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Medical Training in the Maelstrom: The Call to Physician Advocacy and Activism in Turbulent Times

Paul, Dereck W. Jr MS

doi: 10.1097/ACM.0000000000002765
Invited Commentaries
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In this Invited Commentary, the author probes current events overlapping with his early medical education for unwritten lessons. Today’s generation of trainees studies the careful application of science to suffering in the roiling context of resurgent white supremacy, anti-immigrant hatred, climate disasters, contentious public health epidemics, and attacks on the structures undergirding access to health care for millions. The author reflects on the connections between sociopolitical events and his own experiences, as well as those of his classmates, friends, and family members. These experiences, he argues, have galvanized his and his fellow medical students’ commitment to decency, truth, diversity, and equity. He concludes that, in the current climate, the practice of healing is inextricably tied to the social and political context, such that advocacy and activism have become essential to a career in medicine.

D.W. Paul Jr is an MD candidate, Class of 2021, University of California, San Francisco School of Medicine, San Francisco, California; ORCID: https://orcid.org/0000-0001-6099-5933.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Previous presentations: A subset of these stories were shared as oral presentations at Learn Serve Lead 2018: Association of American Medical Colleges Annual Meeting, November 2018, Austin, Texas, and at the University of Michigan’s Inaugural Diversity Conference, February 2019, Ann Arbor, Michigan.

Correspondence should be addressed to Dereck W. Paul Jr, University of California, San Francisco School of Medicine, 513 Parnassus Ave., Suite-245, San Francisco, CA 94131; telephone: (301) 807-1176; email: dereck.paul@ucsf.edu; Twitter: @dereckwpaul.

Even training in the evidence-based practice of medicine, grounded though it is in the objective sciences, cannot escape being shaped by the tumultuous currents of our sociopolitical moment. A generation trains in the careful application of science to suffering within a roiling context of resurgent white supremacy, anti-immigrant hatred, climate disasters, our most contentious public health epidemics, and attacks on the structures undergirding access to health care for millions. And for that we will be changed.

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Bound to Events by Our Identities

The predawn cafeteria holds only a few people: a family whispering in their native language about a loved one undergoing surgery, members of the service staff fueling up before a long day keeping the great hospital afloat, and me—a medical student trying desperately to study neuroanatomical pathways but distracted, as I often am, by the relentless stream of toxic sludge spilling from the wall-mounted television.

The events of just a short period of time have made me more mindful than ever of my umber skin, of my mixed ancestry that weaves from Africa through the Caribbean, that I am of the first generation in a family of immigrants to be born on U.S. soil, that I am the first in my large extended family to attend medical school.

In early August 2017, our University of California, San Francisco School of Medicine class was immersed in learning the basic geography of the human body. As we studied anatomy, white nationalists gathered in Charlottesville, Virginia, to protest the removal of a Confederate memorial. With anti-Muslim, anti-Semitic, and antiblack chants they had resurrected Nazi and Confederate flags as their own proud emblems. Those who showed up uncloaked and in broad daylight for the so-called Unite the Right rally clashed with counterprotesters, leaving Heather Heyer—a 32-year-old woman who felt called to protest hate—slain in the street and heralding acts of racial violence to follow in the coming months.1,2

Thousands of miles away in San Francisco, the Charlottesville rally and the public response to it had a palpable presence in our classrooms. We were collectively reckoning with what some had long known to be true—that the promise of a “postracial America” was an illusion that protected structural oppression, and that race and identity were to be front and center for much of our journey in medicine. Under the sigil of White Coats for Black Lives, students pressured action on curriculum reform so that we could better address persistent racial disparities in health. With the virulence of latent strains of racial hatred revealed, health equity ascended from special interest to core responsibility for most of our class.

