Switching Clinics: Patient Autonomy over the Course of Their Careers in Consumer Medicine

Patient autonomy, or the right to make decisions about medical care, is usually examined either within clinical encounters with medical providers or outside of clinics via social movements to transform care. These perspectives, however, may miss how patients exercise autonomy outside of clinical encounters while remaining in conventional care. Through in-depth interviews with 61 people who pursued fertility treatment in New York City, this article argues that one important way that people exert autonomy in consumer medicine is by switching clinics. This study finds that nearly half of participants switched clinics to reorient their patient careers that were not progressing satisfactorily, attempting to reset, redirect, and escalate them. This article emphasizes that patients exercise autonomy not just over treatment decisions but also over the direction and progress of patient careers themselves. This article suggests that patients’ disparate opportunities to elect to switch medical practices represents an inequity in consumer medicine.

. As the medical system transitioned away from the dominance of paternalistic physicians to patient-centered care (Conrad 2005), patient-consumers came to demand to be treated in particular ways (Timmermans and Oh 2010). Switching clinics, while not available to many patients, is at the core of consumer medicine. Patient-consumers do not just select care, they also change practices when their preferences are not met. Indeed, consumer medical systems are designed for some churn: With medical organizations specializing in niches of esteem and offering special amenities (Menchik 2021;Reich 2016;Young and Chen 2020), they not only advertise to new patients but also cater to patients switching to them from their competitors. In short, patient autonomy in consumer medicine is about the choice to purchase different treatments as well as the ability to move between medical practices.
This article considers fertility medicine as a targeted case for studying switching providers and practices throughout patient careers in consumer medicine. Fertility treatments are expensive and rarely fully covered by insurance, and accordingly, this study primarily speaks to the ways in which economically advantaged people exercise autonomy in consumer medicine. Through in-depth interviews with 61 people who pursued fertility treatments in and around New York City, I find that nearly half of study participants switched clinics throughout the course of their care. This article establishes that people elect to switch clinics to reorient patient careers that they believe have gone "off track." In switching, they attempt to reset, redirect, and escalate their patient careers. Switching clinics also provides a moment for reflexivity: As patients enter new clinics, they recast their experiences at their prior clinics and comparatively make meaning of their experiences at their new clinics.
This case allows medical sociologists to consider how autonomy is often exercised between encounters with providers while remaining tethered to formal medical organizations, building on scholarship that emphasizes the hybridity of experiences within and outside formal medical spaces (Reich 2020;Winnick 2005). These findings invite medical sociologists to reconsider the meaning of shared decision-making and patient-centered care (Charles, Gafni, and Whelan 1997;Mead and Bower 2000): For patient-consumers with the ability to switch, patient-centered care might resemble a matching process across multiple organizations more than a single provider responding to their evolving needs and preferences. Finally, these findings highlight a mode of medical privilege and stratification that has not been emphasized previously, namely, the ability to exit dissatisfactory medical situations and find new care.

Patient Autonomy in Consumer Medicine
In the United States, medical practice was transformed by the transition to consumer medicine at the end of the twentieth century (Conrad 2005). In this new world of medicine, patients have more autonomy to select medical practices and might question physicians' professional authority and resist their treatment recommendations (Freidson 1988). Sociologists have interrogated how patientconsumers exercise their autonomy both in encounters with medical providers and as part of broader patient communities.
Scholarship on medical encounters emphasizes that one of the primary changes wrought by consumer medicine was the shift away from the paternalistic doctor model and toward the shared decision-making model, in which patients are meant to have more autonomy to direct their care (Charles et al. 1997;Mead and Bower 2000). Sociological research on doctor-patient interaction underlines how patients exert their autonomy by resisting providers' treatment recommendations, pressuring providers for prescriptions, and more (Reich 2020;Stivers 2005;Timmermans 2020). That being said, research shows that doctor-patient interactions have remained remarkably asymmetric even in the era of consumer medicine (Ariss 2009;Pilnick and Dingwall 2011). As much as some patients might confront medical providers if they disagree with their treatment approach, most acquiesce to their diagnoses and treatment recommendations in clinical encounters (Peräkylä 1998(Peräkylä , 2002. Indeed, cases in which patients actively resist providers' recommendations stand out for their rarity (Pilnick and Coleman 2003). Consequently, as much as medical sociology underlines the importance of attending to patients' autonomy in their encounters with medical providers, this focus may miss other avenues by which patients exercise autonomy.
Much of medical care takes place outside of clinical encounters, and many of the ways that patients exert their autonomy do as well. For example, patients who acquiesce to providers' prescriptions might refuse to take medication once they are at home (Pound et al. 2005). Patients might leave mainstream medicine altogether, turning to alternative treatments, which has particularly been the case in women's health care (Murphy 2012). Relatedly, patients might also become involved in health movements and activist groups that challenge medical professionals' authority and expertise (Brown et al. 2004;Epstein 1996).
