Establishing Connectedness in Medical School: Perspectives on Reducing the Sense of Isolation
Andrea N. Garcia, M.D., M.S.
Division of Chronic Disease and Injury Prevention, Los Angeles Department of Public Health
Norma Poll-Hunter, PhD
Senior Director, Diversity Policy and Programs, Association of American Medical Colleges
I was invited to write an article about cultural isolation in medical school. As a Latina, I have experienced a sense of isolation while in graduate school, and in some cases while working in different roles. However, I thought it was important to take this opportunity to give voice to someone Native who has experienced medical school. I invited Andrea to serve as co-author and I feel privileged to share her perspective on this issue.
“In all fairness, the first three years of my five year specialized program were quite wonderful. That is not to say that I didn’t realize I was different than my classmates (aside from the standard situation of being the only Native American/Latina in my cohort and relatively poor compared to their backgrounds). For instance, it kind of blew my mind that quite a few of my classmates were not a ‘minority’ but were fluent in Spanish or another language because they’d volunteered or lived abroad. It was also strange how much healthier they seemed to be than anyone I’d ever known. They exercised on purpose, and I finally learned what being kosher and vegan meant. Most of their parents earned professional degrees, and some of them were even doctors. Because of this, it seemed like they knew what to expect, and were already aware of the impending board exams, rotations, etc.. Looking back, I realized that their upbringing better prepared them for the subtleties of the culture of medicine that can’t be taught, even if you do work hard and attain great achievements.1 Yet, although I was vastly different in my socioeconomic upbringing, and culture, we were all like-minded in how we wanted to change the world and help underserved communities. Yes, I was different, but not excluded.
Medical school is already noted as a challenging and arduous time, and adding to these experiences of feeling different may be a sense of isolation for many racial and ethnic minority students. AAMC data show that African American, American Indian and Alaska Native, Native Hawaiian and Other Pacific Islander and Latino students represent less than 13% of matriculated students in 2014.2 By looking at sheer numbers, this sense of feeling different and possibly isolated from other medical school peers may be a reality for many students who are underrepresented at their institutions.
So, why is this important? Feeling connected is found to be critical to health. Research shows that young adults who feel socially isolated are more likely to experience slower wound healing and poor sleep.3 We know sleep is essential for learning. So, what happens when you are in medical school, residency, or starting your first position and you feel disconnected or socially isolated? There is limited research that speaks to the experience of medical school students and social isolation. In a series of letters to the editor of Academic Medicine, leaders recognize that racial and ethnic minority students who feel isolated and may withdraw are likely to be perceived as unprofessional, or not engaged academically. Some argued that achieving a “critical mass – having more students of color” may mitigate a sense of isolation. Others recognize the need for broader cultural change at the institution, including integration of diversity and cultural competence in the curriculum, hosting cultural and social programming, and a safe place for students to share their experiences.4
American Indian and Alaska Native students represent less than .5% of all students enrolled in MD granting institutions.2 This presents a unique experience compared to other historically underrepresented minority groups. Research shows that Native students may experience struggles with maintaining cultural connections in environments that often do not align with their cultural values, in some cases places like medical school. Medical students may feel wedged between two cultures, challenged to live near their families or
tribe, and experience a lack of role models of a similar background. 5,6 This may contribute to feelings of isolation. These are normative feelings and there are ways to manage them.
“The things that mattered to me most (e.g. finding the native community in my surroundings) I did with relative ease. I quickly found the other Natives on campus, I found the Intertribal Friendship House, immersed myself into the pow wow scene, started volunteering with a native youth program nearby, attended ceremonies when possible, and continued participating in ANAMS, and AAIP as much as possible. “
Our medical schools are aware of the importance of nurturing inclusive environments. Dr. Geoffrey Young, Senior Director for Student Affairs and Programs at the AAMC, shared that institutions are responding to this issue for all students in innovative ways. Some emerging practices include the development of smaller learning communities where medical students connect with a cohort of peers and a faculty advisor and other supports, and a focus on medical student wellness. He reminds us that students should not be afraid to seek out services available to all students like the student affairs offices and counseling services are valuable supports for students experiencing a sense of isolation.
Each medical school also has a designated diversity affairs office and leaders who are available to support students. Get to know who is at your institution at https://www.aamc.org/members/gsa/committees_gsa/coda/55126/cosda_welcome.htm
AAMC also has a great portal of resources for medical students at https://www.aamc.org/students/medstudents/
Along the Medical Education Continuum
It is important to know that many students and residents struggle with a variety of emotions on the path to becoming a physician. It is often helpful to hear others’ perspectives and potentially learn from them.
“The actual process of becoming a doctor, the part where I left my little bubble of a 16 person like-minded class, and moved on to the bigger institution to see patients, was, to be clear, very isolating. Literally, on my first day of a clinical rotation, one of my new classmates asked, “What ARE you?” And on learning that I was Native American, assumed without missing a beat, “I bet you get a lot of scholarships.” “Fine,” I thought, “I can handle ignorance.” But the ignorance wasn’t limited to peers. It seemed the standard question every attending wanted to know was, “So what do your parents do?” I wanted to respond, “Does it matter what they do? What sort of biases will you introduce into your evaluation of me, and what does this have to do with my learning today?” Inevitably they’d go down the line where at least one student had a doctor in the family, and then they’d get to me. “Well, one’s an office manager, and one is a janitor.” Then, silence.
