Swedish physicians' perspectives on work and the medical care system—II: The cases of child and maternal health physicians

Sot. Sci. Med. Vol. 2S, No. 5, pp. 515-524, 1987 Printed in Great Britain. All rights reserved

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0277-9536187 33.00 + 0.00 1987 Pergamon Journals Ltd

SWEDISH PHYSICIANS’ PERSPECTIVES ON WORK AND THE MEDICAL CARE SYSTEM-II: THE CASES OF CHILD AND MATERNAL HEALTH PHYSICIANS Ar~inzw C.

TWADDLE

Department of Sociology and Department of Family and Community Medicine, University of Missouri, Columbia, MO 65211, U.S.A. Ah&act-This paper reports the results of focused interviews with child health and maternal health physicians in the public ambulatory care sector of a large Swedish city to describe (1) the organization of their work activities, (2) their perspectives on their work, and (3) their perspectives on the medical care system. Child health physicians (who were attached to a major teaching hospital) practiced in child health clinics for preschoolers and school health clinics. Each physician covered several such settings. Maternal health physicians were attached to local hospitals and practiced full time in maternal health centers. Child health physicians described their work in terms of preventive care, patient care, integration of ambulatory and hospital services, and technological sophistication; they described the system in terms of quality of care, quality of diagnosis and treatment, adequacy of resources, and distribution of services. Maternal health physicians described work in terms of a biophysical orientation, practice independence, relations with hospitals and other specialists, and dependence on nurses; they described the system in terms of technological sophistication, ambulatory and hospital care, and problems of other specialties. Both were more positive about both work and the system than were district general practitioners, and some interpretation is offered. Key

wordr-ambulatory

care, Sweden, physicians, health care systems

This paper is part of a series dealing with the effects of location in the Swedish medical care system on physicians’ perspectives on their work and that system. It is based on a long-standing premise within sociology: that location in any social structure infhtences the perspectives of participants in that structure [l]. In an earlier paper the perspectives of district general practitioners were presented [2]. Other papers will deal with private practitioners and analyze similarities and differences across specialities [3]. This article deals with two primary care specialties: child health and maternal health. Previous work on the Swedish medical care system has presented it as a unitary, if not homogeneous, structure. Its focus has been on the overall organization of medical care at the national level, with a special emphasis on the regionalization of services, particularly the hospital [4]. The data bases for those studies have been interviews with people at the ‘top’ of the system (e.g. politicians, planners and administrators) or data collected to summarize the performance of the system as a whole [5]. By contrast, this research took a ‘bottom up’ view of the system based on interviews with primary care providers in the ambulatory care sector. The working assumption was that this strategy would provide a more differentiated description of the medical care system as one containing several, differently organized, segments. Further, the nature of the segment would result in different kinds of practitioners having distinctive perspectives on their work and on the successes and failures of the overall system.

METHODS

AND DATA

The design of the project from which this paper comes was exploratory [6]. Following the logic of some ethnomethodological designs, the plan was to identify a range of informants whose involvement with medical care would maximize the possibility of capturing the range of perspectives held by those who work in the system. Each informant encounter wouid be a ‘slice’ of data that could serve to construct a tentative ‘schema’ [7l representing the perspectives of a class of respondents. Each ‘slice’ would be an occasion for rethinking the ‘schema’. Through a process of iteration, the adequacy of the ‘schema’ would be improved. Following the logic of grounded theory [8], respondents would be selected to maximize the possibility of gaining new perspectives. New respondents would be added until either no new information was evident in the interviews or there were no new respondents in the category to be found. Respondents were selected to ensure that all types of physicians in primary ambulatory care would be included, along with others whom patients might see on their first visits in the system. Physicians interviewed included those in district general practice, child health, maternal health, social medicine, occupational health, and private practice. In addition, interviews were conducted with nurses, social workers, health planners, administrators, and politicians. The latter three were focused on gaining information about the overall system and identifying potential primary care respondents.

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All others were interviewed using a focused interview guide [9]. That is, questions were posed in an open-ended fashion designed to elicit the respondent’s definition of the situation while guarding against suggesting content or structure for their responses. Questions asked for a description of their work and clientele, main satisfactions and frustrations with work, and their views of the successes and failures of the medical care system as a whole. In all but two cases (one involving an equipment failure in the field and the other a refusal by the respondent) interviews were tape recorded and transcribed. Each interview was reviewed in preparation for subsequent interviews. At the end of the data collection period, a content analysis was performed on all the interviews. The papers in this series report the results of that content analysis. There are two caveats that should be noted with reference to the entire project. First, the data were collected in Goteborg, Sweden’s second largest city, with a population of approx. 430,000 in 1978-1979. Urban areas have a more diverse selection of medical resources than is the case for smaller localities. The medical care system was undergoing changes that have continued past the research period. We will return to these points in discussion. Second, the research is based on a small number of respondents. The data allow no claims about the distribution of perspectives or of practice types in the city or the nation. They were not collected to test hypotheses, but to gain a more in-depth_ understanding that might contribute to the development of valid hypotheses. The focus is on validity, rather than reliability. Large samples and sophisticated statistical design would not be appropriate for the subject matter of the investigation at this stage. The sample is adequate as a start in identifying the types of perspectives held by physicians and others. Following the pattern in the earlier paper on general practice, we now turn to child health and maternal health physicians. For each, we will provide a description of the organization of practice, their perspectives on work, and their perspectives on the system. CHILD HJULTH

