Even preeminent professionals become constrained by rigid organizational rules

Evidence

The Veterans Administration hospital system is a fascinating bureaucracy because it employs doctors, the preeminent professionals, in highly rulebound organizations. The country’s system of socialized medicine for the indigent veteran has developed an extremely complex series of rules because of simultaneous congressional concern to provide veterans with hospital services, maintain strict cost accounting, and (particularly in the past) not compete with private medical practice. In large part because the VA system was to provide hospital care, leaving to private physicians the business of office consultations, the VA hospitals were prohibited from treating patients on an outpatient basis. This conflicted with the doctors’ prerogative to prescribe a level of treatment appropriate to the problem presented. There are many patients who need treatment, but not hospitalization, and to hospitalize such people would be to deny others the hospital space. — Michael Lipsky, Street-Level Bureaucracy, 197

Categorization

• XREF: Connects to the reader’s interest in how bureaucratic discretion interacts with professional autonomy promises — doctors normally hold strong discretion yet here face rulebound structure. — connects to: Three postwar developments transformed lawyers from autonomous professionals into employees — G. Alan Tarr, Judicial Process and Judicial…, 769; Increased professionalism sometimes narrows rather than widens frontline discretion — Michael Lipsky, Street-Level Bureaucracy: Dilemmas of…, 1844; Work situations structurally erode the individual responsiveness that professional norms demand. — Michael Lipsky, Street-Level Bureaucracy: Dilemmas of…, 1172 (+1 more)
• DEFINE: Shows how a rule (inpatient-only care) arises from multiple Congressional goals and then conflicts with professional judgment about needed treatment levels.

Broader Connections

• Organizational necessities force professionals to abandon their trained individualized practice. #corroborates (0.95) — Michael Lipsky, Street-Level Bureaucracy, 353
• Work situations structurally erode the individual responsiveness that professional norms demand. #corroborates (0.90) — Michael Lipsky, Street-Level Bureaucracy, 1172
• Increased professionalism sometimes narrows rather than widens frontline discretion #corroborates (0.85) — Michael Lipsky, Street-Level Bureaucracy, 1844