Author Archives: Katie Poor

About Katie Poor

Anthropology

Bridges and Barriers: The Ins and Outs of Strategic Storytelling

GibsonNeco

© 2016 University of North Carolina at Chapel Hill School of Medicine

Dr. Raúl Necochea is currently an assistant professor in the Department of Social Medicine at the UNC School of Medicine as well as an adjunct assistant professor in the Department of History. Inspired by stories from his OB/GYN mother and questions of unethical sterilizations in his native Peru, Necochea wrote A History of Family Planning in Twentieth Century Peru, which was published in 2014. His book tries to capture the different lived experiences of people regarding family planning. Each chapter represents a different vantage point including those of clinicians, intellectuals, feminists, the Catholic church, and men and women who were seeking abortions. At stake were notions of individual autonomy, the future of gender relations, and national prosperity.

“When I went in to write this book about the history of family planning in my home country of Peru,…I had some vague idea of what it was going to be about; it was going to about family planning and it was going to involve Peru and it was going to involve the 20th century…Once I had that figured out, [I thought] okay, I have all this now, [so] what is the best story that I can tell with all this?”

Grabbing a copy of his book, A History of Family Planning in Twentieth Century Peru, from his office’s book nook, Raúl Necochea settled in his desk chair and briefly sifted through the pages. When reflecting on his role as a historian, Dr. Necochea knew he was tasked with telling and uncovering yet “another story of abuse and negligence of people” who shouldn’t have been susceptible. Although Dr. Necochea recalls always having a particular interest in family planning, his research journey began at the start of his grad career, which was situated within the plight of a Peruvian scandal.

“Right around the mid 1990s, there was a scandal in Peru over some surgical sterilizations that were performed on women seemingly without their consent. They were mainly poor women, indigenous women, mainly women who lived in rural areas, traditionally the women who had always been the last to [be] served by the government and the medical profession.”

Representing a repetitive pattern of victimization, Dr. Necochea was challenged with revitalizing an old tale. Why were the same people still vulnerable and victimized? How were the same trends regarding contraceptive access reproduced? What actors were consistently involved? These probing questions guided Dr. Necochea’s role as an active historian, researcher, and storyteller.

When talking about projects, Dr. Necochea believes creating research projects is a valuable tool to experience. He views it as a bridging opportunity between professors and students to experience the value and importance of research and allow students to explore their interests deeper. “I think that the experience of writing and doing research on your own is really valuable…I mean, oftentimes the way in which we present research to students sort of makes it seem as though our expertise…is there for you to simply accept and consume, but the experience of actually producing the knowledge that goes into books or articles, that’s a very different process.” Dr. Necochea’s advice to students who hope to create their own research project encompasses the idea of producing knowledge through passion. He demonstrated his passion by drawing attention to the needs of the community in Peru. He also spoke about his identity as a Peruvian and the role it played in navigating the exploration of his research. Dr. Necochea stated that being Peruvian “opened a lot of doors for [him], not only speaking the language but being able to navigate and understand the people there. There’s nothing like being a local to open those doors and get others to say what you understand.”

“Beyond [ethnicity], there’s other markers that make you into the right or wrong messenger for some stories. The whole time that I wrote this story for example, I was always worried about the fact that I was a man studying a topic that is primarily about contraception for women”

In addition to his ethnicity, other aspects of his identity played a pivotal role in his research on sexual and reproductive health, especially with regard to gender. Conflicted about the role of men in conversations regarding modern contraceptives and family planning, concepts primarily marketed for women, “being a man was always in the back of [his] mind as a barrier to negotiating some of these conversations that [he] had to have.”

