Paradoxes of Practice Guidelines,Professional Expertise,and Patient Centeredness: The Medical Care Triangle

Abstract

The coexistence of institutionalized evidence-based practice guidelines, professional expertise of medical practitioners, and the patient centeredness approach form a triangle. Each component of this Medical Care Triangle has characteristics that create paradoxes for health care professionals and their patients. The value of a paradox lies in uncovering and utilizing the contradiction to better understand the underlying organizational phenomenon. Method: Following Poole and van de Ven’s (1989) suggested approaches to resolving paradoxes, each paradox of the Medical Care Triangle is defined and analyzed. Results: A total of 10 paradoxes related to practice guidelines, professional expertise, and patient centeredness are revealed. The resolution of each paradox yields insights specific to structuring health care organizations in ways that support the delivery of medical care. Implications: The results renew an emphasis on the centrality of practitioners’ work processes to health care organizations; this has potential benefits for organizations, clinicians/employees, and patients.

Keywords

professional expertise patient centeredness practice guidelines paradoxes organizational structure

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References

Abbott

(1988). The system of professions: An essay on the division of expert labor. Chicago, IL: University of Chicago Press.

Bazzoli

G. J.

(2004). The corporatization of American hospitals. Journal of Health Politics, Policy and Law, 29, 885-905.

Beauchamp

T. L.

Childress

J. F.

(1994). Principles of biomedical ethics (4th ed.). New York, NY: Oxford University Press.

Benner

(1984). From novice to expert. Upper Saddle River, NJ: Prentice Hall.

Cameron

K. S.

Quinn

R. E.

(1988). Organizational paradox and transformation. In Quinn

R. E.

Cameron

K. S.

(Eds.), Paradox and transformation: Toward a theory of change in organization and management (pp. 1-14). Pensacola, FL: Ballinger.

Carman

K. L.

Dardess

Maurer

Sohaer

Adams

Bechtel

Sweeney

(2013). Patient and family engagement: A framework for understanding the elements and developing interventions and policies. Health Affairs, 32, 223-231.

Casalino

L. P.

Gans

Weber

Cea

Tuchovsky

Bishop

T. F.

. . . Evenson

T. B.

(2016). US physician practices spend more than $15.4 billion annually to report quality measures. Health Affairs, 35, 401-406.

Chong

C. A.

Chen

I. J.

Naglie

Krahn

M. D.

(2009). How well do guidelines incorporate evidence on patient preferences? Journal of General Internal Medicine, 24, 977-982.

Classen

D. C.

Mermel

L. A.

(2015). Specialty society clinical practice guidelines: Time for evolution or revolution? Journal of the American Medical Association, 314, 871-872.

10.

Cleary

P. D.

(2016). Evolving concepts of patient-centered care and the assessment of patient care experiences: Optimism and opposition. Journal of Health Politics, Policy and Law, 41, 675-696.

11.

Dale

S. B.

Ghosh

Peikes

D. N.

Day

T. J.

Yoon

F. B.

Taylor

E. F.

. . . Brown

(2016). Two-year costs and quality in the Comprehensive Primary Care Initiative. New England Journal of Medicine, 374, 2345-2356.

12.

DiMaggio

P. J.

Powell

W. W.

(1983). The iron cage revisited: Institutional isomorphism and collective rationality in organizational fields. American Sociological Review, 48, 147-160.

13.

Feldman

M. S.

Pentland

B. T.

(2003). Reconceptualizing organizational routines as a source of flexibility and change. Administration Science Quarterly, 48, 94-118.

14.

Field

M. J.

Lohr

K. N.

(Eds.). (1990). Clinical practice guidelines: Directions for a new program. Washington, DC: National Academies Press.

15.

Flores

Lee

Baucher

Kastner

(2000). Pediatricians’ attitudes, beliefs, and practices regarding clinical practice guidelines: A national study. Pediatrics, 105, 496-501.

16.

Friedson

(1994). Professionalism reborn: Theory, prophecy, and policy. Oxford, England: Blackwell.

17.

Gioia

D. A.

Chittipeddi

(1991). Sensemaking and sensegiving in strategic change initiation. Strategic Management Journal, 12, 433-448.

18.

Goldberg

D. G.

Kuzel

A. J.

(2009). Elements of the patient-centered medical home in family practices in Virginia. Annals of Family Medicine, 7, 301-308.

19.

Graham

Mancher

Miller Wolman

Greenfields

Steinberg

(Eds.). (2011). Clinical practice guidelines we can trust. Washington, DC: National Academies Press.

