Max Jordan Nguemeni Tiako is a 4th year med student (out of 5) at the Yale School of Medicine and hosts his own podcast, Flip the Script, about healthcare disparities. He starts out discussing how some of what we learn about race being a risk factor for some diseases are a product of social constructs, not genetic predisposition. We then discuss racial disparities in substance-use disorder treatment. We then pivot from health disparities to physician training disparities. We learn about the hardships faced by minority medical students from microaggressions from students and faculty to disparities in grading and how this can affect career trajectory. He ends by discussing some pearls he has learned from his own podcast.
Mr. Tiako grew up in Yaounde, Cameroon, and moved to the US to attend Howard University, got a BS in in civil and environmental engineering and then a Masters in Bioengineering from the Georgia Institute of Technology. He is currently doing research connecting his civil/environmental engineering background to identify elements of urban design that can be leveraged to improve health outcomes and move the needle towards health equity. His research fellowship is at the Center for Emergency Care & Policy research at the University of Pennsylvania. He spends his free time writing about racism and medical education in the medical student magazine InTraining.
This episode is brought to you by Orange County Bookkeepers (OCB) Healthcare Accounting: an all in one accounting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB Accountants, is that they are QuickBook professionals with over 20 years’ experience, focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. They are a full-service bookkeeping firm specializing in accounting, payroll, taxes and financial planning. For our listeners, for a limited time, they are offering 25% off their services for the first 3 months. You can visit them at OCBmed.com or call 833-671-3873 or 949-215-6200.
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Max Jordan, England, Jaco is a fourth year medical student out of five at the Yale School of Medicine and hosts his own podcast flip the script about healthcare disparities. He starts out discussing how some of what we learned about race, being a risk factor for some diseases are actually a product of social construct, not genetic predisposition. We then discuss racial disparities in substance use disorder treatment, and then pivot from health disparities to physician training disparities. We learn about the hardships faced by minority medical students from microaggressions from students and faculty to disparities in grading, and how this can affect career trajectory. Hands up by discussing some of the pearls he’s learned from his own podcast. Mr. Chaco grew up in yone de Cameroon and moved to the US to attend Howard University, got a BS in Civil and Environmental Engineering, and then a master’s in bioengineering from the Georgia Institute of Technology. He’s currently doing research conducting his civil environmental engineering background. To identify elements of urban design that can be leveraged to improve health outcomes and move the needle towards health equity. His research fellowship is at the center for emergency care and Policy Research at the University of Pennsylvania. He spends his free time doesn’t sound like there’s much writing about racism and medical education in the medical student magazine in training.
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians. Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have been learning while we were memorizing kreb cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
And now, here’s Dr. Bradley Block.
This episode is brought to you by Orange County bookkeepers, healthcare, accounting and all in one Counting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB accountants is that they are quickbook professionals with over 20 years experience focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. There are a full service bookkeeping firm specializing in accounting, payroll taxes, and financial planning. And for our listeners for limited time, they’re offering 25% off their services for the first three months. You can visit them at OCB med calm that’s OCB m Ed, or call at 833-671-3873 or 949215 6200 and check out the show notes for more information. Max Jordan go mini Tiago. Thanks so much for being on the show today.
Brad, thank you so much for having me.
So, why was it necessary to make your podcast Why do you feel compelled? You’re a busy medical student you have enough on your plate enough studying to do all the rest of the responsibilities that comes with a medical student. Yes, that you decided you were compelled to create this podcast. Why was it necessary? Why is it so important to tell this story for me I you
know, I listen to a lot of podcasts. And while in medical school, that was one of the ways I just sort of entertained myself and one of the sort of struggles in med school so far has been that the quality of our education when it comes specifically to health inequities isn’t particularly great just about anywhere across the country. And so, you know, a lot of times as a black medical students, and I am sure other minority medical students may identify with this. Now we find ourselves either engaging in conversations with our colleagues related to health disparities, especially for those instances where perhaps some of our colleagues have lesser exposure or lesser awareness. Two issues related to racism and equality in this country. And some of those compositions can be toxic depending on the type of setting. For example, in med school, where I go to school at Yale, we have a ethics and professional responsibility course. And some of those sessions health inequities come up or in our public health and Epidemiology course or even in our main lecture, you know, sometimes, you know, one of the lecturer may be giving a lecture or a sale on glaucoma and then nearing the end after we’ve talked about the pathophysiology, and the pharmacology, all the sort of like basic science and clinical aspects of a disease, a little bit of epidemiology gets presented and race as a sort of, how do you call that race as a risk factor is often presented alongside other risk factors that are not social constructs, like say, for example, for glaucoma history of diabetes. And so the sort of conflation of race as a biological factor when truly as more of a social construct and That race by itself is isolated by itself. Race isn’t so much a risk factor, but rather exposure to racism really made me want to share more of this with the world in a way that didn’t feel as taxing as, as was the case early on in med school, sort of like repeatedly engaging in this very much the same conversation over and over.
