Table of Contents for Conflicted Care
1.Doctors' Dilemmas
Chapter 1 introduces the primary premise of the book: the emergence of a hidden curriculum of doctoring on the inpatient wards of the Internal Medicine Service at Pacific Medical Center, a prestigious academic medical center. This hidden curriculum of doctoring stems from a health care landscape that is shaped by the commodification, specialization, and bureaucratization of medicine. Through an ethnographic vignette, this chapter introduces the conflicting pressures, dilemmas, and lessons that Internal Medicine physicians must learn to navigate due to the presence of highly central, yet contradictory institutional logics at Pacific Medical Center. Drawing on scholarship from microeconomic sociology and organizational theory, this chapter also provides an overview of the key theoretical and conceptual arguments that frame the book, as well as the book's contributions to the field of sociology.
2.Conflicting Logics
Chapter 2 introduces Pacific Medical Center and describes the unique characteristics of teaching hospitals, particularly elite academic medical centers, in the United States. The chapter also offers a brief history of US teaching hospitals, describing the emergence of different yet highly central institutional logics in these settings. It explores in greater detail the conflicting nature of these institutional logics—health, market, legal, and training—at Pacific Medical Center, and examines how these logics create a working environment that gives way to the emergence of a hidden curriculum of doctoring. Particular focus is placed on the conflicting objectives, pressures, and dilemmas that Internal Medicine physicians must learn to navigate while providing care on the wards.
3.Notation
Chapter 3 reveals how Internal Medicine physicians encounter the presence of multiple institutional logics at Pacific Medical Center via medical notation. The medical record emerges as a site where physicians are made acutely aware of the contradictory nature of medicine's health, market, and legal logics. Physicians realize that proper medical notation is vital to preserve the institution's health logic, ensuring patient health and well-being. Yet the medical record also exposes physicians to the presence of third-party payers in health care delivery and the vulnerability of physicians to litigation risk. This reminds physicians that proper medical notation is not simply proper clinical documentation but rather, a much more careful crafting of information and clinical decision-making that accounts for the often contradictory pressures of Pacific Medical Center's multiple institutional logics.
4.Consultations
Chapter 4 explores how multiple institutional logics drive the heavy reliance on interspecialty care on the Internal Medicine wards. Internal Medicine physicians are pressured to share their patients with consultants in the name of patient health and well-being. Although the assumption is that consultations benefit the hospital's health logic (improving care quality and patient outcomes), this heavy reliance on interspecialty care is largely driven by the hospital's market and legal logics, at times compromising the objectives of the health logic. The health logic is often even further compromised due to work dynamics shaped by the hospital's organizational culture and the medical profession's intraprofessional status hierarchies; this then leads to unintended consequences for the patient, the physician, and the hospital—jeopardizing the goals of all of the hospital's institutional logics.
5.Discharge
Chapter 5 reveals the multifaceted, and highly charged, nature of hospital discharge management at Pacific Medical Center. Discharge decisions are never simple determinations of patient departure dates, but rather carefully crafted negotiations between patients, families, physicians, insurers, and other third parties. It is arguably the aspect of care delivery where the contradictory objectives of the health, market, legal, and training logics are most acutely experienced by Internal Medicine physicians. As the medical team strives to meet the objectives of one logic through discharge management, this decision frequently compromises the objectives of another logic (e.g., extending a patient's hospital stay at the financial expense of the hospital). Subsequently, IM physicians must learn to carefully weigh and balance these contradictory logics when making discharge decisions, resulting in discharge determinations that are rarely uniform, and instead are situationally produced.
6.Costs
Chapter 6 concludes the book with an examination of how the presence of multiple central yet contradictory institutional logics lead to unintended financial consequences for the hospital and the broader health care system. It reveals how the hidden curriculum of doctoring on the inpatient wards—and its associated learning curve—generate avoidable costs for both patients and the hospital. I reflect on the conditions that promote the emergence of this hidden curriculum of doctoring and the possibility for change to effectively address some of the shortcomings of the current health care system in the United States. I conclude with some practice and policy recommendations for health care practitioners, policymakers, and institutions.