Professional Autonomy and Bureaucratic Organization

Author(s): Gloria V. Engel

Source: Administrative Science Quarterly, Vol. 15, No. 1 (Mar., 1970), pp. 12-21
Published by: Sage Publications, Inc. on behalf of the Johnson Graduate School of Management, Cornell
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Gloria V. Engel

Professional Autonomy and BureaucraticOrganization

Autonomy is regarded as an important dimension of professionalism. A number
of investigators claim that bureaucratic organization limits professional auton-
omy. This study was undertaken to determine empirically the validity of this
claim. The relationship between bureaucratic structure and degree of professional
autonomy within the client-professional relationship was examined by system-
atically comparing the perceived autonomy of professionals in three types of
bureaucratic settings, nonbureaucratic, moderately bureaucratic, and highly
bureaucratic. The data revealed that those professionals associated with the
moderately bureaucratic setting are most likely and those in the highly bureau-
cratic setting are least likely to perceive themselves as autonomous. These find-
ings do not support the contention that bureaucracy is necessarily detrimental to
professional autonomy.

Much of the literature on organizations
shares an antibureaucratic orientation (cf.
Hickson, 1966). Because such factors as in-
novative behavior, upward and lateral com-
munication, and individual responsibility are
not strongly evidenced in a bureaucratic
structure, it is portrayed as nonviable for
many types of organizations. The reduced
range of activities or discretions permitted
within bureaucracies is assumed to bring
about lowered influence and autonomy for
those associated with them.
Merton (1957), Mills (1951), Lewis and
Maude (1953), and other investigators
(White, 1957; Ben-David, 1958; Bendix,
1960; Dixon, 1964; Goldner and Ritti, 1967;
Hall, 1968; and Daniels, 1969) contend that
bureaucracy can be particularly detrimental
to the professions because it limits auton-
omy, an important element of professional-
ism. Other investigators, however, do not
regard bureaucracy as completely harmful
to the professional (Barnard, 1938; Blau,
1955; Goss, 1959; Janowitz, 1960; Dalton,
1961; Kornhauser, 1962; Glaser, 1964; and
Bucher and Stelling, 1967). Since everyone
is increasingly dependent upon professional
services, and since today's professionals are
entering bureaucratic organizations in larger
numbers, it is expedient to determine
whether these allegations can be substan-
tiated. Because much of the literature is
12
anecdotal and general, this study was under-
taken to determine empirically whether
bureaucratic organization does limit in-
dividual professional autonomy.' Goode
(1960:903) has stated that "the two ... core
characteristics [of a profession] are a pro-
longed specialized training in a body of
abstract knowledge and a . .. service orien-
tation." This definition will be used in this
article.
As an ideal, typical conceptualization,
professional autonomy can be viewed as
existing on two separate but related levels:
(1) with respect to the individual profes-
sional, and (2) with respect to the occupa-
tional group or profession. The former is
the concern of this paper and is refined into
personal and work-related autonomy.
Personal autonomy is freedom to conduct
tangential work activities in a normative
manner in accordance with one's own dis-
cretion. Work-related autonomy for the
professional is freedom to practice his pro-
fession in accordance with his training. It is
this type of autonomy which appears to be
important for the professional, since a loss
of work-related autonomy or control to his
1 The author acknowledges the
help given by Ray-
mond J. Murphy of the University of Rochester.
An abridged version of this paper was presented at
the American Sociological Association meeting in
San Francisco, 1969.

