A doctor’s diary from a pandemic: I miss the medical students

My own med school graduation, 20 years ago. Gotta love those glasses. With my family: Julie, Alex, and Abby

Somewhere near the top of my “favorite things about my job” is working alongside medical students. It’s a privilege to get to teach – and learn from – medical students from the University of Minnesota Medical School as they are just starting out on their careers.

Sadly, one of the many casualties of this awful Covid-19 situation is that the medical students are gone for a bit. Due to shortages of masks and gowns, the uncertainties of this new disease, and the need to limit exposures, the students have been doing distance learning for the past few months. That means a lot less energy, curiosity, scholarly discussions, bedside teaching, group problem solving, and general excitement about medicine. Students are definitely a positive addition to our healthcare systems and I really miss them. And if you are ever a patient wondering about going to a teaching hospital, I might add that you should feel great about doing so. Students add a valuable depth of curiosity and attention to the well-being of patients. And teaching hospitals are by their very mission really good at staying abreast of latest medical science. The medical students keep us on our toes!

During each academic year I encounter loads of students. In this post I am going to highlight several and shine the spotlight on the next generation of doctors. I thought you ought to meet the men and women who may be your doctor someday and learn a bit about the process of medical education. Each one has given permission to be included. It’s also the 20th anniversary of my own graduation from med school (see photo above) so here’s a nod to the past while looking to the future.

The first years: Out of the classroom and into the hospitals

I know this first bunch of students pretty well. I met the 9 of them literally in their first month of medical school in the fall of 2018 for their Foundations of Clinical Thinking course which I co-facilitated with my friend (and superb medical educator), Dr. Anne Pereira. Our merry band met periodically for the entirety of their first and second years of medical school as we learned to “think like doctors.”

For several hours each week we’d sit around a table and talk through tough cases. The students did most of the work while Anne and I provided color commentary. Some of us talk more (I’m guilty of talking too much, I know, but I’m working on it!) while others are more subdued. Often someone writes on the white board. Usually one of the students brings treats. OK, correction, one of the students usually brought the treats (thanks, Katie!). Sometimes we’d get off track, joking about this or that (does Notre Dame even have a football team?), sometimes we would have a serious discussion about end-of-life issues. Always, though, we grew together as friends and colleagues.

I can personally vouch for the student doctors in this group. One of them may be your doctor someday!

We did that for two years. Then SARS-CoV-2 hit and that ended our group meetings.

(In case any of the students are reading this, I purposely wrote the official acronym for the coronavirus since medical acronyms often came up in our group discussions and I fully intend to pile onto your misery with yet another. BMP, HgB, PMH, ROS, VTE, DVT, NSTEMI, CVA, MVA, GSW, COPD, HIV, CML, LFT, BLT, and on and on and on and on! To that list we can add SARS-CoV-2.)

At the end of the second year of medical school, Anne and I didn’t get to hang out with our FCT group as our last few group meetings were virtual. Even our end-of-year “party” was via Zoom. I guess that’s better than nothing . . . but I miss this bunch! When I’m an old man, one of you may be my surgeon or my Emergency Med doctor, or my grandkid’s pediatrician. One of you may read my x-rays. Maybe one of you will be my primary care doctor and recommend I exercise more and yell at me to get my PSA checked. Just remember when you are hot shot doctors, I knew you when you were wide-eyed first year medical students when you didn’t know diddly about the spleen. Oh wait, I still don’t know diddly about the spleen so I guess I can’t hold that against you.

So here’s a shout out to my friends from FCT group. I’ve seen you go from that “OMG” look in your eyes in the first weeks of med school to your “I can’t wait to start seeing patients” look now that you are ending your 2nd year and entering the life-changing clinical years. You are ready and you are going to rock your clinical rotations and I really hope I’ll see some of you on the hospital wards at Hennepin Healthcare! (Don’t worry, I’ll go easy on you during rounds!)

They even let us take a picture one day in the swanky little room in the med school where we met. That’s our group of newly-minted 3rd year medical students in the photo above: Peter Kassis Akal, Heather Oas, Justin Lynch, Cecilia DiCaprio, Christian Ndekwe, John McCarron, Charles Warner, Katherine Casty, and Samantha Gibson.

