Emergency Physicians in the Netherlands: The Development and Organizational Impact of New Multidisciplinary Professionals in Hospitals

Transcription

1 Emergency Physicians in the Netherlands: The Development and Organizational Impact of New Multidisciplinary Professionals in Hospitals

2 Print: PrintPartners Ipskamp. B.V., Enschede ISBN: , C.D. Kathan Alle rechten voorbehouden. Niets uit deze uitgave mag worden verveelvoudigd, opgeslagen in een geautomatiseerd gegevensbestand, of openbaar gemaakt, in enige vorm of op enige wijze, hetzij elektronisch, mechanisch, door fotokopieën, opnemen of enige andere manier, zonder voorafgaande schriftelijke toestemming van de auteur. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, including photocopying, recording or otherwise, without prior written permission of the author.

3 RIJKSUNIVERSITEIT GRONINGEN Emergency Physicians in the Netherlands: The Development and Organizational Impact of New Multidisciplinary Professionals in Hospitals Proefschrift ter verkrijging van het doctoraat in de Economie en Bedrijfskunde aan de Rijksuniversiteit Groningen op gezag van de Rector Magnificus, dr. F. Zwarts, in het openbaar te verdedigen op donderdag 17 januari 2008 om uur door Constanze Dorothea Kathan geboren op 9 juli 1975 te München, Duitsland

4 Promotores: Copromotor: Prof. dr. A.M. Sorge Prof. dr. R.O.B. Gans Dr. M.A.G. van Offenbeek Beoordelingscommissie: Prof. dr. H.H. Delooz Prof. dr. P. Kenis Prof. dr. M. Saks Prof. dr. J. Wijngaard

5 To my parents meinen Eltern.

6 PREFACE My first Groningen experience occurred years before I should come to live here: I got the most expensive parking ticket of my life. The second one followed on the day before my Ph.D. job interview and fell quite into line: I went to the coast north of Groningen, where I intended to spend my weekends on the beach and go windsurfing once I got the job. I ended up on the dyke in a grey drizzle, surrounded by sheep, finding nothing but polder and endless mudflat. I got the job and buried my windsurfing ambitions. The years since that day on the dyke have been an extraordinary experience for me, not only because I found Groningen to be an absolutely beautiful city. I learnt a lot about scientific work, conducting research, and my own way of working and looking at things. I had the chance to live in a new country, to immerse myself in the Dutch culture and to meet many new people. I was even able to increase my international horizon by moving to the UK in summer 2006, where I wrote most parts of this book while being a visiting researcher at the School of Sociology and Social Policy at the University of Nottingham. This thesis could not have been accomplished without the support of many people who crossed my way. I would like to take the opportunity to express my appreciation to them. First of all, I want to cordially thank my two supervisors Arndt Sorge and Rijk Gans and my daily supervisor Marjolein van Offenbeek. All three of them were always there for me when I needed them; they kept encouraging me, they were there for critical reflections, and I could count on their support at all times. Even when we were working in different countries, Arndt Sorge was a real Doktorvater to me in the best sense of the word. Rijk Gans lead me through the medical waters and showed me which questions really mattered to the world of healthcare. Marjolein van Offenbeek initiated the project and, together with Marrig Knip and Marije Stegeman, conducted a pilot study on the topic before I came on board. She played a major role in leading me and my project towards success by stimulating and discussing my work in detail. Thanks a lot for your support, your enthusiasm and the effort all of you put into this! Jan ter Maaten from the University Medical Centre Groningen (UMCG) made valuable contributions to this thesis by facilitating the cooperation with other hospitals iv

7 and with the Stichting Opleiding Spoedeisende Geneeskunde (SOSG). The SOSG and the Dutch Scientific Organization (NWO) financially supported parts of the data collection for this study, for which I am more than grateful. My deepest thanks go to the hospitals in the Netherlands and in the UK that participated in this study (which I will not name for reasons of anonymity) and to their staff directors, emergency unit managers, nurses, and doctors. Many of them were willing to share their thoughts with me and allowed me to take a look over their shoulder. I was able to witness their amazing daily work - from putting plasters on kids elbows to resuscitation. Special thanks to the pioneers of emergency medicine in the Netherlands (Dik Meeuwis, Gos de Vries, Trea Sandjer, Mariska Zwartsenburg, Constant Coolsma, and Edwin Müller - to name just a few of them). I also want to thank my colleagues at the University of Groningen, my fellow- Ph.D.s, my friends, and especially my two paranimfs Adriana and Jasper. My various office mates made my work a pleasure; first and foremost Marrig Knip, who has been a perfect companion during my first Ph.D. years. Thanks for teaching me the essentials about the Dutch language, customs, the healthcare system, and especially for helping me with decoding the doctors handwritings. From summer , the School of Sociology and Social Policy at the University of Nottingham provided me with a perfect work environment for writing and finishing my thesis for which I am very grateful. Finally, my special thanks go to my family. I know that my parents are very proud of me for achieving this goal. But I am even more proud to be their daughter as they provided me with the essentials to achieve it: some basic intelligence and Constantia. My brother Achim perfectly hosted thousands of backup files for me. Thanks a lot! Lastly, I want to thank my partner Torsten. He encouraged me to start this Ph.D. project and shared every day of it. Let s keep it that way. Constanze Kathan Nottingham, October v

