Primary Care Physicians as Street-Level Bureaucrats

Abstract

This dissertation is a theoretical and empirical investigation of primary care physicians as street-level bureaucrats. In chapter one, I provide a brief overview of the dissertation and its contributions to the relevant literature. In chapter two, I establish the theoretical framework used in this dissertation by linking literature from public administration and health services, discussing policy implementation from the top-down and bottom-up perspectives, and the role of administrative discretion in these processes. Furthermore, I review the history of decision-making models in the US health care system, from paternalism to shared decision-making, and then discuss common barriers to implementing shared decision-making and the relevance of discretion in this space. In chapter three, I present findings from in-depth interviews with thirty primary care physicians that focus on perceived discretion. While participants initially perceive themselves to possess high levels of discretion, I identify five common threats to their discretion: (1) the adversarial health care “machine”, (2) difficult and time-consuming insurance interactions, (3) unattainable patient expectations, (4) high emotional labor, and (5) the undervaluation of primary care. Participants use multiple coping mechanisms to mitigate these threats, with varying success. This chapter contributes to a richer understanding of perceived discretion and its relationship with patient-centered care and physician burnout. In chapter four, I present findings from a vignette-based experiment with two-hundred primary care physicians that focuses on how they mentally sort patients based on perceived engagement and urgency, and whether these perceptions influence their promotion of shared decision-making with these patients. I find that respondents devoted more time in a fifteen-minute appointment to shared decision-making tasks that precede a decision with a fictional high (versus low) A1C patient. Yet, they were less likely to promote a shared decision with that patient or perceive them to be a good candidate for shared decision-making. Perceived patient engagement and urgency played a mediating role in this decision-making process. This chapter provides an additional explanation for why shared decision-making is not occurring as intended. In chapter five, I provide a summary of the dissertation. In summary, this dissertation emphasizes the importance of viewing primary care physicians as street-level bureaucrats. This perspective contributes to our understanding of policy implementation by focusing on primary care physician discretion, coping, and promotion of shared decision-making. Moreover, it underscores the relationship between discretion and well-being, which has broader implications for the public service workforce.