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 Engel: PROFESSIONAL AUTONOMY
client, or to any lay individual or group,
might reduce the quality of the service he
renders. The studies instigated by the
Human Relations School (Roethlisberger
and Dickson, 1939; Mayo and Lombard,
1944), which stressed the importance of
personal freedom and morale to the per-
formance of the worker, have pointed out
the importance of personal autonomy. Be-
cause of the theoretical separation of in-
dividual autonomy into personal and work-
related autonomy, variables suggested by
the Human Relations School which are re-
lated to personal autonomy will be controlled
so that findings related to work autonomy
can be interpreted. The range of activities
in which a loss of work-related autonomy is
most likely to be a problem for the pro-
fessional is examined in this study.
The definition of bureaucracy used was
derived from the Weberian tradition, with
some modification. Weber conceived of
bureaucracy as an administrative structure
based on legal domination, highly rational
in its organization, and therefore effective
for goal attainment (Blau and Scott, 1962).
The definition considered the effect of both
the administrative structure with which
Weber dealt-in particular, the hierarchical
authority structure and the rules and regula-
tions-and the physical structure, which in-
cludes the amount and types of supplies,
tools, and large items of equipment with
which work is performed, the number of
men working together in a department or
section, and the availability of funds for
such endeavors as research and continuing
education. Since the authority structure of
bureaucracies is more rigid and confining
than that of the professions (Blau and Scott,
1962), if a professional works in a bureau-
cracy, he could undergo a loss of autonomy.
HYPOTHESIS
It was hypothesized that as the degree of
bureaucracy increased, professional auton-
omy would decrease. This hypothesis was
tested by comparing degree of autonomy
with respect to both clinical practice and
clinical research as perceived by three
groups of physicians employed in a highly
bureaucratic, a moderately bureaucratic, and
a nonbureaucratic setting. Physicians were
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13
studied because their occupation has been
widely used as the basis for the traditional
concept of a profession by both laymen and
social scientists (cf. Flexner, 1915; Carr-
Saunders and Wilson, 1933; Marshall, 1939;
Cogan, 1953; Parsons, 1954; Goode, 1957
and 1960; Bucher and Strauss, 1961; Becker,
1962; Wilensky, 1964; and Bullough, 1966).
SAMPLE
A total of 1,628 questionnaires was sent to
physicians who work in (1) solo or small
group practice, (2) a privately owned,
closed-panel medical organization, and (3)
a governmentally associated medical or-
ganization. Of the 684 (42 percent) returns,
40 percent (230 of 580) were received from
those in solo practice, 54 percent (276 of
520) from those in the privately owned
medical organization, and 34 percent (178
of 528) from those in the governmentally
associated organization. While the physi-
cians in solo practice were selected by
random sampling procedures, the total pop-
ulation of physicians in the two organiza-
tions was used to obtain a sufficiently large
sample.
Solo Practitioners
The solo practitioners were sampled from
a highly urbanized area in California. They
worked in an office obtained and equipped
with their own funds and attended patients
who had voluntarily chosen them as their
physicians on a fee for service basis. Most
respondents were specialists: 15 percent
were internists, 60 percent were in other
specialties, and 25 percent were general
practitioners. Although the major work task
for most was clinical practice, approximately
30 percent had part-time clinical appoint-
ments at a medical school. Only a small per-
centage participated in clinical research.
All sampled solo physicians were members
of the local and national medical societies
and were affiliated with at least one private,
accredited hospital, varying in bed size from
20 to 500. The respondents' modal salaries
were $35,000 or more. A small number of
solo practitioners was interviewed to obtain
a close range perspective of their perceived
autonomy. Most of the interviewees claimed
to be highly autonomous.
14 ADMINISTRATIVE
Physicians in the Privately Owned
Organization
The physicians in the closed-panel medi-
cal group provided medical services within
an integrated clinic and/or hospital to pa-
tients who had voluntarily joined a prepaid
health plan. More than 500 salaried physi-
cians worked in this organization. Their
modal salary was in the $25,000 to $30,000
range. Approximately 17 percent were gen-
eral practitioners, 27 percent were internists,
and the remainder were members of other
specialties. While the organization was not
officially associated with any university med-
ical school, 33 percent of the physicians had
part-time teaching appointments.
As with solo practitioners, the major goal
of this organization was the clinical practice
of medicine, although clinical research could
be undertaken by those interested. The or-
ganization was headed by a medical director
and was divided into five subunits, all lo-
cated in a highly urbanized area of Cali-
fornia. Each subunit was organized into de-
partments according to medical specialty
and was affiliated with a modern, well-
equipped general hospital, which varied in
size from 170 to 450 beds. Between 30 and
200 physicians were associated with each
subunit. Business administrative services
were provided by a nonmedical service cor-
poration.
The organization was structured so that a
physician could become a profit-sharing part-
ner, as well as a salaried employee, after
three years of full-time employment. Ap-
proximately 350 physicians in the organiza-
tion were partners.
The partnership was carried on by a board
of directors, consisting of 13 elected and 7
ex officio members who were directly re-
sponsible to the partnership members. Since
they were incorporated within the authority
structure, the partners had substantial con-
trol over organizational policies.
The organization's patient population was
quite similar to that treated by the physi-
cians in solo practice and represented a
cross-section of the community. The free-
dom of choice between patient and physi-
cian found in individual practice was re-
duced, since the patient had to select his
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SCIENCE QUARTERLY
physician from those who worked in the
organization, and the physician was per-
mitted to care only for those patients who
were members of the health plan. A physi-
cian was assigned to a patient, unless the
patient requested a specific doctor.
Physicians in the Governmentally
Associated Organization
The physicians in the governmentally asso-
ciated organization provided medical care
for a select group of individuals who quali-
fied under federal regulations. The organiza-
tion employed more than 500 physicians,
about the same number as the privately
owned bureaucracy. Four percent were gen-
eral practitioners, 37 percent were internists,
and the remainder were engaged in other
specialties.
The four subunits of this organization
studied were in the same geographical area
as the other two groups. Between 20 and
200 physicians were associated with these
subunits.
While this organization was similar to the
privately owned bureaucracy with regard to
the type and accessibility of hospital facili-
ties, it differed in number of hospital beds,
freedom of choice between physician and
patient, and patient population. The hospital
sizes varied from 519 to 1,675 beds; patients
were assigned to the physicians who, in turn,
were permitted to treat only those who
qualified under governmental regulations;
and its patient population was not represen-
tative of the community, most being males
with chronic illnesses.
As with solo practice and the privately
owned organization, one of the major activ-
ities of the governmentally associated or-
ganization was clinical medical practice.
However, research and teaching were also
stressed, and financial provisions were made
in each of the subunits for those who wanted
to participate in clinical research. The sub-
units were also used as teaching settings,
with the local university medical school
supplying a number of consultants and de-
partmental chiefs who, in turn, provided in-
struction to residents and interns. Three
hundred residents and 36 interns were asso-
ciated with the organization. Almost half of
 Engel: PROFESSIONAL AUTONOMY 15

