SPECIAL ARTICLE
Medical anthropology and the physician assistant profession Lisa R. Henry, PhD
ABSTRACT Medical anthropology is a subfield of anthropology that investigates how culture influences people’s ideas and behaviors regarding health and illness. Medical anthropology contributes to the understanding of how and why health systems operate the way they do, how different people understand and interact with these systems and cultural practices, and what assets people use and challenges they may encounter when constructing perceptions of their own health conditions. The goal of this article is to highlight the methodological tools and analytical insights that medical anthropology offers to the study of physician assistants (PAs). The article discusses the field of medical anthropology; the advantages of ethnographic and qualitative research; and how medical anthropology can explain how PAs fit into improved health delivery services by exploring three studies of PAs by medical anthropologists. Keywords: medical anthropology, physician assistants, ethnography, qualitative research, biomedicine, culture
M
edical anthropology is a specialized subfield of anthropology, which at its most basic level investigates how culture influences people’s ideas and behaviors regarding health and illness. As Singer and Baer noted, “While recognizing the fundamental importance of biology in health and illness, medical anthropologists generally go beyond seeing health as primarily a biological condition by seeking to understand the social origins of disease, the cultural construction of symptoms and treatments, and the nature of interactions between biology, society, and culture.”1 Medical anthropologists research a wide array of issues, including the distribution of disease and health disparities; cultural understandings of the causes of illness and the meaning of illness experiences; the perception of risk; the
Lisa R. Henry is an associate professor and chair of the Department of Anthropology at the University of North Texas in Denton, Tex. Portions of this research were supported by the Physician Assistant Education Association and the American Academy of Physician Assistants. The author has disclosed no potential conflicts of interest, financial or otherwise DOI: 10.1097/01.JAA.0000453863.62323.ef Copyright © 2015 American Academy of Physician Assistants
JAAPA Journal of the American Academy of Physician Assistants
cultural construction of life cycle events such as birth, puberty, childbirth, menopause, and old age; health and the environment; and comparative medical systems. The research conducted by medical anthropologists contributes to the understanding of how and why health systems operate the way they do, how different people understand and interact with these systems and cultural practices, and what assets people use and challenges they may encounter when constructing perceptions of their own health conditions. In the 1980s, medical anthropologists started to analyze Western biomedicine as a system of medicine that is based on a set of cultural assumptions about the nature of reality and the nature of health. In discussing Western biomedicine www.JAAPA.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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SPECIAL ARTICLE
as a “cultural system,” medical anthropologists are not denying the knowledge base or efficacy of this system. Rather, they are analyzing it as a system rooted in cultural presuppositions and values, associated with rules of conduct, and embedded in a larger societal and historical context. The system embraces the complex social and cultural arrangements not only of physicians and others who diagnose and treat disease, but also of diverse healthcare personnel and institutions of care, extensive industries, programs of health insurance, research, and multiple government and private agencies. The Western biomedical culture informs participants about conditions of sickness and health (for example, chronic fatigue syndrome has no known biological cause yet it is diagnosed as a medical condition), how sickness and disease are caused and treated (for example, sickness comes primarily from pathogens and is treated primarily with drugs), and how to behave while sick (for example, we expect those diagnosed with cancer to “fight”). THE USE OF ETHNOGRAPHY The research process of anthropology consists of a combination of methodologies through which anthropologists seek to develop context and depth of understanding. The best representation of anthropological research is referred to as ethnography. Ethnography, the systematic study of cultures, is an inductive and interactive process that uses such disparate techniques as participant observation, semistructured and unstructured interviews, focus groups, structured surveys, and textual analysis to better comprehend the cultural frames in which individuals live and behave. Although anthropologists are known for their qualitative research, ethnography should not be considered a synonym for qualitative data collection. Ethnography does use a qualitative approach to research, but also can include quantitative methods if appropriate for a particular study. More importantly, ethnography emphasizes holistic analysis, which takes into consideration the entire context of a society when analyzing any specific feature. For example, when researching how Tahitians decide between biomedicine and Tahitian healing, I used participant observation, qualitative interviews, surveys, and secondary research to investigate the history of Tahitian healing, the history of biomedicine in French Polynesia, the “epidemiological transition” and changing morbidity, the political and religious history of the islands, the transition to a cash economy, kinship relations, health promotion and education, and the cultural revitalization movement. An anthropological and ethnographic approach takes into account the interrelationships among different aspects of culture in order to better understand the specific research topic. Ethnography emphasizes continuous discovery and provides research participants with opportunities to explain why they do what they do and provide context to a research discovery. A hallmark of ethnography is participant observation, in which anthropologists immerse themselves in 54
www.JAAPA.com
the local culture and participate in as many activities as possible. This immersive research technique lets anthropologists experience the local culture over time, observe what people actually do in comparison to what they say they do, build rapport with research participants, and gain insider perspectives that may not be directly related to the formal research questions. For example, while researching the role of PAs in community health centers, I conducted many hours of observations in clinics. I observed everywhere I was permitted and moved around through several areas of the clinic, including the waiting room, the reception desk, the nurses’ station, the practitioners’ offices, the break room, and the laboratory. While I was interviewing a medical assistant in the laboratory, she sometimes needed to stop the interview if a physician, PA, nurse practitioner (NP), or patient came
