Vulnerability as strength: Thoughts on changing medicine’s hidden curriculum

Lab-coats-300x223My most recent post at Absolutely, Maybe is up. Here’s an excerpt:

I recently read this article in Health Affairs regarding the effects of the hidden curriculum on patient safety and, in my usual fashion, have been thinking about it ever since.

Dr Joshua Liao describes an experience he had as a medical student on labor and delivery, when the dynamics of his team contributed to his fear of speaking up about not knowing how to do something. He highlights the importance of subtle team dynamics and pressures:

“Egregious behavior is just the visible tip of a much larger iceberg. Far more prevalent are the subtle behaviors that threaten patient safety but go largely unnoticed and unaddressed… Progress in patient safety may be hindered as much by such subtle behaviors as by overtly inappropriate physicians.”

I share his concern about the challenges of eliminating the hidden curriculum. My medical school’s patient safety curriculum included several small group sessions, during which I heard my own concerns echoed by classmates: how should we navigate hierarchy? Who can we turn to for support? How do we avoid retaliation – both overt and subtle?

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* Image: Lab 15 – Lab coats, from Pi via Wikimedia Commons.

On a Meeting of Selves

When I last wrote, I shared with you the beginnings of some thoughts about emotion, identity, and politics. Here, I share an excerpt of something I wrote years ago, when I was fresh out of my first two years of med school and brimming with thoughts and feelings about intimate encounters across difference:

When I was a first year medical student, a group of students and I had to practice our communication skills using standardized patient actors. In this particular case, the patient was a “difficult” person who did not want to share their information with us. As always, the goal for this interaction was to be kind, empathetic, and effective at extracting relevant details of the patient’s story.

I was the first student to interview the patient actor. His story (all invented for the purposes of the exercise) was that he was a rich, 60-something white man with alcoholism. He was coming to me because he had just been charged with a DUI, and he wanted me to help him sign some papers for his legal case. However, he was reluctant to admit that he had a drinking problem and refused to tell me what had happened. Throughout the interview, snippets of the situation were eventually revealed. He had been drinking and driving when he hit a young black girl, who ended up paralyzed from the waist down. His excuse was that “it’s so hard to see those people at night anyway.” He consistently undermined my authority and my right to be there, expressing his shock that they were letting people like me into medical school.

The fact that he was an actor was inconsequential. It felt all too real. I simply did not handle it well. Afterwards, in a room full of other students, none of whom were black, I was given feedback about my performance: I was condescending. I wasn’t compassionate. I shouldn’t let race- and gender-based comments get to me.  He admitted that he had baited me, but argued that it was my obligation to be kind to him anyway. On my best days, I agree. But such an orientation is easier said than done.

[A note: Though I learned a lot from this experience, I have complicated feelings about the educational merits of using an older white man for the explicit purpose of peppering me with microaggressions as a teaching point. But that’s a topic for another day.]

I share this story both to reveal that I am not always a shining bastion of empathy and interpersonal connection, and to highlight that the issues of empathy and love are, for me, a personal one. In that moment when I was sitting with a person who I didn’t understand, who embodied every stereotype that I could have thought of, and who so clearly was not willing to connect with me, I did not act my best self. More frustratingly, I recognized that my reaction to this patient had as much to do with my past (with other people who look like him) as it did with his behavior in that moment. As Rankine so powerfully illustrated in the quote I shared in my last post, there was too much between us that was not about us for this moment to have ever been generative. And it stoked, for me, the question about forgiveness: should I forgive him for what he represents and how he acts? Am I obligated to be kind to those who are not kind to me? Do these obligations change when we’re in a professional setting – medicine – in which care is what you are offering?

Much of my thinking, whether academic, political, or personal, is fixated on the possibility that we will ever be able to connect meaningfully with those who differ from us, particularly when our relative relationships to power are not equal. How can we realize new forms of solidarity? Is this at all possible? I hope to use the space I have here as one in which I begin the long process of making sense of identity and the limits of empathy. I am, as always, filled with more questions than answers.