The homestretch: the intensity of the clinical years

I met Anna Ayers Looby last fall when I barged into the team rounding room on one of the nursing units of Hennepin County Medical Center. These team rooms are where our “rounds” happen with teams consisting of an attending physician (me), a senior resident physician, a couple of interns, and one or two medical students. Often there is a pharmacist present and sometimes some other health professionals. Usually the room is strewn with empty coffee cups growing various fungi in them, a half-eaten pizza from 6 days ago, a bunch of white coats on hooks, and for some reason a disco ball or a stuffed unicorn sitting on the shelf.

Anna was starting out her 3rd year of medical school and thus she was learning how to put her book knowledge into real clinical practice with real people, real diseases, and real consequences.

Since my time with Anna nearly a year ago, she has now started her 4th and final year of medical school, which is that transition year in which medical students are at the top of their game in terms of book smarts. I always thought that some of the most knowledgeable people in medicine are 4th year medical students. They know just about everything, probably because they are always getting ready for some life-or-death high-stakes exam.

This is the year of medical school where students also have to make the huge decision about what speciality they wish to pursue. Surgery? Pediatrics? OB-Gyn? Family Medicine? Radiology? Or the best one, Internal Medicine (that’s my specialty!). So it is a big year.

Anna Ayers Looby, 4th year medical student

I remember Anna on that rotation last fall. She was really smart and she gave superb presentations. Nobody is born with the skills to do a high-quality presentation of a patient’s case to a veteran attending physician in front of a group of people all of whom are senior to you in experience. It can be an intimidating task but it is a critical skill to learn as a medical student. Some students ramble on for what seems like hours and make the attending physician tend toward daydreaming about what’s for lunch. Others finish their thoughts in about 60 seconds, unsure of what to say next and having forgotten some key bit of information, like say, the vital signs. But Anna was just great at her presentations.

But this isn’t supposed to be a critique of her clinical skills. What I remember most about Anna is her obvious leadership skills in patient advocacy and her commitment to society. She is the type of future leader who will change things. She is grounded in the belief that we need to strive for justice in healthcare for all people, especially the most vulnerable among us. She’s open about that and it is incredibly inspiring.

Anna tells me that she is leaning toward becoming an Obstetrician-Gynecologist. If that pans out, there will be countless women who will benefit from her care. No matter what she ends up doing, though, Anna will make a difference. Although I must say I think Internal Medicine provides better donuts on rounds. Just throwing that out there for her consideration.

A new start: our newest doctors

These last two medical students are not actually students anymore as I write this. They are real doctors now, having graduated from medical school last month and just this week starting up their internship. I met them in the past on our inpatient patient care teams at Hennepin Healthcare/HCMC. Their stories are so different from my own and so I want to celebrate these two new doctors who both happen to be people of color and spent some of their lives in East Africa. Please read about them:

Dr. Mohamed Artan came to Minnesota most recently from Tennessee after his family escaped the conflict in his native Somalia and subsequent life as refugees in Kenya. With that background, he studied Biochemistry and Cellular and Molecular Biology and worked as an East African cultural liaison. In med school he worked to mentor and empower students of color. I swear the students are all over-achievers these days! I found in Artan an engaged, animated, inquisitive guy who gave rapid-fire patient presentations, thorough and complete, and his enthusiasm for learning was contagious. Here’s a brand new doctor who has seen inequities in the world and has the ability and commitment to do something about it. So glad he will be training with us here in Minneapolis in Internal Medicine.

Mohamed Artan, MD

Dr. Olivia Ondigi was also in her 3rd year of medical school when I met her. She is smart and has a keen curiosity. She also has a humble and kind demeanor along with a rich and deep perspective on medicine and society. I remember talking to her about her life as a US-born woman of color who grew up in Kenya, then returned to the United States. As such she brings a perspective to medicine so desperately needed in our profession. Olivia readily speaks with empathy for people who are unlike herself which, when you think about it, is really what you hope a doctor will do. Couple that with a warm personality and Olivia is exactly what this world needs in a doctor. She’s off to Virginia now to pursue her Internal Medicine residency and I can’t wait to see where her career takes her.