Medical anthropology seeks to understand how culture influences people’s knowledge, attitudes, and behaviors about health. in and needed something. These “interruptions” actually provided useful supplemental data that gave me a more holistic perspective of practitioner roles in the clinic, as the medical assistant chatted about the people who came in. The stories and thoughts she shared about these people were not part of the formal interview process, but were a key part of the approved research process and gave me useful insights about interactions, connections, and perspectives in the clinic that could have been missed if I had relied only on formal interview questions. The goal of ethnography is to capture comprehensive insight, not only by asking open-ended questions, but also by collecting and analyzing data through a holistic lens that lets the broadest possible explanations and patterns emerge. Other fields, such as marketing, business, education, and environmental studies, have increasingly adopted the techniques of ethnography as dependable and valuable research tools. MEDICAL ANTHROPOLOGY STUDIES OF PAS My goal in this section is to highlight the ethnographic tools and analytical insights that medical anthropology offers to the study of PAs. I discuss three studies that were designed and carried out by medical anthropologists. The details, results, and conclusions of these studies are published elsewhere; my goal here is to give examples of the methods and analytical techniques that yield the rich ethnographic Volume 28 • Number 1 • January 2015
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Medical anthropology and the physician assistant profession
context that is often missing in quantitative research. All studies were approved by institutional review boards at either the University of Texas Southwestern Medical Center in Dallas or the University of North Texas in Denton. I have been researching the PA profession for 14 years, and have conducted projects on PA education and training, PA retention in rural settings, PA roles in rural health, PA relationships with patients and communities, and most recently the role of PAs in community health centers and serving the medically underserved.2-6 Study #1. PA students and their cadavers: Narratives on the gross anatomy experience This study was designed by a medical anthropologist in the PA program at the University of Texas Southwestern Medical Center in Dallas and involved one research question. Students were asked to chronicle their experiences and thoughts during the first semester in gross anatomy laboratory by writing a narrative. The narrative could take various forms, such as a journal, a letter to the cadaver, or an “autobiography” of the cadaver. Four cohorts of first-year students participated in this study, producing a total of 150 narratives over 4 years.6 This research method lets students discuss the important aspects of their experiences without having to respond to specific questions. The assignment was completely openended and creative. Students could explore and discuss any issue that was important for them as students, as humans, and as future medical professionals.6 I was brought into this project during the analysis phase. After reading 150 narratives (about 500 pages of text) several times, the themes emerged inductively into 35 categories that were then grouped into three major themes. These major themes were: • experiences of the laboratory, in which students mainly discussed anticipation of the first day or commented on individual experiences and coping strategies • observations of the cadaver, in which students noted the need to respect the donor and the body, and to consider the donor’s life and the diseases he or she suffered • career-enhancing experiences in which students discussed teamwork with their tankmates, the hands-on experience of the laboratory, and the “rite of passage” aspect of the experience. A few memorable quotes are below. From a letter to the cadaver: “I have spent a considerable amount of time thinking, studying, and trying to figure out you’re your body is made of, inside and out. I cannot help but to ask myself how your life was before you passed away. Wondering whether you had a lonely, hard life or did you have a good life with loved ones at your side offering compassion and support.” From a letter to the cadaver: “For the first few days of the class, your face keeps appearing in my mind. There were a few nights when I lay awake wondering who you were before you died. What was your life like in your youth? I imagined faces of strangers that could have been JAAPA Journal of the American Academy of Physician Assistants
your wife, daughter, or son. I wondered if they loved you. Then I couldn’t help but wish that I had known you before you passed away.” From a journal entry: “I pictured Betty as a survivor, as a fighter. Her right lung undoubtedly showed the pain that she must have gone through fighting this dreadful disease [lung cancer]. Later, we discovered that she had cirrhosis of the liver as well. I dreaded finding any more signs of illness because I hated to imagine her suffering so much towards the end.” From a journal entry: “After a few weeks of lab, I stopped thinking about the fact that I was dissecting and destroying what used to be a living body. After a while it all simply became learning. To me it may as well have been a cat or an artificial body, I no longer thought of it as a human being.”6 Although this project did not involve participant observation, the open-ended style of the assignment lets students explore their experiences in a more free-form format, without the restrictions of prescribed questions. This emic approach to data collection and analysis investigates the perceptions of the research participants without emphasis on what the ethnographer considers important. The context of the laboratory and their experiences of it emerged clearly through their own words and insights. For more detailed results of the study, see the full article.6 Study #2. Retention of PAs in rural health clinics The goal of this study was to determine the factors that influence retention of autonomous rural PAs practicing in very remote locations. The ethnographic approach consisted of in-depth 1- to 3-day visits to eight rural Texas towns for observations and interviews. In the rural clinics, we observed the patient waiting rooms, the nurses’ stations, and the PA offices. We also made observations around the town—at the grocery stores, the post office, and local restaurants. The