While the shock and horror of the COVID-19 pandemic have stuck with medical students and residents, trainees also recalled moments of resilience and hope at Future I.M. Experience, held virtually by ACP on May 14 and 15.
The first-ever virtual meeting for the College's Resident/Fellow and Medical Student Members offered instruction on career planning, clinical skills, and leadership during more than 20 educational sessions, as well as opportunities to reflect on the pandemic.
“I have witnessed the depths of human pain and sorrow with a frequency that I never dreamed possible: Patients dying alone in glass rooms, family members crying on the phone as you tell them their loved one is getting worse, physicians and nurses whose faces are etched with lines of disbelief,” said ACP Resident/Fellow Member Carlee Fountaine, MD. “But amidst this background of pain and darkness, moments of bright hope have shined through.”
During an Annals of Internal Medicine Story Slam at Future I.M., she and other finalists shared pandemic stories by video, some of which may be published later by Annals. One moment of hope highlighted by Dr. Fountaine, a second-year internal medicine resident at the University of Washington in Boise, Idaho, was a love story that spanned two hospitals.
“Larry's a pretty stoic guy. When he got COVID-19, he didn't want to be admitted because he felt there were others who were more deserving of his bed,” she said. “He was further conflicted by this prospect of hospital admission because his sweetheart, Dorothy, was being admitted to a different hospital across town.”
The two became quite ill with COVID-19. Larry was too weak to eat, leading to a feeding tube, and Dorothy had worsening respiratory failure necessitating increasing levels of oxygen, said Dr. Fountaine. Each day, their children would contact them with updates about the other, “But we all could tell how much they missed each other. … One day, we all decided it had been too long since Dorothy and Larry had seen each other, and so I set about trying to get them connected via video chat,” she said.
It took nearly all day to set up the video call, and Dr. Fountaine had to hold up a tablet for Larry, who was not strong enough to lift it himself. “Dorothy had her high-flow oxygen cannula on her face but beamed in a way that could only be described as pure love when she saw Larry on the screen. … It was one of the honors of my lifetime to get to witness their love for each other,” she said.
The call was short; neither had the strength for a long conversation, Dr. Fountaine said. “But the next day, Larry started eating again. He started sitting up in bed and working with physical therapy. Within a week, he was well enough to get to rehab,” she said. “When he left, I lost my updates on Dorothy, but at our last check-in, she was holding her own. I hope they have come home to each other.”
In addition to the Story Slam on resiliency during the pandemic, Future I.M. featured sessions for trainees on overcoming early-career failures and working for racial justice.
Failures during medical training are usually not as devastating as they may seem in the moment.
In fact, they can lead to great learning opportunities, as evidenced by a panel discussion with Christine Y. Todd, MD, FACP, a hospitalist and chair of the department of medical humanities at Southern Illinois University School of Medicine in Springfield, and Robert M. Centor, MD, MACP, past Chair of the ACP Board of Regents and professor emeritus of general internal medicine at the University of Alabama at Birmingham.
Students and residents often look at accomplished clinicians like Dr. Todd and Dr. Centor without understanding the paths they took to get where they are, said session moderator Susan Hingle, MD, MACP, another past Board of Regents Chair. “So we really want to help to normalize that everyone in this space faces adversity.”
For Dr. Centor, his biggest “so-called failure” was quitting a research fellowship after just one year of studying rats. “I was pretty unhappy because I really missed patients and patient care and clinical decision making. … I was told by my division chief at the time that I would never make it in academic medicine because I quit that fellowship,” he said.
But within a week, Dr. Centor knew he made the right decision. “Two other places offered me a clinical fellowship, I had two emergency medicine jobs available to me immediately so I could pay the rent, and I was invited to come back and join the new division of general internal medicine at the Medical College of Virginia, where I'd done my residency and medical school, and did so four months later,” he said.
This experience taught Dr. Centor a valuable lesson. “I realized that I didn't have to worry about what other people wanted me to do; I had to worry about what I wanted to do, and so it gave me a sense of freedom … and I think the big lesson I learned was to not do what you like, but to do what you love,” he said. “I found out what I loved, and I found out through that experience.”
When he quit his fellowship, he also learned not to burn bridges. “I didn't tell you the end of the story,” Dr. Centor said. “The same person who told me I wasn't going to make it in academic medicine introduced me at grand rounds, 10 years later, as one of his boys.”
This example should resonate with students and residents, who may feel like they're stuck with the decisions they make, said Dr. Hingle, who is a general internist and medical educator at Southern Illinois University, where she also serves as the associate dean for the Center for Human and Organizational Potential. “You know yourself better than anyone else, and you know what makes you happy, and you know what is going to be exciting to you,” she said. “You need to do your best to follow that and to not worry so much about what other people think.”
Some of Dr. Todd's challenges during training related to her being a nontraditional student. “I started college intending very much to go to medical school and be a doctor,” she said, “but I wasn't really happy in all those sort of typical premed classes because I had the general sense that folks weren't learning for the love of learning, that they were just competing with each other for the best grades.”
So for her undergraduate degree, Dr. Todd decided to pursue one of her passions, English literature. “I worked it out with my counselor. I could still do all the premed prerequisites, but also fulfill an English major, and that's what I ended up doing,” she said.
While studying literature and writing helped Dr. Todd figure out her strengths and appreciate patient narratives, it meant a tough first year of medical school. “A lot of that information was very new to me,” she said. “There I was in the anatomy lab, knowing zero about anatomy lab, and my lab partner had a master's in anatomy.”
After failing and retaking tests and spending a summer remediating some courses, Dr. Todd began her second year of medical school thinking that she might not make it all the way to being a doctor and that her self-worth was equivalent to her test scores.
