S6E5: Advocacy in Medical Education

Hạ: Fun fact is that Victoria was supposed to join the conversation on Asian hate and also being a model minority with Derek and I in the last season, but then there was . . . Well, I feel like, Victoria, you should explain what happened.

Victoria: I was staying at a homestead during my family med rotation in a rural area, and there were two roosters that were just too aggressive. And so my hosts had to basically shoot them so that they wouldn't cause a ruckus and cause too much agitation in the herd. And they asked me to stay inside and be aware that there would be gunshots outside.

Hạ: It was just also the way that you you described it when you sent the message going, "Oh, I can't be on. It's chicken killing day." I sat there and I thought, "Is this a holiday that I don't know about in Virginia, despite having family in Virginia, that I don't understand?" RIP to those chickens.

So I guess, hello, dear listeners. Welcome to another episode of "Bundle of Hers." This is Ha in the virtual studio, and I'm joined here today with two very special guests, Victoria Ngo and Karishma Shah. And I'll let them both introduce themselves.

Victoria: Yeah. So I am Victoria. I am a fourth-year medical student at Virginia Commonwealth University in Richmond, Virginia. And I am actually in the residency application process into family medicine.

Karishma: Hi, I am Karishma Shah. I am in the MD/PhD program at the University of Utah School of Medicine. I have finished my first two years of med school, and I'm now in my first year of graduate school.

Hạ: And the reason why, for our listeners, I decided to have Victoria and Karishma come here today as our special guests is because our topic is related to advocacy in medical education. Both Victoria and Karishma have done quite a bit of work in that topic and will be sharing some amazing insights.

To start off and explain a bit why I wanted to have this topic is, as you all know, our theme for this season is identity, and medical education advocacy has been a huge part of my medical school journey.

For context, you might have heard me mention about it briefly in episodes in the past season, but a lot of the work that I've done in medical school has focused on diversity, equity, and inclusion initiatives, particularly changing the preclinical curriculum to increase skin color representation in visual teaching images.

And so this has been something that's been near and dear in my heart, but it's also a topic that sometimes makes me really conflicted, especially when people conflate it with who I am as a person and as a medical student. And so I really felt that this was an important conversation to have.

To start us all off, Karishma, I would love to hear a bit about the work that you've done at our medical school, which I personally know, but I'm sure our listeners would love to hear more about the work that you've done and how you got involved in it and your experiences.

Karishma: Absolutely. I really resonate with what you said about how advocacy work is sometimes conflated with identity, and I think that's important because I did not enter medical school thinking that I wanted to participate in a lot of diversity efforts and a lot of advocacy efforts. I was more interested in expanding the way that I view health and seeing how I could take my parents' cultural view of health and combine it with this very western allopathic view of health. And that was something that has always been an interest for me.

And I guess I kind of just settled into this idea of to be well, you have to have some sort of acceptance of your identity and various parts of your identity. That was something that I saw in medical school isn't always there, and it kind of led me to advocacy.

I remember thinking to myself, "How can people of color be well when they're constantly having to try to fit this mold of what it means to be a minority, and what it means to be a minority that succeeds in medical school in the United States?" And I just don't think that there can be wellness if we don't accept everyone's identity for what it is and don't create space for those identities.

And so I got involved with the Anti-Racism Fellowship through our Office of Health Equity, Diversity, and Inclusion, and I've been working on a project in that office about how we can elevate the voices of BIPOC students so that their voices and ideas can be part of the anti-racism efforts at our school of medicine.

Hạ: It's interesting that you said that you never really thought initially when you entered medicine that you wanted to do this sort of work, and then you ended up being led into it, because I felt the same way when I started medical school.

When they talk about medicine, they talk about doing student-run clinics, about doing research, and about just studying, and my thought was that I just wanted to go in, learn the stuff, be a good clinician for my patients, and go out. But then entering medicine, a lot of it was really hard for me to realize that we weren't getting the space to really embrace all identities.