purpose was not only to observe activities around town, but also to informally discuss local healthcare options, quality, and access with residents. The purpose of this type of research is to gain understanding of the context in which local healthcare takes place. We wanted to get to know each town and understand more about the people who lived there. Was it a town of transplants or of folks who have been in the area for generations? How receptive were they to outsiders like ourselves? What were some cultural characteristics of the town?4 To further our holistic analysis of the local healthcare landscape, we conducted formal interviews with town leaders (either the mayor or city manager), the PAs, and several of the townsfolk. The town leaders typically had a broad perspective about healthcare and politics in the town and region because they had lived in the area for a long time. The PAs had the most experience with the local clinic, could describe options for accessing varying levels of healthcare and technology in the region, and could explain why they had stayed in rural clinics. The townsfolk www.JAAPA.com
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shared their perspectives on local healthcare issues, the clinic, and the PA who worked there. To gain a broader perspective, we talked to both townsfolk who were patients of the clinic and to those who were not. PA retention in this study was related to confidence, commitment, and connections. PAs were confident in themselves as practitioners who could handle medical situations with limited supervision. Most PAs in the study were committed and content in maintaining a practice in a small town. Those PAs who lived in the local town were even more committed. They have built connections and relationships with local residents and community institutions, as well as established homes for their families. Town residents desired that PAs be involved with the community because they felt that participation builds trust and familiarity. For example, townsfolk in one north Texas town wanted to see the local PA and clinic staff sponsoring information fairs, going to the senior center for BP screening, assisting with immunizations, and attending local sporting events. When asked about the importance of being active in the community, the PA noted: “It’s extremely important. I’m the city’s health officers because there are two other doctors in town—one is the dentist and one is the veterinarian. I help out at the local high school doing physicals and working sidelines at the football games. I also work with the SWAT team, serve on the Red Cross and juvenile boards, and teach sports medicine at the junior college. You need to give back to the place where you are.” When asked how long he plans to work in the town, he responded, “Til I’m dead. I would buy this clinic. I would be buried here. I have no plans on ever leaving this place.” This pattern did not emerge solely through PA interviews, but through a holistic analysis of town observations (watching and listening), informal and formal discussions with townsfolk who used the clinic and those who did not, and interviews with town leaders. Relationships and connections were important throughout the town. In answering the question “what contributes to retention among PAs in rural Texas clinics,” the ethnographic approach lets the story of the town dynamics emerge and shed light on the local healthcare history and options. For more detailed results of the study, see the full article.4 Study #3. PAs working with medically underserved and economically disadvantaged populations The goal of this study was to understand the role of PAs in community health centers (CHCs). We investigated the general CHC culture—attitudes, beliefs, and behaviors—as well as the practice characteristics of PAs in CHCs, why PAs work in CHCs, and patient perceptions of PAs. Ten clinics were selected from a stratified sample of the 98 clinics in Texas that employed PAs, five in rural areas and five in urban areas. The ethnographic approach included site visits to each clinic, open-ended interviews, and patient surveys including both open-ended and closed-ended questions. We conducted observations for 1-2 days throughout the 56
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clinic facilities, including the reception areas, waiting areas, nurses’ stations, PA and NP work stations, doctors’ offices, break rooms, laboratories, and even the hallways—everywhere but the patient rooms. We watched and listened to the PAs’ interactions with patients, nurses, office staff, and other practitioners.2 As noted in a previous example, these observations provided holistic cultural insight into the roles of PAs and other practitioners in the clinic. To further our analysis of PAs in CHCs, we conducted formal interviews with patients and with as many clinical staff as possible, including PAs, NPs, physicians, nurses, and medical assistants. The interviews were open-ended and semistructured, designed to provide opportunities for research participants to explain what they think and why they think a certain way, and to provide examples. These data provided the context for analyzing the specific research questions. For example, a physician, an NP, and a PA were asked questions about the role of the PA in the clinic and whether that role differed from the role of the NP.2 This is what they said: Physician: They do the same job. I think that they both have assets that I find attractive. Uh, I see PAs as practicing more like a physician and nurse practitioners, uh, is trained—is probably better trained in education and they tend to spend a little more time with the patient than perhaps a PA or physician does, so they’re great educators, but in this work, they have to be able to see patients. So, sometimes I suspect that they don’t get to do as much education and patient time as they would like to. NP: Well for a provider, I don’t see any difference because whether I think he was a midlevel or a physician, a lot of it comes with experience. So if he was a midlevel that had 20 years’ experience as a midlevel, I would still ask things when I was unsure or had questions. The only thing is, you know, of course, obviously all of the providers, all the doctors treat midlevels equally—it seems here to me. I don’t know what the differences are. I see that we’re both midlevels, but we basically come at our practice from a different perspective. Even though we do the same job and we see the same patients, but it’s just a different mode of how we were taught. Basically…I see it as that we’re equal. Seems as if we’re becoming family care and preventive care and it’s hard to stop yourself sometimes from doing too much. But at the same time I see that the PA provides the same quality of care, it’s just that they go about it with a different type of mindset and training … if that makes sense. It gets to the same place, but we come at it from different … PA: My PA friends say they have worked with nurse practitioners who say how much better they were than PAs because they went to nursing school. And they could do their own shots and draw their own blood and I’m like, “Yeah, but I have a master’s degree.” You know and the thing, what, and I did rotations with doctors. And went to school full-time for 32 months…I don’t know how many times it was thrown in my face, I was not a nurse. And some of it was kind of snotty. And some of it was by some Volume 28 • Number 1 • January 2015
