Shaun Ruggunan, Discipline of Human Resources Management, University of Kwazulu-Natal

The invisible labour process and labour market for histopathologists in KwaZulu-Natal, South Africa.

Shaun Ruggunan, Discipline of Human Resources Management, University of KwaZulu-Natal, South Africa

WORK IN PROGRESS [email protected]

Introduction

The aim of this paper is to assess both the labour market and labour process for histopathologists in KwaZulu-Natal. The labour process of these laboratory based medical specialists is largely invisible in the South African health care system. The reason for this invisibility is that the majority of empirical studies of health care work and workers in South Africa are focused on clinical health care workers such as nurses and clinical doctors. However, as this article will demonstrate, the histopathologist remains an invisible yet crucial part of the health care system and are essential to effective health care service delivery.

By rendering the labour market and labour process for these specialists visible, this article demonstrates that South Africa is facing a recruitment and retention crisis for histopathologists. This labour market crisis is compounded by racial and gendered inequities in the training, recruitment and retention of these specialists. Further, the shortage of these specialists is impacting on the ways in which their work is organised, particularly in the public sector. In addition, the unique nature of the labour process of histopathologists when compared to clinicians and other medical laboratory specialists, presents distinctive challenges in their recruitment and retention. Given that this is first empirical study to focus on histopathologists in South Africa, I adopted an exploratory and qualitative approach. This qualitative study consisted of 16 in-depth interviews conducted in 2011, (70% of the population of histopathologists in KwaZulu-Natal) with histopathologists in the public and private sectors, interviews with other key stakeholders such as the University of KwaZulu- Natal medical school, public and private employers, and the health professionals council of South Africa.

Labour market statistics for the remaining South African provinces were obtained from the relevant regulatory bodies. In addition participant observation of the labour process of these doctors was conducted. This paper makes the following three contributions; firstly it extends South African industrial sociology to include analyses of occupations and professions in service sectors. Secondly it fills the empirical scarcity of knowledge on the labour market and labour processes of medical laboratory specialists such as histopathologists. Thirdly it attempts to balance the South African literature by providing insight into the work of non- clinical medical doctors. I believe that the findings of this study will allow for more meaningful labour market interventions in the health care sector of South Africa.

Background and Context

The World Health Organization (2011) admits that data regarding certain categories of healthcare specialists in South Africa are much less available and in some cases, negligible (Pillay 2009; WHO 2011).This is demonstrated in the lack of precise data on the labour market for South African histopathologists. This is further compounded by inaccurate data keeping by the Health Professionals Council of South Africa (HPCSA) of the actual number of medical laboratory specialists registered and practicing in the country. This makes it difficult to estimate the extent of their shortage or to manage the consequences of a shortage of these medical specialists. In addition the labour process of histopathologists is largely invisible in South Africa, with the majority of research focused on clinical health practitioners.

Laboratory medicine is vital in preserving and protecting health as it enables the identification and measurement of biochemical and molecular risk factors, markers of genetic susceptibility and predictors of disease related complications (Plebani 2002: 93; Guidi and Lippi 2006). The term ‘medical laboratory specialist’ incorporates a broad spectrum of categories of doctors that oversee and perform laboratory investigations for patients. There are many different types of medical laboratory specialists, including haematologists, histopathologists, chemical pathologists, virologists, and microbiologists. Histopathologists also known as are specialists that are concerned with the tissue diagnosis of diseases (Royal College of Pathology of Australia, 2011). The primary function of an histopathologist is the diagnosis of biopsies derived from patients. Once a tissue biopsy is conducted by a doctor, it is sent to a histopathologist for diagnosis. Histopathologists also conduct post-mortems to ascertain cause of deaths where no foul play is suspected.

The labour market for histopathologists in South Africa 3

In South Africa there are officially 245 histopathologists, 115 haematologists, 28 virologists and 115 chemical pathologists (HPSCA 2011). Collectively these specialists are known as medical laboratory specialists. However these figures are disputed. For example the register does not reflect the number of specialists that are practising outside the country but maintain their national registration, nor does it reflect those that have retired from practice but have maintained their registration. Even if the figure of 245 were to be accurate it would reflect a ratio of one histopathologist to every 2 million people in the country. Fieldwork in KZN revealed that there are only 23 histopathologists as opposed to the 26 indicated in the official statistics. The ratio of specialist to population in KZN therefore is one per 10 819 130 people (Statistics South Africa 2011).

