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Ethics Talk: Health Professions Students and the Future of Health Equity

Learning Objectives
1. Identify key ethical values or principles at stake, as described in the program
2. Distinguish among factors of ethical, clinical, legal, social, and cultural significance
3. Articulate how central themes of clinical and ethical relevance in the program can influence health care practice
4. Explain at least one way in which micro-level clinical ethics questions intersect with broader macro-level policy questions in health care
0.25 Credit CME

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The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more

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Audio Transcript

Tim Hoff (Host): Welcome to Ethics Talk, the AMA Journal of Ethics podcast on ethics and health and health care. I'm your host Tim Hoff.

Calls for health professions education curricula to support students' abilities to address inequity in health outcomes, health status, and access to services are not new, but they've been given new attention and momentum by the successes of the Black Lives Matter movement and protests throughout 2020. Shortly after the protests in response to murders of Black Americans by police, many medical schools around the country issued statements affirming their solidarity with social justice advocates. These statements were met with mixed reception. Some were criticized as empty gestures while others drew support for directly naming pervasive racism and supporting those protesting police brutality. Whether these statements said the right things is not really what mattered. Ultimately what did matter were specific actions these institutions took to help build equity into health professions education and these steps were few and far between.

So what can we expect in the future of health professions education? Let's take as an example the suggestion of hiring more full-time Black faculty. Increasing diversity among medical school educators benefits both students who report being more comfortable in caring for patients from a wide range of racial and ethnic backgrounds, and patients who receive more compassionate care as a result, and community members who benefit from the expanded health equity research that happens under more diverse faculty. But in 2015, another year of wide-spread protests against racism and police brutality followed by calls to diversify faculty, only 3% of full-time faculty at medical schools were Black. By 2018 the number had risen but only to 3.6%. Clearly changes in health professions education are slow, and schools are often very poorly situated as a result to respond to the changes that we need now.

So instead of looking to the top of these institutions for direction, to administrations, to faculty et cetera, we might look to students who are increasingly diverse and interested in an education that speaks to the idea that health professionals have responsibilities not only to the specifically medical issues of patients, but to the structural problems that exacerbate these issues. Luckily for us and for the future of health professions education, many students are taking the lead in advancing health equity in their own education, in their careers, and in their communities. With us today is one of those students, LaShyra Nolen.

LaShyra, who many know as Lash, is a second-year medical student at Harvard where she's the first Black woman to serve as student council president. Her work on health equity and social justice can be found in the Washington Post, NPR, the New England Journal of Medicine, and more. She's with us today to discuss how medical education can better support and advance health equity. Lash, welcome to the show.

Lashyra Nolen: Hi, Tim. Thank you so much for having me, I'm excited for our conversation.

Hoff: Given how prolific you are already this seems a little bit unnecessary, but for our listeners who are unfamiliar with you and your work, can you tell us a little bit about yourself and how health equity has become your focus in your growing career.

Nolen: Yeah, I'm happy to. To introduce myself again my name is LaShyra Nolen, most folks know me as Lash. I am a Los Angeles native who was raised by this wonderful woman, Ty Harps, and she raised me as a single mother for most of our lives. She was the first person in our family to get both her bachelor's and master's degree. And it was her who was the person who really breathed so much life and love into my dream even though it wasn't until I was in my freshman year of college that I saw a physician that looked like me. Growing up in Compton I really didn't have people in my environment who were in the sciences. So, it was really my family, both my mother and my grandmother - who didn't have the opportunity to finish high school - that really inspired me and told me to keep going and really made education a huge part of my life growing up. So, I think as I went on in my education I always had community and thinking about these women who have such a huge impact on my life in the back of my mind.

