In the latest installment of the American Medical Association's health equity YouTube series, Dr. Aletha Maybank, chief health equity officer at the AMA, speaks with a panel of medical students, some of the nation’s youngest medical leaders, as they share their thoughts on the immediate and long-term health equity considerations and impact this pandemic poses. 


Moderator

Aletha Maybank, MD, MPH, AMA chief health equity officer

Panelists

  • Alec Calac, Association of Native American Medical Students UC San Diego chapter resident (UC San Diego School of Medicine)
  • Richard Gómez, Medical Organization for Latino Advancement medical student committee member (Loyola University Chicago Stritch School of Medicine)
  • Alex Lindqwister, Association of American Medical Colleges Organization of Student Representatives national chair (Dartmouth Geisel School of Medicine)
  • Osose Oboh, MPH, Student National Medical Association president (Michigan State University College of Human Medicine)
  • Sarah Mae Smith, American Medical Association Board of Trustees (UC Irvine School of Medicine)
  • Yingfei Wu, Asian Pacific American Medical Student Association national president (Medical College of Wisconsin)

Transcript

May 7, 2020

Dr. Maybank: [This] evening's conversation on prioritizing equity. Here with medical students who are going to give us their insight, their experiences of being medical students during this time, but really centering a health equity lens.

My name is Dr. Aletha Maybank. I am chief health equity officer at the American Medical Association and over the Center for Health Equity. Our mission at the Center for Health Equity is to strengthen and amplify and sustain AMA's work to eliminate health inequities, to improve health outcomes, which we know are rooted in historical and contemporary injustices. This week we've been doing a lot of work as I'm sure many organizations have been across the country.

I just want to first announce we released a press release this past Monday. Really warning and urging against racism and xenophobia in the context of COVID and really urging that folks use proper nomenclature. We know that has been a challenge within our country, even though we don't hear it as much from our top-level leadership, we still know people are using language that's not fully appropriate to describe COVID. And just really to reject interpersonal, as well as structural, racism as well. It really affects us within the context of patients within their practices and their systems delivery, but also for communities and our patients. For more information about that, go and visit our health equity resources center at our AMA website. We have a COVID section now for health equity. So definitely check that out.

Let's go to our wonderful panelists for tonight. I thank you all for being able to join me from different places across the country. First we have Osose Oboh, who is president of the Student National Medical Association. Can you wave your hand? 

Oboh: Hi.

Dr. Maybank: And is a board of trustees for the National Medical Association. And she's going to say later what her school is. We're going to go around and do that, and y'all can say all of that.

We have Alec Calac, who is from the Association of Native American Medical Students. Raise your hand if you haven't.

Sarah Mae Smith, who is from the American Medical Association and is on the board of trustees as a medical student representative. Hey, awesome.

Yingfei Wu, who is national president of the Asian Pacific American Medical Student Association.

And we have Richard Gomez who is of the Medical Organization of Latino Advancement, student committee member, and raise your hand.

Gomez: Hi, everyone.

Dr. Maybank: And we have Alex. Alex, I did not forget you. We have Alex Lindqwister who is chair of the Organization of Student Representative for the Association of American Medical Colleges. So thank you all again for joining us tonight.

I want to first just go around and we'll try to do this as smoothly as we can. But I really want to hear from you. One, where are you in med school at what year? What school are you going to? How has it been for you since COVID has started? And are you hearing other things from your members as it relates to equity that folks really aren't considering or haven't really talked about much?

There's a lot in that, but I know we can get through this in a good amount of time, but we all really want to hear from you and the stories and your experience. So Richard, do you want to start? Then you all can just chime in after that.

Gomez: Absolutely. Thanks so much. So hello to everyone who is tuning in. My name is Richard Gomez. I am a, still, third year medical student at Loyola University of Chicago Stritch School of Medicine right now. I'm a Texas and California native. I'm also part of the board of directors for the Medical Organization of Latino Advancement as their medical student committee co-chair. Itzel, who is at the University of Chicago, is my fellow med student colleague.

I think just to briefly kind of describe my experience. It's crazy to think that it's been eight weeks. It's been eight weeks since I've worn a white coat. That's why I'm wearing one tonight. I'm not trying to be extra. I'm just trying to kind of re-envision what it's like to be in a clinic again without actually being there now. So it's been surreal. I think maybe my other peers can echo this, but I think one of the biggest differences this has made for me is it's made me miss being in clinic and miss being with patients again. It's just not the same learning things from a book and doing things virtually versus actually having that interaction and using that active thought process with a group of colleagues.

Overall, just as far as the Medical Organization of Latino Advancement, MOLA, our mission and our goal is to help promote professional and academic advancement for our members, as well as for our community members as well, striving to reduce health inequities for the Latino community and other disenfranchised groups. And just also trying to promote opportunities for our future health care workers, through scholarship programs, through research and through other sort of mentoring programs that we offer through our many different committees. That's kind of it in a nutshell.

Dr. Maybank: All right. Thank you. Alex, do you want to go?

Lindqwister: Sure. Thank you so much. Hi everyone. My name is Alex Lindqwister. I am a third year medical student at the Geisel School of Medicine at Dartmouth, and I'm the current OSR National Chair at the AMC.