8 Table of Contents 1 Introduction Starting point and problem definition Objective of the study and research questions Structure of the book The Development of EPs as a Professional Occupation: A Comparison of the Netherlands and the UK Framework for the national development of EPs Theoretical background and method Development of EPs in the UK and in the Netherlands Cultural mandate Institutional license Parallel streams and organizational mandate Conclusions and discussion: Analogies and differences between the development of EPs in the Netherlands and the UK Design of the Study and Case Selection Design of the Study Case selection Organizational Force Fields in the Development of EPs in Hospitals A Rabsody based force field analysis (framework) A Rabsody based force field analysis (application) Differences in the context and process of EP implementation Conclusions and discussion Theoretical Contingency Framework Structural contingency theory Fit: The patterned systems approach Application of the theory Task environment and context vi

9 5.3.2 Organizational structure Differentiation Coordination Organizational performance Organizational quality of care Costs Working climate Medical quality Summary of organizational performance variables Conceptual assumptions Data Collection and Methods of Analysis Interviews, observations, documents and patient registration Questionnaire Forms per patient Data collection and analysis per variable Task Environment and Context Organizational structure Organizational Performance Descriptive Results Task environment and context Characteristics of demanded care Characteristics of professional resources Managerial and political setting Organizational structure Differentiation Coordination Summary of case characteristics Emergency Physicians Contribution to Organizational Performance EPs contribution to organizational quality of care Waiting times vii

10 8.1.2 Treatment times Throughput times Different contact persons for patients Unscheduled returns Conclusions: EPs and organizational quality of care EPs contribution to decreasing costs Consultation of specialists Number of diagnostic tests Conclusions: EPs and costs EPs contribution to working climate Propositions Data and results Conclusions: EPs and working climate EPs contribution to medical quality Data and results Conclusions: EPs and medical quality Organizational performance: Summary per case Conclusions and Discussion How can differences in the emergence of EPs be explained? Under which task environmental and organizational circumstances can EPs contribute to improve organizational performance? EPs positive impact and limitations Critical aspects of EP implementation Conclusions for theory Limitations of the study and areas for future research References Appendices Samenvatting in het Nederlands (Summary in Dutch) viii

11 List of Medical Terms and Abbreviations 1 AAD = Actor Activity Diagram A&E = Accident & Emergency (brit.) BAEM = British Association for Emergency Medicine (brit.) CEM = College of Emergency Medicine (brit.) ECU = Emergency care unit EM = Emergency medicine EMJ = Emergency Medicine Journal EMRS = Emergency Medicine Research Society (brit.) EMTA = Emergency Medicine Trainees Association (brit.) EP = Emergency physician Dutch: Spoedeisende hulp arts British: A&E doctor FFAEM = Fellow of the Faculty of A&E Medicine (brit.) FRCSEdA&E = Fellow of the Royal College of Surgeons of Edinburgh in A&E Medicine (brit.) Final year student = Dutch: Co-assistant GP = General practitioner GP-resident = General practitioner resident Dutch: Huisarts in opleiding (HAIO) British: GP in training Intern = Dutch: Assistent niet in opleiding tot medisch specialist (ANIOS) British: Postgraduate House Officer/ Senior House Officer NVSHA = Nederlandse Vereniging van Spoedeisende Hulp Artsen (Dutch Society of Emergency Physicians) Resident = Dutch: Assistent in opleiding tot medisch specialist (AIOS) British: Senior House Officer/ Specialist Registrar SOSG = Stichting Opleiding Spoedeisende Geneeskunde (Association of Emergency Medicine Training in the Netherlands) Specialist = British: Consultant 1 We chose to mainly follow the US terminology to refer to medical occupations, which is predominant in the English speaking literature. Please note, however, that not all medical occupations are equivalent in the US, the Netherlands, and the UK. It is therefore not always possible to find exactly matching translations. The given list of terms used is therefore meant as a guide for readers rather than a medical dictionary. ix

12 Dictionary: Terms with different meanings in different academic areas Medical science Management & Organization (applied throughout this study) Case Refers mostly to a patient. Defined according to the level of analysis: Emergency care unit located at hospitals (also referred to as hospital) Case-mix Patient population Refers to the mix of the selected cases. Case report Medical information collected and presented to highlight an interesting treatment or outcome (University of Louisville 2004) Report sent back to the participating cases after finishing the data collection. The report contains an overview of the collected data and results per case. Patient population Case-mix The totality of patients seen at an ECU/ demanded care Specialization A special line of medical work. Horizontal specialization: The number of different tasks conducted by someone. Vertical differentiation: Degree of managerial task division. x