And a recurring theme that listeners may have heard throughout all of the "Bundles" episodes is how a lot of times in medicine we're asked to really box ourselves into certain identities to the detriment of our ability to really care for patients and to really be able to come into the clinical setting without bias.

And as I kept reflecting and thinking about it, I felt the greater need to really be involved in these initiatives. But sometimes it was really weird kind of having to take it on, because I felt that a lot of the expectations that people had is that, "Oh, if you're a person of color, you are expected to really hold on the mantle of doing equity work," and that you really did have to take on that burden.

And I'm curious, Victoria, to hear about your thoughts, especially coming from a different institution than Utah.

Victoria: Yeah, that's really interesting to hear from both of you, because in Richmond, Virginia, we were the capital of the Confederacy when it existed, and my identity as an Asian woman actually does not always put me in a category of being a person of color at my institution.

So a lot of times I would be in a room and they'd say, "Wow, there are no people of color here. How can we talk about this topic?" And so my experiences going through was sometimes even more pushing for the reclamation of my identity as, "I am not white, I have my experiences, and a lot of what you all are teaching in our curriculum doesn't just affect the black students in the class, but it affects all of us."

And really trying to get people to reckon with that and pull that into their own sense of identity, that this anti-racism work isn't just for people who identify as minoritized or marginalized, but really all of us.

So, in our preclinical curriculum, we have this course called Practice of Clinical Medicine where we learn how to interact with patients before our clinical years. And much of our work during my first year was just trying to get more representation because the stories were so heteronormative, so cisgendered white, and that was all we were really able to ask for.

A lot of our societies, which are how our students are grouped together so we have a smaller community within our bigger class, were named after eugenicists. We still had signs pointing to the White House of the Confederacy all around our campus. So we were really going for the small fish there just asking to be recognized and seen.

And once we saw that window of opportunity, that there was bigger pressure, national pressure to do more, we were able to collectively organize and get this anti-racism demand letter written and sent to our administration on how to start addressing curriculum more specifically, how to start incorporating my institution's history, very racist and harmful history in our community, into our curriculum, etc.

I think because I wasn't the perfect person for these words to be coming out of, I often was not asked to do very official roles. A lot of my stuff was just one-on-one meetings with certain administrators, and then they would have larger work groups that I would be excluded from, etc.

So, for me, it felt more like I was trying to reclaim my identity to include this work rather than separate myself from it.

Hạ: It's really wild hearing about kind of your trajectory and the work of your institution. I think Karishma can also agree too, but I feel that it mirrored a lot of what was happening in Utah too.

There had been so much work in changing medical education and bringing in more inclusive values, but there was so much pushback for class on class on class. And then 2020 happened, there was so much uproar, and then suddenly everyone was looking at DEI and that was the cool new thing to do, right? That was the thing that made everyone seem better as an institution. It was the thing that everyone wanted to include.

There were conversations about AOA, which is honestly a very racist organization if you're thinking about it historically and how its metrics have excluded historically marginalized groups. And suddenly AOA is thinking about also including a bit more diversity, and equity, and anti-racist work into its inclusion criteria.

And so suddenly everyone is really pushing for it. And then when you're in an institution where there aren't that many people of color and there aren't that many people who are as vocal, if you even care about equity, diversity, and inclusion work for even a little bit, suddenly you're thrown into the center and you kind of have to figure out who you are while also trying to ask and demand these really big changes.

You make mistakes, and you get really confused, and it was a super huge struggle for me because I never felt that I was equipped to do what I was asked to do. I felt that the stakes were really big because this was my community that I was advocating for. This was the community of the people that I love that I was trying to advocate for. And it was just a growth in the midst of burning flames kind of moment, which was really, really hard.

Karishma, I don't know if you had any thoughts about it, especially since you joined the medical school as all of this movement was starting to happen and people in your class were starting to notice it a lot more, right?

