There is a famous quote from Sir William Osler that has become a mainstay of medical school communications curricula: “The good physician treats the disease; the great physician treats the patient who has the disease.” As first- and second-year medical students whose education has been restructured for the virtual learning environment as a result of the COVID-19 pandemic, my classmates and I have clung to this ethic of patient-centered care, even as our time with actual patients has evaporated.
In March 2020, as COVID-19 cases were starting to spike in the U.S., and the Bay Area issued its shelter in place orders, my medical school courses were rapidly reformatted. My classmates and I left campus on a Friday after taking the final exam for our renal and GI block and returned to school on Monday (now on Zoom) for the first day of our “Health and Society” block. Our simulation center – where medical students learn and practice with Standardized Patients – was closed until further notice. Preceptorships were canceled and shadowing was forbidden. We were abruptly pulled from our clinical microsystems, the clinics and hospitals where we had been meeting with our faculty coaches every week since the beginning of medical school. Three weeks later, the shelter in place orders were extended as we entered our final academic block of the school year: Infectious Disease. As the scope of the pandemic – and its ramifications – came into focus, we sat in our bedrooms and living rooms and kitchens, frantically studying bacteria and viruses, cut off from the patients who were succumbing all around us.
Months later, my now second-year classmates and I are still learning on Zoom, counting down the weeks until our clinical clerkships begin in January. While we were allowed to re-enter the hospital for a few chaperoned patient encounters during the fall, our clinical exposure has still been far less than it would have been at this stage in the pre-COVID world. But although patient care has eluded us, we have not been cut off from the widespread realization of how deeply medicine and health care are woven into every aspect of our society. It has been encouraging to see clinicians step out from the silo of the hospital and join the national conversation, advocating for public health and safety, for the indispensability of science, and for a reckoning with the profound social, economic, and structural inequities that this pandemic has laid bare.
Lifting up these voices has taken courage, and I deeply admire the health care professionals who have invested the time to advocate and educate while simultaneously caring for patients on the frontlines. But just as it shouldn’t take a pandemic for us to come to terms with our national crises of racism, poverty, and structural violence, it shouldn’t take a pandemic to catalyze this type of national-scale and mainstream advocacy among health care workers. For the medical education establishment, the true test of courage will come when we decide whether to lean into this reckoning and really change the way we educate physicians.
It’s time to push beyond lip service to the “social determinants of health.” We have described the problem; now it’s time to address it. Through education and training in authentic community partnership, civic engagement, and public policy advocacy, medical schools could equip their students to identify and dismantle the systems of structural racism, colonialism, and oppression that constitute the root cause of health disparities in this country. This education could take many forms. For example, it could mean protected time for students to volunteer with existing community-based organizations, in order to learn about the needs of their local communities and to support the efforts already underway to address those needs. It could look like assignments that ask students to engage with their local, state, or national representatives on policy issues that affect the lives of the patients they will soon serve. It could be as simple as required reading on the societal structures and historical legislation that continues to ripple forward with deleterious health impacts still felt today — texts like Medical Apartheid, The Color of Law, and The New Jim Crow would be good places to start. Regardless of scope or form, these educational experiences should be integrated and required, tracking in parallel with the biomedical curriculum, to avoid the phenomenon wherein the students who would benefit most are able to opt-out. If we want to leverage the lessons from COVID-19 into a positive transformation in medical education, it’s time to write advocacy into the DNA of medicine.
There are those who disagree. Most notoriously, Dr. Stanley Goldfarb, a former curriculum dean at the University of Pennsylvania’s Perelman School of Medicine, published an incendiary op-ed in the Wall Street Journal last year lambasting medical schools for their increasing focus on social justice issues like “climate change, social inequities, gun violence, bias and other progressive causes only tangentially related to treating illness.” He claimed education on such topics was coming “at the expense of rigorous training in medical science.” The piece prompted a strong rebuke from the American College of Physicians (ACP), but one glance through the comments will show that Dr. Goldfarb is not alone in his opinions. He rallied support for his views again this past spring, in another op-ed, calling for public health training to be incorporated into medical education in the wake of the pandemic. This is where, in my view, the logic of his line of thinking doesn’t add up. I wholeheartedly agree that public health should be integrated into medical education and training – but public health requires an understanding of, and engagement with, the systems and structures of our society that also influence population health, which raises the “social justice issues.” At the beginning of the 2019 op-ed, Dr. Goldfarb cited the ACP’s mission “to promote the ‘quality and effectiveness of health care.’” I see all of these goals as intertwined. If medical students are not educated about the social inequities that impact our patients’ health, if we are not given the training and tools to engage with the systems that have created those inequities, how can we ever hope to deliver effective health care?
Medical schools are responsible for teaching future physicians how to heal the sick and injured. The fact that COVID-19 has ravaged Black, Latinx, and Native communities while barely touching white communities that exist just blocks away underscores something we already knew: the structural inequities of our society are literally killing people. Biomedical science alone won’t heal them. It is no longer enough to treat the patient who has the disease; the most effective physicians will also treat the societal sickness underpinning the individual ailments, as well as the structural trauma maiming whole communities. This may be a bitter pill for the medical education establishment, but we must have the courage to swallow it. The health of our patients, and our society, depends on it.
How has the COVID-19 pandemic altered your expectations for medical education? Share your thoughts and experiences in the comments.
Fiona Miller is a second-year medical student at the University of California, San Francisco and the mother of three feisty kids. She is passionate about racial health equity, reproductive justice, and harnessing the power of human stories towards healing. Fiona is a 2020–2021 Doximity Op-Med Fellow.
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Illustration by April Brust