Author Archives: stfmguestblogger

The Path We Took

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Octavia M. Amaechi, MD

“Oh, you’re Dr Amaechi! You didn’t sound black over the phone!” The seconds following this all-too-familiar statement pass slowly. I glance at the weak, but recuperating, middle-aged patient I cared for over the past week on our busy hospitalist service. His wife had finally arrived to thoroughly review his complicated hospital course and plans for care after discharge after near daily personal updates from me via telephone. From his grim prognosis on admission, time spent at death’s door in the ICU, to making daily figurative and literal steps to recovery on one of our med surg units, we spoke frequently as her unforgiving work schedule and family obligations interfered with her ability to be consistently at his side.

Clearly surprised by the color of my skin she continues “I mean, you explained everything so well, and you don’t have an accent at all…” Still silent, I now glance at the nurse who paged me when she arrived as I requested. As a family physician, I aspire to the tenets of my specialty in every sphere—treating the patient and family in context of their values and individual needs. Patients are especially vulnerable when met with acute illnesses that invariably arrive at the worst moments. A milieu of diagnoses, tests and procedures, room transfers, fear and uncertainty, all heighten stress levels in the inpatient setting. Their values are tested (Do we want this feeding tube?) and their needs are unknown (How long will we need inpatient rehabilitation?). Consequentially, this environment can unshroud racial and cultural misperceptions, bias, discriminatory beliefs, or racism from those we family physicians have promised to serve.

His nurse speaks, “Yes this is Dr Amaechi. You spoke with her yesterday.” There’s another place I glance—to a much younger version of myself in fifth grade. In this moment, and unfortunately others like it, I recall my earliest memories of being accused and teased by classmates for “sounding white.” I am the first American born into a Jamaican immigrant family. I was raised in a neighborhood heavily influenced by Caribbean and a multitude of other cultures from around the globe in the very heart of Brooklyn, New York. How could I sound white, I thought? How do you sound like a color? At 9 years old I had no clue what this meant, but the words from my peers stung. I eventually realized, disheartenedly, that loving to learn, being intelligent, speaking with clarity, and other positive attributes were and often still are associated with whiteness.

Thankfully my social support system, especially my parents and older sister, setting clear expectations and giving constant affirmations outweighed the threat of peer pressure and stereotype conformation. I was encouraged to work hard for whatever I wanted, but also given the freedom to not be perfect. With very few resources and even less knowledge about the American education system I was instilled with miles of grit. Now as a faculty physician at the family medicine residency program where I trained in South Carolina, I still benefit tremendously from a strong professional and personal support system that now includes my husband and two children. Here I have succeeded in positions that align with my strengths, passions, and talents both inside and out of our large community-based hospital system. I have the privilege of teaching medical students and residents alongside outstanding family physicians. I have been awarded the distinction of Fellow of the American Academy of Family Physician and Designation of Focused Practice in Hospital Medicine. I have been elected chair of family medicine within my hospital system, chair our local women in medicine group, and am a board member elect of the county medical society.

Similarly, as an STFM member for just under 2 years I’ve received tremendous mentoring and sponsorship, been entrusted with leadership roles, and continue to collaborate on multiple initiatives and projects with family medicine colleagues across the country. I have been elected to serve as co-chair for the New Faculty Collaborative. I am also quite blessed and excited to work one on one with amazing mentors from the Minority in Medicine Collaborative as a recipient of the STFM Underrepresented Minority in Medicine Writing Scholarship. My STFM membership has allowed me to create many meaningful relationships, and simultaneously ignited my path for academic advancement. In fact, I can now add international conference speaker to my portfolio with successful presentations at the 2019 STFM Annual Spring Conference in Toronto, Canada!

I glance once more to my recovering patient. While there is no single right way to navigate such an encounter, this time my direct silence has spoken volumes. His wife realizes her error in thought and perception grounded in implicit bias that we all undoubtedly have in one form or another. She apologizes and once again my presence has changed the narrative of what one perceives a capable, caring, intelligent, physician to be. We discuss the most pressing concerns and I answer her questions, including one unexpected, but always warming: “Can you be our family doctor once he is discharged?”

One patient, one family, one learner, one presentation, one leadership position, one outreach endeavor at a time—as I strive for professional and personal growth and advocate for the community around me, I hope my life will always silence stereotypes of what a black voice can be.

The Importance of Refugee Care in Family Medicine

The Issue

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Jeffrey Walden, MD

Immigration as a whole, and refugees in particular, have been much in the news for the past several years. According to the United Nations High Commissioner for Refugees, as of 2018 about 68.5 million people worldwide have been forcibly displaced—more than at any other time in human history.1 Over a third of these people have crossed international borders while fleeing persecution and violence, and have therefore been labeled refugees.

