Author Archives: stfmguestblogger

Fierce Women and New Stars

Posted on December 18, 2019 | 4 comments

For a long time I thought I was lucky to have fierce women who walked beside me & now I see the real luck was that these fierce women stayed there until I learned how to be fierce myself. —Brian Andreas, Creator of Story People and Flying Edna

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Andrea Anderson MD
The GW School of Medicine and Health Sciences

These words hang on the wall of my office and were the inspiration of my remarks when I accepted the 2019 Advocate Award for my work in encouraging resident advocacy. As I reflect on my career thus far as an academic physician, it is clear that actively seeking opportunities and receiving excellent mentorship have been driving forces. It is not a secret that mentorship is important in any career path. It is crucial for us as Black and Brown medical educators.

I grew up as the daughter of an inner city public school teacher. Even now, some 20 years later, my mother’s influence is still evident when former students happily greet her around town and proudly show off their accomplishments. After high school, I was accepted into the combined BA/MD program at Brown University. Even at a large progressive school like Brown, I could count on one hand the numbers of Black and Brown faces who stood before our medical school class as faculty or deans. My school was not unique. Nationwide, the numbers of Underrepresented in Medicine (URM) Faculty in US medical schools remains well below 10% and has not kept pace with the increasing diversity among the student body or the society as a whole. One of those faces who significantly impacted me was Alicia Monroe MD, current provost of Baylor College of Medicine. She was one of the plenary session speakers at the last STFM Annual Spring Conference in Toronto. When she was our dean of Minority Students at Brown, my friends and I would go to her office to receive support, guidance, mentorship, or frankly just to see a face that looked like ours. Recently I was heartened to hear that among the reasons she was encouraged by her then department chair to pursue promotion early in her academic career was because of all the female junior faculty and women who looked up to her. I was definitely one of them. My experiences as a student leader at Brown solidified my passion for advocacy and imprinted me with the notion of my responsibility to speak for those who have no voice.  I was awarded the National Health Service Corps Scholarship and committed myself to a career in family medicine.

After Brown I trained at Harbor-UCLA and completed an academic medicine fellowship and chief resident year. I continued to raise my voice as an advocate for marginalized and immigrant populations. In Southern California I became the president of our Resident Union and collaborated with local labor unions to help fight cuts to the community health center safety net.  I began to see how I could combine my passion for social justice with my love of teaching and medical education. Rooted among hardworking new and first generation mainly Spanish speaking immigrants, I became firmly bilingual. One of my patients even called me an honorary Latina. This work became not just something I loved to do, rather, it was something I had to do.  After completing my fellowship, I came to Washington, DC to serve my 2-year NHSC service commitment.

Those original 2 years morphed into 15 years as I stayed far past my service commitment serving a largely immigrant population at a 25,000 patient FQHC in DC. I sought out leadership roles such as medical director, director of student and resident education, and director of family medicine. As core faculty for our teaching health center/GME residency, I was introduced to STFM and attended my first conference in 2015.  I applied for and was selected for the Quality Mentoring Program and the Emerging Leaders Fellowship. In DC I continue to be active in professionalism and assessment as the appointed chair of the DC Board of Medicine and as an item writer and reviewer for the NBME. As a local advocate I have had the privilege to testify on a variety of topics affecting marginized populations before audiences as diverse as the AAFP, the Association of Clinicians for the Underserved, DC government, and the Senate HELP Committee. I taught health literacy, advocacy, and health policy to the students who rotated at our center and to the residents in our THCGME residency. I am excited to continue my interests in advocacy and professionalism as a recent appointee to the Board of Trustees of the Family Medicine Education Consortium and to the Board of Directors of the American Board of Family Medicine.  During my time at Unity, I taught scores of students from the GW School of Medicine and Health Science, a DC target school without an FM presence. I served as a kind of de facto community family medicine clerkship director as FM experiences were few and far between for the students.  My work as an adjunct was recognized—I advocated for increased roles for community medicine faculty role and was accepted into the Master teacher Leadership Development Program at GW, named to medical school committees, chosen to direct the senior capstone course, and promoted to clinical associate professor. These professional opportunities were the result of hard work and dedication along with the influences of key mentors along the way. Recognizing the voids in my past student experiences motivated me to think of creative ways to combine my passion and interests with my career goals. My life was busy and full as I juggled my work with my roles as a mother of two young children, a wife, and a daughter.

Although I felt respected from my adjunct teaching position, I began to feel that I could have a bigger impact at a university level as a full-time faculty member. Years of student and faculty advocacy for FM at GW caught momentum and I was asked to join the leadership of a small new Division of Family Medicine. This switch necessitated that I get firmly on a full-time academic track. But on the other hand, I loved my FQHC patients, families who I had cared for for generations. I struggled with how to advocate for them, full of angst as I announced my decision to leave. Several cards and letters of gratitude poured in from my patients and friends.  However, one from a teenage patient I have cared for since she was in kindergarten left a permanent mark on my heart.  In her adolescent script she said:

“Don’t worry about me, Dr Anderson, I will achieve my dreams. I appreciate you so much.  But I know it is time for you to move on, time to make new stars. Many students will appreciate your hard work so they can light up their dreams as well.”

So this year at commencement, I will walk in my academic regalia, this time with the other full-time faculty. When I hear those bagpipes I am again reminded how proud I am to be an African American woman in academic medicine. In the spirit of those who have mentored me along the way, I march proudly and cheer for my students. As URM faculty, our presence says that we are still here and you can be here too. We are contributing, shaping the scholarly discourse of primary care, medicine, and public health for years to come. I nod to everyone, but especially to all those grandmothers and parents and aunties and uncles of color who have sacrificed, sweated, and prayed so that their loved ones could achieve their dreams. That nod that says I see you, and I am standing up here for you. I think of my own grandmother, a proud, smart, and beautiful woman who missed out on her college and career dreams, so eventually I could realize mine. I think of my former immigrant patients and how it is my responsibility to speak up for them. I think of the theme song played as I accepted my STFM Advocate Award, “Girl on Fire” by Alicia Keys.  STFM is a place where we are reminded that as family medicine educators, we are all on fire to create, as my teen patient and Brian Andreas would agree, Fierce New Stars. Let’s keep our torches burning brightly to do just that.

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Posted in Health Equity, The Path We Took, Underrepresented in Medicine

The Path We Took

Posted on October 31, 2019 | Leave a comment
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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.

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Posted in The Path We Took, Underrepresented in Medicine

The Importance of Refugee Care in Family Medicine

Posted on July 29, 2019 | Leave a comment

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

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Posted in Education, Residency, Uncategorized