The “larger malaise” identified is a global phenomenon in diverse healthcare systems. While Engen has highlighted the challenge to care, there remains a critical need to address the root cause suffocating physicians worldwide: the aggressive dominance of market logic in the provision of health care.

The institutional logics perspective on global healthcare provision

“Institutional logics” are defined as socially constructed values and rules that provide guidance and legitimacy for individuals and organisations [1] A healthy society relies on the balanced dialectical logics of, market, state, profession, religion, and family, to provide essential checks and balances required to safeguard patients, doctors, and the wider community.

However, the New Public Management (NPM) paradigm has globalized market-driven healthcare provision by prioritizing the “3Es”: economy, efficiency, and effectiveness. This shift operates through pseudo-markets where the state purchases health care from self-governing hospitals, quantified performance through Key Performance Indicators (KPIs) such as waiting lists and patient ratings, and labour commodification, treating doctors as one type of resources acquired through labour markets to deliver service targets rather than essential assets to provide care.

By centering measurable service provision targets, NPM has marginalized medical autonomy and empathetic care. This institutional imbalance has triggered a global crisis, causing widespread suffering among young doctors across 70 countries, including the UK, Norway, Kenya, and China [2]

The crisis of medical training and job insecurity of young doctors in modern medicine

Under NPM, hospital managers prioritize service delivery over medical education because training quality is rarely tied to KPIs. Consequently, young doctors are treated as “de facto” fixed-term employees rather than trainees, resulting in fragmented learning and professional distress as depicted by Engen. Late modernity’s “counter-intuitive collectivism” has shifted career responsibility and risk from the institution to the individual doctor [3].

Young doctors are tasked to be responsible for navigating highly institutionalized career pathway now dictated by the market logic. Within the NHS, hospitals utilize “just-in-time” recruitment, treating physicians as flexible labour to maximise cost-efficiency. By relying on international labour market, International Medical Graduates are used as the temp stoppers who constituted 68% of the 2023 intake [4]. This creates severe structural bottlenecks and job insecurity for IMGs and trainees. This systemic failure is exemplified by the 2025 UK paradox: a shortage of 40,000 doctors alongside 30,000 unemployed young doctors [5,6].

Ultimately, business like operation has reduced doctors from “stewards of responsibility” to precarious units of labour, fuelling unprecedented trade union activism global against a failing market-driven model [2]. Historical suppression of institutional diversity inevitably causes systemic failure. This imbalance cost NHS England a projected annual £60 billion in clinical negligence liabilities [7] and over 21 million (Full-time Equivalent) workdays lost in 2025, including over 600,000 monthly days lost to workforce mental health crisis alone [8].

The role of the state in the rethinking of care

To remedy this market failure, the state must directly and swiftly intervene to restore the balance of institutional logics by reducing job insecurity of doctors, the foundational requirement for professional agency. This requires a strategic, state-led management of the medical labour market, including calibrated medical school intakes and more sustainable international recruitment practices that consider the impact on both home and host nations. Furthermore, our research indicates that compassionate senior leadership of hospitals is vital to reducing burnout and prevent doctor exodus [9]. The government must therefore incentivize hospital managers to prioritize long-term training and relationship care rather than viewing AI as another cut-price substitute for human expertise [10]. Only by reinstating professional logic within a democratic and secure employment context can the state provide health care that leads to a healthy society.

References

1. Thornton P, Ocasio W and Lounsbury M . 2012. The Institutional Logics Perspective. Oxford: Oxford University Press
2. You H S, Park K H, & Roh H (2025) Physicians’ Collective Actions in Response to Government Health Policies: A Scoping Review. Journal of Korean Medical Science, 40(6), e90
3. Beck U and Beck-Gernsheim E .2002. Individualization: Institutional Individualism and Its Social and Political Consequences. London: SAGE
4. General Medical Council.2024. Workforce Report. URL: https://www.gmc-uk.org/-/media/documents/somep-workforce-report-2024-ful…
5. British Medical Association. 2025. Medical staffing in the NHS. Available at https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/wor…
6. Hansard, 2025, Resident Doctors: Industrial Action, UK Parliament, Available at https://hansard.parliament.uk/commons/2025-12-10/debates/9527ACD9-2B72-4….
7. NHS England, June 2025. NHS Sickness Absence Rates, available at https://digital.nhs.uk/data-and-information/publications/statistical/nhs…
8. National Audit Office .2025. Cost of settling clinical negligence claims has more than tripled in last two decades, available at https://www.nao.org.uk/press-releases/cost-of-settling-clinical-negligen…
9. Wang, W., Creese, J., Karanika-Murray, M., Harris, K., McCarthy, M., Leng, C., King, C. 2025. Can Compassionate Leadership of Hospital Senior Leaders Help to Retain Trainee Doctors? BMJ Leader. 27
10. Howcroft, A., Bennett-Weston, A., Khan, A., Gay, S., & Howick, J. 2025. AI Chatbots Versus Human Healthcare Professionals: A Systematic Review and Meta-Analysis of Empathy in Patient Care. medRxiv, 2025-06.