In the latest installment Stephen Shortell, Ph.D., M.P.H., M.B.A., professor of health policy and management emeritus at the University of California, Berkeley School of Public Health, and Mark Fleming, Ph.D., assistant professor of health and social behavior at the University of California, Berkeley School of Public Health, discuss the field of medical anthropology and how it can be used to examine patient-centered research and power structures within the field of HSR.
This conversation has been edited for clarity and brevity.
Dr. Stephen Shortell:
What’s unique about the field of anthropology?
Dr. Mark Fleming:
Anthropology seeks a holistic interpretation of human life and considers people’s experiences as forms of power relations and patterns that shaped their life.
It’s probably most closely associated with its main methodological approach known as ethnography. I think of ethnography as conducting research by using yourself as a research instrument and directly encountering people in the places they live, work, seek care, and engage in public life.
I think health services researchers are familiar with ethnography as a form of qualitative data collection. But it’s also cultivating an openness to what you find in the unexpected.
Dr. Shortell:
How is the field of medical anthropology adding to the evidence base of HSR?
Dr. Fleming:
Medical anthropology looks at Western medicine as a culture and a tradition, and how medicine and health care institutions are constructed in social and cultural contexts.
We’re trying to find out what medicine says about people, how medicine is influenced by the broader cultural context, and how those cultural norms are embedded in medicine. And on the other hand, how medicine influences the broader culture.
Dr. Shortell:
Tell me about the research you're doing in the HSR realm.
Dr. Fleming:
I look at interventions to address social determinants of health (SDOH) for people with frequent emergency department visits. We know these people are more likely to face significant social adversity or structural inequality and racism—things like housing insecurity, food insecurity, lack of income, and unmet health care and behavioral health needs.
My particular focus is on case management and navigation programs as strategies to provide integrated services. There's great enthusiasm for these kinds of programs and they're being implemented widely, but less is known about how they work.
We use data sets to find out quantitatively if a change in utilization and integration of social services leads to improved health outcomes and use of less acute care.
Effectiveness is just one component of the research, though. The other part is trying to explain and understand it. To understand how delivering social resources by way of the health care system helps patients or changes their acute care, you have to understand what's going on with patients when they leave the hospital. This is particularly apt for an ethnographic approach based on establishing rapport with people who are oftentimes deeply distrusting of the health care system.
Dr. Shortell:
There's a lot of interest in being patient-centered, yet I have found that providers and provider organizations that are serious about it often still come from the perspective of the professional. It’s what they think the patient wants and needs, and not really listening to the voice of the patient. I’m curious about your thoughts on that through an anthropological lens.
Dr. Fleming:
To be truly responsive to what you hear, including what you hear across radically different experiences or perspectives, you have to be open to self-transformation.
For the entire field of HSR to have a more robust practice of including patient voices, we have to think about the nature of the relationship between researchers and the patients, and part of that involves reflection upon how researchers are positioned within structures of power.
Dr. Shortell:
To give an example of that, in the Paradigm Project we are trying to equalize power and lift the voice of the community in terms of what they see as the problem or challenge they face.
Let’s move on to the issue of trust, which has been relevant during the COVID-19 pandemic and particularly during the vaccine rollout. There’s a growing distrust in medicine and the ability of the health care system and science to deal with these issues. What’s happening with distrust in public health and medicine as a result of, or exemplified by the pandemic?
Dr. Fleming:
I think part of being an ethnographer is being in the awkward position of not really being in an institutional location within health care. To the health care providers, you're this odd person out; to the patients, you're not a provider.
Spending time in the community, getting to know people outside of the clinical setting, is one of the key pieces of learning about how power differentials and lack of trust operate to shape how people access care and make decisions around their health.
In terms of COVID-19, what comes to mind is the importance of continuing in-person research and the necessity of having in-person encounters with the people you want to know more about. During COVID-19, with all the separation between people, we’ve lost a lot of that understanding from multiple directions.
Dr. Shortell:
One of the things I've noticed is the importance of public health communications with the public. I think public health departments have learned over time to be transparent, but also being very candid about what they don't know. I think that comes out of your point, Mark, about carefully listening and thinking about what is it that the public and various groups really need from them.
Dr. Fleming:
Something else comes to mind here, which is understanding how our position as researchers shapes the knowledge that we make.
To understand the relationship between health institutions and communities, it's really important to understand how the history of those relationships affect the present. To do the kind of rigorous research that we need to do with our community, we need to understand how this history plays a significant part in the present, whether that's a history of mistreatment or misinformation.
Dr. Shortell:
As an anthropologist, if you were asked to study the field of HSR as a discipline or as an institution, how would you go about doing it?
Dr. Fleming:
Okay, I love that question, because as anthropologists we're always doing the thing where whatever we're doing informs our holistic interpretation of the context. As I'm developing this HSR agenda, I engage with researchers embedded in the health care system.
One question we’re asking is, ‘How are health services researchers situated in relationship to health care systems, but also in relationship to structures of power?’ And I don't just mean in terms of identity, but also in terms of the intellectual traditions of the field.
In terms of posing a reflexive question—a practice in anthropology where you include yourself and your position within the analysis—I would ask a question like, ‘Given that we know the structure of our economy causes significant poverty, what is the role of HSR in shaping it?’
Dr. Shortell:
How do you see medical anthropology informing the broader HSR field? What will success look like for you?
Dr. Fleming:
I would like analyses of how structures of power operate to be at the core of the HSR discipline, so that an analysis about the efficiency of a health care system includes how power and racial inequality operate within it.