Culture and Medical Culture: Understanding to increase benefit and reduce harm

Culture is often understood, at least by that culture that is in a majority in a given place, as a characteristic of others. That is, we are “regular”, they have a culture. The greater the disproportion between the dominant group and others in terms of numbers, the less diverse a community is, the more this – incorrect – assumption prevails. In the 19^th century, before the work of Bronislaw Malinowski and Margaret Mead, who actually spent time in the places and cultures they were studying,  cultural analysis of the world by anthropologists was often done “offline” by what have become known as “armchair anthropologists”. All European, they ranked cultures from least to most civilized, and guess what: European, and especially Western European, cultures were always at the top!

It should be needless to say that this was wrong. In addition to all the examples that can be given of other non-European cultures were far more advanced (think the Arab world for mathematics and science, China for all kinds of things), all cultures are different. They do not just have “strengths” and “weaknesses”, or areas in which one is “better”, but differences which have developed to serve the needs that existed where they lived. Weather, for a start, makes a difference in the types of crops grown or how housing is designed. In addition, of course, different cultures share many similarities. This allows for, for example, religious ecumenism, in which folks of different religions can come together based upon the values that they share. In the US today, we have seen great advances in understanding not only that differences between cultures do not mean one is better than another, but also that similarities between people usually exceed differences. Recently, we are seeing great strides against racism, sexism, jingoism, and all the other “isms” that promote hatred instead of understanding. Unfortunately, however, we also see a backlash from people who feel threatened by the idea that other people, whom they have disparaged and discounted, are indeed their equals. This has gone beyond attitudes; it has led not only to violence, but to legislation enshrining prejudice, hatred, and discrimination. I hope this will get better, but it might get worse first.

One way that we have on tried to address this issue in medical education has been discussions between small groups of students about how they see common phenomena in the world, in their communities, in families, and relationships. The more diverse a class is, the richer these discussions become and the more the students learn that what they think of as “regular” is in fact just as much a cultural belief as that of other people. Of course, this also can reveal assumptions that they may make about what is “normal” that are not normal for others, particularly regarding financial and socioeconomic issues. Or, for instance, whether the police are seen as your protectors or your persecutors.

This becomes an important entry point for examining medical culture, which certainly exists and carries its own beliefs and prejudices, as do most professions. These beliefs are no more, or less, “true” than sociocultural beliefs. Because medicine involves not only extensive interaction with other people who are not immersed in the culture but, even more, extensive power over the lives and health of those people, coming to grips with what you (and your teachers) believe because, well, we all believe it, rather than what is based in evidence, is important. This is more difficult because a big part of the socialization to a profession such as medicine is for a novice who is from outside that culture to learn the jargon, way of thinking, and indeed prejudices that characterize it, and this can have negative as well as positive results.

For example, our medical students usually enter perfectly capable of speaking English (and perhaps other languages) and conversing with others and communicating ideas and information. As part of becoming doctors, they learn new language, new terms, new acronyms, new meanings, and eagerly repeat them as evidence of their acculturation. Unfortunately, this can become an obstacle to communication with their patients, who do not speak this language. One example: a couple of sentences ago, I used “positive” and “negative” in their usual English senses of “good” and “bad”. However, when doing medical tests (lab, imaging, biopsies) a positive result is usually bad, and a negative result is good. But when a doctor, or student, informs a patient that their results are negative, it is common for the patient to react with fear, since this sounds like a bad thing. We urge them to say “normal”. Whew, that’s a relief!

Some other issues of medical culture are address in an Op-Ed by Robert Pearl in the Los Angeles Times of May 16, 2021, “How doctor culture sinks US health care”. A big part of Dr. Pearl’s critique in the distinct bias, not only in physician attitudes but in medical journal articles, towards intervention and procedures rather than prevention. This, he notes correctly, is very much tied to money, since physicians and hospitals and health systems (which are increasingly the physicians’ employers) stand to make much more money from them. Medical journals are more likely to print articles with positive (there is that word again!) results, demonstrating that a procedure had benefit, than negative results, demonstrating that, actually, compared to something – or nothing – else, something (or nothing) that was easier, cheaper, less interventive, and less dangerous, it had no better outcomes. Of course, anyone can see that knowing this information, that doing something is not worthwhile, is at least as important as knowing that something works well.

