Conflicted Care: Doctors Navigating Patient Welfare, Finances, and Legal Risk

Conflicted Care is an ethnography about how doctors make decisions at a large, prestigious academic medical center. It reveals that patient wellbeing is only one of several factors governing day-to-day decisions, and that harm is built into the practice of medicine in the United States. The book offers novel policy and practice recommendations for health care practitioners, policy makers, and healthcare institutions.

Format: Hardback
Length: 210 pages
Publication date: 11 October 2022
Publisher: Stanford University Press

The oath that doctors take to do no harm suggests that patient welfare is at the center of what it means to be a successful medical professional. It is also understood, however, that hospitals are not only vessels for medical care—they are businesses, educational institutions, and complex bureaucracies with intricate codes of etiquette that dictate how each staff member should approach situations with patients. In Conflicted Care, Hyeyoung Oh Nelson provides an in-depth look at the decision-making processes of physicians at a large, prestigious academic medical center—that she calls Pacific Medical Center—and finds that more often than not patient wellbeing is only one of several factors governing day-to-day decisions.

The steps physicians take reveal a kind of hidden curriculum of the medical world, one that is guided by status and hierarchy, bureaucracy, norms for consulting with third parties, regulations for interactions with patients, and medical uncertainty. While at an institutional and individual level patient care continues to be integral to everything the physicians do, they are forced to reconcile that vow with these other, often-conflicting internal logics. Harm, Nelson argues, is thus built into the practice of medicine in the United States. This harm can take the form of unnecessary treatments and consultations or inadequate treatment for pain to motivate specialist intervention that would otherwise be resisted. These and other practices have the overall consequence of significantly driving up inpatient care costs, which then results in patients forgoing needed, ongoing treatment once they receive their medical bills.

Drawing on a deep ethnography of physicians in the Internal Medicine department at Pacific Medical Center, Nelson offers a nuanced and empathetic account of the challenges faced by these healthcare professionals. She highlights the ways in which physicians navigate a complex web of institutional pressures, patient expectations, and medical uncertainty to make decisions that are often in the best interest of their patients. At the same time, she acknowledges the ways in which these decisions can be influenced by factors such as financial incentives, professional competition, and bureaucratic red tape.

One of the most striking aspects of Conflicted Care is Nelson's analysis of the ways in which status and hierarchy play a role in shaping physician decision-making. She argues that physicians are often influenced by their colleagues' opinions and recommendations, as well as by the perceived prestige and power associated with different medical specialties. This can lead to a culture of conformity and groupthink, where physicians may be reluctant to deviate from the standard of care or challenge established norms.

Nelson also explores the impact of bureaucracy on physician decision-making. She argues that the complex administrative processes and regulations that govern hospitals and medical practices can create barriers to effective patient care. Physicians may spend excessive time on paperwork and administrative tasks, which can detract from their ability to provide quality care to their patients. This can lead to delays in diagnosis, treatment, and follow-up, which can have serious consequences for patients' health outcomes.

In addition to these institutional factors, Nelson also examines the role of patient expectations in shaping physician decision-making. She argues that patients often have unrealistic expectations about the healthcare system and may pressure physicians to provide treatments that are not in their best interest. This can lead to over-testing, over-treatment, and unnecessary complications, which can have negative impacts on patients' health and well-being.

Despite these challenges, Conflicted Care offers a hopeful message about the potential for physicians to make decisions that are in the best interest of their patients. Nelson highlights the ways in which physicians can work to navigate the complex web of institutional pressures, patient expectations, and medical uncertainty to provide high-quality care that is both effective and compassionate. She suggests that physicians can develop strategies for managing conflict, building trust with their patients, and advocating for policies that prioritize patient-centered care.

One of the key strategies that Nelson suggests is the development of interdisciplinary teams that include physicians, nurses, social workers, and other healthcare professionals. By working together, these teams can provide comprehensive care that addresses the physical, emotional, and social needs of patients. This can lead to better patient outcomes and a more satisfying work experience for healthcare professionals.

Another strategy that Nelson suggests is the use of evidence-based medicine to guide physician decision-making. By relying on the latest research and clinical guidelines, physicians can make decisions that are based on the best available evidence and are more likely to be in the best interest of their patients. This can help to reduce the risk of unnecessary treatments and complications and improve patient satisfaction and outcomes.

In addition to these strategies, Nelson also emphasizes the importance of physician self-reflection and self-care. She argues that physicians must take time to reflect on their own values, beliefs, and biases and work to mitigate them. This can help to ensure that decisions are made in the best interest of patients and not influenced by personal or professional factors.

Conflicted Care is a powerful and important book that offers a deep and nuanced understanding of the decision-making processes of physicians in the United States. By exploring the complex web of institutional pressures, patient expectations, and medical uncertainty, Nelson provides a valuable contribution to the ongoing debate about the future of healthcare in the United States. Through her ethnographic research and thoughtful analysis, Nelson offers a hopeful message about the potential for physicians to make decisions that are in the best interest of their patients and to work towards a healthcare system that is both effective and compassionate.

In conclusion, Conflicted Care is a must-read for anyone interested in the healthcare system, the practice of medicine, or the challenges faced by healthcare professionals. Through her deep ethnography and thoughtful analysis, Hyeyoung Oh Nelson offers a valuable contribution to the ongoing debate about the future of healthcare in the United States. By highlighting the ways in which physicians navigate a complex web of institutional pressures, patient expectations, and medical uncertainty, she provides a hopeful message about the potential for physicians to make decisions that are in the best interest of their patients and to work towards a healthcare system that is both effective and compassionate.

Dimension: 229 x 152 (mm)
ISBN-13: 9781503611474