Author: anunag

Anna Nunag

27 March 2023

Mission trips to South America. Independent student research. Leadership positions. Summer volunteering. These are the ways applicants try to demonstrate to medical schools that they are well informed individuals, with a commitment to research and serving the humanity of others.

One consistent theme throughout this module has been the need for a change in culture for both current physicians and medical students entering the workforce. Students are assessed at a high standard to get into medical school, but how is this same well-roundedness fostered once applicants are accepted into medical school?  

I looked into current stances of how these assets are addressed in medical schools, and while it varies from school to school, efforts are being made to put in place ways for medical schools to help their students foster research and awareness for rare diseases, public health concerns, and empathetic interactions with patients. 

Awareness for Rare Disease

One improvement in the medical field that this module has shown light on is the lack of research and awareness for Rare Diseases (RDs). 

According to the World Health Organization (WHO), 400 million individuals are living with rare diseases and from a study surveying preclinical medical students, 92% feel “ill-prepared  to provide rare disease care” (Ayyappan, et. al, 2022). 

…from a study surveying preclinical medical students, 92% feel ‘ill-prepared  to provide rare disease care’

For example, Chronic Fatigue Syndrome or CFS is one contested illness, defined as an “experience [of] incapacitating fatigue” and “symptoms [persisting] for at least six months and cannot be explained by any other diagnosis” (Walker: 2012).

CFS is “without clear biomedical indicators” and shares many variable symptoms with other diseases,  making it hard  to pinpoint and define, and difficult to conduct clinical research trials on, ultimately leading to stigma around this contested illness (Walker: 2012). 

An article in the Journal for Vascular Anomalies, tactics of how medical schools could incorporate rare disease into curriculum while acknowledging the difficulty in diagnosing these contested diseases with no explicit etiology or symptoms.

These tactics include teaching an adequate vocabulary surrounding RDs and keeping students informed on research efforts, and some schools and student groups are pioneering this effort

For example at the University of Pennsylvania, student leaders of the ‘Rare Disease Interest Group’ have created an elective course containing “rare disease-specific information”, incorporating current RD research into lectures, and “training students to recognize rare diseases and to be cognizant of the unique needs and experiences of rare disease patients” (Ayyappan,  et. al, 2022). 

Some medical schools are making progress by offering RD in the form of an elective, but it is not a mandatory requirement standardized over all medical schools. 

Many medical schools are also distinguished research institutions, and RDs can be one area of investigation that is incorporated into curriculum so that more medical students feel confident and informed enough to tend to this patient population.

Public Health discussions

Next, demonstrating that an applicant is well-informed or involved in their community is an important factor for applicants, but these values are not fostered to the same extent in the actual curriculum.

According to an article from the National Institutes of Health, curriculum is a reflection of how “most institutions are evaluated on the basis of molecular science curricula and student performance is assessed via standardized testing on molecular science” rather than ‘relevant disciplines’ of public health concerns such as socio-economic and socio-ecological influences on health in communities (Rao, et al, 2020).

As the United States population is living longer and becoming increasingly diverse, this creates an increasing  need for physicians to have an understanding of socio-economic factors and a “cultural competence” (Rao, et al, 2020) in order to treat the “complex root causes of illness” in this future patient population. 

“…the United States population is living longer and becoming increasingly diverse”

The Crawford article, “Health as a meaningful social practice,” addresses one public health theme by arguing for the way in which health in the United States has become a form of social control, reinforcing social norms rather than taking into account societal factors and disparities that exist between communities.  

The Crawford article argues that health is viewed as personal responsibility rather than a reflection of socio-economic situation. 

This is seen through how “white, middle class Americans [are] privileged in being able to adopt healthy lifestyles, “ (Crawford: 2006) because they have adequate resources to maintain their health. 

On the flip side, those from a poorer demographic and more likely to be in worse health and this is not a reflection of personal failure according to Crawford because of the role of societal factors in personal health. 

This understanding of health as a form of social control is just one public health point of discussion that can be analyzed in medical school. This would allow for future physicians to both understand a patient population through the context of societal factors, but also understand how a patient grapples with their health in a society that views it is the fault of the individual. 

Tools for patient-doctor interactions

Lastly, empathy is another character element that medical schools like to see evidence of, and ‘delivering patient centered care’ is often a key term used in  medical schools mission statements. 

Still, there are no standardized efforts across medical schools that directly address appropriate tools to empathize and approach patients grappling with their chronic illnesses. 