Organization

Child health services had a unique institutional location among the ambulatory care services of the city. All other specialties were located in a Division of Ambulatory Care within the city Department of Heahh and Hospitals (SjukvM.&rvaftnhgen). Pediatric services were part of the East Hospital (Ostra Sjukhuset), a major teaching hospital which functioned as a county and regional facility [lo]. Interviews were conducted with three child health physicians all of whom provided clinical services. Two days were spent observing in two different child health clinics (bamovdrdcentrafer) and an additional two days were spent observing in school health clinics, one at the elementary (grundrkol) level and the other at the high school (gymnasium) level. All the observations were conducted on days when physicians were in attendance. Child health services were divided into two div-

isions. On the one hand, there were 64 child health clinics designed to serve preschool children, one within walking distance of every residence in the city. These were open 40 hr each week, staffed by a fulltime pediatric nurse and one or more assistant nurses. They were typically located in or adjacent to a shopping center. The clinics visited had two examining rooms, a large reception area, a small laboratory, and a consulting room. They were staffed full time by a nurse, an assistant nurse, and a receptionist. Sixteen child health physicians visited each center for at least half a day each week. These same pediatricians could care for patients who were admitted to the hospital from their centers. In addition to medical services, each child health center was visited weekly by a psychologist and a dentist. Other types of health care providers could be brought in by the nurse as needed. The second division was the school health service (skolha”fsovdrd) administered by the school administration and staffed by the Department of Pediatrics at East Hospital. There was one of these clinics in each school: it was open during the school day. Elementary schools (grades l-9) averaged nearly 300 students; high schools (gymnasia) averaged just under 800 in 1977. Like the child health clinics, school clinics were staffed by a full-time nurse, sometimes with one or more assistant nurses. A pediatrician visited each school once a week for at least half a day. Dentists scheduled regular visits. Other health professionals could be called in as needed. Psychological services were provided by specially trained social workers who worked independently of the school clinics. From the standpoint of the child, the system was designed to work as follows. At birth, the child was registered with the parish and the birth was reported to the child health center in his or her neighborhood. When the child was released from the hospital (where almost all births occurred in Sweden), the discharge was reported to the child health center. The child left the hospital with a scheduled appointment for followup examination. If the parent did not bring the child in (a rare occurrence in Swedish neighborhoods, but more problematic in immigrant neighborhoods), the pediatric nurse made a home visit, ostensibly to ‘check the navel’ (child health center nurses were popularly referred to as ‘naval nurses’). From that time until the child entered school, there were regularly scheduled times when (s)he was to be seen by the center. These were done by the physician at ages one and four, at other times by the nurse. These checkups and immunizations were reported to be the ‘right’ of the child. Parents were not given discretion in the use of the system. If a child was not brought in when scheduled, center personnel took the initiative to arrange an examination through home visits or, in cases of extreme resistance, through legal means. The child used this system until entering school at the age of seven. Upon entering school, the child received a complete physical examination with follow-ups in the fourth and eighth year. The child had the right to report to the school clinic on his or her own initiative at any time. That visit was usually to the school nurse who either handled the problem herself (all school

Swedish physicians’ perspectives on work and the medical care system nurses observed were women), held the case until the next visit of the physician, or referred the child to the hospital for diagnosis and treatment. School nurses were also active participants in classroom teaching, conducting lessons in health and hygiene. They had the chance to function as health educators and to observe in the classroom, which provided opportunities to identify health hazards in the school as well as children in need of care who had not come to the clinic. Activities of the school health unit ranged from routine surveillance to preventive medicine to diagnosis and treatment. This system provided care until the child left school at about the age of 16. At that time the adult system took over responsibility. This brief background should be sufficient to understand physician perspectives on their work and the system. Perspectives on Work

Themes garnered from interviews with pediatricians emphasized contributions to the health of their patients: preventive medicine, high quality patient care, integrated hospital and ambulatory care, and technological sophistication in response to disease. Prevention

Child health respondents uniformly said that the core of their work was in preventing the emergence of health problems among children. In this, they saw themselves as more advanced than their colleagues_in other technologically advanced societies. As -expressed by one respondent who had taken part of his training in a major medical center in the United States: In the United States you have a great deal of sophistication. Children coming in for care had very well trained physicians who could respond in a very excellent way to the disease problems and who had the best and most modem tools for treatment. But it all comes too late. That is the problem.

He noted that while in the U.S. he had treated conditions that are rarely seen in Sweden. . . . In your country little is done to see that these diseases are blocked before they have a chance to develop. Particularly the Black children come in with diseases they should

never get, but nobody does anything to prevent them. They are not examined until they are sick. Great emphasis was placed on the fact that all children in Sweden were regularly screened for problems and that both conditions that threaten health and the early indications of disease were identified before major problems were allowed to develop. Child health physicians took pride in this state of affairs and regarded it as both a major accomplishment of their system and a major source of satisfaction in their work. Enormous problems were seen in preventive care, however. These focused on aspects of life style that posed long-term threats to health. Special emphasis was placed on smoking, drinking, and nutrition. Child health physicians used their clinical contacts to educate parents. School nurses used both clinical contacts and classroom time toward the same end. Efforts to have regular classroom teachers participate

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in a program on passive smoking were reported to be not as successful as hoped. Finally, it was reported that preventive examinations provided an opportunity to gather data on ‘trends and changes in health’. Respondents appreciated the research value of such data and noted with satisfaction the low levels of morbidity among children. As expressed by one, “it shows we are doing our job well”. Patient care

