Resisting Throughput Pressures

Abstract

In recent years, quickly discharging patients has become a collective goal at hospitals, as excessive medical workups and extended hospital stays have been associated with unnecessary healthcare spending. Physicians, however, frequently encounter numerous barriers when trying to discharge patients. Presenting ethnographic and interview data collected from September 2010 to September 2013, this paper examines one of the most difficult discharge cases physicians encounter on the internal medicine service at a U.S. teaching hospital: resistant patients—patients and families who refuse to leave the hospital. As physicians try to discharge resistant patients, they are met with conflicting financial and professional incentives. Drawing from the sociological literature on professions, managerialism, and consumerism, I analyze the strategies physicians develop to manage these difficult discharge cases.

Keywords

doctor–patient interactions managerialism medical professionalism professional authority

Expedited hospital discharge has become a critical goal for hospitals nationwide, especially after an influential U.S. policy report indicated that prolonged hospital stays, associated with extensive medical workups, did not result in improved health outcomes (Wennberg et al. 2008). Healthcare professionals and policy makers are optimistic that shortening hospitalizations will reduce inpatient care expenditure, which totaled $936.9 billion in 2013 (Centers for Medicare and Medicaid Services 2014). While the goal is clear, hospital discharge is not a straightforward process, as physicians encounter conflicting financial and professional pressures that complicate discharge decision making. On the one hand, once a patient’s hospital stay has surpassed a set number of days, hospitals will receive the same reimbursement sum regardless of whether the patient remains in the hospital for additional days. Thus hospital administration encourages expedited discharge to allow for a new patient to be admitted into the hospital to reduce unnecessary inpatient expenditure (Holliman, Dziegielewski, and Datta 2001). On the other hand, changes in insurance reimbursement policies that penalize hospitals for patient readmission (Stone and Hoffman 2010) and fear of litigation of medical negligence encourage physicians to prolong hospital stays. Dilemmas of discharge also leave physicians caught between the demands of patients and management. Hospital managers pressure physicians to expedite discharge to improve hospital efficiency. However, increased patient consumerism has resulted in a patient population comfortable rejecting physicians’ decisions regarding patient care. With the presence of these countervailing financial and professional pressures, how do physicians appropriately handle the discharge of patients from the hospital?

Drawing from ethnographic and interview data, this article analyzes how physicians adopt strategies to achieve the hospital’s financial goal of expedited discharge. Successful discharge is contingent on physicians, patients and families, health insurance companies, and other relevant third parties reaching a consensus regarding the discharge plan. I focus specifically on physician management of resistant patients: patients and/or families who reject the physician’s proposed discharge plan. I situate this article within the sociological scholarship on professions, demonstrating that discharge management is an ideal site to examine how physicians respond to the regulations, constraints, and demands placed upon them within a healthcare system associated with increased managerialism (Correia 2013; Martin et al. 2015) and patient consumerism (Armstrong 2014; McKinlay and Marceau 2008). This study’s contribution is twofold. First, continued changes in U.S. healthcare policies and practices have led many to speculate about the experiences of physicians working in highly bureaucratized settings. This study provides interactional data that point to the specific professional challenges physicians encounter in the hospital. Second, this study also contributes to the extensive scholarship on “problematic patients” (e.g., “bouncebacks,” “frequent flyers,” “bed blockers”)—adding another category of patient to those associated with disrupting hospital discharge and patient turnover.

Background

Scholars have documented the overwhelmingly negative consequences for medical professional power due to the increased commodification and bureaucratization of healthcare delivery in the United States over the course of the twentieth century (Pescosolido 2013; Timmermans and Oh 2010). Using financial and legal incentives, third parties have been contributing to physicians’ decreasing autonomy, deskilling, and loss of cultural authority (Light 2000a), spurring concerns of the deprofessionalization (Haug 1988), proletarianization (McKinlay and Stoeckle 1988), and postprofessionalism (Kritzer 1999) of physicians. Organizational theorists have argued that hospital physicians, in particular, have experienced significant limitations to their autonomy and authority due to institutional rules and regulations that “exercise increasing control over physicians, altering their character by making them more formally rational and in turn, contributing to deprofessionalization” (Ritzer and Walczak 1988:4). The rise of healthcare managerialism has further contributed to concerns of decreased professional authority and autonomy and a reexamination of medical professionalism (Correia 2013; Martin et al. 2015).

Healthcare managerialism developed in the 1980s with a market logic driving efficiency and cost containment in the clinical setting (Scott et al. 2000). This entrepreneurial ethos (Learmonth 1997) became further self-evident as profit maximization became embedded in medical decision making. Managers became increasingly involved in care delivery (Beardwood et al. 1999), restructuring patient–physician interactions; they oversaw how physicians provided care to patients, impinging on physician decision making and privileging organizational needs above all else (Brown and McCartney 2000). Managers developed monitoring techniques to measure physician effectiveness and efficiency (Moffatt, Martin, and Timmons 2014), relying heavily on performance indicators and incident reports for evaluation at both individual and institutional levels (Exworthy et al. 2003; Scott et al. 2003; Waring and Currie 2009). Consequently, healthcare organizations and professionals are held accountable (Fisher et al. 2007) for the singular goal of constraining costs without compromising care (Casalino 2004; Shortell and Casalino 2008). Scholars have argued, however, that care delivery is inevitably compromised as greater accountability via managerial control has led to financial factors routinely driving healthcare decisions (Mechanic and McAlpine 2010). Healthcare is frequently rationed, with physicians expected to calculate costs when making care decisions (e.g., time spent with patients, financial implications of medical interventions; Mechanic 2006).

