Changing Logics in Healthcare and Their Effects on the Identity Motives and Identity Work of Doctors

Changing logics and their effect on professional identities in healthcare

Institutional logics refer to ‘organizing principles’ (Friedland & Alford, 1991, p. 248) guiding individuals, groups and organizations’ social construction and interpretation of their material and symbolic ‘realities’ and emotions (Durand & Thornton, 2018; Thornton, Ocasio, & Lounsbury, 2012). These logics shape organizational, individual and professional goals and identities, and the means of achieving them. However, this literature has also shown how institutional actors interpret and enact logics for different motives, at different times and in different ways (Gumusay, Smets, & Morris, 2019). Accordingly, it has provided valuable insights into healthcare change and the identity tensions created by multiple and coexisting logics (Cain, Frazer, & Kilaberia, 2019; Currie & Spyridonidis, 2016; Reay & Hinings, 2009). These insights have highlighted the coping mechanisms of clinical professionals, especially in developing hybrid professional roles as clinical leaders (Chreim, Williams, & Hinings, 2007; Kirkpatrick et al., 2009; McGivern et al., 2015; Waring & Bishop, 2013).

In healthcare it has been usual to identify shifting combinations of three societal-level logics – professional, market and corporate – available to professions and professionals (Freidson, 2001; Reay et al., 2017). Historically, a medical professional logic, based on the expert knowledge of high-status and autonomous doctors, has dominated how individuals, groups and organizations have viewed healthcare systems worldwide and decision-making within them. During the 1980s, however, when healthcare demands in many western countries outstripped governments’ willingness to fund them, market and corporate logics, associated with developments in bureaucratic control and new public management (NPM) (Fincham & Forbes, 2015; Iliffe & Manthorpe, 2018), became influential (Kirkpatrick, Kuhlmann, Hartley, Dent, & Lega, 2016) (see Table 1).

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Table 1.

Institutional logics operating in healthcare and their key features.

Institutional logic	Key features
Professional	• Expertise and autonomy • Quality of care is set by professional expertise
Market	• Laws of supply and demand determine the nature of the service provided • Quality is set by consumer demand
Corporate	• Bureaucratic rule-making by senior managers determines the nature and price of the service • Quality set by organizational targets and processes, and enforced by hierarchical managerial control
State	• Government determines the nature and price of the service in line with political priorities • Quality is set by legislation, government targets and accountable senior managers

Source: adapted from Reay et al., 2017.

Contemporary research has pointed to greater institutional complexity, identifying other important field and organizational logics (Fincham & Forbes, 2015). In healthcare systems subject to strong governmental and legislative pressures, a state logic has become influential (Kyratsis, Atun, Phillips, Tracey, & George, 2017; Reay et al., 2017). This state logic has manifested itself in two ways. First, the adoption by clinicians of the principle of mutuality, which proposes that patients should co-produce healthcare in collaboration with clinical professionals rather than have diagnosis, goals and treatments ‘done to them’ (Howieson, 2016). Second, the influence of a care logic (Fincham & Forbes, 2015). This care logic de-emphasizes the dominant medical narrative that constructs health service users as patients to be treated in hospitals, and promotes the notion of service users as ‘whole persons’ to be cared for, preferably through health prevention and community-based social care strategies (Kyratsis et al., 2017). The care logic and mutuality are increasingly sponsored by governments as the only sustainable ways forward to meet the complex demands arising from ageing populations with multiple medical and care needs. Thus, a state logic that seeks to integrate health and social care services has become pervasive in the United Kingdom (Kaehne, Birrell, Miller, & Petch, 2017). This development is having a fundamental impact in transforming how services are delivered and financed by diverting increasingly scarce economic resources away from the acute sector, particularly from hospital doctors, to primary and social care professionals. Such trends are especially evident in NHS Scotland, the site of our empirical work, which is subject to more direct state and legislative control than the National Health Service systems in England, Wales and Northern Ireland (Bevan et al., 2014; Pearson & Watson, 2018).

