This Jan. 10 episode of the Prioritizing Equity series brings together the physicians featured in "Our Legacy in Practice: A Physician's Story” videos. Panelists will discuss the importance of identity concordance for aspiring physicians and take a closer look at some of the themes highlighted in the videos. Each physician will take a deeper dive into their medical school experience and reflect on an experience in medicine that has impacted their career thus far.
- Javier Guevara Jr. MD—board certified family physician, Northwestern Memorial Hospital; fellow, American Academy of Family Physicians
- Ciciley Littlewolf, MD—internal medicine physician and academic advisor, University of North Dakota School of Medicine and Health Sciences
- Nicole Riddle, MD—pathologist, Tampa General Hospital
- Karthik Sivashanker, MD, MPH—vice president, Equitable Health Systems, AMA Center for Health Equity
Dr. Sivashankar: Greetings all. I'm excited to welcome you to another episode of the Prioritizing Equity Series. I'm Dr. Karthik Sivashanker. I'm a vice president of equitable health systems at the AMA in the Center for Health Equity, and I'm really honored to moderate our discussion today. I am here as a proxy for Dr. Aletha Maybank, who's unable to make it today, but looking forward to this really exciting conversation together where we're bringing together three of our five distinguished physicians who were recently featured in “Our Legacy in Practice: A Physician's Story” videos. This is a collection of videos that showcases the unique journeys of five physicians who are each hailing from different corners of the United States. And what we're going to do today is delve into their individual stories, their identities, how that shaped and impacted their paths in medicine, their membership to the AMA and their continued commitment to support other physicians from marginalized communities and backgrounds. And hopefully to explore a little bit the meaningful contributions we can make together with the AMA and others across the ecosystem to advance equity.
And so, through this conversation, we'll talk through some different themes and I'll invite each guest to share more about their personal experience, their stories, including their medical school and education journey, sharing impactful moments from their careers that have left an enduring mark on them and their communities. And so, it's an important opportunity for us to hear directly from them. So with that, please join me in a warm welcome. I'm going to begin in no particular order here with Dr. Ciciley Littlewolf, who is an internal medicine physician and academic advisor at the University of North Dakota School of Medicine and Health Sciences. We also have Dr. Javier Guevara, who's a board-certified family physician at Northwestern Memorial Hospital and a fellow of the American Academy of Family Physicians.
And last but not least, Dr. Nicole Riddle, who is a staff pathologist providing care at Tampa General Hospital in the general anatomic pathology department with a focus in bone and soft tissue as well as neuropath, gastrointestinal disease and dermatology. So, I'm very honored to welcome these dynamic leaders to the conversation today. So, as we always begin these episodes, I'm going to channel Dr. Maybank's first question, which is where are you joining us from today and what brings you into this conversation? Maybe I'll just invite Javier, how about we start with you and we'll just go around in a circle.
Dr. Guevara: Thank you. Yeah, I'm in Chicago, Illinois, and the reason I'm joining is because I find it very important to share these stories for future generations of underrepresented physicians to be motivated to join medicine and to highlight the reality of what it feels like or what it is to be a physician from underrepresented backgrounds.
Dr. Sivashankar: Ciciley, we'll turn to you.
Dr. Littlewolf: Yes. So, I'm calling in or videoing in from Fargo, North Dakota. So, I couldn't agree more of what was just said, really just echoing what we all come from different backgrounds. I come from a … I'm Native American, I'm Northern Cheyenne out of Montana. And really just how important it is to have diverse physicians because we treat diverse patients and it's so important for a patient to have a doctor that looks like us and comes from the same cultural background, but also highlighting sometimes if you come from a marginalized community or minority community, there's certain spiritual, cultural and physical barriers that we face through our academic journey. And so, thank you for letting me speak.
Dr. Sivashankar: Thank you. And Nicole?
