I am an outsider to medicine. I am a second-generation immigrant, a first-generation college graduate, and a woman of color from the inner city. In my four years of medical school, I have grown increasingly frustrated with our education system, and I will explain why. I came to medical school for my community. I wanted to become the doctor who understood that time, money, structural racism, and inequity dictate more about someone’s health than whether they take their medication as prescribed. As I reflect on my training thus far, I realize that trusting that our medical education system is going to make me the doctor I wish I had growing up is like trusting in capitalism or in white supremacy, two systems that are deeply connected to medical education but were not created for people who look like me to thrive in or get what they need.
During my first week of medical school, when I was still a bright-eyed new student, I was captivated by the amount of time we took in my health systems and policy course to discuss population health, race, ethnicity, gender, class, sexual orientation, and disabilities. As an Afro-Latina who grew up speaking primarily Spanish at home, my experiences with health care had always centered around language. Unsurprisingly, I believed health disparities based on patients’ primary language to be the biggest concern in health care, and I had devoted less mental energy to considering the plight of populations facing other disparities. Seeing these many complex issues named during my first encounter with medical education made me think that the next four years would be the beginning of a lifelong challenge to provide patient-centered care, in every room, with every patient. I welcomed this challenge with open arms because I was in medical school to learn how to care for people no matter who they were and because I saw in it the opportunity to become the provider I had always wished to have.
Looking back, in many ways, I have learned how to provide medical care in a patient-centered manner thanks to mentors who modeled putting patients’ voices at the center of their work. However, I also sense how the hidden curriculum has undercut the lessons from my health systems and policy course. Though I am only in my fourth year of medical school, I already note the impulse to assign more value to my time and my agenda than to my patients’ goals during our encounters. I also notice that this impulse is more pronounced with certain subsets of patients. In considering how this came to be, I believe that beyond the pressure from high patient volumes and limited time, language plays a big role.
The words we use with our patients and those we use to talk about them are important. Trainees and new attendings all look to our mentors’ words and behaviors for approval of our own actions, as examples of how to navigate complex situations, and to learn the language of medicine. In medical education, the words we learn from our mentors and instructors are an important part of how we learn who or what we should center in our practice of medicine. I’ll share a few words that I learned during my clinical rotations.
I will start with the instructor who asked me if it was appropriate for a physician to believe in the Black Lives Matter movement. Then there was the instructor who told me that they did not understand why we wasted so many of our hospital’s surgical resources (nurses, surgeons, anesthesiologists, time, money) on “gangbangers,” as apparently defined by the color of their skin and their home ZIP code. Another instructor cavalierly referred to a patient as a “crackhead” and a “bitch.” Subtler, yet more pervasive, were the instructors who used the phrases “waste of my time,” “not my problem,” “they complain too much,” “big baby,” “punk,” and “loser” to describe patients during times of frustration. Perhaps the most unforgettable for me, though, were the instructors who did not have any words for patients with limited English proficiency. We simply skipped them on rounds because it “takes too long.”
These words taught me that patients’ problems, unless they neatly fall into the box of what we can and want to address that day, are not our problems. These words reinforced the idea that, in the language of medicine, all human lives seeking medical care are not of equal value, and that it is acceptable for me as a doctor to not want to “waste my time” with those I feel are lesser. Although this fundamental bias exists outside of medicine too, I learned it most clearly and explicitly during medical school from doctors I worked with.
Using our words to feed the narrative that implies that structural injustices are just nuisances to clinical workflows and to meeting educational objectives misses the fact that receiving medical care does not and will never happen in a vacuum free from the pressures of money, ability, access to education, and life circumstance. Structural racism,1 disenfranchisement,2 housing instability,3 food insecurity,4 social isolation,5 and poverty6 are pathogenic. For me, understressing, ridiculing, or outright ignoring the importance of these issues to our patients’ lives both in our exam rooms and in our lecture halls means that the care we provide will never truly meet the needs of people who look like me. So I am forced to ask: Will we ever intend to meet those needs?
