From Practice Guidelines to Clinical Outcomes Governance: Surveillance and Discipline in the Fertility Medicine Field

• In Event: 30210 - Shifting Contexts of Clinical Work

Abstract

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 made decisions, I find that they often make decisions about how many embryos to transfer in anticipation of reporting and displaying their outcome statistics. In this article, I refer to this mode of authority dictating their 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 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.

Author

• Eliza Brown, University of California, Berkeley