Olivia Ondigi, MD

So there’s a glimpse at the future of medicine. I intended to write this post to highlight the absence of medical students in our clinical settings and relate that to the Covid-19 pandemic and how that bummed me out. But as I wrote it and reflected on this bunch, and as I wrote their names and posted their pictures, I didn’t want to talk about Covid-19. I felt hopeful. This cross-section of students from the University of Minnesota Medical School reminded me that the future of medicine is in good hands.

So for letting me embarass you a bit on this post and for your commitment to the patients you are privileged to serve, thank you to Peter, Heather, Justin, Cecilia, Christian, John, Chuck, Katie, Sami, Anna, Artan, and Olivia.

David

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“Decade with Dave” and Here 4 Health series

Hi, friends!  See that sign in the picture?  Those signs are all over the campus at Hennepin Healthcare.  Let’s just say my co-workers have shown no mercy in teasing me about them.

But hey – we have something to celebrate!  I’m super pumped to be launching “Decade with Dave”  – our celebration of 10 years of our Healthy Matters broadcast!

We’re starting with a live broadcast of Healthy Matters from the atrium at Hennepin Healthcare’s Clinic and Specialty Center complete with a LIVE audience.  That’s where you come in.  I’m inviting you –  my Healthy Matters listening friends – to be that live audience on Sunday, June 10.   Denny Long will be there, I’ll be there, and I hope YOU will be there.

Here’s what we’re planning for the live broadcast of Decade with Dave . . .

Diabetes and the Sweet Life.  I’ve invited an old friend from my medical training, Dr. Laura LaFave, to introduce her to Healthy Matters listeners.  Dr. LaFave recently rejoined the Hennepin Healthcare faculty in Endocrinology – in fact I don’t even have a link to her picture yet!  She’s a friend, a smart doctor, and a genuinely good person.  She’s been practicing for over a decade but only been back to Hennepin for a few months, so to welcome her back to our family I’m putting her in front of a live audience.  She’s a good friend, eh?  We’ll talk about diabetes and other hormone-y topics.

Arthritis Treatment Options:  Moving from Pain to Gain. Dr. Rawad Nasr is Hennepin’s Director of Rheumatology and another colleague with whom I go way back.  We dragged him back from his practice in Bemidji to join our Hennepin faculty.  His recent show about arthritis was a huge hit with listeners so he’s coming back to chat with me about arthritis and joint questions.  You’ll love this guy.

 

Sleep Health:  What Keeps You Up at Night. Another really popular topic – in fact, perhaps the most popular topic – is sleep.  We all need it, we all want it.  Many of us struggle to get the best sleep we can.  Another Healthy Matters veteran, Dr. Ranji Varghese, will be at the broadcast to meet you, to help us understand sleep, and to answer a few questions.

 

Following the broadcast, we’ll have a bit of Q&A and show you around the place a bit.  We’ll have coffee and munchies (donuts, anyone?).

Let’s fill the place!  The broadcast is free to attend, but we need you to RSVP if you plan on attending.  Click here to RSVP for our special “Decade with Dave” LIVE broadcast.

But that’s not all . . .

Announcing . . . Here 4 Health

Hennepin Healthcare’s Clinic and Specialty Center

After kicking off the summer with “Decade with Dave” we are launching an exciting new health education program for the curious and inquisitive among you.  “Here 4 Health” is a series of three educational sessions on a variety of health topics sort of like a mini Medical School.   Except more fun.  And not nearly as grueling.  Come to learn about health topics from cool experts from Hennepin.

You can attend 1, 2, or all 3 sessions.  They’re all free of charge, but you do need to send your RSVP by clicking here.  All events are at the Hennepin Healthcare Clinic and Specialty Center.

Here’s what we have planned for “Here 4 Health” (subject to change if any of these colleagues chicken out):

Session 1:  Thursday, July 12, 5-7 p.m

How to live to 100 or die trying.  Dr. David Hilden (that’s me) will be updating a popular session I’ve been giving for years.  I’ll take you behind the scenes at a state-of-the-art working clinic with insider tips on staying healthy.