Our sense of urgency for action was heightened in the following months when years of anti-immigrant false alarmism began to manifest as cruel policy at the southern border. The cries of children separated from their parents echoed in our hearts long after they played on the news. In their psychological distress, some of these children were undergoing dramatic developmental regression.3 The separation policy was eventually rescinded following public outcry, but some families have not yet been reunited.4 As of this writing, two children have died in custody at the United States–Mexico border.5

Members of my own large extended family came to the United States in the 1960s. In the early days, my aunts and uncles attended a makeshift school in a Brooklyn basement rather than show up to the local public school for fear of triggering the family’s deportation. It was impossible not to imagine my family members teargassed, separated, and detained as they might have been if trying to come to the United States today. To some, my life has more merit, for no reason other than having been born north of our southern border. This remains incomprehensible to me. That to some, my mother’s life had less merit the day before her citizenship oath is anathema.

Raucous changes to immigration policy threatened to wholly upend the lives of some of my classmates and their families, yet still they carried on with grace and strength. I resolved to be more like my classmate, a practitioner of Islam and son of Syrian immigrants, who, in the same week a third travel ban targeting mostly majority-Muslim countries was upheld by the Supreme Court, had mastered the difficult neurological exam days before the others in my group.6 I listened to classmates who, after years of attending medical school under the Deferred Action for Childhood Arrivals program, bore the heavy uncertainty of whether they would attend residency here in their home country or be forced to return to a land they barely knew.7 In some cases, they had spent less time in the countries of their birth than their well-traveled U.S. citizen classmates had.

Stories of immigrant families afraid to use social services, afraid to bring a sick loved one to the hospital for care, abounded. We knew that our rallies in front of the hospital, where we waved signs that read, “Inmigrantes son bienvenidos aquí,” could not counteract the deep fear felt by many families. Legislative advocacy for ourselves, for our families, and for our patients was emerging as a pillar of our lives in medicine. If the definitions of who was and was not worthy of dignity, social services, and health care remained under the purview of others, we would be unable to live up to our promises to the communities who had sent us to medical school.

In October 2017, I sat in a seminar on the interpretation of scientific articles as a classmate presented a study. Her usually bronze face was pale. Hurricane Maria was threatening to drown her home island of Puerto Rico. Her family and others would have to rebuild almost from scratch, largely on their own and with limited assistance from the federal government. In the aftermath, as public officials denied death toll estimates in the thousands—estimates made by George Washington University and Harvard University scholars—the lesson hit hard.8 Doctors and scientists would have to become guardians of scientific facts. We would have to be advocates for environmental justice in a world where truth seems constantly under siege.

In 2017 and 2018, a confluence of record-long drought and record-high temperatures sent wildfires swirling across the West Coast of the United States. Three months into our program, we had begun to see patients under supervision once a week. When the fires began in Northern California, we manned phones, calling each patient living within the areas overtaken by flames. A few answered their cell phones to tell us they escaped, most with only their lives.

Scientists at University of California, Berkeley and University of California, Merced, usually reticent to call any one event a result of climate change, were willing to say that the aggression of the California wildfires grew from changes in the climate and predicted even more hostile seasons to come.9 While we telephoned patients known to live in now-charred wine country, the Clean Power Plan was rolled back, the Clean Water Act was targeted for delay, and environmental law enforcement decreased by 60%.10–12

To go to medical school amid the California fires, at times wearing particle masks on the walk between classes, was to understand that the environment and health were intertwined in a way that had been obvious to the patients and doctors in places like Flint, Michigan, and San Francisco’s Bayview for decades.

In February 2018, a classmate looked at me with blood-red eyes, eyes that revealed she either had not slept in days, had been privately tearing, or both. She is a graduate of Marjory Stoneman Douglas High School in Parkland, Florida, and had been tirelessly organizing demonstrations and education at our school for the recognition of gun violence as a public health issue. This in the wake of the vicious murder of 17 of her alma mater’s students and teachers in yet another mass shooting.13 Somehow, she was still attending lectures on managing dysregulated metabolism in diabetes. Gun violence continues to emerge as one of the most visible issues for which physicians have raised their voices and deployed their influence.

