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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.

We use end-of-life decision making as a case for examining processes of gatekeeping in medical settings. End-of-life is an exemplar in a broader context of research in professionalized and institutionalized medical settings. Influences of biomedicalization, increases in consumer (patient) options, decreases in physician authority, and a proliferation of treatment options all contribute to a context in which ethnographic study of medical settings is more complex, more urgently needed, and potentially more difficult at the same time. Building on existing literature, we suggest that gaining access to a research site is less a matter of entrée through a gate and more a long-term navigation of a dynamic social web of actors, relationships, and organizations. Further, we borrow from Nader's (1974) concept of 'studying up' to examine how elite power processes may be reflected in gatekeeping. Our discussion of lessons learned considers methodological and conceptual implications with broad relevance for qualitative researchers.

Hospice utilization has the potential to improve quality of life for patients while also decreasing healthcare costs at end of life. Barriers to hospice utilization have been identified, but less is known about how patient, provider, and system domains influence one another. We use in-depth interviews with physicians to examine the social, cultural, and economic contexts of decision making and how physician and organizational domains influence patient decision making around hospice. We identify sources of delay in physicians advocating for hospice referrals for their late-life patients that show how patient, physician, and system factors interact. Our results reveal incentives to postpone discussion of hospice that are not fully captured in policy perspectives, clinical guidelines, or current research paradigms focused on individual domains of influence. Opportunities to address previously identified barriers to hospice will benefit from consideration of how seemingly separate domains function in an integrated social context.