Differences between the labour process of clinical doctors and histopathologists

The South African and global literature has overwhelmingly focused on the labour process and labour market challenges of clinical doctors in South Africa. There is no effort to distinguish between labour processes of the different types of doctors or medical specialists and all medical doctors are subsumed under the occupational category ‘doctor’. However I contend that understanding the specific labour processes of specialist medical doctors is analytically more useful especially when feeding into training, recruitment and retention strategies. I have summarised these key differences in the table below:

Table 1: Similarities and Differences in labour processes of clinical doctors and histopathologists.

Clinical doctors Pathologists

Similarities  Deals with patient health and well being  Advises patients based on test results  Are medical doctors, studied for 7 years including community service Differences  Directly involved with the  Indirectly involved with the patient health patient health care care  Advises patient based on the  Advises clinician based on the results of test results and what diagnostic work. pathologists say  Patient facing environments  Laboratory based environment  Consult with patients  Consult with doctors  Odd working hours; on call  Fixed working hours 8:00-17:00; weekends 24/7;can be called out at any off and compulsory to work 1 Saturday a time; are based at place of month; optional to work weekends or at work (surgery, hospital) home to catch up with work; on call but not often called out  Refer special cases to a  The ‘doctors’ doctor as they are specialists, specialist doctor no referral as they have to have an answer for the clinician.

Race, racism and gender in the labour market for histopathologists

The section below demonstrates two key themes that emerged from the fieldwork into the labour market for histopathologists in KZN. These themes allow for a more complex view of professional labour markets to emerge.

RACE The subject of race and racism was a major theme that emerged during the interview process. The theme emerged as a response to questions on racial transformation of the labour market for histopathologists. The labour market for histopathologists both nationally and provincially in KZN is racially skewed. Nationally the discipline is White male dominated, and in KZN it is Indian male dominated. This reflects historical apartheid legacies of training and employment. For example, the national labour market is comprised of 5% Black histopathologists, 9% Indian, 61% White, with 25% of pathologists remaining racially unclassified. The most likely reasons for this last cohort of racially unclassified 25% are that they represent 25% of ‘missing’ pathologists from the country and practising overseas, and hence difficult to trace and classify. They nonetheless remain on the register. Further, this portion of histopathologists could represent an ageing cohort of specialists who have not been removed from the register despite not practicing. If this is the case then the majority of the 25% would be White South Africans further inflating the percentage of White histopathologists (Interview data: HPSCA official). This is also in keeping with national trends of an ageing White South African population (National Planning Commission Report, 2011)

However, an emerging post-apartheid trend is the preference for many Black medical doctors to opt for specialities that are perceived to offer quicker occupational returns in terms of remuneration and career mobility. These returns are perceived to lie within the domain of clinical specialities as opposed to laboratory based ones. 5

In 2011 there were only three Black medical laboratory specialists practising in KwaZulu- Natal, both of whom are in the private sector. Black female histopathologists are a rarity with only three in South Africa. Experiences of overt and covert forms of racism at sites of practice and training are acutely expressed by Black histopathologists. One of the participants stated challenges of covert racism were more prevalent in the public sector than the private sector (Interview: Madiba 2011). Racism is further made complex by the lack of Black role models or senior histopathologists in both the public and private sectors. (Interview: Madiba). This is less of an issue in clinical specialities that have comparably higher levels of Black practitioners at senior levels.

Black histopathologists interviewed expressed a desire for racial transformation of the discipline in the country as a whole. The public sector is particularly important in this regard, since it is responsible for the recruiting and training of new registrars. (Interview: Madiba). The issue of race, racism and transformation is one that needs to be explored in future research.

GENDER The speciality is male dominated both nationally and in KZN with only 7 of the 23 pathologists being female in KZN. This trend is also evident at a national level with 37% of histopathologists being female. According to employers of histopathologists in both sectors, the relatively stable working hours, working time flexibility and the ability to work from home in some cases, the discipline should be more attractive to female candidates, particularly those who are mothers.

However, interviewees indicated that despite the conditions of work being perceived as more favourable by those wanting more of a work-life balance, the reality is different. There is an intensification of the labour process. Firstly, the interview data revealed that there are higher levels of productivity expected within the same number of working hours in both the public and private sectors. Secondly, histopathologists in the public sector have a range of other duties such as teaching, research and training. These duties extend the hours of work and are compounded by the lack of human resources. It is often difficult to maintain a work-life balance in this context (Interviews Dr. Maistry 26 May 2011 and Dr. Ramlall 19 May 2011). Literature indicates that work-life balance is a key criterion for women in their choice of professions (Richman, Civian, Shannon & Brennan 2008). The erosion of work-life balance in the practice of histopathology was the reason most often cited by interviewees for them leaving the public sector. However, as one interviewee stated, the fact that histopathologists have to work from 7a.m. until 6p.m. in the public sector could account for a general dissuasion of both men and women from choosing to train in the speciality.