all physicians in the organization held part- changes in policy had to be set and ap-
time teaching appointments. proved from a geographical distance. By
The governmentally employed physician contrast, the policies of the privately owned
had no opportunity to become a partner in bureaucracy were mainly determined within
the organization. He could attain higher the structure.
rank only if such a position became avail- A larger number of rules and regulations
able, and he remained an employee as long existed in the governmentally associated
as he was associated with the organization. than in the privately owned setting. When
Higher positions were awarded on the basis the operating manuals and other printed
of ratings which physicians received from materials from the two organizations were
their superiors. compared and information from interviews
Interviews were also conducted with a with physicians employed by the two orga-
small number of physicians from the pri- nizations was evaluated, it was noted that the
vately owned and governmentally associated former had approximately four times as
organizations to obtain the flavor of the au- many recorded rules related to patient care
tonomy in these two settings. As with the as the latter. In many instances these rules
solo practitioners, the majority in both or- were more specific and covered a greater
ganizations attested to their autonomy. Most number of the physicians' activities. The
stated that practicing in an organization was physicians were also required to fill out ap-
no different from practicing solo. proximately twice as many forms related to
patient care as those in the privately owned
VARIABLES AND MEASURES organization.
Independent Variable: Degree of Dependent Variable: Degree of
Bureaucracy Professional Autonomy
The degree of bureaucratization of the In his relationship with his client, the pro-
three settings was determined by noting fessional is usually expected to be autono-
(1) the number of hierarchical levels in mous with respect to such factors as respon-
each setting, (2) the degree to which rules sibility, communication, and innovation, if
and regulations were utilized, and (3) the he is to provide adequate service (Engel,
presence or absence of a physical setting in 1968). He assumes the responsibility for his
which work could be performed in teams or client's welfare because he is more knowl-
groups. edgeable and is acting on his client's behalf.
The settings used represented three dif- He defines the problem, determines proce-
ferent levels of bureaucratic organization: dures, and is accountable for the adequacy
nonbureaucratic, moderately bureaucratic, of his services.
and highly bureaucratic. Solo practice was However, the professional should be free
classified as nonbureaucratic because most to communicate with his client and with his
of the elements defined as bureaucratic were fellow professionals. He should have access
only indirectly present in this type of medi- to privileged information concerning his
cal practice. The governmentally associated client, and he should be free to communi-
organization was categorized as highly bu- cate with those in his field who might pos-
reaucratic and the privately owned orga- sess information which could help him
nization as moderately bureaucratic for the render a better service to his client.
following reasons. The professional should also be able to
When the formal organizational charts innovate. Each client's problem tends to
were compared, the authority structure of require a singular solution. The professional
the governmental organization was noted to should be able to alter typical procedures or
have a greater number of hierarchical levels instigate changes necessary for the solution
than that of the privately owned organiza- of the specific problem.
tion. Because the center of authority, the Professional autonomy within the client-
administrative head, was not located within professional relationship was therefore di-
the local organization, new policies and vided into three dimensions-autonomy