The Ins and Outs of GI Health.  OK, some smart aleck (probably the same guy who decided to make a career of doing colonoscopies) made up the name for this informative session about colon cancer.  Learn from Hennepin gastroenterologist Dr. Jake Matlock  about colon cancer and colonoscopies!  I know Jake.  Great guy.  Ask him to show you a colonoscope.  Then ask him why the heck he thought it would be cool to look at people’s intestines all day.  You’ll also get the special chance to tour a colonoscopy suite – when you’re NOT on the cart getting your own colonoscopy


Session 2:  Saturday, August 11, 9-11 a.m

Dermatology – your skin questions answered.  Hennepin dermatologists Dr. Sara Hylwa and Dr. Jenny Liu will be on hand.  You’ll never get a better chance to tap into a skin doctor’s expertise.  They are smart and they know skin like the back of your hand – literally.  Just don’t ask them if you can skip wearing sunscreen.   (Spoiler alert. . . you can’t .  . these two are so stingy on that point).

 

The Ancient Art and Modern Practices of Integrative Medicine – Acupuncture and Chiropractic.  A certified acupuncturist and chiropractor will show you around the world of integrative medicine.  Maybe you’ll come away just a little less mystified at these ancient practices.  Ask to see an acupuncture needle.   Dr. Richard Printon and acupuncturist Jessica Brown will be on hand!


Session 3:  Saturday, September 15, 9-11 a.m.

You Gotta Have Heart.  Recent Healthy Matters guest and cardiologist Dr. Michelle Carlson will show you around the world of heart health.   You’ll learn from her particular expertise in women’s heart health and the link between heart health and cancer.  You may want to check out the recent post I did with Dr. Carlson here.

 

Best Practices in Breast Health.  Leah Hahn is the supervisor of the mammography program at Hennepin.  See a mammogram machine for yourself.  Men, you too should attend this session.  It will give you a new appreciation for the women in your life.  And men get breast cancer too!  Check out this post I did with Leah Hahn from a few months ago.

 

A Little Help for your Friends.  Hennepin has the best Physical Therapists AND therapy facilities in the region.  Come see a PT gym and look at the amazing possibilities for therapy.  This is state-of-the-art stuff which you can learn from Senior Physical Therapist Beth Stegora.

 

 

Attend all three sessions or pick and choose the ones you want.  They’re all free and all at the Hennepin Healthcare Clinic and Specialty Center in downtown Minneapolis  Probably the most important part of all .  . . the parking is right there underground.  Could not be simpler.

Why should I go learn something?

Here’s why I think you should attend the LIVE Decade with Dave broadcast and why you should attend the Here 4 Health series . . .

You could sit home and watch TV.  Or stare at the grass and watch it grow.  Or sit on your couch and get bad health information from the Internet.

Or you could get out of the house, come to the Here 4 Health series, and learn from fun, smart, and reliable doctors and health professionals.  All while taking in the art-filled and warm setting of a state-of-the-art health facility.  

RSVP here.

Looking forward to meeting lots of you!

David

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The 36-hour shift

I was reading the paper this morning over my tea and crumpets when this headline caught my attention:

“First-year doctors would be allowed to work 24-hour shifts under new rules”

For web Dave Hilden
An old picture of me

Now there’s a topic near to my heart, so I decided without much forethought to subject you to my ramblings about physician training and the unbelievably long work hours that our society subjects physicians to all the time.  But you may be surprised about what my conclusions are on the topic.

For those of you who read my last post Insomnia Part 1 and are looking for Insomnia Part 2, please bear with me because that second part is coming next week, complete with more insights from Samantha Anders, sleep expert from the Sleep Center at HCMC.  I’m hoping to get some video interviewing done with Dr. Anders about behavioral therapy for insomnia, so stay tuned for that.

Why should you care about work rules for doctors-in-training?

That headline was from a Washington Post article covering the a proposed relaxation of work-hour restrictions for interns in hospitals.  So here are some stories from my own experience about the rigors of medical training.  Hopefully you’ll find something in here to get you thinking.   Continue reading “The 36-hour shift” Facebooktwitterredditpinterestlinkedinmail

Book club! How Doctors Think

how doctors thinkHi, everybody!  For about 2 months I’ve been yammering both in this blog and on the radio broadcast about the current Healthy Matters online book club selection, and it’s time to get to it!  As they say in billiards .. “Quit talking and start chalking . . . “

 I don’t know about you, but I’ve been reading How Doctors Think by Jerome Groopman.  For regular readers of MyHealthyMatters, hopefully you’ve had a chance to check it out.  But it’s OK if you didn’t read the book.  I’ll bet you’ll have something to add to the conversation even if you didn’t get to read it!