Still, patients who disagree with medical recommendations or seek alternate therapy often continue to seek out care in medical establishments, unable or unwilling to totally forgo mainstream medical expertise (Reich 2020;Winnick 2005). Indeed, patients who join online patient communities oftenbring this expertise and sense of self-determinationback into clinical consults (Barker 2008;Fox et al. 2005). What's more, although counter-clinical spaces might develop in some fields to allow patients to receive movement-informed medical care (Underman and Sweet 2022), this is typically a multiyear collective process and not something that individual patient-consumers can turn to when dissatisfied. Consequently, it is important to consider other avenues for patient-consumers to express their self-determination while continuing to receive currently available and conventional treatments.
One such avenue is their movement in and out of medical relationships throughout their patient careers. In medical sociology, the concept of patient careers captures developments in people's medical and illness experiences over time. Medical sociology has long been interested in patient careers (McKinlay 1971;Roth 1963). 1 Early conceptualizations focused on the "natural sequence" of the patient career from illness to treatment (McKinlay 1971:449). More contemporary patient career frameworks retain this sequential focus but allow for more uncertainty and multiple pathways (e.g., Aneshensel 2013). Past research has shown how patients are engaged with medical providers and caregivers in mapping out their future trajectories (Corbin and Strauss 1988), but we might also consider how patients orient their careers through chains of relationships with different providers.
People make many deliberate choices regarding the direction and progress of their patient careers, from determining whether to first seek medical attention to deciding when to enter hospice care. One major way in which people make deliberate choices about their careers has not been given its due, namely, electing to exit and enter medical organizations. Although there has not been much scholarship taking this temporal perspective on movement between organizations, research on patients whose illnesses are dismissed by medical providers has mentioned that patients often switch medical providers as part of their search for a diagnosis (Barker 2008;Manderson, Warren, and Markovic 2008), as do some patients who disagree with their clinic's rules (Deml et al. 2022). What's more, because of a medical system in which physicians and medical organizations are highly specialized, research shows that patients switch as their medical needs develop (Menchik 2021). 2

Control and Autonomy in Fertility Patient Careers
The aforementioned conditions, in which patients might not exert autonomy in medical encounters but also might not want to do so by exiting conventional medical care entirely, may be particularly salient in fertility medicine, a field that has been the focus of considerable scholarly attention on patient agency and autonomy. In this area, one line of scholarship suggests that fertility patients primarily have autonomy in selecting and purchasing treatments like egg freezing and in vitro fertilization (IVF), mirroring the autonomy of consumers in the neoliberal state (Franklin 2002;Strathern 1992). Another line of research interrogates how the biomedicalization of reproduction has impacted patients' autonomy, with scholars like Charis Thompson (2005) arguing that fertility patients actually acquire autonomy through the objectification of their bodies in assisted reproduction. Additionally, social scientists have highlighted how fertility patients conceptualize their autonomy over fertility outcomes in light of religious beliefs about God's will (Bell and Hetterly 2014;Roberts 2012), toggling between fatalism and self-determination. Finally, scholarship on fertility treatments explores patients' autonomy as citizens to pursue treatment and to travel to different countries if their preferences cannot be exercised in their home country due to restrictive laws, prevalent moral beliefs, and high costs (Nahman 2016;Speier 2011). These streams of research center patient autonomy in relation to the market, a higher power, the body, and the state, but they do not consider how patients exercise autonomy within medical organizations and encounters with providers throughout their patient careers.
In the United States, about 9% of women seek out medical attention for infertility (Kelley et al. 2019). Fertility medicine is a field of medicine like any other, but it also has unique features that are important to consider with regard to switching clinics. First, fertility patients are not, for the most part, suffering from symptoms in the same way that patients with other chronic illnesses often are. They will not die if they do not seek out care in a medical setting. Indeed, many people who experience infertility do not seek fertility care (Bell 2010). Not suffering from debilitating physical symptoms in the absence of care provides more freedom to patients to switch clinics, even if it means a gap in their care. Second, there is a limited window of opportunity in fertility to conceive prior to menopause. This temporal pressure might fuel patients to seek out new care rather than remain at the same clinic in the hope that treatments will eventually work. Third, although many people seek out fertility services alone, most do so as part of a couple, which changes the balance of power in encounters with providers compared to the typical patient-provider dyad. Having a partner throughout the process may empower fertility patients to switch providers more than in other medical cases in which patients chart their careers alone.
