基层医疗科室的权力场与变革因素——以一家区级医院E科为例

The Power Field and Reforming Factors of a Front-line Medical Department——Taking the Department E of a District Hospital as an Example

本文通过参与观察、深度访谈等方法,以一家区级医院的E科为例,从医疗职业、组织结构、分配制度三个方面探讨了基层医院科室日常运行与变迁的过程和机制。通过研究发现,基层医疗科室处在一个广泛、动态的组织场域之中,场域中各种力量之间的变动不断地推动着基层医疗科室自身的变迁。首先,国家对于卫生系统投入方式的改变使得科室的运行逻辑由公益性向营利性转变,是科室变革的最大驱动。其次,竞争越发激烈的市场环境不但影响着科室医务人员的工作心态,也影响着科室内部结构中的各种关系。同时,韧性的既有结构也存在于科室内部。在各种政策的推动与约束下,组织内的个体积极地调整着自己的行动并利用自己在组织结构内的地位与权力采取各种策略维护着自身的利益。

Recently,the medical field attracts a lot of social concerns.The health care system,including hospitals,doctors and nurses meets much social criticism.Nowadays," difficult" and "expensive medical service has been resolved to some extent.The new medical reform policy has been carried out,but the tension between doctors and patients is even more serious.To explain the problems of the current medical organizations,we must solve two problems:in the past decades,along the process of reform,what change has been taken into the hospital and what caused its changes?With observations,in-depth interviews and other methods,this research examines the process and mechanism of a medical department of a secondary hospital-Department E.We explore three facets of the running and changing of the department:the medical profession,the structure,the distribution system.First of all,we examine the professional history of the three generations of doctors in the Department E,and we find that the professional style of the"doctors" in the Department E has changed a lot in the past few decades.Firstly,the professional role of doctors transformed from experts who specialize in technology before and after the founding of the People ’s Republic of China to technical experts who carry out a specific communist ideology.Since the reform and opening-up,they have been pursuing personal interests under the influence of market forces and became a mixture of " the economic man" and " the unit man".Secondly,it has shown a constant openness in the professional development of doctors,and the inclusiveness of the Medical Departments has been continuously improved.Thirdly,it shows the importance of institutional experience in shaping the behavior of doctors in the profession.Then,we discussed the organizational structure of the Department E.It also has an unique organizational structure.Firstly,the formal structure of the department is divided into three dimensions:management structure,functional structure and identity structure.The identity of permanent staff and nonpermanent staff causes significant differences in status,salary,and welfare.Secondly,informal structure including seniority structure and informal social network partly determines the power map of the department.Thirdly,the structure of the department is also being constructed by day-to-day practice.Daily shift reports and festival parties are very typical.Lastly,we discussed the changes in the income distribution institution of the Department E.There is a triple logic in the economic distribution of the department.The first is the egalitarian logic derived from the " redistribution tradition" under the unit system before the reform;the second is the logic of"technicalism" driven by the characteristics of medical organizations and the marketization of medical organizations,and the last is the responsibilized logic based on a medical organization enterprise.We find that although the traditional distribution logic still works,the changes in the roles between doctors and nurses,the division of the department and other major events reflect more market logic.Through the research,we find that a medical department is not separate in the hospital,it is set in a wide range of dynamic organization field.The government,the pharmaceutical market,the patients,similar medical departments in other hospitals,all of them in the organizational field promote the transformation of the Department E.As a subordinate organization of the hospital,the medical department must accept the order of the adminstrators of the hospital,but the hospital has its " dual authority" attributes.The administrators usually do not have the ability to evaluate the professional work and often distribute the power to the experts of the departments.So the departments get their own independence.The administrative department controls the personnel and finance of the hospital,which makes the medical departments work with the arrangements of the hospital most of the time.Meanwhile,the state government arranges the health work through the health bureau and the hospital to the medical departments.National health policies are the biggest motivation for most changes.The changes of the funding mode of the hospital made the running logic of the medical departments sliding from public-welfare to profit-making.The medical department faces tough competition for their own economic resources.This competition including organizational field within the limited economic resources to compete with the different departments of the hospital and compete for patients with limited resources in the region as well as with the relevant sections of the outer court.Department E,as a secondary hospital department,whose main competitors are the municipal medical institutions.At the same time,due to the " step by step" to cure the patients,the Department E is increasingly difficult to retain the critically ill patient,in practice restrict the establishment of a doctor ’s experience,while located in the entire organizational environment in Department E,as below the municipal Medical Departments of the hospital.The leaders of the Department E seek ways to resist the structured environment of this organization in the field of medical organizations to determine their status.Also in this field,there are market forces.Widespread market economy impacts working mentality and relations in the department.The marketing of medicine and medical equipment made the hospital get on the rail of the medical market.The various actors of the organizational field influence departments in many ways.At the same time,we also see there is a resilient structure in the department.Individuals within the organization under the various policies must adjust their behavior.Meanwhile,department members adopt various strategies to maintain their own interests.