Challenging operations: medical reform and resistance in surgery . Chicago : University of Chicago Press , 2011 , xi + 230 pp. £16.00 (pbk) ISBN 13:978-0-226-43003-4 ( paper)
In 1984 Libby Zion died in a New York Hospital following a medication error. The Grand Jury decided that the fault lay with medical training: that long hours worked by trainee doctors were a threat to patient safety. Her death became part of a wider campaign to reduce junior doctors’ hours and was influential in reform processes which culminated in the American Council for Graduate Medical Education requirement that, from July 2003, junior doctors work no more than 80 hours per week. A series of largely anonymous accounts published subsequently revealed that most hospitals did not, in fact, reduce trainees’ hours. But some did, and this book sets out to explain why.
Katherine Kellogg provides a superb analysis of how institutional change is (and is not) accomplished. Her book describes an ambitious comparative study of three pseudonymous hospitals, Advent, Bayshore and Calhoun, and shows how staff in each responded to the pressure to change and how and why their change trajectories diverged. Her core thesis is that organisational change requires that internal reformers form coalitions and fight, and that the outcome of these battles will be shaped by micro-level processes and local contextual resources. These arguments will probably not come as a surprise to readers of this journal, but don’t let that put you off because this book is a brilliant ethnography of American surgery and policy implementation.
The book begins with a vivid description of hospital residents – the interns, seniors, and chiefs who comprise training grades – so named because the typical 120 hour working week meant they traditionally resided in the hospital. A vignette of ‘Anne’s’ internship brings home the reality of the pre-reform training system and it is followed by a very powerful account of the ‘Ironmen’ (the mainly, but not exclusively, male surgeons) who sought to defend long work hours. By the end of this chapter, which describes the gruelling work practices, interactions and team behaviours associated with surgical training, you fully appreciate why the established surgeons (‘attendings’) were at the top of the hospital hierarchy: as Kellogg says ‘they were treated like heroes. They had paid their dues, had endured, and were now on top of the world’ (p.70).
Kellogg then looks at the introduction of new practices designed to make night shift staff take on work previously undertaken during the (long) daytime period staffed by junior residents. She shows how ‘reformers’ and ‘defenders’ positioned themselves to fight over reduced work hours. Her review of the tactics of professional identity and closure is compelling. The book documents institutionalised bullying of those who do not comply with the macho culture: for example, Kellogg describes how a male chief changed his vote for a teaching award so ‘the women wouldn’t win’ (p.142). She uses the concept of relational spaces to show how informal lunches and afternoon rounds at two of the hospitals enabled collective mobilisation by reformers; and she documents how, at Advent, this was sustained long enough to force through practice changes that reduced work hours. Kellogg also introduces the idea of ‘collective disruption’ to show how reformers interfered with daily activity to force defenders of the old regime to accommodate new practices and how the reformers mitigated the effects of stigmatisation and exclusion.
This ethnography is a gripping read. It stands up well alongside the classic qualitative studies of medical socialisation and as a case study of organisational change. It is easy to see how Kellogg’s analysis could transfer elsewhere: for example, to understand the implementation of the European Working Time Directive. Where the book comes unstuck is in its discussion of theory. Early on Kellogg outlines (p.8) four theories she will use – neo-institutional, law and society, social movement and ‘medical sociology’. She helpfully suggests that ‘readers less interested in theoretical arguments should skip’ to page 13. This may be wise, as the book ignores significant contributions – for example, from social movement theory prior to 1973 – and it summarises medical sociology as if it is a single unified theory.
Given the gender issues that reverberate in the data, the book seems to cry out for a serious consideration of feminist theory – but this, too, is somewhat lacking. Nonetheless, this book represents an important contribution to the field. In her closing argument Kellogg suggests that those seeking institutional change ‘must understand how to effectively engage in face-to-face collective combat processes if they are to successfully accomplish it’ (p.186). As I read this, amidst what is perhaps the most significant political reform of British healthcare for decades, it struck me that this book might also prove an invaluable guide for change opponents, and that perhaps healthcare practitioners and managers might use these ideas to engage in ‘tenacious collective combat’ to defend the NHS.