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 16 ADMINISTRATIVE
with regard to innovation, individual respon-
sibility, and communication-which were
operationalized as follows.
Autonomy with regard to innovation ex-
isted when the physician instigated changes
related to work tasks, was responsible for
TABLE 1. CLINICAL PRACTICE AND RESEARCH AUTONOMY
Professional autonomy
Low Medium
Bureaucracy S %
Low 40.8 35.5
Medium 14.0 34.8
High 46.2 32.1
origination, altered established work meth-
ods, and produced novel ideas and/or
methods. Autonomy with regard to individ-
ual responsibility occurred when the physi-
cian determined the uses to which his work
was put, was not subordinate to those less
knowledgeable, defined his own work goals,
and was permitted to act and think without
interference. A physician was autonomous
with regard to free communication when he
had access to all vital information, could
communicate without interference or obsta-
cles, and participated in democratically or-
ganized discussions.
A professional autonomy questionnaire
was designed to determine the degree of
autonomy which the members of each group
possessed. It dealt with the physicians' per-
ceptions of their autonomy with regard to
clinical practice (part I) and research (part
II) and with the various relevant control
variables (part III).
Since the data did not lend themselves to
Guttman-scaling techniques, two Likert-type,
professional autonomy scales were con-
structed from the responses to parts I and
II of the questionnaire. Each scale was con-
sidered to represent a separate aspect of
autonomy. They were combined to form a
third, overall autonomy scale.
Each of the three scales was empirically
divided into thirds. The upper third was
designated as high autonomy, the middle
third as moderate autonomy, and the lower
third as low autonomy. The degree of per-
ceived autonomy within the client-profes-
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SCIENCE QUARTERLY
sional relationship was then related to the
degree of bureaucracy.
FINDINGS AND CONCLUSIONS
Table 1 shows that a greater percentage
of the physicians in the moderately bureau-
BY BUREAUCRACY
High
% N X2-test
23.7 152 2= 66.96
51.1 221 4 df
21.8 156 p < .001
cratic setting perceived themselves as high
in autonomy than in either of the other two
settings. A slightly greater percentage of
those in the nonbureaucratic setting saw
themselves as moderately autonomous than
those in either of the other two settings,
while a greater percentage of those in the
highly bureaucratic setting perceived them-
selves as low in autonomy.
The findings did not support the hypoth-
esis concerning the inverse relationship be-
tween degree of bureaucracy and degree of
autonomy. They might, however, be spuri-
ous. The apparent anomaly concerning the
lower perceived autonomy of the individual
practitioners, as compared with physicians
in the privately owned organization, re-
quires further examination. Perhaps some
of the other variables on which the solo and
organizational physicians differed could ac-
count for the results.
The solo practitioners appeared to be the
more highly professional group. Their modal
salaries were higher. They were more active
in their professional organizations, sub-
scribed to a larger number of journals, and
enrolled in more graduate courses. Accord-
ingly, they should have been more, rather
than less, autonomous.
One background variable on which the
groups differed, and which might partially
account for the lower perceived autonomy
of the solo physicians, was type of medical
specialty, if any. Depending on their spe-
cialty, solo physicians tended to have dif-
ferent referral sources.
 Engel: PROFESSIONAL AUTONOMY 17