While expected to take on greater financial responsibilities, physicians are also faced with a highly informed and proactive patient, who has shed the passive patient role welcoming paternalistic care (Parsons 1951). This patient is both a by-product and an accelerant of consumerism in healthcare over the course of the twentieth and twenty-first centuries. In the clinical literature, such patients were labeled as “difficult” due to unrealistic expectations that led to deep dissatisfaction with care (DiMatteo, Lepper, and Croghan 2000; Hahn et al. 1994). Social scientists also evaluated the transitions in patient identity, with patients characterized as “well informed,” “demanding,” and “experts” (Armstrong 2014; Barker 2008). The ensuing patient–physician relationship revealed resistance to traditional care exchange, which assumed an inherent asymmetry of knowledge between patient and physician (Parsons 1951).

Growing distrust of physicians due to reports of corruption, negligence, and malpractice (Gray 1997; Haug and Lavin 1983; Reeder 1972) further hastened patient expertise (Hibbard and Weeks 1987; Winnick 2005). The widespread use of the Internet to research, treat, and share knowledge (Burrows et al. 2000; Lupton 2014; McKinlay and Marceau 2008); the rise of the pharmaceutical industry and direct-to-consumer advertising (Barker and Vasquez Guzman 2015); and the growth of nontraditional sources of treatment (Hartley 2002; Winnick 2005) became valuable resources and alternative options that encouraged patients to navigate their own healthcare. With easily accessible medical knowledge, patients increasingly enter medical encounters knowing a great deal about their condition and demand specific treatments (McKinlay and Marceau 2008). In addition, in an era focused on patient-centered care delivery, patient satisfaction has become a critical component of physician and hospital evaluations (Epstein et al. 2010; Manary et al. 2013). Therefore it is unsurprising that physicians often cave to patient or parental expectations leading to unnecessary prescriptions and treatments (Lewin 2013; Mangione-Smith et al. 1999).

Scholars have found that shared medical decision making with patients and families has become one venue through which healthcare professionals can further ensure patient satisfaction and protect against litigation, a fear widely held among U.S. physicians given the nation’s reputation for having a deeply litigious healthcare system (Mohr 2000). Patient satisfaction and physician trust have been positively correlated with physicians forgoing paternalistic approaches to care delivery, promoting effective communication by keeping patients and families informed, and including them in the decision-making process (Bernabeo and Holmboe 2013; Mast, Hall, and Roter 2008; Roter and Hall 2006; Street et al. 2009). Even in incidents of harm, rather than the incident itself, patients’ and families’ perceptions of inadequate and ineffective communication were stronger predictors of legal recourse (Ocloo 2010); patients and families took legal action when questions were unanswered and events lacked transparency (e.g., closing of ranks; Allsop, Jones, and Baggott 2004).

While there are advantages for physicians to foster shared medical decision making, the inclusion of patients and family members can also complicate the decision-making process. Patients, families, and physicians draw from inherently different forms of knowledge (Foucault 1977), which can lead to disagreements. Physicians defer to their professional expertise—relying on intellectual knowledge to formulate care decisions. Patients and families, on the other hand, often draw on personal knowledge and experience to navigate healthcare decisions; they negotiate decisions pertaining to events that are often unfamiliar, unanticipated, or unknown amid emotions of fear and uncertainty (Epstein and Peters 2009; Lichtenstein and Slovic 2006). Consequently, physicians may adopt paternalistic approaches to care and routinely dismiss patients’ and family members’ preferences as uninformed (Quill, Arnold, and Back 2009). In response to inadequate communication, patients and families depend on actions rather than discussion to voice their opinions and concerns (Epstein and Gramling 2013).

An increasingly patient-centered care delivery model, compounded by changes in patient behaviors and the rise of healthcare managerialism, has undeniably influenced how physicians interact with patients and practice medicine. What remains unclear, however, is how physicians respond to the regulations and demands placed upon them in the inpatient setting. I argue that discharge management of resistant patients becomes a critical site to explore this question. Drawing from the sociological literature on professions, managerialism, and consumerism, I analyze how physicians manage hospital discharge decisions while caught between the conflicting demands of patients and administration.

Data and Methods

This article draws from data collected from September 2010 to September 2013 for a multiyear ethnographic project (September 2010 to August 2015) that took place on the internal medicine (IM) service at Pacific Medical Center (PMC), a teaching hospital located in the western United States. IM is a medical specialty dedicated to the prevention and treatment of adult diseases and conditions. It is the largest and most general service at PMC, with IM physicians overseeing patients with numerous comorbidities who often require complex medical care and prolonged hospital stays.