I echo a lot of the sentiment that these are pretty wild times, and I think there's a lot of uncertainty in the air. As far as major areas of equity that are starting to come into fold because of my position with the AMC and within academic medicine, what's really come to the forefront is equity within testing, specifically around USMLE Step 1. At the moment, there's an enormous backlog of students trying to take this exam. And for students who are in limbo, unsure when they'll be able to take this exam, people with lesser socioeconomic means are unable to purchase renewal forms on their studying resources. It's harder to travel. It's harder to be able to access difficult to reach areas that might be offering limited exams.

A lot of the equity focus that we've been centered around in the last few weeks are trying to make it such that when we are working with our NBME colleagues, how can we create solutions such that all students are fairly assessed during this exam and are capable of doing such without incurring disproportionate personal costs and academic costs as well.

Dr. Maybank: Thank you for that. Thank you. Sarah?

Smith: Thank you, Dr. Maybank. My name is Sarah Mae Smith. I'm an MD/PhD student at the University of California, Irvine. I'm currently in my grad school years, so I've been trying to do some writing, but it's a little hard to do immunohistochemistry from home. I'm also the medical student member of the American Medical Association's Board of Trustees.

In the midst of this COVID-19 pandemic, the AMA has really been advocating for medical students by supporting provisions, for example, expanding student loan forgiveness for positions and training on the front lines, as well as collaborating with other entities like the AAMC, through the Coalition for Physician Accountability, to address some of that uncertainty that Alex was talking about around our disrupted medical education including the administration of our board exams and the upcoming residency application process.

Our aim has also been approaching this endemic through a health equity lens, as it impacts our physicians and patients of color. As you noted Dr. Maybank, this has included speaking out against and condemning xenophobic and race-based scapegoating experienced especially by Asians and Pacific Islanders. We also recently advocated to the Department of Homeland Security and the Office of Inspector General to investigate reports that pregnant women seeking asylum here in the United States have been denied timely access to health care by US Customs and Border Protection agents. We recommended that CBP refrain from detaining pregnant women during this pandemic.

We also took action recently to urge congressional leaders to maintain work authorization for individuals currently in deferred action for childhood arrivals status during this national emergency. That's not to mention the work that you've really been leading, Dr. Maybank, with the AMA Center for Health Equity to advocate for the collection and analysis of comprehensive, standardized data on race, ethnicity and language regarding the testing morbidity and mortality associated with COVID-19, recognizing the long standing social and health inequities affecting marginalized, minoritized and medically underserved communities.

Dr. Maybank: Thank you, Sarah. Osose? Right?

Oboh: It's Osose.

Dr. Maybank: Osose.

Oboh: Pretty close. Pretty close.

Dr. Maybank: I was close?

Oboh: Hi, everyone. My name is Osose Oboh. I am a third year, fourth year in a month, med student at Michigan State University College of Human Medicine. I'm currently based at our Flint campus out in Flint, Michigan. I am also, again, like you had said earlier, the new National President for the Student National Medical Association and also the student trustee to the board of trustees to the NMA, which is the National Medical Association.

As far as how COVID has been impacting me. I mean, I'm getting the Zoom fatigue that I've been hearing about from—

Dr. Maybank: I think we all are.

Oboh: You know?

Gomez: For real.

Dr. Maybank: Exactly.

Oboh: I'm currently on a surgery rotation. So this is nothing of what I expected out of surgery. I expected 5:00 AM to 5:00 PM or so days, more hands-on experiences, but I mean, you try to go with the flow in situations like this.

I would say, echoing a lot of the things that have been said, I think a lot of our organizations are doing some great work and there's some overlap there. So just one speaking to the SNMA, I mean, the SNMA has been committed to serving and supporting current and future underrepresented minority students and addressing the needs of our underserved communities for years. That's just the same in line with the NMA, which is going on its 125th anniversary this year, which has been really just here to support African American physicians and also be that voice for parity and elimination of health disparities.

As far as the work that we've been doing in light of this pandemic, one, we had to flip our in-person conference to a virtual one. In that conference, we really try to adjust the game plan that we had. A lot of our plenary sessions now became focused on how to be an advocate during a pandemic and things of that nature. Some of our current programs that we've been doing, the very first program that I started out the year with was entitled “Coping with COVID.” The goal of that was to bring voices of underrepresented minorities who are in medicine, who are in leadership positions, who could speak to the uncertainty that we as medical students are feeling when it comes to medical education. So we had Dr. Gary Butts, who is on the board of NMA, but works out at Mount Sinai, doing a lot of diversity and inclusion work. He brought to the table that medical education perspective, like, this is what our school is trying to focus on, and these are what a lot of schools are trying to focus on and how we help our students.

I had Dr. Nailah Thompson out from Kaiser Permanente in Northern California, who is in charge of their health disparities track. She brought to the table, the program director lens as a lot of students, like myself, are planning to apply and are trying to figure out, what do we do when COVID is impacting our aways and impacting our possibility of having in person interviews? How do I shine now, if you don't get to meet me in person? How do I know whether your program has the space, the capacity and the environment for myself as an underrepresented minority to thrive? That was kind of like the conversation.

