The strategic defense of physician autonomy: State public health agencies as countervailing powers

Forces to Be Reckoned with: Countervailing Powers and Physician Emotional Distress during COVID-19

The "countervailing powers" framework conceptualizes health care as an arena for power contests among key stakeholders, drawing attention to the moves, countermoves, and alliances that have challenged physicians' dominance since the 1970s. Here, we focus on one of the lesser known micro-level consequences of such forces for physicians: emotional distress. We draw on 145 interviews with frontline physicians across four U.S. cities during the COVID-19 pandemic to trace physicians' experiences with three countervailing forces: the state, health care organizations, and patients. We find that threats to physician dominance eroded physicians' sense of mastery (perceived personal control) at work, thereby prompting emotional distress, including anger and moral conflict. Conversely, in certain cases, acts of resistance may have helped increase mastery, thus moderating distress. Our findings advance the countervailing powers framework by elucidating some of the micro-level, personal consequences of macro-level power struggles and offer practical implications for understanding contemporary threats to physician dominance.

Countervailing powers in the labor room: The doula-doctor relationship in the United States

How do health professionals with fundamentally different philosophies toward health, and different status levels, manage power in their work relationships? This paper argues that taking a negotiated order interactionist approach, which contends that the social order shapes behavior but is continuously negotiated through social interactions, and synthesizing it with a countervailing powers perspective can yield insight into the power dynamics between health professionals. It focuses on the birth field, with attention to the relationship between two very different types of birth professionals: obstetricians and doulas. Unlike doctors, who maintain a dominant place in health care and subscribe to a biomedical perspective of birth, doulas hold a low-status position and take a holistic approach toward birth, which may cause conflict in the labor room. In-depth interviews with 43 birth doulas based in the US (May-July 2018) found that the doula-doctor relationship is a complex story of power, deference, and countervailing responses. Doulas reported that doctors are more receptive to them now than in the past but that this is an outcome of creative countervailing responses involving deferential maneuvers and direct challenges to physician authority. Doulas' strategic management of their relationships with health professionals has allowed them entry to the hospital, permitting them to represent a holistic voice in the labor room. A minority of doulas have begun to develop relationships with doctors that constitute a collaborative approach toward birth care, indicating that changes in standard care are possible. By revealing how a subordinate actor can challenge physicians and effect change in care, this study contributes to scholarship seeking to understand the nature of unequal relationships between health professionals in a context of biomedical dominance.

Physicians' perceptions of autonomy support during transition to value-based reimbursement: A multi-center psychometric evaluation of six-item and three-item measures

BACKGROUND

Successive health system reforms have steadily eroded physician autonomy. Escalating accountability demands placed on physicians concurrent with diminishing autonomy plus widespread "cost cutting" endanger clinical work-life quality and, in turn, threaten patient-care quality, safety, and continuity. This has engendered a renewed emphasis on bettering physician work-life to safeguard patient care. Research indicates that autonomy support could be an effective intervention point in this dynamic, and that improving healthcare practitioners' experience of autonomy can promote better patient outcomes. New measures of autonomy support towards physicians during systemic/organizational transformation are thus needed.

OBJECTIVE

We investigated the validity and reliability of two versions of a brief measure of physicians' perceptions of autonomy support.

DESIGN

Psychometric evaluation of practitioners' responses to a theory-based, pilot-tested, multi-center, cross-sectional survey-questionnaire.

PARTICIPANTS

Physicians serving in California, Massachusetts, or upstate New York clinical practices implementing pay-for-performance incentives were eligible. We obtained responses from 1,534 (35.14%) of 4,365 physicians surveyed.

ANALYSIS

We randomly partitioned the study sample equitably into derivation and validation subsamples. We conducted parallel analysis, inter-item/point-biserial correlations, and item-response-theory-based graded response modeling on six autonomy support items. Three items with the highest (a) point-biserial correlations, (b) item-level discrimination and (c) information capture were used to construct a short-form (3-item) version of the full (6-item) autonomy scale. We utilized exploratory structural equation modeling and confirmatory factor analysis to establish the factor structure and construct validity of the full-length and short-form scales before comparing their factor invariance, reliability and interrater agreement across physician subgroups.

FINDINGS

All six autonomy support items loaded highly onto one factor accounting for the majority of variance and demonstrating good data fit. The three most discriminating and informative items loaded equally well onto a single factor with similar goodness-of-fit to the data. The three-item scale correlated highly with its six-item parent, showing equally high sensitivity and specificity in discriminating high autonomy support. Variability in scores nested predominantly at within- rather than between-subgroup levels.

CONCLUSIONS AND IMPLICATIONS

Our data supported the factor structure, construct validity, internal consistency, and reliability of six- and three-item autonomy support scales. These brief tools are easily incorporated into multi-dimensional questionnaires at relatively low cost.

Pushing for partnership: physician engagement and resistance in primary care renewal

PURPOSE

Healthcare policymakers and managers struggle to engage private physicians, who tend to view themselves as independent of the system, in new models of primary care. The purpose of this paper is to examine this issue through a social identity lens.

