This past winter, a train in Chicago derailed because the conductor suffered sleep deprivation. One of my colleagues at the Chicago Medical School (part of Rosalind Franklin University of Medicine and Science) stated that this should not be frowned upon: “Physicians and medical students work with no sleep. But you still want them to save your life.” I paused for a second. “You are really going to make that argument?” I asked. “Of course,” she responded, “you expect the healer to treat themselves as if they don’t matter…as if their lives aren’t important.”
The conductor of the Chicago train did not simply have little sleep. For example, she may have been working three jobs to pay enormous debt and care for a sick mother. Similarly, derailments in medicine aren’t simply caused by miscommunication in a particular situation or other transitory social factors. Incidents, tragedies, and insufficiencies in medicine are often part of deep histories and complicated cultural conditions.
In the last decade, the concept of “Social Medicine” has gained traction. Within the standard model of “Social Medicine,” healthcare professionals are asked to interact with patients and healthcare subjects in a way that allows the healthcare professional to “assimilate” these interactions into the worldview of the healthcare professional. In other words, doctors, nurses, and most everyone else in healthcare are asked to be culturally competent, sensitive to a patient’s social context, and open to alternative ways of thinking about the health of a human being.
It strikes me, however, that there is very little conversation within “Social Medicine” about who these healthcare professionals are. Where do they come from? What makes them tick? How are they made unhealthy within their journeys into medicine?
Medical schools continue to be places of status and privilege. Certain students have certain resources, connections, and privileges that other students do not. These resources, connections, and privileges are often generated through particular communities, clubs, and racial affinity groups that other students are not members of. Students who lack relationships within these communities, clubs, and racial affinity groups often endure alienation before and during medical school. Additionally, medical schools tend to emphasize certain learning skills, often as a means to prepare students for standardized testing, which do not usually align with medical students’ personal learning styles. Their personal learning styles are often products of cultures and heritages that are otherwise applauded by administrators at many medical schools as “diverse.”
Medical schools praise a small cohort of “diverse” students who make it through numerous obstacles on their ways to becoming physicians. The presence of these students in medical schools is supposed to illustrate a changed political and social climate where the best physicians are being trained. But why is this diversity important?
I strongly believe that the contemporary call for diversity is a passive response to urgency for authentic communication in healthcare. At Rosalind Franklin University of Medicine and Science (RFUMS), my home university, I advise and mentor students who are at the beginning of medical school. In this role, I recognize that students coming into medical school from various backgrounds often prepare for their roles as future physicians as if they are neutral positions from which they may begin to decipher the peculiarities of the lives of their patients. But I find that I must consistently persuade my students that their care of patients takes place within highly social contexts. It’s not as if social conditions stop affecting the health of the patient once they enter a hospital or physician’s office. It’s not as if the physician somehow turns off their biases and intuition. Who and what stands before a patient – in the form of a physician or other healthcare provider – helps determine a patient’s health.
Recognition of these truths is empowering. It makes it OK for a physician to be able to speak from their wealth of experiences and not be silenced by an unwarranted objectivity that places biases, non-medical intuition, and general senses of heritage on the periphery of medical care. But to be comfortable speaking in these ways as physicians, students must begin their medical training in the midst of difference and debate that only comes from bringing students from different vantage points and learning styles into medical school.
In that context, medical school admissions becomes a critical point of reflection in the medical educational process. When I first arrived at RFUMS in 2013, I attended a meeting about a Supreme Court case related to university admissions. One of our university administrators stated that use of any racial quota had become illegal. I told this person that I would never suggest a racial quota. Rather, I suggested, we ought to emphasize a connection between certain communities that are defined by certain healthcare disparities and the students who are most likely to research, treat, and eliminate these disparities. To make these changes means that we have to reconsider how medicine is kept alive in its current formations.