So you’re saying it’s not like say Tay Sachs, right? So right, Ashkenazi Jews, they have this mutation, where if two people with this mutation get married, they have, you know, a quarter chance of having a child that has Tay Sachs, right? So this is being a Jew right myself. We still don’t we don’t know. Like, is it a race is a religion. Is it a culture Is it fine, whatever. But that being said, right, that is genetic. So what you’re saying is when the professor is saying that, being African American puts you at higher risk for glaucoma, you what you’re saying is it’s not something inheritable. To the genetics of that individual, it is things that occur in society that put them at higher risk of glaucoma.
Well, so specific to black holes. Now what I would say is the evidence isn’t clear. And so the way it’s often presented, it’s as if it is clear, right? So for example, you’re right, like so illness like Tay Sachs disease? Well, yes, we know about the genetics. And truly those sort of genetic or things that have been shown to be linked to a specific alio are more so related to like ancestry, right? So for example, sickle cell disease is more prevalent among people from Sub Saharan ancestry. Like I grew up in Cameroon. I know so many people who had sickle cell disease and part you know, because of the sickle, the sickle cell trait, and a theory that says the sickle cell trait is supposed to be protective against malaria. So that by itself right, should not be conflated with the fact with like, with black race, in the context of being in America, and even Then Right, so the sickle cell trait is as common in some parts of the Mediterranean, you know, in some countries or regions of country of countries that are adjacent to the Mediterranean Sea. But then you have social factors like access to premarital counseling that are way more, you know, prevalent and say, most parts of like Spain and Greece that aren’t the case and say, in Cameroon, and, of course, then if you don’t have access to premarital counseling, the likelihood of two people with the sickle cell trait, you know, having children together is way higher. So it’s not as straightforward as sometimes we make it seem in the way we we teach race and genetics. And then the other thing is just about your average African American has like something like 25% Caucasian ancestry, right. And the way race is defined in the US is a self identified thing, right? Like so you have African Americans like who self identify as black like Barack Obama, who is however biracial, right, just the way we race was constructed in this country as more around how you’re perceived, and how you self identify and the history of like the one drop rule. And that by itself cannot be used to teach medical genetics, if that makes any sense.
Yeah. Because the way you perceive someone, if you’re then using it to weigh their risks of having a certain problem, might not be genuinely something that should be weighed in there.
Right? It’s not scientific. Yeah.
Yeah. Interesting. Interesting. Okay. So I can see where that would get taxing because you’re hearing it from an authority over and over. And each time you want to raise your hand and be like, yeah, and a shake them like that. It’s just it’s not that straight. Let’s not Stop saying that. I keep hearing that over and over until your best platform for communicating that information was great in your podcast. Yep. Exactly. Because there are people that want to hear and there are people that don’t write there are people that that just want to continue living the way that they’ve been living. And thinking the way that they’ve been thinking not have something changed their mind, because this is what they know. And this is what’s been working for them. And yeah, I’m sure you encounter that all the time in your where you’ll you’ll start talking about something and then you encounter resistance.
Yes, that’s also the case. But I will say right in the context of medical education, it’s important that we get taught what’s true. And this is a debate that comes up a lot, sort of like how do you change the minds of the quote, quote, unquote, Old Guard way of how medicine was taught versus how it should be taught today, as we have so much more advances, you know, when it comes to social science and medicine? So certainly, the podcast itself allows me to disseminate you know, the work of other sorts of social scientists and epidemiologists and physicians and all these people who do fantastic work related to health disparities. It also makes it such that if I ever get in a discussion about any given topic, but someone who you know may be skeptical because I know Maybe sometimes as a black medical student, there’s a perception that my position may be bias because I’m black. And thus I, you know, have a conflict, conflict of interest. So we’re like, well, there’s an anthropologist who did this very work. And I’ll send you the link because she was a guest on my podcast. And that kind of ends. If that makes any sense.