Child health physicians reported that most pediatric care was oriented toward healthy children and their needs. Much as they were “alert to health problems of children and sophisticated in response to disease”, they all held that the focus of their work was more on the child than on disease per se. They reported enjoyment of relationships established with children and their parents and satisfaction with their involvement in a wide variety of concerns including peer relationships and school problems in addition to disease. Indeed, the need to deal with disease was treated as a failure, indicating that adequate preventive measures had not been taken. Integrated care

Child health physicians reported that the integration of ambulatory and hospital care was a unique and satisfying feature of their work. By working in the ambulatory sector (child and school health clinics) they reported themselves as “participating in the core activities of pediatric medicine, prevention and patient care”. By working in the hospitals, they said, they were able to keep up with the latest developments in medical technology involving diagnosis and treatment of disease. All the respondents made almost identical statements: “We live in the best of both worlds”. Working in both ambulatory and hospital settings was said by the child health physicians to have benefits for the children as well as the physicians. It was reported to provide continuity of care, which was “an important value, especially in the treatment of children”. Because ambulatory care physicians could “follow their patients into the hospital and treat the more serious conditions”, a seriously diseased child did not have to adjust to a new physician along with the anxiety induced by a disease and a new setting. The lack of integration of community and hospital and the consequent lack of continuity was seen by the child health physicians as a disadvantage of other primary care specialties and of general practice. By integrating those activities, they reported feeling the satisfactions of interaction with children and parents, intellectual stimulation, and a sense of continuity that resulted in better patient care. Technological sophistication

According to the child health physicians, the location of the pediatric system in a teaching hospital placed pediatric hospital services at the “cutting edge of medical knowledge” and technology. Being part of the hospital was reported to be a source of satisfaction, in that it meant they were kept abreast of the latest developments in medicine and could provide the most sophisticated possible response to the needs

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of children in the event of serious disease. This seemed to be an important part of their identity as part of the mainstream of medicine. At the same time, hospitals were reported to be traumatic environments for children. There are times when it is necessary to put the child in the hospital; it is the only place to treat the disease. But it is terrible for the child to he taken from its mother and to be put in such a place. It is very difficult for the hospital to be sensitive to the needs of children.

Technological sophistication, then, seemed to be regarded with some ambivalence by pediatricians. Embodied in the high technology hospital, it symbolized at once their status as sophisticated physicians (and was important in developing and maintaining their skills) and at the same time the use of the hospital entailed significant costs for the patient and symbolized a failure of preventive medicine. Perspectives

on the System

The child health physicians interviewed reported that the child and school health systems were “the major success story of Swedish medical care”. In looking at pediatric care as a system, they said it was responsive to the needs of children and organized to provide high quality, personalized care. Moreover, it provided sophistication in treatment and diagnosis and had resources adequate to meet needs. Quality of care

Child health physicians all reported iha
TWADDLE

were competent and sophisticated in treating even the most difficult cases. When needed, the best technology could be employed by the same physician who provided the ambulatory services. This meant to the pediatricians that “children have the best chance to have their conditions competently handled without disruptions in continuity. Knowledge of the child in out-patient settings facilitates in-patient care.” Adequacy

of resources

All the child health physicians interviewed said that pediatric services were ‘well developed’. They noted that in the city there was a child health clinic within walking distance of each residence; each school had a clinic. There was a sufficient supply of well-trained pediatric nurses who were available to children and their parents daily. The emergency room at East Hospital was sophisticated and available continuously. There were enough, perhaps too many, pediatricians to provide medical back-up at all levels of the system at any time they might be needed. Distribution

of services

The 64 child health clinics in the city were reported to have accomplished a ‘good distribution of services’ in the city for preschool children. The school health clinics were ‘where the students are’ for older children. All were said to be adequately staffed. The only problem noted, and that by a single respondent, was that: Not all parts of the city are equally popular. There are some places where people don’t like to practice, and this is a problem in keeping them there when there are other possibilities.

This respondent referred to areas of the city in which immigrants were concentrated, areas associated with more crowding in housing, lower income, and more ‘social pathology’. This suggests that in these areas there may be more problems with continuity of care over time. If so, there may be important qualifications to the characterization of quality of care above. Our data do not allow us to pursue this issue. Even with this caution, the distribution of services seemed much closer to need as defined by the distribution of children in the population than would be the case in most advanced societies. One respondent argued that the distribution of services and the orientation to prevention had “broken the link between poverty and disease”. This respondent also gave credit to the development of social programs that made poverty a rare phenomenon in Sweden, especially as compared with the U.S. Indeed, there seemed to be an underlying theme that ran beneath all these others: superiority to the United States. Comment

Child health physicians reported that there were problems in other parts of the Swedish medical care system. They said the separation of ambulatory and hospital care in district general practice and in other specialties, for example, was inappropriate and led to poorer quality care and poorer technical quality. They reported that the use of district general practices for children (which could be found in some