I lived in North Carolina for much of my life. My home community – the Lumbee Indian Tribe – prides itself on a long history of creating doctors. As a youngster, I knew that there were two medical schools that “we” attended if we wanted to go to medical school: UNC-Chapel Hill and East Carolina University. Other medical schools were off limits, it seemed, because “we” weren’t educated at these schools. Wake Forest University School of Medicine, in Winston Salem, North Carolina, is a great example. This university was well known for its history of admitting and educating several generations of physicians (sometimes 4 or 5 generations!) within White families in North Carolina. Years later, when some of my undergraduate classmates from MIT began reporting on their experiences applying to and attending various medical schools, it became very obvious that Wake Forest School of Medicine is not alone in its affinity for students who come from families of physicians.
Medical universities such as Wake Forest understand that they will not have to extend extra resources to students from these “legacy” families because there are mechanisms built within these families that guarantee success in medical school. Historically, “legacy”- which might be described as familial and community propulsion into and through a particular situation – has overwhelmingly helped White students. In recent decades, the “legacy” system is mirrored in a small number of American Black families and in some South Asian communities.
This presses us to consider a very important anthropological concept: recognition. I often think about how a baby stares at a human face. From a very young age, they look at faces in order to establish trust. They do not lose that mechanism for building trust on their journey to adulthood. Humans see faces. Humans learn to trust people in particular moments of identification. And to think that this somehow stops within medicine is absurd.
Thus, we must prepare our students as if they will be recognized beyond the authority of their white coats. There is an assumption within medical education that physicians are people who are legitimate simply because they have finished the academic work necessary to claim an identity as MD or DO. No, healing, like any human action, is context specific. It is culturally situated. It depends on the person being healed, and the person healing. Therefore, medical universities must create educational programs aimed at placing patients with particular cultural needs in contact with healthcare providers who possess particular cultural backgrounds. To create these new programs, however, medical schools must identify and equitably address gaps in status and wealth between students.
This brings us back to economics. The people who likely have the most affinity for particularly underserved populations tend to be the most vulnerable students in medical school classes. Some medical students (usually those described as “diverse”) move through their education against the grain of a historic trend of students advancing into important social positions who are connected to a wealth of resources. If you listen to students who are not “connected,” their stories are often similar. Not only are they often not wealthy, they often possess educational backgrounds that were not supportive of their long-term achievements. Their families and communities care for them, but these families and communities tend to understand very little about the conditions of a medical student’s life. As a result, we should not be surprised if these same students are torn between medical specialties that allow them to practice with their communities and other possibly more lucrative, possibly more alienating medical specialties. Pressure is placed on medical students by other members of the medical community (including their classmates) to seek out the most profitable specialty as a demonstration of machismo and prestige. Still other students begin to look at their careers in medicine as a mechanism to truly deal with a legacy of poverty and disenfranchisement.
On that note, it is saddening to see that some of our students are educated in poverty. How does this poverty look? Many “diverse” students must pay attention to families and communities that pull at them for help in the midst of heavy medical school course loads. Additionally, the $20,000/year stipend from their gargantuan medical school loan does not make up for deep, historic poverty. As a result, they may not be able to afford the study aids necessary for successful completion of medical school practicums.
These are frightening propositions. There is an economic force – which helps energize the “legacy” that I mentioned earlier – that creates a scenario in which simply matriculating into medical school isn’t enough. The medical school of the future must incorporate a new type of community in which future physicians are valued, protected, listened to, and enabled to educate one another on the truths that come from the collaboration of different peoples within the university.
Very simply, a future with “Social Medicine” means that the healers must be healed. We must address the social conditions of medical professionals before they can adequately address the social conditions of their patients. We must be honest about how particular parts of medical education in the United States are diseased. We must use “Social Medicine” as a harsh light that reveals and heals in the selection and creation of the physician
 Kothari, K. The Case for Social Medicine. JAMA. 24 June 2014
 Over the past decade I have worked in pharmacy as a “pharmacy technician.” I
once heard an executive for Walmart’s Wellness division tell a pharmacy student
(at the store for a volunteer health day) that she should have confidence by saying:
“You wear the White coat, not that person you are helping. You are the authority.
You are the expert. Act like it.”
 Some notable exceptions include The University of Minnesota’s Medical School at
Duluth and East Carolina University, both of which have shown a major
commitment to educating Native American physicians.