Abstract
Ethnographies are difficult to do well; however, Katherine Kellogg manages not only to navigate nuance but also to offer a presentation that is more about the underlying dynamic than about the example. In Challenging Operations, Kellogg compares and contrasts both the process and outcomes associated with the implementation of new work rules at three hospitals. While one might reasonably assume that the target audience of a book on medical reform would be healthcare scholars, Challenging Operations is an approachably written treatise on an easily conceptualized change effort that can effectively serve as a foundation for discourse on the challenges presented by all attempts to successfully implement large-scale organizational change.
The 120-hour work shift for surgical interns is a practice that dates back to the 1900s when, as Kellogg recounts, William Halsted established the surgical residency program at Johns Hopkins. At their inception, surgical residencies were constructed to offer an experience with a wide variety of cases as a means to build expertise quickly. If, as scholars have suggested, an individual needs 10,000 hours of experience to become an expert (Ericsson, Krampe, & Tesch-Römer, 1993), then traditional surgical programs seek to increase the likelihood of meeting that threshold before a resident completes their surgical residency through immersion.
It is therefore no surprise that the educators within the current surgical education paradigm would champion the existing system. As recounted by Kellogg, surgeons have invested significant effort to create a professional identity – one where personal responsibility for both the outcome and the process of surgical interventions is supported by an interlocking chain of command with the surgeon as its head. This hierarchy creates a series of interdependencies that further support role expectations. For instance, interns are responsible for insuring that routine laboratory and diagnostic work is carried out while chief residents are focused on ensuring the smooth functioning of the surgery service. However, the existing system has also raised significant concerns, particularly the relationship between resident fatigue and patient safety. Several high-profile cases involving avoidable deaths in hospitals attributed to errors associated with resident fatigue prompted policy action to address what was framed as a dangerous system for both the patient and the resident.
Kellogg succeeds in showing a multitude of perspectives on both the problem and the solutions that were offered. In the minds of some, the 120-hour system was a systemic problem that undermined patient safety. In the minds of others, a system that reduced the hours on site would result in an increase in the number of hand-offs, the process of shifting responsibility of a patient’s care from one person to another, that research had consistently shown to be the greatest source of patient safety errors. In the end, Challenging Operations recounts the dynamics between “Defenders” and “Reformers” that resulted in two of the three hospitals failing to successfully implement the legally mandated reforms.
“Iron Men” are surgeons of the old guard who view the process of surgery residency as both a proving ground and a rite of passage. “American surgeons and surgical residents have traditionally described themselves, and have been seen by others in and outside the hospital, as action-oriented male heroes who singlehandedly perform death-defying feats, courageously acting with certainty in all situations.” This perspective became one of the dominant frames for the behaviors of surgical residents – including the out-of-office characteristics of residents. Primarily men, the activities of surgical residents are described in relation to their role in the organization as well as the cultural expectation that surgeons act as “macho”.
The system under the Iron Men reinforced these roles. Interns were expected to serve the role of “workhorses” who were classified as “strong” when they took ownership of their patients’ care and demonstrated a responsibility for the outcomes of the patients under their charge. This meant managing all the laboratory work, diagnostics and complications of each patient under their charge. Most importantly, it meant that interns did not “hand-off” the responsibility for a patient in surgical care to another. That unwillingness to “hand-off” is presented as one of the professional pressures reinforcing the existing 120-hour workload.
Reformers, Kellogg notes, tended to be those individuals with the greatest to gain from the shifts in practice – female surgery residents, interns from other specialties, and male surgery residents who viewed themselves as “patient-centered”. Each of these constituencies had reasons for supporting changes in the existing system. Female surgery residents did not adequately emulate the traditional “macho” role by choice or design. Interns from specializations other than surgery who were conducting rounds in the surgical service are not vested in supporting the professional identity of surgeons. Finally, some male surgical interns framed the current system as antiquated in a “patient-centered” holistic and team-approach model of care.
As the reform process began, individuals who were against the adoption of a new system, referred to as “Defenders”, engaged in tactics to undermine changes. Defenders began to push back on proposed changes, both individually and collectively, using the tripartite strategy of “preempt, prevent and punish”. Referring to the program of redistributing job responsibilities, attending and defender residents used gossip as a means to “preempt” the use of a structured hand-off program by preemptively degrading those who used the new system as “weak” or “not committed”. Defender residents prevented the use of the new program by actively discouraging attempts to use the program or attributing failures under the hand-off system as a rebuke of the hand-off program’s core premise – that patient safety was better served under the new system. Finally, attending physicians and defender residents punished those using the program by withholding training or affiliation – two of the most important resources in the training of surgeons. In the first round, efforts by reformers at all the facilities were met with effective resistance, and as Kellogg puts it, the reformers were nearly defeated.