Freidson ( 1960) pointed out that there
were two basic sources of referrals: client
and colleague. Individual general practition-
ers maintained their practices mainly by re-
ferrals from their clients. Most solo medical
specialists obtained referrals primarily from
colleagues (Hall, 1948). Internists had two
sources of referrals, colleagues and clients,
and it is likely that they were less dependent
on either source and thus more autonomous
than the general practitioners or the other
specialists. Because the sample of solo physi-
cians contained both a greater percentage of
general practitioners and specialists other
than internists, the groups were separated
by medical specialty to determine the effect
of this variable.
The type of medical specialty as it related
to client and colleague control had little
effect on the individual practitioner's per-
ception of his autonomy, as Table 2 shows.
those who had prepaid, and were required
to use, the organization for all medical ex-
igencies.
Further, even though the social, economic,
and religious characteristics of the privately
owned organization's clients were quite
similar to those of solo physicians, the clients
probably differed with respect to their psy-
chological makeup. Perhaps those who pa-
tronized solo physicians did not join prepaid
medical plans because they preferred to ex-
ercise more control over their choice of
physicians. Several patients of solo physi-
cians who were interviewed remarked that
they would not be interested in going to a
clinic or joining a prepaid group because
they might not be able to get the same physi-
cian whenever they needed him. Others just
wanted the freedom to choose their own
doctor.
The three groups of physicians also dif-

TABLE 2. AUTONOMY AND BUREAUCRACY BY MEDICAL SPECIALTY

Professional autonomy
Low Medium High
Bureaucracy % % % N X2-test
General practitioner
Low 48.4 41.9 9.7 31 X2= 6.78
Medium 33.3 30.6 36.1 36 4 df
High 50.0 33.3 16.7 6 P > .10
Internist
Low 26.1 43.5 30.4 23 2 = 14.22
Medium 13.8 39.7 46.6 58 4 df
High 42.4 35.6 22.0 59 P < .01
Other specialties
Low 41.8 29.1 29.1 79 X2 = 54.00
Medium 8.5 30.8 60.7 117 4 df
High 52.0 26.7 21.3 75 P < .001

Regardless of specialty, differences in the fered on personal satisfaction and length of

basic doctor-patient relationship and the
type of client routinely seen by the solo and
private organizational physicians were rele-
vant variables. The organizational physicians
probably had more control than the solo
physicians because they did not depend di-
rectly upon patients for their income. Since
the solo physicians' clients paid for each
service rendered and were not bound to a
single group of physicians, they were prob-
ably less docile and more demanding than
time in practice, but these were not critical
factors, as Tables 3 and 4 indicate. Variables
such as organizational size, rank in the or-
ganization, and time in the organization
were also introduced as controls to deter-
mine their effect on the degree of autonomy
of the two organizational groups, but no sys-
tematic differences were found.
Since 62 percent of the solo physicians
had not participated in research, while 58
percent of those in the privately owned or-

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 18 ADMINISTRATIVE SCIENCE QUARTERLY

TABLE 3. AUTONOMY AND BUREAUCRACY BY PERSONAL SATISFACTION

Professional autonomy
Low Medium High
Bureaucracy % % % N X2-test
Less satisfying
Low 36.1 39.8 24.1 83 2= 15.56
Medium 26.3 50.0 23.7 38 4 df
High 60.9 29.7 9.4 64 p < .01
Equally satisfying
Low 39.5 34.2 26.3 38 2 = 24.62
Medium 12.9 30.7 56.4 101 4 df
High 40.7 33.3 25.9 54 p < .001
More satisfying
Low 50.0 25.0 25.0 16 2 = 16.00
Medium 10.5 32.9 56.6 76 4 df
High 25.8 38.7 35.5 31 p < .01

TABLE 4. AUTONOMY AND BUREAUCRACYBY TIME IN PRACTICE

Professional autonomy
Low Medium High
Bureaucracy % N % N X2-test
Short time
Low 47.4 28.9 23.7 38 2= 26.19
Medium 14.4 39.2 46.4 97 4 df
High 51.2 20.9 27.9 43 p < .001
Long time
Low 38.0 41.0 21.0 100 x2 = 32.81
Medium 12.5 30.0 57.5 80 4 df
High 38.4 35.6 26.0 73 p < .001