Alongside his identity, Dr. Necochea’s upbringing helped bridge the barrier of potential ideological differences between himself and his research participants. “Another thing that sort of played in my favor is who I am, which is not only a man but also a man who has been educated at a fairly conservative high school [in Lima]” he explained. This high school was a Catholic institution that was very renowned in Lima. Many of the participants in Dr. Necochea’s research had conservative viewpoints and were strong activists of the Catholic church, so his educational background provided a common ground, a sense of trust, and a bridge for critical dialogue. Ultimately, “it created sort of a level of confidence that [he] would not have had otherwise.”

Snapshot of Necochea's archival adventures. Reflective of one of his practical research challenges, "being indoors reminded [him] of how resource-poor archives can be." Pictured

Snapshot of Necochea’s archival adventures. Reflective of one of his practical research challenges, “being indoors reminded [him] of how resource-poor archives can be.” Pictured is one of the buildings of the Regional Archive of Puno, in southern Peru, 4000 meters above sea level.

During his time in Peru, Dr. Necochea faced many unexpected research challenges. He gave us interesting insight into navigating practical and ethical barriers while in the field. On the practical side, he learned that accessing archives would be much more difficult in Peru than in the US or Canada; but, in order to pursue the study, he would have to adjust.

“What I would find is that people were not returning my calls…or the facilities would be closed arbitrarily, or the materials that were supposed to be there were not there…Materials would be scattered around in different places. Archives would close, as in ‘we no longer have the possibility of serving the public because, [we’ve] run out of money’…It [was] a situation I encountered very often and it’s not a situation that is uncommon in developing countries– archived materials [that] ought to be available for public education and research often suffer from lack of funds.”

Dr. Necochea also discussed some of the ethical dilemmas he faced while in the field. He often had to interview individuals with whom he disagreed on the issue of family planning. Sometimes he was able to “make bridges [with individuals] when there [was] a respectful understanding of difference.” Other times, it was not so simple. In one example, he had conversations with physicians who flippantly recalled forced sterilizations they had performed and a pharmaceutical representative who ended up going on an anti-indigenous rant.

“Sometimes not everything can be planned in those situations, and you can be surprised in a bad way…you start to question your own sense of composure. Like, did I really do the right thing in not telling this guy he’s an ass and that I’m out of here or something like that? Or do I just finish my drink and then be on my way? Do I stay in touch with these people, all of whom want to stay in touch? “I mean, what do you do? It becomes a little bit of an ethical conundrum too about how do you stay connected to the field, which is another anthropological thing.”

In order to overcome his own biases, which could also act as barriers to his research, Dr. Necochea found that it was important “[to be] comfortable being sort of alien in a different cultural space. That’s a mainstay of anthropological work and it’s one of the things that has happened to [him] often by having to travel to different places for archives.” Despite being “mainly in archives, you have to be in situations in which you are the odd person out because of the nature of the different archives where [he] was. That attitude of being comfortable with uncertainty helps make you a good observer when you’re on the edge of a different culture.”

Through his research, Dr. Necochea was able to overcome barriers and create powerful bridges by telling a story that ensured voices were heard on a research topic in which he was extremely invested in. Yet, the story does not end here and Dr. Necochea’s research will continue on. Looking towards the future, he plans to write his next book on the “history of cervical cancer in Peru and possibly Latin America.” He “came across a couple of sources from the 1950s of physicians with ties to the government who were speaking out against the use of intrauterine devices for women…[and] started to get very curious about how this particular fear sort of became articulated at different levels — [specifically] at the level of government experts and also at the level of lay people.”

“More needs to be done to end social problems that have health implications, and a law is not gonna change that. We need something more–community participation in changing people’s minds like minds were changed earlier in the 20th century about birth control. That takes a great deal more work than just saying ‘Oh that’s wrong.'”

Now it is our turn. Now is the time to turn the page and bookmark the innovated projects of the future. Now is the time to research our own stories that encompass our passions, our interests, our backgrounds, and our various identities. Each story will bring its own barriers and challenges, however, it will also build bridges and enable us to make connections to the world around us. Dr. Necochea told his story, which story will you tell?