On Love and Forgiveness

A little while ago, I decided to make a project out of forgiveness. At the time, I thought this would be a simple task. I would identify those relationships – or perhaps more accurately, those people – who were problematic or with whom I was holding onto anger, and I would let it go. Just like that, I’d be unfettered by rage, despair, disappointment, and bitterness. Much like dusting out a closet at the onset of spring, I’d find myself lighter, freer, and however briefly tidier, all in an afternoon’s work. Lest you be fooled into thinking that I am a particularly excellent person, I will be the first to admit that I entered this project with the misplaced hubris with which I often begin my personal endeavors. Simply put, a not insignificant part of me imagined that forgiveness would be as simple as declaring that I had forgiven and forgetting anything ever happened. Just like that, I would let bygones be bygones.

I’m sure you see where this is going. In practice, letting go is not that simple. First, it was an exercise in patience – with myself, with the other person, with the slow process of rebuilding or recrafting a relationship. Second, I couldn’t seem to forget. Around this time, I reread Avery Gordon’s Ghostly Matters and was captivated by her metaphor of haunting, of the ghosts that lie just below the surface of the present; in my mind, her writing captures perfectly the problem of forgiving and forgetting. There is no forgetting — that which we are aiming to suppress lies just beyond reach, salient and important nonetheless. But more importantly, it captures the historically-imbued nature of the present: in other words, how the past seeps into the present in unexpected and often unacknowledged ways. Despite my efforts, it was often the case that while trying to interact with or think about Person I Have Forgiven, there was always, frustratingly, a touch of Person Who Has Done Me Wrong in the mix.

Now, seeing as my job as an anthropologist is to extract every last morsel of meaning out of the mundane, everyday ordinariness of fleeting interactions and developing relationships, this fixation with forgiveness and haunting seeped slowly into my intellectual life. And, in the wake of a series of events on my campus honoring the legacy of Dr. Martin Luther King, Jr., I found myself reading his work on love and forgiveness: in particular, his writing on loving your enemies. Of loving our enemies, he writes that it is first important that we learn to forgive, for “He who is devoid of the power to forgive is devoid of the power to love. It is impossible even to begin the act of loving one’s enemies without the prior acceptance of the necessity, over and over again, of forgiving those who inflict evil and injury upon us.” And while people can ask us to forgive them, he notes, he suggests that the forgiving act must be “initiated by the person who has been wronged, the victim of some great hurt, the recipient of some tortuous injustice, the absorber of some terrible act of oppression.” 

I start with this, and with Martin Luther King, Jr. not only because he has recently been commemorated but also because of the particular hold that his legacy has in the imagination of a better, more just world. But also, as I think through emotions and their link to the political imagination, I’m captivated by King’s use of the emotions to rouse the sentiments of the nation (and I’m not the only one: see, for example, this report describing King as an emotionally intelligent leader, or the many analyses of the potency of King’s “I Have a Dream” speech).

As I start thinking through the “cultural politics of emotion,” with King’s reflections on love, hate, and forgiveness, I’m guided by two central questions that structure my research: 1) How do love and hate, empathy and disgust, fear and paranoia, shape reactions to and interactions with others in America today, particularly refugees and other racialized groups; and 2) How might we imagine the role of the emotional realm in imagining the political? What is the landscape of feelings that we imagine might bring us closer to justice?

In King’s speech, he recommends precisely what I and others often struggle to do: to forget without turning a blind eye, to reconcile and to commit to a new start. This, he suggests, is central to loving our enemies.

Forgiveness does not mean ignoring what has been done or putting a false label on an evil act. It means, rather, that the evil act no longer remains as a barrier to the relationship. Forgiveness is a catalyst creating the atmosphere necessary for a fresh start and a new beginning. It is the lifting of a burden or the cancelling of a debt… Forgiveness means reconciliation, a coming together again. 