Swedish physicians’ perspectives on work and the medical care system

districts and in use of the Acute Primary Care Center 1111) meant that some children were being seen by physicians who were not expert in child health. Unlike all other physicians, child health specialists encouraged the use of the East Hospital Emergency Room during the evening hours in preference to the Acute Primary Care Center. These problems were seen as related to utilization, rather than defects in the system. They could be resolved with patient education programs. MATERNALHEALTH The physicians in the maternal health (modraudrd) system shared with child health the fact that practitioners had both ambulatory care and hospital responsibilities. The maternal health physicians studied had appointments to one of 12 maternal health clinics which were attached to multispecialty ‘policlinics’ located in or near shopping centers. They worked full time at a single clinic with several nurse-midwives, laboratory technicians and, occasionally, other personnel who provided patient care. Their hospital appointments were in short-term care facilities, either local hospitals or hospitals attached to the policlinics. The latter were typically open only during the work week. There, they could perform uncomplicated surgery and provide back-up to the nurse-midwives, who did most deliveries. The work activities of the maternal health centZrs involved the supervision of normal pregnancies, relatively simple surgical procedures (D & C, abortions, etc.), uncomplicated gynecological problems, birth control, and health examinations of women. In all but the surgical areas, maternal health nurses provided most of the services, with the physician providing intermittent surveillance and, when patient problems fell outside nominal parameters, back-up services for nurses. The physicians did relatively few deliveries. In uncomplicated cases, these were attended by nurse-midwives; in complicated or high-risk cases, women were referred to the hospital services at the teaching hospitals. A woman seeking a health examination, treatment for a symptomatic condition, or who suspected she might be pregnant would report to a maternal health clinic and be seen by a maternal health physician. Follow-up care in uncomplicated cases would be referred to a nurse-midwife. Maternal health physicians, in comparison with district general practitioners or child health physicians, spent a greater proportion of their time in diagnosis and treatment and less in monitoring and surveillance. If a woman suspected she might be pregnant, she would be screened by a nurse-midwife, who would follow her throughout the pregnancy and usually attend the delivery. Three times during the pregnancy (at the 12th, 28th and 32nd week, nominally) she would be. examined by the maternal health physician. Visits were made monthly for the first four months, biweekly for the fifth to eighth, and weekly during the last month. Birth control advice and dispensing was the responsibility of the nurse-midwives in each clinic. A special clinic for school children was located in the

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downtown area in one of the policlinics [12]. It was staffed by a nurse. Complications involving contraceptives were referred to the maternal health physician. Abortion was available on demand for any women of child-bearing age. Children were generally urged to talk with their parents before undergoing an abortion, but if the child was resistant the abortion would be performed without parental notification [13]. The right of the child to a privileged relationship with her physician was not compromised because of age. Abortions were performed in a local hospital by the maternal health physician. Observations were conducted in two maternal health clinics. Each had an office for each physician and nurse-midwife. Physicians had three examining rooms each, one of which was for infectious disease. Nurses had one. Each clinic had a small laboratory and a waiting room. Both clinics had two physicians. One had four nurse-midwives, the other eight. Each had assistant nurses, a laboratory technician, and a receptionist. One clinic was in spacious accommodation in a shopping center; the other was in more cramped facilities attached to a local short-term specialty hospital next to a shopping center. Perspectives on Work

Four themes were apparent in interviews with maternal health physicians: a biophysical orientation, practice independence, good relations with hospital specialists and other physicians, and good working relations with nurses. Biophysical orientation

When asked to describe their work, maternal health physicians responded in terms of the manageother obstetrical/ ment of pregnancy and gynecological problems expressed in physiological terms. They were more concerned with the technical aspects of work than relationships with patients. Patient relationships were dealt with in normative terms with a focus on the right to care. One respondent put the issue squarely in a way that indicated this focus might be seen as a shortcoming. When it concerns these types of units [ 141. . . we are most interested in their somatic problems and things like that. We haven’t time, so to say, to go deeper into psychological problems and things like that. That’s not good, of course, but we hope it will be better. When it concerns education or how to take care of their baby. . . I don’t think it’s very well handled, always. Another physician asserted that “the women were very happy” with the service and saw no need for concern with interpersonal relationships beyond providing good service. Practice independence

Maternal health physicians were more likely to report that they were independent than was the case for most other physicians. As expressed by one respondent: You are working for yourself, so to say. You have no problems of doing duty during the nights and things like

that. Your weekends are quite your own. No problems with patients there. That, I think, is important. I like it. You can

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make your own decisions. You have no head you must go to and ask every time “What shall I do; what could I do; what am I allowed to do?” I can decide myself.

Independence, then, seemed to have two dimensions. First, maternal health care was a scheduled activity that allowed the practitioner to work a regular 40 hr week with predictable time off. One could have activities independent of the practice. Second, the services were organized to provide the individual practitioner with more autonomy than was thought to be the case for other specialties. Both were seen as desirable features of work. Relations with hospital specialists and other physicians