As I started to learn more about these things called social determinants of health and start to gain this lexicon around public health and the social-political determinants of health, that really became the driving force behind my why when it came to doing the work and healing of being a physician. I went to Loyola Marymount University and that's where I got a lot of that understanding of public health. And then I took two gap years, one I spent in Spain in Galicia, the most northwestern province of Spain, through a Fulbright grant, and the next I spent time doing a year of service through Americorps in Chicago. It was during that time that I really start to realize how policy can influence the lives of patients outside the clinic because I lived on the south side of Chicago and I worked on the north side, and every day I would see the demographics of the train shift as I went from the south to the north. So, the buildings were very dilapidated, you could clearly see who was forgotten in the society, in the world of Chicago, when you sent from the south to the north where people who were more affluent and had more resources lived. I would go and I would work with my patients and they would tell me about the different struggles that they were having that was so beyond the scope of just medicine itself. I think that my life experiences and the experiences of my gap year really gave me this unique lens of health equity as I entered my first year of medical school. And as I started to see these things come up and I started to see how certain folks who weren't being included or represented in our education material, I said this is something I that I need to speak up about. And it's something that I also decided to do as our student council president, making sure that we were bringing those on the margins into our conversations, and looking at our community and realizing who are the folks who don't typically feel like Harvard medical school is a home for them.

Hoff: When you were first working with patients and you heard them talk about these things that some might consider outside the scope of clinical practice or things influencing their lives in that way, did you immediately identify those things as “oh, that's part of my role as a physician to address these” or did it take a little while before you made those connections?

Nolen: I think for me naturally it felt like something that a physician should address. But I definitely realize that it was something that I had learned how to address because of my personal pursuits. Because I decided to read books like Medical Apartheid and I decided to read books like the Color of Law - learning about policy and learning about social determinants of health. But I think that it's easy for folks to feel like “okay, I'm a physician I am here to just give you your diabetes meds and that's it.” But, I was really hearing is and trying to figure out how can physicians do the work of healing that extends beyond just giving the patient the medication but ensuring that they're able to afford it, ensuring that they're able to take it, and ensuring they could make the lifestyle changes necessary for them to be the healthiest they possibly can.

Hoff: In the Boston Globe last year, you describe this striking moment when your mentor was looking at your CV, and they scrolled quickly past the patient education and community service sections to get to the peer-reviewed research section, and you wrote about this as this sort of stark reminder of the biomedical and clinical and micro-level priorities of academic medicine. Given that your mission is to motivate health equity and justice at this macro-level as we've seen is possible through medicine and advocacy and writing and even through social media where your own followers can see your original raps or policy discussions or any wide range of things. It's obviously working, your approach. So how do you want to recruit other leaders in medicine to engage patients and the public in these ways?

Nolen: I think the first step is really a value shift. I think that we in medicine and academic medical institutions we've shown that we're dedicated to doing biomedical science research and we're going to create grants and opportunities at the highest levels even NIH for people to do this type of work. But if someone has a more population-level-based approach, I think that's where we are definitely lacking. When people want to really look at health equity and they want to look at, “okay how do we root out systemic racism in the way that it manifest in our patient outcomes,” I think that people get cold feet a little bit, and they don't want to really engage in or give people the opportunities to do that work.

I also think that manifests in the way that we see certain individuals getting opportunities for a promotion. We see folks who are serving on committees, who are mentors, who are doing community projects, et cetera. But when we look at a CV and that's not what is considered as valuable, then those individuals don't have the opportunities for leadership advancement. So then if you take someone like myself who's interested in doing all this work, but I also have this great interest in academic medicine, if I am not incentivized to have leadership opportunities and professional opportunities while also doing this important community work, I might choose maybe not to stay in academic medicine and decide to do something more that's fulfilling for me and my community. I think that we as an institution have to make a value shift if we hope to have a high retention of these individuals who are committed to community service and making sure that they have opportunities to grow and to help their communities to do the same.

Hoff: Health professions education is typically are built from the top down. It prepares students for licensure, and credentialing examinations, and board certifications for example, and one consequence of this is that health professions curricula are often not flexible enough to prepare students and trainees for what's actually happening now in society and culture that undermines health and exacerbates existing oppressions. Obviously licensure and credentialing is important, but a bottom up approach to preparing health professionals could help programs teach clinicians to care equitably for patients in communities. So what would a grassroots, or maybe more relevant to your particular experience and expertise, a student-centered and student-led health education look like?

