Sorting patients out : the non-clinical evaluation of clientele in Romanian hospitals

Abstract

The non-clinical evaluation of the clientele is well-documented in medical settings. Staff members categorize patients as good or bad, worthy or unworthy, socially viable or not, and considerations of this sort often translate into unequal access to healthcare. Heretofore, most studies have focused on the classification schemes devised by doctors and nurses to sort patients out, the grounds on which non-clinical judgment were made, and the ways in which decisions were accounted for. Another string of literature has examined hospital encounters through interactionist and ethnomethodological lenses and looked for the interactional accomplishment of activities. This thesis bridges the two traditions and approaches the non-clinical evaluation of patients as both categorization work and joint accomplishment. The study relies on 7 months of ethnographic research conducted in 2013 and 2014 in the emergency departments of two public hospitals in Romania. Data-collection consists primarily in observation of triage admission procedures and handling of the patients throughout their stay in the emergency ward, informal conversations and formal interviews with members of triage staff. The main argument is that triage staff categorizes would-be patients in terms of legitimacy of presentation, reasonableness of the visit, and social worth, but the initial categorization is amenable to negotiation during the admission interview. Classification schemes are informed by typification of appropriate emergency. Triage staff uses the temporal patterning of the presentations and the perceived characteristics of the clientele to distinguish between ‘real’ and ‘fake’ emergencies. All other things being equal, membership of categories regarded as low in terms of social worth (elderly, Roma, mentally ill, intoxicated, and ‘social case’) reduces the likelihood of being granted the status of real emergency. The admission interview represents an opportunity for patients to assert worth and claim favorable treatment, and for triage staff to justify their initial considerations. Therefore, often times the encounter takes the form of worth contests. Patients adopt hard- or soft-lines or a crescendo approach during the encounter to support their cause. The study makes three contributions to the scholarship on non-clinical evaluation of patients. First, it unveils the procedural basis of turning informal classifications into formal categorization as medical emergency at the triage. Second, it challenges the dominant representation of would-be patients as powerless and passive in triage encounters, and argues that this is a byproduct of the theoretical approach used in extant studies rather than an accurate reflection of empirical situations. Third, it shows that the practical outcomes of the non-clinical evaluation are contingent upon local arrangements of the triage work. In a larger sense, the study documents the practical accomplishment of inclusion and exclusion in healthcare settings, contributing to a better understanding of the power relations in post-socialist Romania.