“Second year was easier because that information was new to everybody. And then came third year, which became heavily clinical,” she said. “And all of a sudden, I went from being one of the mediocre students in the class to being one of the best students in the class, because that's where all the stuff that I knew really came to bear.”
Shifting her mindset was not easy, and more perspective came later in life. “I thought of myself as somebody at the bottom of my medical school class, and when I talked to some of my medical school classmates, they were like, ‘Yeah, you're the only person who thought of yourself that way,’” Dr. Todd said. “Making connections with friends and being part of a community definitely helped me.”
Prioritizing justice and antiracism
Speaking of nontraditional paths to medicine, internist and lawyer ACP Member B. Cameron Webb, MD, JD, hears the same joke over and over again: You must be trying to keep yourself from getting sued.
“It's not funny—that's literally the joke that everybody tells,” said Dr. Webb, senior policy advisor for equity on the White House COVID-19 Response Team, who gave a keynote speech at Future I.M.
His intention going to both medical school and law school wasn't his own legal protection; it was a love for health policy and social justice. “It's not for everybody, doing that particular combination. But for some, if that's a skillset that you really want to develop—that advocacy skillset—there's no better place to put that in your armamentarium than going to law school,” said Dr. Webb.
He knew he wanted to be a doctor early on in life, inspired by a visit to his primary care doctor, a young Black man. “I remember seeing a Black man in a white coat, and that was powerful to a 5-year-old. I was just like … ‘I want to have an impact on the community, just like him,’” Dr. Webb said. “They say representation matters, and it's true.”
However, the Black and African American community remains underrepresented in medicine, comprising about 7% of those accepted to medical school in the 2018-2019 academic year and about 5% of all active physicians in 2018, said Ryan D. Mire, MD, FACP, during a session titled “Being Antiracist: Strategies for Our Institutions, and Ourselves.” For Latinx populations, these figures represent about 6% for the same metrics, he said.
“Both [groups] are underrepresented because both are well below the existing population in the United States,” said Dr. Mire, an ACP Regent and internist in private practice in Nashville, Tenn., as well as President-elect of the College.
He added that the number of Black men applying to and enrolling in medical school actually decreased from 1978 to 2014. “When I look at this, it is almost disheartening. … In 36 years, this has had a gradual decline, despite an adequate number of Black male applicants. There has been no improvement. Once again: underrepresentation,” Dr. Mire said.
ACP recognizes the importance of racial justice and equal representation, said co-presenter Sue S. Bornstein, MD, FACP, Chair-elect of ACP's Board of Regents and Immediate Past Chair of the College's Diversity, Equity, and Inclusion (DEI) Committee.
“Although we began this journey a number of years ago, only this past summer did we really declare our intent to become an antiracist organization,” she said.
Antiracist organizations demonstrate active resistance in dismantling racism by creating practices, procedures, and policies that promote equity, said Dr. Mire. “Just to say that someone is not racist is very passive,” he said. “To say that you're antiracist tells me that you're doing something that is proactive. It's an action-oriented statement.”
The College initially intensified its focus on DEI as a result of a resolution to develop policy addressing the gender pay gap in medicine at the fall 2016 Board of Governors meeting, which came from the Council of Resident/Fellow Members, Dr. Bornstein said. In 2017, Dr. Hingle, who was then Chair of the Board of Regents, called for the creation of a DEI subcommittee to assess and address diversity in ACP leadership and awards, she said.
The subcommittee conducted in-depth interviews with former ACP leaders to gauge their relevant experiences within the College and suggested revised wording in the language of national awards to better reflect DEI principles, Dr. Bornstein said. “And in 2020, the DEI subcommittee became a full committee reporting directly to the Board of Regents.”
For the year 2020-2021, ACP's priority themes include DEI, along with the goal of being an antiracist organization, she said. An official statement of the College's commitment to being an antiracist, diverse, equitable, and inclusive organization was approved in September 2020.
“2020 was unprecedented in terms of the magnitude of the challenges it presented us: the COVID pandemic and its disproportionate impact on communities of color, an ongoing epidemic of deaths of unarmed Black Americans at the hands of law enforcement, xenophobia and hate crimes directed against Asians in the wake of COVID,” Dr. Bornstein said. “And the murder of George Floyd in May of 2020 really galvanized ACP to look inward and to take additional action.”
Throughout last summer, ACP encouraged its members to send photos of themselves participating in memorials and protests, which she shared during her presentation. Early-career physicians and trainees showed up in great numbers.
“As always has been the case with the American College of Physicians, our younger members put their values front and center and inspire the rest of us to follow them,” she said.
While the ACP statement notes that the College has long fought against discrimination due to race, ethnic origin, nationality, cultural background, or personal characteristics, “Stating our intent to be an antiracist organization was a major step forward,” Dr. Bornstein said.
Next, ACP policy staff got busy writing and produced four evidence-based documents, published in the April Annals of Internal Medicine. The first was a comprehensive policy framework to understand disparities and discrimination in health and health care. The others included proposals for specific policy recommendations to address disparities and discrimination in education and the health care workforce, for specific populations, and in law enforcement and criminal justice.
“Yes, we did go there,” Dr. Bornstein said, referencing the last of these categories. “And I think we went there with a great deal of confidence that what we were addressing was very important to fixing the problems of racism.”
Monitoring the organization's progress against racism will be the next step. “Physicians are very data-driven. We want to see the evidence,” she said. “Certainly, we will follow metrics for multiple elements, including leadership, membership, awards, health equity outcomes. Things like ACP workforce … what do the people that work at ACP look like? Do they reflect our membership? Do they reflect the communities in which they live?”
This will be an ongoing process, said Dr. Bornstein. “In the very wise words of Dr. Kimberly Manning … ‘It's a journey. It's never completed. But when you're making progress, you'll feel it.’”