13 List of Tables Table 2.1: Interviews with ECU staff in the UK...26 Table 3.1: Case selection...47 Table 4.1: Considerations voiced in the for and against EP debate across cases...51 Table 4.2: Strongest driving/restraining force categories per case...52 Table 5.1: Conceptualization of applied organizational performance indicators...83 Table 6.1: Measurement of independent variables...93 Table 6.2: Measurement of dependent variables...94 Table 6.3: Interviews and informal conversations per case...96 Table 6.4: Number of observation days...96 Table 6.5: Available documents per case...97 Table 6.6: Dimensions of working climate and applied scales Table 6.7: Data collection of characteristics of demanded care Table 6.8: Data collection of indicators of organizational quality Table 6.9: Data collection of indicators of costs Table 6.10: Data collection of medical quality forms per case Table 7.1: Number of patients per case per year and average per weekday Table 7.2: Urgency categories Table 7.3: Source of referral Table 7.4: Admission rate (overall admissions, GP-referral admissions, and admissions per specialty) Table 7.5: Characteristics of professional medical resources Table 7.6: ECU s management structure and integration to the hospital Table 7.7: Context of EP implementation Table 7.8: Feedback personal mode (in-degree shares per professional group) Table 7.9: Coordination by programming and feedback (group mode) Table 7.10: Case characteristics Table 8.1: Waiting time per ECU in minutes Table 8.2: Descriptive statistics: Waiting time in minutes (total) for self-referrals and GP-referrals Table 8.3: Treatment time per case in minutes xi

14 Table 8.4: Treatment times (in minutes) for patients of surgery, internal medicine, and cardiology Table 8.5: Throughput time per case in minutes Table 8.6: Average number of different care providers per patient Table 8.7: Unscheduled returns The first row per characteristic provides the percentage, the second row the absolute numbers Table 8.8: Number of consultations Table 8.9: Detail analysis +EP_L_EAR - Consultations for patients treated by EPs as opposed to non-eps Table 8.10: Detail analysis +EP_S_EAR - Consultations for patients treated by EPs as opposed to interns and GP-residents Table 8.11: Consultations for self-referred patients in the large teaching hospitals..155 Table 8.12: Number of diagnostic tests Table 8.13: Detailed analysis +EP_L_EAR - Ordered diagnostics per different doctors Table 8.14: Descriptive statistics of the working climate dimensions per case and significant differences based on ANOVA analysis Table 8.15: Independent sample t-test Table 8.16: Returned forms per case Table 8.17: Patients seen by EPs* Table 8.18: Details on the doctors who saw sampled patients Table 8.19: Correlations of medical quality (across all cases) Table 8.20: Chi-square tests for independence (EPs as opposed to other doctors) Table 8.21: Performance per case, summary xii

15 List of Figures Figure 2.1: Emergence of new occupations...25 Figure 2.2: Emergence of new occupations II...26 Figure 4.1: Typology of situational factors in change processes...50 Figure 5.1: Basic concept of structural contingency theory...60 Figure 5.2: Applied conceptualization of organizational structure...70 Figure 5.3: Contingency framework for ECUs in large teaching and small nonteaching hospitals with and without EPs Figure 7.1: Average number of patients per case per hour Figure 8.1: Waiting time categories per ECU in minutes Figure 8.2: Treatment time categories per ECU in minutes Figure 8.3: Mean treatment times (in minutes) for patients of surgery, internal medicine, and cardiology per case Figure 8.4: Throughput time categories per ECU in minutes Figure 9.1: Development of EPs in the UK and the Netherlands List of Appendices Appendix I: Force Field Analyses Appendix II: Interview guide Appendix III: Questionnaire Appendix IV: Form per patient (medical quality) Appendix V: Actor Activity Diagrams Appendix VI: ANOVA analysis; Kruskal-Wallis Test; waiting times Appendix VII: ANOVA analysis; waiting times for GP-referred as opposed to selfreferred patients Appendix VIII: ANOVA analysis; Kruskal-Wallis Test; treatment times Appendix IX: ANOVA analysis; treatment times for surgery, internal medicine, cardiology Appendix X: ANOVA analysis; Kruskal-Wallis Test; throughput times xiii

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17 1. Introduction I stood outside the emergency room and read my first clipboard: Princess Hope, sixteen, black, pain in the stomach. I went blank. What did I know about pain in the stomach? I d had pain in my stomach, yes, but in a woman it s different: too many organs, and the same pain can stand for a decomposing tuna sandwich or a decomposing ectopic pregnancy that will kill in half an hour. (Samuel Shem, 1978: The House of God) 1 Introduction Emergency care units (ECUs) in hospitals are presently confronted with new developments in the demand for care and in the supply of labor. Moreover, financial and legal settings have recently been subject to change. Hospitals seeking to react to these contextual changes need to consider professional, educational, and organizational adaptations in order to maintain a satisfactory performance. The intention of this study is to determine and analyze factors that influence organizational performance in ECUs in the Netherlands and to deduce recommendations for their organizational design in a changing environment. The most important situational change to be considered is the emergence of new professionals, notably the so-called emergency physician (EP). We compare EPs introduction between countries -the Netherlands and the UK- and between different hospitals within the Netherlands. We show which factors influence the successful implementation of this new profession and discuss whether this kind of vertical job differentiation, which enables horizontal integration of tasks from hitherto separate medical domains, can lead to a better organizational performance in hospitals. 1.1 Starting point and problem definition In 2004 the Netherlands Health Care Inspectorate (Inspectie voor de Gezondheidszorg, IGZ) published a report on the care provided by emergency care units. The report showed that the acute care chain was not satisfactorily coordinated. Especially insufficient was the lack of around-the-clock immediate availability of doctors with appropriate expertise and experience, which was seen to threaten the provision of adequate medical quality. Highlighting the ECU s grievances, the report raised awareness of the problematic emergency care conditions throughout the country. Yet even before the Health Care Inspectorate s report, organizational problems and bottlenecks in emergency care units (ECUs) could be observed 15

