The manager role in relation to the medical profession

Sammanfattning: Background: Managers and physicians have two important roles in healthcare organisations. However, several studies have identified problems in the manager–physician relationship and more knowledge is needed to improve the situation. Using theories on organisation, professions, and role taking to inform thinking, this thesis addresses one aspect of the manager-physician relationship, namely how managers handle their role in relation to the medical profession. This was studied in the context of sickness certification, a frequent and problematic task for many physicians in Sweden. Aim: The aim of this thesis was to increase the knowledge about how managers in Swedish healthcare organisations handle their manager role in relation to the medical profession. Methods: The empirical studies (I-IV) build on one another. Focus group discussions with 26 physicians (I), two questionnaires to all board-certified specialists in Stockholm county (n=2497, resp. n=2208) (II), individual interviews with 18 county council chief executive officers (CEOs) (III), and interviews with 38 healthcare managers (20 clinical department managers (CDMs) and the same18 CEOs as in study III) (IV) constitute the database for the thesis. Qualitative methods were used to analyse data in three of the studies: content analysis (I), grounded theory (III), and linguistic discourse analysis (IV). Descriptive statistics were used in study II. Results: The problems physicians described in their work with sickness certification could be classified into four categories: the design of the social insurance system, the organisation of healthcare, the performance of other stakeholders, and the physicians’ own work situation. Although all of these concern policy issues and managerial responsibility on different structural levels in healthcare, the role of managers was absent in the physicians’ discussions (I). When specifically asked about management of sickness certification issues, the majority reported lack of both substantial management support and a well-established workplace policy (II). With these findings as a point of departure, studies III and IV addressed managers’ role taking. In many ways managers themselves contributed to making the manager role weak and absent in relation to the medical profession (III, IV). The CEOs had a strong focus on physicians and physicians’ behaviour rather than on their own managerial behaviour or that of their subordinate managers. When strategies for managing physicians were addressed, many described physician-specific strategies that led to a paradox of control in relation to the medical profession - the pragmatic strategies helped managers to manage physicians in daily work, but seemed to weaken the manager role in the organisation (III). Few managers used a management-based discourse to construct the manager role. Instead, a profession-based discourse was predominant, where managers frequently used the attributes “physician” or “non-physician” to categorise themselves and other managers in their manager roles. Some managers also combined the two discourses in a “yes, but...” approach to management in the organisation. Expressions of a mutually shared manager community were almost totally missing in the managers’ statements (IV). Conclusions: The results show that managers have a weak, partially absent, and rather ambiguous manager role in relation to the medical profession. How the manager role is handled and regarded within healthcare organisations constitutes part of the organisational conditions for the role taking of managers, physicians, and other healthcare professionals. The findings indicate that there is a need to support healthcare managers in their role taking in the organisation - both those managers who also are physicians, and managers with other underlying professions. Management aspects regarding sickness certification tasks also need to be strengthened. A weak and ambiguous manager role may have negative consequences not only for the work of managers, but also for that of physicians and other healthcare professionals, and for the quality of care.