We also had Dr. C. Freeman who has done a lot of work in the field of psychiatry and brought that mental health piece. Because one of my main focuses for the year is mental health, the mental health of our students as they graduate and become physicians. She brought that mental health piece, talking about what we can be doing now as we're staying safe at home. What can we do to cope during this time? We've been doing work like this for a long time—pandemic, no pandemic.

Dr. Maybank: Absolutely.

Oboh: Trying to support our students, and same with the NMA. We have a series called NMA Talks where we educate our underrepresented communities, specifically African American communities, on the myths behind COVID, because there's a lot of blogs out there, there's a lot of misinformation out there that our communities I think are getting hit with in a disproportionate way. We're seeing how COVID is impacting our communities, again, in a disproportionate way.

Dr. Maybank: Yeah. We're going to come back to that, because I want you to speak about that with Alec and it's been a second. We're going to come back to that in some of the work you all have—you and Alec's organization have led this past week. But I'm going to ask now, I'm going to shift to Alec. Can you just kind of tell us where you you're at school and what year and how it's been going for you?

Calac: Sure. Thank you, Dr. Maybank. Míyu, yam. Hello, everyone. I am currently a second year medical student at UC San Diego transitioning to the graduate side of my MD/PhD training. I'm also one of the students trying to take the Step 1 exam, so it's a very nervous time.

But a little bit about me. I'm from the Pauma Band of Luiseno Indians, which is a small tribe in San Diego County, and currently serve as the National Policy Director for the Association of Native American Medical Students. Our primary goals are really to support students in the successful completion of their studies, because we know that American Indian medical students have the lowest four year completion rate of medical school compared to their peers, and to really assist tribes with the recruitment and retention of Native Americans in the medicine and the allied health professions.

I think as an organization, we're incredibly concerned about the effect the pandemic has had across Indian country, where we have seen the highest rates of infection, particularly in the Navajo Nation in the Southwest, as well as a 39-day delay in COVID relief funds for tribal governments from the Trump administration. For our medical students, we know that American Indians come into medical school with more pre-medical debt than their peers, so this is also an extreme time of financial hardship for students who are, one, stuck at medical school and also not able to return home. So I'm looking forward to our conversation today.

Dr. Maybank: Awesome. Thank you. Yingfei?

Wu: Hi everyone, my name's Yingfei. I am a fourth-year medical student at the Medical College of Wisconsin. So I think I might be the only M4 here who's graduating in this chat. So things about how it's affected me personally, I think since COVID has really affected us in terms of pulling us out of our classes and rotations. As a fourth year, we were on the tail end of our rotations, so I only had one more ICU rotation left. So since then, we've changed to online classes to finish off the year, and we'll be graduating virtually as well. In terms of some of the things would be that we aren't as able to see our friends as graduating fourth years for the last time. But otherwise, the school has been really responsive to helping us get everything that we need done.

So I'm also the National President of APAMSA, the Asian Pacific American Medical Student Association. APAMSA is a national volunteer student run org that addresses the unique health challenges and health disparities of Asian and Pacific Islander American communities. We have over 120 chapters across the US, and our members organize and participate in activities from community service to professional development. So for example, one of our national initiatives is raising awareness about hepatitis in the API community, and we support hepatitis screenings and have a national conference regarding hepatitis and liver issues, because that's just one of the health disparities that our community faces. And recently, in recent years, we've been focusing on advocacy efforts and with the politicization of health care and the increasing instances of racism, as you know, phobia that we've been seeing during this COVID epidemic, we've really been seeing how the voice of the API community is really important.

So some of the things that we have been doing recently is, besides publishing statements about our concerns to show how we stand together, we've also been asking for our members to reflect on COVID and sharing these reflections to our members. We've also been gathering and providing resources for our members on how to respond to and report such inappropriate actions. And on the other side, we also have been advocating for the segregation of API data, especially health data that would be important in instances like this, to see which specific API communities are affected. Yeah. Thank you for having me.

Dr. Maybank: Thank you. So you're graduating. Where are you going next?

Wu: I'm actually going to New York at NYU in Brooklyn.

Dr. Maybank: Good.

Wu: Yeah. Some of the NYU med students who are continuing at NYU are starting early already, but for us we're still kind of on standby. We're likely going to just start on time.

Dr. Maybank: Okay. All right. Thank you. And I just, as I hear it, listen to all of you speak, I just really want to thank you all for your efforts. And it's really an honor for me to be on the call with you. I am very proud of all of you. I just think about back at med school and I definitely was in leadership roles and positions, but I think what you all are doing, and this generation is a whole nother step up than what my generation did, in terms of just your true commitment to advocacy. And I see med students are just so committed and so aware of issues related to social justice, but also aware of your responsibility to focus on them, address them and also organize around them. So I just, I wanted to honor that, because as you were talking, it really came to me. So thank you all for really the work you're doing and how you're showing up.

So back to Alec and Osose. Can we talk about, Oh, I'm sorry, I got to tell you what the question is. Sorry. The question is, you all had released a statement earlier this week, a combined statement from the two of your organizations really calling out the inequities. So I would love for you to kind of both talk about it, and why did you do it, what was the purpose, and what do you expect from it?