Finally, the majority of fertility patients in the United States are structurally advantaged, more likely to be White, high-income, and highly educated (Kelley et al. 2019;Tierney and Cai 2019). These advantages translate not only to more access to fertility treatments but also greater cultural health capital (Shim 2010), which might include knowledge about the importance of switching medical practices if dissatisfied. Searching for an initial and new fertility clinic is particularly relevant in fertility medicine as a "private medical market" more driven by patient-consumers than many other fields (Conrad and Leiter 2004). Because fertility treatments are often not fully covered by insurance, most patients incur large out-of-pocket costs for clinics' services (Wu et al. 2014). Due to their financial resources and the high cost of care, fertility patients might be more likely to switch clinics if they are dissatisfied.
Ultimately, fertility patients cannot control whether or when they will get pregnant or what exactly the doctor or lab does, but they can control, to some degree, the medical setting in which they receive care. This article examines those moments in which patients attempt to reclaim control through switching clinics.

DATA AND mETHODS
I conducted 57 initial interviews and 12 follow-up interviews for a total of 69 interviews with 61 people living in and around New York City who underwent fertility treatments with the aim of having a child. Participants were invited to meet alone or with their partner if they had one, and eight elected to participate together (four couples), for a total of 57 initial interviews. In the initial interview, if participants indicated that they were continuing with fertility treatments or planned to soon reenter fertility treatments, they were invited to participate in a follow-up interview, whereas those participants who indicated that they had completed their fertility career for the next few years were not contacted to participate in a follow-up.
Interviews took place between June 2018 and July 2020. Participants were recruited via neighborhood, parenting, and fertility-focused listservs and social media groups. Participants were eligible if they had undergone fertility treatments with the aim of having a child in the last three years. Men, women, and gender-nonconforming people were invited to participate, but mostly cisgender women volunteered to be in the study (93% of participants). Of the 69 total interviews, 63 took place in person, 4 were conducted over the phone, and 2 were completed via video software. In-person interviews took place in the space most comfortable for the participant, typically the author's office, the participant's home, or a quiet café. New York City is a competitive fertility field with about two dozen clinics, and participants received care at many different practices. Participants received a $20 gift card to thank them for their time.
Interviews allowed me to follow patients' full fertility trajectories, including all of the clinics they visited and how they made meaning of their treatment trajectories (Pugh 2013). I followed a life-story interview approach (Atkinson 1998), beginning the interview by asking participants' about their family, education, and career backgrounds and continuing on to inquire about their experiences trying to conceive. The interviews moved sequentially through participants' experiences of their fertility careers, tracking each of their clinic changes. Participants were asked questions about how they found their clinics, chose their clinics, and depending on the case, why they decided to switch clinics.
Interviews were recorded, transcribed verbatim, and coded in Atlas.ti. Participants were coded as having switched clinics if they had at least a consult with the intent to pursue treatment at more than one clinic even if they did not complete treatment at more than one clinic. At-home inseminations conducted by medical professionals were also considered a "clinic switch" because participants often considered this option in tandem with in-office inseminations, but at-home sexual intercourse or inseminations without providers are not considered switches because participants did not need to exit a provider relationship, and neither was ancillary care like acupuncture. Participants were assigned pseudonyms. Clinic names are anonymized as CLINIC 1, CLINIC 2, and CLINIC 3, depending on where they fell in a patient's career, to further protect the privacy of participants.
Codes regarding clinic switching included the reason for switching clinics, with subcodes such as "poor communication" and "too expensive"; the meaning of switching clinics, with subcodes such as "feels like a fresh start" and "feels like time was wasted"; and why the participant did not switch clinics, with subcodes such as "positive relationship with doctor" and "time it would take to start over." Throughout the study, abductive analysis was practiced (Tavory and Timmermans 2014), fine-tuning the theoretical understanding based on surprising empirical findings. This means that although the interviews were always structured to include questions about all the clinics where patients received care, more attention was devoted to these junctures once switching clinics emerged as a salient theme.
The majority of participants were White, highly educated, and upper-middle class, and lesbian women are overrepresented (see Table 1), similar to many of the people who receive fertility treatments in the United States. Because most patients pursuing fertility treatments are structurally advantaged, they are more likely to be able to select and change clinics to fit their preferences. Consequently, although fertility medicine in New York City serves as a strategic medical field for interrogating switching clinics in the patient career, there are many aspects of this case that may not apply to other medical experiences.

Switching Clinics
Of the 61 participants, 28 switched clinics throughout the course of their care, or 46%. Participants who switched clinics were demographically similar to those who did not, with some slight variations, such as women in their 40s being more likely to switch compared to women in their 30s, perhaps due to an increased sense of a need to rush before the end of fecundity (see Table 1). Patients were more likely to find and select first clinics through doctor referrals and were more likely to conduct research and interview multiple doctors in searching for and selecting a second or third clinic. They were more likely to switch clinics due to "push" factors, notably frustration with clinics being disorganized and not giving personal attention, rather than "pull" factors, such as positive reviews for another clinic. Patients rarely started and were much more likely to end with highly specialized clinics that catered to hard-to-treat cases. In short, how patients found and chose clinics and the types of clinics they started and switched to developed as they progressed along their patient careers.