18 1. Introduction everywhere in the Netherlands (De Vries 1999). Some of these problems are not specific to the Netherlands and have also been brought up in the international literature (e.g. Doronzynski 2002; Derlet et al. 2001; Graff 1999; Shih et al. 1999). They result from changes in environmental conditions (e.g. Lee et al. 2003, Washington et al. 2002, Lang et al. 1996, Green and Dale 1992, Bianco et al. 2003, Jaarsma-van Leeuwen et al. 2000) and necessitate reflection on job structure and skill mix, in addition to modifications in the workflow and the mix of coordination instruments. The main changes for ECUs currently are the following: in the past, ECUs primarily focused on trauma patients, but recently, they have been facing a dramatic growth in patient diversity. Consequently, ECUs have become rather generalized departments that have to deal with an increasing variety of medical problems. One of the reasons for this development is the loosening of bonds between patients and their general practitioners (GPs) due to improved mobility, urbanization, and tourism (Hebly 1998). In addition, GPs increasingly have to cope with capacity problems. In order to avoid waiting periods, patients refer themselves to ECUs at hospitals ( self-referrers ) instead of first seeing their GP. A few years ago, the percentage of self-referring patients in a large Amsterdam hospital was as high as 60-70% (Buiter 1999; de Vries and Luitse 1999). In another inquiry, performed at the ECU of the University Medical Center in Groningen in 2001, 42% of the patients came on their own initiative. Another change ECUs have to deal with concerns patients attitudes: generally speaking, people coming to hospitals have become increasingly demanding. They expect prompt and satisfying treatment and they may check the quality by insisting on a second opinion (Dassen 2001, Rieffe and Wiefferink 1995). Moreover, the increased ageing of the population plays a role. More elderly people need to be treated and often, co-morbidity and previous afflictions must be taken into account. Aside from patients behavior, the demands of the labor market and employees have also been subjected to major changes. Doctors who work in the ECUs of large hospitals are usually residents in training to become specialists. In smaller nonteaching hospitals, ECUs are commonly staffed with interns, i.e. doctors who have recently finished medical school, and GP-residents. This causes three problems. First, it causes a high turnover of medical staff working in ECUs, which in turn leads to the instability of routines and extra work for nurses. Second, the doctors working in ECUs 16

19 1. Introduction tend to have little experience (de Vries 1999, de Vries and Luitse 1999) and thus specialists often need to be consulted and the total workload increases. Third, in addition to these organizational aspects, problems result from the changing professional supply provided by the labor market. Doctors, especially interns, are becoming an ever more scarce resource. Attracting and keeping qualified doctors forces hospitals to increasingly take the individual employee s preferences into account. Many young physicians, among which there are a growing number of women, want to work fewer hours (RVZ 2001, p. 55, 60) and would welcome shorter training programs (van Offenbeek et al. 2005). Therefore, current plans are to drastically shorten the duration of residencies by introducing a more intensive and better structured program. Residents will spend their time exclusively on work that directly contributes to the curriculum of their specialty. It will no longer be possible to employ them to do the daily main work of the ECUs. On the one hand, it is obvious that hospital managers need to revise their traditional views of the occupational structure, training and education, work structure, workflow, and coordination instruments at the ECU (Hebly 1998). On the other, it is difficult to realize changes that affect the role, formal position, educational and professional domain, career, work and income of old-established medical specialists. Informal substitution of medical tasks by other professionals has already been shown to be a widespread phenomenon (Scholten et al. 1999). However, formal delegation of tasks within the medical discipline by vertical job differentiation and between the medical and nursing discipline by task rearrangement is only a recent development and is still controversial (van Offenbeek et al. 2002). In 1997, a Dutch university hospital started formal educational programs for a new job family, the so-called hospital physicians. These doctors are characterized by a non-specialist, multidisciplinary three-year training program (Jaspers et al. 1999). Van Offenbeek (2004) has showed that by supporting this initiative, medical specialists themselves are starting to address the fragmentation caused by specialization. According to the long-established specialists involved, the hospital physician does not threaten their own professional domains. EPs in the Netherlands can be defined as a type of hospital physician. The idea of EPs, however, is not Dutch and it is not new. In several countries EPs are recognized specialists and have been working in ECUs for decades. In the USA, for example, EPs started working in the late 1960s, in the UK in the 1970s, and in Australia in the 1980s (Arnold 1999). 17