Yeah. You have a bibliography. Right. Yeah. That’s great. And, you know, something that I found an advantage of my podcast is if I have a question, I could just find an expert on it and invite them onto the show. And there you guys, I get my
answer. Right. Yeah, exactly. And I’ve gotten to learn a lot by doing this myself. So
so that’s that was gonna be one of the things that we can discuss. Excellent segue. So what are those? What are the some of the issues that that you’ve discussed that you maybe weren’t aware of before that have been particularly enlightening? So some of the things that you learned from your podcast my
first guest was Professor Colin Roberts at Yale College and history and Africana Studies, she studied the role that physicians played in the British transatlantic slave trade and as well as the sort of birth of the pharmaceutical industry way back during the slave trade, like, for example, one of the things that I learned is the pharmaceutical industry that we know today and the center of that context of mass production of medication came out of actually it was sort of born out of the out of the transatlantic slave trade where they were up. How do you call the apple tech carries? I don’t know how to pronounce that. Well. apothecaries. Yeah, there you go. Yeah. So for example, GlaxoSmithKline traces its roots all the way back to slavery, or, for example, the medical examination that physicians had to perform on those that were captured and, you know, at the cost of the African continent, and then brought on to the boats and how, you know, physician had to sort of force them to remain alive. You know, there was a lot of force feeding that happened on these boats or ships, I guess I should say, lots of force feeding, making sure that people remained as healthy as possible. And there interestingly, you know, what Professor Roberts describes because a lot of her work was archived All she knows she went to the UK and dug up letters that some of these physicians wrote back to their wives in the UK about what they were doing. And some of them were conflicted about what they were up to. But there was such a good financial incentive, while poverty may have been breaking back in the UK that they felt like well, you know, this is what I got to do. And it speaks to the eyes to me as a medical student now, right like thinking about the Hippocrates boats off, right, like, Who are we what is our allegiance to, to our pockets or to the board to people and people that were meant to serve, and society. So that’s one of the things that I’ve really liked. It really sat with me after I did that recording, another set, sort of like learning experiences for me amongst all my episodes was about this concept of a two tiered system of addiction treatment that we have in the US and the guests. The first guest I had on this was a professor Helena Hanson. She’s a psychiatrist and anthropologist and a You and this is the first time I had to like travel somewhere to interview. I guess it was really exciting. So basically, you know, the US has a history of splitting how we treat opioid addiction, right methadone versus buprenorphine, where buprenorphine is basically it, you know, the partial agonist to the new receptor versus methadone, which is a full agonist. And as it turns out, even an orphan is more accessible in areas that are richer, have more white people, less black people, as Hispanic people and people that are more more likely to be privately insured. And methadone is more, you know, accessible to black and Hispanic people and just the nature of how people access methadone versus buprenorphine. It’s really there’s a stark difference there this concept of the carceral state, but you know, but not within carceral institutions shows up in the provision of methadone, right. You have to show up to a clinic every single day and somebody has to watch you take your medication then you have to pee in a cup for a day. You and drug test. I mean, some people do eventually sort of quote unquote, in the trust of their provider and get to be able to, I don’t know, get a month a week’s worth of supply of methadone as opposed to showing up to the clinic every day. But overall, it’s a very invasive and intrusive process. And it’s almost like wonderful co wrote about the carceral state. And it’s sort of like, just uses throughout society, he thought about how methadone will be provided. Whereas with paper norson, you know, you can go to your doctor like you, you go get, I don’t know, your prescription for I don’t know, an SSRI, and then you go to the pharmacy, and then you pick it up. But, you know, it provides some level of privacy and normalcy that being a methadone patient just doesn’t and it’s a highly racialized, and that’s one of the favorite episodes in terms of just how much I learned from talking to Professor Hanson.
The interesting, you would think if there’s a method of treating something that is in an economically disadvantaged area, you’re doing it in a way that costs more Right, like because although it’s very labor intensive to have people come in, and it just it like from an economic standpoint, if it just doesn’t, it just doesn’t make sense.
You know, I have actually never thought about that until now. I mean, you know, methadone was introduced in like the 70s. And Duke wasn’t FDA approved for serious disorder until like, 2002. And before then people were sort of using it, I’m prescribing it off label. So I think part of it maybe the sort of latency with court, you know, people getting with the times, but even then, most recently, New York State just disagreed. I think maybe the governor vetoed it. I can remember the detail behind it, but basically, the state legislature, and the governor’s mansion in the state of New York got in the way of making sure that the orphan will be equally as accessible as methadone, basically cementing the the existing system that is in New York state right now, especially in New York City. Yeah, I haven’t thought much and I should take that up, like So how much does it cost you a pair operationalize. methadone clinic versus buprenorphine provision. But I also understand to an extent, right, why you have if you if you need methadone, I suppose if you need methadone, and you need to show up to a clinic every day, methadone is a full agonist, and there is a risk of overdose. And so the sorts of provision, some of it may be too much. But some of it may be like rationalize bubble, but as long as methadone and buprenorphine as are equally available, I think that this sort of notion of opportunity of choice for patients doesn’t necessarily exist for black and Hispanic patients, especially if they’re low income.
And just to be clear, so to the listeners, you’re a medical student, I’m an otolaryngologist, neither of us have expertise in the differences between these two medications. So you know, I think we will we I think we should change focus a little bit. Yeah.
Maybe I got too in the weeds.