By the end of the first preclinical year, traveling into Oakland on the Bay Area Rapid Transit (BART) train was routine for me, but this trip felt different. I looked at the web of colored lines on the wall and tried to figure out how I might be able to avoid having to see the doors open up on the MacArthur BART platform. There, a week before, 18-year-old Nia Wilson, on her way home from a party for her cancer-stricken aunt, was stabbed by a stranger and bled out in her sister’s arms. The attack, suspected to be an act of racial hatred by a man lying in wait during a nearby meeting of white supremacists, sparked protests across Oakland.14

Nia Wilson in Oakland; Stephon Clark in Sacramento; Eric Garner in New York City; Laquan McDonald in Chicago; Tamir Rice in Cleveland; Walter Scott in North Charleston, South Carolina; Freddie Gray in Baltimore; Sandra Bland in Prairie View, Texas; Alton Sterling in Baton Rouge; Philando Castile in Falcon Heights, Minnesota; Michael Brown in Ferguson, Missouri. I knew their names better than the state capitals. When had brutal killings become the landmarks in my mental map of the country?

A month before, a group of researchers had published a study showing that the annual killing of 300 black persons by police in the United States has a detrimental effect on the psychological health of black Americans at large.15 I tricked myself into thinking that because I spent most of my days in a classroom, the shootings I had seen on YouTube could not affect me in the same way. That mirage lasted until the summer of 2018, when I jumped into an old Honda a friend had just purchased from an auction.

As the police officer pulled us over, my friend remembered that we had forgotten to put the registration sticker on the license plates. We agreed that the officer approaching likely thought it was a stolen vehicle. My deep internalization of the endless police shootings around the country emerged when the sound of the officer’s night stick slamming against the back window sent flashes of my friends and family faced with my death running through my mind.

Those flashes were an important reminder that, even if I wanted it to, higher education will never allow me to escape my identities. Those flashes are a lens through which I view my classmates and their endless combination of intersecting identities and experiences, which I will never claim to understand but am honored to bear witness to.

I will never know how it felt, amid learning about the devastating mental health outcomes in sexual and gender minorities, to hear that people who identify as you do are not allowed to serve in the military. I will never understand how it felt for my colleagues who are survivors to study the underreported, overwhelming, and overlooked rates of interpersonal and sexual violence while watching the congressional testimony of Dr. Christine Blasey Ford, a research scientist and psychologist who works just 40 minutes away from our campus.16

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Answering the Call to Action

In a short span of time, an appreciation of the deep interconnectedness of our sociopolitical world and the practice of medicine has been thrust on medical students across the country. To those who bore the true burdens of these events, we owe a resolve to change our world so that tragedies of the past remain so located, and we owe a commitment to social advocacy that builds on the work of physicians who have long called for the elevation of advocacy and activism in health care.17–20 The storm may quiet and the stories of the events overlapping our preclinical years will fade from our everyday consciousness, but the generation trained in this moment can take lessons from these times and use them to shape our future.

Buffeted from the outside, we can be hardened in our values of decency, truth, diversity, and equality. These ideals may be the necessary tools to approach the tasks before us that loom enormous but are made conquerable by the growing strength of our voices and our practice in the art of fighting for ourselves, our families, and our patients. Among the many lessons I have learned in the early years of medical school, one stands out: that justice for all people, health equity for all people, and the push for progress on our most difficult health epidemics are not areas of peripheral interest to a life in medicine; they are essential to it.

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Acknowledgments:

The author expresses deep gratitude to his classmates Daniella Cordero, Matthew Ryan, Carmen Lee, Amy Ransohoff, Amer Alsoudi, and Shakkaura Kemet for their inspiration and review of this manuscript, and to Dr. Louise Aronson and Dr. Daniel Lowenstein for their wisdom, mentorship, and review of an early version of this manuscript.

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