In this context, senior medical professionals in the acute sector are increasingly required to accommodate, reinterpret and integrate market, corporate and state logics into their professional identities and relationships with other clinical and care professionals (Pearson & Watson, 2018). Nevertheless, while logics have become central to the running of healthcare systems and organizations, they are not always seen as compatible with medical professionalism (Besharov & Smith, 2014). In the past, the medical literature explored the specific problems faced by doctors, who have enjoyed substantial degrees of autonomy when interpreting their role identities as expert professionals (Christmas & Millward, 2011). This literature focused on doctors’ interpretations and enactment of deprofessionalization, in which new logics were seen as incompatible with traditional medical-professional identities (Freidson, 2001; Pratt et al., 2006).

More recently, however, the identity work literature on doctors has pointed to three ways in which they exercise significant agency when responding to identity threats; that is, situations where they perceive that one or more of their preferred identity narratives are being challenged (Brown & Coupland, 2015). The first has emphasized how doctors have integrated new logics into their professional role identities – either willingly or incidentally – to become hybrid medical professionals (Chreim et al., 2007; Kirkpatrick et al., 2009; McGivern et al., 2015; Reay et al., 2017; Waring & Bishop, 2013). The second draws on the concept of co-optation, which refers to how institutional actors selectively adopt strategic elements from one logic that retains the essential features of their dominant logic (Andersson & Liff, 2018; Pache & Santos, 2013). In doing so, medical professionals may seek to regain control over their professional goals by borrowing the means from other logics. However, we should note that this integration may be smaller in scope and slower than some researchers assume (Bresnen et al., 2019; Spyridonidis et al., 2015; Von Knorring, Alexanderson, & Eliasson,, 2016) – a point to which we return in the discussion.

The third trend draws on the concept of liminality or being ‘in-between’ (Beech, 2011), whereby identity reconstruction undertaken by professionals is seen as partial under conditions of ambiguity. Thus, ‘identities can be thought of as temporary “fixes” concocted by individuals to impose a degree of coherence in the face of assorted vulnerabilities. . .’ (Brown, 2019, p. 10). To cope with such ambiguity and impermanence, doctors and other professionals engage in a dialogue with themselves and others (MacIntosh, Beech, & Martin, 2012) by experimenting with new identities, reflecting on the views of significant others, and recognizing new identities projected onto them by new discourses and logics (Beech, 2011). One good example of liminality is the ‘incidental hybrids’ in the study by McGivern et al. (2015) that highlighted a group of essentially traditionalist doctors temporarily occupying medical leadership roles.

Different types of identity work

Different identity motives generate different types of identity work (Lepisto et al., 2015). Although there are multiple definitions of identity work (Brown, 2015), most of these acknowledge the original definition by Snow and Anderson (1987, p. 14) who depicted it as ‘the range of activities individuals engage in to create, present, and sustain personal identities that are congruent with and supportive of the self-concept’. Vignoles et al. (2006, 2008) added a dynamic, temporal twist, suggesting that these activities involve cognitive, affective and social interaction processes, which must be understood within changing cultural and local contexts. In the professional context, Lepisto et al. (2015) saw professionals’ identity work involving three basic processes: retaining identities through maintaining, strengthening, affirming or stabilizing work; adding new identities by adopting, enhancing, embellishing or enriching work; and subtracting identities by deleting, losing or revising work. Thus, we define professional identity work as the cognitive, affective and social processes and tactics used by individuals, professional sub-groups and professions to add new identities, retain existing identities and abandon unwanted identities to form a dynamic and contextually bound self-concept. When professionals face identity threats arising from insecurities (Brown, 2019), they often draw on ‘retaining’ identity work to maintain continuity with the past, provide a continued sense of meaning or purpose, and build self-esteem. They may also use ‘adding’ and ‘letting go’ work (Brown, 2015; Petriglieri, 2011). Table 2 summarizes existing findings on responses to threats to professional identities, analysed according to ‘adding’, ‘retaining’ and ‘subtracting’ (or ‘letting go’) identity work.