On addiction, by the way. Oh, so you do
Yeah, I got to have become an addiction researcher basically, after having learned so much from Dr. Hansen. Yeah. So I should have probably said that
that is something that allowed you to kind of springboard into that area. Yeah. So something that you are and also are an expert right now is being a student. And so one of your episodes was a big hit your way to success. And I just thought that that term was, was interesting, right? And really telling of, you know, standardized tests. So right, what does that mean? And what is what are some of the things that you guys talked about on that episode?
So big idea way to success? It’s kind of a joke, like an online running joke back that’s been going on for a while now. And so if you google bigger your way to success, there’s like a list of a bunch of racial stereotypes that are known to show up on the US Emily’s standardized tests both step one and step two. So, for example, you know, if you get like a question about a young, I don’t know, 35 year old black woman who’s coming in with a dry cough You don’t even need to read the whole paragraph you kind of know that oh, this is gonna be about sarcoidosis. Right? Yeah. So, there are several of those. You talked about Tay Sachs disease earlier, when you know like you just kind of them when they tell you Oh, this person is like French Canadian or like those stereotypes are very much ingrained in both in how medicals our medical curricula are designed, but also ultimately how the standardized test I don’t know whether it’s kind of like to give us freebies. But at the end of the day, it I feel sometimes it can contribute to reinforcing stereotypes such that you know, some diseases may end up being under diagnosed and subpopulations because we don’t always even have the presence of expanding our differential diagnosis just based on this kind of statistical discrimination. Oh, yeah. You
don’t know what you don’t know about this person and exactly what example my wife’s father is black and her mother is an Ashkenazi Jew. So to look at her, you know, most people look at her and think she’s black. Some people look at her and think she’s Dominican. But most people look at her and they think black. And so, you know, she could be a carrier for Tay Sachs. Right? We were tested, we have three kids. And so we she wasn’t. But like, if you were looking at that multiple choice test and looked at her, right, you would not test this person or take socks, that’s not going to be the way you’re going to answer that question. So right, you know, so you don’t know you don’t know what you don’t know about this person’s history.
And, and my advisor, my academic advisor, tells a story of a patient who had cystic fibrosis black kid, and this isn’t a day where sometimes like x rays would be printed out. And four weeks, no one would figure out what’s going on with this kid. And someone else looked at the X ray without knowing the history without knowing this patient’s history and was just like, Whoa, who’s the kid would see just by looking at the X ray, and it hadn’t crossed the medical you know, the medical teams mind at the time because it’s like, oh, you have a black kid with a lung issue is no one is thinking about cystic fibrosis because we it’s so ingrained in us Think CF is for white people a sickle cell is for black people, sarcoidosis is for black. That’s kind of those are the stereotypes of medical licensure exams. And my guests on that episode is Dr. Jenny sighs. She’s an emergency medicine resident at Yale. And I met her while she was still doing this work as a med student as well. So she’s done some studies that kind of fine comb through the curriculum of the medical school over Bronwyn where she trained and wrote some papers about the need for introduction of critical race theory and a lot of medical school curricula, right thinking about how race is constructed, racism is constructed and how it affects disease and inequality and those types of things. And I think, you know, with that kind of approach, where we embrace the social sciences and what they have to offer medical education that we ultimately gain right from being just better trained physicians, but that’s basically what that episode was about. So before we move on, are
there are there any other particular lessons that you’ve learned from your episodes that you think bear mentioning there’s so many
more one more nugget. Well, so episode specific, I think my episode so I did two episodes about reproduction, especially black, you know, related to black women. And I interviewed a professor of bridges, garbage issues and anthropologist and Professor Robert doty. Robert so she wrote killing the black body. And he our bridges wrote are reproducing race and they both talked about ways in which the medical preparedness along with the instruments of the state and state by state i mean capital and state had this element of control over reproduction, especially off black women. So kRb just work at the time I interviewed her is centered around the experience of low income black woman on Medicaid in New York City who basically felt a lot that their experience seeking prenatal care was a lot more invasive, compared to the experience of women who are not on Medicaid just because a lot of the testing and a lot of the questioning and a lot of the things that are required a pregnant woman drink Natal care of mandated whereas it’s not the case for women who are on more, you know, private insurance and Professor Roberts work, you know, killing a black body and our compensation in general was about the criminalization of black women during pregnancy. And, you know, we talked about how, you know, during the crack cocaine epidemic, you know, black men were punished really harshly for using during pregnancy. And today, in the context of the opioid epidemic, some of the laws that were put in place during the, you know, around drug use during pregnancy, are basically now sort of like reverberating and affecting pregnant women who are using opioids. In fact, Dr. Bridges just wrote a paper in the Harvard Law Review about opioid use disorder of pregnancy, and how using drugs in this new context actually can erode one’s white privilege. So just fantastic work. I’m so lucky to have just been able to sit and ask them questions. Yeah,
it’s a great medium. It’s a great medium, it really allows us to put ourselves in some In front of some incredible people and their self included, yourself included
learner, or sort of Elon,
well, we’re all learners. We’re all there. So, okay, so one thing we’re going to talk about was your experience as a learner, right? So we’re going to talk about interpersonal racism as a medical student, and institutional racism as a medical student. So what can you tell us was let’s start with interpersonal racism? How does that affect medical students specifically?