Maternal health physicians reported that their relations with hospital specialists were ‘excellent’. They differed, however, in their relationships with district general practitioners and with the hospital system. These differences reflected the differences between the two practices in their structural relationships with both district medicine and the hospitals. One clinic was headed by the first Chief of Obstetrics and Gynecology at a community hospital where most of his patients were hospitalized for deliveries and surgical procedures. He had been on the staff of the hospital for 20 years and knew all the other staff. For him and his colleagues, there was no separation of hospital and outpatient service. Physicians at this clinic reported no referrals to the regional teaching hospital and seemed to have little to do with-it, either formally or informally. They saw the practice as entirely separate from district general medicine and reported no contacts with district general practitioners, all of whom were in solo practices in that part of the city. The other clinic was attached to a local short-term specialty hospital where they carried out most sur&al nrocedures. The nhvsicians renorted thev had iood ;elationships with the rest of the hospital staff. Thev also claimed excellent ties with the regional teaching hospital, which held weekly meetings& the Department of Obstetrics and Gynecology attended by the clinic staff. This was reported not only to keep them abreast of developments in the field but also to facilitate communications which improved referrals and a flow of information about patients. This arrangement was characterized as ‘excellent’. This clinic was also located near a new care center (vdrdcentraf) [15] composed of several district general practitioners, a Child Care Center, community nursing and other services. Respondents reported that they visited the care center frequently to consult on cases and that there was a weekly luncheon meeting of the policlinic and care center physicians. Maternal health physicians in this clinic said they knew the district general practitioners ‘quite well’ and had a good working relationship with them. Physicians in both clinics felt, in different ways, that they had integrated their practices well with other segments of the medical care system. Dependence upon nurses

Physicians in both clinics reported that they were dependent upon nurses for the conduct of their clinical activities. Nurses handled most of the preg-

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nancy surveillance and virtually all of the contraceptive advice and prescription that made up the bulk of the practices. They agreed that there was “too much for the physician to do” and “without the nurses the majority of the clinical work would have to be abandoned”. Physicians in the two clinics differed, however, in how they reported their relationships with the nurse-midwives. In one clinic, the physicians reported that they were the core of the practice and “the final authority on all decisions”. The nurses were said to be competent and necessary, but the physicians in the clinic referred to them as ‘my girls’. The work of the nurses was said to be delegated by physicians. In the other clinic, the work of nurses was also reported to be ‘competent and necessary’. Physicians there saw the relationship differently, however. In dispensing birth control and managing pregnancy the nurses were said to be the primary caretakers. Physicians saw themselves as consultants to the nurses and became the primary caretakers only when a medical problem became a central issue or when a surgical procedure was indicated. In those cases, nursemidwives referred the patient to the physician and became consultants. A more collegial relationship between physicians and nurses was evident in this clinic. Perspectives on the System

Maternal health physicians reported general satisfaction with the medical care system as it impinged on their work. Themes from their interviews centered on technical sophistication, relationships between ambulatory and hospital care, adequacy of training, and freedom of action for patients and physicians. One respondent said there were problems in other parts of the overall system, including care of older people, difficulty in finding suitable entry points into the system for patients, development of care centers, and a need for district hospitals. Technical sophistication

Respondents felt they had been well trained to recognize and respond to problematic pregnancies. They pointed to Sweden’s very low rates of maternal and infant mortality as evidence of their success. They said they could discriminate pregnancies that needed medical supervision from those that could be handled safely by nurse-midwives. They reported that the most sophisticated technology and expert consultation were available for difficult deliveries. Maternal health physicians said the maternal care system was a “major success story” that could be emulated by other parts of the medical care system and by other countries. Pointed comparisons were made with the higher levels of infant mortality in the United States. The maternal health physicians interviewed were not positively disposed to the home birth movement in the United States, saying it was a move toward increasing the risk to both the mother and the child. While they said they were interested in making the hospital environment more home-like, they indicated little sense of urgency. Indeed, it was their contention that Swedish women had no objection to the existing hospital environment. As expressed by one respondent:

Swedish physicians’ perspectives on work and the medical care system

. . . sometimes we hear or we read in the newspapers some patients say there was so many apparatus and everything.

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tals. SO . sometimes it is very diiIicult to know where to go when they get ill. But we have this sjuku&&&ysningen [ 161,we call it the “duty center”. They could call a number

But most of them are very happy. And that depends upon that the midwives are so enormously well educated and so nice. They are so n&-not like the older time midwives,-who were not so nice to the women. But they are so kind and so good so that when they were in the hospital. . especially simple people from the lower social

days and then you should come to us, and so on”. And this, I think, is good. It’s much easier for people to reach the right level at once, so to say.

groups; they find that to have a room.. . They get rather good food and much freedom. So I think they like it very much. . . The problem is to close the small hospitals, that is a problem. Then it will be demonstrations. But after they are

Two respondents reported that the emerging care centers (ubdcentrafer) would “be a good thing”, but noted that they expected problems in staffing them.

closed everybody will be happy. They forget it very quickly. Far from a movement toward smaller, more homelike settings for childbirth, the maternal health physicians said they were working to eliminate lower technology local hospitals as a place for deliveries, favoring concentration of births in the larger, higher technology centers. Ambulatory and hospital care

By practicing in community or short-term specialty hospitals, maternal health physicians said they could handle not only ambulatory care but also ‘small surgeries’. As they were trained in a surgical specialty, the ability to do surgery was reported to be important to their identification with the specialty. While they did not report this hospital linkage as a major source of satisfaction to the degree reported by child health physicians, they did report that is was important to have greater continuity in the care of uncomplicated cases. It might be inferred from the reported pmference for births in large high-technology centers that they felt they would be better served by appointments to a teaching hospital service, although no respondent articulated this directly. Freedom of action

As compared with other Swedish physicians, maternal health physicians reported that they had considerable autonomy in organizing their work and in their freedom to make medical decisions. That the system provided for this freedom was reported to be a favorable aspect that should be generalized to other specialties. This is the systemic aspect of the ‘practice independence’ discussed above as a positive perspective on work expressed by these specialists. The larger system One respondent drew a sharp distinction between the maternal health care system and the larger medical care system. In the former he focused on satisfaction, in the latter on problems. He talked about the rapidly growing older population (almost 17% of the population was over 65 at the time of this study) and the lack of interest of physicians in geriatric medicine as one problem area. His discussion of the problem was vague and limited to the statement that “we have these problems with old people. Much more should be done there, I think”. He also talked about the difficulty some patients had in making contact with a physician.