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Medical anthropology and the physician assistant profession
of the nurses … I feel, how I felt before is that nurse practitioners and PAs are two different routes to get to the same place. They’re both mid-level and if you get a nurse practitioner who has 20 years’ experience and you get a PA that has two, that nurse practitioner is going to be better. At least I hope they are. And the opposite way, cause there is so much by book that you don’t do. These quotes show that in general the interviewees all thought that practitioners in primary care have the same basic role, though there are nuances in perception from each practitioner. The ethnographic approach combines interview responses with observational data in order to understand the clinic cultural context and underlying perceptions that influence attitudes and perhaps behavior in subtle ways. The main patterns we discovered through this research were: • nine out of 10 clinics gave PAs their own panel of patients and used PAs in a similar capacity as physicians • most CHC clinical staff (67%) perceived no difference between physicians and PAs in their scope of practice • patients reported high levels of satisfaction with PAs • positive organizational dynamics and clinic culture may be the most important factors that help PAs thrive in CHCs. For more detailed results and discussion of this study, see the full article.2 DISCUSSION The goal of this article is to highlight the contribution of medical anthropology to the study of the PA profession. Anthropology uses culture as a framework to understand what people think, what people believe, what people do, and why they do it in particular ways. And medical anthropology, more specifically, seeks to understand how culture influences people’s knowledge, attitudes, and behaviors about health, illness, and ways of practicing medicine. Medical anthropologists use ethnography as an inductive and recursive tool to understand the holistic cultural context in which people—patients, practitioners, educators, and policy makers—live and make decisions about healthcare. The goal of ethnography is not to make generalizations about the PA profession as a whole, but rather to understand the local context in which PAs work and provide medical care. Medical anthropologists have been doing ethnographic research in Western biomedical healthcare settings since the 1980s, mostly in clinical settings looking at physician-patient encounters.7-13 I contend that ethnography and medical anthropology have much to offer PA research as well. For PA researchers interested in learning more about the techniques touched on in the article, there are many sources to learn more about ethnography. One of the most comprehensive sources is The Ethnographer’s Toolkit by Margaret D. LeCompte and Jean J. Schensul.14-18 This is a five-book series that covers designing, conducting, and initiating ethnographic research; essential and specialized JAAPA Journal of the American Academy of Physician Assistants
ethnographic methods; and analysis and interpretation of ethnographic methods. The content is a practical how-to guide and the writing is accessible. Through the use of ethnography, medical anthropology has much to contribute to the study of PA roles in health services delivery. Ethnography is more than qualitative research; it emphasizes inductive discovery and uses an interactive, recursive process of analysis. Anthropologists contend that a holistic lens will broaden the understanding of the cultural context in which research questions are investigated, and thus provide deeper insight during the analysis of the study. JAAPA REFERENCES 1. Singer M, Baer H. Introducing Medical Anthropology. Lanham, MD: Alta Mira Press; 2007. 2. Henry LR, Hooker RS. Physician assistants working with medically underserved and economically disadvantaged populations. JAAPA. 2014;27(1):36-42. 3. Henry LR, Hooker RS. Autonomous physician assistants in remote locations and the views of their communities. J Physician Assist Educ. 2008;19(1):34-37. 4. Henry LR, Hooker RS. Retention of physician assistants in rural health clinics. J Rural Health. 2007;23(3):207-214. 5. Henry LR, Hooker RS, Yates KL. The role of physician assistants in rural health care: a systematic review of the literature. J Rural Health. 2011;27(2):220-229. 6. Henry LR, Hooker RS, Statler M. Physician assistant students and their cadavers: narratives on the gross anatomy experience. Perspective on Physician Assistant Education. 2002;3(1):17-23. 7. Gaines A, Hahn R. Among the physicians: encounter, exchange and transformation. In: Hahn R, Gaines A, eds. Physicians of Western Medicine: Anthropological Approaches to Theory and Practice. Dordrecht, Netherlands: Kluwer Academic Publishers; 1985. 8. Lazarus E. Theoretical considerations for the study of the doctor-patient relationship: implications of a perinatal study. Medical Anthropology Quarterly. 1988;2(1):34-58. 9. Grimen H. Power, trust, and risk: some reflections on an absent issue. Med Anthropol Q. 2009;23(1):16-33. 10. Hunt LM, Arar NH. An analytical framework for contrasting patient and provider views of the process of chronic disease management. Med Anthropol Q. 2001;15(3):347-367. 11. Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA. 2000;283(19):2579-2584. 12. Zimmerman DH, Bowden D. Structure in action: an introduction. In: Boden D, Zimmerman D, eds. Talk and Social Structure. Berkeley, CA: University of California Press; 1991. 13. Duranti A. Linguistic anthropology: history, ideas and issues. In: Duranti A, ed. Linguistic Anthropology: A Reader. Malden, MA: Blackwell; 2001. 14. LeCompte M, Schensul J. Designing and Conducting Ethnographic Research: An Introduction. 2nd ed. Lanham, MD: AltaMira Press; 2010. 15. LeCompte M, Schensul J. Initiating Ethnographic Research: A Mixed Methods Approach. Lanham, MD: AltaMira Press; 2012. 16. LeCompte M, Schensul J. Essential Ethnographic Methods: A Mixed Methods Approach. Lanham, MD: AltaMira Press; 2012. 17. LeCompte M, Schensul J. Specialized Ethnographic Methods: A Mixed Methods Approach. Lanham, MD: AltaMira Press; 2012. 18. LeCompte M, Schensul J. Analysis and Interpretation of Ethnographic Data: A Mixed Methods Approach. Lanham, MD: AltaMira Press; 2012. www.JAAPA.com