So I think their interpersonal racism and med school as kind of twofold, both like experiencing it, and also witnessing it and by experiencing it, I mean, like, sort of, in one on one encounters with classmates, residents, colleagues, even lecturers and then witnessing, it’s so being wielded against classmates or even wielded against patients directly or indirectly. And so for me in med school, I’ve had Yeah, and they haven’t necessarily been like The most egregious forms of quote unquote interpersonal racism in terms of like what’s happened to me, but at the time some you know, it can feel like, Oh my god, I can’t believe this is happening. So a good example, my first year, Terence Crutcher among many black men were killed by the police. And you know, some classmates went to a protest. I didn’t go Actually, I had to get the VA and then come back to campus and the DS not not super close. So after they went to this black lives matter, rally, you know, in their white coat, as physicians often do when they go to political demonstrations, one of our classmates called, like, how do you call it like a panel discussion around should physicians wear their white coats to protest and it felt like a very clear direct attack on those of us who did go to the rally, but in general, those of us who support Black Lives Matter, it wasn’t like a direct like, you guys. Black lives don’t matter, but it felt that way. Right. It felt that clearly my class felt that even if I think like last matter, I need to know I need to leave stuff out before I come into Medical School or into the classroom or whatever and it’s in, you know, some of us don’t have that luxury, the activism that we engage in, or the advocacy that we engage in isn’t only about our patients, it’s like also about ourselves, right? Because like, when I walk out of the hospital, I think that white coat off and I’m just another black dude that the police can pull over. And, and that was probably one of the bigger things that I felt hurt about in that school as a first year. But, you know, the worst things that I’ve seen are more so around, you know, witnessing issues related to patient care, you know, seeing patients being labeled as quote unquote, medication seeking even though how can you tell we can’t read people’s minds, you know, and it often happens around like mission was in a sickle cell crisis. Sorry, before
you move on. For that point. I just thought, you know, as, as medical providers, right, I know. That term. We’re doctors, right, but we’re under the umbrella of providers, doctors, nurses, and other other health professionals, right. Our goal is to help people people live longer, better lives, right? And so something that plays an incredibly important role in living a long healthy life is social determinants of health. Right? that determines health outcomes, much more so than the Lipitor that we’re prescribing the hydrochloride size for your blood pressure, right? So by wearing your white coat to a rally to help improve social determinants of health, it seems to me a completely appropriate thing to do. Right. What was the counter argument to that? What is it that you heard that said that someone said, why you shouldn’t be doing that? Is it because it’s political, and you should leave politics out
of medicine? Right. So that’s one of the arguments that were made. And I think, you know, race or racism kind of ruffles, you know, still still today ruffles people’s feathers in ways that Other political issues don’t nearly as much right? I have never. So as a med student, I was also part of this coalition. And that was for saving the Affordable Care Act. I did phone banking for funding for chip, you know, children’s and insurance. No one’s ever said, Oh, leave your white coat before you go outside and do as a demonstration for the Affordable Care Act. But the way insurance is decided in this country is the heavily political issue. But I think there’s just a discomfort, right with a lot of non black people when it comes to embracing the notion of racial justice that led to some people feel like Oh, we got to have a conversation about this. I don’t feel comfortable with people wearing yellow gear, or their white coats at this demonstration. And rightfully, some of us were like, Are you kidding me?
Yeah. Interesting. Interesting.
I mean, someone even suggested, well, what would you say if someone is wearing their white coat to a neo nazi rally kind of making the false equivalence between neo nazis and the Black Lives Matter movement, which is
Yeah, I don’t even know what to say about that specific comparison. But yeah,
so I think the counter argument would be, if this person did that, there would have to there would potentially be consequences, but they can find feel free to do that. However, if you are seeing doing it, then, you know, and you’re in a program, and your program director sees like, there, there are ramifications to to doing that. And I would hope at least that there wouldn’t be ramifications to doing that in something like blacklivesmatter. Right.
