My current projects span four inter-related research areas: (1) professional status hierarchies; (2) gender inequality and mental health; (3) medical education; and (4) diagnosis.
Professional Status Hierarchies
My NSF-funded dissertation, Doctoring with Inequality: Status Separation in the Medical Profession, examined the construction and implications of status inequalities among doctors. The US relies on osteopathic and international medical graduates (non-USMDs) to fill residency positions due to a shortage of American graduates (USMDs). Non-USMDs, however, are informally excluded from top residency positions, while USMDs tend to fill the most prestigious residencies, sometimes resulting in fully segregated programs. How do such status distinctions emerge among supposed equals (medical residents), and how do these distinctions impact the residents’ training and professional mobility? To answer these questions, I conducted 23 months of ethnographic fieldwork, including more than 120 interviews and over 1,200 hours of observation, comparing two segregated internal medicine programs.
Findings point to a process I call status separation, whereby status distinctions emerge among trainees in the same specialty, according to where they train. I find that structural advantages and disadvantages were consistently misrecognized as individual differences in achievement, helping USMDs float to the top of the status hierarchy. This process helped USMDs secure top training positions, while pushing non-USMDs towards less desirable “left-over” spots, creating a professional buffer to shoulder the elite. By training in lower-resource environments, non-USMDs, in turn, received poorer residency training and lower supervision than USMDs, which negatively impacted both their approaches to patient care as well as career prospects. Still, these graduates consented to such inequality. Residents of all stripes espoused unwavering beliefs in meritocracy, which buttressed USMDs’ claims of superiority while giving non-USMDs the illusion that with enough work and dedication, they could overcome the odds. In the end, I find that the US does not need formal policies to prioritize American-trained MDs; by relying on informal status distinctions that equate status with merit, and eclipse structural disadvantages, non-USMDs become willing participants in a system that subordinates them to USMDs.
These findings help reorient sociological thinking on the medical profession, which until now has overlooked the role of non-USMDs, as well as the informal mechanisms that contribute to pedigree-driven hierarchies between doctors in the same specialty. They also advance the literature on health disparities by shedding light on how professional inequalities may contribute to patient inequalities. Several articles have already been published from this research and will continue to emerge, along with a book manuscript in press with Columbia University Press (expected June 2020).
Physicians' Mental Health and Gender Inequality
This new project explores why physicians, and especially female physicians, suffer disproportionately from poor mental health. On the one hand, in the medical literature, doctors are known to be at higher risk for mental illness than the general population, and have lower rates of psychiatric service utilization than other professionals, but the mechanisms behind these poor mental health outcomes are not well understood, particularly among female doctors who complete suicide at 130% the rate of women in the general population. Medical sociology, on the other hand, has documented the wide range of changes affecting the medical profession in recent decades, including rising corporatization and growing interference by non-medical actors, but it has yet to link these macro-sociological changes to individual health providers’ wellbeing. This project will use in-depth interviews with male and female physicians to better understand what it is about the medical profession that makes doctors sick—and female doctors possibly sicker. In so doing, it will help bring these two disparate literatures into conversation, and produce insights that will be of interest to sociologists and physicians alike.
A specific portion of this project, funded by the International Association of Medical Science Educators (IAMSE), will investigate the unique determinants, experiences, and manifestations of burnout and poor mental health among female residents in the frontline specialties of emergency medicine (EM) and internal medicine (IM). Physicians in these fields are respectively among the most burnt out in their profession and report the lowest rates of happiness at work. Little is known, however, about how female residents’ unique experiences in these front-line specialties can affect burnout, career satisfaction, or mental health more generally compared to men. There is growing evidence of systematic gender inequality and bias against women throughout the medical profession, especially in some front-line work, like EM, with highly masculinized norms. Women residents therefore not only face the usual risk of burnout associated with the nature of the clinical work; they’re also training in a profession where they are systematically lower in status than men, with untold consequences for their mental wellbeing. This study will leverage the strengths of qualitative methods to characterize the gendered experiences of burnout among residents in frontline specialties.
These projects build on my previous research on medical education, a field which is experiencing a resurgence in sociology (see new Sociology of Health Professions' Education group website). One article, co-authored with four undergraduates student-mentees, considered the factors contributing to medical student wellbeing (published in Advances in Health Sciences Education, 2018). Using a secondary analysis of previously collected life-story interviews, we looked at how medical students make sense of their own experiences, identify turning points, and reflect on how these factors contribute to, or attenuate, stress. The article also makes a case for the broader value of secondary data analysis in qualitative studies, particularly in medical journals where the use of qualitative methods is still relatively in its infancy. Another article (under review) uses longitudinal data gathered at various medical schools to understand the factors influencing medical students’ choice of specialty. A third article coauthored with colleagues at The University of Chicago (published in the Journal of Graduate Medical Education, and selected as a “Top Article in Medical Education 2017” by the Academic Pediatric Association) examined gender bias in emergency medicine training. A final article (published in Contexts, 2016) examined the phenomenon of degree rationing in American medical education. All four of these publications involved collaborations with physicians, and several of them were published in medical journals, thereby allowing my research to extend beyond sociology, and have an impact in the world of healthcare and medicine.
I have also been an active scholar in the emerging subfield of the sociology of diagnosis. In 2011, I co-authored an article published in Social Science & Medicine, which proposed an innovative theoretical framework for sociologists and clinicians to put diagnoses into social context, known as “social diagnosis.” I then updated the framework in 2017 (in Social Science & Medicine) using the contentious diagnosis of intersex to illustrate the need for a framework that accounts for social resistance to diagnosis. Other work I have done on diagnosis has examined the extent to which sex and gender are incorporated into genetics research, and how future research might be better able to integrate social scientific perspectives (American Journal of Public Health, 2013). Future plans for research in this area include a mentored research project with an undergraduate student on gendered patterns in self-diagnosis among physicians, particularly regarding mental health.
Together, these projects build on my robust research trajectory thus far in the sociology of health and medicine, including work on social determinants of health, healthcare access, and gender and health.