Karishma: Yeah. I mean, I just remember at orientation we had this whole lecture on health equity. It was two hours long, and I remember feeling like our class was very split in half. There were the white students who were able to engage in what was being shown and talk about health equity, and then there were the BIPOC underrepresented students that were sitting there kind of feeling like, "Okay, I already know this. I experience this. This is not really helpful for me. In fact, it is kind of traumatizing to have to hear this for two hours, and then hear white perspectives on it during every discussion session."

And it was just a very difficult spot to be in because it definitely felt like it was just splitting our class into these two categories. Either you were a BIPOC student who is expected to be a BIPOC student, whatever that means, or you were a white student who was allowed to be whatever kind of student you wanted to be and participate in these discussions that administration wanted you to participate in.

I feel, like you were saying, how there's this pressure to be a voice or be this perfect minority, or if you want to participate in this work, there are particular voices they want to hear, there are particular faces to those voices that they want to hear, and I definitely struggled with that.

I don't think I'm the perfect voice for BIPOC students or for underrepresented students or anything like that, but it is kind of like you're just thrown in it and expected to learn how to be that perfect voice.

And I think it's kind of frustrating because I really think anyone could be that perfect voice, even if they aren't underrepresented or BIPOC. You can have white people who want to be involved and be that perfect advocate. All you have to do is listen to the people you're trying to advocate for and share that perspective instead of trying to almost fabricate a perspective because of the role that you're in.

That's just been kind of a difficult thing to navigate. How do I speak and be true to my own experiences while also having others acknowledge that my experience is not the only BIPOC experience that exists?

Victoria: I completely agree with that, with the whole white perspective thing, because a lot of my white classmates are allowed to make mistakes and they're allowed to learn from these experiences, whereas I am supposed to be teaching these experiences.

And a lot of times, I have to sit through my third implicit bias lecture where students are like, "Wow, I had no idea that I had implicit biases." And for us, it's something that we've probably known since kindergarten, since we've been out in the public eye.

Hạ: Both what you and Karishma have said really resonates with me because I have always felt that I am . . . Whenever I do any of this advocacy work, things have to be absolutely perfect. I have to say the right thing at the right time, and I have to be really thoughtful about all these different perspectives.

First, I recognize that I come from as a model minority, which is another topic in and of itself. I come from a place of certain privileges too, even while my model minority status is being used for oppression. And I have to navigate that, but then I also have to always navigate everybody's different feelings. Doing this equity work, I'm also sometimes asked to make sure to not make people too uncomfortable when I'm trying to push for change. Also, to be really careful and to watch my back, because if I push things too far then I'm also going to get screwed over too, if I'm going to be real.

And always as I wage advocacy work, pushing and thinking about what can I do to really, really push and make sustainable change, but what can I do to still make sustainable change but not put me in the line of the target?

It's just this balance that has been really frustrating and really hard, and sometimes I wish I could be like my white peers who can come in well-meaning and be given a lot of that grace because they care, and that's a big thing because all of that intent and that care is enough to really carry them through all their mistakes. And accountability doesn't matter as much to them. How we hold accountability to them is very different than how we hold accountability to people of color doing this work.

Victoria: Something my upperclassmen taught me very early that I tell myself all the time is perfection and urgency are tools of white supremacy. And so every time someone tries to say, "Oh, that wasn't perfect to me," I apologize, whether or not I mean it depending on who's criticizing me, and I say, "I hear what you were saying. Let's talk about it." So far, that has gotten me out of all the trouble I've ever been in line of.

Hạ: I really like that. I feel like I need to etch that, embroider it. I don't know how to embroider, but I should learn how to embroider and embroider it everywhere.

Karishma: To build on to what Victoria was saying, I also feel like people assume that we have different goals. When people of color try to do advocacy work, I feel like the institution or administration views that as, "BIPOC students trying to expose the school of medicine and basically tear it down and show how bad we are as an institution," whereas when white students want to get involved in advocacy work I feel like it's viewed as, "Oh, they want to help us be better and they're not going to show how bad we are to the entire world. They just want to help us get better."