. . . it could be difficult for them because they don’t know where to go.. . We have these. . . general practitioners.. . ; we have these specialists, policlinics; we have the big hospi-

and talk to a very experienced nurse and she will tell them “you should go there. . . and then you have to wait so many

District physician positions in the city are adequate to create such a system, but many of the positions are untilled. Without enough general practitioners the care center is an impossibility. One respondent, who worked in the clinic attached to the short-term specialty hospital, said there should be a comparable development of short-term specialty hospitals with outpatient services, such as the one he worked in. As you know, they now intend to divide this town in five districts with about one hundred thousand people in every district. And in every district they will have several u&dcentruler. And I should say that if one besides that could have a hospital like this.. . in every district, I think that should be very valuable. SUMMARY The primary care specialties reviewed above were organized differently and, consistent with the assumptions stated at the outset of the paper, members of each reported different perspectives on their work and on the system within which they worked. Child health specialists were attached to a major teaching hospital, which provided them with state of the art technology and association with a wide range of other specialists. They practiced primary care as a part-time activity. They attended a few hours a week in clinics (in both neighborhoods and schools) that were run by nurses. Maternal health specialists were attached full time to clinics and had appointments to Iocal hospitals. The clinics were ‘theirs’. They were dependent upon nurses to get the work done, but they were not attending in a clinic that belonged’ to the nurse. They practiced a lower technological level of medicine than that characteristic of teaching hospitals and made referrals to the teaching hospital when they encountered complicated cases. In response to focused interviews, child health physicians emphasized integration of the hospital and ambulatory care aspects of their work, prevention of disease and technological sophistication in response to disease, and their ability to respond to the needs of the whole patient. They saw the pediatric system as providing high quality of both technical medicine and patient care. They reported their resources to be. adequate and well distributed. Maternal health physicians emphasized autonomy, and good relations with hospital physicians. They said they focused on the technical medical problems and left patient care to the nurses. They saw the system as sophisticated and providing freedom of action while integrating ambulatory and hospital care for uncomplicated cases.

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ANNEN c. DISCUSSION

Having demonstrated that some ambulatory care specialties in Sweden differ in the organization of work and there is a correspondence between work organization and the perspectives of practitioners, several problems remain. First, there is a problem of discriminating the degree to which these perspectives are inherent in the specialties rather than the organization of work. Are child health and maternal health physicians in Sweden different from those in other nations with differently organized services? Second, there is the problem of generalizing findings from this study to Sweden and a larger international arena. To what extent are physicians in a large city representative of their colleagues in Sweden? To what extent are the findings a product of a particular historical moment? What are the implications for international comparisons? Definitive answers to these questions cannot be offered with the data at hand. Some speculation, however, may be useful. Comparisons of specialties One impressive finding is the difference in focus when child or maternal health physicians are compared with district general practitioners in Sweden [3]. Both were the most likely to respond in terms of satisfaction with work and the system of all practitioners studied while general practitioners focused predominantly on problems. The less routine nature of their work, the adequacy of their resourcesrelative to demand, and their hospital appoint&nts all differentiated them sharply from general practitioners, suggesting these as factors influencing physician satisfaction. Mechanic [ 171, drawing on Faith [ 181, concluded that perceived stress, remuneration relative to reference groups, work conditions, autonomy, and opportunities for self-improvement and self-actualization were determinants of satisfaction. The findings in this study are certainly consistent with his. There are also some specific findings worth further exploration. For example, child health physicians shared a patient centered orientation with those general practitioners who were most satisfied with their work. While not a necessary condition of job satisfaction, it is possible that such an orientation might compensate for the absence of other positive features. If so, this would be consistent with other research on physicians’ attitudes [ 191. Political alienation as described by general practitioners was not mentioned by either child or maternal health physicians. It is possible that their professional organizations have more political clout, a factor worth taking into account in future studies. Specialty versus work organization

Medicine and medical specialties are to a great degree international phenomena. Physicians throughout the western world, and much of the remaining world as well, are similarly trained. There are more similarities than differences among physicians in the same specialty when viewed cross-nationally. Indeed, systems that look very different when viewed from the ‘top-down’ can look very similar when viewed from the ‘bottom-up’. Indeed, to this writer, experienced in

TWADDLE

research in U.S. settings, the Swedish system looked very familiar through the eyes of respondents in this research project. This raised the question: are the perspectives of Swedish child and maternal health physicians the result of their being in work settings with a Swedish organization or of their being child and maternal health physicians? The answer is probably ‘both’. Primary care pediatrics in the U.S., for example, has increasingly assumed a posture focusing on the social, psychological and behavioral problems of children. They are patient centered in the same sense as their Swedish colleagues. Pawluch [20] has argued that this was a necessary strategy in maintaining pediatrics as a specialty. At the same time, pediatricians in the U.S. are reported to be among the most frustrated physicians [21]. Most are not appointed in teaching hospitals and do not have the level of technological resources reported by their Swedish colleagues. Indeed, it seems that Swedish pediatricians spend most of their time in non-ambulatory care, spending about two days a week in the clinics. They are in an intermediate position between their mostly ambulatory care colleagues in the U.S. and their consultant colleagues in the U.K. Being pediatricians produces similarities, organization of practice likely produces differences. It would be instructive to compare systematically a nation where pediatrics is a consulting specialty, as in the U.K., with Sweden and the U.S. In the case of maternal health, the Swedish physician is in a unique position. Most of the primary care is handled by nurse-midwives. Complex problems are referred to the teaching hospital, which handles the tertiary care. This leaves the physician with relatively simple secondary care problems. In the U.S., the obstetrician/gynecologist handles a greater range of problems across the spectrum of care. Again, systematic cross-national comparisons would be. instructive. While not providing definitive answers, our data do suggest some specific dimensions that need to be taken into account in making international comparisons. Generalizability