When I asked Ursula what it was like to start trying to get pregnant at a fertility clinic, she remarked, "To me it felt like a new project" (Ursula interview, 07/25/18). She anticipated that she was embarking on a trajectory that was going to require her direction (Brown and Patrick 2018), even if in the beginning the path to conception was unclear. As patients' careers progressed and they learned more about their cases, clinics, and fertility treatment, they sometimes wanted to adjust their course. Switching fertility clinics was one of the only ways in which patients could reorient these "projects." When patients no longer had confidence that their career was on the right track at their current clinic and they believed that they might progress in the direction they wanted elsewhere, they chose to exit one clinic and enter another. As the following three sections elucidate, participants exercised their autonomy over the course of their patient careers in their attempts to reset, redirect, and escalate their care through switching clinics.

Resetting Patient Careers through Switching Clinics
For patients who reached an impasse at their current clinic, whether due to disagreements with their providers, clinic disorganization or miscommunication, or emotional depletion, switching clinics functioned as a reset. These participants exerted their autonomy over the course of their patient careers by initiating a fresh start. Patients might look to reset their patient careers soon after they have begun. Kristin started at a large private clinic her friends had recommended to her that was conveniently located. After undergoing testing, she repeatedly emailed her doctor's assistant without receiving replies and then found out that the provider had left the practice. Kristin explained, "That was our false start. So I lost like a couple of months there. And I was so pissed about that that I decided that . . . even though it was very convenient to where I lived, that I was no longer going there" (Kristin interview, 11/12/2018). At her second clinic, an academic clinic far from her home, her physician recommended that she have surgery right away. After a "false start," Kristin reset her patient career at a new clinic with a new treatment trajectory, and critically, she was the one who "decided" to do so. For some participants, this meant attempting to restart their patient career entirely, or "start from scratch." Cheryl started at one academic clinic and switched to another when all her eggs disintegrated before they could be fertilized, switching not only medical providers but also anonymous sperm donors in the process. She recalled, "After I left [CLINIC 1] disgusted, I said I'm starting all over again fresh. A new fertility clinic, [CLINIC 2], and a new sperm bank, [SPERM BANK NAME]. I wanted to start from scratch" (Cheryl interview, 10/22/2018). For Cheryl, a reset in her patient career meant changing everything she could about her treatment, including the genetic material. Still, even though she was "disgusted," she did not leave conventional fertility care, like in cases of patients turning to alternative health care (Murphy 2012), but instead exerted her patient autonomy by switching clinics. At her second clinic, Cheryl ended up hiring an egg donor due to the repeated nonviability of her eggs. In reflecting on her experiences during our interview, Cheryl remarked: "Maybe they [CLINIC 1] had a point. . . . It wasn't their fault" (Cheryl interview, 10/22/2018). Although she had blamed her first clinic for her failed treatment at the time and switched clinics in response, after experiencing the same problem elsewhere, she recognized that maybe it was not the "fault" of the first clinic. Still, Cheryl, a single woman in her 40s, defended the switch because of the temporal pressure of fertility, explaining: "I was running out of time. I couldn't really just wait and see" (Cheryl interview, 10/22/2018). With the pressure of the biological clock (Brown and Patrick 2018), patients were propelled to reset their careers before it was too late.
Switching clinics can also serve as an emotional or psychological reset, allowing patients to reason that they did not get pregnant because of the shortcomings of a previous clinic rather than locating the problem in their own bodies. For example, Opal started at one academic clinic and then switched to doing at-home inseminations with a midwife for a more personal experience. When that failed to work, Opal and her wife decided to go back to fertility a One participant refused to disclose any information about her income. b n = 34 because it includes one switch for the 28 participants who went to two clinics and two switches for the 6 participants who went to three clinics. Opal explained that comparing the different clinics was "helpfully distracting," allowing her to externalize some of her feelings about her arduous fertility patient career. Rather than blaming herself for not getting pregnant, she could focus on the problems with her previous fertility clinic and providers, not unlike fertility patients who feel agentic through distancing themselves from their bodily material (Thompson 2005). Switching clinics throughout the course of patient careers means not only forming new relationships but also renewing hope as one moves along trajectories. Opal, and other patients like her, exercised their autonomy by finding moments to reset emotionally.

Redirecting Patient Careers through Switching Clinics
For patients who have come to believe that their fertility careers are headed in the wrong direction, they might attempt to redirect them by switching clinics. As Torie put it, she and her wife went from being deeply troubled by their physician's recommendations to realizing: "We can just break up with them [CLINIC 1] and find another pathway." They exerted their patient autonomy by redirecting their patient career, switching from a small private clinic to working with a midwife, which perhaps, they reflected, made it take longer to conceive but gave them their preferred patient career. Their patient career did not just happen to go down "another pathway" (Aneshensel 2013), they reoriented it that way by initiating the "break up" with their clinic.
