August 5, 2022, 9:09 a.m. Scott Wilson (Kansas City, Mo.) — A strong atmosphere of renewed connection coursed through the full ballroom where Student Storytelling: A Collection of Powerful Voices opened the second day of the 2022 AAFP National Conference of Family Medicine Residents and Medical Students, which met in person July 28-30 for the first time in three years. National Conference Student Chair Morgan Weiler, of the University of Kansas School of Medicine - Wichita, kept her opening remarks short as she introduced the speakers, leaving them time to speak as they’d been billed: powerfully.
“‘This is my daughter. She’s a doctor,’” began Marie-Elizabeth Ramas, M.D., of Concord, N.H. “This is how my mother would introduce me to her oncologist.”
The care team, Ramas said, “would see my dark-skinned, thickly accented Caribbean mother as not well-educated, compared with her daughter. Introducing me helped balance the spectrum, helped her navigate her rare diagnosis.”
The physicians in that room would have to recalibrate their biases.
“What if I told you that the American dream was not initially meant for everyone?” Ramas said. “Someone like me is four times higher to have an adverse pregnancy outcome than my white counterparts, regardless of education, income, status. This boils down to one word: equity.
“Equity is my passion. It’s my why. It’s the foundation of creating healthy communities. In order to achieve health equity, we need to cultivate respect for humanity, the personhood of individuals. While this seems logical, I haven’t seen it demonstrated in my health care career.
“When we put our equity hat on and peer at American history, what is the picture that tells us about the practice of medicine? What does the physician look like? What does the patient look like? What are the pictures on the walls and in the textbooks telling us about who is important?”
The pictures don’t necessarily show communities as family physicians know them.
“That moment several years ago, sitting next to my ailing mother, I experienced a paradigm shift,” Ramas said. Until then, she said, her equity focus had kept h from succeeding. “I failed, by two points, my first year of medical school. So I said, ‘Next year, I’m going to excel and create a mentorship program for medical students of color.’
“Our why has taken us places. But I can’t stop there. If your why has gotten you here, your why not is what you’ll need to excel. It’s what allows us to imagine the possibilities of what could be. Embracing the why not, we can create an authentic experience. This freedom is what aligns with equity.”
Ultimately, Ramas said, this led her to an ambitious project for her third-year residency, via her state’s Academy chapter. She wrote a white paper on nurse practitioner scope-of-practice expansion, arguing that such a change “wasn’t the answer to health equity in rural areas.”
Now, she said, “I can see a lot of why nots. It’s exciting to see the opportunities that come with embracing the why not: Why not see patients and do advocacy work? Why not deliver babies?
“When people say you can’t practice self-care and be a selfless physician for your patients, ask, Why not? You can’t find joy in primary care anymore? Why not?
“I ask everyone today: Why not embrace possibilities? Why not discover beyond what is expected of you? Why not?”
One day when Lt. Cmdr. Brian Ford, M.D., was first out of residency, working at “an austere Navy hospital in Guam,” he held the hand of a dying patient. Then he delivered two babies.
After that formative shift — “my heart so full it was about to explode” — Ford found himself thinking of the way he’d been one of the last to touch one person and the very first to touch another. To harness those feelings as a new medical student educator, Ford said, he knew he wanted to use a piece of art.
“So I Googled ‘doctor art,’” he said, earning a laugh. And he found what anyone does when searching the internet for a famous painting of a physician at work: the Luke Fildes painting “The Doctor” that hangs in London’s Tate Gallery. The screen behind Ford filled with the 19th-century image.
“I immediately connected with the presence in this painting,” Ford said. “This person, this doctor, seems to really know what’s going on.” (It was Fildes who knew too much about some things, having lost a child. In his painting, though, the light indicates that this time the result will be different.)
When first showing the artwork, in 1891, Fildes said he had set out to depict “the status of the doctor of our time.” Ford’s talk did something similar for family medicine, a specialty that draws from a similar palette: skill, professionalism, empathy.
“It’s 1891,” Ford said. “Was this doctor doing an antibiotic, imaging, differential diagnosis? No. He is sitting there. He is exuding competence. He is exercising connection, being there. This is how I introduced students to the healing profession.”
He closed his portion of the event with a challenge to the audience.
“Update this painting,” he said. “What is true about this that still captures the essence of what we do? Who is the doctor? is the question I think is apropos for 2022, and it has a different answer for each of us. But that’s the beauty of family medicine. I would love to see a new version of this painting showing what the family physician is doing in 2022.”