However, the inclination (or perhaps prejudice) among most physicians is to do something, to intervene; aside from making money, it makes them feel that they have skills, are justified, are important. Unfortunately, this is also an attitude quite prevalent among their patients, who want something done to help their problem – to cure their disease, or increase their lifespan, or improve the quality of that life, and in particular to ease their pain. But doing something does not always improve things, and can definitely increase the risk of harm. We need to know what works (and what doesn’t), and in what circumstances, and what the dangers are, and what the alternatives are, and their potential benefits and risks, and then have discussions together about what, in the specific circumstance a specific person is in, what would be the best choice for them.

This effort is likely to overlap with more traditional sociocultural and religious beliefs, which can have an influence on what a person thinks would be best for them. Communication around this requires care, and a real effort on the part of the medical professional to understand and to make their own thoughts clear and clearly expressed. This is even more complicated when, as is the case, physicians are from a pretty narrow slice of the American population, racially, culturally, and economically (and, again, a good argument for increasing its diversity). As in all situations where there is a power differential (and in medical care, the greater power lies with the physicians and health systems) it is incumbent on those with greater power to make the effort to understand those with less. And, at least as important, to not make decisions for and about people based on only your understanding – or worse, assumptions – about what they want, or are because of race, religion, gender, national origin, etc. Doctors, even when they are well-meaning (and all of them are not always) too often allow themselves to fall victim to the ecological fallacy, and confuse “condition X is more common in population Y” with “the patient is a member of group Y so probably has condition X”.

It is, of course, also very important to recognize that all interventions and procedures are not a bad idea; indeed, they are often the best treatment. And, also, that not everything sold as “preventive” is really so; plenty of tests and treatments called preventive are not proven to prevent anything. It is not easy to overcome prejudices and beliefs.

But understanding that we all have culture, and trying to not be bound by it and doing our best to understand that of others, is a good start.

Beyond Flexner 2016: Medical schools still need to up their social mission

The “Beyond Flexner 2016” Conference was held in Miami September 19-21, 2016. It was the third in this series of conferences, originally stimulated by the 2010 Annals of Internal Medicine article “The social mission of medical education: ranking the schools”[1]. The first conference, held in Tulsa in 2012, featured the authors of the article and leaders from many “community-based” medical schools founded in 2 rounds of medical school expansion, the 1970s and the 2000s, discussing their real or proposed innovations (Beyond Flexner: Taking the Social Mission of Medical Schools to the next level, June 1, 2012). The second, held in Albuquerque in 2015, had major growth in attendance, and a group of national speakers who powerfully addressed the failures of both medical schools and our medical system to address the health needs of the American people, especially through (lack of) diversity in our health care workforce, equity (especially racial) in the care provided, and the inadequate numbers of primary care doctors being produced (Beyond Flexner: It is time to stop shoring up the bridge and figure out how to cross the river!, April 7, 2015). The metaphor for that blog’s title came from a talk by Don Berwick, in which he compared the US health system to the sturdily-built Choluteca Bridge in Honduras that withstood Hurricane Mitch only to be useless because the hurricane moved the river. (Such a great picture I’m posting it again here!)

The Miami conference, again sponsored by the Josiah Macy, Jr. Foundation along with Florida International University, was very good, although it had some disappointing aspects, notably the attendance, about 350, which was a little less than that in Albuquerque. The speakers were again excellent, with several standouts:  Mona Hanna-Attisha, the pediatrician who exposed the Flint lead poisoning crisis, gave a powerful talk in which she observed that despite being in Michigan, the “mitten state” surrounded by the largest collection of fresh water in the world, Flint’s water even today is still not safe. Robert H. Brook, of the RAND Corporation and UCLA gave a talk where he challenged the “rights” of medical schools, suggesting that hospitals (especially academic medical centers, AHCs) that do not care for their fair share of Medicaid and uninsured patients should not be allowed to have residency training programs, and that, more than allowing community service to count toward promotion and tenure, we should not allow anyone to be promoted without community service. Julio Frenk, the President of the University of Miami, a public health physician who served as Secretary of Health in Mexico, spoke about the need for building social capital that did not just “bond” communities but created “bridges” between them. He also noted that education had to move from the “informative” (providing the knowledge to become a professional) to the “formative” (creating the character and roles that define a professional) to the “transformative”, where professionals could truly create change both in their professions and in society.

