As I sit down to consider my life’s trajectory since the conclusion of my formal medical anthropology education—now five years past—I am having a hard time knowing where to start. The snow-ball effect that an education in medical anthropology initiated has touched almost every facet of my life: from the personal to the professional. At first I thought that I would write on the lens I felt I carried into hospitals as a new medical trainee—or on my experience of witnessing death first hand for the first time, both gruesome and quiet— or how hard it was to pull myself out of the world of prestige in medicine, a place I never imagined I would find myself entangled. I have found the teachings of medical anthropology wildly and widely applicable. Five years out, I utilize the praxis of medical anthropology daily.
In my anthropology courses, I learned from writers, professors, and classmates reflecting on where we as members of our particular culture place emphasis and praise power. I recall being fascinated by the many ways the authorities we commonly and reflexively accept, in turn, shape our experiences of the world around us, particularly in the most vulnerable and universal of moments: death, birth, illness, and pain, and in perpetuating injustices for vulnerable populations, particularly in the minute details. Beyond the classroom, I have found that those reflections helped me in advocating and fighting for the rights of my patients and community on individual and larger scales, but they also now implicate me, soon to be a functioning member of the medical authority’s “upper” class.
As I’ve progressed in my medical career, the experience of being in the medical world has changed the way I see myself fitting into the life of the community around me. As an undergraduate, I was prepared to sign up to work for a community health center—the province of the advocate, the anthropologist, and the community organizer in medicine, as I saw it— and that I did. I worked at a community health center for a year prior to medical school and landed in medical school thinking that community health centers were the only places that appropriate care was provided for the poor and underserved—but even that care, as I witnessed it, was often limited and bereft, patched together from the scraps of the mainstream health care system. Providers were often jaded, bearing the weight of the lack of the prestige of an academic career, and “team-based care” was, at times more fantasy than reality as teams were often made up of some who were mission-driven, some who were world-weary and mission-cynical, and some who were there just to get paid: a recipe for resentment. Even so, I continued to pursue a career of working at a community health center, feeling a call to provide the best, highest quality medical care I could to folks in my own community. I wanted to try to provide a consistent and reliable presence in what seemed to me to be a frightening sea of institutionally-engendered mistrust, exacerbated by the transience of burned out personnel.
That’s not to say that community health centers don’t work. In fact, I have been privileged to witness some of what the most respected community health centers in our country have to offer: many are excellent models, based in community and operating through ethnography, and they do work! I am lucky enough to be beginning my residency in the coming months at one of the highest functioning community health center systems in the nation – The Cambridge Health Alliance – and I cannot wait to do so. But that said, we do not have a health care system that effectively serves the vulnerable. We do a poor job of training our providers and providing a caring culture as is evidenced by vast health care disparities, the discrepancy in medical dollars spent in end of life care, and the huge shortage of psychiatric and primary care providers that we face. It was not only an education in medical anthropology that gave me the nuanced appreciation of all the areas that we fall short in providing adequate care—but the experience of being a medical student peering through that lens that has allowed me to see enough to fear the challenges I will face.
I entered the residency process confident in my philosophy of medical care, but timid about how to attain the best training for what I see myself doing. The residency search is a hard one—and one that expects you to know what you need to be taught prior to being taught. To back up a little, here’s how it works: you graduate from a four-year medical school and in the beginning of that fourth year, you apply to residencies. A residency follows medical school and will narrow your training to the specific specialty that will make up your career. For certain specialties, there will be a fellowship after residency that further narrows your scope of practice. Thus the first discernment process is to determine what specialty you want to enter (surgery, obstetrics, psychiatry, family medicine, internal medicine, pediatrics, radiology, etc.). The second discernment process is what kind of environment you want to be trained in in that particular specialty.
For me, the first discernment step was fairly easy—I want to be a generalist who works in primary care. I waffled between the specialties that allow for that kind of training: family medicine (which would include broader training in pediatrics and low-risk obstetrics) and internal medicine (general medicine confined to those 17 years of age and up, with no obstetric training). I, personally, decided on primary care internal medicine as I knew that limiting myself to adults in my training would allow me to delve more deeply into adult primary care issues, particularly those of the chronically mentally ill.