20 1. Introduction Despite these earlier examples and despite the seemingly analogous terminology, the EP concept differs considerably among countries. It is hence important to provide a definition of EPs in the Dutch context. By developing an EP job description that served as a basis for EP implementation in many hospitals, de Vries and de Goeij (2001, p. 1) put forward a definition at an early stage of Dutch EP development: The emergency physician judges as the first medic on the scene the nature of the medical help needed. He/she decides on the medical urgency, and puts the first medical treatment indicated into action. If necessary the emergency physician asks the consulting specialist then available or directly refers through. The emergency physician is responsible for the co-ordination in the reanimation/resuscitation team in the emergency department, and together with the trauma-surgeon carries the responsibility for the co-ordination in the trauma team. The emergency physician works together with the emergency nurses, ambulance staff, administrative staff and all the specialties which are in the hospital. The first training program for EPs in the Netherlands was launched in 1998 (Hirschler-Schulte et al. 1999). A university hospital and a number of large teaching hospitals soon followed. During the last few years, interest in educating and employing EPs steadily increased. In 1999, the newly educated physicians established their own professional association. Since 2004, a number of hospitals have joined forces to establish a national accredited educational program for emergency physicians, which is planned to come into action in Despite the increasing interest in employing EPs, scientific evidence on their effects for ECU performance in the Netherlands hardly exists and their benefit remains hitherto unproven. The only attempt, put forward by Maas et al. (2007), concludes that EPs contribute to faster treatment times, less diagnostic tests and fewer patient admissions. The authors, however, restrict their study to trauma patients and base their findings on a single hospital with only two trained EPs. Their evidence is hence rather limited. This study fills the existing research gap by presenting a comprehensive investigation of the implementation of EPs in selected Dutch hospitals and their effect on the performance of the ECU. 18

21 1. Introduction 1.2 Objective of the study and research questions This study has two research objectives. First, it aims to reveal similarities and differences in the development of EPs as a profession and their professional role. Two comparisons are conducted: 1) between the Netherlands, where EPs are newly emerging, and the UK, where EPs have been employed for several decades and which is often referred to as an example for Dutch EPs to follow; 2) between hospitals within the Netherlands. While the unit of analysis in the first instance is countries and hospitals respectively, in the second we compare emergency care systems. The study determines for which organizational configurations and to what extent emergency physicians enable a better fit between contextual characteristics and organizational structure in ECUs, leading to improved organizational performance. With regard to the first objective, the comparison between the development of the EP profession in the Netherlands and the UK will be based upon the work of critical professionalization theorists (e.g. Freidson 1970, Elliott 1972, Larson 1979, Abbott 1988). The comparison of their role and position in individual hospitals within the Netherlands will follow Lewin s (1951) force field approach. The corresponding research questions are as follows: (Q1) How can differences in the development and deployment of EPs be explained? (Q1-a) What are the similarities and differences in the professional development of EPs in the Netherlands and the UK? (Q1-b) Which forces explain the implementation and development of EP roles in individual hospitals in the Netherlands? With regard to the second objective, we draw on the theoretical assumptions of the structural contingency approach: The better the work structure fits the task environment, the better the organizational performance of a work unit will be (e.g. Van de Ven et al. 1976; Van de Ven and Ferry 1980; Van de Ven and Drazin 1985). The performance of a work unit is therefore determined by a simultaneous fit between a number of contextual and structural variables. This approach has regularly been applied to patient care units (e.g. Van de Ven and Ferry 1980; Alexander and Randolph 1985; Mitchell et al. 1996). We investigate how the characteristics of patient populations, occupational structure, and the organization of the care process 19

22 1. Introduction relate to a number of indicators of organizational performance in ECUs. The corresponding research questions are as follows: (Q2) Under which task environmental and organizational circumstances can EPs contribute to improved organizational performance? (Q2-a) Can EPs contribute to a higher organizational quality of care? (Q2-b) Can EPs contribute to reducing costs? (Q2-c) Can EPs contribute to a better working climate? (Q2-d) Can EPs contribute to better medical quality? 1.3 Structure of the book In order to provide answers to the research question, this book follows Pettigrew s (1987) structure of systematizing change. He distinguishes the context, content and the process of change. The chapters in this book cover these three elements: chapter 2 covers context, chapter 4 process and chapters 5-8 content. They are subsequently brought together to a conclusion in chapter 9. A more detailed structure of this book is as follows: Chapter 2 investigates the development of EPs as a professional occupation in the national context. It compares the EP development in the Netherlands and the UK. Chapter 3 describes the design that has been applied to the rest of the study. It provides details about the process and the applied criteria for the case selection. Chapter 4 narrows the focus of the EP-development down to the Netherlands and investigates what forces determine the development process of EPs within hospitals and how these forces shape the way EPs are utilized. Chapter 5 introduces the theoretical framework that is applied for evaluating the performance of ECUs. Chapter 6 describes the different methods of data collection and analysis. Chapter 7 presents parts of the empirical analysis in a comparative way. The cases are described in detail and overviews of the cases characteristics of task environment and organizational structure are provided. This chapter acts as a reference for the subsequent chapter 8, which comprises the analysis about the effect of EPs on four performance dimensions. 20

23 1. Introduction Chapter 9 summarizes the results of the study. It discusses the findings, draws conclusions about the theoretical implications and formulates guidelines for hospital executives regarding the implementation of EPs. It shows the limitations of this study and raises suggestions for further research. 21