One of the new events was the presentation of the First Annual Josiah Macy, Jr. Foundation Awards for Social Mission in Medical Education. The Institutional Award went to Morehouse School of Medicine, the Individual Award to Thomas Curtin, MD of Massachusetts and a leader in establishing Teaching Health Centers, and the program award to the University of Florida for its “Putting Families First” interprofessional education program. The highlight was the presentation of the Lifetime Achievement Award to H. Jack Geiger, whose achievements, from establishing the first Community Health Centers in the US, Physicians for Social Responsibility, Physicians for Human Rights, to serving as Dean of the Sophie Davis School of Biomedical Sciences at CCNY, are enough for several such lifetime awards. Dr. Geiger, who spoke eloquently at the 2015 conference, again addressed the group. He is nearly blind but as powerful and articulate a speaker as ever; he noted that "I have lost most of my eyesight, but it turns out you don't need good eyesight to hang on to a vision!"

In my 2012 blog on the Tulsa Conference, I noted 4 areas I felt were important for focus, and reiterated them writing about the 2015 Albuquerque Conference. They were:

·         Diversity: How does the school produce a health workforce that looks more like American by enrolling, and supporting, a group of students that is truly diverse in ethnicity, gender, socioeconomic status, and geographic origin?

·         Social Determinants of Health: How does the school teach about and train students in, and carry out programs aimed at addressing, the social determinants of health? How does its curriculum and work invert that of the traditional medical school, which focused most on tertiary hospital-care, and emphasize instead ambulatory  primary care, community based interventions, and interventions on the most important health determinants including housing, safety, education, food, and warmth?

·         Disparities: How does the school, through its programs of education and community intervention, and its research agenda and practices, work to reduce disparities in health care and health among populations?

·         Community Engagement: How does the school identify the community(ies) it serves and how does it involve them in determining the location of training, kinds of programs it carries out, and in identifying the questions that need to be answered by research?

There was more emphasis on interprofessional diversity at this conference, with panels including two national nursing leaders (Divina Grossman and Randy Rausch), and a panel including a community (and FQHC) based Dental School Dean (Jack Dillenberg). There was great ethnic and racial diversity in the speakers and moderators, but somewhat less emphasis on diversity in the content of the talks than in 2015. Primary care was still emphasized, but I remain concerned that the conference still features relatively small programs in medical or health professions schools aimed at increasing diversity, primary care, and community engagement. This is, of course, because most such programs are small within their AHCs, and nowhere near as important as the provision of tertiary and quaternary medical care and obtaining NIH research grants. Until these can be scaled up, until producing a majority of graduates entering primary care, enrolling and graduate underrepresented minority and low-income students at least in proportion to their percentages in the population, and working in the community becomes the highest priority of an AHC, the movement is stalled.

It is sometimes tempting to think that AHCs are incorrigible, that they are set in their ways – and in the way that they are financed – and that achieving the goals I have outlined above, or even more modest improvements in social mission – are not going to happen, at least any time soon. The Association of American Medical Colleges (AAMC) supports in word – and to a limited extent in deed – the goals of diversity and community engagement, but not enough to change the core focus of their members. Indeed, tellingly, they continue to call for increasing the number of residency positions, but not on targeting them to primary care, as does the American Academy of Family Physicians (AAFP). The largest specialty in medicine, Internal Medicine, opposes AAFP’s proposal to fund only “first certification” residency positions, as this would not fund their subspecialty fellowships.[2] Thus, they put self-interest (having funded fellows in their subspecialties) ahead of the need for America to have more primary care doctors.

Yes, it can get frustrating to work with medical schools and their entrenched anti-social values. But this is where the medical students are, where they are trained, and where they get their ideas of what might be the most appropriate specialties to enter and what th

e professional role of a physician is – e.g., working in the community or not. They need both individual and institutional role models.