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Table 2.

Response to threats through identity work.

Lepisto et al., 2015	Adding by: • Forming a new identity • Gaining a new identity • Enhancing an existing identity	Retaining by: • Maintaining an existing identity • Strengthening an existing identity • Affirming an existing identity • Stabilizing an existing identity	Subtracting or letting go by: • Deleting an existing identity • Losing an existing identity • Eliminating an existing identity
Petriglieri, 2011		Identity restructuring by• Changing importance of identity• Changing its meaning• Identity protection by• Discrediting others• Concealing true identity• Creating a positive-distinctiveness of existing identity in relation to the sources	Abandoning identity and associations
Kyratsis et al., 2017	• Incorporating new political/ social ideals	• New authentication claims• Reframing new identity in different lights	• Cultural repositioning
Reay et al., 2017		• Revealing the logics causing tension• Reinforcing the tensions• Reframing what it means to be a professional• Re-embedding the new logics
McGivern et al., 2015	• Integrating managerialism and medical professionalism	• Maintenance of medical professionalism• Representing and defending the medical profession• Regulating medical professionalism	• Challenging medical professionalism

What underlies most of these forms of identity work, however, is the notion of legitimacy, which has been defined as a ‘generalized perception or assumption that actions of an entity are desirable, proper and appropriate within some socially constructed system of norms, values, beliefs and definitions (Suchman, 1995, p. 571). Legitimacy strategies lie at the heart of identity work narratives identified by Kyratsis et al. (2017), McGivern et al. (2015) and Reay et al. (2017), which we explore in our findings.

In summary, the literature on institutional logics, identity motives and identity work helped us frame our questions on the differences between the identity motives and identity work of doctors who fail to incorporate new logics into their professional role identities, and those who succeed in doing so, and why these differences exist. In the next sections, we describe our methodology, present our findings and analyse them through a new, inductively generated framework showing the links between institutional logics as identity triggers, identity motives, identity work and potential identity work outcomes.

Data analysis

The interviews were analysed inductively by members of the research team using a common method, employing NVivo 11 (QSR International, 2015), to move back and forth between the data, the relevant literature on institutional logics and professional identity work, and our emerging theoretical framework (see online Table 3: Data structure) (Gioia, Corley, & Hamilton, 2012). We began our analysis using open coding (Strauss & Corbin, 1998) of the interview transcripts to identify first-order codes, typically beginning with consultants’ descriptions of issues they raised, which we occasionally recoded as a consequence of our knowledge of the relevant literature. This first-order coding was followed by axial coding into more abstract, second-order conceptual categories. Axial coding was assisted by our literature review of institutional logics, professional role identity motives and identity work in medicine and other professions (see online Table 4).

We aggregated these second-order conceptual categories into four theoretical dimensions to explain how and why consultants responded to pressures from changing logics. These dimensions were: (1) identity motives leading to the rejection of changing logics; (2) identity motives leading to the integration of changing logics; (3) identity work processes and tactics used to reject changing logics as part of their professional role identities; and (4) identity work processes and tactics to integrate new logics into their professional role identities. Finally, we analysed the backgrounds of consultants to compare them according to their identity motives and identity work (see online Table 5).

Traditionalist consultants’ identity motives

The most striking identity motive narrated by traditionalists was a threat to their efficacy to treat patients arising from a loss of medical autonomy and control. They narrated their sense of purpose purely as dedication to patient care:

My motivation is patient-centred not management-centred. . .managers obviously have their targets and their waiting list targets but I have my thoughts on who needs the appointments the most, and those differ. (IntB1-LCPhys)

I realize. . .the bottom line is largely financial; however, my bottom line is patient care. (IntC8-MCPhy)

Traditionalists interpreted the incursion of corporate and state logics as a threat to the overarching aim of the medical profession to prioritize patient care, while at the same time appreciating financial constraints on the health service. They regarded high-quality patient care as best guaranteed by traditional medical professionalism, defined by doctors’ expertise, professional status and autonomy to make care decisions within the confines of an individual doctor–patient relationship (Reay & Hinings, 2009; Reay et al., 2017). Consequently, interviewees often narrated their accounts of their employers’ actions as ‘real and present’ threats to their professional role identities:

