It is widely assumed that the use of medical care will lead to improvements in health, yet questions remain about the medical system's contributions to health disparities. In this review, we examine these issues with a specific focus on how health care systems may actually generate or exacerbate health disparities. We review current knowledge about inequality and bias in the health care system, including the epidemiology of such patterns and their underlying mechanisms. Over the past three decades, we observe growth in our knowledge about provider cognitive and psychological processing, including the development of precision measuring tools to analyze provider bias, racial and otherwise. In the same timeframe we observe decreased emphasis on social, interactional, organizational, and structural factors that shape variation in medical treatment. We frame our discussion within a modified social ecological model and discuss tools for moving forward and reinvigorating sociological presence in this important research area.

Background: Facilitating patient conversion to hospice at end of life is a prominent clinical concern. Enrollment in outpatient palliative care services is often assumed to encourage seamless transition to hospice care, but this has not been demonstrated. Moreover, decisions to convert from palliative care to hospice are generally treated as dichotomous, thus hampering our ability to understand decision processes. Objective: To examine medical decision-making among patients who are prospectively evaluating whether to convert from palliative care to hospice. Design: Qualitative case study, using in-depth interviews and constant comparative method. Setting/Patients: Terminally ill patients currently enrolled in outpatient palliative care services (N = 26) and their caregivers (N = 16), selected purposely for maximum variation in condition and personal background. Measurements: Themes identified in qualitative in-depth interviews. Results: Patients rarely refused hospice outright but more often postponed using a “soft no,” in which they neither accepted nor overtly refused hospice. Justifications patients and caregivers offered for why hospice was not needed (yet) appeared in these themes: (1) not seeing the value added of hospice, (2) assuming the timing is premature, and (3) relying on extensive health-related support networks that justify or endorse continuation of active care. Conclusions: Despite assumptions to the contrary, benefits associated with utilization of outpatient palliative care services have the potential to incentivize the delay of hospice in some cases. Clinical interactions with outpatient palliative care patients should consider the influence of these broad social support systems when discussing hospice options.

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The term patient noncompliance emerged in the 1970s as a tool for analyzing why people do not follow medical directives. Despite its early popularity, the term has languished in sociology while flourishing in biomedical arenas. It seems flaccid in a contemporary healthcare context as it overestimates physician authority and is tone-deaf to biomedicalization. I draw from sociological and anthropological traditions, as well as qualitative interviews with terminally ill patients ( N = 26) and their caregivers ( N = 16), to consider facets of a biomedicalized health experience and implications for an updated vision of compliance. First, pathways to care have proliferated under biomedicalization. With increased pathways comes increased need for understanding how treatment plans are socially constituted and assessed. Finally, increased complexity demands a more diverse vocabulary for understanding health related decisions. This paper is a call to sociologists to take the lead in transforming and updating this consequential concept.