As noted at the outset, this study was conducted in a large Swedish city in 1978-1979. We need to address the question of the degree to which the data might be generalized to Sweden at that time and/or to other historical moments in Sweden. We then need to address the question of generalizing to a larger arena. Large cities are distinctive in the richness of the medical environment. Giiteborg had more hospitals, a greater variety of hospitals and clinics, and a diversity of specialists that could be found in few places in Sweden. In small communities, the work of child and maternal health physicians would be done by general practitioners. Since specialists were an urban phenomenon and each county was free to organize its medical services within national guidelines, child and maternal health physicians in Gateborg were probably more representative of their colleagues in the nation than was the case for general practitioners. They may have been practicing in settings that were somewhat different from those in other cities.

Swedish physicians’ perspectives on work and the medical care system Medical care in Sweden was undergoing rapid change at the time of the study. There was a push to expand general practice and limit opportunities for specialization (except in pediatrics and long-term care). Political decisions to combine ambulatory care disciplines in primary care centers were in the process of being implemented. In 1982, the city of Goteborg reorganized its medical care extensively, creating a new administrative structure. In 1983, a new national law on health and sickness care took effect [22]. Other nations have taken different approaches to the organization of medical care, even in response to similar pressures for change. All of this suggests that neither the characterization of practice organization nor physician perspectives should be generalized without extreme caution. What, then, have we found? An exploratory design which allows physicians to respond within their own cognitive framework generates valid data. The perspectives reported here are those actually used by the physicians. They were not imposed by the research instruments. This study has provided several ‘slices’ that have led to a typology of perspectives of ambulatory care physicians in one city. Different typologies were presented by different types of physicians. There was little variation in perspectives among physicians within a specialty. There were sharp differences in perspectives between specialties. While broadly consistent with findings from studies using more positivistic methods, this approach generates greater refinement in descriptions of those perspectives. The approach taken here could be fruitfully applied in other countries and other work settings. This would allow us to make comparisons in the terms used by the respondent groups. Finally, the evidence supports the contention that the social organization of work influences the perspectives of workers and suggests some of the ways this connection works. It will take a large number of studies using similar approaches to arrive at a point where distributively oriented research can proceed with confidence in its validity.

Acknowledgemenfs-The research on which this paper is based was supported by the Svenska Institut, Sociologiska Institutionen of GGteborgs Universitet, and the Graduate School of the University of Missouri. I am grateful to Derek Gill. Richard Hessler and two reviewers for this journal for- helpful criticism. REFERENCES 1. That location in social structures influences perspectives

is so commonplace as to be an implicit premise of social psychology from a number of theoretical perspectives. See, for example: Atkinson D. Orthodox Consensus and Radical Alternative. Basic Books, New York, 1972; Berger P. and Luckmann T. The Social Construction of Reality. Doubleday-Anchor, Garden City, N.Y., 1967; Biddle B. Role Theory: Expectations, Identities and Behaviors. Free Press, New York, 1979; Gerth H. and Mills C. Character and Social Structure. Harcourt, Brace & World, New York, 1953; Glazer B. and Moynihan P. Ethnicity: Theory and Experience. Harvard University Press, Cambridge, Mass., 1975; Kohn M. Bureaucratic man: a portrait and an interpretation. Am. Social. Rev. 34, 461-474, 1971; Kohn M. Gc-

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cupational structure and alienation. Am. J. Social. 82, 11l-130, 1976; Kohn M. and Schooler C. Gccupational experience and psychological functioning: an assessment of reciprocal effects. Am. Social. Rev. 38, 97-118, 1973; Maye; K. Class and Society. Random House, New York, 1955; Maines D. In search of mesostmcture: studies in the negotiated order. Urban Life l&267-279, 1982; Strauss A. Negotiations. Jossey-Bass, San Francisco, 1978. We have not found, however, a direct and explicit test of the propostion. Without questioning its heuristic value, it remains implicit. 2. Twaddle A. C. Swedish physicians’ perspectives on work and the medical care system: the case of district general practitioners. Sot. Sci. Med. 23, 763-771, 1986. With respect to work, they reported that it was medically routine, patient centered, overdemanding with respect to numbers of patients, and isolated from colleague support. With respect to the system they reported it was successful with respect to financing, but posed problems in relationships with hospitals and specialists, participation in political decision-making, and district sizes. 3. The complete study of physician perspectives in relation to location in the medical care system is presented in a manuscript entitled Structure and perspectives: Swedish physicians on work and the medical care system. The

manuscript is currently under review for publication. 4. The Swedish medical care system is noted for the extent to which the hospital system is regional&d. It contains regional, county, and local hospitals. Both medical specialties and technology are allocated by level of hosoital. c.f. Navarro. 1974; Side1 and Sidel, 1983; Twaddle and Hessler, 1987 in [5]. 5. See, for example: Andersen R. ef al. Medical Care Use in Sweden and the United States: Comparative Analysis of Systems and Behavior. University of Chicago Press, Chicago, Ill., 1970; Anderson 0. Health Care: Can There be Equity? Wiley, New York, 1972; Anderson 0. What can the U.S. learn from Scandinavia? Scandinavn Rev. 49.3 November 1975; Hessler R. and Twaddle A.