The other component I was completely ignorant of was that medicine has a culture of its own, vastly different than anything I’ve been around: hierarchical, paternalistic, and exclusionary. As a medical student, you were definitely at the bottom of the totem pole, and treated as such. There was the constant ‘pimping,’ being made to feel like you were the dumbest person on earth, never mind the male patients who called you nurse, never mind the nurses who didn’t want to work with you, or your peers who tried to out-do you. I was told “fake it till you make it”—this act of appearing confident and loud, when in fact I was scared to death of making the wrong decision that may affect a patient’s a life. I was not only an introvert, and a woman of color, but it turns out I suffered a major case of the impostor syndrome7 (no thanks to the lack of diversity in my peers and attendings), which turned out be the WRONG traits to have in medical school. And unlike my spiritual beliefs where health is about the physical, mental, spiritual, and emotional, the system was not meant to engage the entire patient. We are busy, after all, and God forbid a patient wants to be social on morning rounds before I’ve completed my notes!
Eventually, I became stuck with two versions of myself: 1) the self who was tired, beaten, and just did the bare minimum to keep it together and survive, and 2) the self that still had a little bit of fight and remembered why she was so excited the day she got the phone call saying she got into medical school. Up until this point I used every chance I got to make my research projects and spare time about learning about the health status of my people, so that I could one day return and share my knowledge and skills. I also made it a point to stay grounded and remain present in my community, not just look down upon them from my ivory tower. Luckily my community was incredibly supportive throughout the process.
The only problem was, where I needed my community the most at that time, they simply were not there. The positive impacts of having Native role models at my institution, like someone who might have had shared research interests, someone to understand and be an advocate, someone who shares our perspective on health and wellness, someone with an innate understanding of the social determinants of health, someone with that good old native humor, were just not present in the confines of my medical school walls. I had to reach out beyond my university (which was fine), but it was all the more difficult. The reality is that some of these mentors already had full plates, likely paying the ‘minority tax’8, being the only natives at their respective institutions. Through this process, I learned to be persistent, resourceful, and how to network.
This is not to say that I didn’t have excellent non-Native mentors and teachers throughout my experience. Unfortunately, they happened to be the minority. And even though I wasn’t from the same type of families that my friends were from, their families sure took me in as their own, and still offer career advice to this day, if needed. As much as I can continue with the stories of how emotionally and spiritually draining medical school was (just ask my fiancé), I’d rather focus on the positive.
So to you, future doctor who may be feeling down in the dumps, this is what I’ve got: As angry, and sad, and alone as I felt about the lack of support, diversity, and twisted culture of medicine, I realized that the biggest barrier was myself. I became whole again, and I became determined when I realized that I did deserve to be there. Not only did I pass all the same exams and rotations, I had gifts, and a perspective, and a way with patients that my colleagues didn’t have, and couldn’t be taught. I realized I had a voice, and it was powerful beyond measure. I didn’t take no for an answer. I knocked on doors, picked up phones, and created opportunities that weren’t there. I humbled myself and learned how to ask for help. I gave thanks where thanks was due.
Our medical schools are committed to supporting all students, and they value the diversity of perspectives that you bring. Make sure to reach out and talk with someone – a peer, faculty member, and administrator – to support you along this medical school journey. Focus on your strengths and build your networks, get involved at your school, and connect with your Organization of Student Representatives school’s designee (more information available at https://www.aamc.org/members/osr/)
“Remember that the ‘underprivileged’ community from which you come is quite rich and greatly endowed with the gifts of culture, spirituality, and resilience. We are healers, and we are warriors.”
References at the en
1. Farrell H. Why are working class kids less likely to get elite jobs? They study too hard at college. (An interview with Lauren A. Rivera, the writer of Pedigree: How Elite Students Get Elite Jobs.) Washington Post. Sept 23, 2015.
2. AAMC 2014. Table 12: Applicants, First-Time Applicants, Acceptees, and Matriculants to U.S. Medical Schools 2013-2014 and 2014-2015 by Race/Ethnicity, 2013-2014 and 2014-201. Available at https://www.aamc.org/data/facts/
3 . Hawkley, J T, Cacioppo, LC Social Isolation and Health with an Emphasis on Underlying Mechanisms
Perspectives in Biology and Medicine. 2003, Summer 46, (3); S39-S52.
4. Boateng, BA, Thomas, B. How can we ease the social isolation of underrepresented minority students? Academic Medicine. 2011 Oct. 86 (1); 1190-92.
5. Hollow WB, Patterson, DG, Olsen, PM, Baldwin, L. American Indians and Alaska Natives: How do they find their path to medical school? University of Washington; WWAMI Center for Health Workforce Studies. 2014, January. Available at http://depts.washington.edu/uwrhrc/uploads/CHWSWP86.pdf
6. Kalishman, S, Padilla, S, Devoe, P, Baca, P. Using Lessons from American Indian Health Professionals at a Health Science Center. Academic Medicine, 76 (5); 500-01.
7. Young, V. The Secret Thoughts of Successful Women: Why capable people suffer from the impostor syndrome and how to survive in spite of it. Random House Publishing. 2011.
8. Rodríguez JE, Campbell KM, Pololi LH. Addressing disparities in academic medicine: what of the minority tax? BMC Med Educ. 2015 Feb 1;15:6.