Furthermore, using our words to feed problematic narratives means that we neglect to notice, and become complacent with, the ways in which we as a medical community contribute to structural injustices. Top-tier medical societies endorse individuals whose policies directly and negatively impact the health, survival, and well-being of already-vulnerable populations.7,8 The tools devised to measure our core competencies and help instructors decide who is “excellent” among us continue to consistently favor a single demographic, despite increasing numbers of Asian and underrepresented in medicine students in training.9 We check patients’ genetic variants before we ask if they can pay for treatment.10 We set aside time and craft essay prompts to reflect on difficult patient encounters when they make us feel bad, but we fail to reflect on the implications of our words and the life circumstances of our patients when they do not return for follow-up care.
I am not immune to this hidden curriculum—I am a learner just like my classmates. I had to catch myself the first time I used the phrase “Medicaid patients” as a blanket term for black and brown bodies. I had to catch myself when I got upset at a woman with epilepsy who yelled at my instructor because she was told she could not drive to work and had no other means of providing for her child. I had to catch myself when I rushed a physical exam on a woman of color with cancer pain because I believed she was exaggerating.
All this is to say that I find it challenging to trust the medical education system to produce the kinds of doctors who people like me would want to care for them. As a patient, I regularly have to volunteer that I am in medical school just so physicians will look me in the eye, explain things to me clearly, and ask if I have any questions. These physicians’ behaviors are the result of encountering subtle, repetitive words and actions throughout medical training that teach doctors to be complicit with structures of power and oppression. I must prove my value by offering up a piece of often-irrelevant information, my status as a medical student, to negate the assumption that my skin color means I do not understand or deserve information about my own health. The question those in medical education must ask and honestly answer is: Is it optional to provide truly patient-centered care to all patients regardless of income, race, ability, and primary language? The answer to that question will also determine if it is optional to train a future physician workforce that can rise to the occasion and provide such care.
To keep patients’ voices and experiences at the center of their medical care is to value them as humans just like us, which cannot happen if we do not acknowledge how power works and how our language reinforces that power.11,12 We cannot center patients’ voices if the words we choose to describe them already indicate their worth in our eyes and undermine their own experiences in their bodies. We cannot center their experiences if we have already determined that they are a waste of our time and resources. We cannot change medical culture if we do not actively challenge our own most private, unexplored or blatant biases, no matter our career stage and position in the hierarchy in medicine. Changing medical culture is a process that I believe begins with our leaders and our language, because words set intentions and intentions become actions. The leadership team of the Association of American Medical Colleges, medical school and hospital administrators, residency program directors, clinical faculty, and clerkship and preclinical course leaders have the power and influence to call out and address the problematic complicity with structural injustice that persists in medical education.
What could this type of practice look like? Imagine the impact of standardizing and intentionally talking about structural inequities and bias in every mortality and morbidity conference.13 Imagine the impact of collecting trainees’ experiences of bias on the wards and using them as learning opportunities for faculty. Imagine the impact of talking about class in medicine and how trainees contribute to gentrification and displacement and unequal access to the medicine pipeline.14,15 I am constantly learning of new strategies to embed structural competence into medicine and medical education, such as the concept of socially accountable academic health centers, as reported in Academic Medicine,16 and the idea of case studies in social medicine as described in the New England Journal of Medicine.17 In medical education, teaching structural competence is not standardized; it is not done everywhere; and it heavily relies on the will and expertise of individual instructors, students, and training programs.
I do believe that our medical education system has the potential to work. I have met enough incredible clinicians and instructors who went through this process before me. And I have committed my own time to my medical school by leading clinical electives, participating in student government, and helping with diversity and inclusion initiatives. No assembly line is perfect, but ours certainly has room for improvement. If we continuously blame “the system” but both neglect to examine how the medical community reinforces that system through our language and actions and neglect to teach tangible solutions to overcoming its deficiencies, we will never fix it. Current events are actively calling us to think critically about our role as individual providers and our contributions as a community to perpetuating health disparities. Some of these events include the opioid epidemic; the current crisis in maternal health, particularly black maternal health; persistent disparities for patients with limited English proficiency; and disparities in preventive health services for people with disabilities. How do we balance our up-to-date biomedical knowledge with our patients’ expectations of being at the center of their care, their expectations of being treated with dignity and with full respect to their identities? Medical students cannot be expected to learn how to practice in this way if the words and actions of our mentors do not help us develop the language to do so.
