Lectures

The Thinness of Care: The Promise of Medical Anthropology in MD/PhD Training

In the mid-twentieth century, recognizing the growing need for innovations born of clinical experience, pathways for training MD-PhD physician-scientists emerged in the hopes that this hybrid training could produce novel insights into disease and ultimately, treatments. In the years since formal MD/PhD training programs were established, a growing number of institutions have established pathways for a combination with non-traditional disciplines, like anthropology, alongside more traditional degrees in the basic biological and physical sciences. Increasingly popular with pre-medical students, these programs have grown in size and prominence. Recent investigations into this training pathway find that MD/PhDs in the social sciences and humanities are able to successfully meet the goals of these programs, and are ultimately “involved in mutually-informative medical research, clinical practice, and teaching – working to improve our responses to the social, cultural, and political determinants of health and health care” (Holmes et al. 2017). Implicit in this characterization of the growth of dual-degree career paths in the social sciences and humanities is that such programs will serve to address medicine’s failures in these arenas–that is, the shortcomings that have long been the focus of social theorizing about medicine.

As dual-degree trainees in anthropology and medicine, we have experienced firsthand the hope attendant in the figure of the physician-anthropologist; such affective investments, indeed, brought us to this path. In this essay we reflect, from our positions as combined trainees nearing the end of our program, on the promise of the training we will complete and our roles in the futures of anthropology and medicine alike. We suggest that while the goal of such programs may be to produce mutually-informative research across the fields of medicine and anthropology, such exchanges are often understood to be one-directional. In the recent study of physician-scholars in the social science and humanities cited above (Holmes et al. 2017), for example, participants elucidated several roles for graduates of these programs. The first, notably, was to contribute to “training clinicians to be more sensitive and critical thinkers.” As we will elaborate, the curricular role of such scholars is among the most prominent in framings of this field. The other themes also revealed the potential insights that the social sciences and humanities could give to medicine: contextualizing the culture of medicine itself and understanding the patient experience. Finally, in this work physician-scholars in the fields of the social sciences and humanities are uniquely poised to intervene upon policy, given the focus on their various fields of scholarship on the social world. 

These comments reflect the many ways that anthropology is framed in the encounter between medicine and anthropology that the physician-anthropologist represents.[i] In each instance, the role is to transform medicine through the encounter with anthropological thinking. As trainees in these fields, we call attention to this framing because these encounters are perhaps more fraught and complex than common discourses would represent. In our estimation, many of the tensions present in the relationship between anthropology and medicine — and thus, those embedded in the training of the physician-anthropologist — stem from basic contradictions at the heart of medical anthropology itself. Is the role of the anthropologist to be the cultural broker, who translates the world of society into the clinic, thus preventing harm to patients? Or is the anthropologist a critic of the system at large, hoping to deconstruct the vagaries of biomedicine towards a new and more radical future? The physician-anthropologist, whose training represents a sustained experiment in such encounters between the anthropologist and the clinic, embodies these tensions. In practice, we find, this question is less either/or and more both/and, with the physician-anthropologist confronting the longstanding contradictions of what Nancy Scheper-Hughes termed “clinically applied” medical anthropology (1990).

If physician-anthropologists promise to bridge medicine and anthropology, it is worth looking at the frameworks that exist for managing this interface.  Throughout our training, these conversations have been dominated by the framework of structural competency, as articulated by Jonathan Metzl and Helena Hansen (both physician-scholars) and elaborated by many others (e.g., Bourgois et. al 2017, “structural vulnerability”). In this paradigm, structural competency is defined as:

“the trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases (e.g., depression, hypertension, obesity, smoking, medication “non-compliance,” trauma, psychosis) also represent the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, or even about the very definitions of illness and health”

(Metzl and Hansen 2014: 128)

Structural competency draws the attention of practitioners and trainees towards both the presence of injustice, as well as the participation of health systems in entrenching inequality. In doing so, this paradigm levels a critique of medical institutions and creates an opening for social theory to meaningfully intervene in medical practice.

This body of literature is key to understanding the role that is imagined for the contemporary physician-anthropologist. First, much of this work was initially developed by physician-anthropologists and other physician-humanists and social scientists. In many instances, these curricula are shaped and taught by physician-anthropologists as well. Second, we suggest that, in their mere existence, physician-anthropologist training programs exist to further the aims of cultural humility and structural competence in medicine more broadly, training a cadre of practitioners whose habitus is fundamentally shaped by these conversations. Broadly speaking, these literatures and the training of physician-anthropologists are animated by the same political desire.

