Urban Hospitals As Anchor Institutions: Frameworks for Medical Sociology

SRDXXX10.1177/2378023118817981SociusFranz et al. 817981research-article2018 Original Article Socius: Sociological Research for a Dynamic World Volume 5: 1 –10 © The Author(s) 2019 Urban Hospitals as Anchor Article reuse guidelines: sagepub.com/journals-permissions Institutions: Frameworks for DOI:https://doi.org/10.1177/2378023118817981 10.1177/2378023118817981 Medical Sociology srd.sagepub.com Berkeley Franz1, Daniel Skinner2, Jonathan Wynn3, and Kelly Kelleher4 Abstract Recent policy developments are forcing many hospitals to supplement their traditional focus on the provision of direct patient care by using mechanisms to address the social determinants of health in local communities. Sociologists have studied hospital organizations for decades, to great effect, highlighting key processes of professional socialization and external influences that shape hospital-based care. New methods are needed, however, to capture more recent changes in hospital population health initiatives in their surrounding neighborhoods. The authors describe three promising sociological frameworks for studying the changing hospital: (1) the study of professions, (2) social network analysis, and (3) community-based participatory research. The authors argue that future analyses of hospitals and health outcomes must move beyond the internal-external dichotomy to see hospitals as complex institutions that are increasingly entwined with communities and subject to changes in state regulation. Keywords social science, hospital, population health, research methods, medical sociology, neighborhoods More than 20 years ago, a group of prominent scholars observed In the hospital, all preexisting forms of social inequality are that “American health care is in a state of hyper-turbulence found in their most concentrated and toxic forms. If one is inter- characterized by accumulated waves of change in payment sys- ested in exploring how social groups manage uncertainty, define tems, delivery systems, technology, professional relations, and acceptable risk, account for unexpected adversity, and rationalize societal expectations” (Shortell, Gillies, and Devers 1995). why virtue is so often unrewarded while evil so often goes unpun- Likening this turmoil to an earthquake, they argued that the epi- ished, a better site for inquiry than the hospital is difficult to center was the hospital. Today, the hospital remains in a state of imagine. transition. Shaping the conceptual contours of these changes is the oft-mentioned “triple aim,” which identifies improving the Bosk’s questions are central to the mission of medical health of surrounding communities, enhancing patient experi- sociology, but the importance of hospitals extends beyond ence, and reducing the per capita cost of care as key goals of the focus on the clinical relationships that occur inside these American health care (Halvorson, Tanski, and Yackel 2017; institutions. Sociologists have been at the forefront of chal- Whittington et al. 2015). lenging the current medical model of disease and emphasiz- Although health care scholars have written extensively on ing the role that social factors play in the development of the triple aim and its goals, sociologists have rarely consid- ered the dramatic impact these changes could have on how 1Ohio University Heritage College of Osteopathic Medicine, Athens, OH, we understand hospitals as urban institutions. This is curious USA considering the sociological tradition of studying hospitals as 2Ohio University Heritage College of Osteopathic Medicine, Dublin, OH, USA 3 sites for professional socialization and the enactment of medi- University of Massachusetts–Amherst, Amherst, MA, USA 4The Research Institute at Nationwide Children’s Hospital, Columbus, OH, cal hierarchies. USA Charles Bosk (2014), in his Leo G. Reeder address, awarded by the medical sociology section of the American Corresponding Author: Berkeley Franz, Ohio University Heritage College of Osteopathic Medicine, Sociological Association, emphasized the significance of the Department of Social Medicine, Grosvenor 311, Athens, OH 45701, USA hospital as a lab for sociological research: Email: [email protected] Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution- NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 Socius: Sociological Research for a Dynamic World illness, but sociological methods have not yet been applied to engagement with surrounding neighborhoods and providing a understanding the important role that hospitals play in urban more expansive depiction of hospitals. communities as anchor institutions and collaborators in pop- This article has two key goals. First, we reconsider some ulation health. Although hospitals have historically influ- of the assumptions underlying previous sociological work on enced communities through their presence in neighborhoods hospitals, arguing that hospitals have been described primar- and through physical expansion, we argue that the applica- ily as contained, inward-facing institutions focused on clini- tion of sociological research methods to hospital-community cal care. Second, building on recent research, we propose a engagement is particularly needed now as rapid changes in programmatic case for studying hospitals in light of their health care occur. These changes are pushing hospitals to dynamic and changing relationships with communities. We focus on improving health outcomes in their surrounding assert that sociologists are well placed to produce this body neighborhoods and not merely the needs of individual of research. Specifically, we explain how three common patients entering their facilities. sociological approaches can be helpful in examining the con- Recent research has explained why these hospitals have temporary urban hospital amid their changing relationships started the turn toward the social determinants of health. A with surrounding communities. Although not advocating for key stimulus has been changing reimbursement structures one model over the others, we suggest that each offers a that reward value instead of the mere provision of a service. unique vantage point for urban medical researchers. The These policy reforms incentivize hospitals to look outward resultant analysis allows sociologists to better capture the to communities with the key goal of preventing admissions sustained externalizing of traditional hospital activities. in the first place. This policy dynamic is moving hospitals from sites primarily concerned with acute care to prevention Institutional Norms versus External (Chee et al. 2016). Another change includes new legal Forces: The Depiction of Hospitals in requirements for nonprofit hospitals in exchange for tax Sociology exemption. These new reporting requirements are meant to encourage progress in identifying and addressing pressing Sociologists have long been interested in hospitals, seem- health needs in local communities (Rosenbaum 2013). ingly because they provide an opportunity to tell a sociologi- Although these changes may appear to be minor adjustments cal story about institutions and the organizational in the financial and tax statuses of hospitals, they stand to relationships that arise within them. Without claiming to pro- reshape the role of clinicians and the dominance of the medi- vide a systematic overview of sociological findings on hos- cal model within hospitals. Sociologists are well equipped to pitals, in this section we evaluate the key assumptions capture how these developments could fundamentally alter sociologists have tended to make about urban hospitals. We the identity of the hospital. argue that the most prominent sociological studies of hospi- U.S. hospitals, the majority of which are urban and non- tals focus on the clinical care that hospitals provide within profit, are beginning to supplement their traditional focus on hospital walls, where professional norms, socialization, and the provision of direct patient care, engaging their communi- roles can be clearly elucidated. Although sociological ties in the areas of disease prevention and the social and envi- research has accounted for various external forces, including ronmental factors that underlie population health (Marmot policy changes and economic constraints (Light 2000; Starr et al. 2008; Marmot and Wilkinson 2006; Phelan, Link, and 1982), the focus has tended to remain on how clinical activi- Tehranifar 2010; Ross and Mirowsky 2001). The programs in ties and social norms have been shaped within the hospital which hospitals are engaging—community gardens, crime and left the binary of internal (hospital) and external (com- reduction, employment initiatives, and safe and affordable munity) forces largely intact. housing programs, to name just a few examples—are each of Goffman’s (1961) influential Asylums exemplifies the great sociological interest. They are especially important and sociological focus on hospitals as contained research sites. timely as race- and class-based health disparities in U.S. cities Although certainly not the first sociological study of a hos- persist for indicators ranging from infant mortality to life pital, this book introduced the resonant concept of the “total

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