Calac: Sure. So I think taking this first, our ANAMS members have really always demonstrated a dedication and passion for working to improve the health status of tribal communities, and we've been involved with the American Medical Association probably going on for about two, three years now. As an organization, really trying to be more kind of public facing when it comes to informing policy and to making sure that our voice is heard as American Indian medical students. According to the AAMC, 91% of medical schools have four or fewer Native American medical students.

So as an organization, we really linked together a lot of our students at all these schools, and working with other medical student organizations like SNMA, we really recognize the kind of disparate impact that the pandemic has had on both black, African American, indigenous, and other communities of color. And we think that many of these issues aren't often covered in the media as they should be. They're covered by much smaller news organizations that don't get the same kind of coverage. So we really wanted to call for action that the state and federal level, really support our own communities as medical students, because realizing that we can have an impact now at this stage, where we're medical training, and we don't have to wait until we finish medical school. So that's kind of some of the motivation I'm sure Osose can say a lot more.

Oboh: Yeah. Yeah. I mean, you really hit the nail on the head there with that summary. I do just want to add, I mean, that the purpose of this statement, the purpose of the other ones at the SNMA has signed on to, and the purpose of this cross collaboration is that a lot of times there are solutions that are created that will still leave behind the most vulnerable populations. And that is literally what we're seeing, and that is what we spoke to in that statement. And so we had a list of recommendations that we feel are necessary to ensure that these historically forgotten communities can be seen. That's the importance of this, and I know we're going to be talking about the CARES Act, but that's even a piece of legislation that was put out, but there's so many people that are falling through the gaps, even in that.

Dr. Maybank: Yeah. So, I mean, let's talk about it now. I mean, Sarah, I know folks at AMA have elevated to my office for sure and our team for us to do some advocacy as it relates to the CARES Act. You want to talk about some of the work related to it and what it is for folks who may not be aware?

Smith: Sure. So the CARES Act is some of the legislation around trying to address the stimulus related to COVID-19 and addressing some funding for hospitals, small businesses, et cetera. It's certainly been an honor for me to serve as the member of our AMA’s Board of Trustees that was elected by our Medical Student Section, which is really often at the forefront of bringing a lens of health equity to organized medicine efforts. And I've been trying to use this position to work in concert and collaboration with many of our medical student members to raise their voices and elevate issues affecting minoritized and marginalized populations. And this is certainly included with working with folks like Alec, who has really been a stalwart champion for addressing the under resourcing of the Indian Health Service, as he noted, as well as the imperative to disperse that $8 billion in funding that was allocated for tribal governments under the CARES Act, but took, as he noted, 39 days to actually be allocated, and there continued to be issues with that.

I also wanted to note that medical students within the organization also called attention to potential efforts to restrict access to reproductive health care during the pandemic, which we know would have disproportionately impacted lower income patients, and working to support advocacy by our organization to oppose that. I've also been focused on the conditions in immigrant detention centers, where physical distancing can be virtually impossible and access to adequate health care is limited, which creates a virtual tinderbox for COVID-19 outbreaks. This is another issue that medical student advocates have been bringing to the attention of our leadership and advocating for change, both in terms of exploring alternatives to detention and ensuring adequate health care for immigrant populations. I know that, tragically, here in Southern California, a man detained by immigration and customs enforcement died yesterday of COVID-19, which was one of the first reported deaths in immigration custody, but certainly speaks to the ongoing danger experienced by those being detained.

Dr. Maybank: Thank you for that. And any of you feel free to chime in if you have other comments or anything to anything that somebody says. Richard, I wanted to come to you and speak with you about some of the work that you are doing in Chicago. Who definitely—the city's experiencing tremendous inequities. Lots of publicity around black communities, not as much around Latinx communities. As was already mentioned, kind of the invisibility that happens oftentimes just in terms of our historical context and othering and what that creates in the division among us as people of color, as a result of oppression and supremacy. But also just the realities of our data and what's not being collected, and people who are not being tested. So can you talk about some of the work in Chicago, and what's the experience that's happening there, and what are you all doing as students?

Gomez: Yeah, no problem. Thank you. So I believe it was just yesterday that local media sources released some data showing that in the Latino community that seemed to be the most impacted currently, particularly with the Cicero neighborhood kind of more on the westward part of the Cook County being just kind of the epicenter of that right now. So as far as MOLA's mission, our focus is trying to educate and to provide resources toward our community members. Some of the initiatives that we have done have included partnering with the Medical Spanish Task Force. With this, we've been able to create online reliable sources. Most of them translated into Spanish, and this can be directly shared with the community as well as used as an educational tool for medical students and health professionals to learn how to effectively communicate with Latino patients, as far as providing a better understanding of the accurate information that should be disseminated.

Other initiatives that we have done have also included medical students who have taken it upon themselves to be first responders as well. A lot of them partnering with community members to help with building resources, including things such as sewing machines to make masks and face shields that can be donated for a health care task force. Additionally, MOLA, we are doing a scholarship program. This is actually the second year that we've done a scholarship program where we've selected 10 or more scholars to be involved in research. It was slightly disrupted in terms of our scheduling for getting the project started. But as of our last board meeting, we are doing progress checks, and we're noticing that students are maintaining engaged focus on their research projects as part of their scholarship contingencies.

