Research Confusion. Interorganized Medical Units. Part III

September 3rd, 2007 Posted in Analysis, Research Confusion

Act III. Discovery of the Basic Missing Fact.

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Cliffhanger: Like a hound who has been offered the wrong scent, I was making progress on a meaningless track. The denouement, the last cliff, was fast approaching.

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In the novel “The Crying of Lot 69″ Pynchon describes a since forgotten event that is the actual cause of the current social order. Closure, resolving the mystery, is totally dependent on the discovery of the disconnect. What you do not know can hurt you.

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I went to meet Dr Pub in a borrowed office at the hospital. He had given up his own when he resigned his position a short while before.

A graduate of an Ivy League medical school with a specialty in public health, he had the always winning combination of modest energy and openness. An appreciated change for me from my boss, Professor X, who related to me with a secret reserve that made him nearly inarticulate and with a cold shy manner that made him unapproachable. Pub talked to me for close to four hours. I was one of his official last acts before he decamped for what I suspected was a veiled exile to a new position in Hong Kong. Just under the wire, a day later and I would have missed him and the understanding he gave me about my strange convoluted research situation. Before me was the fox I hadn’t known I was chasing.

The interorganizational links among the medical units in the neighborhood of the hospital divided into two blocks: The traditional agencies of hospitals and nursing homes on one side and the recently constructed clinics and associated services designed to cater to neighborhood residents with special needs–the people with lower incomes, the aged still on their own, the addicts, the unwed mothers, the local general practice physicians without hospital affiliations.

The engineer who set-up and supervised these later units was of course Dr Pub. His public recognition minimal, he had been outside my net, my method. Unawares I had cornered the elusive pimpernel.

Over several years Pub secured grants and set up his service agencies. His role was very similar to that of Robert Moses who with a minor connection to the city and state governments was able, as an almost free entrepreneur within the bureaucracy, to gather governmental grants and other financial instruments plus plans for the radical transformation of roadways and transit systems and to quickly implement them. These were reforms that the responsible officials could not hack. Later, carried away by his task, he had to be stopped before he paved over the entire city.

So Pub was the engine behind a large portion of the interorganizational activity in the neighborhood. There was nothing naturalistic about what he had wrought. He had, for the moment, brought an active and partially rationalized health system to the neighborhood community.

The financial support for his projects appeared to be the same federal agency that was paying for my own work. They were in the odd position of looking for something that they already possessed. They asked a question whose answer they should have known didn’t exist.

So the interorganization, the links among the medical units, connecting the hospital with the people around it was in some significant part planned and administered by an agent of government.

The Dr Pub organized satellites tied to the hospital for funds and guidance but otherwise independent in operation. A clinic for general health care, a service agency for single mothers, agencies to advise the elderly, treatment for drug addicts and the like. Most impressively he brought in unaffiliated neighborhood general practitioners for specialist lectures designed to bring then up-to-date technically and to give public support to their professional identities. These were the doctors who won hospital admissions for their patients via the emergency room.

One of my mentors at graduate school had talked about informants who could tell a social investigator the inside story, but he was thinking about an elevator operator or a ward aide and not the chief entrepreneur himself.

The good doctor talked and went off to Hong Kong and I was left with the knowledge of his gallant effort and the vision of our health services actually taking a rational form however flawed. What, I had to wonder, should I do? I had a stake in my career but also a stake in the accomplishment of the good doctor and, even more, in the need to recognize and preserve for others the consciousness of his vision. Any report I wrote should be faithful to the social order and process I encountered including the meta-process of the funding and the control of the research project itself. My options at the time were to either reach the false conclusion laid down by my sponsor or to unmask my ultimate employer. I resolved the dilemma by telling the truth but keeping a secret–I described the formal interorganizational order I had observed but I withheld Dr Pub’s role. The error of my silence is perhaps healed here.

I was fired and with the position I lost the free lunch. Maybe the report fell short professionally. The good professor X complained to me during our final meeting, witnessed by an associate of his, that I had found too many agencies. I thought I had enumerated just the right amount. Everyone who had said “Here” when I called the roll.

I believe that most of this public health bubble, these satellites constructed by the good doctor with government money, eventually evaporated. The politics went to the right and has continued in that direction since.

Pub’s work was not perfect. Heroic but narrow. A patch. It was not comprehensive. It touched only the local and those qualified for welfare so the issue of the larger system and how it generated the crisis was not addressed. The plan came from above and did not allow the people and the medicos to appreciate the new consensus and ethics and aesthetic that had to be part of the new communal way he proposed. It implied a discipline, a mutual regard, a sharing, a respect for craft, a changing definition of social mobility

What was offered was another small lifeboat on the Titanic–not enough space for everybody. And people approached it with the usual desire for advantage. Everyone in a struggle for jobs, the honey-pot, the fiddle. a little like grabbing loot at a riot. W. Reich talked about personalities formed in a prior era and culture unable to appreciate the new consensus called up by a new social setting.

The rush at the bargain table in the department store. Some of the satellites were flooded with people seeking jobs and grants and special treatments. Others, managed by unimaginative leadership, could not find their supposed clients. Patients complained about rude treatment from ideologically laden and resistant medicos.

Re the interorganizational manifestation: I found four strands, all supported by governmental and other funding agencies, that I called Tametrags: TA for teaching affiliations, ME for mergers, TRAG for transfer agreements, and S for satellites.

(1) Teaching affiliations are agreements between medical schools and hospitals and medical delivery agencies that permit interns and residents supervised employment in active medical settings. Other medical specialties also have such affiliations. (2) Mergers are the unification into one administrative unit of two previously separate and independent units. Sometimes these mergers are at the administrative top alone, but the control and destiny in any case is now linked to a single source. (3) Transfer agreements usually involve nursing and old age homes that are legally required to seek the affiliation. Agreement with hospital involves a promise to accept patients for care as required. Practically it means reserving beds. The usual hospital demand in these agreements is that the nursing home counter reserve its beds for patients from the hospital. (4) Satellites are separate agencies linked to a sponsoring organization for advise and material support but otherwise independent.

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The lesson from all this: Avoid working on someone else’s project unless you can with clear conscience accept it as though it were your own. In the event represent your own position clearly and directly to the other and if he is not able to accept it then disengage. Make sure that your method fits the madness.

Easy to preach but difficult to practice. An artist-sculptor told me that the key was to establish the scene, that is the space, equipment and time, for your own work, and I think he was right. Work minimally for money if you must but save time and place and independence for your own vision, interest, development.

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All my training discouraged speculation. But it is my primary inclination, right up there with analysis. They might be the same thing. Speculation is analysis with fewer facts. Add concept and method, the way to go, and now we have the tools. Add the definition of the social field. All then clobbered together like the dummy of love–legs from some old table, arms from some old chair, and from a mop you get some hair–gives you sociology itself.

(This is the last of three posts that together form a single essay.)