DESIGN/METHODOLOGY/APPROACH

Through in-depth interviews with 33 decision-makers and 31 fee-for-service family physicians, supplemented by document review and participant observation, the authors studied a Canadian province's early efforts to engage physicians in primary care renewal initiatives.

FINDINGS

Recognizing that the existing physician-system relationship was generally distant, decision-makers invested effort in relationship-building. However, decision-makers' rhetoric, as well as the design of their flagship initiative, evinced an attempt to proceed directly from interpersonal relationship-building to the establishment of formal intergroup partnership, with no intervening phase of supporting physicians' group identity and empowering them to assume equal partnership. The invitation to partnership did not resonate with most physicians: many viewed it as an inauthentic offer from an out-group ("bureaucrats") with discordant values; others interpreted partnership as a mere transactional exchange. Such perceptions posed barriers to physician participation in renewal activities.

PRACTICAL IMPLICATIONS

The pursuit of a premature degree of intergroup closeness can be counterproductive, heightening physician resistance.

ORIGINALITY/VALUE

This study revealed that even a relatively subtle misalignment between a particular social identity management strategy and its intergroup context can have highly problematic ramifications. Findings advance the literature on social identity management and may facilitate the development of more effective engagement strategies.

Evaluating the role of public health in implementation of genomics-related recommendations: a case study of hereditary cancers using the CDC Science Impact Framework

Public health plays an important role in ensuring access to interventions that can prevent disease, including the implementation of evidence-based genomic recommendations. We used the Centers for Disease Control and Prevention (CDC) Science Impact Framework to trace the impact of public health activities and partnerships on the implementation of the 2009 Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Lynch Syndrome screening recommendation and the 2005 and 2013 United States Preventive Services Task Force (USPSTF) BRCA1 and BRCA2 testing recommendations.The EGAPP and USPSTF recommendations have each been cited by >300 peer-reviewed publications. CDC funds selected states to build capacity to integrate these recommendations into public health programs, through education, policy, surveillance, and partnerships. Most state cancer control plans include genomics-related goals, objectives, or strategies. Since the EGAPP recommendation, major public and private payers now provide coverage for Lynch Syndrome screening for all newly diagnosed colorectal cancers. National guidelines and initiatives, including Healthy People 2020, included similar recommendations and cited the EGAPP and USPSTF recommendations. However, disparities in implementation based on race, ethnicity, and rural residence remain challenges. Public health achievements in promoting the evidence-based use of genomics for the prevention of hereditary cancers can inform future applications of genomics in public health.

Navigating the evidentiary turn in public health: Sensemaking strategies to integrate genomics into state-level chronic disease prevention programs

In the past decade, healthcare delivery has faced two major disruptions: the mapping of the human genome and the rise of evidence-based practice. Sociologists have documented the paradigmatic shift towards evidence-based practice in medicine, but have yet to examine its effect on other health professions or the broader healthcare arena. This article shows how evidence-based practice is transforming public health in the United States. We present an in-depth qualitative analysis of interview, ethnographic, and archival data to show how Michigan's state public health agency has navigated the turn to evidence-based practice, as they have integrated scientific advances in genomics into their chronic disease prevention programming. Drawing on organizational theory, we demonstrate how they managed ambiguity through a combination of sensegiving and sensemaking activities. Specifically, they linked novel developments in genomics to a long-accepted public health planning model, the Core Public Health Functions. This made cutting edge advances in genomics more familiar to their peers in the state health agency. They also marshaled state-specific surveillance data to illustrate the public health burden of hereditary cancers in Michigan, and to make expert panel recommendations for genetic screening more locally relevant. Finally, they mobilized expertise to help their internal colleagues and external partners modernize conventional public health activities in chronic disease prevention. Our findings show that tools and concepts from organizational sociology can help medical sociologists understand how evidence-based practice is shaping institutions and interprofessional relations in the healthcare arena.

Understanding the potential of state-based public health genomics programs to mitigate disparities in access to clinical genetic services

Purpose

State Health Agencies (SHAs) have developed public health genomics (PHG) programs that play an instrumental role in advancing precision public health, but there is limited research on their approaches. This study examines how PHG programs attempt to mitigate or forestall health disparities and inequities in the utilization of genomic medicine.

Methods

We compared PHG programs in three states: Connecticut, Michigan, and Utah. We analyzed 85 in-depth interviews with SHA internal and external collaborators and program documents. We employed a qualitative coding process to capture themes relating to health disparities and inequities.

Results

Each SHA implemented population-level approaches to identify individuals who carry genetic variants that increase risk of hereditary cancers. However, each SHA developed a unique strategy—which we label public health action repertoires—to reach specific subgroups who faced barriers in accessing genetic services. These strategies varied across states given demographics of the state population, state-level partnerships, and availability of healthcare services.

Conclusion

Our findings illustrate the imperative of tailoring PHG programs to local demographic characteristics and existing community resources. Furthermore, our study highlights how integrating genomics into precision public health will require multilevel, multisector collaboration to optimize efficacy and equity.