To outside observers, “management” is often seen as part of the problem with healthcare. Whether it be the top-heavy administrative structures of most health systems, the lucrative executive salaries, the denials of access and coverage under the pretense of “cost savings,” the degrading working conditions for frontline clinicians and staff, or simply the tyranny of the profit motive, managers are often seen as implicated in the worst of the industry’s woes.
And yet, any large-scale provision of care requires some form of planning, budgeting, and allocating of limited resources—or in a word—management. For better or worse.
For those of us on the inside of healthcare management (or occupying some peripheral role close enough to the action), there is both a palpable sense of the field’s questionable legitimacy, and underlying this, a barely-suppressed professional identity crisis. Sure, there is the pragmatic argument that someone must manage, but there is also a deep sense that the field itself is ensnared in something intractable and compromising—broken, even—in its pretense to be at once a scholarly discipline and a legitimate practice modeled after business.
Elsewhere, I have explored how healthcare management scholars and practitioners have trod the steady path of “professionalization” in an effort to legitimize a field barely a century old (Gerard, 2019; 2021). Professionalization is a longstanding practice across various occupations—medicine and law perhaps the most notable examples—that includes the standardization of jobs through systematized knowledge, prescribed training, and exclusive jurisdiction. But professionalization also harbors a protective and power-bolstering dimension in its attempt to erect occupational hierarchies, shape public beliefs and opinion, and above all assert control.
The psychoanalytic question here: What do these efforts represent unconsciously, and what do they attempt to cover over or deny?
In healthcare management, what figures most prominently in the field’s professionalization efforts is accreditation—specifically, the accreditation of healthcare management education programs in an attempt to garner legitimacy in the eyes of prospective students, university administrators, and, of course, the job market. Despite its ostensibly rational aims, accreditation acts as an insulating force, protecting faculty and students from having to confront the field’s dubious complicitly with questionable managerial regimes that, in the least, reinforce a hardly neutral status quo of health inequities, and at worst, exacerbate social injustices. In this sense, accreditation acts as a narcissistic blanket of “excellence” in direct proportion to both willful ignorance and unconscious insecurity.
It is no coincidence, therefore, that accreditation entails a lengthy process of data gathering, evaluating, and reporting that mirrors management. By extensive modeling and measuring, one can somehow—through shear repetitious tedium—justify one’s right to exist while simultaneously pulling attention away from anything inconveniently complex or ambiguous, let alone contentious and political. But there is also an overarching denial of the reality that healthcare management has always been (and perhaps always will be) an interdisciplinary endeavor without any clear academic “home” or domain of practice, and thus without any firm footing as it navigates some of humanity’s deepest anxieties.
This, to my mind, is a strength—if the field could only let down its defenses and see through its insecurities.
To manage healthcare, in the most human sense, is to grapple with one’s need for another’s care while at the same time yearn for independence. It is to cope with oneself and others in the face of acute fear, anxiety, loss of hope, and death, juxtaposed with the prospects of recovery and continued life.
Yet, any sense of the profound challenges of “managing” in the face of these experiences is evaded for the comfort of technical models, data-driven interventions, and above all pretentions to rigorous science that, however justifiable and valuable, create the false image of an uncontested field devoid of depth.
Some may retort here that accreditation is a good thing because it instills a sense of “professional ethics.” Yet, healthcare management ethics has conveniently and without much thinking incorporated mainstream medical ethics by upholding the principles of distributive justice, beneficence, and non-maleficence. And like managerial models, these principles are geared toward providing a framework for decision-making and often demonstrated through case studies in textbooks. But note here the denial of the institutional structures that surround these decisions (the structurally organized inequalities of power coupled with the micropolitical actions that reinforce them) as well as the unconscious. Put simply, ethics are not simply a matter of sovereign subjects making reasoned “choices,” but rather structurally determined ways of viewing the world that mirror organized inequalities of power.
In psychoanalysis we might call this defensive behavior, and particularly a “reaction formation” to unconscious cruelty. And just how this cruelty becomes codified in policies, procedures, and whole structures of organizing has been examined in detail by psychosocial scholars ever since Menzies’s seminal study of a nursing service within a London teaching hospital in the mid-20th century.
In the instance of accreditation specifically, there is an internalization of norms that reinforce a social defense structure. That is, accreditation imposes ways of knowing and acting that become just as rigid in character as the checks and counterchecks of Menzie’s nurses that blunted their compassion and abdicated responsibility; or the referring to patients by number and disease, instead of name that allowed nurses to avoid the human complexities of attachment. In the broadest sense, accreditation is a way to signal a veneer of professionalism that offers a pretense of ethics, while behind the scenes garners social and economic currency (power).
These musings remind me of a meeting I had with an exceptionally atypical CEO of an NHS Trust in the early 2000s, arranged at the time by my boss, a primary care doctor, when I was a lowly research assistant working on a service integration project in the UK. My boss, a wonderful human being who could intuit my path into healthcare management would not be easy nor always fulfilling, arranged for this meeting to discuss “career options.” The conversation eventually veered into questions of motivation and meaning, and the CEO somewhat spontaneously handed me a copy of David Whyte’s The Heart Aroused: Poetry and the Preservation of the Soul in Corporate America, mentioning that this was an important book for him. Upon finishing our meeting, he told me to keep it.
This experience still gives me hope that the soul of healthcare management (whatever that might be) is not lost. And that there are managers who manage in ways that go beyond the pandering and get at something more. This experience also suggests that instead of obsessing over accreditation in healthcare management education, we encourage our students to read widely—including poetry. In addition to Whyte’s book, a particularly great place to start would be The Psychodynamics of Toxic Organizations: Applied Poems, Stories and Analysis by my dear colleagues, Howard Stein and Seth Allcorn.