The second part of this paper examines the labour process of histopathologists in more detail. Whilst there is a set of generic labour processes for all histopathologists , some processes vary according to whether they work in the public or private sector in Kwazulu-Natal. The section specifically examines managerial control, control of time and regulatory control of these professionals. Thereafter it examines the role of technology and skill in the profession.

The Labour Process of Histopathologist in the public and private sectors

Managerial Control

The difference in the way managerial control of the labour process is exercised differs significantly in the public and private sectors in KZN. The primary driver of managerial style is that the organisational structure of the public sector allows for a head of department to run the department of histopathology autonomously and unilaterally. This often results in autocratic leadership styles. However the challenges and constraints faced by the public sector often support and foster this type of managerial approach. For example the lack of senior histopathologists in the province’s public sector means that there is limited pool of candidates to appoint as head of department. A consequence is that tenures of headship can occur uninterrupted for a decade or more. The private sector is dominated by three laboratories, Lancet, Ampath and Purcell. Of these, Lancet is the dominant employer of histopathologists in KZN and the country. The managerial style is one of management through partnership, and histopathologists automatically become associates of the company. However private laboratories are primarily profit driven and this comes with its own set of demands for the histopathologist working in the private sector.

Dr Nair, who recently resigned from the public sector to work in the private sector suggests that the public sector is not the most supportive sector to work in. He contends that: 7

“It’s hard to strike a balance between time for research versus your normal day to day work and how much time you want to give your family as well at the end of the day. So it’s very much up to the head of department.”

An African histopathologist1, compares his personal experience in both the public and private sector environments included that this was his main reasons for moving from public to private,

“You know here in private it’s more relaxed. In the public sector we had a Head of Department that was motivated in making us feel less confident about what we were doing, whether she was doing that to all races, that’s debatable. I felt victimised and I felt she was not interested in my growth. I felt that I was not given an equal opportunity as other people. She had her favourites as a certain group of people were writing articles, even so I realised when I left, the reason why I left is that I felt I was not going to grow, I wasn’t going get where I wanted to be. So I left and I came into private practice. Here, you have got good leaders who are, who have made the environment comfortable for me. Obviously I was the first African consultant to work here and knowing the environment I had been exposed to, this is a totally different environment. It’s not about the colour of your skin, where you come from, it’s all about just moving forward, it’s all about what can we provide to the company. You grow based on your work. So that is one thing. It’s measurable, at every stage you know how you are doing, at any stage you know when you are not doing well. And you are told in a very amicable way, you know, that if you do this, you will grow, if you do this you won’t grow. And you can see where you are at any given stage. So my immediate head here has been very good. The CEO of the company…The chairman of the company as well, they have been very good, not only to me but to all pathologists. It’s a fair company. I

1 This interviewee insisted that the full quote be used as a condition for granting the interview can become whatever I want to become here. Whereas in the state I would have had to beg the HOD... there are degrees of racism and we live in a smart world where we have got educated people. And they can debate their actions and say we are not racially motivated you know. But personally I have felt that I was being discriminated because of my race in the public sector.”

Dr Aniruth’s observations demonstrate that the working environment of public sector is too autocratically managed, and that work flexibility is non-existent. Given the ‘super skilled’ nature of the profession, he argues that this is an anomaly, as professionals should not be managed in this way. He further states that due to the many roles that pathologists in the public sector play, they should be allowed some degree of flexibility to switch between the roles or to focus on one role instead of having to perform all the different functions such as teaching, service work, management, administration, analysis and cutting up of specimens. Dr Chetty, a public sector histopathologist contends that the managerial style of the KZN state sector has become too autocratic. He contends that:

“Obviously a lot depends on the head of department and the way that they run the department. If you are going to run a department like in the form of a dictatorship or keep strict control on the lives of staff from the moment they come in till they leave, then you have to accept that people are going to leave and there will be a shortage, if the work environment is restricted.”

Dr Maharaj adds to this line of argument by contending that ‘there is a lack of freedom’ in the public sector as there are many restrictions that consultants have to work under. For example histopathologists hold dual employment contracts with the NHLS and the University of Kwazulu-Natal. As such, they have teaching responsibilities to students as well as service work for state hospitals. Dr Maharaj, having worked in both the public and private sector argues that says that there are little or no hierarchies in private sector and it’s a flexible environment. Dr Maharaj portrays a very Tayloristic environment in the public sector, 9

“In the public sector you have to clock in at a certain time and you have to clock out at a certain time. What you do it doesn’t matter. You can sit and stare at the ceiling and have a cup of tea as long as spent your eight hours and you go home after that.”