Dr. Riddle: Hello. Yes, I am here today sitting in my office in Tampa, Florida. And the reason why I want to be here I guess is twofold for exactly what my colleagues have said. So, it's absolutely true, expanding the physician workforce and having it be more diverse, having us better understand the patient care population that we serve. And then also, particularly for people with differing abilities, it's literally about trying to change the actual physical structure or architecture of a workplace, not only people's minds and opinions and actions, but then literally the physical places that they work.
Dr. Sivashankar: That's great. And you've already started to answer in some ways the next follow-up question I had, which is, if you could just share a little bit about why representation matters so much to you from your personal experience or lens or what impact has this had on you in terms of your training or in terms of being in the workforce?
Dr. Riddle: So for me in particular, I think it's important because everybody has a lived experience. And then if you have a close friend or colleague who has a different lived experience than you, but because you are friends with them, because you're close with them, then you can understand that better than somebody who has never been exposed to it. And it makes sense that people who have never been exposed to maybe certain types of people or certain sort of situations, of course they won't understand them as well. So, I feel that by having more diversity, more expansion of different types of people, abilities, et cetera, than even if we haven't because of our circumstances, experienced them ourselves, we're more likely to have interacted closely with someone that will help us understand and be better able to comprehend what somebody else is going through.
Dr. Littlewolf: I'll go next. So, I got my education at the University of North Dakota and there's a program that the med school has, it's called INMED. So, their focus is to recruit Native American pre-med students so we can increase the workforce of Native American physicians. And in my class, there were one of six patients, or sorry, six students, and I was one of two to actually complete training, complete medical school and go on to residency. And so, I talked about those unique physical, cultural and emotional barriers. Our families look different. Sometimes we face barriers that most people don't. Depending on what tribe you come from, there are special ceremonies that have to be performed before viewing patients, especially a patient who's at end of life. And so really just tackling these barriers that we face going through medical training and then of course being able to get us in a workforce so we can work with patients. It's so important that patients see doctors that look like them, come from the same cultural background because it increases trust, but also that cultural awareness that I talked about.
Dr. Sivashankar: Thank you. Javier?
Dr. Guevara: Yeah, for me, representation matters because there's no question the data is out there, that the more diverse medical school is, that institution is, the better skills, the different perspectives and the more better care it's provided for those different perspectives and skills that each individual brings. It also highlights new ideas, new ways to do research, new ways to care for patients and even care for diverse populations where socioeconomic, nonmedical issues may contribute that other physicians from underrepresented backgrounds may be more attuned to. So, and for me it's important to represent that because I have also encountered times where we go to neighborhoods of underrepresented background minorities and they don't feel that it's even an option for them to go to medical school. And I want to break that barrier. I want to break that falsehood. I believe that we should have everybody have the opportunity to come to be a physician and provide their perspective to health care.
Dr. Sivashankar: So I didn't warn you about this, but I'm going to go off script, which is something I enjoy doing and kind of follow up on some of the ideas that you're bringing up, which I think are so important. And the first one really is about story and storytelling and that connection to your story and identity. I'm wondering if there is a particular moment or a memory that you have from your experience that you feel informs you as a individual, as a parent, or a brother, or a sister, or as a physician at the end of the day. And so curious if you have a story that is resonating for you in this particular moment in time, and no worries if not, but just curious what you might want to share.
Dr. Riddle: Anyone who lives with something outside the norm is going to have stories of times where they were surprised how poorly somebody dealt with whatever it was or how well somebody dealt with whatever the difference is. And then stories where you love that like, so I have a bone disease and I really love it when my friends are like "After I'm friends with you and now that I go around with you, I think about it all the time of how would a patient do this? How would Nicole do that?" And I'm sure everybody has similar stories, that when they are friends with people, like I said, it's all about who you can be around and the people that you have contact with and you learn from them, they learn from you. And I think we all have stories where it's like, ‘Oh, I have learned from this person how to do things better.’ And then it's nice that every now and then you've helped somebody else learn how to do something better.
