conducted semi-structured in-depth interviews with six early career surgeons transitioning from training to establishing their careers in private practice. The participants, all Fellows of the Royal Australasian College of Surgeons (RACS), came from two surgical specialties; general surgery, and plastic and reconstructive surgery. Four participants were female, two were male. Four worked in a combination of private and public practice and two worked exclusively in private practice. The average age was thirty-seven years.


The interviews ranged from fifty-five to eighty-six minutes long with an average length of seventy-two minutes. After general questions about why they became a doctor, participants were asked to describe how they navigated the dual roles of medical practitioner and business operator. They were asked how they set fees, where and to whom they turned when they had questions or needed help, and whether or not they considered themselves entrepreneurs.


Gallagher recruited participants through several purposive sampling methods, including criterion sampling whilst attending the 2018 RACS Annual Scientific Meeting and a variation of criterion snowball sampling. Participants had to meet the following criteria:


1. Fellow of the Royal Australasian College of Surgeons (RACS) or equivalent surgical training college;

2. Have been admitted to RACS within the past five years;

3. Have entered or be in the process of considering entering private practice;

4. Have completed their specialist surgical training in Australia.


The interviews were recorded, transcribed verbatim style and annotated by Gallagher in regard to professional jargon. Gallagher has worked with surgeons on a daily basis for more than twenty years in her capacity as co-director, co-founder and co-owner of a private surgical practice attached to a Sydney public teaching hospital. Gallagher analysed the data in consultation with Olsson using an inductive approach of constant comparison.


Names of the participants have been changed to protect their identity. Pseudonyms have been chosen from the list of most popular boys and girls names in Australia in 1983, the year of participants' birth based on their average age.


Findings

Participant interviews typically progressed from straight forward, relaxed narratives describing information practices in the role of doctor as clinician to fraught and emotional narratives describing the difficulties and obstacles encountered in the role of doctor as entrepreneur.


Patterns in accounts of information practices


Participants provided extremely rich accounts of their information practices. They described great difficulty navigating the two roles of clinician and entrepreneur. These difficulties were sometimes matters of practicality, for example, an inability to find an authoritative or definitive source. At other times, the difficulties were ontological as participants tried to balance expectations with reality.


Practical difficulties: no official guidelines


Descriptions by participants of their information practices while functioning in the role of doctor as clinician were unsurprising. They were consistent with the evidence-based pedagogy of their training and usually included talking to colleagues and referring to academic journals. Here Amanda responds to being asked to what or whom she turns when she has questions about the clinical aspects of her practice:


Clinically, I read journal articles. I look up, I look up a journal article because I think journal articles are - all my colleagues internationally are, like, there for me. Like they – so here's my series of a thousand patients for this operation, so if I'm ever not sure, I just read, which is what we used to do when we were training, right, because you can't call your boss for everything and then, then if you ask one person, you're limited by their experience, whereas if you internationally seek data then that's better, you're researching it and I think, like, you're a strong believer of that. (Amanda)


Amanda searched for similar resources when she tried to address her information needs in the role of doctor as entrepreneur. In the following excerpt she describes her experience trying to determine the best way to set her fees:


So I called the College [RACS], 'Okay, what are your guidelines about setting up a practice?' and they said, 'It's our job to train you to be a surgeon. It's not our job to train you to run a practice.' (Amanda)


This account is also typical. Participants described starting the process of answering their questions by searching for formal guidance and instructions. They described searching for resources online and over the phone by contacting their training colleges and professional societies. They also described attempting conversations with their more experienced colleagues. As participants exhausted formal information sources, participants turned to informal sources:


So basically, we Googled, like the top – like five average surgeons in Sydney, some of which published their prices and I went, 'Okay, let's go half to 75% of their fee'.... I haven't had a guideline. (Amanda)


Most participants described engaging with financial advisors, lawyers and accountants for professional advice but not in regard to setting fees. Typically participants used their personal experience as paying customers of other trades and services to justify their fees. Comparisons included plumbers, other trade professionals, and event managers:


And so, you – you're really stuck, you're really stuck, so you do spend some time having a crisis of conscience trying to figure out, how to go about things, and then you kind of spend time thinking about, 'How I'm going to – how, how I rationalise this in my head?' and then, eventually, you call a plumber to come and quote you for something at home or you ask a tradie to come for whatever reason and you – your jaw drops when they tell you the price that they charge, and then you think to yourself, You know what? I'm actually dealing with people's health. Like I'm actually trying to extend their lives, relieve their pain, you know, suffering. (Christopher)


The locum: learning while working in another doctor's practice


All but one of the participants in this study had worked as a private locum or were employed at the time of the interview as a locum in another doctor's private practice. In a typical locum position, the locum does not work in the practice at the same time as the doctor who employs them. The participants described learning a great deal about private practice from their locum experiences, including clinical and business practices of which they did not approve. Their descriptions of interactions with practice staff also revealed status distinctions between themselves and individuals they did not consider to be performing clinical functions. These signals of self-identified hierarchical location are an example of identity work. They are also signals of knowledge ranking. In the description below the participant asserts her superior clinical knowledge to discount a request from a non-clinical manager:


I had someone come to me and tell me I had to cut down my – the length of my letters and I find that really difficult as well, so. That it was taking them too long to go through, to edit my letters, and that GPs [general practitioners also known as primary care physicians] didn't want long letters and that I should therefore cut them down and put it as bare bones and that didn't sit very well with me …. So, it came down from – so, the person who spoke to me about it was sort of a practice manager, but not. She like was in the middle between the surgeons and the practice manager. And it had come from one of the surgeons. There's like the chief surgeon, I guess, in the practice. And I thought, I'm not your lackey… So, it really riled me up and that was the second defining moment where I said, 'This is n