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Outcomes Governance: Surveillance and Discipline in the Fertility Medicine Field
Medical sociologists have documented the shift in clinical decision-making from one depending on individual physicians’ professional judgment to one of fieldwide standardization and practice guidelines. Much of the evaluation of clinical decision-making, however, does not stem from determining if a provider followed guidelines, but rather based on the outcomes of their clinical decisions. In this article, I employ the critical case of the United States fertility field, in which fertility clinics are required to report the outcome of in vitro fertilization (IVF) cycles to the federal government. Specifically, I interrogate the field’s aim to lower the incidence of multiples, or twins, triplets, and more, as IVF birth outcome by lowering the number of embryos transferred back to patients’ uteruses at one time. Although changing practice guidelines influenced how fertility specialists and patients made decisions, I find that doctors often steered decisions about how many embryos patients could choose to transfer in anticipation of reporting and displaying their outcome statistics. In this article, I refer to this mode of authority dictating practices as clinical outcomes governance, or the surveillance and disciplining of clinicians according to their clinic’s aggregate outcomes as opposed to direct guidelines concerning which medical practice should be employed with individual patients. Through a multisite ethnography of three fertility clinics along with interviews with 28 fertility specialists and 79 fertility patients, I argue that clinical outcomes governance is key in influencing fertility providers to change their treatment recommendations for patients. The concept of clinical outcomes governance is especially useful for understanding why providers might counter the preferences of patient-consumers in a largely consumer-driven private medical market like fertility medicine. Clinical outcomes governance can help elucidate inducements to changes medical practices that go beyond professional standards across medical fields.
Preparing for journal submission
Field Guides: How Physicians Establish Medical Niches in Patient Consults
Sociological scholarship on fields focuses on how social actors frame their action in relation to others in the field. What has not been well-theorized is how actors narrate field dynamics to those who are not yet embedded in them. This is important because in many fields, particularly those in which distinctions between entities are not obvious to actors outside the field, recruitment of new actors is facilitated by mapping out the confines of the field. In this paper I introduce the concept of field guides, or organizational actors who orient unfamiliar consumers to the field to illustrate their organization’s status within it and emphasize the goods in which they rank high. This paper illustrates this argument through the strategic case of fertility clinics, a consumer medical field in which patient-consumers often struggle to perceive differences in quality of care. I show how fertility providers make organization-organization and organization-field comparisons to patient-consumers to illustrate their clinic’s position in the field as part of securing their business, and how these comparisons differ depending on if the organization is an incumbent or challenger in the field. The concept of field guides is a novel approach for bringing together interactional and field approaches, and underlines the importance of social learning through explicit guidance rather than unmitigated experience.
Preparing for journal submission
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