It is an exciting time in medicine. We know more about the human body than ever before, women make up more than half of matriculants to medical school, and more underrepresented in medicine students are making their way into our classrooms and wards.18,19 The sheer volume of these “outsiders” in medicine will force care teams, small groups, and instructors to function differently and (hopefully) to watch their words. But focusing on volume alone cannot and will not get us to our goals. I am just as vulnerable to learning to practice medicine that is complicit with structural injustice as my white classmates are.
In closing, I am one woman of color, sharing one experience. Trust is defined as a firm belief in the reliability, truth, ability, or strength of someone or something.20 That first week of medical school, my health systems and policy course challenged me to think about what it would take to practice patient-centered care with an awareness of the social injustices that negatively affect health and bring on illness way too soon. Somewhere along my journey, even with the life experiences that inform my passion for medicine, I came to believe that overcoming the challenge of providing patient-centered care was entirely optional. Given my experiences, I still do not know if I can firmly believe in the reliability of our medical education system to produce the types of doctors who people like me want and need. My hope, though, is that this commentary spurs a larger conversation about trust, words, and actions at every training institution.
Acknowledgments: The author wishes to thank Kira Neel, Zoila Quezada, Carla Castillo, and Peter Friedrichs for their support during the revision process for this Invited Commentary. Additionally, she would like to thank the editorial staff at Academic Medicine for their constructive feedback and valuable advice.
1. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: Evidence and interventions. Lancet. 2017;389:1453–1463.
2. Purtle J. Felon disenfranchisement in the United States: A health equity perspective. Am J Public Health. 2013;103:632–637.
3. Brown RT, Goodman L, Guzman D, Tieu L, Ponath C, Kushel MB. Pathways to homelessness among older homeless adults: Results from the HOPE HOME study. PLoS One. 2016;11:e0155065.
4. Gundersen C, Ziliak JP. Food insecurity and health outcomes. Health Aff (Millwood). 2015;34:1830–1839.
5. Bhatti AB, Haq AU. The pathophysiology of perceived social isolation: Effects on health and mortality. Cureus. 2017;9:e994.
6. Mani A, Mullainathan S, Shafir E, Zhao J. Poverty impedes cognitive function. Science. 2013;341:976–980.
8. Glied SA, Frank RG. Care for the vulnerable vs. cash for the powerful—Trump’s pick for HHS. N Engl J Med. 2017;376:103–105.
9. Boatright D, Ross D, O’Connor P, Moore E, Nunez-Smith M. Racial disparities in medical student membership in the Alpha Omega Alpha Honor Society. JAMA Intern Med. 2017;177:659–665.
12. Nimmon L, Stenfors-Hayes T. The “handling” of power in the physician–patient encounter: Perceptions from experienced physicians. BMC Med Educ. 2016;16:114.
13. Cifra CL, Miller MR. Envisioning the future morbidity and mortality conference: A vehicle for systems change. Pediatr Qual Saf. 2016;1:e003.
14. Youngclaus J, Roskovensky L. An updated look at the economic diversity of U.S. medical students. AAMC Analysis in Brief. October 2018;18(5).
16. Smitherman HC Jr, Baker RS, Wilson MR. Socially accountable academic health centers: Pursuing a quadripartite mission. Acad Med. 2019;94:176–181.
17. Stonington SD, Holmes SM, Hansen H, et al. Case studies in social medicine—Attending to structural forces in clinical practice. N Engl J Med. 2018;379:1958–1961.
19. Acosta DA, Poll-Hunter NI, Eliason J. Trends in racial and ethnic minority applicants and matriculants to U.S. medical schools, 1980–2016. AAMC Analysis in Brief. November 2017;17(3).