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Gems about Dr. Necochea

Tar Heel Bred: “I’m a big fan of this place [and] organizationally what UNC is and stands for. I mean, public education for one — I’m very proud of the fact that I can contribute to training of people who are so grounded in this space of this state and who get some kick ass education and experiences and opportunities to go as wide as they can.”

Elements of Anthropology: “I really enjoy ethnographic tales where anthropologists sort of reflect on their position of being on the edge of something and being able to understand its differences and similarities with other places.”

Favorite Quote: “The restricted use of anovulatories* […] does not infringe on the terms of the [Humanae Vitae] Encyclical, according to the judgment of authorized experts in morality” – Juan Landázuri, Archbishop of Lima (1955-1990) and Cardinal (1962-1990)

* – contraceptive pill

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Is Medical Anthropology “All in Your Head?” An Interview with Dr. Mara Buchbinder

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An Introduction

Photograph of Dr. Mara Buchbinder

Dr. Mara Buchbinder’s most recent book, All in Your Head: Making Sense of Pediatric Pain, offers an exciting perspective on pediatric pain by focusing on the intricate dynamics of a small clinic in California she refers to as the “West Clinic”. By following the lives of several adolescent patients, families, and clinicians, she identifies numerous variables which contribute to making sense of pediatric pain. The book challenges its audience to recognize the social expectation which culture has linked to definitions of pain. This interview on her newest academic feat was conducted by a team of undergraduate Medical Anthropology minors.

“Because the mind is the province of imagination, ‘”all in your head'” may also suggest that the pain is made up, […] the invention of a self-defeating mind, or, worse the fabrication of a malingerer.”

Sources of Inspiration

When did you decide you wanted to go into medical anthropology?

M.B.: I had this really fantastic opportunity to do an interdisciplinary undergraduate thesis project at Dartmouth College. I developed this idea based on my summer research at The Children’s Hospital, Boston to make visual illness narratives of adolescents with type 1 diabetes. For my senior project, I produced a video component about what it was like [for these adolescents] to live with type 1 diabetes. I loved doing that and it got me very excited about going to graduate school and doing research. That’s what actually got me into medical anthropology.

What inspired you to write about this topic? Why did you choose to focus on pediatric pain?

M.B: I have always been interested in children’s health issues and how families manage children’s chronic health problems. What I found really compelling me about medical anthropology was the focus on people’s narratives about illness. That is why I wanted to look at pediatric issues. In terms of the focus for my dissertation research, I happened to find out about this clinic and it seemed like a very interesting research opportunity because it was unique in the way that it was set up and the the kinds of pain that it dealt with.

“What really compelled me about medical anthropology was the focus on people’s narratives about illness.”

The Project

All in Your Head: Making Sense of Pediatric Pain

Image of the cover of Dr. Buchbinder’s book, “All in Your Head: Making Sense of Pediatric Pain”

What were some of the challenges you faced in the writing and research behind All in Your Head?

M.B.: One thing that was a little challenging was that I didn’t leave home to do this project. [In anthropology,] there’s an expectation that you will go somewhere else and experience a foreign culture. Initially, I had a hard time getting my research off the ground and thinking “Am I in the field now?” and “What is the field? What defines the limits of the field?”. I also had methodological challenges and had to adjust the research design. It was sometimes difficult to recruit families to participate, but I incorporated more of what I saw as low-hanging fruit. Most families let me observe their clinical appointments with physicians, so I did a lot of that.

With respect to writing, I think it was challenging that so much of what I saw in the clinic was very particular. The patient population was very privileged and didn’t really reflect the socio-demographics of the surrounding area. I struggled because I was talking about a type of health care that a lot of people didn’t have access to. I thought about how to set up the story so that it would reflect on larger themes, even though it’s not representative of the American health care system. There was a patient that I had recruited for my study but didn’t end up going to the clinic because her state insurance wasn’t accepted. I decided to write a chapter about her experience because it showed what happened when people didn’t have access to the clinic.