The article “Illness Narratives”  describes the stigma that chronically ill people face and other stresses that patients and their families experience as a result of illness.  

The article describes the important role that practitioners have in controlling the fear or  anger, “[restoring] confidence in body and self” and, “[educating] sick persons to escape both excessive feelings of guilt over failures in life activities and jealousy towards others” (Kleinman: 1988).

For example, in the “Illness Narratives,” a  patient with severe eczema felt shamed standing in front of physicians and their medical students inspecting his body. He felt shamed and exposed as a result of the physicians being insensitive to his privacy and respect.

Empathy to address these interactions is not a ‘hard science’ that can be taught or tested, but may come through experience and being better informed on how the effects of illness are felt by a patient and their family and how they internalize the societal stigma placed on a patient. 

“…how the effects of illness are felt by a patient and their family and how they internalize the societal stigma placed on a patient”

A course that directly addresses the importance of empathy in patient-physician interactions is not standardized, but it is possible that some schools may offer electives, such as at Temple University (Ayyappan, et. al, 2022). At this medical school part of the curriculum is having students practice interacting with patients with disabilities such as volunteer patients with congenital muscular dystrophy, with the goal that “such initiatives would humanize rare disease, training students to consider in addition to biological and clinical data, the human that lies beneath” (Ayyappan, et. al, 2022).

While offering an elective is making progress, it does not allow for appropriate tools for all future physicians expected to deliver ‘patient centered care’ and approach a patient grappling with their disease.  

Across all medical schools, there is no standardized way that Rare Diseases, public health, and strategies to approach patients are addressed.  

Continuing Medical Education may not be realistic avenue to change the way physicians think and what they value, so this proposal might be most effective by targeting the future medical doctors at the lowest level: medical schools.

The medical school curriculum should show that they are committed to developing well rounded, future physicians to reflect how they are valued in medical school applications in an evolving patient population.

Works Cited 

Gawande, A. (2017). The Heroism of Incremental Care. The New Yorker. 

Ayyappan, V.,  et. al.(2022). Spotlighting Zebras: A Role for Medical Students in Shaping Rare 

Disease Care. Journal of Vascular Anomalies.  https://journals.lww.com/jova/Fulltext/2022/03000/Spotlighting_the_Zebras__A_Role_for_Medical.4.aspx.

Walker, J. (2012).  Researching Contested Illnesses: The Case of Chronic Fatigue Syndrome \(CFS). Boston University School of Medicine. 

Rao, R, et al. (2020). The Evolving Role of Public Health in Medical Education. National Institutes of Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7344251/.

Crawford, R. (2006). Health as a Meaningful Social Practice. An Interdisciplinary Journal for the Social Study of Health Illness and Medicine. 

Kleinman, A. (1988). Illness Narratives: Suffering, Healing, and the Human Condition. 

20 February 2023

This summer I worked my first job as a Certified Nursing Assistant at a state nursing home in a predominantly white suburb of Philadelphia. This would be my first patient contact experience in healthcare, but I learned more about society and the healthcare system from the people I worked with than the residents I took care of.

As an aide I would be responsible for bathing, transferring, toileting, and feeding my assigned residents on the dementia floor of this nursing home in my 7am-3pm shift. Everyday I worked alongside a team of nurses and aides, of which the majority were from the African country of Sierra Leone. Other than the activities director, I was the only non-black worker on the floor last summer.

One common occurrence last summer was the way coworkers rotating on the same floor as me would assume that I was the nurse. I wore a surgical mask, scrubs and dirty shoes like every other aide, no makeup, and no jewelry, so this was probably based on my phenotypic differences from the other workers. The difference in my appearance other than my size and age were my straight hair and my biracial tan skin tone.

…coworkers rotating on the same floor as me would assume that I was the nurse.

Still, at least twice a week, a coworker would begin asking me a medical question, and I would quickly cut them off and direct them to the nurse on the floor.

 This was a firsthand experience seeing how racial differences are associated with higher status even to people of color and in health care. While this assumption was not an insult to me, it was showing her internal bias that a black person such as herself would have a job that requires less education and a non-black person would have a job requiring a higher degree.

From the beginning, I struggled at the physical demands of this job. I would need to ask for help, adding to my workload of my coworkers who would reluctantly assist me.  At the end of the first week they made it clear they did not think I would be able to do this job.  Little by little I gained the trust of my coworkers that I would be able to handle a full workload as they do, turning obese residents and working efficiently enough to care for thirteen plus residents at a time.