So the need to work for a social mission for medical – and health professions – education is still an important goal.

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[1] Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M,“The social mission of medical education: ranking the schools”, Ann Int Med 15 June 2010, Vol 152, No. 12,

[2] Butkus R, et al. Ann Intern Med. 2016;doi:10.7326/M15-2917.

Roosevelt University: A commitment to diversity and social justice

On December 13, 2013, I attended the winter Commencement ceremonies at Roosevelt University in Chicago. As a new member of the University’s Board of Trustees, it was my first such event at Roosevelt; the Board had met the day before. I have, of course, been to other graduations. Some have been of family and friends, but most have been as a faculty member in medical school. I have sat on the stage looking out at the assembled graduates and families before, but never in the role of a Trustee, and never at Roosevelt.

Graduations are pretty special events. At the medical school graduation ceremony, we look on as our future colleagues march across the stage, many of them people we know and have taught, while their families watch and clap and sometimes cheer. We have pride in them, and also wonder how fast the time goes, remembering when they were just starting a few short years earlier. But the Roosevelt graduation was different, and not just because it was not a medical school and not just because I was there as a Trustee.

For starters, it was in Chicago’s beautiful Auditorium Theater, in the Auditorium Building designed by Louis Sullivan, opened in 1889 and about to celebrate its 125^th anniversary next year. I have been there before but only in the audience; sitting on the stage looking out at this gorgeous auditorium whose balconies soar 6 or 7 stories, filled with 4,000 people, was amazing. Roosevelt owns the Auditorium, and the building has long been its home, but recently the 40-story Wabash Building has been built next to it, rising 40 stories, the top 27 dorms with priceless views, its own architectural splendor complementing in a very different way that of Sullivan.

There were also some special events during the graduation. The honorary degree recipient was Joe Segal, a Roosevelt alumnus who for 60 years has run Chicago’s Jazz Showcase, bringing all of the great jazz artists of those years to perform at a series of venues; I began attending his shows in the 1970s. Danielle Smith, graduating with a bachelor’s degree in Special Education (and a minor in Spanish) was the first-ever current student to be commencement speaker. She was joined on the stage by Sheree Williams, receiving a Master’s in Early Childhood Education, who was the 85,000^th graduate of the school (it took 60 years to get to 65,000 and only 6 for the next 20,000).

Those of you who read my last post, Suicide: What can we say?, know that the date, December 13, was also the 11^th anniversary of my son Matt’s suicide. While the two facts are coincidental, they are not unrelated; my presence on the Board and thus at the graduation was entirely about Matt. A few years after leaving his first (quite elite) college and then obtaining an associate’s degree, Matt moved back to Chicago and enrolled at Roosevelt. He loved it. It was, and is, a school, originally established to focus on returning GIs and people of color, that both educates young (and older) people from all backgrounds and prides itself on its diversity, and its explicit commitment to social justice. This resonated with Matt, and does with me. I later met President Charles Middleton through the sponsorship that Matt’s mother and I do of the annual Matthew Freeman Lecture in Social Justice (see, most recently, Matthew Freeman Lecture and Awards, 2013, April 26, 2013), and later when he hosted my group of American Council on Education fellows at the university. Dr. Middleton calls Roosevelt the “most diverse private university in the Midwest”, and sitting there as the graduates cross the stage it is not hard to believe. Virtually every race and ethnicity was represented by the graduating students, many obviously first-generation Americans, and the pride in their faces was unmistakable.

 

In her speech, Ms. Smith spoke about coming to Roosevelt from an all-white, middle-class, suburb, in large part to play tennis – which she did. She also, however, learned about diversity, and met fellow students from all races, religions, ethnicities, and socioeconomic groups, and made them her friends. She talked about a concept that she had never heard of before but was omnipresent at Roosevelt, social justice, which she says will guide the rest of her life. Ms. Williams’ presence on the stage, as 85,000^th graduate, may seem like a quirk, but she also is “typical” of Roosevelt; an African-American woman who received her bachelor’s in education there and now her Master’s, and will be teaching second grade in Chicago, before, she plans, to get her doctorate. Wow.