20.

Greenfield

Ignatowicz

A. M.

Belsi

Pappas

Car

Majeed

Harris

(2014). Wake up, wake up! It’s me! It’s my life: Patient narratives on person-centeredness in the integrated care context: A qualitative study. BMC Health Services Research, 14, 619.

21.

Guerci

Carollo

(2016). A paradox view on green human resource management: Insights from the Italian context. International Journal of Human Resource Management, 27, 212-238. doi:10.1080/09585192.2015.1033641

22.

Halm

E. A.

Lee

Chassin

M. R.

(2002). Is volume relate to outcome in health care? A systematic review and methodologic critique of the literature. Annals of Internal Medicine, 137, 511-520.

23.

Hoyer

D. L.

(2012). 75 Years of mortality in the United States, 1935-2010 (NCHS Data Brief No. 88). Hyattsville, MD. National Center for Health Statistics.

24.

Huang

J. L.

Chiaburu

D. S.

Zhang

X. A.

Grandey

A. A.

(2015). Rising to the challenge: Deep acting is more beneficial when tasks are appraised as challenging. Journal of Applied Psychology, 100, 1398-1408.

25.

Hulsheger

U. R.

Schewe

A. F.

(2011). On the costs and benefits of emotional labor: A meta-analysis of three decades of research. Journal of Occupational Health Psychology, 16, 361-389.

26.

Institute of Medicine. (1996). Primary care: America’s health in a new era. Washington, DC: National Academies Press.

27.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.

28.

Interlandi

(2016, April 1). The paradox of precision medicine. Scientific American. Retrieved from http://www.scientificamerican.com/article/the-paradox-of-precision-medicine/

29.

Issel

L. M.

Kahn

(1998). The economic value of caring. Health Care Management Review, 24(4), 43-53.

30.

Issel

L. M

. (2016). Experiment with management, not reimbursement. (Editorial). Health Care Management Review,41-74.

31.

Jame

Wittenberg

Potter

M. B.

Feishchmann

K. E.

(2015). The new lipid guidelines: What do primary care clinicians think? American Journal of Medicine, 128, 914.e5-914.e10.

32.

Kane

C. K.

(2017). Updated data on physician practice arrangements: Physician ownership drops below 50 percent. Retrieved from https://www.ama-assn.org/sites/default/files/media-browser/public/health-policy/PRP-2016-physician-benchmark-survey.pdf

33.

Kaskie

Knight

B. G.

Liebig

P. S.

(2001). State legislation concerning individuals with dementia: An evaluation of three theoretical models of policy formation. The Gerontologist, 41, 383-393.

34.

Katz

Kahn

R. L.

(1966). The social psychology of organizations. New York, NY: Wiley.

35.

Klein

(2003). Intuition at work: Why developing your gut instincts will make you better at what you do. New York, NY: Doubleday.

36.

Lantz

P. M.

Evqans

D. W.

Mead

Avarez

Stewart

(2016). Knowledge of and attitudes toward evidence-based guidelines for and against clinical preventive services: Results form a national survey. Milbank Quarterly, 94, 51-76.

37.

Larson

E. B.

Yao

(2005). Clinical empathy as emotional labor in the patient-physician relationship. Journal of the American Medical Association, 293, 1100-1106.

38.

Lega

DePietro

(2005). Converging patterns in hospital organization: Beyond the professional bureaucracy. Health Policy, 74, 261-281.

39.

Liberati

E. G.

Gorli

Scaratti

(2016). Invisible walls within multidisciplinary teams: Disciplinary boundaries and their effects on integrated care. Social Science & Medicine, 150, 31-39.

40.

Luscher

S. L.

Lewis

M. W.

(2008). Organizational change and managerial sensemaking: Working through paradox. Academy of Management Journal, 51, 221-240.

41.

Maizes

Rakel

Niemiec

(2009). Integrative medicine and patient-centered care. Explore, 5, 277-289. doi:10.1016/j.explore.2009.06.008

42.

Mazor

K. M.

Smith

K. M.

Fisher

K. A.

Gallager

T. H.

(2016). Speak up! Addressing the paradox plaguing patient-centered care. Annals of Internal Medicine, 164, 618-619.

43.

Mickan

Burls

Glasziou

(2011). Patterns of “leakage” in the utilization of clinical guidelines: A systematic review. Postgraduate Medicine Journal, 87, 670-679.

44.

