The (im)possibilities of clinical democracy.

ABSTRACT

In this article, we argue that homogenising discussions of medical dominance on the meta-level of professions do not fully capture the complexity that characterises current clinical care in multidisciplinary health care teams. We illustrate this through an empirical study of a multidisciplinary team attempting to enact their work in a clinically democratic way. The challenges that arose in putting this into practice highlight the depth and complexity of enculturated medical dominance in Australian hospital practice. Our study shows that effective facilitation of clinician reflexivity has the potential to challenge and change deeply embedded structures and behaviours.

KEY WORDS

Medical dominance, clinical democracy, sociology, hospital ethnography, multidisciplinary clinical team, reflexivity

Introduction

The idea that all health care professionals--medical, nursing and allied health--could be respected for their specific area of professional expertise and have equal voice in care-management decisions according to that expertise, remains, for most health care workers, an impossible dream. Medical dominance, as relevant in Australia in 2006 as it was when first described by Willis (1983) over two decades ago, works against multi-vocality in decision making within multidisciplinary clinical teams. The challenges to implementing clinically democratic modes of decision making appear to be no less complex and multifaceted now than they were twenty years ago.

Willis' original medical dominance thesis (1983, 1989) belongs to a body of work that regards the medical profession as mobilising selected means to restrict and exclude other professions from gaining legitimacy in the field of health care (Freidson 1970; Illich 1976; Larson 1977). Willis' historical analysis of medicine's professional relationship with neighbouring professions highlighted three specific modes of domination: subordination, which ensures other professionals conduct their work under direct control from doctors; limitation, which restricts other professionals' access to important institutions; and exclusion, in which formal licensing processes deny official legitimacy. Since the book's appearance in 1983, analyses of medicine and its relationships with other professions and the state have appeared that have illustrated tendencies away from medical dominance, including proletarianisation (McKinlay and Stoekle 1988; White 2000), deprofessionalisation (Haug 1973), and a loss of public trust (Daniel 1994). More recently still, shifts in interprofessional boundaries (Freidson 1994), arising from the contemporary 'climate of workforce change' (Nancarrow and Borthwick 2005:914), have been interpreted as important challenges to medicine's original means of control (Nancarrow and Borthwick 2005).