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25 2 The Development of EPs as a Professional Occupation 2 The Development of EPs as a Professional Occupation: A Comparison of the Netherlands and the UK This chapter answers the first sub-question (Q1-a) i.e. what are the similarities and differences in the professional development of EPs in the Netherlands and the UK? It therefore brings a cross-country comparative perspective to the question of how differences in the emergence of the EP profession and role can be explained. We investigate whether the development of EPs as a profession in the Netherlands follows the role model of a country where EPs are recognized specialists, the UK. 2.1 Framework for the national development of EPs In most countries, emergency medicine is not recognized as a medical specialty. Still, EPs are no new phenomena; they have been emergency care specialists in a few countries for decades e.g. in the UK (McHugh and Driscoll 1999; Rutherford and Evans 1983), in the USA (Pollack et al. 2003; Marx 1997), and in Belgium- (Askenasi and Vincent 1983). In the past two decades, there has been growing interest worldwide in emergency medicine as a separate medical field (Arnold 1999; Kirsch et al. 1997; Noji 1989), and several countries, like the Netherlands, are currently trying to implement and establish EPs as a new profession. Other example countries in the literature include Armenia (Aghababian et al. 1995), Japan (Onji and Tsuyoshi 1983), Costa Rica (Mitchell 1991; Doezema et al. 1991), Turkey (Bresnahan and Fowler 1995), and Israel (Halpern et al. 2004). For an overview of the status of emergency medicine see Arnold et al. (2001), who conducted a survey study on emergency medicine in 36 countries. Kirsch et al. (1997) note that some countries seeking to develop emergency medicine and planning to train EPs, do so without learning from other countries previous experiences. In effect they reinvent the wheel, which leads to both a reduplication of efforts and unnecessary variances in the scope, content, and conduct of training programs (Kirsch et al. 1997, p. 997) 2. Despite using an analogous term for emergency physicians, differences with regard to their professional role exist 2 These differences do not refer to the distinction described by Arnold (1999) between the Anglo- American model i.e. emergency medicine being started in the pre-hospital setting and being continued into the ECU, possibly being a recognized specialty- and the Franco-German model i.e. emergency medicine taking place exclusively in the pre-hospital setting without being a recognized specialty- of emergency medicine. 23

26 2. The Development of EPs as a Professional Occupation between countries. The UK is an important example for the development of EPs in the Netherlands. Experts in the field, asked about their vision of emergency medicine in the Netherlands, told us, we should do it as they do in the UK. Dutch hospitals also tried to establish training exchange programs with UK hospitals, enabling Dutch EPresidents to spend some months of their residency experiencing the British emergency care system. For this reason, it is interesting to compare the professional development of EPs in the Netherlands and their role models in the UK 3. The literature on profession development describes several requirements for the sustainable development of new professions (see section 2.1.1). This chapter investigates these requirements in the UK and the Netherlands, enabling us to draw conclusions about similarities and dissimilarities and the extent to which the Netherlands follow the British model Theoretical background and method Theoretical background According to Nelson and Barley (1997), five quests subsume the sustainable development of new occupations. They are based on the work of sociological writers (e.g. Freidson 1970, Elliott 1972, Larson 1979, Abbott 1988) who are often referred to as the critical theorists (Evetts 2006; Hodgson 2002). (1) Founding an occupational association, (2) developing a training system, (3) linking practice to formal knowledge, (4) securing legal authority to license practitioners, and (5) acquiring the right to self-discipline. By taking these actions, new occupations gain institutional recognition, or as Hughes (1958) calls it, an institutional license. Abbott (1988), in this respect, talks about jurisdiction. Nelson and Barley (1997) build on Hughes (1958) and point out the incompleteness of this reasoning. They argue that these steps cannot be left to stand alone. They can only become effective after two other requirements are fulfilled: first, a group of practitioners needs to be present, who are self-confident precursors and put forward collective action. Second, the professional community needs to acknowledge 3 These two countries do not only lend themselves well to comparison because EPs in the UK act as role models for the Dutch development. The Netherlands and the UK are also quite similar countries with regard to their overall social welfare structure. 24

27 2 The Development of EPs as a Professional Occupation the tasks that shall be performed by the new group as work (see also Abbott 1988). These two aspects together form the cultural mandate. Put graphically, Hughes (1958) and Nelson and Barley s (1997) argument is conceptualized in Figure 2.1. Cultural mandate Institutional license New occupation Figure 2.1: Emergence of new occupations Nelson and Barley (1997) focus their study mainly on the construction of an occupational mandate, the transition from unpaid to paid work, which forms a part in the creation of a cultural mandate. Both Nelson and Barley and the critical theorists however, neglect another potentially important aspect of professionalization: interaction effects with parallel streams of other newly emerging occupations and organizations decisions. Abbott (1988) does refer to the importance of interaction effects with other professionals. However he focuses on jurisdiction by other existing, licensed professions rather than referring to concurring, newly developing professional groups. We argue that even if a cultural mandate is achieved, and even if institutional recognition has been gained, parallel streams of other practitioners groups can influence the success or failure of another occupation s sustainable development. This may especially be true when the planned task portfolios overlap. Several groups of practitioners battle over fulfilling similar tasks; we think that the final decision on which occupation succeeds is being taken by organizations that are loosely coupled with one another. Based on certain aspects, the organizations decide which professionals are employed for certain tasks. Only if several organizations decide on the same professional group, will this group finally be able to establish itself as a new occupation. Besides the cultural and institutional mandate, we hence argue that the final determinant as to whether or not a group of practitioners can become a new occupation depends on parallel streams of occupational developments and on the organizations mandate. Figure 2.2 illustrates this reasoning. 25