Really, I think that's so frustrating because that's my goal too. I don't want to expose anybody, but I also don't want to pretend either. Not that I'm saying that white students would pretend, but I feel like there's this shift in mentality based on the student trying to do the advocacy work.

Hạ: Karishma, I really like that point that you brought. And truly, it is really peculiar because I feel that whenever I do advocacy, I really do it out of love, right? I wouldn't be devoting all of my hours and time trying to talk to an institution and trying to really get change on all of this level because it's a huge tax. It's a huge emotional burden.

It's pretty scary to honestly speak up and do these things, but I do it because I have sometimes a little bit of hope that maybe we could push the needle forward a bit more, and also because I love the communities that I am trying to make a better world for. I'm not doing it to be inflammatory or to make people uncomfortable. That's just what happens because this topic is such a sore point for a lot of people.

And talking about advocacy with institutions, one of the things that I've been thinking a lot about . . . It came to me because I was having a conversation with other activists in medical education across the nation. And one of the comments that was made is a lot about how in recent years, after everything that happened in 2020 and DEI is now seen as the new cool thing to do, there's been a lot of cannibalization, that was the term that was used, by institutions of a lot of grassroots movements and really important DEI work.

And I would love to hear your thoughts about all of that. Victoria, what do you think about this idea of cannibalization of DEI?

Victoria: I think it is absolutely happening. I see it all the time, and I myself have to be really careful not to engage with it too much because sometimes an institution is actually trying to take control of what's being said about them and the path that change takes.

They don't want to actually have to hold any of their employees or faculty accountable, but they don't want students to be complaining about their institution to the outside world too. So it feels like sometimes they erect these committees or these work groups that have no real goal, or they'll have dialogues or they'll have open meetings with the deans for students to complain, and that complaining doesn't go anywhere, just for us to burn out our wheels.

And sometimes I hear these invitations and I think, "Wow, this is a chance to use my voice and make change," and then I actually engage with it and I realize, "Oh no, nothing I say here matters. They're just trying to use up my time and my energy. And then someone is going to take what I said, water it down as much as they possibly can, and present it in their own words under their own name as something that the institution has been doing long before I even got there. They've been working on it this whole time."

You're nodding your head, Karishma. What's your experience?

Karishma: I really resonate with everything that you've said, and it reminds me of this project that I'm working on where our entire school is basically trying to revamp its curriculum, and we're changing our curricular structure and everything. A large focus on it, at least what is said is a large focus, is inclusion and diversity, and equity, and teaching students to be better about it, and improving the experience for underrepresented BIPOC students as part of the process, like reducing student-on-student mistreatment.

And so I was really shocked when I proposed my project to the OHEDI Office about, "Hey, I want to interview BIPOC students and see what their experiences have been and what suggestions they have, so maybe we can share it with administration as they're building this new curriculum."

The very first thing that was said to me, and this was said out of love and concern, was, "Karishma, I don't know if that's a good idea."

And I'm like, "You're trying to improve our new curriculum in all these ways. This is a major touting point that I have heard over and over again, and the minute I try to bring student voices into it, it's not welcome, or it's considered something that could be very damaging for me in terms of how I look to the administration that I'm later going to need when I apply to residency."

It was such a shock to me because it's like, "Okay, so what you're saying is DEI efforts are important, but they're not important enough to listen to students that are directly affected by it. They're important to the organization, but they're not important on that student level." I don't know if that made sense, but . . .

Victoria: That completely makes sense.

Hạ: Yeah, Karishma. It does get really frustrating because I think about how I've tried to engage in so much DEI work, and the one that ended up sticking, which I'm happy it had the change and the effect that we wanted it to, but it was the project where it was increasing skin color representation in the preclinical curriculum. It was the one that we could talk about and see what our institution was really doing and really pushing and making change.

And while I'm really happy that we were able to get it, and I think also part of it was because it was something that was maybe a bit more measurable and tangible, it still really pains me.