Traditionally doctors would have thought of themselves as relatively autonomous and I think we’ve lost most of the autonomy now. . .so we’ve put piles of management into it but it’s not actually making the place efficient, so we’re counting more, we’re measuring more, we’re manipulating things more. (IntA2-LCPhys)

Most criticism, however, arose from the direct influence of the Scottish government’s policies and legislation. Performance-related, patient waiting-time targets in particular were cast as misguided ‘populism’, generating unrealistic expectations among the public and interpreted as an intrusion into consultants’ professional independence and judgement. Stories of problematic and direct control by Scottish government were ubiquitous among these consultants, despite recognizing that the government had made manifesto commitments to improve service access and reduce healthcare inequalities, and that the media had a legitimate role in holding healthcare providers to account. The following extract shows how a strong political discourse and alleged government interference were appraised as incompatible with interviewees’ identity motives to remain as autonomous medical professionals, especially notable in interviews with later-career consultants:

The targets and the government standards are set, then the senior managers have things that they’re then required to do and the things that they choose to do. . .but it doesn’t translate at all well into patient care, face-to-face. . .the staff in general enjoy seeing patients and it demoralizes and demotivates them to have excessive bureaucracy. (IntA12-LCPsycML)

The above quote emphasizes traditionalist consultants’ overriding sense of efficacy in caring for patients where targets often conflicted with consultants’ judgements over which patients to treat and when to treat them. Thus, one later-career surgeon gave an account of the dysfunctional consequences of waiting times:

Managers obviously focus on quite narrow targets. . .In medicine, you have ethics to think about and we know which patients we would like to treat earlier, but with the target culture of course, everyone is treated the same, irrespective of the. . .urgency of their condition. (IntA8-LCSurg)

Avoiding a loss of self-esteem is a key motive in professional projects (Suddaby & Viale, 2011). This motive is particularly evident in research on the status of doctors in healthcare and society (Bartram et al., 2018; Kyratsis et al., 2017). The aforementioned surgeon later explained how a corporate logic had diminished the status of the medical profession in his eyes:

Medicine is no longer the profession it once was and. . .undoubtedly medical professionals have been devalued, not only directly and financially, but also in terms of their status within hospitals. . .Now, people can’t wait to retire and I include myself in that. (IntA8- LCSurg)

Many traditionalists narrated similar diminishing self-esteem, both personally and professionally. The following quote also illustrates how traditionalists saw their expertise and professionalism being devalued compared with unqualified (in the medical sense) managers, unusually, this time, discursively related by an early-career consultant:

I had a meeting with the Chief of Medical Staff, the Chief of Nursing Staff and the Hospital Manager about the concerns I’d raised with two aspects of care. One was the nursing staffing levels. . .and the other was the decanting of patients inappropriately overnight. . .So the bed manager overnight took the decision to move elderly, frail, fragile patients from those wards into the [. . .] unit and as a result three of those patients had delayed discharges. I brought that up and I was told to shut up. Literally told to shut up. . .despite the fact that I had the evidence. (IntC15-ECPhys)

Seeking continuity with a past era when medical professionals enjoyed autonomy and power is another widely discussed identity motive (McGivern et al., 2015). This continuity with the professional values of the past is evident in the following quote, evoking a ‘world we have lost’ narrative, redolent of later-career traditionalists:

Twenty years ago there was much more self-determination, I think, by consultants. You were appointed to a job, you were there until you retired and you were left to get on with it and you shaped that job the best way you could to deliver the best service you could for your patients. . .whereas now everything that we do is micromanaged, it’s inspected very closely and it’s measured against targets. . .not targets that we would set ourselves as clinicians. . .one of the beauties of medicine is the fact that in the past certainly with so much clinical freedom there was very much more a challenge to each person as an individual to weigh up the evidence, talk to the patient, weigh up the patient, try and think of what was the best thing to do. . .The way that it is in medicine is that we qualify as doctors because we want to be doctors and we don’t want to be managers, we didn’t set out to do that. (IntB5-LCPhys)

Romanticization of the past was often accompanied by feelings that junior doctors currently do not experience the same type of professional development as their predecessors, which may influence their future views of medical professionalism.