28 2. The Development of EPs as a Professional Occupation Orga. 1 Stream 1 Cultural mandate Institutional license Orga. 2 Orga. 3 Stream 2 Cultural mandate Institutional license Orga. 4 Orga. 5 Orga. 6 New occupation Orga. 7 Stream 3 n Cultural mandate Institutional license Orga. n Organizational mandate Figure 2.2: Emergence of new occupations II In the following we investigate the development of emergency physicians as a new occupation in the UK and in the Netherlands with regard to the existence and creation of the cultural mandate and the institutional license. We will then show how parallel streams of occupational developments interact and finally show the role of organizations employing professionals in the emergence of a new occupation. Method Expert interviews and documents served as data sources for this chapter. Details about the interviews conducted with Dutch emergency care experts and available documents can be found in chapter 6.1. In addition, interviews about the development and the present role of EPs in the British emergency care system were conducted with ECU staff members from a large UK hospital (Table 3.1). Table 2.1: Interviews with ECU staff in the UK Introductory interviews Semi-structured interviews 1 Consultant A&E 1 Consultant A&E 1 Consultant A&E / Clinical Director A&E 1 Business Manager A&E 1 Senior House Officer 1 (Senior) Emergency Nurse Practitioner 1 Emergency Nurse Total number of interviews 7 26

29 2 The Development of EPs as a Professional Occupation Development of EPs in the UK and in the Netherlands This section describes the development of EPs in the UK and in the Netherlands. After a brief general portrayal, characteristics about the creation of a cultural mandate and institutional license are presented. Subsequently, parallel streams of ECU occupations and the development of an organizational mandate are investigated. The United Kingdom The development of A&E medicine in the UK had its early roots in 1962, when the so-called Platt Report recommended new skills for doctors at the ECU which, according to the report, would best be met by orthopedic surgeons (Sakr and Wardrope 2000). In 1971, another report, the so-called Bruce Report, highlighted problems that the Platt package had caused: first, the field of orthopedic surgery developed away from trauma to more elective complaints; second, emergency patients showed an increasing number of internal medicine complaints (Wilson 1980). The Bruce Report therefore proposed the creation of 32 experimental emergency medicine consultant posts, i.e. medical specialists. The Department of Health accepted. With the appointment of these consultants in 1972, Accident and Emergency (A&E) Medicine became a new medical specialty. The 32 consultants came from different, mainly surgery specialties (Skinner et al. 1997). The heterogeneity of their skills soon stimulated the need for a new, coherent training system for EPs. Today, over 600 emergency consultant posts exist and over 500 specialist registrars are in training (BAEM 2006). The Netherlands EPs were developed as an answer to the changing patient demand and the medical labor supply described earlier. The first advances were made in 1997 when a university hospital started formal education programs for a new job family, the socalled hospital physicians. Hospital physicians are characterized by a short, multidisciplinary three-year training program (Jaspers et al. 1999). EPs can be seen as a type of hospital physician. The first short-track training program for EPs in the Netherlands started in 1998 (Hirschler-Schulte et al. 1999). A university hospital and a number of large teaching hospitals soon followed with a more coordinated threeyear program. During the last few years, interest in educating and employing EPs has steadily increased. According to information provided by the SOSG (Stichting 27

30 2. The Development of EPs as a Professional Occupation Opleiding Spoedeisende Geneeskunde), in spring 2006, about 32 fully trained EPs were working in Dutch ECUs with another 75 were in training Cultural mandate To achieve a cultural mandate, Nelson and Barley (1997) suggest two requirements: 1) the existence of a group of practitioners who are sufficiently self-confident to pursue collective action; 2) members of the culture acknowledge the activity as a form of work. Members of the culture acknowledge activity as a form of work The necessity of treating casualties is as old as mankind. FitzGerald (1998) sees the beginnings of organized prehospital emergency care with the Knights of St. John. Sakr and Wardrope (2000, p. 314) describe the care chain of prehospital and intrahospital care as being advanced by Napoleon s chief surgeon who collected and treated all the injured in an area close to the front line where they were brought by fast light horse drawn vehicles, the Ambulances volantes. Before the introduction of EPs, emergency departments in the UK were mainly staffed by surgeons and orthopedic surgery doctors (Sakr and Wardrope 2000). In the Netherlands, interns and residents fulfill the tasks under the supervision of respective specialists. The existence of self-confident practitioners United Kingdom. The Platt Report was supported by the Department of Public Health, which pointed out that ECUs needed to be supervised by consultants who are specifically dedicated to emergency medicine. Still, due to limited career prospects, adequate staffing was a problem and permanent ECU work was regarded as a dead end (Sakr and Wardrope 2000). It was only after the Department of Health s decision, taken in 1971 and realized in 1972, to create 32 consultant posts that ambitious doctors, most of whom were from neighboring medical areas, chose the ECU as their preferred medical field. Only 4 years later, the number of A&E 4 Please note that these numbers include only trained EPs who are accredited by the SOSG. Likewise, the number of EPs in training refers only to doctors in training programmes within hospitals with SOSG accreditation. 28