Sweden’s crisis in medical care: political and legal changes. J. Hlth Polit. Policy Low 7, 440-459, 1982; Heidenheimer A. and Elvander N. The Shaping of rhe Swedish Health System. St Martins Press, New York, 1980; Navarro V. National mrd Regional Healrh Planning in Sweden, USDHEW-NIH Publication 74-240, 1974; Side1 V. and Side1 R. A Healthy State. Pantheon, New York, 1983; Twaddle A. and Hessler R. Power and change: the case of the Swedish commission of inquiry on health and sickness care. J. Hlth Polit. Policy Low 11, 19-40, 1986; Twaddle A. and Hessler R. A Sociology of Health. Macmillan, New York, 1987. By contrast, this study looks at the system “from the bottom up” by using as informants those who provide direct services to patients. The original plan was to also interview patients, but that had to be postponed because of time constraints. 6. See Kaplan A. The Conduct of Inquiry. Chandler, San Francisco, 1964. 7. This language is that proposed by Agar M. Speaking of Ethnozraohv. Saee. Beverlv Hi&. 1986. See also. Kirk J. and Miller M:&abiIi~y and Validity in Qua&ative Research. Sage, Beverly Hills, 1986. 8. See Glaser B. and Strauss A. The Discovery of Grounded Theory. Aldine, Hawthorne, N.Y., 1967. 9. See Merton R., Fiske R. and Kendall P. The Focused Interview. Columbia University Press, New York, 1954. Copies of the interview guide are available from the author. 10. No attempt was made to investigate the hospital component of the child health services, although the dual nature of their work was important to alI the pediatricians interviewed. Instead, to maintain consistency

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all the physicians studied, attention was confined to the ambulatory component. The Acute Primary Care Center (Jolrrcentrul) was created as an attempt io reduce use oi emergency ;ooms for mimarv care. At its core was a teleohone bank staffed by nur&s who could answer quest&s, make referrals, or dispatch a physician to the home. In addition the center had its own clinic for diagnosis and simple treatment. The center was described and the perspec tives of physicians working in it were reported in Twaddle (1986). See [2]. Children could also receive contraceptive advice and supplies through the school health services. One reviewer of an earlier draft contended that children under 15 require the permission of their parents. The statement in the text was made by respondents in the study. Referring to the Maternal Health Center (Modruacross

11.

12. 13.

14.

odrdcenral).

15. The udrdcenrml, which is translated here as the ‘care center’ is a newer organization replacing the solo district general practice reception. A single center houses several general practitioners and other primary care specialties, including community nursing, pediatrics, dentistry, maternal health and others in specific instances. The city had made a political commitment to convert to care centers and the process was underway at the time of this study. See [l]. 16. This term translates literally as ‘sickness care advice’ and is a major component of the jourcenlruf [l 11. 17. Mechanic D. Physicians. In Handbook of Health, Health Care, and the Heahh Professions. Free Press, New York, 1983. 18. Faith R. Social and structural factors affe$ng work

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satisfaction. Unpublished Ph.D. dissertation, University of Wisconsin, Madison, 1969. 19. Breslau N., Novak A. and Wolff G. Work settings and job satisfaction: a study of primary care physicians and paramedical personnel. Med. Cure 14 850-862, 1978; iichtenstein k. Measuring the job satisfaction of physicians in organized settings. Med. Care 22,56-68, 1984; McCranie E., Hornsby J. and Calvert J. Practice and career satisfaction among residency trained family physicians. 1. Fumify Prucr. 14, 1107-l 114, 1982; Peters A. and Markello R. Job satisfaction among academic physicians: attitudes toward job components J. med. Educn. 57, 737-739, 1982; Shore B. and Fracks P. Physician satisfaction with patient encounters. Med. Care 24,580-589, 1986; Mechanic D. Public Encounrers and Health Care. Wiley, New York, 1974. 20. Pawluch D. Transitions in pediatrics: a segmental analysis. In The Sociology of Health arid Illness (Edited by Conrad P. and Kern R.), pp. 155-171. St Martins Press, New York, 1986. A parallel case to that made for pediatrics might be offered for family practice, which is placing emphasis on ‘behavioral medicine’ as a way of salvaging legitimacy as a specialty. There would seem to be similar needs pushing the fields into similar stances. 21. Pawluch D. c.f. Medical Economics (1956), Medicine’s most frustrating specialty. 33, 68-74, 1986. 22. On developments in Sweden see Heidenheimer A. and Elvander N. (1980) [5]; Hessler R. and Twaddle A. (1982, 1986) [S]; Twaddle A. and Hessler R. (1986) [5]. On the move toward primary care centers, see Mechanic D. Ideology, technology and health care organization in modem nations. Am. J. publ. Hlth 65, 241-247, 1975; Jefferys M. and Sachs H. Relhinking General Practive: Dilemmas in Primary Medical Cure. Tavistock, London, 1983.