Participants required patient autonomy to redirect their patient careers, but they also experienced redirecting their patient careers by switching clinics as a means of developing patient autonomy. Gloria switched from one large private practice to a clinic that specialized in a particular treatment approach. Gloria explained that at the first clinic she believed that relatively simple inseminations would work and that she would not require the "big guns" of IVF. Throughout her time at the first clinic, she "started to lose confidence pretty quickly." When it became clear that she had more severe fertility challenges, Gloria brought up some experimental treatments to her physician, which she called "rogue science." Gloria explained, "And then I said to myself, well if you're not willing to at least hear me out then I don't want to keep down this path." She decided she "had to jump ship." Gloria had started going to therapy as part of managing the emotional distress of experiencing infertility and explained that therapy, in part, is what instigated switching clinics: I started to realize that I was more in charge than I thought. I used to have a lot of sessions about like, I used to think doctors know best. And I was starting to express to my therapist that I know myself best, and I'm the best decision-maker for myself medically. (Gloria interview, 11/05/2018) For Gloria, switching clinics is simultaneous and co-constitutive with her learning to express her own patient autonomy. She found that she was able to exit a relationship with a provider who was not interested in her ideas about reproductive immunology and redirect her patient career by going to a doctor who practiced that medical philosophy.
Once making the transition, most participants remarked that their new clinics differed markedly from their first clinics. They may have been hoping to redirect their patient careers through a switch but only realized how sharp a turn they made after the fact. Dina remarked: "And then I switched to a small clinic called [CLINIC 2]. And they were really wonderful. If I had known the difference between [CLINIC 1] and [CLINIC 2] I would never have stuck with [CLINIC 1] . . . I mean it was just a completely different experience" (Dina interview, 10/30/2018). In switching from a large academic clinic to a more boutique clinic, Dina was surprised to learn about the second clinic's different communication style and treatment recommendations. Redirecting patient careers is not only about finding a different treatment approach but also can mean finding a different organizational structure, clinical setting, and communication style.
Patients might recast their past experiences at fertility clinics as moving in the wrong direction based on their new experiences at second clinics, particularly in cases in which they are informed by their new providers about mistakes that were made at their previous clinics. When Lena switched from an academic clinic to a private clinic, she discovered that at her first clinic, she had experienced a chemical pregnancy (a pregnancy that appears in blood tests but ends before it can be observed on an ultrasound) that had never been reported to her: [DOCTOR AT CLINIC 2] got my bloodwork from [CLINIC 1] . . . and said, "So what was different about the time you had a chemical pregnancy?" And I said, "I'm sorry, what?" He was like, "You had a chemical pregnancy on this cycle." I said "They never told me that." . . . I was like, "You've got to be kidding me." (Lena interview 07/13/2018) With this information, Lena gained a different perspective on her experiences at her first fertility clinic. In switching clinics, she redirected her future care, but she also recast her prior experiences. Although in some medical specialties physicians rarely criticize the work of other physicians (Menchik 2021), this was not the case in fertility medicine. Many patients reported that their new clinics did not hesitate to comment on what they perceived to be mistakes in their care and to sell them on how they could improve on their previous experience. Criticizing prior care cements for patients that they have successfully redirected their career in switching clinics, following a new trajectory with a different medical approach.

Escalating Patient Careers by Switching Clinics
For patients who feel that their treatment has run its course with their current clinics, switching clinics represents an escalation relative to their previous care. Valerie started at a private clinic near her house and got pregnant with her first child, but when she returned the next year to try to have a second child, she no longer had insurance that covered treatment and switched to a more affordable clinic to save money. She did not think that this clinic provided personalized care, and so after one failed treatment, she returned to her first clinic. She quickly left her first clinic again, however, because they did not have new recommendations for her. She then switched to a third clinic that she felt was better suited to her specific needs. Finally, she returned to the first clinic to use embryos stored there and, working with a new doctor who had a new approach, got pregnant with her second child. Reflecting on her experiences, Valerie explained how she developed from thinking that she could get pregnant at any clinic to believing that she needed advanced care: I feel I grew more critical over time . . . when we picked a doctor, I had gone to my midwife for my regular care and said, "I'm interested in getting pregnant can you recommend someone who can help me?" And she gave me the names of two reproductive endocrinologists, and I picked the one that was more conveniently located and that was literally the extent of my research of the doctor we should work with. Because at that point I was like, we're just going because we're two women. We don't have any issues. And then over time . . . it became clearer that it would really benefit us to have someone who is really skilled and experienced. (Valerie interview, 03/07/2019).