 

To get you thinking, I’m going to talk about the book in the following format:

  1. My summary and reflections about an aspect of the book, broken into 3 topic sections
  2. A few questions for you to consider in response to my reflections.  Hopefully you’ll leave a comment at the bottom with your own thoughts.

I’d rather this be a two-way conversation – an online book discussion – rather than just me talking.  (I talk enough).  I’m most interested in your thoughts so please join the conversation even if you didn’t get a chance to read the book.  (Just like in-person book clubs where half the people didn’t actually read the book!  You know who you are.) Continue reading “Book club! How Doctors Think” Facebooktwitterredditpinterestlinkedinmail

The stethoscope of the 21st century?

V0003303 René Théophile Hyacinthe Laënnec auscultating a tuberculous Credit: Wellcome Library, London. Wellcome Images images@wellcome.ac.uk http://wellcomeimages.org René Théophile Hyacinthe Laënnec auscultating a tuberculous patient at the Necker Hospital, Paris. Gouache after T. Chartran. By: Théobald ChartranPublished: - Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/
Credit: Wellcome Library, London. Wellcome Images
http://wellcomeimages.org
René Théophile Hyacinthe Laënnec auscultating a tuberculous patient at the Necker Hospital, Paris. Gouache after T. Chartran.

“That it will ever come into general use, notwithstanding its value, is extremely doubtful; because its beneficial application requires much time and gives a good bit of trouble both to the patient and the practitioner; because its hue and character are foreign and opposed to all our habits and associations.”

Such was the opinion of the stethoscope by an English doctor in 1821 named John Forbes.   The stethoscope had recently been invented by French physician René-Théophile-Hyacinthe Laënnec in an effort to protect the modesty of his female patients by removing the necessity of placing his ears directly against their chests.  The skepticism of Dr. Forbes notwithstanding, the stethoscope is now considered one of the greatest inventions in history.  Check out the patient of Dr. Laënnec at the left – head firmly pasted to the chest of this guy with tuberculosis.  Oh my!   (Since this patient was male, the good doctor did not need to use his new stethoscope invention).

Whether the doctor actually contracted tuberculosis I know not.

But in the year 2016, the stethoscope is so familiar to patients that we probably would wonder what was wrong if the doctor did not have one hanging around his or her shoulders.  An old doctor sitting with his arms crossed

So what is the technology that doctors will be using in the future?

Enter the ultrasound

The stethoscope is nearly 200 years old.  Although I doubt I’ll ever hang my stethoscope up for good, today we do have some newer tools to help with diagnosis.  The ultrasound, though a tool we have had for many years, has now hit the bedside.   Today I spent some time with my colleagues (inpatient doctors, or hospitalists) learning how to use portable ultrasound machines in our practice.  As a patient, you will likely encounter a doctor with an ultrasound in his or her pocket and you may wonder what the heck this is all about.

So this post is a sort of “mini-Medical School” into the use of ultrasound in clinical diagnosis – a brief look at how clinicians of today can use this tool in medical practice.

Most medical students are repeatedly taught that 80% of the diagnoses they make on their patients will be from the history and physical exam.  In other words, fancy blood tests, high-tech imaging (x-rays, CT, MRI . . . ) and other extensive tests are needed much less often than we all may think – perhaps just 20% of the time.  So we teach doctors-in-training to learn the skills of talking to patients and laying on of hands by doing a physical exam.  Most of us can recall some of our mentors and teachers, patiently and skillfully showing us the tried-and-true physical exam skills.

An anecdote from my training about one of the great ones . . .  I rememasingerber Dr. Richard Asinger, here at HCMC, putting his stethoscope on the top of a patient’s head.  I thought he was messing with me, but he said he could actually hear a heart murmur up there.  I was in awe of this pure genius.  On the other hand, maybe he really was just messing with me!  He’s still at HCMC; I should go ask him.  On a side note, he’s also a killer dancer on the dance floor.