In terms of flexibility there are numerous ways in which companies can allow for flexibility. Dr Watkins, a histopathologist in the smallest private laboratory in KZN, considers flexibility in his laboratory the norm. He argues that it is counterproductive to micromanage such highly skilled professionals whether in the private or public sectors.

All private sector histopathologists (all of whom worked in the public sector) asserted that the advantage of having a flexible working environment in private laboratories is that they are still able to further their studies to ensure upward career pathing. They compare this to their experiences in the public sector, where workloads are so substantial that, studying further to become a super-specialist is not always possible. There is also unanimous agreement that histopathologists enjoy higher levels of autonomy than their public sector counterparts.

The public sector by contrast offers a challenging environment for histopathologists in terms of autonomy. Dr Suraj illustrates the working hours in the public sector are closely related to the large workloads that they have. He states,

“ I think firstly it’s the working conditions in terms of the working hours. In the public sector because of the volume of work that we have, our working hours are quite long. So we actually extend beyond what is expected of us because we just need to complete the work.”

Dr Suraj notes that there is a problem with not only the remuneration in the public sector but also the lack of opportunity to grow professionally. In this respect he contends that the public sector cannot compete with the private sector. In addition to higher remuneration one has the possibility of expanding their career by becoming a partner so one has a career path, whereas in the public sector that is not really well defined unless one is inclined towards an academic career. However the fieldwork for this study indicates that it is very difficult for a histopathologist to develop a sustainable academic career in histopathology due to burdens of workloads.

The impact of management style on the labour process is that the more autocratic management gets the higher the levels of professional dissatisfaction of histopathologists. All interviewees in the public sector feel that the paternalistic style of management infantilised them, and given that they are ‘super specialists’ this did not bode well for their job satisfaction levels. Dr Ndlovu contends that the monetary rewards in the public sector can often be higher than the private sector but monetary rewards are not sufficient to retain staff in the public sector. He states that state salaries can range between R50 000 to R100 000 per month for qualified histopathologists, whilst private sector salaries average at R65000 a month and rarely reach the R100 000 a month level. Dr Ndlovu further contends that he is less motivated by money and more motivated by recognition and non-monetary incentives such as work flexibility, time off and access to resources for research. All histopathologists interviewed said their primary motivation for shifting from the public to the private sector is not motivated by higher salaries.

Table 2 summarises some of the key differences observed between working conditions of histopathologists in the private and public sectors.

Public sector Private sector

Similarities  Diagnostic work  Consulting with clinicians  Requires extensive training in becoming specialists  Requires a certain type of personality  No clinical patient interaction Differences  Employed by NHLS  Employed by a partnership of pathologists, e.g. Lancet, AMPATH, Purcell Laboratories  Laboratory involvement:  Laboratory involvement: Has a actively involved in laboratory separate working environment from activities the laboratory not integrated at all  Quality control:  Quality control: Has a separate pathologist assures the quality manager to assure quality – lab of specimens manager  Type of environment:  Type of environment: Flexible 11

restrictive and controlled: and autonomous: -Working hours stipulated, -Working hours, can agree with sign registers, have to work another pathologists to cover you, given hours whether one has or if work is complete for the day work or not can leave -Not enough time for study, -Study leave even though an academic -Ample leave time for rest and facility relaxation -No time for leave, too high volumes of work  Further Education:  Further Education: -no time to further personal -employer allows for time to further studies as workload and other one’s own studies commitments are too much -can teach on a contractual basis or -compulsory teaching and voluntarily training duties due to dual employment (NHLS and academic centre)  Technology and finances:  Technology and finances: In the public sector they have In the private sector technologies access to government based are adopted pending on how funding and are a research effective it will be with regard to education based institution, turnaround times and from a therefore have reason and business point of view increase grounds to purchase many organisation profit. In addition to technologies this if it serves a large population of cases or a few special cases. Therefore they don’t find the need to invest in unprofitable technologies

Diagnostic Turnaround Time One informant from the public sector, Dr Maharaj states an example of how the managerial style and staff shortages in the public sector have led to the private sector intervening to provide pathology services to the Newcastle area. This occurred due to the intensification of workloads in the public sector.

As Dr Maharaj states

“I will give you a practical example of the effect the shortage has had on service delivery. In Newcastle Ladysmith area, the surgeons and the doctors working in those public hospitals are getting frustrated as they have to wait for weeks for a histology result. They do a procedure and they take a mass out and they don’t know the result and they are stuck with the patient. So they went and had a removal of limb and the patient has to wait weeks to know why it was removed... these doctors went and met the local minister of health and said we can’t work like this anymore and requested that they send service to the private.”