So with that, as far as engaging with the community and making sure that there's linguistic understanding, and as far as pushing forward with research in this area, as well as some other areas that affect community health, that's been our main focus right now. And just to also add one last little bullet point, one other thing we did do recently was we did do an online bilingual virtual town hall, where we invited MOLA clinical psychologists to discuss and provide guidance on the psychological impact of this, and how community members can maintain their wellbeing as well during this period.

Dr. Maybank: Fantastic. Oh, that's great. Great to hear. Alex, so in the environment of the Association of American Medical Colleges, what do you see happening as it relates to kind of the future of whether it's medical education or just the environment around teaching as it relates to COVID and equity? How is it going to evolve?

Lindqwister: Sure. Thank you so much. So the AMC has been meeting extensively with stakeholders within medical education, including student affairs leaders, educational affairs leaders, as well as students themselves, to try to devise workable solutions as we kind of roll through this pandemic. I think that we're all experiencing a lot of, as Osose kind of brought up earlier was, we're obviously transitioning to more online and virtual platforms, and as far as how the future of medicine may change with this, I'm wondering if that this rapid adoption of online and virtual learning platforms will be more readily adopted. I think things were trending in this direction already, but I think this pandemic has certainly accelerated that.

I think what this does in turn is it complicates a major, a very important question within medical education, which is cost. The cost of going to medical school is extraordinarily expensive. And it's often seen as prohibitory for many students who are underrepresented minorities. So as we start transitioning to more and more online and remote modules, the question becomes more complicated with value-added and how will cost effect individual students.

I think additionally, this crisis puts specifically underrepresented minority students who are applying into medical school and underrepresented minority students in medical school at particular risk because not only are these populations disproportionately affected by the pandemic, not only disproportionately underrepresented by the pandemic, they also have lesser means to respond as certain major facilities become less available, such as testing. When you consider the application of residency process, if it's remote, suddenly the background in which you're projecting your video becomes important, your quality of your Wi-Fi, et cetera. So we may be introducing biases that are unintended into these sorts of processes as we transition to this remote environment. So within these conversations, we have a M3/M4 working group that specifically is addressing these issues of equity and how can we as an AMC list effective practices in best addressing these so that all students have the best chance possible within their medical career and medical journey.

Dr. Maybank: Fascinating. That's helpful. Yingfei, so we earlier, as I mentioned, released a statement against phobia and racism, and I just wanted to have a sense of your own context and your personal experience. One of our earlier calls, maybe about two to three weeks ago, maybe four weeks ago, Dr. Winston Wong was on the call and really elevated the challenges of the community. And he was one of the ones who inspired us to make sure that we made a statement as AMA against xenophobia and racism, just based on probably his own experience, but also what he knows his patients and other physicians are going through. So I just wanted to hear from you, what's been your experience. I know a lot of you all have been home, so it's a little different, but still, we're still connected in many different ways to people. So can you speak a little bit to that?

Wu: Yeah. Thank you so much for having Dr. Winston Wong on the last live stream as well and taking onto account for that brief statement that you guys have published. It's definitely been very challenging for the API community.

Personally, because I've been staying home mostly, and I've been done with my rotations. I personally haven't experienced this racism, xenophobia. However, through APANSA we have heard about a lot of different instances of that as medical students, but also in the community of people of API backgrounds being abused and having racist remarks. And I'm sure some of you have seen the news and the videos that have been going around on the media about such blatant acts of hatred and disregard. So for example we, as a response to that and how our members are dealing with it internally, whether they're blatant acts of racism, xenophobia, or whether they're microaggressions that have been happening more often for our members. We asked them to reflect with us and we've published some of their reflections.

Some of them include just how to cope really with it as a community where we're supposed to be the model minority, where we're supposed to be okay and we're supposed to have these expectations that we're safe and nothing happens to us. So definitely this has been challenging for us.

Like I mentioned earlier, we've been providing resources for our members on how you can report these instances and also respond in a constructive way. I think, despite us encountering these challenges, which can oftentimes feel very personal, we've also seen our chapter members too, who are still very committed to helping our communities during this difficult time. For example, some of our chapters have been helping with interpreting COVID informational materials into Asian languages. They've been donating their time and resources with mass distribution and helping the elderly in the communities. So overall I think this difficult time demonstrates how we all share struggles as people of color in the US and how it's really important to come together and support all groups of people.

Dr. Maybank: Wonderful. Thank you for that. And thanks for sharing the stories. Any others on the panel experience any type of aggression, racism, anything, you've heard things either to yourself or other folks that you know, within those spaces that you've been working before, recently?

Oboh: Before...pre-COVID?

Dr. Maybank: Well, before pre-COVID, I'm going to say yes. Anything that's been kind of, I guess, amplified during this time, or I guess, or just to your point, reconfirmed, in terms of this experience.

