My research uses qualitative methods to explore how seemingly value-neutral organizational processes produce unequal outcomes. My current projects focus on the U.S. healthcare system, and primarily on healthcare workers. Within this agenda, I have three main strands of research.
Organizational Constraints, Medical Decision-Making, and Opioids
My current book project, Painful Solutions, is an ethnography of how organizational constraints shape medical decision-making about pain management in an urban hospital. Over the past several decades, major cuts in federal and state funding for Medicaid have brought about new challenges for hospitals. To stay financially afloat, hospitals need to balance their “payer mix,” or the number of patients with profitable private insurance versus Medicaid or no insurance. While prior research has primarily focused on how hospitals attract “desirable” high-income patients, Painful Solutions asks, how do hospitals deter “undesirable” low-income patients from seeking care through their organizations?
To answer this question, I draw on two years of ethnographic research at “Metro University Hospital” (MUH), a private academic hospital in a large American city. Although MUH’s organizational goals would be best served by treating the most socially privileged and medically complex patients, MUH’s location in a highly disadvantaged neighborhood means that many chronically ill low-income patients seek care there. This population includes a significant number of patients with severe pain disorders.
In the first part of Painful Solutions, I make the case that pain, the most common symptom reported by patients seeking hospital care in the U.S., epitomizes the challenges facing contemporary hospitals in the face of Medicaid funding cuts. Pain – especially chronic pain – is socially concentrated among poor populations of color on whom hospitals like MUH lose money. Further, pain as a condition is rife with clinical uncertainty: providers often cannot know whether patients are really in pain or how severe that pain it is. I leverage fieldnotes, quotes from interviews, and archival data to show that these factors caused pain to represent an organizational problem at MUH. Providers in my study saw their low-income, Black pain patients as a barrier to the “real” work of providing care to patients with more biomedically certain illnesses, many of whom were also a better source of revenue for the hospital.
The second part of Painful Solutions describes how healthcare providers used opioids to resolve the organizational problems presented by pain. While many MUH healthcare providers wished they could formally exclude chronic pain patients from the hospital, legal constraints and public image concerns prevented MUH from denying services to this “undesirable” clientele. Instead, I show how healthcare providers took part in a process I call client steering, or the effort to informally manage individuals’ pathways through an organization while maintaining the appearance of adherence to external pressures. For undesired pain patients, client steering involved using opioids as tools to direct patients’ behavior. I detail two client steering strategies: permissive prescription and restrictive prescription. Through permissive prescription, providers gave opioids liberally to placate pain patients, suppressing the needs of these patients so that they could focus on tasks they deemed more urgent. Through restrictive prescription, providers withheld opioids to motivate patients to leave the hospital and to train them to seek care elsewhere. Ultimately, providers who engaged in either form of client steering were willing to sacrifice the well-being of their most disadvantaged patients to advance organizational goals.
Painful Solutions contributes to a growing body of scholarship on how medical organizations address the economic challenges that emerge as healthcare becomes increasingly commodified and profit-driven. In contrast to prior work that primarily focuses on the bureaucratic responses that healthcare administrators impose on healthcare providers, such as staffing cuts or time limits on interactions with patients, my research shows how providers themselves interpret organizational efficiency as a problem they ought to solve via medical decision-making. The research presented in this book is based on my dissertation, which received honorable mention for the Roberta G. Simmons Outstanding Dissertation Award from the ASA Medical Sociology Section.
I have also written two article manuscripts from this project to top sociological journals. The first of these, “Convenient Disasters: Exogenous Shocks and Ambivalence Toward Professional Standards for the Management of Severe Pain with Opioids,” has been revised and resubmitted to the American Sociological Review. This article takes the case of a sudden shortage of intravenous (IV) opioids to examine how professionals navigate exogenous shocks that threaten their ability to adhere to formal standards when they feel ambivalent about those standards. I show that before the shortage, healthcare providers at my fieldsite were conflicted about following best practices guidelines that suggested that they should prescribe IV opioids to their low-income, Black patients. When the IV opioid shortage challenged their ability to adhere to professional standards around pain management, clinicians embraced it as a convenience because it provided a new, legitimate framework through which they could resist standards in ways that they had previously seen as desirable, but not justifiable. This article won the Louise Johnson Scholar Award from the American Sociological Association Section on Medical Sociology and the Best Graduate Student Paper Award from the Society for the Study of Social Problems Health, Health Policy, and Health Services Division.