Dr. Guevara: For me, few stories and its moments that highlight and resonate with my background and the importance of doing what I'm doing, is English is my second language. And there have been when I was a medical student resident and I will get confused with terms or everything, right, that for them, they told me they were concerned that I would not be able to be good at my job given that I was using the wrong terminology. And I don't think that me, I could explain myself. I may not have the term, but I could explain what we're doing, and I think it's unrelated to my ability to be a skilled physician.
Another was being the only of two Latinos in my class and trying to join a group to study with, and going to an MSA and it was kind of like the shocker of like who is this guy trying to come and study with us? To have that experience to feel cast out or not belonging, it was really shocking to me and it highlighted the importance to show to my peers, my professors, and eventually my junior residents or my junior medical students, and when I became a faculty, all my residents and to my patients, the importance to be open and careful of the assumptions we make and to always welcome everyone because I think that when we segregate ourselves, we're defeating the purpose of diversity. So those stories have resonated to me.
Dr. Littlewolf: I'm trying to think about my educational journey while being a resident. And I have one story in particular where in residency I was the only Native American resident. And so, coming from a background and a place where when I was younger, I think the world around me told me that being Native American, it was less than other people. So, I really felt that growing up. And it wasn't until I became more confident, got older, went to school and then medical school that I really started to feel proud of who I was and where I came from.
And so, I went from being maybe insecure of who I was and where I came from to being very proud of who I am and where I'm from and being able to be a resource not only to my peers, but to the faculty and staff here. But I do remember one patient had said something to me my intern year when I was rounding in the hospital and they had mentioned I took care of them, they were leaving in the hospital, they were doing better. And I always shake everybody's hand before they leave. And I do that today.
And I went to go shake his hand and he wouldn't let go of my hand because he wanted to say something to me. And he said, "For a Native American doctor, you did a great job." And so I, in that moment, it kind of reminded me of the environment I grew up in as a younger Native American teenager, young adult, but also made me realize that I am exactly where I'm supposed to be. And that being able to represent Native American people in a very positive and helping way, but also gives me the opportunity to help medical students, residents who are in a similar situation whether, not necessarily Native American, but being viewed as maybe a little less than because of the background they come from and still reinforcing that they're important and they're exactly where they're supposed to be because we make an impact in the care we give.
Dr. Sivashankar: Thank you. I'm so appreciating the points you're making and each of you have used words that are important themes, and I kind of want to put them together a little bit and see what reflections you have. But one theme I'm hearing I think is one of especially entering into the profession and the field, perhaps one of isolation or loneliness or a feeling of not belonging and seeking that belonging and value and being valued and seen and connectedness. And I really appreciated the I am where I'm supposed to be. So then that makes me think about, well, who else is not where they're supposed to be? I just wonder if you might want to reflect on that. Who else is not where they're supposed to be right now?
Dr. Guevara: I do want to share that's resonating because I joined the board for the medical school and created a committee, inclusion and allyship to highlight diversity, promote diversity within the alumni and then the medical school. And we have tried to reach out to those alumni who feel de-franchised from the school because of a negative experience during their career in the medical school. And often when we reach out to them, there's a lot of trauma, a lot of resentment, and my always come back to them is that's the reason why you should join. If you went through that and you have that experience, what can you contribute back to the medical school to make it better? We're trying and we're doing changes and there have been amazing changes happening in our school and that's not enough. We need more.
And so, we need your perspective, we need your experiences, and we need your ideas of how to make it better, how to correct that for future generations so that there's no, a next individual that has the same experience. Right. And so, I think the more we reach out, the more we get the story. So you can see that out there are so many individuals that unfortunately have felt very disconnected, very offended, and perhaps not, and just staying quiet or staying put or just going by their day. And I just wish they would open up and talk and advocate for changes and share their stories because that would help change.