While war and political upheaval have uprooted people for centuries, the plight of those fleeing persecution formally became codified into law with the 1951 Convention Relating to the Status of Refugees. Based on this definition, a refugee is someone who, “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country.”2

The United States has historically resettled between 70,000 and 80,000 refugees per year, with a steep drop-off in the past several years due to changes instituted by the current presidential administration.3 With almost 30 million refugees worldwide, these numbers mean less than 0.3% of the world’s refugees are resettled in the United States in any given year. We as a nation can thereby exercise much discretion when selecting which refugees enter the United States. Indeed, the process to vet potential refugees involves security clearances by numerous federal agencies, including the Department of Homeland Security, and can take upwards of 18 to 36 months.

Historically, the United States has not discriminated a refugee’s case based on his or her ability to integrate. While this ensures granting the most vulnerable equal access to protection and resettlement, refugees may therefore arrive with chronic or serious health problems.4

The Importance to Family Medicine

Although all applicants for refugee status undergo health screening overseas by a trained panel physician, refugees may have had little prior care for any of their longstanding medical issues. Family physicians, whether in academic centers or private practice, therefore often encounter refugee patients after arrival in the United States. Learning to care for these—and by extension other—underserved patients serves an important part of the undergraduate and graduate medical education curriculum.

Refugees form a heterogeneous group, arising from areas of the world as disparate as East and Central Africa, the Middle East, Southeast Asia, Eastern Europe, and Central and South America. Despite these differences, they have some unifying factors—all refugees have faced persecution, by definition of their status. Many have been subjected to various diseases of poverty and nutritional deficiencies. All will face challenges when resettling in the United States with cultural issues and social determinants of health.

Culturally appropriate care—the type of care typically provided by family physicians—can help these patients better integrate into US society. Assisting refugees along their path toward self-sufficiency and citizenship requires developing strategic partnerships and community engagement. Fostering such relationships can potentially strengthen a clinic’s outreach in the community to address other social determinants of health for all clinic patients.

Involving Learners

Since 2014, the Cone Health Family Medicine Residency Program has sponsored a dedicated refugee and immigrant clinic within our larger family medicine clinic. Structured toward both learners and patients, the clinic serves as an intake evaluation to review the patients’ overseas paperwork, obtain medical and social histories (often the main difference between these patients and “regular” patients), screen for infectious disease, and identify any current needs or issues. The first 30 minutes of each clinic are dedicated to didactic teaching about a specific refugee topic, after which residents interview and examine the patient. The resident who sees that patient then becomes his or her primary care physician. All residents rotate through the clinic during their community medicine rotation:  2 weeks during their second year and 4 weeks during their third year.

Our clinic also serves as a rotational site for visiting third- and fourth-year medical students. This has provided students the opportunity to experience underserved care within a primary care and family medicine context. By working specifically with refugees, learners gain opportunities for advocacy, improvements in cultural humility and competence, and the ability to pursue global health work without needing to find the time or funds to travel.

Due to ongoing worldwide conflicts, issues of migration won’t be going away anytime soon. Exposing learners to such issues can broaden medical education while serving a community need. Beyond that, caring for refugees and learning how they have responded to persecution can teach clinicians valuable lessons about resilience in this time of perceived physician burnout.

Ways to Get Involved

  • Commit to seeing refugee patients in your clinic
  • Develop a refugee, migrant, or other underserved clinic within your program
  • Volunteer at an underserved clinic or health department
  • Conduct medical forensic evaluations for those seeking asylum
  • Complete N-648 certifications—a topic for a future blog post

Further Reading

References

  1. The UN Refugee Agency, Office of the United Nations High Commissioner for Refugees. Figures at a Glance. https://www.unhcr.org/figures-at-a-glance.html. Accessed May 22, 2019.
  2. The UN Refugee Agency, Office of the United Nations High Commissioner for Refugees. The 1951 Refugee Convention. http://www.unhcr.org/pages/49da0e466.html.
  3. Migration Policy Institute. S. Annual Refugee Resettlement Ceilings and Numbers of Refugees Admitted, 1980-Present. https://www.migrationpolicy.org/programs/data-hub/charts/us-annual-refugee-resettlement-ceilings-and-number-refugees-admitted-united. Accessed May 22, 2019.
  4. Hebrank K. Introduction to Refugees. In: Annamalai A, ed. Refugee Health Care: An Essential Medical Guide. New York: Springer Science; 2014:3-11. https://doi.org/10.1007/978-1-4939-0271-2_1

In Pursuit of Equity

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Cleveland Piggott, MD, MPH

“He died because he’s black!” screamed his mother, inconsolable in the intensive care unit as her unresponsive teenage son underwent formal neurologic examination. We had done all that we could. Mr M had experienced a cardiac arrest for unknown reasons at home, and his mom felt the emergency medical technicians treated her son differently, possibly even withholding care, because of his race. She already knew what the result of the neurologic testing would be, as did I, a second-year family medicine resident at the time. Now I’m an assistant professor, and I still remember the despair in that mother’s voice and the weight of her statement.

