Keeping out and getting in: reframing emergency department gatekeeping as structural competence

Abstract

Sociologists have tended to frame medical gatekeeping as an exclusionary social practice, delineating how practitioners and clerical staff police the moral boundaries of medicine by keeping out patients who are categorized as ‘bad,’ ‘deviant,’ or otherwise problematic. Yet medical gatekeeping, understood more broadly, can include not only keeping patients out of particular clinical settings, but also redirecting them to alternative sources of care. In this article, I draw on qualitative analysis of audio-recorded patient-provider interactions in a United States emergency department (ED) to illustrate medical gatekeeping as a two-step process of, first, categorizing certain patient complaints as unsuitable for treatment within a particular setting, and second, diverting patients to alternative sites for care. I refer to these as the restrictive and facilitative components of medical gatekeeping to denote how each relates to patients’ access to care, recognizing that both components of medical gatekeeping are part of a coordinated organizational strategy for managing resource scarcity. By illustrating how ED providers reveal intimate knowledge of structural vulnerabilities in diverting socioeconomically disadvantaged patients with chronic back pain to clinical sites that are better equipped to provide care, I suggest that we rethink the emphasis on restrictive practices in sociological accounts of medical gatekeeping.

Reasonableness: legitimate reasons for illegitimate presentations at the ED

“…Carine Vassy's (: 629) identifies ‘an informal system of positive discrimination’ devised by staff members in a French ED to respond to the cultural and economic barriers faced by vulnerable members of the society in accessing primary health care. More recently, Mara Buchbinder () describes the ED gatekeeping at a US hospital in terms of structural competence.…”

“…Reasonableness also intersects only partially with the concept of structural competence (Metzl and Hansen , Metzl et al . ) adopted by Buchbinder (). Romanian triage nurses tend to avoid incorporating judgments about patients’ presumed social, economic, and cultural vulnerability in their gatekeeping practice.…”

“…To sum up, reasonableness appears to be the missing link between legitimacy and deservingness in the non‐clinical evaluation of users, attenuating their exclusionary consequences and addressing some pitfalls in the delivery of primary care in Romania. Thus, the assessment of reasonableness during the triage admission interviews illustrates the hitherto largely neglected ‘facilitative component of medical gatekeeping’ (Buchbinder : 1166). However, in Romanian EDs reasonableness does not apply to the most vulnerable members of the society, and is not consistent with the ideas of structural and cultural competence.…”

“…Building upon such findings and original empirical evidence on the handling of chronic back pain patients at the ED of a teaching hospital in the United States, Mara Buchbinder () made the case for a different approach of ED gatekeeping. The focus on the exclusionary dimension of gatekeeping led to a partial and distorted representation of the practice in the sociological literature.…”

“…Although unable themselves to provide service to those who do not meet the formal criteria of entitlement to emergency care, practitioners often equip them with the knowledge and practical resources that allow them to get treatment elsewhere. Buchbinder (: 1175) framed the supportive responses of doctors, residents, and nurses as examples of structural competence and called ‘for expanding the scope of sociological work on medical gatekeeping to include attention to how it may facilitate, as well as restrict, patients’ access to treatment’.…”