Time Is of the Essence: Using Institutional Ethnography to Explore the Introduction of a Cancer Care Policy

This PhD project contributes a critical analysis of the increasingly tight standardization and bureaucratic management of professional work. The focus is on the introduction of a cancer care policy entitled cancer patient pathways (CPPs), which assigns fixed time frames to each phase in the diagnostic process: from the identification of a reasonable suspicion of cancer until the start of treatment. Institutional ethnography provides the theoretical and methodological framework for this study. The empirical study is part of a larger project evaluating the introduction of CPPs based on patients’ and healthcare professionals’ experiences and perspectives. In my study, I take a physician standpoint to explore how physicians’ experiences and practices are socially organized. The overarching research question guiding the study is: How do physicians engage with CPP guidelines in their daily work? Based on semi-structured interviews with physicians and other healthcare professionals (N=72), I aim to develop knowledge about some of the work processes connected to the CPPs and trace how different ideological and discursive practices mediate this work. The thesis consists of three journal articles and one article for a Norwegian anthology on institutional ethnography in practice. In Article I, I explore how general practitioners (GPs) and specialist physicians balance different demands in their work with the referral of patients to CPPs. The analysis illustrates the complexity of the referral process across primary and specialist healthcare. Whether or not a CPP is initiated depends on the interaction between physicians and patients, how the referral is written and subsequently interpreted, and how this work is discursively mediated. Article II focuses on specialist physicians’ experiences of how CPPs influence their work with cancer diagnostics. Specifically, it shows how, in practice, the requirement to keep the CPPs’ timeframes conflicts with the requirement to achieve diagnostic precision. In Article III, I explore how physicians and other healthcare professionals communicate with patients in CPPs. The analysis illustrates how CPPs, with their explicit focus on deadlines and transparency, generate tensions between biomedical, psychosocial and political understandings of what constitutes good patient care. Article IV details how I have used institutional ethnography for my thesis as part of a larger research project. Since I have collaborated with other researchers, I have adapted the use of institutional ethnography to accommodate my situation. I use physicians’ accounts of their referral work as an example of how institutional ethnography helped me to illuminate the social organization of the initial phase of CPPs