From September 2010 to September 2013, I shadowed IM teams, which were composed of an attending physician, senior resident, two interns, and two medical students.¹ I observed these teams during their daily morning rounds on the hospital wards, which took place Monday through Friday and ranged in length from approximately two to four hours. During rounds, trainees would present on patients currently on the service. The team would then discuss the patient case and determine future treatment plans. After each presentation, the team would visit with the patient, though occasionally the attending would forgo patient visits to expedite rounds. Each week I would round with a team for three to five days.²

I also sporadically attended afternoon interdisciplinary rounds with the attending physician and resident.³ These rounds brought together the attending physician, resident, case manager, and other relevant professionals involved in patient care. Approximately 30 minutes in length, afternoon rounds consisted of the attending physician or resident presenting “one-liners” on each patient—a brief summary of the issues discussed in detail during morning rounds. In particular, they identified “red flag” patients—individuals who were difficult to discharge due to financial and social issues. During both morning and afternoon rounds, I jotted notes, which were then elaborated into full field notes within 24 hours of being in the field. After the first full year of fieldwork, I would leave the wards for approximately four weeks every three months to analyze the data.

In addition, I attended monthly IM hospitalist meetings from February 2012 to February 2013. These meetings, which ranged from 30 minutes to one hour, were dedicated to discussions on various aspects of care delivery and residency education. I also conducted semistructured interviews with 40 IM attending physicians. Interviews were focused on physicians’ general perceptions of financial issues in care delivery, the consultation process, and hospital discharge. Interviews lasted 20 minutes to two hours and were audio-recorded and transcribed. Institutional review board (IRB) approval from the University of California, Los Angeles was granted to conduct this research (IRB No. 11-001316). For further information on methods, please see Oh (2014).

Data analysis consisted of adopting an abductive analytical approach to my data (Timmermans and Tavory 2012). I first coded all field notes and transcribed interviews with a vast range of existing sociological theories in mind. I selected the most relevant theories and concepts that emerged from my data and conducted additional rounds of focused coding on these themes (Emerson, Fretz, and Shaw 1995). I then wrote extensive integrative memos, analyzing and incorporating relevant sociological scholarship (Emerson et al. 1995); these memos went through multiple revisions through deeper engagement with key theoretical concepts. All names of institutions are pseudonyms. Individuals are differentiated by “H[number]” in interview excerpts; the H refers to hospitalist and the number refers to the order in which they were interviewed.

Results

Throughput on the IM service at PMC refers to turning beds over—preferably before noon—so that a new patient can be admitted to the hospital. One attending explained the process as follows:

All medical centers are under pressure to save money and to rein in costs. So you have the situation where you are in an environment where you’re teaching trainees and you want to be thorough and you want to encourage them to examine the patients and you want them to in essence rule in and rule out their hypotheses and follow the patient through time while they’re in the hospital. At the same time, you have this pressure to get the patients in and out as quickly as possible because our emergency rooms are filling up and there is a bed crunch . . . . [So] throughput is something I never heard of until maybe three or four years ago . . . and [it] is the . . . pressure to . . . open up beds for patients [or paying customers] that are coming through. So [when] you know somebody can continue their workup as an outpatient, you know you want to discharge them as soon as possible. And not only discharge them but discharge them before 11 AM or noon so that you can turn the room around and bring in the next patient. (H3 interview, October 14, 2011)

As evidenced in the physician’s words, PMC’s hospital administration has zeroed in on expediting patient discharge to maximize utilization while minimizing unnecessary healthcare spending in the hospital.

While expedited discharges are the collective goal of administrators, physicians, and other healthcare professionals on a patient’s team, delays of discharge inevitably occur. PMC physicians refer to patients who unnecessarily remain in the hospital as “rocks.” Some patients become rocks due to organizational factors: inability to transport patients out of the hospital, unavailable beds at skilled nursing facilities, and delays in procuring home healthcare are just some examples of organizational barriers to discharge. Others become rocks when consensus regarding a discharge date cannot be reached among healthcare professionals covering a single patient; divergent opinions regarding patient discharge among consultants are common as some argue for continued inpatient treatment and monitoring. In other instances, patients or family members disagree with the physician’s discharge plan, claiming that the patient should remain in the hospital. In this article, I focus on this last set of patients because they exemplify how patient consumerism can be deployed against professional interests. I refer to this group as “resistant patients.”

Finding and Moving Resistant Patients

Resistant patients are a deep source of frustration to physicians who ascertain that there is no medical or organizational reason for the patient to remain hospitalized. These frustrations are further exacerbated by the fact that PMC physicians must manage at least one such patient and/or family on a weekly basis on the hospital wards.⁴ These patients frequently require a great deal of time, attention, and emotional support. One attending physician who had completed her residency three months prior to her interview voiced her frustrations dealing with these patients during her residency: “You know the stress of residency can make you irritated and you think, ugh, I have one more [unnecessary] person to round on. It’s one more patient to have to deal with” (H33 interview, September 19, 2012).