Dr. Littlewolf: Absolutely. I couldn't agree more. I think that as students progress through their medical training and residency, they should see teachers and faculty and staff that look like them as they make their journey through their educational journey. And one thing I thought about when you were saying or talking about just making sure everything is more diverse because we can't, diversity is so important within our faculty and staff too, because if we don't have a diverse faculty and staff, changes won't happen. Just like you described. And that's so important. I recently joined the academic advisor for the medical school, and right now, the Native American medical students going through the first or the fourth year, how awesome would it be to have their academic advisor reach out to them. And I come from the same cultural background, which is so cool and it benefits them.
So I always ask myself, because a lot of the times I'm the only Native American in everything I do, whether that's with medicine. I'm also a captain in the Army National Guard, and I always told myself, people say, "Why do you keep pushing?" And I say, "Well, because if nobody does, if I don't, who will?" Because I'm the only one in this space, whether it's in medicine or with the army. Being able to stay, even though I may be the only one, but it's so important because other people are always watching, whether that's young soldiers or young medical students, pre-med students, and just having that yeah, a resource available is so important.
Dr. Sivashankar: Well maybe I'll ask a follow-up question here because I think what I'm hearing is a theme about reclaiming space in a way and the power that comes with just being in the space as people who are not typically represented there. And I'm also hearing, I think that there's a cost that comes with that to you potentially as individuals, but also it feels like a sense of purpose so that you're kind of paving the way for others so that it's easier and not as costly for them. So, the question is what is it that is making it so clear that the space is for you and not you? Right. Because we don't put signage up necessarily saying, at least we don't anymore in that way, that this is for you but not you. And yet we know that we have a highly segregated system. Javier, I think you used that word.
And so where is that coming from? What's the message or how is that message being delivered? If I'm a patient and I'm walking into a hospital, for example, what's on the walls, or who's behind the front desk, or where we do our advertising or building our clinics, curious what you're seeing from your experience and from your communities that is making it so clear about where you belong and maybe where you're not so welcome.
Dr. Riddle: I was thinking of that twofold because I think at one point you said, was it, where does that start or how do you know this is for you or not for you? And that's a bigger dissertation of itself, is how does everybody just seem to know that in society. It's just kind of built in this society that by the time you are a middle schooler, if not an elementary schooler or younger, you've unfortunately already figured that out, usually by experiences, the way people talk to you or don't talk to you or treat you. And so, by the time you get to adulthood, whether it's in medical school and you're a medical student or a resident or faculty or whether it's your patients, I mean, that's already very much ingrained in our interactions.
And then I was thinking about how, I forget the other question, but at the same time, the reason why we stand up and we do something is every time somebody says you're a good physician, even though you're X, or you're a good physician even though you're in a wheelchair, or oh, that's amazing that you can actually do that. Or people say to my husband who is a stay-at-home dad while I work like, ‘Oh, you're so lucky he's around to take care of you.’ And I'm like, smile and nod. But anytime you can nicely kind of redirect or correct that, I think that hopefully helps move things incrementally farther along so that then it will hopefully be a little less difficult for the next group. That's my hope. Or physically actually just get buttons put on doors or remove the stairs. Because I have to tell you, when the physician lounge is not ADA accessible, that certainly speaks volumes. And when they have no interest in making it accessible, that says something different and probably even worse in my opinion.
Dr. Guevara: I think we see signage left and right everywhere, and not just in our institutions, right, but in good signage, bad signage, things that look progressive, things that look backwards. Anytime that you see on screens or patient information handouts, someone that reflects your diverse background, whether it is someone darker skinned, men, same-sex relationships, makes you feel more welcoming, more trusting, more happy to be able to be yourself and perhaps discuss more openly your experiences from either a patient perspective or a physician perspective. But then when you get signage or information like the Supreme Court ruling about admissions and everything, it makes you also see that there's some changes that are not as positive or what would you hope.