But in my personal life, Person Who Has Done Me Wrong is someone who, in the context of our relationship, has hurt me in some way big or small, real or imagined. There is an act for which they are being forgiven. But what if the problem is not so much one specific action so much as the fact of your different racial inheritances, privileges had but not earned, or other facts of asymmetry in a relationship? Perhaps this person is not the one who has harmed you, but looks an awful lot like someone who has, or someone who’s hurt your ancestors. In Citizen: An American Lyric, her stunning book of poetry, prose, and images, Claudia Rankine captures this phenomenon well, writing:

A friend argues that Americans battle between the ‘historical self’ and the ‘self self’. By this she means you mostly interact as friends with mutual interest and, for the most part, compatible personalities; however, sometimes your historical selves, her white self and your black self, or your white self and her black self, arrive with the full force of your American positioning. Then you are standing face-to-face in seconds that wipe the affable smiles right from your mouths. What did you say? Instantaneously your attachment seems fragile, tenuous, subject to any transgression of your historical self. And though your joined personal histories are supposed to save you from misunderstandings, they usually cause you to understand all too well what is meant (14). 

These interactions, between historical selves and self selves, past and present, wronged and oppressor, letting go and holding on, are the subject of much of my work. They also form the basis of a series of posts I hope to eventually make about emotions, the political, and identity (with an emphasis on race/ethnicity, in particular). More soon.

(Hi)stories our bodies tell: experiencing racism

Sharecropper, by Elizabeth Catlett.
Sharecropper, by Elizabeth Catlett.

My latest for Scientific American blogs:

I am currently still reveling in Black History Month. Yes, it is no longer February. But I hope to retain that mindfulness, grasping onto this moment each year that forces us to pay attention to the stories of black peoples across America and draws into stark relief how histories have been written to erase the contributions of people of color. It is a month where we highlight the achievements of the African Diaspora and pay attention to how our present situation has come to be.

As I write this, I am sick. It’s just your run of the mill, achy-runny-stuffy cold, nothing serious. But it comes on the heels of two weeks of frantic activity, high stress, and seemingly endless midterms. Many of us experience this: just as we come out of a stressful period, our bodies break down, we get sick, and we are forced to rest.

But stress is broader and more serious than the worry of turning papers in on time, and the consequences can be much more detrimental than the occasional cold. While momentary stress can help us deal with an impending crisis – the oft-mentioned fight-or-flight response – chronic stress is linked to increased risk of disease. Stress has been linked to everything from heart disease to the ability to cope with cancer. There is also evidence to suggest that long-term social stressors are particularly challenging for us to deal with.

Read more… 

*The image of Sharecropper, 1952, printed 1970, color linoleum cut on cream Japanese paper by Elizabeth Catlett via Wikimedia Commons. Read more aboutthis work and Elizabeth Catlett.

Out from the shadows of racist anthropology…

Skull-300x205The skull was smaller than I expected it to be, shockingly light in my hands. Despite its yellow-stained surface it had the appearance of being well kept, almost as if it had been polished. On the forehead was a simple label: American Idiot. As if that told us everything we needed to know about the person whose thoughts it had once held. I stared at it for a while, then passed the skull on to the student next to me.

In the center of the class of bright-eyed first year grad students stood a cart containing specimens from a large collection of skulls owned by the university. They had been collected by Samuel George Morton who was famous for his craniometry studies, in which he classified human races by skull size. His ultimate argument was that “Caucasians” had larger skulls (and therefore larger brains) than the other races that he had studied.

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The image of the inscribed, unidentified skull is from Wellcome Images.


Be vital. Be involved.

I have spent quite a bit of time thinking about this Gerald Berreman quote from a recent Savage Minds post:

“Our professional obligation is to present what we know and the inferences we draw from our knowledge as clearly, thoughtfully, and responsibly as we can. This is a value position with practical and humane consequences and with scientific legitimacy.