Mintzberg

(1983). Structure in fives: Designing effective organizations. Upper Saddle River, NJ: Prentice Hall.

45.

Morche

Mathes

Pieper

(2017). Relationship between surgeon volume and outcomes: A systematic review of systematic reviews. Systematic Reviews, 5, 204. doi:10.1186/s13643-016-0376-4

46.

Morris

J. A.

Feldman

(1996). The dimensions, antecedents, and consequences of emotional labor. Academy of Management Review, 21, 986-1010.

47.

Nunes

J. A.

Ferreria

Queiros

(2014). Taking part: Engaging knowledge on health in clinical encounters. Social Science & Medicine, 123, 194-201.

48.

Papachroni

Heracleous

Paroutis

(2015). Organizational ambidexterity through the lens of paradox theory: Building a novel research agenda. Journal of Applied Behavioral Science, 51, 71-93.

49.

Plester

Cooper-Thomas

Winquist

(2015). The fun paradox. Employee Relations, 37, 380-398. doi:10.1108/ER-04-2013-0037

50.

Poole

M. S.

van de Ven

(1989). Using paradox to build management and organization theories. Academy of Management Journal, 14, 562-578.

51.

Precision Medicine Working Group. (2015). The Precision Medicine Initiative Cohort Program: Building a research foundation for 21st century medicine. Retrieved from https://www.nih.gov/sites/default/files/research-training/initiatives/pmi/pmi-working-group-report-20150917-2.pdf

52.

Putman

L. L.

Fairhurst

G. T.

Banghart

(2016). Contradictions, dialectics and paradoxes in organizations: A constitutive approach. Academy of Management Annuals, 10, 65-171.

53.

Ramirez

G. A.

(2012). Sustainable development: Paradoxes, misunderstandings and learning organizations. Learning Organization, 19, 58-76.

54.

Rathert

Wyrwich

M. D.

Boren

S. A.

(2012). Patient-centered care and outcomes: A systematic review of the literature. Medical Care Research and Review, 70, 351-379.

55.

Raven

B. H.

(1965). Social influence and power. In Steiner

I. D.

Fishbein

(Eds.), Current studies in social psychology (pp. 371-382). New York, NY: Holt, Rinehart and Winston.

56.

Rickert

(2012). Patient-centered care: What it means and how to get there. Health Affairs Blog. Retrieved from http://ahpo.net/assets/patient-centered-care-what-it-means-and-how-to-get-there-blog2.pdf

57.

Schulman

P. R.

(1993). The negotiated order of organizational reliability. Administration & Society, 25, 353-372.

58.

Shaller

(2007). Patient-centered care: What does it take? Retrieved from http://www.commonwealthfund.org/publications/fund-reports/2007/oct/patient-centered-care–what-does-it-take

59.

Shekell

P. G.

Ortiz

Rhodes

Morton

S. C.

Eccles

M. P.

Gimshaw

J. M.

Woolf

S. H.

(2001). Validity of the Agency for Health Care Research and quality clinical practice guidelines: How quickly do guidelines become outdated? Journal of American Medical Association, 286, 1461-1467.

60.

Smith

W. K.

Lewis

M. W.

(2011). Toward a theory of paradox: A dynamic equilibrium model of organizing. Academy of Management Review, 36, 381-403.

61.

Starr

(1982). The social transformation of American medicine. New York, NY: Basic Books.

62.

Sterman

J. D.

Repenning

N. P.

Koffman

(1997). Unanticipated side effects of successful quality programs: Exploring a paradox of organizational improvement. Management Science, 43, 503-521.

63.

Sullivan

Glantz

(2010). The changing role of agriculture in tobacco control policymaking: A South Carolina case study. Social Science & Medicine, 71, 1527-1534.

64.

Thompson

J. D.

(1967). Organizations in action. New York, NY: McGraw-Hill.

65.

Vogus

T. J.

McClelland

L. E.

(2016). When the customer is the patient: Lessons from health care research on patient satisfaction and service quality ratings. Human Resource Management Review, 26, 37-49.

66.

Waitzkin

(1985). Information giving in medical care. Journal of Health and Social Behavior, 26, 81-101.

67.

Weick

K. E.

(1995). Sensemaking in organizations. Thousand Oaks, CA: Sage.

68.

Weick

K. E.

(1976). Educational organizations as loosely coupled systems. Administration Science Quarterly, 21, 1-19.

69.

Woolf

S. H.

(2008). The meaning of translational research and why it matters. Journal of the American Medical Association, 299, 211-213.