For Valerie, exercising patient autonomy over her career meant transitioning to more specialized care to get her desired outcome. Valerie's case also serves as important example of a patient who, at some point, switched clinics for financial reasons. For patients who switched clinics to save money, there was not the same narrative about switching clinics as an instance of exercising patient autonomy. Quite the opposite. Participants described having little choice in these situations. Indeed, Valerie was skeptical about the quality of care at the more affordable clinic, but she said, it "felt like our only option at that point." Ultimately, she was "super dissatisfied with the care" at this clinic and switched clinics to escalate her career by charging expensive treatment to credit cards.
Valerie, like about a third of participants in this study, entered fertility care not because she had attempted and failed to conceive without medical intervention but because she was in a same-sex relationship. In this study, lesbians were not more likely to switch clinics compared to heterosexual participants. Still, there are several important distinctions relevant to switching clinics. On one hand, because many lesbians "don't have any issues," as Valerie put it, they conceive relatively quickly and have limited opportunities to switch clinics, even if dissatisfied. On the other hand, for lesbians like Valerie who struggle to get pregnant, there can be even more frustration than with heterosexual couples who enter with the expectation that they have a problem to solve, which can prompt a desire to reorient their patient careers as they learn about health challenges. Lesbians also often found first and subsequent clinics through different avenues than heterosexual participants: Because most lesbian participants had lesbian friends who had conceived at fertility clinics, they often received recommendations through this social network. These recommendations might touch on same-sex couples' different criteria for care compared to straight couples, such as finding a "gay-friendly" clinic. In short, for lesbian same-sex couples, switching clinics remains an important way to exert autonomy in the patient career, albeit with some differences in entries into care, criteria for a satisfactory medical experience, and events that instigate exiting a clinic.
Returning to the more general question of reorienting careers, patients need not select a more specialized clinic to feel like they are escalating their patient careers through clinic switching. I interviewed Robin and her wife Quinn, who switched from one large academic practice to another but felt that the second offered a higher caliber of care. Robin explained: Then we left that clinic. Nothing was working . . . . We were out of insurance money, we had no idea how we were going to do anything out of pocket. The cost after that was skyrocketing. So we did all of that [intrauterine insemination (IUI) treatment], and we went back in, and we were like what do we do? And she [fertility doctor] was like, "We could do another IUI." And we were just like, "OK we're leaving. You're obviously like not, you guys are churning and burning here, there's no personalization." So then after that we decided to interview three separate clinics that handle it in three separate ways. . . . We went to another midsized clinic and . . . and it was night and day. . . . The facilities were great. It was a burn-and-churn, like they had the cattle-call every morning. But . . . it was done really well . . . of course it was the most expensive one, but we were like, "Let's not fuck around anymore. If we're going to do this let's do this." (Robin interview, 07/22/2018) Like Valerie, Robin and Quinn decided to leave a clinic when their provider recommended that they do the same treatment that they had already attempted, and which had been unsuccessful. Although they faced the same problem of running out of insurance coverage, rather than go to a more affordable clinic like Valerie, they elected to go to a more expensive clinic, reasoning that if they were paying out of pocket, they should go to the place where they thought they would be most likely to be successful quickly. As Quinn put it in our follow-up interview, "When it gets in a little more complicated situations, I think that's when you really need to go to a different echelon of caretaker" (Quinn interview, 03/12/2019). And like patients receiving care in other medical fields besides fertility, "great facilities" often indicated that higher "echelon" (Young and Chen 2020).
Participants attempted to escalate not only treatment approaches through switching clinics but also their sense of self as patients. Eshe reflected on her experience at her first clinic: "I was new to the process then. I didn't know what I now know." In the beginning of her patient career, she did not know much about fertility or how to exercise her patient autonomy. As she became a more experienced patient, in part through switching clinics, she learned more about medicine, but also how to stand up for herself with doctors: I changed doctors three times (laughs). That I'm quite happy about. I think I learned how to be a better advocate for myself . . . it's a funny thing too, being your own advocate but then also having a doctor who's OK with you being your own advocate without thinking you're being pushy or whatever. A couple of times she said something like, "Well I'm the one who has 17 years of medical experience." And I was like, "Well I have my whole life of living in this body!" . . . So then we moved on. (Eshe interview, 10/30/2018) Learning more about fertility medicine through her experience undergoing multiple IVF cycles at several clinics helped her become an advocate for herself as a patient, with a "whole life" of experience. Still, switching clinics is often "empowerment without power" (Barker 2008), given that patients like Eshe are free as consumers to switch fertility clinics, but they are still dependent on the formal medical system to receive the treatment that they desire. As much as switching clinics is a way for patients to reorient their careers, patients are still not fully autonomous in their engagements with the medical system.