Traditionalist consultants’ identity work

Traditionalists are engaged in delegitimizing and legitimizing identity work to affirm their professional identities as the principal guardians of patient care. Delegitimizing was underpinned by three narratives that sought to diminish or destroy the legitimacy of new logics. First, traditionalists engaged in constant discursive efforts to discredit bureaucracy and non-clinical managerialism, which arose from the incursion of corporate and state logics. Often these stories sought to distance themselves from non-clinical managers (Martin, Beech, MacIntosh, & Bushfield, 2015):

The huge dislocation between managers and what actually happens on the ground so I might go to strategy meetings, I might go to health board meetings. . .we talk about strategy design. . .and the individuals in the room, I look around and I think they don’t know what they’re talking about, they don’t know. (IntC1-MCPsyc)

I would make a distinction between medical managers and non-medical managers. . .I’ve got no problem with the medical management side of things, it’s the non-medical managers who are desperate to be seen to be doing something but it’s not always the right thing and they don’t always ask because we’ll tell them that. . .Well I feel quite disempowered and less enthusiastic about my job, I would definitely like to be looking at service developments in line with the government’s key priorities but I’m unable to do so because I’ve been sidelined. (IntC4-LCPhys)

Both of the above quotes can also be interpreted as consultants asserting their own traditionalist expertise by defining themselves by who they were not – as managers who ‘don’t know what they are doing’, and so should make better use of clinicians’ knowledge to improve patient experience.

A second narrative was used to diminish the role of medical elite bodies. One key explanation of deprofessionalization among doctors in the UK is the influence of medical elite bodies, such as the General Medical Council (GMC) and medical royal colleges, which seek to regulate the profession (Kirkpatrick, 2016). Traditionalists’ narratives were frequently critical of their effectiveness, as illustrated by a later-career consultant:

The GMC has [influenced my practice] a lot because it’s stepped up the paperwork trail with revalidation. . .so it adds a lot more time. . .people now feel they have to spend a lot more time doing that and look at job plans. . .The colleges I think are used to regulate. . . there’s a lot more demonstration that you are fit enough to be a trainer or a supervisor. . .you have to show that you are a suitable person to be trained, I think a lot of people feel the actual test that they provide doesn’t actually mean very much because people have these qualities or they don’t. (IntC5-LCPhys)

By characterizing these elite bodies, and their strategies of appraisal and revalidation, as a threat to medical professionalism, the above quote also illustrates important identity work in disconfirming the legitimacy of elite bodies and casting the process of internal regulation either as irrelevant or self-defeating in not sifting out ‘the worst doctors’. Traditionalists frequently narrated stories of how ‘adverse incidents’ involving doctors were not prevented by increasing internal bureaucracy.

A third, and perhaps the most surprising, narrative strategy of delegitimization used by traditionalists was discursive attempts to discredit medical leaders. This narrative strategy was the most overt expression of resistance used to define traditionalists by who they were not, and in casting doubt on the widely promoted notion of medical professional ‘leaderism’ (Iliffe & Manthorpe, 2018) as a solution to healthcare reform. Some of the hybrid literature has pointed to medical leadership being seen positively by doctors, who are thought to wish for more doctors in leadership positions (Kirkpatrick et al., 2016; Numerato, Salvatore, & Fattore, 2012). Our data not only question the role of medical leaders in doctors’ reprofessionalization, but also the motives of willing and incidental hybrids (McGivern et al., 2015). Few traditionalists provided accounts of medically trained leaders doing an effective job in improving service delivery or in representing patients’ interests to senior managers. Instead, traditionalists’ narratives were aimed at discrediting the professional and social identity changes that appointees to medical leadership positions were seen to undergo – literally becoming ‘different people’ when taking on these roles. The following quote illustrates this marked professional values conflict between traditionalists and those consultants who pursued medical leadership careers.