The doctors did this because they felt that the pathologists in private sector were more equipped to handle the workload and they were confident that they would receive a result in 2 days. They therefore influenced the then minister of health to do that in KwaZulu-Natal. As a result a private laboratory was contracted do the public histology service for the Newcastle area. In addition to that Dr Rampersad admits that the shortage in the public sector became so severe that they were forced to outsource some of their workload, the pathology service to the private laboratories, as in the above case mentioned by Dr Maharaj.

Turnaround time as a measure of effectiveness of work organisation

Turnaround time gives a clear indication of how efficiently work is organised in the public and private sectors. It refers to how long a specimen is processed from the time of collection of a sample to the delivery of the report and consultation with clinician. When pathologists were questioned on the turnaround time for a specimen, all those employed in private laboratories stated that 99% of their work is turned out in a 24 hours period. However, there 13 are 1% to10% that are special cases that require second opinions and in those cases, turnaround time is 48 hours maximum. In contrast, in the public sector, there is no stipulated turnaround time, and diagnostic work can take two days to several weeks. It is important to note that the populations that the two sectors service is very different. The public sector is responsible for the majority of the KwaZulu-Natal population whereas the private sector is concerned only with patients that have private medical aids.

Dr Suraj explains the private and public sector service populations in relation to the turnaround time

“Our expected turnaround time is two weeks. So from the time you get it to the time that you diagnose and your report is released is two weeks. That is the expected time. Actually for most cases it’s less than that. We try to do that. But the problem is that, ok to put it in perspective, my department serves most of KwaZulu-Natal. There are some that won’t send it to my department. So roughly we are talking about 14 million people and we only have one.. two… three, I think five consultants. So one private lab in Durban has more than that and serves a significantly smaller population. So you can imagine the work load here.”

Fieldwork indicated that the average turnaround time in the public sector is a week. Dr Aniruth sketches the turnaround time for the public sectors as well as what the consequences are of delayed turnaround times.

“I know in the state and we have got all these complaints about it, it takes about three weeks even up to a month to get a result. Which I think as a pathologist is criminal. You can’t have a patient with a breast lump or a cancer waiting for one month to get a diagnosis. Whereas in the private sector, within three or four days that patient is treated and had surgery and had chemotherapy or radiation therapy, whatever it is.” Given the nature of histopathological work, quality control of diagnosis is imperative. Quality control is demonstrated in different ways in the public and private sectors. In the private sector a separate manager exists to perform the quality assurance, which most often is the laboratory manger whereas in the public sector pathologists perform the quality control themselves through a peer review system. This is a further intensification of their labour process and is partly attributable to the limited support function provided by laboratory technical staff and the limited number of laboratory support staff in this sector.

National Health Laboratory Services – and the two year retention contract as a control strategy

A further control strategy is the use of the NHLS 2 year contract, that registrars are bound to once they qualify as histopathologists. This compels histopathologists in the public sector to remain there for two years unless a private laboratory choses to ‘buy’ them out of their contract. The 2012 buyout rate is two million Rand and histopathologists have the option of buying themselves out of the contract. The reality is that with vast amount owed in student loans, these specialists are not able to buy themselves out of these contracts and there is no recorded case of anyone doing that since the implementation of the clause in their employment contracts.

Participants interviewed were divided as to the usefulness of this contract. For example, Dr Aniruth strongly believes that this contract is a positive implementation as he feels it is a manner in which graduates can gain experience and confidence needed to proceed to private.

“Look why would anyone want to leave the public sector immediately after qualifying as a specialist? Surely it’s in your own best interest to gain experience. Before you go into private practice and are left on your own you need to have some degree of confidence especially in Anatomical Pathology. Once you are a registrar there is always someone supervising you. And you have got to work as a consultant and supervise others to gain the confidence and the knowledge. So I think it’s absolutely essential. I think that nobody should go into private with at least three to five years experience in the public service. And so look if it’s a deterrent then that person should not do 15

pathology actually because it’s only to their benefit. And you are working as a specialist you are getting paid as a specialist and the salaries are very very good actually. The salaries in the public sector have improved tremendously from when we were there. In fact is comparable to the private sector in many areas.”

Dr Nair concurs with the above view and states that

“Currently what the NHLS is paying is actually even more than what private is offering. So it’s not actually a deterrent.”

However, Dr Chetty implies that the contract is restrictive and could be seen as a deterrence to pathology in general:

“I think in a way it’s a bit of a deterrent, and that is why we have a bit of a shortage in private practice, because by the time you finish your two years, you are a senior specialists. You are getting are really competitive salary, you know...it is a retaining strategy and they have to pay quite a bit to get out of that contract, hey. I think it’s about R3m or something. So I don’t know anybody who has got that amount to buy themselves out.”