I sat in so many other different committee meetings and so many other different things, and if there wasn't really a tangible equivalent or an end goal or something that was measurable that could eventually maybe be published or be talked about at a conference, it was something that was a lot harder to get backup for.

And it really pains me because I do think that a lot of times, being able to really create change is to hold everyone accountable. Even on my own personal thing, I've been able to develop the way that I've been able to develop because people have held me accountable.

Even when I do activism, people have kept me grounded and held me accountable in certain ways that as I've been working on my work, I don't accidentally turn into something that's more savioristic, and that I really do ground everything I do on community.

But the institutional work neglects that fact, neglects that accountability can sometimes look really ugly, but it's okay because that's the way that you can push for change.

Victoria: I hear that, Ha. I feel like since I've now been at my institution for four years, I've actually seen so much change that sometimes when I hear the first-years say, "Oh, boo this, boo that," I want to say, "Oh, well you have no idea what it was like four years ago." But their new opinions keep me accountable to the fact that just because there has been change doesn't mean there can't be more.

I am not the hero here, right? It's not like now that I'm graduating, the work is done. It's continual and it's so wonderful to be able to pass that baton off now that I'm about to graduate.

Hạ: Victoria, I definitely love that you mentioned that, because similarly, I just think about . . . Sometimes it makes me really sad realizing that all of that I have tried to do and people still have the same concerns, and people still feel the same pain that I did as a first-year.

But then I remember that perspective that I am just one small part of a bigger movement. And that's really what is most important, is to just to try to do what you can and have faith in the communities that come after you to keep really pushing things forward.

Victoria: You're in an MD/PhD program, right, Karishma? So you have more time with the institution.

Karishma: Yeah, which is both a blessing and a curse. I feel like in medical school sometimes, like both of you were saying, it's, "Okay, you have four years. You need to have something to show for everything you work on. Otherwise there's no point wasting your time on it."

You have four years to build up your whole ERAS application, right? And sometimes it becomes more about, "How can we publish what has already been done or the first little steps we've taken to give you some measurable results? And then we'll see what happens after that."

But I feel like oftentimes, if you're just a med student, that's the reality. You'll be passionate about a project and work on it really hard, and at the end of the day you have to kind of cut it at its knees and sell it short and publish what you can with it. And of course, you can only publish what your institution would be okay with you publishing on it, and you don't ever get to see the full end result of your project.

So, yeah, I think it's a blessing and a curse. I get to see how slowly things actually move, but I get to be there for it.

Hạ: Yeah. And I feel like MD/PhD students hold such a powerful position because you are . . . A lot of times, I feel that institutions work on the high turnover of students, but you all are kind of a good institutional memory, to just really stay on for a while and really kind of help prevent institutions from being able to do that, which is awesome.

Karishma: I think part of that also is that I've just seen . . . Every round of first-years that come in, I just hear the stories of how . . . Just even within our MD/PhD program, which is maybe six to eight students a year, the underrepresented students in this program, invariably, every year there's one horrible incident that's demeaning, racist, and really kind of affects their academic performance, their mental health, their overall wellbeing.

I see it every single year, and it is such a reminder to me that a lot of what we go through as BIPOC or underrepresented students is not the same, but it's very, very similar. Those feelings are very similar.

And as someone who is two years ahead in the program, I can be there for those students and just build that community and build that resilience, because oftentimes we don't really have another choice. But I get to play that role that I wish I had had when I was a first-year feeling those feelings.

That's one of the most powerful roles I've found in the MD/PhD program, is I'll get to be a connection for those students for the next four or five years. And if that's the only thing I do in terms of EDI work, I'll be happy with that. It's just so powerful to have someone who's maybe a year or two above you tell you that it's not your fault that you're feeling those things.

Victoria: Yeah, hard retweet on that.

Hạ: Yes.

Victoria: Hard retweet. Oh, my gosh.