And both, I think both are really good at pushing or at least motivating me to keep on going. Right? The fact that good things are showing up in signage means we're on the right track, so I should continue. And then when things like the Supreme Court ruling happen, then it makes me more motivated to then, this is then also why I'm doing it. Right? There's still this need for highlighting the importance of diversity and under representation. So signage good, not bad everywhere, not just in our institutions.
Dr. Littlewolf: I agree. I feel like things are getting better and things can always be improved, but things are getting better from advertisements, signage, not only I think with hospitals, but in general. I think everything is moving in a better direction. One thing you had mentioned, and it kind of just stuck with me, you said reclaim a space. I wonder if sometimes we're claiming a space that didn't exist because that's how I feel that I'm claiming space and I'm making space for others that look like me, come from the same background as me, but also other diverse diversity that exists outside of me and my own cultural background. And being comfortable in that space and then also just being proud of being in that space and making sure that I stay, and I want to stay, and I want to continue to be and live in this space and promote diversity because I always think, if not me, who then? Who would do this?
Dr. Sivashankar: That's a big burden and a big weight to be carrying and to carry every single day. And I guess if there's one kind of thought you might want to share with others in this moment who might be listening, what might that be as it relates to what you've kind of spoken to? Whether it's the importance of it, of having these diverse spaces and creating that in our space itself or the way we do things or the power in doing the work that you're doing or the burden or weight, what kind of takeaway would you want someone to leave with?
Dr. Riddle: That's easy for me. I would implore people to continue to evaluate yourself, search yourself and look for areas where you could learn and improve. Even those who are voluntarily watching something like this, everybody has something. So try to be like, oh, I don't have a friend who's a wheelchair user. Let me think about what that would be like. I don't have a friend who's Native American. When I'm walking around, let me view things from that perspective. Or just when you're watching TV or look around and you see something that you're like, oh, that is different than me and my experience. Well, why don't I actually just think about what that might be like? And I would just implore people to really try to think about things that you normally wouldn't have or haven't done because it never came up. Because I feel like the more we do that, then the better and more inclusive or understanding that we can be.
Dr. Guevara: I will say if you are someone who is from an underrepresented background, join. We need you. We need your voice, we need your experiences, we need your stories to highlight the importance to change matters and improve things. And for those who believe that they are maybe from a majority background, I think there's always a diversity even with them. There's a different perspective from those who believe might be from a more majority background and to share their stories and share that aspect that makes them different. But if not, and this resonates to you where you understand that highlighting under-representation and promote diversity leads to better communities, better health care, better patient outcomes, we also need you. We need your voice and we need your advocacy. We need your support. We need that time of saying, I'm sorry, I'm learning, or I apologize if I didn't get it right. Or what can I do to help? If you notice something, say something type thing too. I think the point is everybody regardless needs to join this movement to improve diversity in health care.
Dr. Littlewolf: Yeah. I'm not going to repeat what you guys said because I agree with what both of you just said, but what I see the most when I have a medical student or a resident who, or even pre-med student who feels like they are not worthy, maybe they feel like they can't do this. I always, and if you're that person watching today, I want to say, you absolutely can do it. You can accomplish your goals; you can move forward. And life is tough sometimes times. Life is not fair sometimes, but I want you to pick yourself up. I want you to continue to move forward and then know that you are supposed to be in this space and to keep moving forward. What I've seen with young medical students, young residents, they need that coach. They need that somebody in their life to say, you know what? You can do it.
And if you're listening, you can do it. And they just need that support. Wow. It's so powerful to have someone believe in you no matter where you exist, especially if you're not in a good space or life is being unfair, yet you have these responsibilities and this educational journey that you committed to, you can do it. Sometimes all we need is that word of encouragement to give us that extra energy to move through that space to get over that difficult time, to pick ourselves up and keep moving forward. And then knowing you have that same person if another hard time comes by again.
