Abstract
Hyeyoung Oh Nelson’s book on physician decision-making dilemmas in providing patient care is part of a resurgence in American medical sociology on investigating doctoring in contemporary clinical settings. The evolution of sociological research on physicians moved from studies of medical and nursing students in the 1960s to accounts of professional dominance and power in the 1970s to the inroads on that power by countervailing forces (managed care, government cost controls, corporate medicine, etc.) in the 1980s. After a brief hiatus in the early twenty-first century, we are seeing a return to studies of medical doctors in today’s practice environment, with Oh Nelson’s Conflicted Care: Doctors Navigating Patient Welfare, Finances, and Legal Risk a prime example of this trend.
Her study is an ethnographic investigation of the professional challenges and relationships common to physicians in an internal medicine service in a highly specialized elite West Coast teaching hospital, which she anonymously calls “Pacific Medical Center.” While noting that only 5 percent of U.S. community hospitals are located in academic medical centers, she points out that they conduct the vast majority of the nation’s medical research and provide extensive patient care. Moreover, they train most of the country’s physicians who go on to practice medicine in a variety of settings and geographic locations. Their influence on the physicians trained within their hospital wards and laboratories is substantial.
Oh Nelson’s study is based on ethnographic observations over 26 months as she accompanied an internal medicine team on daily morning rounds. She also conducted interviews and attended internal medicine staff meetings and those of other medical specialties. She uncovered what she describes as a hidden curriculum of doctoring that requires physicians to deal with multiple institutional logics in providing patient care. As Oh Nelson puts it: “In sum, this book explores what it means to practice medicine in the current era of commodification and bureaucratization, in which physicians must balance the often conflicting demands of cost-cutting initiatives, patient-centered care, fears of legal recourse, and bureaucratic practices and policies” (p. 17).
The centerpiece of her analysis is a focus on the interrelated logics of (1) health (helping patients and doing no harm), (2) market (constraining costs), and (3) legal (avoiding litigation) that guided patient care decisions. Other logics, such as training and research considerations, also existed, but the health, market, and legal logics were the most prominent. One would think that the health logic featuring the provision of quality health care to patients, what Oh Nelson (p. 25) describes as the profession’s “overarching moral imperative,” would be the overriding dominant logic, and it was. But at times, the health logic conflicted with the market logic of cost containment and overtreatments necessitated by the legal logic.
For example, Pacific Medical Center featured inter-specialty care, and when specialists were brought in, they made their assessments and tests, increasing costs. “Merely calling a consultant,” says Oh Nelson, “triggers a fee” (p. 29). Once on the case, specialists became the final authority in diagnosing and determining treatment plans. Additional physicians led to greater expenditures of time and money and higher probabilities of obstacles to consensus, yet they bring in expertise and the opportunity for better care. Nelson notes that inter-specialty care is not driven solely by the nature of medical work and the profit motive but also by the demands of patients to have the best care available.
Different health insurance coverages, limitations, and deductibles further complicated efforts at providing care. Decisions about lengths of hospitalization and the management of hospital discharges were made on a case-by-case basis, with the patient’s health needs, insurance coverage, family desires, and cost of care all operating as variables. There were also instances of patients being discharged early because their insurance was insufficient, and a more extended hospital stay would result in patient financial problems or bankruptcy. Conversely, Oh Nelson reports that a homeless patient without insurance might be hospitalized longer than necessary until a suitable place to live could be found, with the hospital absorbing the expense. Hospitals, in turn, have to have sound financial management to stay in business. So, the market logic could not be ignored.
The legal logic enters into decision-making when doctors practice “defensive medicine” by overtreating and overtesting to avoid potential lawsuits for malpractice or to satisfy patient demands, even though the care rendered is unnecessary or excessive. In this situation, both the health and the market logic are in conflict with the legal logic. However, the current institutional emphasis in medicine on patient satisfaction with physicians and ratings of services in response to patient consumerism promotes a focus on the patient’s approval.
In sum, this book provides a sociological analysis of medical practice in today’s clinical setting. It is precisely written and well crafted. There are ample examples of how the various logics affected particular patients and their care. Oh Nelson correctly points out that although health care systems are structured differently worldwide, cost containment and quality care issues are global. She provides an insightful account of how physicians in the United States confront its complexities in everyday practice. The book has six chapters organized into (1) Doctors’ Dilemmas, (2) Conflicting Logics, (3) Notation (medical records), (4) Consultations, (5) Discharge, and (6) Costs. There is also a useful Appendix describing her methods for collecting data in a challenging research setting.
This book is particularly relevant for premed and medical students wanting to know more about everyday work as a hospital doctor and sociology students and practitioners seeking insights into the contemporary medical workplace. The one sociological shortcoming, in my view, is the absence of an overall theoretical viewpoint modeling the observed behaviors. Otherwise, this book is an excellent analysis of contemporary medical decision-making in a complicated work environment.