There’s a suspicion. . .some of the senior medical hierarchy will go with the flow or with the policy because they will be rewarded later on. At a local level, this can be with discretionary. . .awards but you see it even at high levels. Many doctors who help a government report will get an OBE [an honorary title conferred by the Queen], or if you sit on a certain committee and support government policy, you’ll get a knighthood. As a result, I think many younger consultants feel their medical leaders. . .do not represent them. They get so high up in the system that rewards them that they become part of the management system rather than representing doctors. (IntB6-LCPhys)

The narrative of doctors having crossed to the ‘dark’ rather than the enlightened side, often attributed to their needs for personal gain and rewards or a failure to be a ‘good doctor’, was espoused by traditionalists, usually but not always by later career consultants without medical leadership experience. As part of this narrative, trust in medical leaders’ competence, integrity and benevolence was frequently queried (Schoorman, Mayer, & Davis, 2007). Distrust was expressed over medical leaders’ motivations and values because they had ‘sold out’ by accepting the centrality and compatibility of multiple logics:

And then the management chip gets implanted in them and they forget about being a doctor. . .associate medical director and up. . .they then cease to be like doctors and then become part of management. (IntA2-LCPhys)

If I have a leader, I like to be able to know that I trust the leader to make decisions. . .whereas with my medical colleagues who go into management I’m not sure that I do. (IntB9-LCPhys)

Though many traditionalists accepted the legitimacy of the ‘office’ of medical leadership, they were sceptical of the motives of doctors who chose to become medical leaders and were reluctant to follow them. Most saw those who sought and gained such positions as the ‘wrong people for the wrong reasons at the wrong times’ in their career:

I think certain clinicians should go into leadership but not necessarily those clinicians that apply for the leadership roles. . .We’ve got a culture which. . .allows younger clinicians to be managers. . .The trouble is, it does encourage people who see it as a quick way to power and to self interest, and perhaps because they don’t actually like their clinical jobs. . .for the reason that they can’t do it. (IntA8-LCSurg)

Incorporated consultants’ identity motives

Incorporated consultants were the mirror image of traditionalists in their identity motives and identity work. We believe this finding might be explained by them having a more mixed, career-stage background – but not, surprisingly, from a greater likelihood of experience of medical leadership roles. One noteworthy theme emerging from the interviews with incorporated consultants lay in their narration of the efficacy motive as efficacy for system-wide effectiveness rather than purely patient care. In contrast to traditionalists, incorporated consultants narrated a motive to ‘move with the times’: to create a different healthcare system that recognized the contribution of managers, medical leaders, and service-user expectations. The following extract from a later-stage consultant showed how he was motivated to accept a more pluralistic view of the health service and to work with managers and service users to improve the healthcare system:

I knew that nowadays. . .to change things, to improve your service. . .there is no way you can do it on your own. There is no way that you can make anything better for patients without engaging with your managers. . .the relationships with your service managers are much better, which ultimately allows you to bring all your services together. (IntC11-LCSurg)

Another identity motive that characterized incorporated consultants was their changed sense of meaning expressed through new medical professionalism. Incorporated consultants’ identities were typically characterized by a version of medical professionalism that embraced changing logics, especially in legitimizing doctors’ needs to be responsive to the management of an increasingly resource-constrained service. Their narratives usually showed they were more inclined to integrate the multiple logics underpinning the values, strategies and organization of modern healthcare organizations into their role identities. A later-career consultant reasoned:

I’m not in the least bit anti-manager. . .a lot of doctors, they’re anti-manager. I’ve worked as a manager. I think some of them [think]. . .nobody has it as hard as doctors and managers have it easy. Yet, when you go into medical management you realize. . .the stresses are different, but they are just there in just exactly the same way. The idea that an organization as big and as complex as the NHS shouldn’t be managed is just ludicrous. (IntD8-LCPsycML)