But even listening with our stethoscopes to hear abnormalities of the heart (murmurs, for instance, which could mean valve disease) , or of the lungs (like rales, which could mean pneumonia) it is still a bit primitive.  Sometimes we want to know how much extra fluid a person has in their body due to heart failure (called hypervolemia).  Or we need to know if they have a partially collapsed lung with air around it (called a pneumothorax).  Or if they have a blood clot in their legs (called a deep venous thrombosis, or DVT).

So that is where ultrasound comes in.

iStock_000063540139_Large

This is an ultrasound image of a heart.

  • See the four chambers?  Clockwise from upper left: right ventricle, left ventricle, left atrium, right atrium.
  • See the valves?  There are four valves in your heart – you can really see the mitral valve leaflets in this picture – the two white lines that look like a tent at about the 3:00 position.

If the chambers and vessels look big – maybe you have too much fluid in your body.  If the valves are not opening and closing correctly, maybe that is what is causing that murmur we hear with our stethoscope.  If the heart is not beating strongly, you may have heart failure.  So much information can be learned from these pictures!

Ultrasound training with the HCMC Hospitalists

I thought Healthy Matters listeners and blog readers may like to see how we stay competent in the medical profession – so here’s a sneak peek of our group at HCMC  learning to use ultrasound in our daily practice.  The technology is really neat.  The machine is just a bit bigger than your smartphone, so now we can carry them around in our white coat pockets.  I think you will see more and more of this when you are a patient – doctors pulling out teeny little ultrasound machines.  I have even heard that we will be able to use our smartphones for this purpose at some point.

Here’s my colleague, Dr. Mike Lawson – an HCMC graduate, all-around good guy, and Minnesota Vikings fan – recently returned to Minneapolis after a spell as a doctor in the Seattle VA Medical Center.  He’s really good at using ultrasound and one of the best teachers around so he was helping the rest of us become proficient at it.

Mike

These pictures are of two of our outstanding clinicians working with the ultrasound machines (Chief Resident Dr. Marissa Durman on the left and Physician Assistant Erica Monroe at right).  Look at how tiny the machines are!  The doctors and PAs in our group were worried that they were going to have to do ultrasounds on pregnant women.  No worries – we have specialists for that!  Relief all around.

Ultrasound training at HCMC

From putting an ear to a patient’s chest to listening through the tubes of a stethoscope to using sound waves on a portable ultrasound.

The centuries-long attempt to probe the human body continues.

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Reflections on bias in health care

Do black people feel less pain than white people?  Are overweight people at fault for developing diabetes?  Do doctors evaluate symptoms differently if a white man reports them than if a black woman reports themrace bias nejm?

Most of us would emphatically answer these no, no, and no.  But there is evidence that the answers actually are much more complex than that.  For instance, there is scientific data that suggests that people hold unacknowledged attitudes that African-Americans feel pain less than white people.  Some people do feel that overweight people are personally to blame for their diabetes.  And there are studies that suggest that doctors evaluate and treat people differently based on race.  (The punch line of the study is that when the actors in this picture reported symptoms to doctors, they received different treatment recommendations despite identical symptoms – a fascinating study).

I think these are disturbing but important things to think about if we are going to address disparities in health care.

This post is prompted by a class that I facilitated at the University of Minnesota Medical School.  I was pinch-hitting for a colleague this week in a small-group discussion class that that aims to get these first-year medical students to think about something other than biochemistry and physiology.  Stuff like bioethics, humanistic care, doctor-patient relationship, and so forth.  There were ten of us seated around a table discussing the week’s topic – bias in medical care.  (As an aside – if these 10 thoughtful students are any indication – the future of health care is in good hands.)

I’d like to share some reflections from that session and offer some interactive resources for you to try – the exact same ones the students did.  And you don’t have to pay medical school tuition!  So read on, think about it, check out some of the links, examine your own biases, and leave a comment on this blog post. Let’s talk about it.

(At the bottom there is a link to a thought-provoking self-assessment that you may wish to consider doing yourself).