Oboh: I mean, I can share just a really random experience that I've just had. So I'm from California originally. I know someone else in the panel is also a California native. And I had flown back home to take CS early, March 11th. Like I left March 8th or so. And because of COVID, my school was unsure what the effects would be by being in California, which at the time was one of the really heightened, one of the kind of peak areas. So we had to fly back right after I took my exam. Then after that clerkships were canceled within the next five days. I had a loss of a family member. It's like all of these transitions were just happening. And so I chose to come back home again.

So I was home for the past six to seven weeks, and my sister and I decided to come back to hopefully be more productive. Because again, this virtual life is a little rough. And came back to Michigan. And when we came back, we had lots of stuff with us. And so we're in the airport. We have the masks on, everything, and someone came, and was kind of like just peeking, peeking at us from the side. And I think normally when I travel, after being in med school, I have really tried to wear school paraphernalia of some sort. Because for whatever reason, I am less likely to have some odd stares or any kind of anything if I'm wearing in bold Michigan State. I got a stethoscope symbol on my chest. Oh, maybe this gives me more worth in society. And so that day though, we did not have anything that designated what we did in life. And someone came to check and kind of look at our bags and try to check our tags, and the airport's empty.

And so I think it just adds on another layer to this experience. I mean, we just heard of Ahmaud Arbery who was just gunned down when he was jogging. And so I think living in this pandemic, all of the discrimination that, I'll speak on black experience, African Americans experience, the experiences that we were having before. And when you layer COVID on top of it, it is definitely a more difficult space to navigate. And I can't imagine what I think my premeds who are trying to apply in this climate are going through, and I can only speak on the medical experience cause that's what I'm currently living in. But it's definitely been a lot more difficult.

Dr. Maybank: Thank you. Anybody else?

Gomez: Can I chime in just briefly?

Dr. Maybank: Sure, absolutely.

Gomez: All right, thanks. Fortunately I've not had any personal experiences with any microaggressions or harassment. One thing I have noticed that I feel is playing a role as far as why we're seeing a lot of data showing that COVID is impacting the Latino Hispanic community significantly is the fact that I think there's a disproportionality in those who are able to work from home versus who have to go out in the environment in order to work as well. And so there have been these moments or arguments that I've had with fellow members who are in white collar jobs and have the fortune of earning a paycheck from home, while doing work from home, being very critical of those who are saying, "You should just stay home. Why are you going out and working?"

Well, some people don't have the fortune of being able to work from home. They have to go out and endanger themselves, whether it's through labor work in restaurants or stores or in the airports as flight crew staff and so on. And I notice that that is something that is significant with the Latino and Hispanic community, especially for immigrants.

And so, there is that gap in understanding and empathy that I think has been frustrating, and that's just pronounced more, or at least revealed more to us, kind of like the gaps in opportunity for those who can fully protect themselves, versus those who still have to put themselves in harm's way in order to make ends meet.

Dr. Maybank: Absolutely. So thank you for that as well. And I'm going to have a question slightly related to it. And so the questions are starting to come in, and if folks have questions, please post them. I will do my best to answer them. They're getting sent to me. So it may be a little bit selected, they come to me, just letting you know. But so one of the first questions I have, there was recently a New England Journal of Medicine article that was published discussing how disparity figures, without background context, can continue to perpetuate harmful misinformation. There we go.

Can you all speak on this? Please.

Oboh: Let's talk about it.

Dr. Maybank: Let's talk about it.

Calac: Yeah. If I could tackle this one.

Dr. Maybank: Go ahead. You all can tackle, you all have your opportunity to respond. Please, go ahead.

Calac: I think I've heard about this article in the New England Journal, and I think it reminds me of when I first started medical school, and a physician in the community told me that the only thing that I need to know about American Indian health as a medical student is that if a tribe has a casino, they have great health care. Which couldn't be further from the truth. Tribal gaming is such an essential part of kind of a economic engine that allows tribes to fund their health care, their education and other key social services when the federal government does not provide enough funding to even have those services provided at an equitable level.

I think that the pandemic has really laid inequity bare. In that with what we're seeing in tribal communities and the Indian Health Service, people don't understand why the Indian Health Service exists. They don't understand that this system that cares for close to 3 million people has less than a hundred ventilators in the entire system. So you can go from factoid after factoid. But the reality today is that there are over 4,600 cases of COVID-19 in the area served by the Indian Health Service, and more than half of those cases are in the Navajo nation. So when we start to think about the experiences that our relatives are going through, you really need to understand the historical context and how these policies put us in such an unfortunate position for this pandemic. Because when we had the 1918 flu pandemic, Native Americans had a four times higher mortality rate than any other racial and ethnic group. When there was the H1N1 pandemic, there was a four times higher mortality for Native Americans than any other racial and ethnic group. And I fear that the same will happen with this pandemic if we're not proactive now.

Dr. Maybank: Yeah. Thank you for that. And I think the other part that Dr. Wescott of the Association of American Indian Physicians brought up is the unique aspect of the Indian Health Service really saying, it's a part of a treaty that health is a right. And that all are to get access to health care that's of good quality, et cetera. So she really, I valued that she elevated and reminded us all of that point too, that many people don't know about and realize. Who else would like to respond to that initial question?