As noted it is used as a control mechanism to attempt to retain pathologists in the public sector for a minimum of 2 years, this has its advantages and disadvantages as the specialists have highlighted. It will also assist the government in retaining their graduates for that period to assist with the large volumes of workload that the pathologists in the public sector experience, such as teaching, training, laboratory duties, analysis, diagnostics and consultations. However for a pathologists that is experiencing difficulties with the manner in which the department is run in the public sector they are forced to remain in an unproductive environment for those additional 2 years, which makes them restricted and spirits dampened with no options. Table 3, below, summarises the control measures identified in the public and private sectors respectively. Control measures that are prevalent in the workplace

 Registers – signing in and out of the workplace (Public Sector)  ‘In-Out’ boards – indicating when in the office and when out of the office (Public Sector)  Pie charts on the door – describing where one could be (toilet; cafeteria; meeting; laboratory; gone for the day,) Public Sector  IT system used as a tracking system  Monitoring turnaround times  Access to training – restricting growth  Controlling leave (Most acute in the public sector)  Controlled working hours  Lack of internet facilities so no leisure browsing is allowed in public sector  Quality control  NHLS 2 year retention contract in public sector  Control over Continuous Professional Development – the requirement that even when qualified pathologists are required to keep abreast with advancements in their field.

Despite pathologists being super skilled professionals, control over them still exists directly and indirectly. This is in keeping with the way control is deployed in a range of other expert occupations. Work by Child (1984) and Friedman (1977) demonstrate that the levels of control tend to be higher in the public sector and the levels of individual autonomy are quite low (Child 1984 and Friedman 1977 cited in Thompson & McHugh, 2009: 65). However in the private sector pathologists are positioned in managerial positions and are more autonomous individuals that are required to perform management duties in addition to diagnostics duties. The management style in the public sector seems to be very authoritarian whereas the private more independent and pathologists are allocated duties and it is their responsibility to carry them out.

Technology Amongst the different types of medical laboratory specialisations (Virologists, chemical pathologists, microbiologists and haematologists), histopathology is the least dependent on new technologies. Diagnosis is primarily by ‘eye’. This diagnosis by eye means that the labour process for their diagnostic work cannot be replicated by technology in the way it is occurring for chemical pathology for example. This in effect means that there is no trend towards deskilling by technology as there has been in the other medical laboratory 17 professions. Turnaround time and diagnostic effectiveness is determined by and limited by the body and not new technologies.

Dr Watkins revealed in his interview that that there is little dependence on technology by histopathologist sin his private laboratory however it is the technologists that are dependent on technology, he says that

“Histopathologist is relatively low tech compared to other pathology groupings. We have got tissue processors that take tissue from water based through to wax based so that we can cut them. We have got micro tomes for cutting sections, we have got staining processors but generally those, some laboratories are mechanised, ours we do them more manually. For ourselves we have got microscope and Dictaphone, very low tech.”

Dr Watkins stresses that technology cannot replace the human capital element of pathology, however technology developments does pose a threat for the technologists. In order to increase diagnostic turnover rates, laboratory technicians have to use new technologies to process more specimens at faster rates. This has speeded up their work.

An unexpected finding was that the public sector has far more ‘advanced’ technology available to its histopathologists. Both Drs Suraj and Mkhize agree on the superiority technology in their public sector department. The private sector is more conservative about how it invests its money into new technologies. As Dr. Suraj contends

“One of our functions is research so we can justify why we have to spend money on those technologies.”

However despite this access to cutting edge technology, the rate of diagnostic turnover cannot be speeded up any further, given the reliance on diagnosis by eye as opposed to machine. The new technologies in the public sector enable specimens to be prepared faster but not diagnosed any faster. For example Ultra Rapid Tissue Processing speeds up tissue processing by technologists from14 hours to 30 - 60 minutes. In theory this means that a specimen can be processed, diagnosed and signed out in 21 hours from the time of arrival, and in some cases even sooner. However the bottle neck occurs at the level of the histopathologist. Histopathologists can only humanly diagnosis a finite amount of specimens accurately in a working day.

What this section has accomplished is that as the patient population increases there is a need for technology to develop to assist with the large volumes. However the discipline of Anatomical Pathology is somewhat of an anomaly when it comes to the issue of new technologies. Unlike Chemical Pathology, Histopathologists have a low reliance on new technologies in aiding their work. Their diagnosis is purely by eye. New technologies play a role in supporting the preparation of biopsies for diagnosis but do not end up being a substitute for diagnosis by these specialists. However for other laboratory disciplines such as chemical pathology, technological advancements pose a deskilling and a de-professionalising risk.