The second article from this project, titled “Painful Feelings: Opioids as Tools for Avoiding Emotional Labor in Hospital Work,” is currently under review. In this article, I make the case that healthcare providers use opioids as tools for avoiding emotional labor and burnout.
Gender Inequality in Medicine
My research agenda also includes a body of work on gender inequality in emergency medicine. This is part of a collaborative project with a team of sociologists and medical doctors. Over the past several years, we have analyzed a unique dataset composed of 33,456 numerical and textual performance evaluations of emergency medicine residents, written by their professors, assessing their ability to meet a new set of nationally-standardized performance milestones. Our work contributes to the sociology of medicine, gender, professions, and education.
In 2020, my collaborators and I published an article from this project in the American Sociological Review, titled “Who Gets the Benefit of the Doubt? Performance Evaluations, Medical Errors, and the Production of Gender Inequality in Emergency Medical Education,” on which I am the first author. In this paper, we used qualitative analyses to investigate how a previously-established and statistically significant gender gap in evaluations emerges over the course of the three years of EM residency. We found that as the reference group for evaluations shifts from ‘resident’ to ‘colleague,’ women are disproportionately punished for medical errors while, at the same time, men are disproportionately given the benefit of the doubt. Based on these findings, my coauthors and I argued that women are advantaged in educational contexts and disadvantaged in workplace contexts because of the ways that ‘student’ and ‘professional’ roles are implicitly associated with gender. This article received honorable mention for the Eliot Freidson Outstanding Publication Award from the ASA Section on Medical Sociology and was a finalist for the Organization and Management Theory Best Published Paper Award from the Academy of Management.
My collaborators and I are working on several additional manuscripts from this dataset, including one titled “Taking the Time: The Gendered Burden and Consequences of the Workplace Assessment Economy.” This paper combines computational and qualitative methods to show that women EM faculty provide more and higher quality evaluations of residents than their men colleagues. Our findings demonstrate how small, socialized behavioral differences in how workers spend time on low-promotability tasks – like the assessment of subordinates – can contribute to larger patterns of gender inequality in organizations, even when tasks are designed to be egalitarian. We revised and resubmitted this manuscript to the American Sociological Review.
In addition to investigating how organizational and institutional structures reproduce gender inequality within the medical profession, my research has also explored the reproduction of gender inequality by medical professionals. I published an article in Social Science & Medicine in 2018 titled “’We were on our own’: Mothers’ Experiences Navigating the Fragmented System of Professional Care for Autism.” This article examines how the organization of medical expertise affects the well-being of parents of children with autism. I argue that the fragmentation of professional care for autism has increased pressure on parents to reduce their workforce participation. Since gender roles place the brunt of the burden for childcare on mothers, this fragmentation was especially detrimental to women, many of whom experienced financial precarity following the loss of income and health insurance.
Healthcare Consumerism and the Quantification of Patient Satisfaction
My next book project, tentatively titled Constructing the Satisfied Patient, examines how healthcare providers and administrators work to make patients feel “satisfied” with their care. As the U.S. healthcare system has become increasingly corporatized, medical work has begun to resemble consumer service work. Patient satisfaction surveys are one significant facet of this new consumer ethic in medicine. All hospitals across the U.S. are now evaluated via externally-administered patient satisfaction surveys that have powerful consequences for their economic stability: quantitative satisfaction ratings go into an algorithm based on which insurance companies decide how to reimburse hospitals for patient care. Low ratings can mean that hospitals lose money. Hospitals are, therefore, under enormous pressure to provide their patients with pleasant customer experiences.
Patient satisfaction surveys are generally regarded as tools that will improve the quality of medical care. In medicine, however, the customer may not always be right. Patient wishes can conflict with scientific evidence, professional standards, and organizational limitations. For instance, patients may reject vaccinations or request medications their providers believe they do not need. When providers confront these scenarios, how do they balance the imperative to do the right thing for their patients’ health with the need to “satisfy” their patients? To answer this question, I will conduct an ethnography of three healthcare clinics that serve demographically different patient populations. This design will allow me to examine a range of issues that arise in the construction of patient satisfaction. It will also allow me to investigate how providers navigate conflict between patient wishes and clinical imperatives differently by patient race, class, gender, and other identity characteristics.