A different operating procedure

When Katherine Kellogg did her dissertation research, she was wearing scrubs and making rounds with surgeons. That is not the normal operating procedure for a prospective PhD in management, but then Kellogg was not pursuing a normal project. She was studying, from the inside, a heated controversy in medicine: the debate over reducing the time medical residents spend on the job from 120 hours per week to 80 hours per week. Proponents of shorter hours claimed the change would prevent mistakes; opponents felt it would lead to training that was insufficiently rigorous.

There was just one problem with Kellogg’s research project: She herself had small children at the time, and naturally found that maintaining some semblance of a resident’s demanding schedule was, well, demanding.

“When your research method is to live the life of the people you’re studying, maybe that wasn’t the smartest group to pick with young children,” Kellogg says with amusement. “On top of spending all these hours in the hospital, then it meant I needed to be in the hospital every night between 6 and 11 p.m.,” the hours when she needed to observe how surgical shift changes were handled.

Still, the research worked out. Kellogg had a flexible enough schedule to look after her children at other hours. Her husband and other family members helped cover for her. And after more than two years, Kellogg finished her research. The result was a well-received book — “Challenging Operations,” published by the University of Chicago Press in 2011 — elaborating on her findings.

Kellogg studied three hospitals that had agreed to reduce hours for surgical residents, but discovered that only one of them actually implemented the change. To make policy changes actually stick, she found, reformers inside such institutions must act collectively, and work to change an organization’s culture on a daily basis; otherwise, those mandates will effectively evaporate.

The book helped earn Kellogg tenure at the MIT Sloan School of Management, where she is the Mitsui Career Development Associate Professor in Contemporary Technology, and where she is conducting new on-the-scene studies of medical practices.

“This is my research method, as an ethnographer, to go into this world people are living in, and spend enough time in it that I really understand where they’re coming from,” Kellogg says. “When I was in the field, wearing scrubs, going around all these hours a day, it started to become the most natural thing in the world for me. Then it’s important, when you leave, to be able to really step back and critique it, to tell both sides of the story.”

Eye on medicine

Medicine was long a part of Kellogg’s career plans — although those plans shifted quite a bit over time. As an undergraduate at Dartmouth College, Kellogg was a pre-med student who worked in hospitals for a couple of summers.

“I decided being a doctor probably wasn’t for me,” Kellogg says, adding that she needed more time for reflection than the medical life allowed. “I like writing, so I thought: Could I do something else that’s related to health care?”

After college, she worked as a consultant for Bain & Company, advising biotech firms, then received an MBA from Harvard Business School. Next, Kellogg worked as a manager for the Red Cross, overseeing blood-donor supplies in the Baltimore-Washington area, but found she wanted a more analytical position. Before long, Kellogg entered MIT Sloan’s PhD program, where she worked under Lotte Bailyn, the T. Wilson Professor Emerita of Management, and seized the opportunity to do her thesis research inside hospitals.

While following surgical residents on their rounds, Kellogg found an unexpected dynamic at work. “What was surprising was that many trainees themselves didn’t want [reduced hours],” Kellogg says — despite the fact that residents were working 36-hour shifts. “They often fell asleep while I was observing them,” she says. “They were so exhausted.”

But doctors steeped in the powerful culture of medicine resisted the change, and many residents picked up on those cues from their superiors. “As a training thing, they feel [shorter hours are] not teaching people to always put the patient first,” Kellogg says, “and that there is something about learning surgery under high duress that is going to help you deal with anything.” There was also, she notes, a gendered culture at work, with proponents of longer hours labeling reform efforts as “feminine” intrusions into the tough world of high-pressure medicine.

Reformers need ‘relational spaces’ on the job

So how did the change to shorter hours actually occur at the one hospital out of three — Kellogg does not reveal their identities — that implemented the reform? It happened, Kellogg says, because that hospital provided “relational spaces” for reformers, that is, circumstances in which these practitioners could discuss and test new working methods. Given this chance to think through the new guidelines, the reformers “were able to try out new things, and experiment with [shorter hours] in a way that worked, without having to have all the defenders of the status quo see them and mock them, and say, ‘You guys are just too weak to do it the old way.’”

Ultimately, Kellogg’s research, in her book and additional published papers, suggests that there are few shortcuts to organizational change, but that major reforms can happen, as long as coalitions of workers have these kinds of relational spaces inside organizations.

Looking ahead, Kellogg has new medical research projects on her agenda. Currently she is researching a reform called the “patient-centered medical home,” where patients are cared for by a team of medical workers, rather than having care directed by a strict rank of doctors and nurses. “There are people who are lower down in the hierarchy who are doing things doctors have controlled in the past,” she says. Among other things, the patient-centered approach may be able to reduce costs while maintaining the same quality of care.

Currently Kellogg is examining the use of this method in both community health centers and in one hospital. And there is one obvious benefit to the current research project: no exhausted night shifts while wearing scrubs.