President Middleton, in his closing address, asked several groups to stand. They included the international students, who had to add learning English in addition to their studies, and the families, friends and other supporters who jammed the Auditorium. Most impressive, to me, however, was when he asked all the graduates who were the first members of their families to get a degree at their level to stand. Some were getting doctorates and master’s degrees, but the large majority of the graduates were receiving bachelors. Two-thirds of the graduates stood, to rousing cheers.

There are plenty of colleges that offer the opportunity for students from working-class and poorer backgrounds to get an education, for first-generation students to learn. They include the our community colleges (I still remember a talk at the 2008 ACE Conference by the president of LaGuardia College in NYC, where she said -- as I remember it -- “there are two kinds of colleges; those that try to select the students who will be the best fit at their institutions, and community colleges, that welcome students”), and our state universities. And some are private schools, like Roosevelt. And others may have the explicit commitment to social justice that Roosevelt does.

But I am proud to be associated with one that so overtly and clearly demonstrates it.

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Cross-posted to "Life, the Universe, and a Few Things"

Beyond Flexner: Taking the Social Mission of Medical Schools to the next level

In my blog entry for June 20, 2010, A New Way of Ranking Medical Schools: Social Mission, I discussed the article by Mullan, Chen and colleagues that had just been published in in the Annals of Internal Medicine, “The social mission of medical education: ranking the schools”. That seminal article provided concrete data on how medical schools ranked based on 3 criteria related to social mission: percent of underrepresented minority students in their classes, percent of graduates practicing in health professions shortage areas (HPSAs) and percent of their graduates actually practicing in primary care following their residency training. Unsurprisingly, the schools at the top of these rankings were a very group than those at the top than of more traditional rankings, such as US News and World Report, which are based on criteria like reputation, selectivity (what percent of applicants are rejected?) and research funding from the National Institutes of Health (NIH). Indeed, those schools that tend to rank at the top in the latter set of criteria were generally at the bottom of the list in social mission.

It didn’t make those traditional "powers" happy to be ranked at the bottom, and so they did the two things usually done by people and organizations who are found to be lacking by the data: they denied that it was true, that somehow the data was wrong, and they attacked the values of social mission, saying, in essence, that the characteristics being measured by the social mission rankings were not the important ones. The important criteria, of course, were those in which they -- the schools ranked low in social mission and high in traditional rankings – did well. Denying the truth of the study was hard, because the statistics used for measuring the 3 social mission criteria were not inaccurate. Mostly, then, their argument was “Oh, that data is old. We are better now!” But the reason the authors looked at graduates from 1999-2001 was that it allowed them to see several years after completing their primary residency training, not only whether graduates were really practicing in HPSAs, but whether they were really practicing in primary care. Medical schools like to count all students entering internal medicine residencies as “primary care”, when only a small percent do not enter subspecialty fellowships or practice as hospitalists and actually end up in primary care. And, in fact, in that 8 year interval, in the first decade of the 2000s, the numbers got worse.

So these critics mostly focused on the second defense, downgrading the importance of social mission. The measures they suggested (which they do well on) were: 1) getting a lot of money to do research (a little self-fulfilling, since the NIH panels that award research grants are largely staffed by people at the institutions that get research grants; in addition, this research is overwhelming done in the basic biomedical laboratory or early clinical trials, not in the community or the general population); 2) having a great reputation so that faculty who want to get big research grants want to come work there and students with high grades, mostly from the elite upper and upper middle class, want to attend, and 3) having a great reputation, so “peer” evaluators will say “yeah, you’re good!”

One can reasonably argue that the 3 criteria examined by Mullan and colleagues do not completely reflect the social impact of medical schools. Other criteria might include creation of community training experiences, community involvement and engagement in providing venues for training and in determining the type of research carried out by medical school investigators, the degree to which research and programs carried out by the medical school decrease health disparities, and the degree to which the health of communities and populations are increased by the activities of the medical school in practice, research, and education. However, these are not the criteria that the traditional “top” schools want to be evaluated on. The fact is that they are doing what they do, and what they do does not address diversity of the workforce, disparities in health, community involvement, or modern models of interprofessional education.