And I think a ton about you know, the first do no harm, which is part of our posts, right. And this debate of physicians engaging with social responsibility and politics is as old as like the 1800s right when Barca was super engaged in Germany and and like, you know, pushing the government to create a program for compulsory needs expectations, right. That’s how we found out about chicken Some may argue, oh, well, your job as a doctor is in a clinic room and not outside. But truly, it’s everywhere. It’s no, no, but here’s,
here’s, here’s what it is. If they agree with you, then it’s your job to be involved in advocacy. And if they disagree with you, then usually the white coat at home, right? It’s just that that’s just what it is whether they agree with your whatever your you know, it’s the same way when like someone in Hollywood, right says like, you know, Trump is terrible, or Trump is amazing. And then, you know, if you just if you agree, you’re like, yeah, I totally agree with this person. And if you disagree, you’re like, is singing or whatever. So I think I think the same thing applies here. Right? If they agree with you, and they think great. If you wear your white coat, then it should it gives you some more like authority and respectability of the institution that you can carry with you to this rally. And if you disagree, then you’re you know, abusing your privilege as a medical student. And yeah,
my personal take. Okay. So we’re also going to discuss studies that you’re familiar with that focus on racial climate for medical students and residents and fat and faculty. And you we’re going to we’re going to discuss that as well as disparities in grading and career advancement. So, so what can you tell us about just in general the the racial climate for, for trainees,
right. So I think in general, you know, medical students, especially those who are underrepresented in medicine, describe what seems to be a tense, often tense racial climate and medical school and that, you know, not necessarily feeling supported as minorities, you know, feeling higher burden when it comes to contributing to educating our peers on matters of health equity or health inequities, and facing kind of a barrage of microaggressions from tears faculty, residents and whatnot and
some study what what’s a microaggression? Because some of our listeners might be familiar With that term Good point, I don’t
personally like using the term microaggression. But it’s it’s, it’s
just use it for now you got it I know.
So microaggressions are, you know, considered to be slights that are typically not intentional based on a marker of difference that you may carry, but that land within negative impact and can leave like a lasting effect on the recipient of the microaggression. So for example, something that’s as commonly told to black people is like, Oh my god, you sound What is it? You sound so articulate, right, which oftentimes is rooted in the assumption that you you’re not supposed to be articulate or that you don’t, you know, that you’re not supposed to sound educated as a black person, even though you may be still like in higher education and a lot of about microaggression is basically based on prior experiences as the recipient and also just having faced them over and over and kind of what the expectation and interpretation is. And and I guess they’re called micro only if the person who is the perpetrator didn’t intended to offend it, but there’s so much right. So
so they intended to offend that it’s a macro aggression. Oh, yeah, it’s
a total aggression.
Micro is based on the intent, not how it was received, like if I bother you a little makes it a microaggression versus my value on. It’s the intention of the person making the statement.
Right. I think that’s that’s my understanding of the way that psychologists who, who coined the term described it as Yes, yeah. Oddly enough, though, you know, that there isn’t. I mean, maybe there is and I’m just not as familiar but like in the, in the, in the literature regarding medical students experiences, there’s a there’s quite some about, you know, microaggressions but I guess that’s in part because those are way more common and be sophisticated, highly educated settings, right. People don’t just call you the N word. You know, by the time they’ve reached medical school, they know better or you know, they mean like this Things that are more macro and that they happen like middle school or, you know, like, happen a little less commonly and in, in higher education and perhaps that’s why there’s more of a focus on micro aggressions. That being said, though, there are some macro aggressions that’s still happening.
And then how does that lead to? How does it affect outcomes like grading or career trajectory?
So I think microaggressions by themselves, you know, the climate in general and medical school has an effect on medical students like mental health, you know, and, you know, feeling burnt out and sort of like increasing rates or feeling socially isolated and not supported. And so you can think how that may have an impact on one’s ability to or just like one’s even will to to do as well as they may have meant to initially from that sort of like intrinsic element of the experience as a medical student, but there’s also when I think about grading, what’s been What’s out there literature wise is that they are disparities and grading. And they’re more so rooted in the perception of those who do great medical students, because a lot of these studies basically kind of control for all the other things that are more intrinsic to the students like sort of like performance, right? How did you do on step one? How did you do on those kind of like objective metrics that have nothing to do with a third party deciding whether you get honors versus high pass or pass and for example, the comments that students get in their in their evaluations oftentimes are racialized and gender. So there’s a study that was done at Yale by one of my mentors, my mentor came in a few of my interests, actually, Dr. Wright and Dr. Smith and the rest of their team, there’s a large team that looked at letters, how do you call this MSP The, the big letter that goes out when you apply to residency? I’m not there yet. And I look at comments from the from tertiary grades, and the most, the letters that are more likely to have those superlatives. Not excellent those Kind of terms are way more likely to go to white male medical students and black male medical students are more likely to be sort of just labeled as competent, maybe like hard worker, but never those superlatives that program directors tend to look for. And then women get labeled as carrying, you know, kind of this sort of kind of benevolent sexism that often shows up where the qualities of the students are highlighted based oftentimes on race and gender. And then when you think about career advancement opportunities, like la Alpha Omega alpha, right, lucky, I mean, I don’t know whether that’s lucky or not, but we don’t have a chapter on my medical school. But the same team that did this study on MSP