Category Archives: Alumni voices

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.”

****

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.

Sarah Sexton: “Promotion of Health Access in Peru’s Sacred Valley”

sarah-1

As I placed my feet onto the red-eye flight to Lima, Peru I instantly felt a rush of emotions that had been building up in my stubborn self for several months. From the discussions of packing to the safety concerns from my family, it was not until my long flight that I started to consider what I had gotten myself into. The next 24 hours of travel that involved several plane transfers, unsafe cars, donkeys, and wagons proved to become a microcosm of the adventures I had voluntarily placed myself in for the next few months.

As a health education coordinator working for Sacred Valley Health in Ollantaytambo, Peru, it was my responsibility to develop and train community health workers (promotoras) in 7 surrounding communities. With little knowledge about the communities, I found my first day hiking 8 hours with a Peruvian nurse to quickly learn about my main areas of focus. Let me say that hiking over 14,000 ft. passes and extreme conversation barriers leaves a lot of time to think, and a lot of time to complain about your aching legs. In fact, the majority of my time in Peru was spent in solitude trekking across the mountains, riding donkeys across the passes, or more commonly hitchhiking in the back of an animal truck just praying to get back to my village. Everyday I left my home in Ollantaytambo, never knowing what danger I may face, or if I would make it down the mountain alone. If I wasn’t hiking or up working in one of my communities, my time was spent in my own village. This often included hour-long meals eating guinea pig, being chased by rabid dogs, or more simply just living out underneath the beauty of the stars. With zero electricity, I didn’t have any modern conveniences such as a hot shower, running toilet, or even a normal sleeping arrangement for several months. Despite the hardships that I faced, these were the three best months of my life, and I am yearning for the moment that I can return.

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Bobby Nieland: “Life and death”

I believe that my personal discovery of the field of medical anthropology, though occurring relatively late in my time at university, has nonetheless been one of the most influential aspects of the liberal arts education that I attained at UNC. And though the readings from my med anth classes reached far and wide in content, one text in particular from a class with Professor Rivkin-Fish continues to stand out with rippling effects in my life: …And a Time to Die. How American Hospitals Shape the End of Life by Sharon Kaufman.

Kaufman’s book grapples with a topic that is by its very nature innumerable shades of grey in every respect. How do we think about death? How do we think about others’, our own, as a concept, or as an acute reality? How are specific ways of dying created and promoted in the American hospital setting? What sociocultural, political, and economic factors play into creating these paths and guiding (or forcing) people along them? How much of the decision process do you want responsibility for, or do you think you should be responsible for, in another’s death? In your own? How do you want to die? When? Where? Why do people think they can ultimately have a real choice when it comes to these questions? I hadn’t honestly thought in depth about many of these ideas before coming in contact with Kaufman’s book. My major take away from the text: death is an invaluable discussion to have with friends and family during life and any time is the right time. In respect to life and death, I personally believe that ignoring the inevitability of the later can truly detriment one’s experience of the former.

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