Others have stated with exasperation that these patients are utilizing limited resources in the hospital; each patient who unnecessarily occupies a bed prevents someone who truly needs the bed from being admitted to the hospital. Accordingly, discharging resistant patients as soon as possible is a collective goal for the medical team. The first task to achieve this goal is to identify whether a patient is resistant; this is commonly done by “testing” the patient. The following data excerpt demonstrates how the team tests whether a patient, initially hospitalized with severe colon impaction and gastrointestinal problems, does not want to leave the hospital:

After physically examining the patient, the resident told her that she probably could go home today. The patient responded that she did not want to go home today because she was too weak. The resident and attending agreed with the patient, stating it would be ok, “but then you have to go tomorrow.” The resident then asked, “Would you want to go to a rehab facility?” The patient vehemently disagreed, stating she had been at a rehab previously and it had been abusive and she did not want to go back. The attending then asked if she had any help at home. The patient stated that she had her daughter. The attending asked if her daughter was “enough [help]” and she responded, “Yes, she is.” The physicians concluded the examination and told the patient they would check in on her later this afternoon. We then left the room. The attending said, “OK it is fine for her to stay today, but tomorrow before noon she needs to be discharged even if she does not want to go.” The attending stated that since the team told her that she will be discharged tomorrow, if she had “a new complaint in the morning” then they would know that she was just trying to stay longer. The attending said that her pain may be real but it may also be because she wants (to stay here) since there is more help at the hospital [than at home].

This example portrays a baiting strategy—where the physicians disclose a discharge date to test the patient to see if a new vague symptom or problem is reported the following day.

Other resistant patients are identified through word of mouth. While attending physicians rotate every 5 to 14 days on each team, house staff remain on the same team for 28 days. Subsequently, whereas a patient may be new to an attending physician, house staff may already have experienced difficulties discharging the patient in the previous week(s). Thus, house staff warn colleagues and superiors of resistant patients.

Once resistant patients have been identified, physicians adopt strategies to quickly discharge these patients. Strategies can be differentiated into two basic categories: marshaling medical knowledge and capitalizing on the presence of third parties. Physicians marshal medical knowledge to explain the health risks to patients who unnecessarily remain in the hospital. The physician presents medical data, revealing all necessary care was administered and the patient’s acute condition was managed. The physician then proceeds to review the health risks associated with remaining in the hospital. One attending physician discussed her approach: “I go over the risks of being in the hospital for infection, clots, a fall, and so forth. I explain what has been done thus far. I go over their concerns” (H17 interview, January 19, 2012). Another physician emphasized the importance of revealing the dangers of being in a hospital to patients:

The hospital—it’s a dangerous place to be in if you don’t need to be here. So I try to remind them . . . of the risks of staying in the hospital—like getting an infection or having some sort of medical error—a nurse could accidentally come into the room and give you a medication by mistake. I just try to tell them that there are many reasons to be in the hospital, but if you don’t need to be in the hospital—there are risks also associated with being in the hospital. So I try to tell them that. I try to come up with a good plan for them going home or wherever they are going to go so that they feel more comfortable with the plan. (H14 interview, January 13, 2012)

All attending physicians interviewed reflected these sentiments; they made it clear to the patient that their discharge decisions were motivated by consideration of patient’s health and well-being.

In contrast, when physicians capitalize on the presence of third parties, they deflect responsibility of discharge decisions to health insurance companies. Physicians explain that remaining in the hospital will leave patients financially accountable due to insurance restrictions. Physicians blame the pending discharge on the insurance company’s denial of coverage, shifting discharge decision-making power away from physicians. One physician explained the process as follows:

And then there are . . . people that really can’t tell you why [they want to stay] . . . They just say, “Well I just want to stay one more day.” . . . To those patients you just have to be very clear that you know that when they’re ready to go they really need to go. [Tell them] that there’s no medical reason to keep them here. We often will tell them too if their insurance doesn’t find an acute medical need for hospitalization that they could end up with the bill because we [the hospital] won’t get paid. That often is very motivating . . . for people. (H13 interview, January 13, 2012)

This commonly used strategy points to the authority of health insurance companies in determining lengths of hospital stay as well as the potential financial repercussions to patients for prolonged stays.

In some instances, physicians present these financial issues as private information that the physician is disclosing to the patient. In the following excerpt, the physician explains that while he discusses finances, he tries to broach the subject as an ally to patients rather than merely stating that the patient will be responsible for all healthcare costs:

Sometimes they feel like, “You guys are just a business, you don’t care about me, you’re just doing this because of the money.” In those cases what I will do is I’ll often go in and say, “I just want you guys to know for full disclosure—there’s a very good chance that any day after today is not going to be covered [by your health insurance company].” (H1 interview, March 15, 2011)

These final two examples demonstrate physicians’ attempts to align with the patient, placing the decision to discharge the patient squarely on the financial assessments of third parties.