The next step in the Social Missions of Medical Education movement occurred in Tulsa, OK, May 16-18, 2012 at the “Beyond Flexner” conference. 100 years ago Abraham Flexner was commissioned by the Carnegie Foundation to look at medical education in the US. As a result of his report, more than half of US medical schools closed. Those that remained were largely the ones that had adopted a scientific basis for their medical education and were based in or tightly tied with research universities. For over a half-century, these schools grew with emphasis on the biomedical research enterprise and the training of highly skilled subspecialists, and little interest in any kind of social mission. The social movements of the 1960s and 1970s saw the first large number of new medical schools, and then quiescence until this decade, with a number of additional schools being created. Many of those in both the 1970s and 2000s groups manifested, at least initially, a social mission – that is, they had the goal of actually producing doctors and research that would improve the health of the population.

“Beyond Flexner” was co-sponsored by Mullan’s Medical Education Future Studies group from George Washington University and the new University of Oklahoma-Tulsa School of Community Medicine, led by Dr. Gerry Clancy, President of OU-Tulsa. Under Dr. Clancy, OU-Tulsa has transformed from a site for clinical training of a portion of the students from the OU School of Medicine in Oklahoma City to become the first 4-year school officially called “Community Medicine”. It was also one of the 6 schools that were part of the follow-up study of social mission, and whose leaders presented some of their innovations and successes at the conference. Three, including OU-Tulsa, Florida International University, and the AT Still College of Osteopathic Medicine in Arizona, are in the newest group, and have yet to graduate a class. Their contribution was largely in the creative and innovative methods that they are using to select and enroll and educate students, emphasizing diversity, community-based education, dispersion of educational settings, ambulatory (rather than hospital-based) training, emphasis on primary care and concern for the social determinants of health and health disparities. (A fourth new school, the University of Northern Ontario, in Canada, was also part of this group.)

The 3 other schools were part of the prior wave of new schools created in the 1970s and have had significant social impact, Morehouse University, the Southern Illinois School of Medicine, and the University of New Mexico School of Medicine. These are certainly not the only schools that have made a major commitment to social mission, and perhaps they are not in all respects the perfect exemplars, but they are certainly among the leaders in the field. They are part of an international movement of medical schools that were founded in the same period, to create physicians who would have the skills to care for people (primary care), have the knowledge to do research on community and population health, have the relationships to train and work with people in community settings, and have the intelligence to challenge traditional methods of classroom teaching by increasing clinical and interprofessional training experiences. Representatives from these and other schools described pipeline programs, interprofessional training, dispersion of training sites, innovative curricula, emphasis on primary care, and many other models and efforts.

The bottom line is that outcomes matter, and that judging a school by the impact that it has on the health of the population is the gold standard. Biomedical research contributes important knowledge that may, someday, impact human health, but this can be done in research institutes (see, for example, Karolinska, Rockefeller, Insitute Pasteur, Stowers) and certainly should not determine the core mission of schools focused on training doctors and other health professionals. The steering committee of “Beyond Flexner” is developing key principles that need metrics to assess outcomes; I would suggest the following:

·       Diversity: How does the school produce a health workforce that looks more like American by enrolling, and supporting, a group of students that is truly diverse in ethnicity, gender, socioeconomic status, and geographic origin?

·       Social Determinants of Health: How does the school teach about and train students in, and carry out programs aimed at addressing, the social determinants of health? How does its curriculum and work invert that of the traditional medical school, which focused most on tertiary hospital-care, and emphasize instead ambulatory  care, community based interventions, and interventions on the most important health determinants including housing, safety, education, food, and warmth?

·       Disparities: How does the school, through its programs of education and community intervention, and its research agenda and practices, work to reduce disparities in health care and health among populations?

·       Community Engagement: How does the school identify the community(ies) it serves and how does it involve them in determining the location of training, kinds of programs it carries out, and in identifying the questions that need to be answered by research?

Maybe by the time of the next “Beyond Flexner” conference, every one of our medical education institutions will have bought into these principles and their implementation, and be able to be examples of how it can and should be done.