TABLE 5. CLINICAL PRACTICE AUTONOMY BY BUREAUCRACY

Professional autonomy
Low Medium High
Bureaucracy N % % N X2-test

Low 37.9 37.5 24.6 224 x2 123.06

Medium 16.2 36.5 47.2 271 4 df
High 64.9 23.8 11.3 168 p < .001

TABLE 6. CLINICAL RESEARCH AUTONOMY BY BUREAUCRACY

Professional autonomy
Low Medium High
Bureaucracy % S % N X2-test
Low 35.8 41.8 22.4 67 x2 = 7.74
Medium 41.2 30.6 28.2 85 4 df
High 29.8 29.8 40.5 84 p> .10

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 Engel: PROFESSIONAL AUTONOMY
ganization and 32 percent of those in the
governmentally associated setting had not
participated, the autonomy scores were ex-
amined separately with respect to clinical
practice and research, and the relationships
shown in Tables 5 and 6 were obtained.
With respect to clinical practice, physi-
cians who worked within a moderately bu-
reaucratic setting again perceived them-
selves as experiencing a greater degree of
autonomy than those in the other two set-
tings. In clinical research, however, while
physicians in the nonbureaucratic setting
tended to maintain their moderate position,
those in the other two settings reversed their
positions.
It was not surprising that physicians in the
nonbureaucratic setting were not more au-
tonomous than those in the other two groups
with respect to clinical research. Physicians
in solo practice did not have ready access to
research funds, nor did they deal with the
kinds of patients who were willing subjects
for research. However, the reversal between
physicians in the two organizations requires
further explication.
While both organizations viewed patient
care as a major function, the governmentally
associated setting stressed research in addi-
tion to patient care, and funds were set aside
for physicians who desired to undertake a
research project of merit. Also, the highly
bureaucratic setting was less bureaucrati-
cally organized with respect to clinical re-
search than the moderately bureaucratic
setting. In the former, administrative proce-
dures were often less formal, in that fewer
rules and regulations were imposed upon
physicians who were pursuing research ac-
tivities.
Further, unlike the other two settings, the
patient population of the governmentally
associated organization lent itself to re-
search. There were no out-patients; most
patients were chronically ill and had to be
housed within the organization for long
periods; and since their medical treatment
was provided without charge, they were less
likely to resist being employed as research
subjects.
Since the controlled variables did not ac-
count for the findings, the results may be
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19
explained by considering recent changes in
society and their effect on the professions.
The scientific and technological innovations
which have been developed since World
War II have had a major impact on the
structure of all professions (Kast and Rosen-
zweig, 1963:39-40; Levitt et al., 1963:16).
Their number, size, work settings, and in-
ternal patterns of relationships have been
altered. New types of tools and skills have
become essential. Professionalism has be-
come, of necessity, a collective enterprise.
Societal changes have also affected the
traditional bureaucratic form. Unlike the
rigid structures of the past, many bureau-
cracies are now adaptive, fluid systems devel-
oped for the solution of complex problems
which require the services and skills of pro-
fessionals from diverse fields (Bennis,
1969:45).
Bureaucracies, especially professional bu-
reaucracies, can serve the needs created by
these alterations in professional practice by
supplying those professionals who work
within bureaucracies with funds, various
kinds of equipment, technical personnel, and
other physical facilities essential for con-
temporary professional performance, and
with a stimulating intellectual climate for
interchanging information and controlling
quality of performance. These organizational
characteristics will enhance the development
and performance of today's professional.
Working in isolation, he is less likely to have
access to the social and physical features
which bureaucracies can provide.
This could explain why the professionals
in the moderate bureaucracy perceived
themselves as having more autonomy than
those in either the nonbureaucratic or the
highly bureaucratic setting. The nonbureau-
cratically employed may have experienced
a lack of essential physical facilities, while
those who worked in the highly bureaucratic
organization might have felt limited by its
rigid administrative structure. Those in the
moderate setting, on the other hand, may
have experienced fewer of these limitations
upon their professional autonomy. These
findings suggest that the professional type
of bureaucratic organization is not neces-
sarily detrimental to professional autonomy.
20 ADMINISTRATIVE SCIENCE QUARTERLY

Gloria V. Engel is an assistant professor military psychiatry." Journal of

in the department of community medicine
and public health at the University of South-
ern California.
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