Diagnosing and reporting from home

New technologies allow for histopathologists to telework or work from home. The Lab Track IT system is used in public sector laboratory and the MediTech system is used in the private sector. As long as a histopathologist has a microscope and a laptop connected to the laboratories server, s/he is able to work from a remote location. The exception to this would be when frozen sections need to be done. This requires the histopathologist to travel to specific hospitals. However frozen sections constitute less than a third of the histopathologists work.

However the implementation of the ‘work from home’ systems remains a contentious issue both in the public and private sectors. Managers in both sectors expressed ambivalence about having staff work remotely. Drs Manicum and Govindsamy, managers, who work in the private sector state that they actively discourage staff from working from home as they feel 19 such a system may be open to abuse. This is despite the monitoring functions built into histopathology software. Doctors themselves expressed mixed feelings about the teleworking system. They argued that flexibility also infringes their private time and space and they would rather work on site from 8am to 5pm. They further contend that management, especially in the private sector will put pressure on them to ‘sign out cases well after normal working hours and may even do so on weekends’.

As Dr Rampersad from the public sector asserts:

“Do I want to work from home is another issue, as I will be forced to do work 24 hours a day and that will infringe on the time I have to spend on life and my family.

A further finding was that many histopathologists described their work as a very isolating and solitary profession and that working from home exacerbates this solitariness. As averred to in the above discussion, despite the technology being available to allow histopathologists to work remotely, there is reluctance from both histopathologists and managers to engage in this practice.

Conclusion and implications for South African industrial sociology

The above empirical study demonstrates that analysis of professional work, and in this case the example of histopathologists is useful for several reasons. Firstly it allows for a disaggregation of the occupational category of ‘medical doctor’. Through this disaggregation we can see that labour processes differ remarkably between clinical doctors and laboratory based doctors. This has potential policy implications in that a ‘one size fits all’ policy recommendation for the recruitment and retention of doctors may not necessarily be the best alternative. To date the South African literature treats all medical doctors as one occupational category with a few attempts to distinguish between different medical specialists. Secondly, the above case shows that racism, and gendered issues are prevalent even at the most highly skilled occupational levels. Given the country’s labour market policies to grow the number of Black African professionals in fields such as medicine, the findings of the challenges faced by Black African professionals is useful. Thirdly the stark differences between managerial style between the public and private sector is important. Even though I am unable to generalise beyond the KZN findings, any policy interventions should focus on why these managerial styles have developed in the way they have in both the sectors. Finally the case study poses some substantive theoretical and empirical challenges to South African sociology. This is discussed further below.

Industrial Sociology in South Africa has traditionally focused on the industrial sector, manufacturing work and male blue collar workers. As a result research on work has become synonymous with the study of factory work. This focus is prevalent in the theoretical underpinnings of the discipline as well as its empirical focus. More recently there has been an attempt to shift to studies of livelihoods. The livelihood stream in industrial sociology challenges many of the traditional ideas of what work is and shifts the focus from the factory to a variety of other types of workplaces especially in the informal sector. However in shifting towards this new empirical project in industrial sociology, the sociology of professions continues to be neglected.

Analysis of professional work and expert occupations has largely been left to the ambit of industrial psychology, human resources management and business schools. This is in keeping with international trends where the study of professional work and expert occupations is also found outside industrial and economic sociology. Through these processes a critical approach to the study of professions and professional work has been marginalised from South African sociology.

The empirical case presented in this paper demonstrates that many of the themes that underpin South African industrial Sociology can be extended and explored at the level of professional work. I argue that it is by understanding the changing nature of professional work and the ways in which work is organised for professionals provides unique insights into the processes of capitalism, the economy and the emergence of new managerialisms in South Africa. The South African economy is expanding beyond the manufacturing sector. There is a growth in the service sector and in the number of professionals in the labour market. The scope of South African sociology and industrial sociology needs to broaden to include sociology of work that is reflective of this. 21

Bibliography

Allsop, J., Bourgeault, I.L., Evetts, J., Bianic, T.L., Jones, K., and Wrede, S. (2009). Encountering Globalization: Professional Groups in an international Context in Current Sociology; 57 (4): 408-505.

Bach, S. (2003). International migration of health workers: Labour and social issues. Kings College, London.

Beckering, R. and Brunner, R. (2003). “The lab shortage crisis: a practical approach” in MLO Med Lab Obs. 2003; 35(6):48-51

Bersch, C. (2003). “Combination of demands sharpens pinch of personnel shortage” in MLO Med Lab Obs; 35 (4): 52.

