Notes on the Sociology of Medical Discourse: The Language of Case Presentation

Also CSST Working Paper #19.http://deepblue.lib.umich.edu/bitstream/2027.42/51147/1/379.pd

“Being Guided”: What Oncofertility Patients’ Decisions Can Teach Us About the Efficacy of Autonomy, Agency, and Decision-Making Theory in the Contemporary Critical Encounter

Recent research on patient decision-making reveals a disconnect between theories of autonomy, agency, and decision-making and their practice in contemporary clinical encounters. This study examines these concepts in the context of female patients making oncofertility decisions in the United Kingdom in light of the phenomenon of “being guided.” Patients experience being guided as a way to cope with, understand, and defer difficult treatment decisions. Previous discussions condemn guided decision-making, but this research suggests that patients make an informed, autonomous decision to be guided by doctors. Thus, bioethicists must consider the multifaceted ways that patients enact their autonomy in medical encounters

Repertoires of trust: The practice of trust in a multinational organization amid political conflict

Sociologists and other social scientists have recently renewed their interest in the concept of trust. Multidisciplinary studies have identified social psychological, economic, and structural determinants of trust; traced its development in interpersonal relationships; and explored its transformation in response to modernization. Drawing on ethnographic research at a multinational corporation operating in a politically charged environment, we reexamine these approaches to trust. We explore trust relations between Israeli and Jordanian managers in an Israeli-Jordanian industrial site. Trust, always tenuous in multinational collaboration, poses formidable challenges to this fragile relationship between former enemies. Comparing trust relations during normalization and political unrest provides a natural experiment for observing how forms of trust change in response to a transformed political environment. We show how Jordanians and Israelis apply different forms of trust alternately and interchangeably, transcending cultural dichotomies such as tradition and modernity and deviating from presupposed developmental paths. Following practice theory, our "trust repertoires" approach depicts actors as knowledgeable agents who select, compose, and apply different forms of trust as part of their cultural repertoires. By applying forms of trust, actors demarcate the boundaries of their social relationships. At the same time, actors' strategies are inextricably intertwined with the power structure and political context. In the conclusion, we consider the implications of this analysis for control and coordination in the workplace, including labor process theories

Conscience reconsidered: The moral work of navigating participation in abortion care on labor and delivery

How do caregivers make decisions about participating in morally contested care, such as abortion? Debates about conscience in the delivery of health care generally assume that participation decisions stem from religious beliefs and moral values. Few studies have examined this question in the context of everyday practice. Drawing on 50 interviews with the staff of a labor and delivery unit offering abortion care including nurses, maternal fetal medicine specialists, obstetrics and gynecology residents, and anesthesiologists we show that respondents have varied definitions of "participation" in abortion care and that participation decisions are driven by an array of factors beyond personal beliefs. We present a conceptual model of "moral work" that shows conscience to be an emerging, iterative process influenced not only by beliefs religious and non-religious but also by personal and work experiences and social and institutional contexts. Our study brings new insights into understanding conscience and participation in contested care.</p

Paradoxes of professional autonomy: a qualitative study of U.S. neonatologists from 1978‐2017

The professional autonomy of physicians often requires they take responsibility for life and death decisions, but they must also find ways to avoid bearing the full weight of such decisions. We conducted in‐person, semi‐structured interviews with neonatologists (n = 20) in four waves between 1978 and 2017 in a single Midwestern U.S. city. Using open coding analysis, we found over time that neonatologists described changes in their sense of professional autonomy and responsibility for decisions with life and death consequences. Through the early 1990s, as neonatology consolidated as a profession, physicians simultaneously enjoyed high levels of professional discretion and responsibility and were often constrained by bioethics and the law. By 2010s, high involvement of parents and collaboration with multiple subspecialties diffused the burden felt by individual practitioners, but neonatology’s professional autonomy was correlatively diminished. Decision‐making in the NICU over four decades reveal a complex relationship between the professional autonomy of neonatologist and the burden they bear, with some instances of ceding autonomy as a protective measure and other situations of unwelcomed erosion of professional autonomy that neonatologists see as complicating provision of care.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163653/2/shil13169.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163653/1/shil13169_am.pd