Oboh: Yeah, I would love to. I think, Alec, thank you so much for sharing that with us. Until we did this joint statement, I think that I did not have the educational understanding to even understand the impact that it was having. And so, one, thank you for sharing that. Thank you for sharing that perspective. This kind of sheds the light for me, that I've already been thinking and having these discussions with leaders at my school is that education is key. I think that right now, I mean, when I started medical school, we all have the PBLs, the small groups where we go over cases. And I think one of the main things that stands out to me very quickly, maybe it's the public health background, is when we throw out a statistic and just let it sit there as if it doesn't have a story.

And so I think that it is very, very important in medical education, as future physicians, that we challenge our curriculum committees to make sure that they are providing historical context in medical school to address the health disparities that we're seeing, and that we're seeing even more so now that COVID is having its impact. And I think that there's physicians out there that are also researchers like Dr. Anthony Iton, who has talked about health disparities in relation to geographical context, like where you live, can tell you what kind of health outcomes you might see. And I think that this is very, very important for us as a nation to remember the history and to see how it played out to leave us where we are right now.

Dr. Maybank: Absolutely. And to that. So I just, when you said something, and I'm an MD/MPH. So clearly I have a liking towards MPH. Do you feel that all med students should have an MPH background? Do you think it would be helpful? And, Alex, would love to hear kind of your opinion to that.

And when I say public, I'm not saying necessarily you have to go through a MPH program. But should medical education evolve to be inclusive of some of the tenants of public health education? I have my opinions on it, but this is about you. So I want to hear what y'all say.

Lindqwister: No, I appreciate the question. I think that, as we're discovering, as we're going through this COVID pandemic, that public health education is really essential to what it means to be a physician in the modern era and what it means to be a leader at least in your community as far as having expertise in medicine. I think that one of the biggest things that I've noticed within COVID is that there's a lot of misinformation moving around online, and a lot of language games that are being played. And, similarly to we were talking about earlier, statistics without context, I find that a lot of that is used and manipulated in ways such that different racial prejudices can be advanced, or different narratives can be advanced, contrary to what I think most would consider is the scientific consensus.

And I think that, as people privileged enough to be able to get a medical education, part of that is being educated enough in public health to be able to inform the public and impart some sort of betterness to the public with the knowledge that we have. And for this, I think, having at least a moderate degree of understanding in how disease dynamics, particularly infectious disease dynamics, can affect underrepresented minorities, can affect people of low socioeconomic standings, how people historically have been mistreated and how inequities in our system may be magnified by situations like these.

Dr. Maybank: Absolutely. Thank you. And I think it's for everybody really just to understand how is health graded in the first place. I don't think there's always a clear understanding around that, and there's so much focus on the health care system, outside the context of all these other foundational things that create health for all of us. And so I think a broader understanding of that is absolutely critical. And from my perspective, I think Richard and Yingfei, you both wanted to also, I thought I saw your hands, but if not, okay. [crosstalk 00:48:37]

 Wu: I wanted to add on to the point from before, but also I do also have an MPH. I do also agree that public health information is very important, not only for physicians to be aware of, but also for us to be able to tell the public about and inform them accurately.

So in terms of regarding the health data in regards to different ethnicities, I do want to also emphasize how important APANSA is focusing on advocating for the greater desegregation of API data. So various API communities have different health disparities and experience different social determinants of health, just like other minority groups, and we feel like the methods that we need to address these challenges are different for each group. But because oftentimes API populations are aggregated in our health data, it's easy to overlook which communities are being left behind. And COVID has been a really good example that highlights this problem.

The National Council of Asian Pacific Islander Physicians recently compiled a report that showed very different data reporting by different health departments by stage. So for example, only 26 states report data on COVID cases among Asians, and of that, only 12 states report data on COVID cases among Native Hawaiian Pacific Islanders. So for example, some states are showing that Native Hawaiian Pacific Islanders are disproportionally hit by COVID cases, but this could be happening more in other states, but we just don't have the data. So we do really want to encourage more advocacy and more resolutions regarding the importance of that too so that we can find out more about the actual health data of our different groups in our population.

Dr. Maybank: Absolutely. So I have a question. I'm going to, Sarah, I'm going to put you on the spot first. And if you had a choice of thinking about the future of medicine, and you all are going to be leaders, you already are leaders in this space in terms of shaping medicine, what is one thing that you would want to change or have or think should happen. I'll give you all that span of flexibility to kind of think of as it relates to the future of medicine.

Smith: If there's one thing that I could change regarding the health care system, it could be really including addressing social needs within the health care context and realizing that some of these issues are health policy issues that need to be addressed. What really brought me to the AMA and involve me in this work was looking at homelessness, for example, as a public health issue and advocating for housing first approaches to homelessness and allocating stable, affordable housing and more recently, opposing the criminalization of homelessness. And I think certainly COVID-19 has laid bare the necessity of addressing issues like this if we're going to preserve the health of some of our most vulnerable populations.

Another example being criminal justice issues. A group of medical student section members had emailed me earlier this week wanting to address some of the same vulnerabilities related to immigrant detention centers in terms of inability to physically distance and consider for example, expansion of compassionate release policies, especially for those that are most at risk.

