UCLA

With one of the highest health care expenditures in the world, phrases such as "a broken system" and "expensive medical waste" are commonly used to refer to the U.S. healthcare system. With numerous cost-cutting initiatives in place, what are the consequences for the medical profession as they provide care? My dissertation, a three-year ethnography of physicians on the Internal Medicine (IM) Service of a teaching hospital, examines how financial issues become salient for physicians in inpatient care delivery. Situating my work within medical sociology's socialization literature and the theory of professions, I reveal the emergence of a hidden curriculum of finances during residency training on the IM service. This curriculum exposes novice physicians to the financial dilemmas and pressures present in the current health care system. I focus on three key components of care delivery by which this curriculum emerges: the medical record, consultations, and discharge management. As trainees proceed through the curriculum, they learn valuable profession lessons: (1) limitations to physicians' autonomy via third parties; (2) conflicting financial pressures present in care delivery; (3) increased agency of patients; (4) the intra-professional status hierarchy of the medical profession; and (5) risk of litigation.

This study fills the gap in the medical sociology literature on the socialization process of becoming a physician - revealing the financial socialization of physicians. This study also demonstrates the resilience of physicians as they develop strategies to mitigate the professional challenges they encounter in the clinical setting. And lastly, this study offers some explanations regarding the inefficiencies plaguing the nation's medical system. The fact that the financial curriculum is hidden results in the routine deprioritization of finances in physicians' decision-making - the consequence is unnecessary medical workups and delays of care. With minimizing medical waste placed at the forefront of national cost-cutting conversations, this study reveals a few pathways to the generation of inefficiencies in the inpatient setting. The consequences of this deprioritization of finances however extend far beyond the financial ramifications for the hospital and broader health care system: patients' health and well-being are at stake as superfluous treatments expose them to avoidable physical and emotional risk.