Therefore, his identity motives were consistent with his taking up a medical leadership position and to accept the need of a managerialist health service. Alongside incorporated consultants’ needs to seek new meaning was the motive for distinctiveness by breaking with the past’s ‘outdated’ medical professionalism. The following quote shows how one mid-career consultant defined his distinctiveness beyond a focus on patient care to seek diversity in his roles:

I definitely feel more engaged in the process as I have a vested interest. That doesn’t mean there’s not days when I feel demoralized and feel I’m banging my head against a brick wall. . .I think the more you feel you’ve got buy-in and you work together, I think the more committed you become to the job. . .I do a lot of teaching and education, leadership, clinical practice. . .what gives me pleasure is the diversity. (IntC1-MCPsyc)

Another early-career consultant set out some of the managerial and bureaucratic role prescriptions for new consultants, which showed his early acceptance of multiple logics and distinctiveness from traditional professionalism:

So we’re working hard on being more recognized. . .we have a good few young consultants here, who are very dynamic. . .One, in particular, is an excellent manager, you could call him, almost. He’s got a very good understanding of the NHS politics, and government politics, and he’s a very good advocate. (IntA1-ECPhys)

Incorporated consultants occasionally invoked the baseball metaphor of ‘stepping up to the plate’ to transform a healthcare system constrained by ‘old-style professional power’. These consultants distanced themselves from traditionalist colleagues by articulating a version of medical professionalism that embraced managerialism. One mid-career medical leader opined this could be achieved by ‘gently giving more managerial responsibility to clinicians as they mature through their career’ (IntA19-MCPhysML).

Incorporated consultants’ experiences of working with changing logics also led them to voice a new sense of esteem derived from being leaders of their profession. Although recognizing shifting logics sometimes resulted in tensions, they rarely saw these as threats to their professional identities, status or wider social standing. Most suggested that working in medical leadership had allowed them to influence change positively for the benefit of patients and emphasized the need for leadership as part of doctors’ training. This new narrative was particularly evident among early and mid-career incorporated consultants but, as the nextquote shows, was also evident among some later-career leaders.

Clinical leadership is going in the right direction, but more thought has to be given to getting the right or best ones in post and also getting people at the right time. . .building in training when doctors are in their 30s (mid-career) would be beneficial. This would mean that they can develop these skills over time before having to deal with the pressures of a dual role. (IntD2-LCPhys)

Incorporated doctors sought to co-opt elements of managerialism into their new professional role identities and used phrases such as ‘stepping up’, ‘driving the vision’ and ‘taking the lead’. Indeed, some consultants saw obtaining a position as a medical leader either as a natural progression or as a way out of the routine nature of medical practice.

Incorporated consultants’ identity work

Incorporated consultants also engaged in delegitimizing and legitimizing identity work, but it was a mirror image of traditionalists’ efforts. These types of identity work build on the ideas of Besharov and Smith (2014) and Lepisto et al. (2015) on integrating new identities.

Legitimizing drew on two narrative strategies. The first was a narrative in support of managerialism, which was seen as being necessary to reform healthcare systems. Incorporated consultants’ identity work often attempted to legitimize the role of non-clinical managers and to articulate why consultant colleagues needed to change their approach by working in partnership with them:

I think as clinicians with the patients that we have autonomy. . .We are occasionally approached to say, does this person need to come in today or not. . .that’s not an unreasonable thing to do and [managers] do listen to what you say. . .it comes back to that partnership and if partnership works well it’s a good team and if it doesn’t work well you will always be clashing. (IntD6-LCPhys)

Incorporated consultants discursively related how easy it was to blame managers because they had responsibility for implementing difficult financial and political decisions, but argued that mutual respect between doctors and managers was essential to deliver effective healthcare:

There is a closer liaison with doctors and managers. . .when you’re able to explain your position to them, generally speaking managers are able to respect you for your opinion and take you on side. . .Doctors still have a degree of standing, at least in my experience, I am still leading the team. . .every team I suppose has to have a leader who is able to take things forward and take the patient’s side. (IntB13-MCPhys)