I remember one day a coworker, an African aide, asking me about my ethnicity. I told her my dad was born in the Philippines and my mother was white. I remember her saying, “Oh that is why you are so beautiful, your mother is white.”  Later in the conversation she confided to me how stressful this job is for her, and further how she believes this job is ‘meant for black people.’

“Oh that is why you are so beautiful, your mother is white.” 

I remember not knowing how to respond, but I later understood why my abilities were underestimated when I first started. I think my coworkers could not grapple with someone from a non-black race sharing their same workload.

Both of these occurrences remind me of the Desmond and Emirbayer article that describes this “internalized racism” in which “people of color often internalize prejudice at their own racial group, unintentionally contributing to the reproduction of racial domination” (Desmond and Emirbayer, 2009: 346). The racial based comments my coworkers made were never offensive, showing how society gives my half-whiteness a higher, respectable status.

As seen in the US Health Care System Profile, “There is no universal coverage for long term care services” for Medicare or private insurance users. Public spending in the United States for long term care facilities, such as the state nursing home where I worked, represents “approximately 70 percent of total spending on long-term care services, with Medicaid accounting for the majority” (Tikkanen et al., 2020). The lack of funding for workers at this nursing home would be one of its biggest problems.

Three to five aides would be on a floor and have to provide for fifty-five residents of which the majority needed total assistance, making this job nearly impossible to give each person the care and attention they deserved. The lack of funding to nursing homes like this shows in the lack of supplies available to our residents, hurting their quality of care. Lack of funding also contributes to the low wages for both aides and nurses that would often work doubles, 7am-11pm multiple times a week. While I enjoyed the sense of accomplishment I got from my job, I did not have the stamina to do what they did.

Three to five aides would be on a floor and have to provide for fifty-five residents of which the majority needed total assistance, making this job nearly impossible

The stress and burnout of this job that I noticed in my coworkers manifested itself in habits and physical appearances.  One thing I noticed about my coworkers was how common it was for the aides to use their fifteen minute break to smoke cigarettes, as well as how many of the aides and nurses I worked with were experiencing obesity.  As seen in the Remote Area Medical movie, smoking is a way to cope with stress, and the nature of the job and the long hours worked certainly contributed to the need for this coping mechanism.

I came to view these habits not as the culmination of ignorance to health risks, but rather a coping strategy to work related stresses. The Zola article described the over medicalization of conditions in society deemed pathological (Zola, 1976).  While I do not deny the biological basis for conditions such as obesity, the over medicalization of obesity puts the fault on the individual and overlooks the underlying societal factors in one’s environment that contribute to these health conditions.

I came to view these habits not as the culmination of ignorance to health risks, but rather a coping strategy to work related stresses.

In this work environment I saw how my coworkers experienced stress, a lack of sleep and a lack of time and ability to care for their physical needs due to their financial need to work overtime. Society would first question an obese person’s eating habits, rather than how lack of sleep (Beccuti et al., 2011) and stress (Van der Valk et al., 2018) can contribute to one’s experience of obesity. 

The summer I was able to experience firsthand how systemic factors contribute to people’s health and bolster the effects of internal racism and over medicalization. To me, improving long term care conditions for both providers and residents, and solving the cycle of internal racism is multifaceted. The combination of lack of funding and coverage from Medicaid and Medicare (respectively), the lack of enforced legal restrictions on how many residents an aide can provide for at a time, and the lack of coverage for a high proportion of black women working in healthcare (Dickman et al. 2017) are all systemic factors that contribute to the health of black women in healthcare.

Works Cited 

Beccuti, G. and Pannain, S. (2011). Sleep and Obesity. National Center for Biotechnology 

Information. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3632337/.

Desmond M. and Emirbayer M. (2009). What is Racial Domination? 

Dickman, S., Himmelstein, D., Woolhandler, S. (2017). Inequality and health-care systems in the USA.  The Lancet. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30398-7/fulltext

Reichert, J. and Zaman, F. (2013). Remote Area Medical. IMDb.

Tikkanen, R., Osborn, R., Mossialos, E., Djordjevic, A., Wharton, G. (2020). International Health Care System Profiles: United States. The Commonwealth Fund. 

Van der Valk, E., Savas, M., van Rossum, E., (2018). Stress and Obesity: Are There More Susceptible Individuals? National Center for Biotechnology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5958156/#:~:text=The%20Interplay%20Between%20the%20Stress%20System%20and%20Obesity&text=High%20levels%20of%20cortisol%20can,to%20abdominal%20obesity%20%5B4%5D

Zola, I., (1976). Medicine as an Institution of Social Control.