content, looked at resident applicants that that submitted applications to Yale, so something like maybe 15,000 medical students from across the country and they found that when you control for grades, step one scores like you know, all the kind of the semi objectives, I don’t really think they’re all that objective, but the number of things Black and Asian medical students are six times less likely still to be inducted in AOA up their homes, you know, their home institutions and, you know, some program directors filter applications by a by, you know, elite status. And it’s a huge thing to think that it has six times, you know, my take on that is there are people that are eligible on AoE, typically based on their, I guess, ranking in their medical school class, like, you know, are you in the top, whatever quartile it isn’t different institution, and then there’s a body of student members that that often have to vote on, on induction membership, whatever, based on, I don’t know, some criteria set within the school. And, you know, you can imagine that some of it is basically kind of a popularity contest, and it’s kind of telling that those were way less likely to make it into a way are black and Asian students. You know, kind of like least likely to look white, I guess I’d like to present or potentially present us like, it’s kind of my read on that. If you ask me. That’s kind of racist. And the stuff
I don’t know if kinda is
in that statement. Yeah. So So what you’re saying is that it affects your grades. Right? Yeah. In that and that can be that’s been studied for, right that’s what you’re saying is, is that if you blind, you know, if you blind someone, to, to what this person looks like, as much as possible by just doing the objective multiple choice tests that we all have to take and we’re all then it really the data really seems to speak for itself and so that I think if you turn if you think of things in terms of like, I heard actually Jamie Foxx once referred to himself as the arrow and his grandma was the bow so I thought that was a great analogy for the way that my wife and I are raising our kids we just were aiming the bow and the arrow is gonna go or the I was gonna go. But if you’re if your career trajectory is like is the bow pointing in a certain direction, if you’re already starting at a lower angle, because this is good Preventing you, now you’re getting lower grades. Because you’re being described this way your letter of recommendation aren’t as compelling. You’re not, you’re less likely to get an eo, this is talking in terms of career trajectory, where you’re going to end up 2030 years from now, you’ve already attained the bow in a different direction, right? And there’s no quantify. I mean, there’s like no exact way of being able to sort of quantify that, I guess, unless we were to kind of look at things in the perspective like a prospective cohort. This I mean, there is a chord out there. I don’t know what questions they asked the participants, but the change does a lot of studies on like bias and microaggressions and whatnot. Amongst medical student It was a cohort that initially enrolled like 5000 med students across the country, and they followed them and I think they’re now 30 are residents so I’m, you know, I’m curious to see when they’ll make some of the some of the questions that they’ve asked available and, and and how far one could ask like, oh, what, how did the trajectory of some of these students change based on their experiences with with racism and whatnot in med school. And I’ll give you an anecdote in terms of both the grading and some of the, you know, the gatekeeping structures that may exist. So I had an experience where I that’s so rare, I had a black male resident in a longitudinal clinic. And I was and, you know, supervised by an attending who was white, and during that time, it was a weekly clinic, and most of the time on collections, you know, you spent a lot of your time with, with the resident and not so much with the attending, and this resident at the end, and we have great, you know, great working or poor, you know, every day at the end of clinic, would maybe spend 15 minutes sorting out the attending. At the end of the clerkship, this resident will be a super long, very good about ration. I mean, I was beaming with pride, even though he submitted it late, and they’re attending on his end, nothing in the part of the evaluation that’s supposed to go in my transcript, literally nothing. So he saw nothing that’s worth talking about me and what would end up being my MSP letter. So I email my clerkship director, because this resident had turned it has turned his evaluation late like, Hey, you know, do you think we can also add the residents evaluation just for more text in my eval? And you know, it, this is a rotation that are honored anyways. And I did really well, overall. So there was no, there was no grid issue. I just wanted those comments to also appear. And the response was, well, for that specific clinic, we really just wanted comments from the attending and not so much for the residents and needed so well anyways, that it doesn’t matter. Now, imagine if I didn’t do well, and that the structure is that we just want comments from the attending and the attending pays me no mind, but the one time that I do get a black president has evolved doesn’t even make it, you know, into my transcript that’s sort of like dwindling representation amongst who supervise us has an impact ultimately on whether what are you know, what are, how do you call that what our msps are tracking So I have are going to look like I spent an entire year on the war. I never had a black attending who was going to give me a grant. I had a few black presidents. You know what I mean?
Yeah, you know that that sums it up in terms of your experience. I don’t know. Sometimes I think it’s very telling in terms of your experience, right? One or no black attendings, a few black residents. And so this is what this is what your experience is like. And as opposed to students of other backgrounds who are able to look and see people who look like them in all sorts of specialties. So so when you when you see, let’s say, you did have one, black attending, right? And how do you think that would affect your decision with regards to specialty Do you think that would in that would alter your decision making I mean, it’s hard, because you’re, you’re, you’re it’s hard to take yourself out of the situation and look at it objectively, but, I mean, generally, if you’re on a rotation, and you’re Your attendings and residents are jerks, you’re less likely to go into that specialty, you’re not gonna have a good experience. Whereas, even if it’s maybe not the right fit for you, if you have a specialty where, where you have a great time, because you’re getting along with everybody, you’re more likely to go into that specialty. So what about your situation where there are very few people who look like you? And yet, you have one, maybe two and other specialties? How do you think that will alter your decision making in terms of what you ultimately choose?
