Making standard doctors : residency training reform, relational contexts, and inhabited institutions in Chinese hospitals

Abstract

This thesis examines the institutional changes in residency training and people’s responses to those changes in Chinese hospitals. Since the 1980s, residency training in China has experienced a rapid development and shift from traditional model of training to Standardized Residency Training Program (SRTP) that emphasizes accountability. As SRTP was institutionalized as a compulsory state policy in 2013, training hospitals still coupled their training practices with formal rules and regulations in divergent ways and in various degrees. This thesis aims to explain the varied responses to SRTP by different groups of actors on the ground. Theoretically, this thesis drew on concepts and insights from new institutionalism and inhabited institutionalism to explain people’s actions under similar institutional pressures. New institutionalism emphasizes structural isomorphism and assumes decoupling as the default response to institutional s the default response to institutional changeschanges,, while inhabited institutionalism pays more attention to social interaction and local practice. Both approaches neglect intra-organizational arrangements and contexts as important factors in shaping organizational responses. To unravel the research puzzle, this thesis employed ethnography as the main method for data collection through 8 months of fieldwork at Peace Hospital and Harmony Hospital in Southern China. This thesis found that intra-organizational relational contexts played a central role in molding divergent responses to institutional prescriptions. First, this thesis examined how administrative staff performed their roles as street-level bureaucrats in different ways. Peace Hospital and Harmony Hospital developed different approaches to SRTP management mainly because of the forms and characteristics of connections betweethe forms and characteristics of connections between n administrative personnel and clinical staff. administrative personnel and clinical staff. Second, this thesis discussed different teaching styles adopted by two clinical departments in Harmony Hospital. Whether teachers preferred affective and particularistic teaching or detached and universalistic one depended on how their departments incorporated trainees into existing work arrangement and social order. Third, relational contexts were also salient in shaping various learning perspectives among trainees. Trainees were normally categorized into four types based on their employment status. The he organizational supportorganizational support and pressure experienced by different categories of trainees and pressure experienced by different categories of trainees significantly shaped the significantly shaped the levels and directions of effortlevels and directions of effort they placed in SRTP training. they placed in SRTP training. In sum, this thesis contends that the divergent responses to SRTP reform are produced by internal relational contexts in training hospitals. This thesis contributes to sociological institutionalism by showing that the enactment of institutions in practice does not occur in relational vacuums. Only by taking into consideration intra-organizational relational contexts can we better explain the effects of institutions on daily practices inside organizations. This thesis also provides a fresh micro-sociological perspective to shew new light on medical reform in China.