His mother may be right. The report Unequal Treatment showed us that health care disparities still exist among racial and ethnic groups even when you control for income, age, insurance, and severity of medical condition.1 Regardless of the facts of Mr M’s clinical course, his mother lost a son that day. Her trust and view of the health care system will never be the same. Our health care system often fails people that look like Mr M. It fails people that look like me.

Being new faculty and the only black, male member in our department of family medicine (DFM), which comprises more than 200 faculty, comes with its share of challenges and opportunities.

I love what I do. I’m so incredibly grateful that I found a job where they pay me to do what I love:  care for patients and teach the next generation of physicians. I find that to be a great privilege and honor. However, I pay close attention to what opportunities I take on, as I try to minimize the “minority tax” I have to pay.

The minority tax refers to the extra responsibilities placed on minority faculty in the name of diversity.2 This tax is extremely complex, and it is sometimes self-imposed by faculty due to a sense of responsibility they feel. For example, as a young faculty member in medical education, I know a day will come when I have to decide if I’ll be the one implementing curriculum or the one creating it. I worry that my ability to develop curriculum and essentially create change will be limited by my own obligation to make sure students of color see faculty that look like them. Nationally, only 4% of full-time faculty in academic medicine are black/African American, Hispanic/Latino, or Native American/Alaskan Native.3

Being an example for students of color is something I don’t take lightly. However, I have mixed emotions at times. I’m happy to stand with them in solidarity on issues that disproportionately affect them and people who look like them, but it can be emotionally exhausting at times—never more so than at last year’s White Coats for Black Lives Annual Die-In on the medical school campus.

During our demonstration, I felt a variety of emotions. Pride, as I lay on the ground with more than 50 medical students, residents, and other faculty as we reflected on dire outcomes inequity has in our society and the importance of health professionals using their power and their voice to advocate for change. Sad, that not a single one of my family medicine colleagues was out there with me. Tired, as I reflected on the long road ahead to achieve equity for all people. Determined to continue to advocate for equity, diversity, and inclusion (EDI) in medicine, starting with my own DFM.

Though family medicine boasts to be a specialty that advocates EDI, I was disappointed in the work happening in my own DFM. When I brought up some of my concerns with my department chair, to my surprise, he agreed. Additionally, he provided support and a stage to make improving EDI a priority in our department. I, along with some of my colleagues, formed a working group with that mission, and we called ourselves the “Justice League”.

Through the Justice League, we’re changing the culture of the DFM and have a lot of accomplishments and ongoing endeavors in less than a year of work, including the following:

  • Changing our mission, vision, and values statement to reflect our verbal commitment to EDI,
  • Providing monthly education sessions to DFM personnel on issues of EDI in medicine and how they can make change,
  • Reinvigorating a conversation among our researchers on how we incorporate EDI in all of our research,
  • Changing our website to make EDI more visible,
  • Collaborating with our clinical affairs team in changing their hiring practices,
  • Analyzing our health outcomes based on race and ethnicity at our largest clinic,
  • Conducting a climate survey to take a hard look at ourselves and areas of improvement,
  • Partnering with an outside consultant to do a training on racism in medicine,
  • Lastly, we’re in the process of creating a senior leadership position for EDI for our department and in negotiations for funding a team.

I’m incredibly proud of the work we’ve done and know we have so much more we can do both inside and outside of our department. More importantly, I look forward to seeing the impact this work and our future work will have on my colleagues, medical students, and our community.

Though I have little faith that we’ll get to equal treatment in this country, I am proud to be someone fighting to close the gap, one step at a time.

References

  1. Nelson A. Unequal treatment: confronting racial and ethnic disparities in health care. J Natl Med Assoc. 2002;94(8):666-668.
  2. Rodríguez JE, Campbell KM, Pololi LH. Addressing disparities in academic medicine: what of the minority tax? BMC Med Educ. 2015;15(1):6. https://doi.org/10.1186/s12909-015-0290-9
  3. Association of American Medical Colleges Diversity Policy and Programs. Diversity in Medical Education: Facts and Figures. Washington, DC: AAMC; 2012.