Conflicted Care
Doctors Navigating Patient Welfare, Finances, and Legal Risk
Hyeyoung Oh Nelson




Prior to the autumn of 2010, Jordan, a 33-year-old man of African descent, had no previous medical history. In October, however, he began to experience headaches, weakness, fatigue, and fever. The symptoms became so severe that he admitted himself to a local hospital. What ensued were many hospital visits over a two-month period during which a full-body workup was completed. Infectious disease specialists and neurologists were brought on board after preliminary tests indicated lesions on the patient’s brain. A myriad of blood panels, tests, and procedures were completed, yet the results remained inconclusive: infectious disease panels—including HIV—and two bone marrow biopsies came back negative. Even with numerous consultants caring for Jordan and a slew of tests and procedures ordered, the patient’s condition remained unknown. He felt progressively worse over several months, and in February of 2011 brought himself to the Emergency Department at Pacific Medical Center (PMC). He was immediately admitted to the Internal Medicine Service after presenting with increased weakness, instability, and brain lesions.

Once admitted, the Internal Medicine (IM) team treated Jordan for his acute symptoms, and within a few days his frail grip, due to general weakness, and his limited movement, due to an inability to lift his leg, improved considerably—so much so that from a hospital administration standpoint he was fit to be discharged. Jordan’s primary care team, however, was concerned about his pending discharge because his diagnosis remained inconclusive. They were suspicious that he may have lymphoma, but with all tests and additional medical workups still pending they could not be certain. Typically, this situation would not be worrisome, as most patients would already be scheduled for immediate follow-up care with all necessary physicians at PMC or another medical center. Unfortunately, Jordan was uninsured. His insurance status prohibited his return to the center and limited his other outpatient care options. With the uncertainty, and potential severity, of Jordan’s medical status looming, his primary care team needed to figure out care options for him.

Outside the patient’s room, Jordan’s primary care team launched an intense conversation. They considered the best care options for Jordan and his potentially life-threatening condition. Christopher, the intern on the team, asked whether the patient, despite his insurance status, could simply remain in the hospital until all test results came in and a definitive diagnosis could be determined. Dr. Max, the attending physician, responded that this would be impossible because Jordan no longer needed any inpatient therapies (e.g., IV medications). He explained that if Jordan were to stay, he would be expected to pay out of pocket—leading to bankruptcy—or the hospital would have to foot the bill. Dr. Max reassured Christopher that this decision was not motivated by Jordan’s financial status, explaining that even if the patient was insured, at this stage of recovery he would be released. Therefore, the primary dilemma the IM team had to address was not whether he could stay in the hospital but how he would receive follow-up care.

Jennifer, the team’s second-year resident, and Christopher contemplated possible follow-up care options for Jordan. Dr. Max suggested that if the intern were to work at one of PMC’s outpatient clinics that accepted underresourced patients in the near future, he could take over treatment for the patient. Dr. Max explained that if Christopher were rotating at this outpatient clinic, the clinic could schedule an appointment with the intern directly and designate him as Jordan’s primary care physician. Christopher unhappily responded that he was scheduled at other institutions and would not be rotating at the clinic for at least another month. The attending replied that one month was too long for Jordan to go without any follow-up care.

Dr. Max then asked Jennifer if she could act as the patient’s primary care physician at the PMC-affiliated hospital she mainly worked at. Jennifer was hesitant, explaining that because of bureaucratic protocols, even as his PCP she could not simply schedule an appointment for Jordan. Rather, Jordan would need to go to the hospital’s Urgent Care with a prescription that she had written for him and wait to be seen. Lauren, the team’s case manager, reminded everyone that even with the prescription, the wait at Urgent Care typically lasted twenty-four hours. Unsurprisingly, many patients simply left without receiving medical attention. Jennifer confirmed that while this was the unfortunate reality of her institution’s Urgent Care, if Jordan were to wait to be seen, from that point on it would be easier for him to make appointments with her. The attending dismissed this solution. He stated that this might be too arduous for the patient, resulting in his opting to forgo care, which would likely be fatal.

Lauren reminded them of a small free clinic in a neighboring area that used the same computer system as Pacific Medical Center. This did not facilitate access to records, but once the PMC records were obtained, the physicians could easily read and interpret the patient’s medical notes. Dr. Max pondered this and eventually agreed that this would be the best option and that the patient should be directed to go there. Christopher voiced unhappiness with this decision—concerned that the clinic was not equipped to meet all of Jordan’s health care needs—but eventually agreed with the proposed plan.

Extending beyond the typical five-to-ten–minute presentation and discussion of each patient during morning rounds, Jordan monopolized a large portion of the team’s rounding time because of his uninsured status, tenuous follow-up care, and probable severity of his condition. Of particular note was Christopher’s struggle to come to terms with the follow-up plan: he balked at a decision that he perceived as not in the best clinical interest of the patient.

This struggle to reconcile what Christopher wanted to offer Jordan as his physician and what actually could be done given the constraints of the patient’s resources and of the US health care system is just one of many critical lessons that Internal Medicine physicians-in-training encounter on the hospital wards at Pacific Medical Center. These lessons, which are lacking in medical school education, expose trainees to the realities of practicing medicine in a system that is highly specialized, commodified, and bureaucratized. In this book, I explore these lessons and their associated struggles, revealing a hidden curriculum of doctoring that manifests itself on the Internal Medicine Service of an elite academic medical center. While many of the lessons stem from the nature of current US health care (commodified care, specialized medicine, etc.), these lessons are further complicated by the dynamics in the medical profession itself as well as in elite academic medical centers, which juggle multiple conflicting institutional logics that inevitably shape the dilemmas that surface and the decisions that are made on the inpatient wards.