Challenging Operations: Medical Reform and Resistance in Surgery

By Fabio Rojas

Challenging Operations: Medical Reform and Resistance in Surgery
by Kate C. Kellogg, The University of Chicago Press, 2011.

“Good evening, everyone. My name is Captain Fred Jones. I’ll be your pilot today. It’s my pleasure to take you from Chicago to Miami. We’ll be departing in a few minutes, once we complete our pre-flight checklist and get some fresh pretzels.”

“The flight should be uneventful , except for Hurricane Peggy, which is now hitting Miami. Even though I haven’t slept in forty-eight hours, I’m fully confident that I can fly this sucker through 100 mph winds and rain. You see, flying without sleep is part of my training. Every pilot is required to go through an extensive training program where we will go days without sleep and get wild and crazy. Just this morning, I helped someone fly a helicopter onto an oil rig in a snowstorm.”

“Yes, you may have heard about the new regulations that limit work shifts for trainees. You might also be aware of the massive amount of research showing that sleep deprivation undermines nearly all cognitive skills. But those ignorant folks have never piloted a plane themselves. They don’t know that flying a Boeing 737 requires super tough hombres who’ve been through the hardest training. Getting you all killed this evening is an integral part of our education. It builds character.”

“The pretzels are here! Thanks for flying. Enjoy your trip to Miami.”

I.

Kate C. Kellog’s Challenging Operations: Medical Reform and Resistance in Surgery is an ethnography of surgery residency programs at three hospitals. The book explores an episode of medical education reform in the early 2000s. After scandal and external criticism, various medical associations recommended that surgical resident shifts be limited to twelve hours a day. Traditionally, medical residents would learn their craft by staying with patients for very long periods of time. Surgery trainees refuse to be hand-offs, where a patient would be transferred to a doctor who appears at the beginning of a new shift. Surgical patients require a great deal of monitoring and there can be unexpected complications, which means that residents can spend days in the hospital as they wait and assess the outcomes of their procedures. The recommended policy change is that residents limit their time in the hospital to twelve-hour shifts (e.g., 6 AM to 6 PM). At the end of the day (or in the morning), the patient will become the responsibility of a different surgeon or physician. The goal of the policy was to improve patient safety by having more alert caregivers and improve the quality of life for surgeons.

Challenging Operations is an ethnographic account of this policy change. Kellogg spent two and a half years observing surgical residents and chiefs first hand at three hospitals. She also conducted extensive interviews with dozens of people who participate in surgical residency programs, such as interns, attending physicians, and directors.

The book is an explanation for why policy reforms succeed in some organizations and not others. Kellogg’s book focuses on three different issues. First, there is the issue of why long working hours are considered an important component of surgical training. Second, there is a succinct description of the two sides of the conflict. Third, there is a nuanced argument that explains why policy reform – shorter resident hours – only succeeded in one hospital out of the three that she observed.

II.

The first half of the book will not be much of a surprise to anyone familiar with the medical profession. Occupational groups develop post-hoc rationalizations for their irrational behaviors, and surgeons are no exception. Kellogg has a lot of nice examples of behaviors that display status and authority, while reducing patient safety. For example, she notes that surgical residents like to wear their scrubs in public, which is not safe because of the diseases they may bring into the hospital. The key point is that excessive shift lengths, and other practices, are often tied to a heroic identity, not evidence-based assessments of what might constitute good care. The organization of surgical training is designed to project this identity to the public, their colleagues, and to themselves.

It is the second and third parts of the book that are much more interesting. Kellogg makes an interesting claim. Within the social world of surgical residents, “the Iron Men,” who defend the status quo, are actually in the minority. The Reformers are numerous, but fragmented. Yet, the Iron Men are in a particularly strong position to stop policy change. The key mechanism is power over careers. When administrators institute the “night floater” program, where patients are handed off to other surgeons or physicians in the evening, younger residents refuse to cooperate. While they recognize the value of getting rest, they are often afraid that their career will be stymied. Kellogg mentions a well-known case of a resident at Johns Hopkins who reported that residents were violating work shift restrictions. The resident was so ostracized that he transferred to another hospital, which is rare for surgical residents.

The third part of the book is the most important. Kellogg identifies a few factors that make it possible for reformers to win the day. First, reformers can’t be isolated from each other. Second, there need to be spaces within the organization where reformers can share strategies and assessments of the conflict over policy. Third, reformers need to maintain solidarity. Residents who identified strongly with status quo defenders were more likely to defect to the status quo during the course of the conflict and undermine reform efforts.

III.

This book is relevant to social movement research because it provides an interesting way to think about movement outcomes. Early research focused on national policy. Do governments institute the policies that movements want? Recently, there has been a push to understand the institutionalization of non-state movement outcomes, such as changes in corporate policies (King 2008) or school curricula (Binder 2002; Rojas 2007, 2010). It would be misleading to describe Kellogg’s book as a study of social movements because these actors are not engaging in disruptive or contentious conflict. The book’s value for movement scholars is to provide some hypotheses into how organizations process change that is imposed on them from the outside, whether it be instigated by movements or other actors.

The first insight is that reform movements don’t always lead to myth and ceremony (Meyer and Rowan 1977). There may be genuine conflict. Second, the structure of the organization has a large role in shaping outcomes, especially when external sanctions are weak. Free spaces seem to play an important part in organizing reform. Without them, reformers are fragmented. Third, reformers need to build their own oppositional identity. The lack of an identity may mean that the “foot soldiers” of reform are co-opted by status quo defenders.

Finally, it is important to remember why this is an important study – patient safety. Every year, there are thousands, perhaps millions, of preventable health care associated injuries. Sleep deprived surgical residents are only a small part of the problem, but they represent a larger issue in medicine. The medical professions are extremely slow to change, even in the face of strong evidence that a particular practice needs reform. This book provides an important insight into the conservative nature of medicine. Let’s hope that policy makers will learn the lessons and design hospitals in ways that facilitate evidence-based reform.

References:

Binder, Amy. 2002. Contentious Curricula: Afrocentrism and Creationism in American Public

Schools, Princeton University Press.

King, Brayden G. 2008. “A political mediation model of corporate response to social movement

activism.” Administrative Science Quarterly. 53: 395-421.

Meyer, John and Brian Rowan. 1977. “Institutionalized Organizations: Formal Structure as Myth

and Ceremony.” American Journal of Sociology, 83(2): 340-63.

Rojas, Fabio. 2007. From Black Power to Black Studies: How a Radical Social Movement Became an Academic Discipline. Baltimore, Maryland: The Johns Hopkins University Press.

Rojas, Fabio. 2010. “Power Through Institutional Work: Building Academic Authority in

the 1968 Third World Strike.” Academy of Management Journal 53:1263-80.