Organizational constraints as communicative variables in bureaucratic medical settings: A case study of patient-initiated referral talk in independent practice association-affiliated practices
Title:
Organizational constraints as communicative variables in bureaucratic medical settings: A case study of patient-initiated referral talk in independent practice association-affiliated practices
Author:
Freeman, Sarah H.
Appeared in:
Discourse processes
Paging:
Volume 10 (1987) nr. 4 pages 385-400
Year:
1987-10
Contents:
In complex, bureaucratized settings, organizational code tends to be highly elaborated and concrete, emphasizing the presence of organizational agendas in decision-making processes. In large, complex, bureaucratically-organized medical settings, providers and patients alike must regularly construct accounts that incorporate organizational agendas. By contrast, small-scale private practice has traditionally represented a more personalistic decision-making domain, wherein the physician's role has tended to dominate, not only as a locus of professional authority, but as a locus of organizational authority as well. Thus, bureaucratic medical settings and small-scale private practice settings have represented rather distinct organizational models, and their differences have been reflected interactionally. However, this situation is changing, due in part to the rapid rise in private practice of an economic model known as “contract medicine.” This model introduces powerful new organizational constraints on member settings and thus on interactions between member physicians and their patients. Although settings which undertake contract practice may subsequently look the same, and may employ the same numbers and kinds of personnel as they did formerly, participants must begin to include new organizational frames in their communicative activities in order to accomplish goals. For example, under contract medicine, referral to a specialist becomes a limited-access commodity: physician assumes the role of gatekeeper, and patient—in a new role as consumer—must be organizationally as well as medically persuasive in seeking referral. This paper examines the negotiation of specialty referral in two practices participating in contract plans. Analysis of such cases can help to sharpen our understanding of the relationship between locally-enacted, goal-oriented communicative tasks, and macro-level organizational processes.
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