In addition to the limits to patients' power in switching clinics, there are also limits in finding a higher level of care. Bethany started her treatment at an academic clinic, switched to a large private clinic, and then switched to a private clinic out of state. She switched to her third clinic because of its rave reviews in the online fertility community (Barker 2008) and ultimately became pregnant there. However, after the fact, she reflected that there was not a marked difference in the quality of care at the third clinic compared to her second: I still don't know if I did the right thing. I think I could have stayed at [CLINIC 2] and I think I would have eventually had luck. They're a great clinic, they have great numbers. It just was like I felt like I needed to try something new, and [CLINIC 3] was just this magical place that everybody talked about, and I was just like, "Okay, I'm going to do it." But I don't know, maybe they did something a little bit different. It seemed like they kind of did the same stuff but maybe their embryo culture was just a little bit better, and you know it worked the first time at [CLINIC 3]. (Bethany interview, 11/05/2019) Although Bethany reflected on the major differences between her first clinic and second clinic, the third clinic seemed nearly the same to the second. She also remarked on how little she knew at the beginning of her patient career compared to the expert patient that she grew to become, saying, "I feel like I know the fertility world, like all the doctors and clinics." She became so expert, in fact, that she recognized that getting pregnant at one clinic or another is often a matter of "luck" rather than slight improvements in quality. Still, Bethany explained that she "felt like she needed to try something new," which illustrates the importance of the emotional resonance of switching clinics. Patients reorient their careers by progressively moving through time and space but also continuously retrospectively making meaning of prior experiences.

Sticking It out: Resistance to Reorienting Patient Careers through Switching Clinics
Participants who got pregnant quickly rarely switched clinics. There were several participants, however, who underwent multiple treatment cycles, did not like their clinics or providers, and even experienced medical errors who did not switch. Although some patients could not switch clinics because of the limits of cost and insurance, the most common reason that these patients did not change clinics was the "hassle" of starting at a new clinic with a new provider. Grace went through extensive treatments at one fertility clinic before getting pregnant. When I asked her how she decided to stay at her first clinic, she explained: I guess momentum, laziness. Also, I should say that at that point, we had relationships with doctors there, and while I would never have said I was a hundred percent happy with how they did things, I also felt like we were in so deep, it would have been like a lot of logistical hassle to switch, it felt like to me. And I just kind of wanted to stick it out. (Grace interview, 03/14/19) Even though she was often unhappy with the care that she was receiving and had the ability to switch clinics based on her insurance, she chose to "stick it out" and be propelled forward along her patient career by "momentum." Grace highlights how some aspects of the reset of switching clinics are undesirable, such as transferring files and learning new protocols as well as the emotional investment required to research clinics, establish new relationships, and risk being disappointed. The logistical and emotional cost of transitioning between clinics can feel too steep for the possible gain of higher-quality care.
Indeed, participants needed to believe that there was the possibility of better care than what they were receiving to switch clinics. When Brianna first searched for a clinic, she selected one based on its location because looking at reviews led her to believe that fertility clinics are "all equally terrible." She recounted how she had to go to the hospital after she received too much medication during treatment. I asked her if she considered leaving the clinic after that negative experience, and she said no. She explained, "We might have at some point . . . but again . . . just looking at reviews, it didn't seem like anyone's experience anywhere else was any better" (Brianna interview, 03/14/2019). She added that although the clinic she went to was "a bad place," she liked her own doctor and already knew the system there. Brianna simply did not believe that going to another clinic would solve the problems that she saw in the field of fertility medicine.
Participants required not only optimism that care might be better elsewhere to seek out another clinic but also the wherewithal to do the work necessary for a switch. Willa, who at the time of her interview was estranged from the father of her IVFconceived twins, explained that she conducted an internet search of her physician and found that he had been sued several times: I was like, "This guy is not a good person." But . . . I didn't feel the efficacy to go somewhere else, you know? It's just like, "Okay, this is what I'm doing." I didn't really know how to do the research to go somewhere else and I certainly didn't have support from [EX-PARTNER]. That was on my own. The whole thing was just on my own. I didn't have the support at all. (Willa interview, 03/09/19) Willa did not think that she was receiving care at a high-quality clinic or by a good provider. She acknowledged, however, that because she was not receiving support in pursuing treatment, she did not have the "efficacy" to do the work required to change practices. Willa's case highlights how the ability to switch clinics can drive inequities in quality of and satisfaction with care in consumer medicine.
These negative cases underline the primary argument that switching organizations functions as a way for patients to exercise autonomy over the direction and progress of their patient careers. Participants who both switched clinics and stayed at the same clinic conceptualized changing clinics as a reorientation of their patient careers, even if they did not agree about whether the work required to go down a different path would yield better results, like Brianna. Participants who did not switch clinics recognized that doing so required autonomy, something that they might not have wanted to exert out of "laziness," like Grace, or were unable to without support, like Willa. Ultimately, switching clinics is an important way to exercise autonomy over patient careers, but it is not always possible or desirable.