31 2 The Development of EPs as a Professional Occupation consultants had risen to 105. The Department of Health s decision thus stimulated doctors to get involved with A&E medicine; it gave them the consciousness to act as professional pioneers. Professionals state the year 1972 and the employment of the 32 emergency medicine consultants as emergency medicine s year of birth in the UK. The Netherlands. Two important differences exist between the UK and the Netherlands with regard to the first doctors working as EPs. First, while the UK appointed non-eps as emergency care consultants i.e. a formal specialist position-, the first EPs in the Netherlands were not senior doctors from existing specialties. No EP had completed a residency before commencing the EP-training. All Dutch EPs were hence rather young and had comparatively less experience than medical specialists. Second, most doctors starting out the EP-training in the Netherlands did not have any job security for a future appointment. After the three-year training contracts were concluded, hardly any formal assurance existed for subsequent employment. Due to their limited experience and job insecurity, the Dutch EPs work context possibly provided them with less self-confidence than their British colleagues Institutional license Nelson and Barley (1997) outline the following five requirements for gaining an institutional license: (1) founding an occupational association, (2) linking practice to formal knowledge, (3) developing a training system, (4) acquiring the right to selfdiscipline and (5) securing legal authority to license practitioners. Founding an occupational association United Kingdom. Two main bodies unite A&E practitioners and their interests in the UK: the British Association for Emergency Medicine (BAEM) and the Emergency Medicine Trainees Association (EMTA). The BAEM was founded in 1967 as the Casualty Surgeons Association. The initial name, which clung to the nature of the early specialty, was changed in 1990 to British Association for Accident and Emergency Medicine. In 2004, it was renamed again and received its present name (BAEM 2007). Membership of the BAEM is 29

32 2. The Development of EPs as a Professional Occupation available to any registered medical practitioner with a professional commitment to emergency medicine. In February 2007, the association had more than 1700 members. According to interviewed experts, the association s changing names reflect the issues surrounding the specialty s focus. While emergency medicine was initially regarded as closely related to surgery, changing patient demand and interests caused it to develop into a more stand-alone discipline. For an overview of the association s explicit roles see Hughes (2005). The EMTA was established as the national body that represents all emergency medicine trainees. It is partially funded by -and hence closely related to- the BAEM. Membership is free and automatic for trainees. The Netherlands. In September 1999, shortly before the actual start of most EP training programs in 2000, the Dutch Society of Emergency Physicians (Nederlandse Vereniging van Spoedeisende Hulp Artsen - NVSHA) was founded. Five years after its foundation, in June 2004, the NVSHA had 180 members. By February 2007, it comprised 202 members, of which 59 are trained EPs and 143 EPs in training (based on information provided by the NVSHA). Development of a training system United Kingdom. In the early days of UK emergency medicine, consultants skills could vary widely due to their previous affiliation and background (see above). The development of a coherent training system for new EPs started in 1975, 3 years after the employment of the first 32 EPs, when the Specialist Advisory Committee in Accident and Emergency Medicine was formed. Its task was to create a recognized training system, leading to equally skilled consultants. Two years later, in 1977, the first specialist registrars i.e. the British resident equivalent- were appointed for training. The first pre-specialty examinations, which enable senior house officers i.e. senior intern equivalent- to apply as specialist registrars, took place in Passing the exam grants the title Fellow of the Royal College of Surgeons of Edinburgh in A&E Medicine (FRCSEdA&E). Since 2005, the College of Emergency Medicine (CEM) is the leading institution to advance education in emergency medicine. It emerged from the 1993 founded Faculty of Accident and Emergency Medicine. Members of the BAEM were involved in its creation. CEM is responsible for setting standards of training and for 30

33 2 The Development of EPs as a Professional Occupation administering exit examinations, the first of which were conducted in Passing the exit exam awards the fellowship and membership of the College. The corresponding title is Fellow of the Faculty of A&E Medicine (FFAEM) (McHugh and Driscoll 1999). The Netherlands. At the beginning of the EP development, several hospitals elaborated training systems which were partly based on individual expectations, local requirements, or existing cooperation with other hospitals (de Vries et al. 2001; Hirschler-Schulte et al. 1999; Jaspers et al. 1999). In 2004, a body was created to standardize the various schedules and to develop a coherent national training system, the Stichting Opleiding Spoedeisende Geneeskunde (SOSG) 5. This association emerged from the, initially informal, cooperation of a number of large teaching hospitals and a university hospital. It was formally founded in March 2004 with the explicit goal of creating a nationally accredited EP training scheme. Moreover, it aims at embedding the new schedule into existing medical training structures and at registering doctors who have completed an accredited EP training. The SOSG s registration and training committee mainly consists of surgery and internal medicine specialists from hospitals offering EP training. In February 2007, only two out of eight members were EPs (in training). The most important difference with the UK is the relation between the creation of the formal specialty and creation of a training system: in the UK, emergency medicine is said to have existed as a medical specialty since 1972, even though no training system existed back then. This is entirely different from the Netherlands, where a training system is currently being established without knowing whether emergency medicine will develop into a recognized specialty. Linking practice to formal knowledge United Kingdom. In 1983, the Emergency Medicine Research Society (EMRS) was established as the first attempt to advance research in the field. The society organized annual meetings in EM science. In 1985, the British Journal of Accident and Emergency Medicine renamed in 2000 as Emergency Medicine Journal (EMJ) was launched (Hughes 2005). EMJ is the official journal of the BAEM. Since 1986, 5 The SOSG does not have an official English name. We therefore suggest translating its name into Association of Emergency Medicine Training in the Netherlands. 31