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57
Medical anthropology and the physician assistant profession Lisa R. Henry, PhD
ABSTRACT Medical anthropology is a subfield of anthropology that investigates how culture influences people’s ideas and behaviors regarding health and illness. Medical anthropology contributes to the understanding of how and why health systems operate the way they do, how different people understand and interact with these systems and cultural practices, and what assets people use and challenges they may encounter when constructing perceptions of their own health conditions. The goal of this article is to highlight the methodological tools and analytical insights that medical anthropology offers to the study of physician assistants (PAs). The article discusses the field of medical anthropology; the advantages of ethnographic and qualitative research; and how medical anthropology can explain how PAs fit into improved health delivery services by exploring three studies of PAs by medical anthropologists. Keywords: medical anthropology, physician assistants, ethnography, qualitative research, biomedicine, culture
M
edical anthropology is a specialized subfield of anthropology, which at its most basic level investigates how culture influences people’s ideas and behaviors regarding health and illness. As Singer and Baer noted, “While recognizing the fundamental importance of biology in health and illness, medical anthropologists generally go beyond seeing health as primarily a biological condition by seeking to understand the social origins of disease, the cultural construction of symptoms and treatments, and the nature of interactions between biology, society, and culture.”1 Medical anthropologists research a wide array of issues, including the distribution of disease and health disparities; cultural understandings of the causes of illness and the meaning of illness experiences; the perception of risk; the
Lisa R. Henry is an associate professor and chair of the Department of Anthropology at the University of North Texas in Denton, Tex. Portions of this research were supported by the Physician Assistant Education Association and the American Academy of Physician Assistants. The author has disclosed no potential conflicts of interest, financial or otherwise DOI: 10.1097/01.JAA.0000453863.62323.ef Copyright © 2015 American Academy of Physician Assistants
JAAPA Journal of the American Academy of Physician Assistants
cultural construction of life cycle events such as birth, puberty, childbirth, menopause, and old age; health and the environment; and comparative medical systems. The research conducted by medical anthropologists contributes to the understanding of how and why health systems operate the way they do, how different people understand and interact with these systems and cultural practices, and what assets people use and challenges they may encounter when constructing perceptions of their own health conditions. In the 1980s, medical anthropologists started to analyze Western biomedicine as a system of medicine that is based on a set of cultural assumptions about the nature of reality and the nature of health. In discussing Western biomedicine www.JAAPA.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
53
SPECIAL ARTICLE
as a “cultural system,” medical anthropologists are not denying the knowledge base or efficacy of this system. Rather, they are analyzing it as a system rooted in cultural presuppositions and values, associated with rules of conduct, and embedded in a larger societal and historical context. The system embraces the complex social and cultural arrangements not only of physicians and others who diagnose and treat disease, but also of diverse healthcare personnel and institutions of care, extensive industries, programs of health insurance, research, and multiple government and private agencies. The Western biomedical culture informs participants about conditions of sickness and health (for example, chronic fatigue syndrome has no known biological cause yet it is diagnosed as a medical condition), how sickness and disease are caused and treated (for example, sickness comes primarily from pathogens and is treated primarily with drugs), and how to behave while sick (for example, we expect those diagnosed with cancer to “fight”). THE USE OF ETHNOGRAPHY The research process of anthropology consists of a combination of methodologies through which anthropologists seek to develop context and depth of understanding. The best representation of anthropological research is referred to as ethnography. Ethnography, the systematic study of cultures, is an inductive and interactive process that uses such disparate techniques as participant observation, semistructured and unstructured interviews, focus groups, structured surveys, and textual analysis to better comprehend the cultural frames in which individuals live and behave. Although anthropologists are known for their qualitative research, ethnography should not be considered a synonym for qualitative data collection. Ethnography does use a qualitative approach to research, but also can include quantitative methods if appropriate for a particular study. More importantly, ethnography emphasizes holistic analysis, which takes into consideration the entire context of a society when analyzing any specific feature. For example, when researching how Tahitians decide between biomedicine and Tahitian healing, I used participant observation, qualitative interviews, surveys, and secondary research to investigate the history of Tahitian healing, the history of biomedicine in French Polynesia, the “epidemiological transition” and changing morbidity, the political and religious history of the islands, the transition to a cash economy, kinship relations, health promotion and education, and the cultural revitalization movement. An anthropological and ethnographic approach takes into account the interrelationships among different aspects of culture in order to better understand the specific research topic. Ethnography emphasizes continuous discovery and provides research participants with opportunities to explain why they do what they do and provide context to a research discovery. A hallmark of ethnography is participant observation, in which anthropologists immerse themselves in 54
www.JAAPA.com
the local culture and participate in as many activities as possible. This immersive research technique lets anthropologists experience the local culture over time, observe what people actually do in comparison to what they say they do, build rapport with research participants, and gain insider perspectives that may not be directly related to the formal research questions. For example, while researching the role of PAs in community health centers, I conducted many hours of observations in clinics. I observed everywhere I was permitted and moved around through several areas of the clinic, including the waiting room, the reception desk, the nurses’ station, the practitioners’ offices, the break room, and the laboratory. While I was interviewing a medical assistant in the laboratory, she sometimes needed to stop the interview if a physician, PA, nurse practitioner (NP), or patient came
