Medical technology and professional dominance theory

The expansion of medical technology in hospitals is commonly asserted to be a result of the preferences of medical doctors translated into organizational policies as a result of professional dominance in health care organizations. This paper examines the theoretical and empirical bases for hypotheses of professional dominance and the utility of these hypotheses in explaining hospital decisions to adopt new medical technologies. The analysis, which is based on 5 years of data collection including 378 personal interviews at 25 U.S. hospitals, indicates that appropriate application of the concept requires specification of the type of physician exercising influence and of the hospital decision systems within which it is exercised. Specification is needed because neither physicians nor hospitals are unitary categories when considered in relation to technology adoptions. In this paper, four categories of physicians are identified: community generalists, community specialists, referral specialists and hospital-based specialists. Members of these categories exhibit different skills and interests, different relationships to hospitalstechnologies, and differential access to the resources of organization influence including two unrelated to professional dominance. To understand the exercise of physician influence, it is further useful to differentiate three decision systems which review and pass judgement on different types of hospital technologies. They are: the medical-individualistic, the fiscal-managerial and the strategic-institutional. The three decision systems make decisions in accord with different values and goals and display different decision structures and dynamics. Ironically, the physicians who most clearly possess the resources of influence associated with professional dominance are centrally involved in only one of the three systems. They play only minor roles in the two which make the most far reaching and costly technological decisions.