title: The doctor-patient relationship as a toolkit for uncertain clinical decisions.
abstract: Medical uncertainty is a well-recognized problem in healthcare, yet how doctors make decisions in the face of uncertainty remains to be understood. This article draws on interdisciplinary literature on uncertainty and physician decision-making to examine a specific physician response to uncertainty: using the doctor-patient relationship as a toolkit. Additionally, I ask what happens to this process when the doctor-patient relationship becomes fragmented. I answer these questions by examining obstetrician-gynecologists' narratives regarding how they make decisions when faced with uncertainty in childbirth. Between 2013 and 2014, I performed 21 semi-structured interviews with obstetricians in the United States. Obstetricians were selected to maximize variation in relevant physician, hospital, and practice characteristics. I began with grounded theory and moved to analytical coding of themes in relation to relevant literature. My analysis renders it evident that some physicians use the doctor-patient relationship as a toolkit for dealing with uncertainty. I analyze how this process varies for physicians in different models of care by comparing doctors' experiences in models with continuous versus fragmented doctor-patient relationships. My key findings are that obstetricians in both models appealed to the ideal of patient-centered decision-making to cope with uncertain decisions, but in practice physicians in fragmented care faced a number of challenges to using the doctor-patient relationship as a toolkit for decision-making. These challenges led to additional uncertainties and in some cases to poor outcomes for doctors and/or patients; they also raised concerns about the reproduction of inequality. Thus organization of care delivery mitigates the efficacy of doctors' use of the doctor-patient relationship toolkit for uncertain decisions. These findings have implications for theorizing about decision-making under conditions of medical uncertainty, for understanding how the doctor-patient relationship and model of care affect physician decision-making, and for forming policy on the optimal structure of medical work.
authors.affiliation: Boston College, Sociology Department, 426 Mcguinn Hall, 140 Commonwealth Avenue, Chestnut Hill, MA, 02467-3807, USA. Electronic address: brownyj@bc.edu.
authors.forename: Lauren
authors.initials: L
authors.lastname: Diamond-Brown
mesh_terms: D001900:Boston; D003657:Decision Making; D006801:Humans; D009774:Obstetrics / Q000379:methods; D010817:Physician-Patient Relations; D010820:Physicians / Q000523:psychology*; D036301:Qualitative Research; D035502:Trust; D035501:Uncertainty
keywords: Decision-making; Doctor-patient relationship; Fragmented care; Interactive knowledge; Organization of care delivery; Patient-centered care; USA; Uncertainty