DISCUSSION
This article makes the case for attending to how people direct their patient careers. Patients exert their autonomy not only in medical encounters or as part of patient empowerment movements but also over the course of their care. Failing to account for patients' movement across clinical spaces misses a key avenue for patient self-determination in consumer medicine. Through switching clinics, patients reorient careers they feel have in some way gone "off track." Switching clinics serves to reset, redirect, and escalate their patient careers. Most participants perceived that they received higher-quality care at the clinics they elected to switch to compared to the clinics that they switched from. Higherquality care, however, does not just mean more evidence-based treatments or advanced laboratory techniques; it also means a better clinical setting, communication style, and cultural fit. Switching clinics helps patients regain a sense of control over an unpredictable situation, allowing them to ameliorate at least one aspect of attempting to get pregnant with medical assistance. This article underlines how patient autonomy and switching clinics are coconstitutive: Patients require medical autonomy to exit clinics and then acquire autonomy through the act of initiating a switch.
There are several limitations to these findings. The interview participants resided and received care in and around New York City, which meant that they could choose between dozens of fertility clinics without traveling a significant distance, whereas rural patients do not have the same opportunities. Most of the interview participants were White; Asian, Black, Hispanic, and Indigenous participants might not have the same experience transitioning between medical practices in their patient careers. Finally, fertility patients who had more arduous patient careers might have been more likely to volunteer to participate in a study about experience in fertility treatment, potentially biasing my results about the commonality of switching clinics in the fertility patient career. With regard to applying these findings to other medical cases, it is important to note that not every patient career is a likely candidate to become one that involves multiple clinics. Patient careers need to be long enough for there to be opportunity to switch practices. Additionally, patients cannot be incapacitated and elect to switch clinics.
Switching clinics is particularly important in consumer medicine. Consumer medicine systems are structured for patients to match with organizations geared toward their financial resources and medical needs (Reich 2016;Young and Chen 2020) and therefore encourage some degree of churn when the first match is not a good fit. Even if it does not mean total patient autonomy, when patients have consumer power, they can elect to take their business elsewhere. Patients with managed care health care plans like Medicaid are less likely to be able to switch clinics compared to patients with expensive insurance like PPO plans who have more choice over providers. In the U.S. hybrid medical system, this means that patients with more economic resources can pay for clinic choice-and the opportunity to switch clinics if dissatisfied-while patients with fewer economic resources often have fewer opportunities to initially select or elect to switch. Future research might compare how different medical systems encourage or discourage switching clinics and what this means for patient experience.
Even though infertility is different in many ways from the experience of chronic illnesses that cause physical symptoms and if left untreated result in death, addressing the role of switching clinics has particularly important implications for research in this area. Research on chronic illness finds that patients' preferences change along their trajectories, such as whether they are looking for relief from pain or a relationship with their medical provider (Bury 1991), and we might imagine these preferences differ depending on whether patients are speaking with their first or third doctor. Moreover, just as patients' identities change throughout the course of chronic illnesses according to their symptoms (Charmaz 1991), they might also evolve as they move through multiple medical organizations, developing not just a sense of being someone with a disease but also being someone "on their third clinic." Finally, this article extends scholarship on difficult-to-diagnose chronic diseases in which patients might switch clinics several times in their patient careers because their reports of symptoms are ignored (Manderson et al. 2008).
Attending to switching clinics in patient careers opens new directions for research on medical inequities. The ability to switch clinics might itself be understood as a medical inequality, something that the advantaged can pursue as a means of addressing dissatisfaction with medical care but that is not available as a recourse for the disadvantaged. Switching clinics is also important for considering racial disparities. People of color, especially Black people, are more likely to experience negative encounters with medical providers and receive a lower quality of care and therefore might have a greater impetus to switch clinics (Hagiwara et al. 2013;Rondini and Kowalsky 2021), although because of a racial capitalist dynamic, they might have less freedom to do so. Future researchers might examine whether Black patients respond to racist or biased medical encounters by switching clinics and how this is mediated by patients' resources. Finally, it is important to consider how switching clinics is not just about disparity in access but can actually perpetuate more inequality if medical organizations attempt to attract wealthy patients away from their competitors through more luxurious features rather than catering to new patients who require more affordable care (Link and García 2021;Reich 2016).
To conclude, this article highlights how people direct their patient careers through their movement across different medical practices. Switching clinics provides opportunities for patients to reset, redirect, and escalate careers that they perceive to have gone off course. This article invites medical sociologists to integrate scholarship on patients' experience within medical organizations with their experience across organizations throughout their trajectories.