Castro-Leal, F. Dayton, J. Demery, L. and Mehra, K. (2000). “Public spending on health care in Africa: do the poor benefit?” in Bulletin of the World Health Organization; 78 (1)

Chanda, R. (2002). “Trade in health services”, in Bulletin of the World Health Organization; 80 (2)

Chen, L, Evans T., Anand, S., Boufford, J.I., Brown, H., Chowdhury, M., Cueto, M., Dare, L., Dussault, G., Elzinga, G., Fee, E., Habte, D., Hanvoravongchai, P., Jacobs, M., Kurowski, C., Micheal, S., Pablos-Mendez, A., Sewankambo, N., Solimano, G., Stilwell, B., de Waal, A., and Wibulpolprasert, S. (2004). “Human Resources for Health: overcoming the crisis” in Lancet; 364: 1984-1990.

Coovadia, H., Jewkes, R., Barron, P., Sanders, D., and McIntyre, D. (2009). “The Health and Health system of South Africa: historical roots of current public health challenges” in The Lancet, Volume 374.

Crisp, N. (2000). “Transformation of laboratory services” Chapter 12, in South African Health Review; p251-261 Garrott, P. (2008). “Clinical Laboratory Practitioners Speak out on Capitol Hill” in Clinical Laboratory Science; 21 (3):130-1.

Guidi, G. C. and Lippi, G. (2006). “Laboratory medicine in the 2000s: programmed death or rebirth?” in Clinical Chemical Laboratory Medicine; 44 (8): 913-917.

Hagopian, A., Thompson, M.J., Fordyc, M., Johnson, K.E. and Hart L.G. (2004). “The migration of physicians from sub-Saharan Africa to the United. States of America: measures of the African brain drain” in Human Resources for Health; 2 (17).

Health Professionals Council of South Africa. (2010). Date and time accessed: 20:08:2011; 11h30 Hendriks (2008). Financing South Africa’s Health system through National Health Insurance.

HSRC Policy Analysis Unit. HSRC Press http://www.hpcsa.co.za/downloads/statistics/2010_registered_practitioners_stats.xls http://www.statssa.gov.za/ Date and time accessed: 9:02:2011; 13h00

Hudson, M. (2011). “Where have all our practitioners Gone?” in HPCSA Bulletin, 2011/12 Annual Fees.

Jacob, J. I., Bond, J. T., Galinsky, E. Hill, E. J. (2008). “Six critical ingredients in creating an effective workplace:, in The Psychologist-Manager Journal, 11:141-161.

Khadria, B. (2010). The Future of Health Worker Migration. IOM International Organization for Migration.

Kuehn, B. M. (2007). “Global Shortage of Health Workers: Brain Drain Stress Developing countries” in The Journal of the American Medical Association; 298 (16): 1853-1855

Pillay, R. (2009). “Work satisfaction of professional nurses in South Africa: a comparative analysis of the public and private sectors” in Human Resources for Health; 7 (15): 1-10.

Pogue, T. E. (2007). Mobility of Human Resources and Systems of Innovation. A Review of Literature. HSRC Press, Cape Town.

Richman, A.L., Civian, J. T., Shannon, L. L., Hill, J., and Brennan, R. T. (2008). “The relationship of perceived flexibility, supportive work-life policies, and use of formal flexible arrangements and occasional flexibility to employee engagement and expected retention”, in Community, Work and Family 2008. 11 (2): 183-197.

Rispel, L. & Setswe, G. (2007) Stewardship: protecting the public's health. In: Health Systems Trust South African health review 2007. Durban: Health Systems Trust. 3-18.

Rohde, R.E., Falleur, D.M., Redwine, G.D., and Patterson, T.L. (2010). “Growing Our Own: Teaching and Doing Research in CLS” in Supplement Clinical Laboratory Services; 23 (3):11-8.

Sanders, D. and Chopra, M. (2006). “Key challenges to achieving for all in an Inequitable society: The case study of South Africa”, in American Journal of Public Health; 96 (1): 73-78. Statistics South Africa (StatsSA). (2011).

Stilwell, B., Diallo, K., Zurn, P., Vujicic, M., Adams, O., and Dal Poz, M. (2004). “Migration of health-care workers from developing countries: strategic approaches to its management” in Bulletin of the World Health Organization; 82 (8): 595-600.

Vertovec, S. (2002). Transnational Networks and Skilled Labour Migration.http://www.transcomm.ox.ac.uk/working%20papers/WPTC-02-02%20Vertovec.pdf Date and time accessed: 13:02:2011; 9h00 23

Ward-Cook, K. (2002). “Medical Laboratory Workforce Trends and Projections: What Is Past Is Prologue” in Clinical Leadership Management Review; 16 (6): 364-9.