Christen Johnson, M.D., M.P.H., of Columbus, Ohio, painted a different scene, a starkly personal one.
“I was sitting across the table from someone who was supposed to be a mentor to me, guiding my professional development to release me into the world as a family physician. And he says, “There’s a place to be a leader and a place to be a resident, and your place here is to be a resident. The system isn’t broken. We don’t need your help.”
The contradiction in this moment, of someone recruited for her leadership qualities now being hushed, followed a familiar pattern: the “frustration of someone responding to my question in a way that told me I wasn’t valued and didn’t exist to them,” she said. “The idea of not fitting in.”
In that moment, she said, “I was being told to be someone I wasn’t.” What she was — what she remains — is a person “asking tough questions because no one else is.”
“Leadership being a choice for some is a privilege,” she said. “For others, leadership is merely existing.
“As I’m sitting here across from this person telling me not to lead, then, I have an option. I can stay silent again, worry about stereotypes, let impostor syndrome tell me I don’t belong. Or I can accept the job put before me and move forward.”
Her voice left no doubt which course she’d taken.
“I think about Luke 12:48: ‘To whom much is given, much will be required,’” she said. “Every one of us was made for such a time as this, placed here on purpose. Each of us has a voice, has the privilege to lead as physicians, that quintessential picture of intelligence and authority. I can’t lay down the role of leadership. When I speak and I ask questions, someone else doesn’t have to suffer.
“We can shut our eyes and pretend, or we can open up and hear all the questions and create a world of medicine that looks like the world as it is now. My passions for health equity, for anti-racism, for academic medicine, for correctional medicine, are all things that will allow me to touch the patient.
“Be seen. Be heard. Be OK making good trouble. That’s the only way we’re going to fix medicine.”
Rose Marie Leslie, M.D., regional medical director for Aledade Inc., speaking last, was perhaps the panelist best known to audience members. She has built a strong, amusing presence on the social media platform TikTok. Strong enough, in fact, to get her drafted onto the national airwaves (as a “millennial doctor”) to talk about teen vaping at the kind of early hour that can make you wonder if there’s been a mistake.
“I was about to be on Good Morning America,” Leslie said. “And I had this overwhelming feeling of What am I doing here? How did I get here? I understood the logical progression of events: I’d started this TikTok account with health information, and things kind of blew up. A ton of young people were listening.
“But still. I’m not a public health expert. I’m not an epidemiologist. I’m not a pulmonologist. And this was my face.”
On the screen appeared a still photo of Leslie, wearing a just-woke-up, open-mouthed expression.
“Impostor syndrome,” she said. “You have flashbacks to other times you’ve had it. You get worried.
“For me, in this instance, I remembered when I was 14 and in public school in Minneapolis, and I’d signed up to be in the clinic, where someone decided I was giving a sex-ed talk to my sister’s senior classroom. This is a top-10 embarrassing moment, and I still think about it a lot.
“And then I thought about a situation, after my first year, when I went to the Minnesota capitol to talk to a state senator about why a universal health insurance plan would be good for our state. I’m not an expert. Why am I here?
“A few weeks prior to this TV interview, I’d been working with a patient, doing a 20-week ultrasound that ended up diagnosing fetal congenital anomalies. So there were meetings with the NICU, and my patient would call me and ask me to help figure it out, help her interpret notes for her. I was with my faculty and being like, ‘I don’t think I’m the right person for this. I have no idea what half these terms are.’
“All these flashbacks, and this news producer snaps me out of it and says it’s time for the interview. I was so terrified, I think I’ve blacked out most of it. But watching the footage, it wasn’t that bad. And maybe my experiences getting up and talking about things, advocating using the voice I had, regardless of where I was, or translating in the way family docs do so well — maybe that all added up to something. Maybe all of these experiences training as a family doctor had helped me become an expert in health communication. Maybe communicating was something I’d built up a lot of skill in.”
This, Leslie said, was her epiphany.
“I realized in that moment that it’s just so important to think about our expertise, what we know, what skills we’ve acquired and built.
“As residents, you can also be experts. Get out and become an expert in how your patients live in their communities, the context in which their health exists. You have the time to go talk to them. You can be that expert.
“We all have expertise. When I was a second-year resident, I realized I was a health communication expert. Look within: What are you an expert in?”