Redrawing medical professional domains: new doctors, shifting boundaries, and traditional force fields

This paper aims to investigate the forces that influence the shifting of professional boundaries on the entry of a new medical occupation in Dutch hospitals - non-specialist emergency physicians.

Five case studies of Dutch hospitals were conducted and the emergency physicians' implementation process was analyzed by means of force field analysis.

Emergency physicians were conceptualized as being the answer to unequivocal contextual changes. However, their contribution to better performance varies due to problems in the implementation process. Strong socio-political forces between traditional specialties and these new doctors mediate the intended improvement. The emergency physicians aim to establish their own organizational-, patient- and knowledge-domain by redrawing professional boundaries but they are not on a par with the specialists who set these boundaries. Consequently, emergency physicians only gradually redraw the existing boundaries, resulting in limited added value. Their reaction is to obtain power by striving to develop into a recognized specialty; ironically, by becoming an additional layer in the traditional medical hierarchy they might lose their envisaged added value.

This paper is based on the first Dutch hospitals that implemented emergency physicians. The number of cases is therefore limited. Moreover, the study took place at an early stage of emergency physician implementation.

The extent of successful redrawing depends on the implementation's transition logic, the existing degree of differentiation and boundary permeability and on the ideological power developed by the leaders.

The introduction of emergency physicians is currently being discussed in many countries worldwide, and some countries consider following the Dutch example of non-specialist doctors. This paper supports health professionals and hospital managers in not falling prey to the same pitfalls as some Dutch hospitals.