I think for me, I probably would end because there’s like I said, there are so few and just about every specialty, right? So it’s so the bets are like almost non existent. But I think it would make the experience better in that one. As a student on that rotation, I maybe I’ll spend a little less time worrying whether the feedback or criticism that I’m getting from the attending is like from a place of assumption of inferiority that sometimes we just kinda have to wonder like, Oh, this is attending thing I’m done, right? Like, that doesn’t tend to be the case, when you have another black attending that may hold you, they may even be I have just from having conversations with other peers that sometimes a black attending or even resident may hold you to a higher standard because they want you to, there’s this link fit in making sure that you do well. And we’ve all kind of been, it’s all been ingrained in us that you have to be twice as good to have it half as half as good. That’s kind of like the saying that just about every black parent tells their child so I don’t think for me, at least it would like make me want to go into a specialty versus versus another. But I think for some people, though, it may in that being told that you are welcome in this specialty is very meaningful, right? And that is indeed perhaps more likely to happen if the time that you attended and that specialty. You had a mentor who took ownership of you as a student and like mentor to you. Yeah, there’s some specialties out here. Even if everybody was black I wouldn’t go into.
And whenever I have a student rotating with me, one thing I always tell them is, it’s the most important thing is to find out what you don’t like.
There’s a bunch of stuff out there that you’d be happy doing. Just make sure you’re not in one of the ones that you won’t be.
Yeah. So I think the impact is not so much of a, seeing a black attending is going to make somebody go into it, but guess is not having a black attending and then also not being welcomed or even not being being told that Oh, you’re never gonna make it or people not showing enthusiasm or not mentoring you the lack of black attendings as opposed to the presence of them. I don’t know if I’m making a clear argument here that can impact you know, those trajectories is my guess. I mean, there isn’t often an assumption that Oh, minority medical students are aware and more likely to budget primary care without investigating the root of it. All right, like Sure, yes, we are more likely a bunch of primary care but nobody knows. Whether when we came into med school, whoo, half of us were like, Oh, I’m gonna do plastic surgery or I’m gonna do neurosurgery or whatever, right. But as I would like for it to be studied, whether during those clerkship experiences the, you know, experiences of not feeling included, being actively or passively has made people more or less likely to say, oh, bump that I’m not going into insert specialty, because, like you said, those people were jerks, or those people didn’t include me, or those people just never saw me as fitting with them. My opposite one of my optical faculty members, like y’all, she’s a black woman, Dr. Kristen, why will, she said when she was a resident, you know, she is a tiny black woman, and everybody who walked in who was a tall white man, they would say, Oh, he’s gone. And he just looks like his daughter right now. And she said, I’m going to retina but people never ever supported the idea that she would be a retinal surgeon. But she said, I’m going to do it from an intrinsic motivation. And she did it. She’s a retinal surgeon but barrage with these assumptions on all year. You’re just you’re just going to be a generalist, although it’s obviously it’s great to be a generalist, regardless of being as in primary care or like a generalist and that surgical specialty, it almost kind of robs you of your dreams sometimes, you know, to not be told that you can do it, you can also do it. Yeah.
Well, Max This is this would be a great conversation. I really appreciate you taking a lot of time out of the busy students schedule and away from your studies to have this conversation and and to put together the podcast because it’s clearly clearly a lot of very important conversations that need to take place. And I’m, I’m so glad that you found this platform. So where can people find us? Where can people find your podcast? So the podcast is flipped a script. If you can find it on iTunes, Spotify, SoundCloud, if you search for flip the script, yell, I think there are a few things that show up as flip the script by itself. So it’s the one with the El blue yell logo. It’s the broadcast center that helps me with hosting. flip the script yell, it’s easy to find. On on Twitter, the handle is flips pod. Yeah, so check it out. So we’ll include links to all that in the show notes because I certainly had trouble finding when I just looked for flip the script and then the done popping up and it didn’t make any sense I was looking for Yeah. So now I find,
yes. Well, thank you so much for the opportunity to have this discussion. I really appreciate it.
That was Dr. Bradley Block at the physicians guide to doctoring. He can be found at physicians guide to doctoring calm, or wherever you get your podcasts. If you have a question for previous guests, or have an idea for a future episode, send a comment on the web page. Also, please be sure to leave a five star review on your preferred podcast platform. We’ll see you next time on the physicians guide to doctoring.
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