“I’d say a really high percentage of them could get better… if their parents would let them.”

-Nina Herrera, clinical coordinator, West Clinic

In Chapter 4, “Treating the Family”, you focus on how the West Clinic team assumptions of normative family roles relate to explanatory models behind treatment decisions. Can you expand on how other normative assumptions contributed to treatment decisions?

M.B.: I think that a lot of the decisions about restoring functioning were motivated by ideas about what defines success in adolescence, and so a lot of the decisions were oriented toward, getting kids into college. There was a lot of talk about getting [them] into college and getting them back into their high-achieving tracks. Of course, sometimes I think the clinicians helped families and patients get off that track, and that was also part of what they did. But I think sometimes they were implicitly motivated by middle class values about education and achievement and success.

In Chapter 5, you begin with a quote by George Beard about American nervousness “Without civilization there can be no nervousness…”. In what ways does this quote relate to the West Clinic patients’ experiences with navigating their roles in civilization as both patients and humans?

M.B.: I was very drawn to historical work on diseases that affect certain socioeconomic groups. Much of the discussion in the clinic meetings was about the culture of stress facing today’s adolescents. I think it’s true that adolescents today are under a lot of stress, but there’s a particular class privilege that marks the kind of stress that these kids are experiencing that is quite different from that of working class teenager in certain parts of the country. I got really fascinated with Beard’s work on nervousness because it is kind of a byproduct of modernization and civilization growth. There was something similar going on with the way people talk about what is going on with the West Clinic patients, which I think is very interesting.

Moving Forward

“I think there’s been growing interest in thinking about complementary and alternative treatments.”

What do you think are next steps in the field of pediatric pain research?

M.B.: I think there’s been growing interest in thinking about complementary and alternative and integrative treatments, and there are big funding and structural constraints with incorporating those into pediatric pain treatment. That is one place where people should probably be devoting more attention. Generally speaking, the financial issues are big because pediatric pain is really underfunded. And actually, pain in general is underfunded by the NIH. That is a challenge for future research. I would like to see more interest in the productive side of language and the productive possibilities of using particular types of metaphors to explain things to pediatric patients. I think that [research] could be very generative and low cost. Low cost, high yield I would say.

Thank you Dr. Buchbinder for speaking to us about your new book.

Fun Facts

Favorite book: Rayna Rapp’s Testing Women, Testing the Fetus: The Social Impact of Amniocentesis in America

Current research: Cultural impact of Vermont’s physician aid-in-dying law

Advice for students entering the field of medical anthropology: To think collaboratively and interdisciplinary – how insights from medical anthropology can enhance approaches to health problems from other disciplines such as public health and clinical medicine.

For information about Dr. Buchbinder’s previous book, Saving Babies? The Consequences of Newborn Genetic Screening, click here.

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Finding a Balance Between Prestige and Purpose

med-anth-pic

Five years out, I utilize the praxis of medical anthropology daily.”

UNC Chapel Hill Alumni Sarah Stoneking, MD discusses how medical anthropology helped her find her place in the medical world.

Part I: Considering Life’s Trajectory

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.

Reflections from Undergraduate Years

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!

2

Preparing for Residency

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.

3

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.

Discerning the Call

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.

4

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.

Moving Forwards

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.

 

Sarah Stoneking- Alumni Voices

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.

Patient-Centered Care: How Anthropology is Innovating Healthcare

It’s a Skype interview, but the hustle and bustle of the café Felipe Dest has settled down in reflects the fast track his life is currently on.

After graduating from UNC with an Anthropology degree, Dest spent time in AmeriCorps, leading to his interest in patient care after working in a community health center in Berkley, California. “It was a 10 month program and after I finished, I got hired on and worked my way up into the quality improvement department there, at the community health center. I was doing a lot of stuff related to patient experience. I worked with the patient advisory council within the community health center and I did a lot of data analytics.” Right from the start, it’s clear that unique experiences have shaped Dest’s career path, from his Anthropology interests at UNC (Professor Rivkin-Fish’s classes are one of his top recommendations) to a study abroad program in Brazil, his subsequent work in AmeriCorps, and now at Johns Hopkins pursuing a masters in Health Administration.

