Bureaucratic flexibility : large organizations and the restructuring of physician careers

Abstract

This thesis contributes to theory and research at the intersection of professions, labor markets, and careers. To do so, it draws on longitudinal and cross-sectional data on physicians in different organizational arrangements. Physicians have been migrating into larger medical practice organizations over the past three decades, creating a valuable research opportunity. Previous writing on the professions and on careers implies that large, bureaucratic organizations constrain autonomy and are therefore anathema to professionals. Instead, I observe that many physicians find these larger structures to be emancipating because such organizations provide unique access to highly-valued career options. These career options are possible because large organizations have scale and systems that address a fundamental temporal problem for doctors: availability whenever the patient requires attention. With a pool of substitutes for the individual physician, and systems that facilitate patient hand-offs, the large organization offers a predictable schedule and moderate hours when compared with traditional private practice. As a result, large organizations open up an expanded portfolio of career options, including part-time clinician, and facilitate transitions between different roles. These career options are greatly valued within the current physician workforce, particularly among the growing ranks of female physicians and those physicians in dual-career families. The dissertation is organized into three papers. The first paper asks which types of physicians are employed in large organizations, testing two competing accounts from professions theory and careers research using national survey data.

(cont.) The second paper uses a longitudinal survey conducted by the author in order to investigate how different career options are utilized over time within one large medical practice organization. Finally, the third paper draws on detailed interview data from that same setting to document how the large organization enables schedule restructuring and, as a consequence, provides an expanded range of career options. Taken together, this work contributes to a new understanding of professionals, one that emphasizes heterogeneity in career interests and the possibility of meeting those interests through individually-tailored careers inside large organizations. By neglecting this individual heterogeneity, we risk assuming that the movement of professionals into large organizations will result only in dispirited practice. In contrast, through the lens of career diversity, bureaucracies actually take on a liberating character for many doctors. Similarly, while the careers literature has emphasized the flexibility of independent practice arrangements, I find physicians to value bureaucratic employment precisely because it accommodates their temporal career interests.