Dr. Maybank: Thank you. Who wants to go next?

Gomez: Can I go ahead and share mine?

Dr. Maybank: Sure.

Gomez: Thanks. Yeah, I think that's definitely an important consideration. I think one thing that I would add to that list is I believe that I think we also have to revolutionize our health care task force to be representative of the communities that we serve, both demographically and socioeconomically. I think that has a significant effect in terms of our ability to provide competent and culturally adequate health care. I think in order to do that, we're going to have to remove a lot of socioeconomic barriers toward the MD admissions process in terms of just the amount of money that has to be invested toward clinical experiences, toward testing, toward applying.

And then once getting into a medical school, making sure that we provide enough financial resources and living expense stipends for our students so that way they're not overwhelmed and stressed, if they're financially stretched, that they can just then focus on being the best doctors that they can be. And I think by providing more of those resources, either through policy reformation or what have you, I think it's going to help push forward diversifying our health care task force.

Dr. Maybank: Thank you. Who's next?

Oboh: I just want to just hop in. I 110% agree. I think we all agree.

Dr. Maybank: Yes.

Oboh: And I think just another important point with that diversification is that we could also use it in our leaders, and that's from anywhere from the NBNME, to the ACGME, the AMA, that we have a diverse group leading that also leans towards having diverse group of perspectives to come to the table so that when we're coming up with these solutions and innovative ideas to deal with how to work through this pandemic, that we're able to have representation across the board, and I think that's super important to note too.

Dr. Maybank: Thank you. Who wants to go next?

Calac: I can go. I think two things that I would really focus on is, again, as Osose said, leadership. In the entire country, there are only three assistant American Indian deans that focus on undergraduate medical education in the entire country. So when we talk about a lack of representation, as well as that vertical visibility, it's really not there.

The second thing that I would focus on is the inclusion of American Indian health content into the curriculum of medical schools because, according to the AAMC, 13% of medical schools talk about American Indian health, which means that the majority do not. And as you alluded to with Dr. Wescott and Dr. Warne, what we're seeing on many of our reservations is the culmination of broken promises that were made between tribal governments and the federal government. So there's so many issues to tackle, but you really have to understand the context with the special population.

Dr. Maybank: Yes. Thank you. Yingfei?

Wu: I think one of the things that I would change about medical education, which has been kind of happening with revent changes of the MC guidelines on step one exam, is just how emphasized scores are, and grades are, evaluations are in the whole medical education system. It puts on a lot of stress on students to be able to perform well in these evaluations that don't actually show how well you are interact with patients as a person, as a physician.

And of course, what the recent changes with the MSC changing step one to a pass-fail, which is in a good direction. However, having step two still being a number system, that still puts in a lot of pressure for students. And there's definitely a lot of pros and cons to deciding what is the best. But I also like to emphasize in terms of health equity on how important it is to consider how different people with different ethnic groups that have different backgrounds and abilities to be able to have access to these resources and how well their communities can afford to have these changes will be affected.

Dr. Maybank: Thank you. Alex?

Lindqwister: Oh man, Yingfei, you took mine, right. You beat me to it. But kind of like tying—I echo all the sentiments that were said by the previous panelists. I think that representation within medical education, and within medicine in general, is so important in inspiring the next generation of medical leaders and to really give a voice to communities that historically have not been able to have that sort of perspective added.

To the comment that I was going to say on, on high stakes exams, I think that ultimately a transition from these sorts of high stakes exams where a single number kind of defines you, I think that transition to a more holistic model where you can really capture the intrinsic story that all of us bring to the table, that really better captures who are you going to be as a doctor and who are you as a person rather than I studied really hard and I could afford to buy a bunch of question banks and X, Y and Z. So I think that sort of transition, which is, it seems to be already happening insofar as step one becoming pass-fail recently is a step in the right direction.

And kind of built into this argument is also the notion of cost, which I think Richard talked about earlier, but cost singularly is an incredibly preventative barrier for learners and patients within our medical system. An it's the sticker shock value of a medical education is prohibitive for many, many people. And while significant resources do exist for students, that often isn't sufficient and the amount of investment required alone is oftentimes enough of a deterrent to push people away from medicine who would be fantastic doctors and would be excellent representatives of the communities of which they come from.

Dr. Maybank: Absolutely. Well, Osose, Alec, Sarah, Yingfei, Richard and Alex, I just want to thank you for this evening. You all inspire me. And I think many of us physicians that are out there working and also trying to advance equity in the space and the context of our country. We appreciate, I know I appreciate the accountability that you hold us to and the responsibility that you keep reminding, I think, yourselves, but us as well that we have to the space of advancing equity. So again, thank you for your voice, for your work. We're going to look forward to seeing. You all are leaders kind of at the top line of leadership in your student organizations, so we will be seeing more of you, I know it for sure, in the future. So thanks for taking the time tonight, I really appreciate it, and have a wonderful evening and please stay safe and stay healthy.

Oboh: Thank you so much.

Smith: Thank you, Dr. Maybank.

Dr. Maybank: Of course.

Lindqwister: Take care.

Wu: Thank you. Bye.

Dr. Maybank: Good night.

Oboh: Good night.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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