Resisting Discharge

Even with such strategies in place, discharging patients is not a unidirectional process with physicians and hospital administrators wielding the power to move patients from the hospital. Patients and families find various ways to prevent or delay a hospital discharge. There is only one official strategy to delay discharge from the hospital: patients and family members can legally appeal the discharge. Many insurance plans, such as Medicare, allow for formal contestation of a discharge decision. The patient is held in the hospital for a minimum of 48 to 72 hours while the insurance company considers the request. If the insurance company agrees with the appeal, the patient remains in the hospital; however, if the insurer agrees with the physician, the patient must leave the hospital immediately. Patients and family members often appeal discharge decisions without necessarily speaking with physicians; physicians are typically alerted by nurses and case managers during morning rounds that an appeal has been filed.

All other strategies to prevent discharge are informal in nature. Similar to physicians marshaling medical knowledge to justify hospital discharges, patients and family members also marshal medical knowledge to prove that the patient’s stay is medically necessary. Common explanations include either noting a new symptom has manifested (e.g., the patient vomited, had diarrhea, spiked a fever, etc.) or by arguing with observational data against a physician’s diagnostic or prognostic decision. When reporting symptoms, the patient or family member frequently explains that these events occurred overnight, when physicians and nurses were unavailable. In the case of vomit or diarrhea, once an episode has been reported, physicians and nurses request that future episodes be preserved for medical assessment. Patients and family members, however, are frequently unable to provide physical evidence, stating that they “accidentally flushed the materials” or “needed to flush the materials” for others’ bathroom use. Nonetheless, even without “physical evidence,” because these symptoms are medically possible in light of the patient’s condition, physicians find it difficult to reject these reported symptoms.

Family members also present “medical evidence” to convince physicians of an improper medical assessment. The following excerpt depicts family members challenging the physician’s medical evaluation and discharge plan:

The family called the physician to the room because they had observed a change in the patient’s condition that they believed justified further stay in the hospital. Upon physical assessment, the attending said that the patient never tracked with her eyes or squeezed her fingers. The family however was convinced that the patient was lucid at times and told the physician this was the case. The physician called for the nurse tending to the patient. The nurse arrived outside of the patient room and told the team that indeed the patient was lucid but she never experienced any alertness [from the patient]. The attending explained that she was not lucid and that there was no neurological activity from her for five days. The physician stated that the family’s belief that the patient was lucid however was delaying potential discharge because they refused to agree with the proposed discharge plan. The attending told the team that the only solution was for him to bring the family members to her bedside and ask them to show him what they believe indicates that she is responsive. In order to prove to the family that she was unresponsive, the attending also asked for the intern to request a brain-imaging scan to show the family that she had an altered mental status. (Field notes, August 11, 2011)

The family’s interpretation of a physical change in the patient leads to conclusions that defy the physician’s assessment. The attending’s solution is to teach the family members with medical evidence that his evaluation is correct. Nonetheless, regardless of who is “right,” when met with medical concerns from the patient or family, physicians routinely question their discharge decision and prolong the patient’s stay to ensure that there have been no significant changes in condition.

Patients and family members also attempt to delay discharge by capitalizing on the presence of various parties in care delivery. This strategy takes on multiple forms. Patients and family members delay discharge plans by failing to engage in conversations with physicians and other team members, stymieing plans to move forward. For instance, family members are unavailable for physician-coordinated meetings or fail to return phone calls regarding the patient’s status.

Family members may also delay visits to placement centers, such as skilled nursing facilities and nursing homes. For patients who cannot simply be discharged home, the case manager determines all eligible facilities a patient can be transferred to; eligibility is determined by the patient’s health insurance plan and bed availability. Once a list of facilities is generated, family members may visit each facility to make their decision. When they fail to visit these centers in a timely fashion, discharge becomes delayed, for without the family’s consent, the patient cannot be transferred out of the hospital. In some cases, family members refuse all proposed centers; discharge is halted as the physicians and case manager must find alternative housing solutions for the patient.

Furthermore, patients and family members may play different parties off of one another. One patient’s family was debating between requesting a thoracentesis, an invasive procedure to remove air and fluid from the pleural space, and transferring the patient to hospice care. Hospice care would result in the patient’s discharge from the hospital. The physicians believed the procedure was unnecessary and told the family that the procedure should not be considered. The patient’s children seemed to agree that a thoracentesis should not be performed. In order to facilitate the transition to hospice, the General Hospice Center (GHC) was working with the family and case manager to establish all necessary medical equipment in the patient’s home—at which point the patient could be discharged:

During rounds, the resident said he had to clarify if the family had spoken with General Hospice Center and put in a request for everything. The case manager interjected and explained to the team that there were unfortunately more issues with the family again. She had spoken with her contact person over at GHC, recounting to the team that she had a specific person she was corresponding with to help expedite this process. “The family had told me [the case manager] that the paperwork was at home and then told the Center when they offered to come over to the house last night that the paperwork was at the hospital.” (Field notes, April 12, 2012)

This example portrays how family members provide discrete information to different parties, delaying care delivery without explicitly refusing the physicians’ recommendations.