Like many students at UNC, Felipe Dest arrived to college with an interest in pursuing a career in medicine . He was aware of his interests in public health, sociology, and environmental impacts on health, but struggled to find a program of study that truly reflected and encompassed all of these areas. After some friends recommended that he take a class with Professor Rivkin-Fish, he realized that medical anthropology was this program that he had been looking for. Dest noted that “it seemed to culminate all those things I was interested in,” and he enjoyed the way the classes challenged him to think about health and systems of care from different perspectives.

Dest’s academic interest in anthropology is also reflected in the extracurricular activities he was involved in at UNC. He was involved with MANNA Project International through Nourish International, a part of the Campus Y, where  he worked with a UNC anthropology professor on summer projects in Peru. He remembered how the professor would provide the local residents with basic health necessities in exchange for community protection of his archeological dig sites. Dest’s studies in medical anthropology also helped him determine where he would spend his semester abroad. He studied in Brazil, analyzing the health care systems and methods of healing in the local society, with a specific focus on nutrition. This experience led him to working with the UNC Center for Health Promotion and Disease Prevention, working with a Warren  County community to promote healthy eating and food security. Through these activities, he developed his passion for patient-centered care. His work helped him develop into a patient advocate, giving patients a stronger voice to assert their health needs.

Post-grad life definitely hasn’t swayed Dest from his passion for medical anthropology. His anthropology degree is something that has been a major talking point in his interviews. He’s looking forward to spending the coming months working in and observing hospital life and attributes his observation skills to his time studying under UNC’s anthropology department. He’s pursuing his passion of patient-centered care and restructuring healthcare systems in his Masters work in Health Administration. His main priority is taking care of patients and, in doing so, considering the “different factors that play a role, whether it’s environmental, political, structural, or social.” Dest is appreciative of his anthropology background having given him a perspective outside of that of a businessman or a healthcare provider.

That outside-looking-in point of view really came in handy when he did a stint in AmeriCorps prior to graduate school. He was able to coordinate the patient advisory council, implementing new initiatives and programs, ultimately giving patients a stronger and more active role in their own care. He has always been committed to revealing the heart of the issue or need.  Anthropology, he believes, will allow him to do just that. “You could figure out more in depth like what staff or organizational culture is like and provide analysis on a way to actually improve it from a deeper level, which would result in more sustainable or longstanding change.” Dest felt most impacted when it came to his view of health care, both nationally and internationally. His eyes were opened by his Carolina education to conditions around the world and what health care actually looks like, logistically from the most basic levels to the chaotic functionality of a busy hospital. He emphasized the Health Administration program as a perfect fit for him as he’s always been interested in enacting policies at a larger level, as a person who “could change things.”

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Year of graduation: 2011

Profession/employment/post-graduate study: ten-month AmeriCorps immediately following graduation; currently pursuing a Masters degree in Health Administration at Johns Hopkins University

What inspires you: The desire to give patients a stronger voice and make them more active participants in healthcare; solving complex challenges

Favorite anthropology book: When Bodies Remember: Experiences and Politics of AIDS in South Africa by Didier Fassin

How I define medical anthropology: The ways that political and social structures impact systems of care delivery and people’s perceptions of their own health

By Katie Huber, Hayley Conyers, Rachel Bailey, and Doreen Nalyazi

[FD1]an interest in pursuing a career in medicine. (or something like this. My actual desires to become a doctor were quite low.)

[FD2]The Peru project was with Nourish International (also part of the Campus Y)

[FD3]Warren County

[FD4]I would find a different way to say this. I’m not sure what’s meant by the superficial aspects of organizational work.