In contrast to the distrust expressed by traditionalists, the above quote highlights how incorporated consultants were more trusting of the motives of managers. Moreover, it illustrates the view held by incorporated consultants that leadership was integral to their identity as a consultant. This leads to a second narrative strategy of legitimization, which lay in relating medical leadership as new medical professionalism. Thus, as several participants suggested, medical leadership sought to temper traditional medical professionalism by taking multiple stakeholders’ interests into account:

My job is to be the patients’ advocate and the advocate for my staff. I think the manager’s job is to work for the organization. . .it’s important there are good relationships. (IntD6-LCPhys)

Delegitimization also drew on two narrative strategies. The first lay in a need to reframe medical professionalism in a different light (Kyratsis et al., 2017). Incorporated consultants related that gaining a new identity meant letting go of traditional identities, one of which surrounded the traditional hierarchical relationship between medical professionals and other clinical professions, especially nursing staff. Discarding hierarchy and status among clinical professionals, and also within medicine itself, was frequently articulated as essential for medicine to reprofessionalize itself:

The word deprofessionalization has a. . .connotation of ‘we think we’re the best and we should be in charge of everything’. . .There is a historical view of doctors and I think there is still a lot of senior consultants around. . .those are the people I mean who are struggling with the idea that you can sit in a [specialist] team meeting and for two of the nurses to say, we don’t like the way you are running your clinics because we don’t think it’s best for the patients. . .[Some consultants] find that very challenging. . .personally that’s not an issue for me. (IntB12-LCPhys)

Reframing medical professionalism, therefore, lay in effective collaboration and mutual respect between professionals and managers, which was crucial to effective patient care.

A second delegitimizing narrative was underpinned by a need to let go of traditional identities (Lepisto et al., 2015). This narrative not only discredited the concept of traditional medical professionalism but also distanced incorporated consultants from traditionalist colleagues who were hanging on to a ‘world we have lost’ by responding negatively to reform of healthcare systems in their hospitals:

I wouldn’t call them deprofessionalized; I would call them thoroughly unprofessional. They have obligations to the organizations which pay them, and they just don’t get it. (IntA22-LCPhysML)

Often these became narratives of despair over the general state of affairs in their hospitals and the lack of engagement among their consultant colleagues in bringing about change and innovation in their clinical practice. These accounts were frequently accompanied by identity work to lay claims to leadership and change of the profession:

So we met [senior doctors on a development programme] and we brought them together to hear how their learning, this investment we’d made in them over the year, was making a difference. . .It was just devastating actually because. . .it was this tale of woe that nobody was coming to them and asking for their help and support. . .There was this business of waiting to be invited in, whereas my experience had always been, see the problem, map out two or three potential solutions. (IntA19-MCPhysML)

Finally, Besharov and Smith (2014) point to integrative work as a key strategy in coping with multiple logics. By integrative work, they meant the ability to combine the effects of logics and integrate them into the day-to-day functioning of individuals and groups, as illustrated here by an early-career consultant:

There’s the two extremes, I guess. The very critical person, who checks everything that you’re suggesting, and then the other person, who is, ‘Whatever you say, Doctor’, and just do it. . .That’s a very important part to patient care. . .we’re talking about patient-centred care. You’re trying to respect their wishes, as much as you can – and their habits, their character. (IntA1-ECPhys)

The notion of patient-centred care was common across the interviews, with many incorporated consultants emphasizing the need to involve patients in mutual decision-making:

Society, patients in general feel that they should be more involved with their treatment, rightly so. . .The changes that have taken place in the NHS in the last twenty years have been stellar. . .The number-one priority has always been the patient. . .not our professional self-esteem, nor our professional standing, nor our financial remuneration. (IntD10-LCPhys)

The above extract further emphasizes the desire to involve patients, along with the view that contemporary professionalism involves speaking out for patients rather than self-interest.