BUREAUCRACYa greater level of individual output and perform-
ance is required, more personal and closer forms
of supervision need to be employed. This closer
supervision increases the visibility of power rela-
tions, a consequence that may undermine the
effect previously achieved by the use of general
and impersonal rules.
The satirical, but nonetheless insightful, work
of Peter and Hull (1969) indicates that bureaucrat-
ic processes may not always reflect the principle of
personal expertise. Peter and Hull contend that
even though individual talent and expertise are
the formal requisites for recruitment and promo-
tion within a bureaucracy, individuals often are
promoted to positions that exceed their level of
competence. Since the act of promotion often
requires the assumption of new duties, an element
of uncertainty over whether individuals will be as
efficient in their new positions as they were in their
previous positions is ever present. Not until an
individual has had the position for a period of time
is it apparent if he will be able to perform the newly
assigned tasks in an efficient and competent man-
ner. Most individuals are able to achieve an accept-
able level of competence in their new duties; but
what about those individuals who are unable to
perform their new duties competently? Peter and
Hull contend that, instead of being relocated to
more suitable positions, these individuals remain
in the elevated positions due, in all likelihood, to
the difficulties and organizational costs associated
with removing and reassigning them. Consequent-
ly, some individuals may be promoted to and
remain in positions that exceed their level of com-
petence, a portrayal clearly at variance with the
image of operational efficiency.
THE PERVASIVENESS OF BUREAUCRACY
IN SOCIETYThroughout the nineteenth and twentieth centu-
ries, a notable increase occurred in the number
and type of functions performed within or regulat-
ed by a bureaucratic organization. Bureaucracies
have superceded other more personalized, par-
ticularistic operations (ostensibly due to the tech-
nical superiority of the bureaucratic process) or, as
new processes developed, they developed within
the context of a bureaucratic structure. The ubiq-
uitous presence of bureaucracies in modern socie-
ty is indicated by the common usage of the term
‘‘red tape.’’ The term originally denoted unneces-
sary and prolonged bureaucratic paperwork and
procedures, and has since been expanded to en-
compass a more generic sense of unproductive
effort. The level of everyday exposure to bureau-
cracies is sufficient such that notions of what a
bureaucracy is (or perhaps more importantly, what
it is not) have become a part of the popular culture
of modern society. Fictional settings in which bu-
reaucratic procedures interfere with the good in-
tentions of people, promote an unproductive or
unhealthy outcome, or lead to an uninspired work
environment are common themes of movies, nov-
els, syndicated cartoon features, and television shows.
The expansion of bureaucratic procedures
has clearly impacted developments in the areas of
health care and labor. In the area of health care,
changes in the technological base of medicine, the
methods by which medical services are financed,
the regulatory role of government, as well as ef-
forts to enhance the efficiency and accountability
of health care providers has culminated in the
bureaucratization of medical care (Mechanic 1976).
In contrast to past medical practice settings char-
acterized by a private and dyadic relationship be-
tween a doctor and a patient, the delivery of
medical care in bureaucratized settings, intended
to provide broader and more uniform care, in-
creases the likelihood of conflicts of interest and
the diminished salience of individualized care.
When medical care is delivered in a bureaucratic
setting, the specific features of patient care may be
based on a number of nonclinical elements in
addition to the clinically pertinent factors. Nonclinical
criteria such the determination of what services
will be provided and the avoidance of ‘‘unneces-
sary’’ services, patient case management by
nonmedical personnel, a predetermined referral
protocol and network, and the disclosure of sensi-
tive patient information within the bureaucratic
organization all limit the role of the doctor. Each
of these nonclinical, bureaucratically derived ele-
ments introduce different and potentially conflict-
ing viewpoints in an evaluation of effective patient
care and may direct attention more toward resolv-
ing organizational conflicts than enhancing pa-
tient care. The issues facing bureaucratic medical
care will likely become more acute with the ‘‘ag-
ing’’ of society and the need to attend to a greater
number of patients suffering from debilitating,
protracted, and nonrecoverable medical conditions.