Medical anthropology seeks to understand how culture influences people’s knowledge, attitudes, and behaviors about health. in and needed something. These “interruptions” actually provided useful supplemental data that gave me a more holistic perspective of practitioner roles in the clinic, as the medical assistant chatted about the people who came in. The stories and thoughts she shared about these people were not part of the formal interview process, but were a key part of the approved research process and gave me useful insights about interactions, connections, and perspectives in the clinic that could have been missed if I had relied only on formal interview questions. The goal of ethnography is to capture comprehensive insight, not only by asking open-ended questions, but also by collecting and analyzing data through a holistic lens that lets the broadest possible explanations and patterns emerge. Other fields, such as marketing, business, education, and environmental studies, have increasingly adopted the techniques of ethnography as dependable and valuable research tools. MEDICAL ANTHROPOLOGY STUDIES OF PAS My goal in this section is to highlight the ethnographic tools and analytical insights that medical anthropology offers to the study of PAs. I discuss three studies that were designed and carried out by medical anthropologists. The details, results, and conclusions of these studies are published elsewhere; my goal here is to give examples of the methods and analytical techniques that yield the rich ethnographic Volume 28 • Number 1 • January 2015
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Medical anthropology and the physician assistant profession
context that is often missing in quantitative research. All studies were approved by institutional review boards at either the University of Texas Southwestern Medical Center in Dallas or the University of North Texas in Denton. I have been researching the PA profession for 14 years, and have conducted projects on PA education and training, PA retention in rural settings, PA roles in rural health, PA relationships with patients and communities, and most recently the role of PAs in community health centers and serving the medically underserved.2-6 Study #1. PA students and their cadavers: Narratives on the gross anatomy experience This study was designed by a medical anthropologist in the PA program at the University of Texas Southwestern Medical Center in Dallas and involved one research question. Students were asked to chronicle their experiences and thoughts during the first semester in gross anatomy laboratory by writing a narrative. The narrative could take various forms, such as a journal, a letter to the cadaver, or an “autobiography” of the cadaver. Four cohorts of first-year students participated in this study, producing a total of 150 narratives over 4 years.6 This research method lets students discuss the important aspects of their experiences without having to respond to specific questions. The assignment was completely openended and creative. Students could explore and discuss any issue that was important for them as students, as humans, and as future medical professionals.6 I was brought into this project during the analysis phase. After reading 150 narratives (about 500 pages of text) several times, the themes emerged inductively into 35 categories that were then grouped into three major themes. These major themes were: • experiences of the laboratory, in which students mainly discussed anticipation of the first day or commented on individual experiences and coping strategies • observations of the cadaver, in which students noted the need to respect the donor and the body, and to consider the donor’s life and the diseases he or she suffered • career-enhancing experiences in which students discussed teamwork with their tankmates, the hands-on experience of the laboratory, and the “rite of passage” aspect of the experience. A few memorable quotes are below. From a letter to the cadaver: “I have spent a considerable amount of time thinking, studying, and trying to figure out you’re your body is made of, inside and out. I cannot help but to ask myself how your life was before you passed away. Wondering whether you had a lonely, hard life or did you have a good life with loved ones at your side offering compassion and support.” From a letter to the cadaver: “For the first few days of the class, your face keeps appearing in my mind. There were a few nights when I lay awake wondering who you were before you died. What was your life like in your youth? I imagined faces of strangers that could have been JAAPA Journal of the American Academy of Physician Assistants
your wife, daughter, or son. I wondered if they loved you. Then I couldn’t help but wish that I had known you before you passed away.” From a journal entry: “I pictured Betty as a survivor, as a fighter. Her right lung undoubtedly showed the pain that she must have gone through fighting this dreadful disease [lung cancer]. Later, we discovered that she had cirrhosis of the liver as well. I dreaded finding any more signs of illness because I hated to imagine her suffering so much towards the end.” From a journal entry: “After a few weeks of lab, I stopped thinking about the fact that I was dissecting and destroying what used to be a living body. After a while it all simply became learning. To me it may as well have been a cat or an artificial body, I no longer thought of it as a human being.”6 Although this project did not involve participant observation, the open-ended style of the assignment lets students explore their experiences in a more free-form format, without the restrictions of prescribed questions. This emic approach to data collection and analysis investigates the perceptions of the research participants without emphasis on what the ethnographer considers important. The context of the laboratory and their experiences of it emerged clearly through their own words and insights. For more detailed results of the study, see the full article.6 Study #2. Retention of PAs in rural health clinics The goal of this study was to determine the factors that influence retention of autonomous rural PAs practicing in very remote locations. The ethnographic approach consisted of in-depth 1- to 3-day visits to eight rural Texas towns for observations and interviews. In the rural clinics, we observed the patient waiting rooms, the nurses’ stations, and the PA offices. We also made observations around the town—at the grocery stores, the post office, and local restaurants. The purpose was not only to observe