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In this paper, we delineate how staff of two complex care management (CCM) programs in urban safety net hospitals in the United States understand trauma. We seek to (1) describe how staff in CCM programs talk about trauma in their patients' lives; (2) discuss how trauma concepts allow staff to understand patients’ symptoms, health-related behaviors, and responses to care as results of structural conditions; and (3) delineate the mismatch between long-term needs of patients with histories of trauma and the short-term interventions that CCM programs provide. Observation and interview data gathered between February 2015 and August 2016 indicate that CCM providers define trauma expansively to include individual experiences of violence such as childhood abuse and neglect or recent assault, traumatization in the course of accessing health care and structural violence. Though CCM staff implement elements of trauma-informed care, the short-term design of CCM programs puts pressure on the staff to titrate their efforts, moving patients towards graduation or discharge. Trauma concepts enable clinicians to name structural violence in clinically legitimate language. As such, trauma-informed care and structural competency approaches can complement each other. [ABSTRACT FROM AUTHOR]

There is growing concern among US-based clinicians, patients, policy makers, and in the media about the personal and community health risks associated with opioids. Perceptions about the efficacy and appropriateness of opioids for the management of chronic non-cancer pain (CNCP) have dramatically transformed in recent decades. Yet, there is very little social scientific research identifying the factors that have informed this transformation from the perspectives of prescribing clinicians. As part of an on-going ethnographic study of CNCP management among clinicians and their patients with co-occurring substance use, we interviewed 23 primary care clinicians who practice in safety-net clinical settings. In this paper, we describe the clinical and social influences informing three historic periods: (1) the escalation of opioid prescriptions for CNCP; (2) an interim period in which the efficacy of and risks associated with opioids were re-assessed; and (3) the current period of “opioid pharmacovigilance,” characterized by the increased surveillance of opioid prescriptions. Clinicians reported that interpretations of the evidence-base in favor of and opposing opioid prescribing for CNCP evolved within a larger clinical-social context. Historically, pharmaceutical marketing efforts and clinicians' concerns about racialized healthcare disparities in pain treatment influenced opioid prescription decision-making. Clinicians emphasized how patients' medical complexity (e.g. multiple chronic health conditions) and structural vulnerability (e.g. poverty, community violence) impacted access to opioids within resource-limited healthcare settings. This clinical-social history of opioid prescribing practices helps to elucidate the ongoing challenges of CNCP treatment in the US healthcare safety net and lends needed specificity to the broader, nationwide conversation about opioids. [ABSTRACT FROM AUTHOR]

How do health professionals with fundamentally different philosophies toward health, and different status levels, manage power in their work relationships? This paper argues that taking a negotiated order interactionist approach, which contends that the social order shapes behavior but is continuously negotiated through social interactions, and synthesizing it with a countervailing powers perspective can yield insight into the power dynamics between health professionals. It focuses on the birth field, with attention to the relationship between two very different types of birth professionals: obstetricians and doulas. Unlike doctors, who maintain a dominant place in health care and subscribe to a biomedical perspective of birth, doulas hold a low-status position and take a holistic approach toward birth, which may cause conflict in the labor room. In-depth interviews with 43 birth doulas based in the US (May–July 2018) found that the doula–doctor relationship is a complex story of power, deference, and countervailing responses. Doulas reported that doctors are more receptive to them now than in the past but that this is an outcome of creative countervailing responses involving deferential maneuvers and direct challenges to physician authority. Doulas' strategic management of their relationships with health professionals has allowed them entry to the hospital, permitting them to represent a holistic voice in the labor room. A minority of doulas have begun to develop relationships with doctors that constitute a collaborative approach toward birth care, indicating that changes in standard care are possible. By revealing how a subordinate actor can challenge physicians and effect change in care, this study contributes to scholarship seeking to understand the nature of unequal relationships between health professionals in a context of biomedical dominance. • Explores the relationship between doulas and doctors in the United States. • By acting deferentially, doulas' relationships with doctors have improved. • Doulas challenge physician authority in primarily indirect but also direct ways. • A minority of doulas have collaborative relationships with doctors. [ABSTRACT FROM AUTHOR]

The role of fetal development in abortion work is unresolved, mirroring a broader cultural ambivalence regarding the fetus. The collective, cultural notion of fetuses tends to lie on a dichotomy between "clump of cells" and "baby," with little public attention to the realities of fetal development during all stages of pregnancy. This tension is exacerbated by an absence of medically accurate images of aborted fetal tissue available to lay audiences. In this paper, we examine how independent abortion providers manage contradictory messages surrounding the fetus when providing patient-centered pregnancy tissue viewing (PCV). More specifically, we investigate how providers navigate public and private understandings of the fetus in their healthcare provision amidst a void of nuanced fetal imagery. Through interviews with 25 independent abortion providers in the United States, we analyze the discursive framings providers employ to make sense of the fetus and provision of PCV. Using a symbolic interactionism framework, we grouped results into three overarching themes: tensions in language, the impact of gestation as de- or re-stigmatizing, and looking as "making it more real." Our findings support the notion that the fetus is largely socially constructed, mutable, and variant across individuals, context, and time; our findings also highlight abortion providers' ability to hold nuanced and sometimes conflicting thoughts and feelings about fetuses while providing patient-centered care. This study addresses a largely overlooked practice within medical sociology and furthers our understanding of how cultural narratives shape the provision and meanings of patient-centered care, the professional socialization of healthcare workers, and the patient-provider interaction. • The "baby vs clump of cells" cultural binary affects interactions in the clinic. • Fetal symbolism is malleable and variant across individuals, context, and time. • Providers use mirroring and affect assessment to navigate cultural fetal ambiguity. • Language and gestational age shape fetal meaning and PCV makes abortion "more real." • Providers can have complicated feelings about fetuses but be confident in their work. [ABSTRACT FROM AUTHOR]