We’re in a transition in primary care training. There are physician educators who hold tight to the inpatient (hospital) experience and argue that that is where residents learn the best. There are others who claim there’s not enough outpatient (clinic, primary care) training and that physicians are being discouraged from primary care because of the lack of experience and poor training in that area: they end up taking jobs in the hospital because that’s where they’re comfortable working at the end of training. There are those who say that residents who train primarily in hospitals have an “illness bias” or tend to think patients are sicker than they are and go down the route of medicalizing the normal. There are those who think that with too much emphasis on outpatient training you end up with physicians who have a “wellness bias” and have trouble recognizing when someone is really sick and needs to be hospitalized for more intensive care. There are those who advocate for training that prepares residents to take care of whomever walks through the door—and those who say such training is too broad, there’s too much to be known and there’s a place for specializing for the patient’s sake.
Add to all of this the fact that the few medical schools that are attempting to integrate medical humanities into their training are finding that their efforts are often lost in the 80 hour work weeks of residents. There are limited residencies that train physicians to recognize the biopsychosocial determinants of health, that offer curriculums on being physician advocates, on rehearsing and working in the pedagogy that medical anthropology has to offer. Not to mention, the patient population. The years of residency are the most formative years of your medical education: you are formed by your patients. Learning to practice medicine in urban Boston is likely much different than the experience of learning to practice medicine in Prospect Hill, North Carolina. The vernacular of patients, how they describe, narrate and experience their illness and wellness is different. Learning to use a translator 40% of the time for your highly immigrant patient-population is a different experience from primarily speaking English. Working with patients in a community health center environment versus a private practice are different learning experiences. Getting the chance to work in academic hospitals, VA hospitals, and community hospitals are different experiences, requiring different skill sets. Do you want a large program, with lots of residents or a small one? What happens when you’re in a residency that churns out specialists, creating a culture of specialization, deemphasizing primary care tacitly? And, does the prestige of the program count for anything? Does prestige equal better training? And if the best training is what I want to offer to my patients, do I go with prestige, even if they churn out specialists and don’t spend as much time focusing on primary care training?
I really had and have no answers to these questions. I did get caught up in them, obsessed with them. Despite having remembered reading David Hilfiker’s Not All of Us Are Saints five years prior and feeling viscerally disgusted at the fact that he described feeling worried that his position of working in an underserved area was not “prestigious,” five years later I found that my pride got caught up in the prestige of some of the programs I was considering. If I chose to attend a program that was focused on primary care, would other physicians think I was not a great physician? Years down the line, I had become a part of the system I had analyzed so cavalierly years earlier.
Maybe not so gracefully, and maybe not so perfectly, I have ended up at the residency that will, I believe bring me full circle. At The Cambridge Health Alliance, I will be in a place that is known for its academic rigor. I will be in a small class of residents from diverse backgrounds and experiences, all who want to go into primary care internal medicine. I will be around psychiatry residents in a community atmosphere. My clinic will be in a community health center where I will see patients and get to know patients from all walks of life. I will work primarily in a large community hospital, but will do some of my rotations at academic hospitals in the area. I will have a longitudinal curriculum in physician advocacy and social justice. I will do home visits, work in innovative model programs for care of geriatric populations, the chronically mentally ill and medically complicated, and will be in a place where internists provide medical abortions. I will be in the same city where there are residents, much like me, who have chosen to be in large academic centers—and we will be shaped as physicians in different cultures. We will do disparate amounts of hospital versus primary care training. They will take care of very sick oncologic patients—I will do this rarely. They will run many “codes” or life-saving, high intensity endeavors in the hospital in attempts to buy someone more time. I will be trained in these procedures, as well as run many, but I will have more time focused on honing my serious illness conversational skills in the primary care setting.
No residency is perfect and we certainly haven’t perfected medical training. In the process of discerning my own path, I have fallen back on my roots in medical anthropology daily: in the personal and professional. I have attempted to use the skills I have learned not only to be a non-judgmental, critically thinking professional, but to be someone who does their best to figure out where I fit into the world I’m in. I plan to continue reading widely, thinking and talking in an interdisciplinary manner for the rest of my career. For me, the insights that medical anthropology provides upon my work has made me a better student and medical professional. It has given me a praxis to be a more thoughtful community member and a more careful practitioner of care.