The contemporary emphasis on the structural dimensions of the relationship between medicine and society emerged in part in response to older models’ perceived failings. Key interventions in early medical anthropology entailed understanding diverse perspectives on the body, health, and healing, often in contrast to Western biomedicine. In time, the recognition that biomedicine itself had a culture led to important interventions into medical practice. Often, these interventions were framed in the language of cultural competence, which aimed to instill in healthcare providers a framework for approaching cultural difference in the clinic. They worked to increase physician awareness of cultural difference, deconstructing the hegemony of Western biomedicine to acknowledge the importance of other ways of being and healing, highlighting the many approaches that individuals from different communities may have to ensuring health and wellness. This training also drew from narrative approaches in medical anthropology to focus on the experiential dimensions of suffering, understanding illness as a culturally-shaped and -determined, yet ultimately individual experience with countless forms (e.g. Kleinman 1988). At its best, cultural competence instilled empathy and curiosity. Yet, as Metzl and Hansen wrote, even as they acknowledged the historical value of cultural competency, “the politics of the present moment challenge cultural competency’s basic premise: that having a culturally sensitive clinician reduces patients’ overall experience of stigma or improves health outcomes” (126-7).

We do not mean to imply a linear trajectory from cultural competency to structural competency or suggest that culture is no longer relevant to medicine (nor would the proponents of structural competency suggest this). These ideas have been reimagined in many different ways. Proponents of cultural humility refined these culture-centered approaches, steering away from the operationalization of cultural competence as a list of attributes of particular groups that must be learned and memorized by trainees and practitioners. Instead, structural competency-informed paradigms promote the production of an orientation towards patients which emphasizes curiosity, uncertainty, and non-knowing (Tervalon and Murray-Garcia 1998; Kumagai and Lypson 2009; see also Kleinman and Benson 2006). 

Yet we draw attention to the fact that in all of these paradigms, the relationship between medicine and medical anthropology is understood in a consistent way: it is often assumed to be a one-directional transfer of knowledge. As physicians with academic training in anthropology, we are expected to bring knowledge — of culture(s), or more likely, of marginalized or oppressed people’s lives — into medicine. Sometimes this is figured as translation: much like a cancer biologist might provide biomedicine with knowledge about the molecular process in a particular malignancy, an anthropologist provides biomedicine with specific knowledge about human cultures. Other times, this is figured more critically: anthropologists should not contribute to medicine, but instead should seek to expose and transform the forms of oppression and violence upon which medical practice depends (Scheper-Hughes 1990). In either way of looking at it, medicine will be enhanced or transformed by anthropology, and not the other way around. We might think of this as part of the “field imaginary” of medical anthropology. This term, used by Donald Pease and elaborated by feminist theorist Robyn Wiegman, refers to, “the field’s fundamental syntax—its tacit assumptions, convictions, primal words, and the charged relations binding them together” (Pease 1990:11; see also Wiegman 2012). This is not to say that all medical anthropologists exclusively see their work as an application of anthropological ideas to medical practice. But it is important to call attention to this skewed pattern, not so much as a set of rigid or explicit boundaries on anthropological work, but rather as a set of partly disavowed desires. In other words, in an interdisciplinary space whose terms are usually set by the language of medicine or by a critique of medicine, we see an opportunity to reverse the gaze and think reflexively about the anthropology in medical anthropology.

In his critique of thick description, John L. Jackson writes of “a hubris at the center of the anthropological project, a hubris that has imagined ethnographic thickness to be far thicker than it actually is” (Jackson 2013:14). Jackson is concerned with the distortions of a body of knowledge that refuses to acknowledge its limits. Yet as anthropologists increasingly see their work of knowledge production as a form of care (Munyikwa 2019), this hubris might be not only about the thickness of our descriptions but also about the power of our caring. It is often the case that the claim to thickness is not just a testimony to the epistemological grounds of anthropology but its ethical grounds too. Thickness is what frames ethnographic knowing as not only more true, but more just. In its holistic approach to the lifeworlds of the ethnographer’s interlocutors, anthropological ethnography makes a claim towards omnipotence. This care is also the affective grounds of anthropology, enabling ethnography itself to be read as a practice of care towards the other. If, as Jackson posits, we may benefit from embracing the epistemic potential of thin description, we may further probe thin description’s challenge to the grounds of just ethnography. 

In medical anthropology, in particular, we run the risk of representing anthropological practice as a kind of pure or authentic care through an opposition with biomedical care, which is made to appear reductive, superficial, or insincere. Jackson writes that he wants to challenge an anthropology that, “would pretend to see everything and, therefore, sometimes sees less than it could.” In a similar spirit, we ask what it would mean for anthropology to acknowledge the thinness of its care. This might begin with recognizing that many of the faults that anthropologists find with biomedical practices are reflections of the perceived shortcomings of our own field. We, too, do violence to our interlocutors’ lifeworlds through abstraction and analysis. Our relationships are limited by the time horizons of research initiatives, and they are shaped—no less than doctors’ relationships—by the mercenary anxieties of professional advancement. Freed from this exaggerated binary, we might be better able to realize the depth and complexity of biomedical caring. In this sense, anthropology might have something to learn from medicine.

