Medical Dominance and the Governance of Quality: Strategic Adaptations to Performance Measurement and Feedback in Orthopaedic Surgery

Abstract

Background: This thesis investigates how orthopaedic surgeons interpret, adapt, and respond to continuous quality improvement (CQI) systems in everyday practice, using the Adverse Event Performance Measurement and Feedback (AE-PMF) tool as a case example. Drawing on sociological theories of medical dominance, evidence-based medicine (EBM), and audit and feedback, it explores how data-driven accountability mechanisms are received, negotiated, and reshaped within the professional norms, institutional contexts, and collegial dynamics of surgical care. Methods: A qualitative case study was conducted in a single orthopaedic surgery division in Ontario. Data collection included semi-structured interviews with surgeons and clinical leaders, along with analysis of institutional documents related to CQI. Thematic analysis was used to examine how participants engaged with CQI practices, particularly the implementation and perceived utility of the AE-PMF tool. Results: Surgeons did not passively adopt CQI tools but strategically reframed them to preserve clinical authority. They engaged selectively with quality initiatives—developing localized protocols, leveraging collegial networks, and navigating audit systems in ways that aligned with professional judgment. Collegiality served as a key mechanism of internal accountability, while transparency efforts, intended to promote oversight, often reinforced existing hierarchies. Adverse events were not objectively reported but socially constructed through peer negotiation, reputation management, and contextual discretion. Discussion: The findings demonstrate that audit and feedback tools like AE-PMF are not neutral instruments, but sociopolitical artefacts embedded in professional power dynamics. CQI systems both challenge and sustain medical dominance—limiting autonomy in some cases while enabling its strategic preservation in others. This study contributes to the sociology of health care by showing how performance measurement is shaped by cultural norms, professional discretion, and peer governance. Conclusion: To be effective, CQI systems must move beyond compliance-based models and account for the interpretive, relational, and institutional realities of clinical work. Tools like AE-PMF should foster reflective learning and shared accountability rather than symbolic oversight. Recognizing surgeons as active agents in defining and enacting quality is essential for building contextually meaningful and sustainable CQI frameworks.