1 | 2 | 3 | 4 | All | Print this article

Challenging operations: implementing medical reform in surgery

Katherine C. Kellogg, PhD ’05

By: Katherine C. Kellogg, PhD ’05
Mitsui Career Development Professor,
Associate Professor of Organization Studies

In 2003, in the face of errors and accidents caused by medical and surgical trainees, the American Council of Graduate Medical Education mandated a reduction in trainee work hours to 80 per week. Over the course of two and a half years spent observing residents and staff surgeons trying to implement this new regulation, Katherine C. Kellogg, PhD ’05, the Mitsui Career Development Professor, discovered that resistance to it was both strong and successful. In fact, two of the three hospitals she studied failed to make the change. Challenging Operations takes up the apparent paradox of medical professionals resisting reforms designed to help them and their patients. Through vivid anecdotes, interviews, and incisive observation and analysis, Kellogg shows the complex ways that institutional reforms spark resistance when they challenge long-standing beliefs, roles, and systems of authority.

Over the last several decades, numerous attempts to improve America’s healthcare system have been made. Most of these efforts have fallen short. And so, when the American Council of Graduate Medical Education attempted to remedy the serious problem of overworked medical trainees by demanding that hospitals reduce the hours their residents worked, I saw an opportunity to observe firsthand how the healthcare system implemented reforms—and why these reforms often failed. I gained access to the surgery departments of three hospitals—Advent, Bayshore, and Calhoun (pseudonyms)—and, donning surgical scrubs to fit into the setting, for two and a half years I studied how surgical residents and staff surgeons dealt with the new regulations mandated by the reform.

Implementing—and defeating—reform at three hospitals

In order to reduce work hours, all three hospitals introduced “night float teams.” Previously, surgical interns had often worked back-breaking shifts, arriving at the hospital at 4 a.m., leaving at 10 p.m., and staying overnight on call every third night. Under the new system, first-year residents handed off any work not completed by 6 p.m. to the night float team, did not return to the hospital until 6 a.m. the next morning, and were rarely on call overnight.

This new system was a win-win situation; interns were no longer exhausted by their 36+ hour shifts, and patients were less likely to be endangered by half-awake interns. And yet, these reforms were vigorously resisted at all three hospitals and were successfully implemented at only one. How can one account for this extraordinary outcome?

I discovered that reforms proved difficult because they disrupted the established authority relations and challenged long-standing beliefs about proper medical care and the appropriate roles of interns and surgeons. At all three hospitals, defenders of the status quo resisted change, punishing those who attempted to implement the reforms. Cowed by the defenders’ superior positions in the surgical hierarchy, interns at all three hospitals stopped attempting handoffs.

Mobilizing for change at Advent and Calhoun

But after this initial defeat, reformers at Advent and Calhoun rallied and began to build coalitions to challenge the status quo. Advent and Calhoun were successful, because, unlike Bayshore, they had relational spaces—spaces where, isolated from defenders, reformers could meet face-to-face to try out new tasks, play new roles, and discuss nontraditional ideas without fear of retaliation.

Failure at Calhoun, success at Advent

And yet, only at Advent were reformers able to face down defenders’ renewed attempts to defeat them. Calhoun reformers folded under pressure. Why?

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.

Recommendations for medical providers

  • Think collectively
  • Established roles and long-standing authority relations are difficult to overcome individually. At the three hospitals I studied, reformers were successful only to the degree that they acted collectively.

  • Identify allies
  • Reformers should actively seek out others to support change, paying particular attention to those who receive fewer rewards and opportunities for training and promotion under the traditional system, since they are more likely than others to be potential reformers.

  • Find spaces apart from defenders of the status quo for new practice creation
  • In organizing their efforts, reformers must find spaces where, isolated from defenders, they are comfortable talking about new ways of doing things. Face-to-face interaction is also crucial, as is the inclusion of reformers from all work positions.

  • Minimize visibility of lower-status reformers during new practice creation
  • Coalitions are vulnerable to the degree that their lowest-status members are exposed. Keep them out of the limelight.

  • Enlist transients to help roll out new practices
  • Since activism entails significant risk, those moving through organizations—the less committed transients—may be the most effective change agents.

In sum, healthcare organization members who would benefit from reform (and their supporters) must understand how to effectively engage in collective change processes, on-the-ground in everyday work, if they are to successfully accomplish it. To bring to fruition the opportunities hard won by external reformers, reformers inside organizations must successfully find relational spaces apart from defenders of the status quo to coordinate their efforts across diverse work positions and social identities. They must stand up to aggressive attempts to divide their coalition. And they must enlist transient reformers to put themselves on the line for change. Only by engaging in such robust collective action can internal reformers accomplish the reform that those outside have fought so hard to promote.