Similarly, patients and family members may also play physicians off of one another, arguing that one physician said the patient could remain in the hospital. This, however, may not reflect a patient strategy to delay discharge but rather is indicative of having numerous consultants covering a single patient. Specialists may approach care in contradictory ways—leading to divergent treatment and discharge plans. IM physicians try to prevent this conflict and delay of discharge by meeting with consultants and agreeing on a single care plan before anyone speaks with the patient and family.

Holding “Rocks”

While expedited hospital discharges are the goal, in some cases, physicians extend a patient’s hospital stay. They ignore the hospital’s financial objective and exercise agency in when they discharge patients. The physician allies with the patient and grants the patient additional days, disregarding the financial costs incurred by the hospital. The majority of physicians offered an extra day rather than embroiling themselves in a battle to discharge patients on a given day. Some physicians draw from medical reasoning in order to justify the extended stay. One attending physician explained the factor that typically determined his likelihood of holding a patient:

There are some patients that are so sick [that] you know they are coming back to the hospital . . . two weeks later . . . a month later. And you know that if you give them an extra day and say, “OK let’s compromise. I’m going to give your wife an extra day here. We’ll see how much oxygen she needs tomorrow, let’s give her some more physical therapy, set her up for outpatient pulmonary rehab.” . . . You kind of make some compromises [when] you know that they [will] come back two weeks later. [And then they will say], “Oh doctor—good to see you again, thanks for trying to help us but it didn’t really work.” Whereas if you kick them out one day earlier and say, “No, get out of here—you have no acute medical needs, your insurance company keeps calling me and says we can’t take care of you anymore.” Then they come back two weeks later and they’re gonna say, “I told that doctor she wasn’t ready to go and now she’s back and she might die because she’s even more hypoxemic and it’s all his fault.” (H2 interview, October 12, 2011)

The patient’s condition strongly influences physicians’ discharge decision making. Very sick patients who inevitably must return to the hospital are granted an extra day to avoid conflicts down the road. Physicians justify these decisions as acting not only in the patient’s best interest but also in preventing future patient–physician conflicts.

Age is another important component in determining the decision to hold patients. Elderly patients have greater potential for unexpected adverse health outcomes and thus may be held for a condition when a younger patient would be discharged. For example, an 87-year-old woman had fallen in her home and fractured her arm. She required outpatient surgery yet remained in the hospital for “pain control.” Her family had complained that she should not leave the hospital with limited mobility and high pain, and the physicians agreed:

The attending explained during rounds that typically with arm fractures there is not much of a mortality difference so they do not keep the patient in the hospital. “They sometimes put a cast on it, re-evaluate it, and then fix it. Sometimes they won’t even fix it—especially if the patient is older and debilitated.” In cases of hip fractures, the patient stays inpatient. The family was uncomfortable with the arm fracture and the attending agreed. In order to justify her stay to the insurance company, the notation on the patient’s medical record was changed to indicate that the patient was on pain control through IV medications. (Field notes, March 5, 2012)

The physician chose to keep the patient hospitalized because her age increased the likelihood of further injury even though the arm fracture itself was a “nonurgent” matter.

As evidenced in the previous example, another conventional strategy is for physicians to change notation in the medical record or alter treatment plans to bypass financial restrictions and justify a prolonged hospital stay. For example, a patient had cellulitis in his leg that was not improving. However, the case manager was notified that the patient’s insurance company expected the patient to be discharged from the hospital:

The attending told the team that this decision was problematic since his leg was not getting better. She stated she would not feel comfortable discharging him with his [current] leg [condition] and no one to monitor [it]. She told the intern to change the orders on the patient’s medical record and to prescribe an IV medication, which would ensure that he could stay in the hospital without interference from health insurance companies. (Field notes, April 7, 2011)

In such cases, physicians are able to avoid interference from third parties when making care decisions for their patients.

While physicians may be acting in the best medical interest of patients, there is one significant professional incentive in place for physicians to prolong hospital stays: risk of litigation. As the physician on record, and the individual legally responsible for the patient’s care, the attending physician must consider litigious patients responding to perceived inadequate care provision—motivating physicians to tread carefully around discharge decisions. One physician explained:

[Patients argue], “I’m not better . . . if I don’t get better . . . and I get readmitted [after being discharged] I’m going to—not sue but something along those lines.” And if that’s the case then you need to get legal involved. (H7 interview, October 28, 2011)

With even perceived threats of litigation, physicians become cautious and avoid immediate discharge. One physician extended a patient’s stay for four days after the patient’s family involved the legal department. In another case, physicians were hesitant to push a discharge because the patient’s brother was a medical malpractice lawyer and the patient’s sister-in-law was a registered nurse. These examples reveal how discharge decision making can lack uniformity as physicians prolong the stay of certain patients, often at the expense of the hospital. These decisions are largely driven by professional concerns, such as litigation, that encourage physicians to occasionally ignore the hospital’s financial goal of expedited discharge.

