“It can be challenging, it can be scary, it can be gratifying”: Obstetricians’ narratives of negotiating patient choice, clinical experience, and standards of care in decision-making

This paper examines obstetricians' perceptions of standards of care and patient-centered care in clinical decision-making in childbirth. Patient-centered care and standardization of medicine are two social movements that seek to change how physicians make clinical decisions. Sociologists question if these limit physician discretion and weaken their social power; the degree to which this occurs in everyday practice is up for debate. Of additional concern is how physicians deal with observed tensions between these ideals. These questions are answered through in-depth interviews with 50 self-selected obstetricians from Massachusetts, Louisiana, and Vermont collected between 2013 and 2015. Interview data was analyzed using a grounded theory and template approach. The author problematizes obstetricians' attitudes about standards of care and shared decision-making, mechanisms that encourage or discourage these approaches to decision-making, and how obstetricians negotiate tensions between patient choice, clinical experience, and standards. The key findings are that most obstetricians feel they have the authority to interpret the appropriateness of standards and patient choice on a case-by-case basis. They feel empowered and/or constrained by pressures to practice patient-centered care and standards depending upon their style of practice and the organizational context. Following standards of care is encouraged through organizational mechanisms such as pressure from colleagues, malpractice threat, hospital policy, and payer restrictions. Practicing shared decision-making is challenged when the patient wants something that violates the physician's clinical experience and/or standards of care. When obstetricians prioritize patient choice over experience and/or standards this is done for moral reasons, less so because of organizational pressures. These findings have implications for theorizing the social status of medical professionals, understanding how physicians deal with tensions between standardized and individualized ideals in medicine, and illuminating the way obstetricians interpret power in the physician-patient relationship.