Nolen: I think that - I couldn't agree more with everything you said in this question - I think there are medical students who are on boards and committees looking at board certification and credentialing examinations who are pushing for more inclusion of discussions around public health and social determinants of health in our learning material. I think that we need to continue to empower those students who are doing that work. Personally I haven't served on any of these boards as I enter my second year in medical schools, but I think that there are people who've been pushing for these changes and who are doing the work but haven't necessarily have the backing or haven't had a listening ear to really push these changes forward. But absolutely, I think that it's so key that we continue to have a holistic education that is going to be tested - because I think that's really how you get folks to… who might not usually engage with these topics to feel like they're more incentivize to. Because if not they're going to be like, “oh, why do I need to learn about public health if that's not going to be something that's going help me become said specialist.” I think that's definitely going to be key moving forward.

Hoff: As president of the Harvard Medical School student council you are uniquely positioned to influence the future of health professions curricular design. So how do you draw on this position to work with health professions, both students and faculty at Harvard, to motivate equity as a key feature of what it means to be a physician?

Nolen: I think that I've a lot of mentors and faculty support at HMS to really help push these things forward, which has been awesome. I think that all the student leaders that came before me have really kind of blazed and paved this path so that, you know, it's easier for us to have these conversations. But I think that this point, it's been awesome because I feel like the infrastructure is there. But I think that right now what I really try do in my leadership position is try to push for these conversation to not be opt-out conversations. I think the issue is that usually when we have conversations around health equity and justice, they are optional lunch talk types of opportunities. So what ends up happening is that you have the same students eating the same pizza having the same conversation, and we're really not getting anywhere because the folks who need to be in the room who never really engage with these topics aren't there engaging in dialogue. I think that that is something that is so important. And then once these topics become key parts of our curriculum, I think that it'll really help folks understand that to become a clinician leader and healer in your community, these are imperative topics that you must have a good grasp and understanding of. As long as we continue to move in that direction where these topics and conversations are mandatory parts of our curriculum, we're going to be moving in a very positive direction.

Hoff: Mentoring young Black girls in America has also been one of your very important commitments. Can you tell our listeners about the Uniquely You Summit and how it connects to your own process of growing into your responsibilities as a physician?

Nolen: Oh my goodness, yes I'm happy to - yeah, so I actually got reached out to by Shaleah Sutton, and she created the Uniquely You Summit, which is a summit for Black girls and young women who are interested in various types of fields. And what they do is they have these conferences where they celebrate young Black women and just really tell them that “you are loved, you are worthy ” and provide them opportunities and mentorships where they can be as successful as possible in whatever field they might be interested in. So when I was approached I was approached to be their commencement speaker for their Uniquely You Summit graduation. It was just such an honor to spend time with the next generation of Black women leaders as they talked about how they're going to become engineers, and directors and future physicians, and really just got to share words with them about my journey. I think that's such an important part of what I'm doing because, you know, people really celebrated me when I became the first Black woman student council president at HMS, but I've always said that I do not want to be the last. And it's was never about just being the first, it's about how do we create a pipeline for the next group of women to come in and do the same exact thing. We also have heard the same message from Vice President-elect Kamala Harris that's it's not about being the first, it's about how do we make sure that we continue to inspire and pave the way for the next generation to come in and continue the work that we're doing. I'm always always down and excited to speak to young Black girls interested in medicine because they're the future and that's the only way that we're going really be able to make a difference in this field.

Hoff: That was Lash Nolen a second-year student and student council president at Harvard Medical School. Lash thank you so much for joining me.

Nolen: Thank you for having me, Tim, it's been a pleasure.

Hoff: That's our episode for the month. Thanks to Lash Nolen for joining us. Music was by the Blue Dot Sessions. To read our March issue, Racial and Ethnic Health Equities in the US - part II, visit our site, JournalOfEthics.org. While you're there, explore all of our other articles including part I of this two-part issue, watch our videos, listen to more episodes of the podcasts, and earn continuing education credit, all for free. Follow us on Twitter and Facebook, @journalofethics. And we'll be back next month talking about compassionate uses of force. Talk to you then.

Audio Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.25 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

AMA CME Accreditation Information

CME Expiration Date: %creditExp:1%

Credit Designation Statement:  The American Medical Association designates this %creditFormat% activity for a maximum of %creditCount:1% AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to: 

  • %creditCount:1% Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;
  • %creditCount:1% Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • %creditCount:1% MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and
  • %creditCount:1% Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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