His call to be vital and involved has me thinking about what our professional obligation is as anthropologists (and perhaps scholars in general). This preoccupation started in earnest a few months ago, when I went to see Michelle Alexander speak about The New Jim Crow. While the talk was fascinating, equal parts enraging and inspiring, I have spent the most time since that event thinking about the question and answer session. 

To be honest, I only really remember one woman, who identified herself as a member of the community. She told us how her son, after fooling around with some of his friends in a local park, was arrested and detained without bail or concrete charges. How she went to visit him in this facility and saw a room full of black boys ages 18-25. How when the bail was set, it was so high she had to mortgage both her house and her parents’ to pay the fine. She was at a loss to figure out how to get the best legal representation for her son. In desperation and frustration, she e-mailed faculty members across the region who studied mass incarceration, and none of them responded. For her, this was a source of outrage and shock. How could no one have responded to her? What were we here for, studying this stuff, if we aren’t going to help community members as they need it?**

Since then, I have been thinking about what activism means in the academy, and what implications an activist orientation has for our scholarship. More than that, though, what are our obligations to go beyond the production of socially-relevant information? To what extent can and should we be available to our communities? While I had previously considered the extent of my engagement to be the clear, thoughtful, and responsible presentation of my findings, I am wondering: what else I should and could be doing in the future to engage ethically in research?

This issue has continued to vex me because like many physician-anthropologists before me, I do not have a neutral stance towards the phenomena that I study. Additionally, as I become more aware of feminisms of color and womanism, I am increasingly thinking of praxis as central to my scholarship. This is all to say that I have a perpetual eye for change, and believe it is my ethical obligation to consider: How can I make use of my position as a physician & a scholar to fight oppressive structures? How can I work to change the systems that I am a part of that contribute to human suffering and inequality?

Academic Activism

This is a perennial topic, and I am certainly not the first student to wonder how to integrate their activist leanings with their scholarship. I recently read  Eric Grollman of Conditionally Accepted’s  response to Fabio Rojas‘s critique. Can academics and activism mix? I think, ultimately, I am likely to agree with Dr. Grollman, and cannot imagine engaging in this career without an element of activism. I’m hoping to avoid the beating that grad school promises (wishful thinking, perhaps?).

For my part, I do not want to be separated from the work of, in my case, thinking critically about health care and access. On the one hand, academic critique, rigorous data collection, and creative dissemination of research findings can be instrumental in raising awareness. Dr. Alexander’s cross-country travel to promote her work highlights one way that we can become clearly involved in shaping the discourse around key issues in this country. One the other hand, in some ways I decided to become a physician, and to some extent an anthropologist, because I am attracted to the particular. I’m interested in reaching out to *specific* individuals and leveraging the resources and institutional privilege I have to make change. 

I also wonder what I should be doing now as opposed to later. On the one hand, I’m full-time in a strenuous program, and in some ways I feel stretched thin already. On the other hand, I long for more involvement. I long to do the work. I want to be more in touch with what I told myself I’m here for. Many of my grad school friends (especially this last, first, semester), express a feeling of disconnection – from ourselves, from the work that sustains us, and from communities that support us. I do feel less active, less involved, and more distant as I slowly surround myself more and more with books and spend the day strapped to my computer. 

It is becoming clearer, however, that attention to poverty and inequality does not limit us to working outside of academia. Karen Kelsky’s recent PhD student debt survey revealed the ridiculous amount of academic debt and poverty in the academy and took my breath away, and numerous articles drive home the point that the academy is in serious trouble. Additionally, a recent Tenure, She Wrote posts breaks the silence surrounding poverty and the amount of inequality that exists within our own ivory walls. Activism is no longer something we do to help “them” outside of the walls of academia, but an attention to the staggering numbers of contingent faculty and unemployed PhD is vital for us all to address. For now, when I feel like I never leave the academy, becoming more knowledgeable about the issues in academia might provide an outlet for me to be involved in meaningful change in my institution. 

** I think I should be clear that I don’t mean this post as a critique of the faculty, but more a musing on what the place this sort of engagement holds in anthropology.