Managing indigent care: a case study of a safety-net emergency department

To examine how one safety-net emergency department (ED) managed problems associated with the provision of indigent care in everyday life.

Interview and observational data collected in County Hospital ED, a public teaching hospital in a California city, during 6 months of 1999.

The study used ethnographic methods to document and understand day-to-day routines and practices for providing indigent care in a safety-net facility.

One- to 2-hour semistructured interviews with a snowball sample of eight ED physicians were tape recorded, and fieldnotes were recorded in situ during 10-30 hours of participant observation per week in all areas of the ED. Data were coded to highlight themes of interest and to identify recurrent patterns of behavior.

In everyday life, providers at County ED relied on graduate medical education (GME) to manage two everyday problems, social use and tenuous financing, associated with the provision of indigent care. GME helped manage problematic social visits to time ED by defining them as interesting cases. GME helped with tenuous finances by creating a work culture that encouraged the provision of uncompensated work.

Safety-net facilities often face problems similar to those in County ED. Future research should assess the extent to which the everyday management of these problems in County ED resembles that in other safety-net facilities.