Surrogate Decision Makers\u27 Perspectives on Family Members\u27 Prognosis after Intracerebral Hemorrhage

BACKGROUND: Surrogate communication with providers about prognosis in the setting of acute critical illness can impact both patient treatment decisions and surrogate outcomes. OBJECTIVES: To examine surrogate decision maker perspectives on provider prognostic communication after intracerebral hemorrhage (ICH). DESIGN: Semistructured interviews were conducted and analyzed qualitatively for key themes. SETTING/SUBJECTS: Surrogate decision makers for individuals admitted with ICH were enrolled from five acute care hospitals. RESULTS: Fifty-two surrogates participated (mean age = 54, 60% women, 58% non-Hispanic white, 13% African American, 21% Hispanic). Patient status at interview was hospitalized (17%), in rehabilitation/nursing facility (37%), deceased (38%), hospice (4%), or home (6%). Nineteen percent of surrogates reported receiving discordant prognoses, leading to distress or frustration in eight cases (15%) and a change in decision for potentially life-saving brain surgery in three cases (6%). Surrogates were surprised or confused by providers\u27 use of varied terminology for the diagnosis (17%) (e.g., stroke vs. brain hemorrhage or brain bleed ) and some interpreted stroke as having a more negative connotation. Surrogates reported that physicians expressed uncertainty in prognosis in 37%; with physician certainty in 56%. Surrogate reactions to uncertainty were mixed, with some surrogates expressing a negative emotional response (e.g., anxiety) and others reporting understanding or acceptance of uncertainty. CONCLUSIONS: Current practice of prognostic communication in acute critical illness has many gaps, leading to distress for surrogates and variability in critical treatment decisions. Further work is needed to limit surrogate distress and improve the quality of treatment decisions

Paradoxes of professional autonomy: a qualitative study of U.S. neonatologists from 1978‐2017

The professional autonomy of physicians often requires they take responsibility for life and death decisions, but they must also find ways to avoid bearing the full weight of such decisions. We conducted in‐person, semi‐structured interviews with neonatologists (n = 20) in four waves between 1978 and 2017 in a single Midwestern U.S. city. Using open coding analysis, we found over time that neonatologists described changes in their sense of professional autonomy and responsibility for decisions with life and death consequences. Through the early 1990s, as neonatology consolidated as a profession, physicians simultaneously enjoyed high levels of professional discretion and responsibility and were often constrained by bioethics and the law. By 2010s, high involvement of parents and collaboration with multiple subspecialties diffused the burden felt by individual practitioners, but neonatology’s professional autonomy was correlatively diminished. Decision‐making in the NICU over four decades reveal a complex relationship between the professional autonomy of neonatologist and the burden they bear, with some instances of ceding autonomy as a protective measure and other situations of unwelcomed erosion of professional autonomy that neonatologists see as complicating provision of care.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163653/2/shil13169.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163653/1/shil13169_am.pd

Civil rights as patient experience: How healthcare organizations handle discrimination complaints

The nondiscrimination clause of the Affordable Care Act, known as Section 1557, formally expanded patients’ civil rights in nearly every healthcare setting in the United States in 2010. Regulations required healthcare organizations to name a person to handle grievances and set up an internal grievance process for resolving them. Drawing on interviews with 58 healthcare grievance handlers, this study examines how healthcare organizations respond to patients’ discrimination complaints. We find that organizations incorporated the new right into preexisting complaint and grievance procedures, treating possible patient civil rights violations as patient experience problems. Grievance handlers smooth over problems using customer service strategies. These procedures diminish the efforts of policymakers to expand civil rights protections in healthcare. For civil rights to provoke real organizational change, discrimination complaints would need to be handled by professionals attuned to rights consciousness.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/167779/1/lasr12554_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/167779/2/lasr12554.pd