And I want to talk to all my colleagues out there who are currently working, whether it's faculty, working as a clinical professor, working with residents, you can be that person for a resident. You absolutely can be that person for that medical student, giving them that extra encouragement. And what I've noticed is when a resident pulled me aside and said, "You know what Dr. Littlewolf? You had no idea I was going through this, but that encouragement you gave me, it meant the world to me." So being able to give that encouragement and that support and believing in them, because we don't know what they're going through and maybe they won't tell us, but it's more powerful than we think.
Dr. Sivashankar: That was really powerful. And I want to say that you almost read my mind because I actually do have one more question, and you kind of answered it in a way I think. But the question was, if you were going to tell a story to your young self now, maybe your young self in a hard moment, a particularly hard moment that you remember, what would that encouragement be? And I feel like you just described it in a way, but feel free to add anything else you'd like. And then the second part of that is what story would you want told to you by your future older, wiser self? What story do you want to hear in this moment? And I know that's a hard question, so invite, whatever you can provide there. Maybe we'll just start with you Ciciley with that one since you kind of segued us.
Dr. Littlewolf: Yeah. So, I've actually been asked this question before, and so I've had time to think about this on several occasions, and I would tell myself, you're going to be okay. I would tell myself life is going to be unfair. There's going to be things that happen out of your control and you're going to be okay. Because I've been in that situation where I've had teachers give me encouragement and they had no idea what I was going through. And that was so powerful, and that's something I took with me and still carry with me. But also, I try to pay that forward with current students and residents. And if I were to look back at my older self, looking back at me now, I guess I would say be kind to yourself. Be gentle because I think I'm my own worst critic, whether it comes in different forms, meaning, gosh, you probably could have ran that extra mile and put the cookie down. It's okay. But yeah, being kind to myself in every aspect, be less critical and give myself grace because I don't often do that.
Dr. Riddle: That's an excellent answer.
Dr. Guevara: I would tell myself baby, hold on, because it's going to be a wild ride, but just like my parents always were really good at telling me and in English, never give up. And that phrase stuck with me even in hard times. And to have that resonate to say, just never give up. And my dad would always add, don't take a step back, not even to take impulse, just keep moving forward.
So I think I agree also with Ciciley about be kind to yourself, and thinking about what I will want to hear right now, what advice I think my future wiser self will tell me perhaps would be to keep on growth, keep on this journey of being just better. However that means, whatever that means, whether that is more patient, more kind, more open, more relaxed, more supportive, more giving, whatever that is, more faithful, more believer. I think that that's what it will tell me. Just keep on this journey and keep trying every day just a little bit more. Be a little bit better, be a better version to yourself and to continue to be kind to yourself as well. So I think those are the messages.
Dr. Riddle: I would tell my younger self you actually made it. You made it, you got there. You're good. Because when you're younger, things are rough and you don't know if it's going to happen or not. So, I wanted to be a physician since I was like five, which was not something that was expected or common in my family. And then I would love if my older self, and I hope there is an older self, one of my things is always getting old is the goal. I hope there is an older me, but I would love it if my older self would tell me it was worth it. All the extra sessions like this, all the extra mentoring sessions I do for other schools, all the extra educational sessions I do for other specialties, all the extra stuff that many of those like us do that maybe our colleagues don't. It would be great to find out that you know what, it was worth it. And I should be kinder to myself and maybe do less of all those things, but hopefully I'll find out that it was worth it.
Dr. Sivashankar: Well, I so appreciate each of you. Thank you so much for this conversation today and want to encourage the audience to take a listen to all the videos of your stories. You can watch all five of “Our Legacy in Practice: A Physician's Story” videos on the website. It's ama-assn.org/physician-story. So thank you so much. Really appreciate you. I believe it's worth it and very much appreciate your time, and your energy, and your spirit here today.
Dr. Guevara: Thank you.
Dr. Littlewolf: Thank you.
Dr. Riddle: Thank you.
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.