activities around town, but also to informally discuss local healthcare options, quality, and access with residents. The purpose of this type of research is to gain understanding of the context in which local healthcare takes place. We wanted to get to know each town and understand more about the people who lived there. Was it a town of transplants or of folks who have been in the area for generations? How receptive were they to outsiders like ourselves? What were some cultural characteristics of the town?4 To further our holistic analysis of the local healthcare landscape, we conducted formal interviews with town leaders (either the mayor or city manager), the PAs, and several of the townsfolk. The town leaders typically had a broad perspective about healthcare and politics in the town and region because they had lived in the area for a long time. The PAs had the most experience with the local clinic, could describe options for accessing varying levels of healthcare and technology in the region, and could explain why they had stayed in rural clinics. The townsfolk www.JAAPA.com
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shared their perspectives on local healthcare issues, the clinic, and the PA who worked there. To gain a broader perspective, we talked to both townsfolk who were patients of the clinic and to those who were not. PA retention in this study was related to confidence, commitment, and connections. PAs were confident in themselves as practitioners who could handle medical situations with limited supervision. Most PAs in the study were committed and content in maintaining a practice in a small town. Those PAs who lived in the local town were even more committed. They have built connections and relationships with local residents and community institutions, as well as established homes for their families. Town residents desired that PAs be involved with the community because they felt that participation builds trust and familiarity. For example, townsfolk in one north Texas town wanted to see the local PA and clinic staff sponsoring information fairs, going to the senior center for BP screening, assisting with immunizations, and attending local sporting events. When asked about the importance of being active in the community, the PA noted: “It’s extremely important. I’m the city’s health officers because there are two other doctors in town—one is the dentist and one is the veterinarian. I help out at the local high school doing physicals and working sidelines at the football games. I also work with the SWAT team, serve on the Red Cross and juvenile boards, and teach sports medicine at the junior college. You need to give back to the place where you are.” When asked how long he plans to work in the town, he responded, “Til I’m dead. I would buy this clinic. I would be buried here. I have no plans on ever leaving this place.” This pattern did not emerge solely through PA interviews, but through a holistic analysis of town observations (watching and listening), informal and formal discussions with townsfolk who used the clinic and those who did not, and interviews with town leaders. Relationships and connections were important throughout the town. In answering the question “what contributes to retention among PAs in rural Texas clinics,” the ethnographic approach lets the story of the town dynamics emerge and shed light on the local healthcare history and options. For more detailed results of the study, see the full article.4 Study #3. PAs working with medically underserved and economically disadvantaged populations The goal of this study was to understand the role of PAs in community health centers (CHCs). We investigated the general CHC culture—attitudes, beliefs, and behaviors—as well as the practice characteristics of PAs in CHCs, why PAs work in CHCs, and patient perceptions of PAs. Ten clinics were selected from a stratified sample of the 98 clinics in Texas that employed PAs, five in rural areas and five in urban areas. The ethnographic approach included site visits to each clinic, open-ended interviews, and patient surveys including both open-ended and closed-ended questions. We conducted observations for 1-2 days throughout the 56
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clinic facilities, including the reception areas, waiting areas, nurses’ stations, PA and NP work stations, doctors’ offices, break rooms, laboratories, and even the hallways—everywhere but the patient rooms. We watched and listened to the PAs’ interactions with patients, nurses, office staff, and other practitioners.2 As noted in a previous example, these observations provided holistic cultural insight into the roles of PAs and other practitioners in the clinic. To further our analysis of PAs in CHCs, we conducted formal interviews with patients and with as many clinical staff as possible, including PAs, NPs, physicians, nurses, and medical assistants. The interviews were open-ended and semistructured, designed to provide opportunities for research participants to explain what they think and why they think a certain way, and to provide examples. These data provided the context for analyzing the specific research questions. For example, a physician, an NP, and a PA were asked questions about the role of the PA in the clinic and whether that role differed from the role of the NP.2 This is what they said: Physician: They do the same job. I think that they both have assets that I find attractive. Uh, I see PAs as practicing more like a physician and nurse practitioners, uh, is trained—is probably better trained in education and they tend to spend a little more time with the patient than perhaps a PA or physician does, so they’re great educators, but in this work, they have to be able to see patients. So, sometimes I suspect that they don’t get to do as much education and patient time as they would like to. NP: Well for a provider, I don’t see any difference because whether I think he was a midlevel or a physician, a lot of it comes with experience. So if he was a midlevel that had 20 years’ experience as a midlevel, I would still ask things when I was unsure or had questions. The only thing is, you know, of course, obviously all of the providers, all the doctors treat midlevels equally—it seems here to me. I don’t know what the differences are. I see that we’re both midlevels, but we basically come at our practice from a different perspective. Even though we do the same job and we see the same patients, but it’s just a different mode of how we were taught. Basically…I see it as that we’re equal. Seems as if we’re becoming family care and preventive care and it’s hard to stop yourself sometimes from doing too much. But at the same time I see that the PA provides the same quality of care, it’s just that they go about it with a different type of mindset and training … if that makes sense. It gets to the same place, but we come at it from different … PA: My PA friends say they have worked with nurse practitioners who say how much better they were than PAs because they went to nursing school. And they could do their own shots and draw their own blood and I’m like, “Yeah, but I have a master’s degree.” You know and the thing, what, and I did rotations with doctors. And went to school full-time for 32 months…I don’t know how many times it was thrown in my face, I was not a nurse. And some of it was kind of snotty. And some of it was by some Volume 28 • Number 1 • January 2015