In isolated cases, reformers found success in what Kellogg calls “relational spaces” – buffered environments where individuals not only received positive feedback for reform efforts but experienced the absence of negative feedback as well. Two of the three facilities provided the necessary resources, safe spaces and accountability frameworks to overcome the initial resistance to change. Key to the process was the existence of reformers at multiple levels who served to redefine the existing hierarchical power structure, reframe accountability of the actors within the system and redefine the identity of what it meant to be a “good intern”.
Kellogg takes the reader through more back and forth between defenders and reformers. Defenders counter-organized against reformer efforts by denigrating both reformers and their practices as “weak”. In an environment where strength is seen as an important trait, these efforts can be effective. Defenders also sought to co-opt reformers. These two counter-approaches were seen as particularly effective at one of the two hospitals where relational spaces had been successful, in part because they effectively marginalized female reformer leaders. The point Kellogg makes is that the divisiveness around gender was a pre-existing condition to the reform; while it existed in both cases it was only successfully leveraged at one of the facilities.
With only one hospital still engaging in reformer activities, Kellogg closes by describing strategies employed by that group to ensure that defender efforts to undermine reforms were unsuccessful. Reformers redefined the social expectation of the surgical residents and interns. A team approach was implemented, where the surgeon’s metaphor was successfully transformed from “Iron Man” to “Coach”. In so doing, the metaphor drove the transformation of mental models to one where the team expanded to include more resources and the errors of hand-offs were minimized. While the shift was not without its problems, the team model eventually manifested a culture of ownership of both the outcome and the total process, with everyone having a newly defined role.
The depth of the ethnography as an approach to contrast these three very different experiences should not be underestimated. The ethnographic perspective in this book provides a striking and unforeseen benefit to Challenging Operations. As a result of the details presented, the book has a reach far beyond the traditional health management and policy audience. It presents a human resource problem – overworked interns – that is also an organizational problem, emerging from an existent culture. Kellogg concludes with an exploration of the institutional theories that might shed light on the dynamics presented in the three cases.
In discussing the case from an institutional theoretical perspective, she argues that “reform is driven by macro-level actors external to the organization” (Kellogg, 2011, p. 169). Kellogg then draws on institutional theory through four lenses: Neo-Institutional Theory, Law and Society Theory, Social Movement Theory and Medical Sociology. She submits that each of these theories inadequately addresses the dynamics seen, suggesting that the case sheds light on the strengths and weaknesses of each of these theoretic constructs.
Throughout the discussion she argues how institutional theory’s macro-level perspective ignores micro dynamics, advancing the concept of “micro-institutional” theory as an alternative framework that adds to the discourse. For instance, Kellogg argues that “change occurs because external reformers disseminate new practices across organization fields, circulate new compliance programs, create new frames, mobilizing structures, and political opportunities, and fight jurisdictional battles” (Kellogg, 2011, p. 170). She then submits that, for these change efforts to succeed, there are also “face-to-face collective combat processes occurring on the ground inside organizations” (Kellogg, 2011, p. 170). In summary, Kellogg argues that institutional theory is extra-organizational and that, to truly understand why change succeeds and fails, one must also account for intra-organizational dynamics.
The advancement of “micro-institutional” theory is one where scholars will find reason to debate the value of Kellogg’s contribution. One could argue that Kellogg fails to address how micro-institutional theory is not simply a label for the dynamics explored by traditional organization behaviorists. While a relatively minor part of the book in total, the theoretical framework assumes that a macro-level explanation must exist and hold in all three of these cases. I suggest two approaches to critiquing this argument. First, one could argue that the failure of institutional theory to adequately explain the different outcomes is to ignore the impact of existing dynamics.
If Kellogg wanted to use a macro-level theory that incorporated such dynamics, the theoretical framework offered by Complex Adaptive Systems (CAS) is a well-established, macro-level theory which offers a plausible explanation for the totality of the case as presented. The literature on open systems and self-managed teams is particularly relevant to the issue of structure and its relationship to power and conflict in systems. CAS scholars argue that, in any environment, there is a set of factors so interrelated that a change in one may create changes in the others. As factors of a system interact, members of the organization receive feedback on whether they are accomplishing their goals (Katz & Kahn, 1978). This feedback is especially apt in a context of contemporary dynamic systems that require participants to monitor and adapt to external changes to survive (Manz, 1992). Within this context, systems must themselves be able to adapt and such adaptation would be subject to the dynamics both intra- and extra-organizationally.
Challenging Operations offers the right mix of perspectives to keep the reader engaged, a plot that unfolds in a clearly understandable way and therefore an opportunity to engage others in discourse about the nature of large-scale change and the strategies one might employ. In the end, Kellogg’s case speaks to the old maxim “context matters”, and whether one chooses to explore that context through the lenses of institutional theory, organization behavior, or complex adaptive systems, such discourse, intelligently presented, is always welcome in the academy.