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Challenging operations: implementing medical reform in surgery (continued)

At both hospitals, defenders of the status quo attempted to divide the reformers by negatively labeling reform practices as “feminine.” This tactic worked at Calhoun because, given the unusually high number of female chief residents there that year, male reformers were already concerned about the loss of status. By contrast, at Advent initial status threat was low, and male reformers did not feel threatened. Too, sympathetic chiefs and senior interns at Advent, as well as interns from nonsurgical specialties (who were less committed to traditional roles and practices), played critical supportive roles in making the reforms accepted practice.

My findings suggest several ways in which medical administrators and providers can facilitate reform.

Recommendations for medical administrators

  • Create new accountability systems
  • New accountability systems can make mid-level professionals responsible for change. Until the directors at Advent, Bayshore, and Calhoun assigned the chief residents accountability for change, even those supportive of reform were not willing to work for it. Once they were made accountable, they began to support change openly.

  • Provide new staffing systems
  • Staffing systems that allow reformers to mobilize together in the absence of defenders—trying out new tasks, playing new roles, and discussing nontraditional ideas—are critical.

  • Use informal evaluation systems
  • Providing reformers with nonrepressive evaluation systems will allow them to collectively challenge defenders. At Advent, informally asking reformers how the new system was working allowed them to tell directors about defender resistance without violating the professional code of “covering each other’s back.”

  • Pay attention to gender and hierarchy
  • Avoiding the creation of any visible programs for female professionals (or other lower-status professionals) that appear to favor them as a group minimizes threat. Similarly, reform systems should be structured to minimize the need for junior professionals to challenge the authority of senior professionals.

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