On Balance and Contrast

Nicole Stern, MD
MMEP, Class of 1991
The more American Indian physicians we have, the more likely that they’ll return and practice in the communities they call home.

Nicole Stern is a study in contrasts.

First, there’s her heritage: her father is Jewish, her mother full-blooded Mescalero Apache. Then there’s her training: Stern is board certified in internal medicine and sports medicine. And as a woman practicing sports medicine, she is an uncommon presence in a male-dominated profession.

“I certainly have a lot of dual things in my life,” she muses.

Stern’s cultural background gives her a unique vantage point on health care, particularly the disproportionate number of Native versus non-Native practitioners. According to the Association of American Medical Colleges, American Indians represent less than 1 percent of physicians.

As president of the Association of American Indian Physicians (AAIP) from 2012 to 2013, Stern pushed to increase the pipeline of American Indian and Alaska Native medical students. She continues to support AAIP in reversing what she calls a “flatline” in applicants and matriculants from Native populations.

“We need to raise our numbers,” she says. “The more American Indian physicians we have, the more likely that they’ll return and practice in the communities they call home.”

Respecting Cultural Differences

Awareness of the need for cultural competence in health care is growing, thanks to research showing that “some patients may delay seeking care due to perceived cultural insensitivity, concern that they will receive a lower quality of care, or the perception that they have been treated unfairly because of race or ethnic background.”

The problem is especially acute in Native communities, which suffer disproportionately from treatable and chronic diseases and a shortage of health professionals. One study conducted with Native physicians found that they received their medical training “in environments without American Indian role models.” They also experienced isolation and a sense that they weren’t welcome at their training institutions. As for the reasons why health among American Indians and Native Alaskans is poorer than other groups, the Centers for Disease Control and Prevention say they include cultural barriers, geographic isolation, and economic factors.

Since its beginnings in 1989, the Robert Wood Johnson Foundation-funded Summer Medical and Dental Education Program (SMDEP) has committed to increasing the pipeline of providers from underrepresented populations, including American Indians and Alaska Natives.

“MMEP taught me a lot, not just about my profession but about the kind of person I wanted      to be.”

Nicole Stern participated in SMDEP’s predecessor, the Minority Medical Education Program (MMEP), in 1991 at the University of Washington site.

“It was wonderful,” she remembers. “The class was very multicultural—a lot of African-American and Latino students, a few Native students, and students of other cultures. It didn’t seem to matter where we were from; we were all part of this special group.”

That summer, Stern got her first lesson in maintaining professional distance. She was shadowing in the emergency room at Harborview Medical Center, a Level 1 trauma center, when a homeless man was brought in for treatment. “He had been run over by a train, and he was not all in one piece. I remember how traumatic that was for me, and thinking, ‘What am I getting into?’” she says.

Rather than let fear or nausea take over, Stern focused on the humanity of the victim. “I had to recognize that this was a human being going through a very traumatic experience, and to learn from the doctors who were taking care of him so I could understand it from a medical standpoint.” Knowing how to maintain some emotional distance from patients, she says, is important. “If you don’t get caught up in the emotion of the situation, you can get to the core of the medical problem and make sure the patient gets the right care.”

The ER experience, and others during her MMEP session, convinced Stern that her future was in primary care. “I realized I was not going to be an ER physician or a surgeon. I wasn’t someone who was ready to see a lot of blood and guts!” She also learned to understand and respect the cultural differences between people, the importance of teamwork, and the value of mentorship—lessons she passed along when she returned to MMEP as an adviser following her first year of medical school.

Of the program, she says, “It taught me a lot, not just about my profession but about the kind of person I wanted to be.”

The Science Behind Sports Medicine

In her recent position as associate athletics director and team physician for the University of California–Santa Barbara (UCSB) Gauchos, Stern took care of more than 430 athletes, providing everything from physical exams to concussion management to mental health referrals. She now treats a range of injuries as an urgent care physician at Santa Barbara County’s Sansum Clinic.

“I’ve done a lot of urgent care in the past, as well as academic internal medicine and student health,” she explains, adding that her patients are not typical for an internist, who generally treats adolescents, adults, and the elderly. But Stern cares primarily for young adults, noting, “I typically don’t do a lot of geriatrics or gynecology.”

Stern is atypical in other ways as well. As one of only about 150 internists in the country who are also certified in sports medicine, she belongs to a rare circle.

“My training taught me about sports medicine not only from the orthopedic standpoint but also from a medical standpoint,” she says. “I learned how to take care of athletes who suffer from common medical conditions like diabetes and asthma, and how to manage mental health and nutritional issues in athletes.” It’s an approach that goes beyond orthopedics to what she calls “the science behind sports medicine.”

Those skills came into play in her previous positions as a team physician in Oklahoma, Arizona, and UCSB, where keeping college athletes healthy was no small task. Stern describes a delicate balance between maintaining safety while supporting team success.

“Sometimes coaches want players back sooner than they’re ready, and athletes withhold information so they can keep playing. But our priority is getting the athlete back onto the court or onto the field safely.”

Exercising Caution

Getting players back on the field is a challenge in its own right. Although football gets the most press, Stern says that basketball and soccer tend to generate a higher number of injuries. Those include concussions, which vary—“everything from a ball to the head to head-to-head impact, like in a soccer game, to a head hitting a goalpost.”

Concussion-management protocols have evolved over time, becoming more cautious in recent years. At the college level, she says, athletes who suffer concussions are pulled off the field or court immediately. “We all follow similar guidelines. We typically don’t send that person back into the game or practice situation the same day.”

She adds, “The return-to-play protocol is very gradual and closely monitored. We return them to non-contact activity before we return them to regular play, but they have to be symptom-free—and even then, it’s a gradual return.”

Stern points to the 2014 World Cup, which was marred by numerous head injuries, as proof of what not to do. “It’s unfortunate, but players were put back into the game when they shouldn’t have been,” she says. “There are still discussions on an international level about what happened there.” She believes that soccer societies and organizations worldwide must come together to craft and follow universal guidelines for the benefit of the athletes.

“It seems the rules change at the professional level, but I don’t think you should treat a professional athlete any differently than you would treat your own child participating in middle school soccer,” she says firmly. “It is not safe to let them get back into competition too soon.”