Being privileged

I think the first step toward addressing bias is to examine our own situation.  Here is my situation, in the proverbial nutshell:

  • White
  • Male
  • Straight
  • Financially secure
  • Naturally-born United States citizen
  • Protestant Christian
  • English-speaker
  • Not overweight

I don’t apologize for any of them – I am happy with who I am.  But it is crucial to realize that I didn’t do anything to accomplish any of those things – and yet, my personal characteristics put me in a place of privilege.  Nobody would doubt me if I showed up in an Emergency Department with chest pain.  I’d get the appropriate tests in an instant and probably be provided with pain medications without delay.

Would I get the same great medical care if I were a disheveled homeless man?  If I didn’t speak English?  If I were a Muslim woman wearing a hijab?  If I were a transgender person?  If I were a woman?  If I were overweight?  Maybe, maybe not.

So we talked about this with the medical students, starting with recognizing one’s own privilege and naming it out loud.  I told the students, especially the white guys, that it is totally OK and cool to be a white guy.  No apologies.  But it is important to recognize the privilege that comes with personal characteristics which you were simply born into.

Great quote:  “When you find yourself on 3rd base, don’t assume you hit a triple to get there.”

Unconscious bias vs. conscious bias

What is bias, anyway?   The medical students in our class watched the following video of a talk given by a physician who reflects on his own bias.  It is worth 15 minutes of your time:

This video raises several points to ponder, but two stick out for me.  First, Dr. Attia painfully recalls the contempt for which he held a diabetic patient – basically blaming her for needing a leg amputation because she was – as he recalls – “fat” and therefore somehow responsible for her decaying leg.  Years later he still feels the need for her forgiveness for this attitude that he wasn’t even aware of at the time (be sure to watch it to the end).  The second point is his recognition that medical science may, in fact, not always be accurate.  This second point is certainly true and something I hope to explore in future posts.  The first point is a perfect example of bias.

In our medical school discussion, we tried to acknowledge the possibility that we could be harboring bias even without knowing it – implicit or unconscious bias as opposed to  explicit or conscious bias.

Explicit bias

First the one that is easy to identify – explicit bias.  This is something we deliberately think about and often verbalize.  Consider the current United States presidential campaign, when serious candidates for the presidency are endlessly providing examples of explicit bias:  accusing whole groups of people of nefarious deeds (Mexican people as rapists), labeling hundreds of millions of people into stereotypical categories (lumping all Muslims together), openly advocating mass killing of innocent people for being not like us (“carpet-bombing” whole populations of civilians).

These are open, deliberate attitudes that should be easy to identify and weed out (although sadly we often fail at this).  I would call them explicit biases and we should reject them outright.

Now the harder one.  Contrast explicit bias to implicit (or unconscious) bias.  These are the attitudes that we are not conscious of and that we may well deny holding when confronted with them.  But they are real.  Like Peter Attia in the Ted talk (click picture above if you missed it), I would never openly accuse a person with diabetes of being personally responsible for her gangrenous leg.  But deep inside me, would a part of me wonder if she could have tried harder to lose weight?  If she had only cared for her leg a little better could she have avoided an amputation?  I think that it is not only possible that I could hold such unconscious biases, I think it likely that I do.  And most of my physician colleagues do as well.

This part is hard  . . . examining our own bias

The medical students were asked to take a self-assessment, called an IAT (Implicit Association Test).  My first reaction is that the IAT is just another bit of academic jargon, but having tried it I found it actually sort of cool.  The test involves words and images appearing on the screen, and the students are asked to rapidly react to the images by making a selection.  No thinking about it logically.  Just react.

I encourage you to try an IAT – take a test yourself.  This can be difficult emotionally, so prepare yourself.  Hearing your own results may not be easy but it is eye-opening.  Before you take a test, read the materials from the Implicit project (a consortium of researchers) on the website and then take the test yourself.  Note that the interpretation of your results may be troubling to you.  With that in mind – give it a try.

Did you discover any unconscious bias in yourself?  How did it make you feel to hear that you may harbor attitudes that you were not aware of?  Do you agree that such biases exist in you?  And if so, what ought we to do with that information?  How is our society affected, not only in healthcare, but in other aspects of our life, when such biases exist?  Does bias contribute to unequal health care outcomes? 

This is a conversation worth having.  Tell me what you think – leave me a comment!

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