The potential fruits of this reframing are multiple, but one potential area of transformation is with respect to the anthropological optimism around knowing. There remains an optimism, rooted in the critical turns of anthropology, which places faith in the radical political potential of comprehensive understanding. By knowing better — and, particularly, through the production of just knowledge — we may productively intervene upon conditions of injustice and social inequality. However, decades of anthropological investigation have produced a wealth of knowledge about the failures of good intentions — indeed, the subdiscipline of medical anthropology is perhaps the vanguard of such investigation. Grappling with the contradictions inherent in the simultaneous will-to-know and acknowledgement of the tenuousness of action is, we suggest, necessary to imagining alternative paths for medical anthropology. We are particularly inspired by anthropological work that emphasizes the radical potential of uncertainty and not-knowing (e.g. Stevenson 2014), as well as recent trends in scholarship across feminist and queer theory and Black studies which complicate optimism, framing a pessimism that does not veer into despair but rather acknowledges the complexities of human action and brings political futures to fruition. 

An aspect of the clinician’s orientation which is commonly perceived as burnout, cynicism, or pessimism may be fruitful here. Physicians often find themselves laboring in systems whose transformation is far from guaranteed, negotiating an ethical position of action that exists in spite of the dearth of optimism. Medical acts do not necessarily have to produce revolution to be ethical — rather, they just are — and such pragmatic form of action is a hallmark of a field whose claim to heroism is weaker with each passing day. Anthropological framings of care often reveal a hope, on the part of the ethnographer, that empathy and positive sentiment can undo what years of inequality have wrought; perhaps by attending to the affective orientation of the clinician, we might find a new anthropological orientation less rooted in the optimism of feeling hopeful but rather in an embrace of the ethical stakes of toiling forward in a struggle that holds no guarantees (Hall 1986). In this, we suggest, medicine has much to offer anthropology.


Joshua Franklin is a medical anthropologist and student in the MD/PhD Program at the University of Pennsylvania. His dissertation, entitled Following the Child’s Lead: Care and Transformation in a Pediatric Gender Clinic examined practices of gender-affirming care for children and adolescents.

Michelle Munyikwa is an MD candidate at the University of Pennsylvania, where she earned her PhD in anthropology in 2019. Working at the intersection of political and medical anthropology, she has conducted fieldwork across the United States on race, migration, and politics. Her dissertation, “Up from the Dirt: Racializing Refuge, Rupture, and Repair in Philadelphia,” integrated archival research, ethnographic participant observation, and contemporary media analysis to examine the challenges that institutions face in resettling refugees in Philadelphia.


Notes

[i] Anthropologists are prominent among SSH MD/PhD trainees; they represented 22% of those surveyed by Holmes et al. (2017), the most frequent discipline after health services research (24%). Our discussion here is specific to our experience as anthropologists. While it may be true in some regards for historians or bioethicists, it likely differs as well. The construction of “social sciences and humanities” as a meaningful category in relation to medicine is a topic worthy of further consideration.

Works cited

Bourgois, Philippe, Seth M. Holmes, Kim Sue, and James Quesada. 2017. “Structural Vulnerability: Operationalizing the Concept to Address Health Disparities in Clinical Care.” Academic Medicine 92 (3): 299–307. 

Hall, Stuart. 1986. “The Problem of Ideology: Marxism without Guarantees.” Journal of Communication Inquiry 10 (2): 28–44. 

Holmes, Seth M., Jennifer Karlin, Scott D. Stonington, and Diane L. Gottheil. 2017. “The First Nationwide Survey of MD-PhDs in the Social Sciences and Humanities: Training Patterns and Career Choices.” BMC Medical Education 17 (1): 60.

Jackson Jr, John L. 2013. Thin Description: Ethnography and the African Hebrew Israelites of Jerusalem. Cambridge, Massachusetts: Harvard University Press.

Kleinman, Arthur. 1988. The Illness Narratives: Suffering, Healing, & the Human Condition. Basic Books.

Kleinman, Arthur, and Peter Benson. 2006. “Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It.” PLoS Medicine 3 (10): e294.

Kumagai, Arno K., and Monica L. Lypson. 2009. “Beyond Cultural Competence: Critical Consciousness, Social Justice, and Multicultural Education.” Academic Medicine 84 (6): 782–87.

Munyikwa, Michelle. 2019. “On Gratitude, Ethnography, & Care.” S Y N A P S I S (blog). October 28, 2019. https://medicalhealthhumanities.com/2019/10/27/on-gratitude-ethnography-care/.

Pease, Donald E. 1990. “New Americanists: Revisionist Interventions into the Canon.” Boundary 2 17 (1): 1–37. https://doi.org/10.2307/303215.

Scheper-Hughes, Nancy. 1990. “Three Propositions for a Critically Applied Medical Anthropology.” Social Science & Medicine 30 (2): 189–97.

Stevenson, Lisa. 2016. Life beside Itself: Imagining Care in the Canadian Arctic. Berkeley, California: University of California Press.

Tervalon, Melanie, and Jann Murray-Garcia. 1998. “Cultural Humility versus Cultural Competence: A Critical Distinction in Defi…” Journal of Health Care for the Poor and Underserved 9 (2): 117–25.

Wiegman, Robyn. 2012. Object Lessons. Durham, North Carolina: Duke University Press.


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