Discussion

This paper reveals the complexities of hospital discharge as physicians encounter opposing financial incentives and professional challenges when making discharge decisions. On the one hand, prolonged unnecessary hospital stays are financially problematic, which physicians are reminded of daily by case managers. On the other hand, widespread healthcare consumerism has led to increasingly proactive and well-informed patients who challenge the efficacy of physicians’ discharge decisions. Patients’ and families’ medical claims leave physicians faced with the prospect of an immediate hospital readmission and a financial penalty incurred by the hospital due to a premature discharge. In addition, adverse health outcomes and perceptions of medical neglect increase the risk of litigation against the physician and the hospital. Consequently, resistant patients and families force physicians to grapple with financial, professional, and legal stakes when making discharge decisions.

Resistant patients pose a direct obstacle to discharge, because unlike routine care decisions (e.g., running morning labs), physicians cannot simply make a unilateral discharge decision. Patients and families must comply with the decision in order for a successful discharge to take place. The predicament of physicians can be paralleled to those met by professionals within client-centered workplaces, where professional–client relationships are not always voluntary and clients are more likely to question or refuse professional expertise and authority (e.g., organizations that undergo external audit, assessment, and/or evaluation research; Huising 2015). Scholars have identified that in these settings, how information is presented largely affects whether clients adhere to professionals’ recommendations (Abbott 1998; Huising 2015; Van Maanen and Barley 1984). With the increased reliance on patient satisfaction as a metric to determine hospital and physician quality and subsequent compensation (Manary et al. 2013), patients’ demands cannot be dismissed as inconsequential. Unsurprisingly, physicians carefully craft discharge conversations in hopes to elicit patient compliance.

Physician-led discharge discussions emphasize patient welfare and safety as the justification for discharge. Physicians specifically avoid any mention of finances or deflect financial considerations to third parties—primarily health insurance companies—in the context of hospital discharge. Emphasizing patient welfare and minimizing financial considerations in the decision-making process foster trust—counteracting concerns of physicians’ financial motives (Mechanic 1996; Ozawa and Sripad 2013). Trust is especially important in collaborative tasks, as clients are more likely to defer to professional recommendations when there is trust in the professional’s expertise (Freidson 1970) and a sentiment that the client’s personal interests have been adequately addressed (Huising 2015). These techniques reflect the reliance on effective healthcare communication via shared decision making (Roter and Hall 2006) to promote patient satisfaction and deter litigation. The health communication literature finds that patients’ and families’ perceptions of meaningful involvement in medical decision making translates to greater trust and satisfaction in the care received in spite of health outcome (Allsop et al. 2004; Mast et al. 2008; Ocloo 2010; Street et al. 2009). Concerns of litigation further incentivize physicians to ensure patient satisfaction (Epstein et al. 2010; Milewa, Valentine, and Calnan 1998) by yielding to their requests (Kravitz et al. 2005; Lewin 2013).

Even with such strategies in place, patients and families exercise agency and reject discharge decisions. On the one hand, disagreements among patients and physicians reflect how medical uncertainty leads to a high level of interpretative ambiguity regarding discharge decisions. More importantly, however, these disagreements bring to the forefront the different forms of knowledge (Foucault 1977) and “expertise” held by patients and physicians. It is unsurprising that disagreements emerge, as both parties privilege different forms of information when making discharge assessments (e.g., physicians may turn to past cases and/or evidence-based medicine, while patients draw from physical symptoms and past personal experiences). These forms of “knowledge,” however, are entrenched in differentials of power and status inherent to the patient–physician relationship—leaving patients with an uphill battle to be effectively heard. Many patients and family members may subsequently relinquish disagreements of discharge, resulting in the common occurrence of “routine” discharges.

Resistant patients and family members consequently emerge as a professional challenge for physicians, as they actively contest physicians’ discharge decisions by directly voicing their concerns or by relying on actions to reveal their discomfort with discharge. These strategies—particularly the nonverbal cues—resonate with the literature on medical communication, which has extensively examined how patients (re)gain power in the medical decision-making process—and the patient–physician relationship—through actions rather than through speech (Koenig 2011; Roter and Hall 2006). While these data cannot explain resistant patients’ true motivations to prolong a hospital stay, we can make some inferences from the extant literature.

First, as mentioned previously, patients and family members draw from different knowledge banks (Foucault 1977) when determining discharge decisions; their interpretation of physical symptoms and severity of condition plays an integral role in their acceptance or rejection of a discharge recommendation. Patients and families may foresee specific concerns that physicians initially disregard—as evidenced by the fact that physicians prolong certain patients’ hospital stays. Second, the desire to delay discharge may stem from fear of leaving the medical personnel and resources available in the hospital after a loved one suffers a serious health episode (Epstein and Peters 2009; Lichtenstein and Slovic 2006). Moreover, family members may have difficulty facing a patient’s prognosis (e.g., transitioning to hospice care; Kaufman 2005) and believe that additional treatment may reverse the outcome. Furthermore, in spite of increasingly informed patients (Armstrong 2014), there remains an inherent power dynamic that persists in the patient–physician relationship—frequently leaving patients and family members feeling powerless and unheard, leading them to question and defy physicians’ motives (Huising 2015). Last, discharge disagreements may also reflect the nature of healthcare exchange—consumers will never have complete information (Light 2000b); patients and families may expect full recovery prior to leaving the hospital, even when this is medically impossible.