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Medical anthropology and the physician assistant profession
of the nurses … I feel, how I felt before is that nurse practitioners and PAs are two different routes to get to the same place. They’re both mid-level and if you get a nurse practitioner who has 20 years’ experience and you get a PA that has two, that nurse practitioner is going to be better. At least I hope they are. And the opposite way, cause there is so much by book that you don’t do. These quotes show that in general the interviewees all thought that practitioners in primary care have the same basic role, though there are nuances in perception from each practitioner. The ethnographic approach combines interview responses with observational data in order to understand the clinic cultural context and underlying perceptions that influence attitudes and perhaps behavior in subtle ways. The main patterns we discovered through this research were: • nine out of 10 clinics gave PAs their own panel of patients and used PAs in a similar capacity as physicians • most CHC clinical staff (67%) perceived no difference between physicians and PAs in their scope of practice • patients reported high levels of satisfaction with PAs • positive organizational dynamics and clinic culture may be the most important factors that help PAs thrive in CHCs. For more detailed results and discussion of this study, see the full article.2 DISCUSSION The goal of this article is to highlight the contribution of medical anthropology to the study of the PA profession. Anthropology uses culture as a framework to understand what people think, what people believe, what people do, and why they do it in particular ways. And medical anthropology, more specifically, seeks to understand how culture influences people’s knowledge, attitudes, and behaviors about health, illness, and ways of practicing medicine. Medical anthropologists use ethnography as an inductive and recursive tool to understand the holistic cultural context in which people—patients, practitioners, educators, and policy makers—live and make decisions about healthcare. The goal of ethnography is not to make generalizations about the PA profession as a whole, but rather to understand the local context in which PAs work and provide medical care. Medical anthropologists have been doing ethnographic research in Western biomedical healthcare settings since the 1980s, mostly in clinical settings looking at physician-patient encounters.7-13 I contend that ethnography and medical anthropology have much to offer PA research as well. For PA researchers interested in learning more about the techniques touched on in the article, there are many sources to learn more about ethnography. One of the most comprehensive sources is The Ethnographer’s Toolkit by Margaret D. LeCompte and Jean J. Schensul.14-18 This is a five-book series that covers designing, conducting, and initiating ethnographic research; essential and specialized JAAPA Journal of the American Academy of Physician Assistants
ethnographic methods; and analysis and interpretation of ethnographic methods. The content is a practical how-to guide and the writing is accessible. Through the use of ethnography, medical anthropology has much to contribute to the study of PA roles in health services delivery. Ethnography is more than qualitative research; it emphasizes inductive discovery and uses an interactive, recursive process of analysis. Anthropologists contend that a holistic lens will broaden the understanding of the cultural context in which research questions are investigated, and thus provide deeper insight during the analysis of the study. JAAPA REFERENCES 1. Singer M, Baer H. Introducing Medical Anthropology. Lanham, MD: Alta Mira Press; 2007. 2. Henry LR, Hooker RS. Physician assistants working with medically underserved and economically disadvantaged populations. JAAPA. 2014;27(1):36-42. 3. Henry LR, Hooker RS. Autonomous physician assistants in remote locations and the views of their communities. J Physician Assist Educ. 2008;19(1):34-37. 4. Henry LR, Hooker RS. Retention of physician assistants in rural health clinics. J Rural Health. 2007;23(3):207-214. 5. Henry LR, Hooker RS, Yates KL. The role of physician assistants in rural health care: a systematic review of the literature. J Rural Health. 2011;27(2):220-229. 6. Henry LR, Hooker RS, Statler M. Physician assistant students and their cadavers: narratives on the gross anatomy experience. Perspective on Physician Assistant Education. 2002;3(1):17-23. 7. Gaines A, Hahn R. Among the physicians: encounter, exchange and transformation. In: Hahn R, Gaines A, eds. Physicians of Western Medicine: Anthropological Approaches to Theory and Practice. Dordrecht, Netherlands: Kluwer Academic Publishers; 1985. 8. Lazarus E. Theoretical considerations for the study of the doctor-patient relationship: implications of a perinatal study. Medical Anthropology Quarterly. 1988;2(1):34-58. 9. Grimen H. Power, trust, and risk: some reflections on an absent issue. Med Anthropol Q. 2009;23(1):16-33. 10. Hunt LM, Arar NH. An analytical framework for contrasting patient and provider views of the process of chronic disease management. Med Anthropol Q. 2001;15(3):347-367. 11. Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA. 2000;283(19):2579-2584. 12. Zimmerman DH, Bowden D. Structure in action: an introduction. In: Boden D, Zimmerman D, eds. Talk and Social Structure. Berkeley, CA: University of California Press; 1991. 13. Duranti A. Linguistic anthropology: history, ideas and issues. In: Duranti A, ed. Linguistic Anthropology: A Reader. Malden, MA: Blackwell; 2001. 14. LeCompte M, Schensul J. Designing and Conducting Ethnographic Research: An Introduction. 2nd ed. Lanham, MD: AltaMira Press; 2010. 15. LeCompte M, Schensul J. Initiating Ethnographic Research: A Mixed Methods Approach. Lanham, MD: AltaMira Press; 2012. 16. LeCompte M, Schensul J. Essential Ethnographic Methods: A Mixed Methods Approach. Lanham, MD: AltaMira Press; 2012. 17. LeCompte M, Schensul J. Specialized Ethnographic Methods: A Mixed Methods Approach. Lanham, MD: AltaMira Press; 2012. 18. LeCompte M, Schensul J. Analysis and Interpretation of Ethnographic Data: A Mixed Methods Approach. Lanham, MD: AltaMira Press; 2012. www.JAAPA.com
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