Professional autonomy under pressure: towards a dialectical approach.

Purpose - The purpose of this paper is to explore the process of evolution of medical autonomy as an analytic and historical aspect of the medical work organization in a public bureaucracy. Design/methodology/approach - The authors draw on the analytic concept of organizational contradictions (Heydebrand, 1977) to inform a dialectical approach in organizational analysis. Semistructured interviews with 20 doctors of a Greek general public hospital were conducted and archival data were collected. Findings - The findings suggest that the historical development of two contradictions characterize the process of medical autonomy evolution. The first contradiction tends to develop between medical autonomy, as a self-control relation, and the established division of labour through which bureaucratic control is exercised over the allocation of resources and over the distribution of healthcare service. The second contradiction tends to develop between those reified aspects of the medical work organization and the ongoing organizing activity, i.e. activity towards extending, intensifying and centralizing organizational control over labour, resources and the distribution of healthcare services. These contradictions indicate a pressure towards constraining health professionals' power to self-define their relationship with patients and towards curtailing their discretionary domain over the use of resources. Originality/value - This paper offers an empirical approach to materialist dialectics for organizational analysis towards conceptualizing change as a historical process.