Hospital Discharge: A Profession’s Challenges

Through interactions with resistant patients, the management of hospital discharge exposes physicians to a variety of contemporary professional dilemmas—many of which relate to the new professional roles and expectations of physicians working in bureaucratized institutions (Briscoe 2007; Noordegraaf 2011). Scholars have examined the varied ways in which the professional authority and jurisdiction of physicians become challenged in increasingly complex healthcare settings. While administration regularly reminds physicians of the financial stakes associated with hospital discharge, this study reveals that patients and families play a far more significant role in challenging physicians’ professional authority and autonomy in the medical decision-making process.

The professions literature has comprehensively argued that authority and autonomy are defining traits that distinguish professionals from other occupational groups—the underlying assumption being that professionals have full control over their work (Abbott 1988; Freidson 1970). This study demonstrates how patients and family members regularly challenge physicians’ authority through the rejection of discharge plans. Consequently, physicians encounter the distinction between having legal authority in a particular workplace versus having clients and coworkers actually adhere to one’s decisions (Huising 2015); professional authority does not necessarily produce action within a highly bureaucratized and consumer-driven healthcare system. Patients’ increased agency has translated to patients and family members making demands, challenging physicians, and defying recommendations (Armstrong 2014; Barker 2008). Subsequently, the “professional authority” of physicians is dependent on the interactions between patients and physicians—it becomes meaningful only if physicians are able to persuade patients to defer to physicians’ discharge plans.

The inability of physicians to successfully discharge resistant patients from the hospital represents physicians’ ineffectiveness in accomplishing a responsibility that has both financial and professional implications. At a fundamental level, patients must leave the hospital for new patients to be admitted; this turnover is required for patients to receive care. There are also financial repercussions for the hospital if patients remain without any acute medical needs. Reflective of the increased monitoring and evaluation of healthcare professionals within organizations (Exworthy et al. 2003; Waring and Currie 2009), physicians are assessed on their abilities to manage “systems issues”—which include hospital discharge and patient turnover. Beyond institutional priorities, there are professional incentives for efficient discharge as well. The need to address dilemmas of hospital discharge prohibits physicians from practicing “actual” medicine; days become filled with tasks far removed from their expertise (Abbott 1981; Abbott 1988). Furthermore, the structuring of care delivery in academic medical centers and the extensive workloads placed on house staff (Mizrahi 1986; Szymczak and Bosk 2012) incentivize trainees to quickly “get rid” of patients. Hospital discharge thus becomes a site of convergence for various financial and professional concerns that physicians must navigate while making discharge decisions.

This study, on the one hand, reveals the countervailing financial and professional incentives steeped in hospital discharge and, on the other hand, demonstrates that “actionable” professional authority is relationally produced. Resistant patients and family members emerge as a prominent challenge to professional authority. In response, physicians reposition themselves—drawing on strategies to align with patients—in order to effectively discharge patients from the hospital. Compared to patients and family members, interference from hospital administration is ostensibly minimal; in fact, physicians make discharge decisions that directly contradict the hospital’s expedited discharge policy, reflecting a decoupling between the rules of the institution and the practices of the actors (Meyer and Rowan 1977). While some have argued of the deprofessionalization of hospital physicians (Ritzer and Walczak 1988), the dual authority structure of hospitals (Scott 1983) affords physicians a great deal of agency and considerable power in shaping organizational behavior regardless of organizational rules and regulations.

Hospital administrators are often aware of physicians’ decisions to extend patients’ stays and do not intervene. Tolerance of physicians’ discharge practices resonates with the presence of organizational gray zones, where the independence and identities of workers can be created and sustained (Anteby 2008). Physicians may not only capitalize on the presence of gray zones but may help create them as their social position within the hospital increases their ability to modify or defy institutional objectives (Battilana 2011); in turn, these gray zones allow physicians to adopt strategies—that contradict the organization’s financial objectives—to persuade patients to comply with their discharge decisions. Physicians, however, are not the only ones taking advantage of gray zones—patients’ and families’ successful contestation of discharge decisions also demonstrates the malleability of institutional rules related to hospital discharge.

Footnotes

Acknowledgements

I am deeply grateful to the research participants. I give special thanks to Stefan Timmermans, who provided extensive feedback on multiple iterations of this paper. I also thank José Escarce, Hannah Landecker, Gabriel Rossman, and Edward Walker for comments on earlier drafts.

Notes

Author Biography

Hyeyoung Oh is an assistant professor in the Department of Sociology at the City University of New York–Lehman College. Her research interests include the sociology of health and illness, race and ethnicity, organization studies, and ethnography. Her work has been published in Sociology of Health and Illness, Qualitative Health Research, Journal of Health and Social Behavior, and the American Medical Association’s Virtual Mentor.

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