Hạ: Yes, hard retweet. I love that so much, Karishma. It's something I feel that I spent all of my preclinical years and third-years doing this kind of institutional work, and what I ended up landing on as a fourth-year med student now is I just care about building community. I feel that that's a lot of where the change is.

And I guess this now goes into kind of . . . I feel like the wrap-up thought that I really want to hear from both of you all is just thinking about how are we more than our advocacy work, and also how we continue doing advocacy moving forward, right?

I feel like in a lot of my residency interviews, that's what I keep getting asked about, is like, "Oh, how are you going to continue this work in residency and beyond?" And it's been really weird for me getting asked that question because I first feel like they've branded me as an advocacy person when I have so much more to me. And also, sometimes I sit and I don't know if the advocacy work I've done in med school is really how I want to move the needle forward.

So I'd love to hear both of your thoughts about it. Maybe we can start off with Victoria.

Victoria: I've had an interesting experience where three or four times now, I've been told by interviewers point blank that I need to build better boundaries based on my application because of the advocacy work that is in it, I guess. I don't know. I'm not really sure, but they're always saying, "You can't care about everyone." And I'm always like, "Then why did I become a doctor?"

But yeah, there's so much that I feel that I am that I don't get to talk about as much because it feels like I have to make that a lower priority in medicine, where I'm not really allowed to talk about what I'm interested in, or the communities I want to work in, or really anything except for advocacy and DEI. I want it to be heard so much, and I'm scared that it won't be heard if it's not the only thing I talk about, and then it's also the only thing I get asked about. So it just spirals.

Hạ: It is kind of weird. And it's so weird when also they say, "Oh, you must be proud," or something like that, "of all the work you do." I just sit there, and I just feel so cringy because I just think, "I don't know."

It just feels like you put all this effort, and at the end of the day it's boxed into something that's a bit capitalistic, a bit looking pretty for bowties. And I sit there, and I go, "Do I just keep wanting to do this?"

Victoria: And it's also not just us, right? We don't do this work in a vacuum, but I can't sit there and be like, "Well, actually, it was me and also my friend, and my other friend, and my other friend, and actually this entire community." But I can't put that on . . . we can't have a joint CV, so I can only talk about my role and pretend that it's so important.

Karishma: I honestly feel like there's this pressure that any EDI work needs to be this super transformative, super meaningful, identity-altering thing. That's the expectation. People want you to be able to talk about it as if it was this unbelievably meaningful thing.

And I can understand that there are meaningful parts about it, but honestly, most of the time that I do the project or spend a couple hours on it, I just end up feeling sad and disillusioned.

And I know that's not how I'm ever allowed to talk about it, which makes it feel very fake whenever I have to present that work I've done to anybody else, because I feel like I'm blowing it up to be this meaningful thing when honestly some of the most meaningful parts have been when I've felt so sad, I felt like what I was doing is pointless, and I didn't really want to do it anymore.

I think the meaning comes from the fact that there's something about it that makes me do it anyway. And I think you really touched on that, Ha, when you said, "I do it out of love."

Victoria: I think what y'all talked about in regards to doing this out of love is so important. I think if at any point you feel like you're not doing it out of love anymore, it's probably time for a break, and kind of returning to your roots and see what really matters and find healing.

This is a traumatic process and it really, really beats the love out of you. So just coming back to that love, I think, is so important, and I love that you guys said it.

Hạ: Thank you so much, Victoria and Karishma, for those beautiful closing thoughts. To our listeners, I hope that our discussion today has given you some things to think about, whether or not you're interested in doing DEI work. I hope that it's given you a little bit of space to process. I hope that some of the things that we have said maybe have resonated with you. And I hope that we can all keep going, as both Victoria and Karishma said, back to our roots and doing things out of love.

Thank you so much for listening, and stay tuned next week for more episodes of "Bundle of Hers." You can follow us on IG, listen to us wherever you listen to your podcasts, and we'll keep chatting with you. Bye.