When Organizations Collide: The Case of Physicians and Hospitals in the United States

Hierarchical organizations, in which authority is clearly defined and, for the most part, centralized, typically undertake routine operations in which the bulk of the workforce is expected to perform the same activities or groups of activities repeatedly. One of the main goals of these organizations is therefore to restrain people from exercising their individual judgment, since deviations from routine patterns may disrupt the entixe flow of work. Hierarchy and centralization are inappropriate, however, when there is a substantial mount of uncertainty present in the production process. If producers must frequently make complex choices, even instruction books may be inadequate and the use of a role-based Weberian bureaucracy [Weber, 1946, 1947] becomes impractical Professions provide examples of organizations whose work is highly uncertain and contingent, requiring professional practitioners to rely heavily on their individual skill and judgment within the norms of accepted practice for their particular professions. But professionals must often draw on resources that are concentrated in institutions that they do not control. While these organizations may be intended specifically to assist professionals in the independent use of their judgment and skill, they nevertheless pose problems because they are most often not owned by these professionals and their administration is not entixely under professional control. This creates the potential for conflicts between independent practitioners, who seek to preserve their authority and autonomy, and the administrators of complementary institutions, who have responsibilities of their own. In this article, we examine the growing tension between monitoring usage of hospital-based resources and the maintenance of profession authority and autonomy in the medical profession i the United States ince 1918. We show that, from the end of World War I, the professional behavior of