S7E5: Strategies for Change. Implementing Equity in Medical Training

Gitanjali: So my current obsession . . . I make really good brown butter and dark chocolate chip cookies, but I've recently started putting Gochujang in it, the Korean fermented chili paste. So it's a little bit spicy and has that caramelized crystals in there. It's so good.

Lilly: I'm sure you could sell those in a coffee shop. Hello, everyone at home, our lovely listeners. This is Lilly and I'm so stoked to come to you through the virtual studio today with one of my great mentors and friends, Gitanjali.

I'm going to have her introduce herself and tell you a little bit more about herself, but I really wanted to dive in today and have a conversation with her about impactful changes we can make, and I feel like she just embodies that so well. So I'm so excited that you're here.

Gitanjali: Thanks, Lilly. I'm so happy to be here. Thanks for inviting me on to your podcast. So I'm Gitanjali. I'm one of the fourth-year neurology residents at the University of Utah, and I'm also our education chief for this academic year. So kind of my big role is to help with creating the educational curriculum for our neurology residents.

One of my personal goals in this role was to really make it a more well-rounded experience where we kind of experience and learn a lot more about the social determinants of health with the biggest project I've worked on being this anti-racism educational series.

Lilly: Amazing. And before we dive into our conversation for today, I also did want to put out a disclaimer that all of the opinions and thoughts that we share on this episode are those of our own and they don't represent any type of institution or employer. We just wanted to share our personal experiences with you all listening at home or in the car, wherever you are right now.

So for those of you who don't know, I am going into neurology, so it was just amazing to find her in this field. And it really got me thinking of this go, go, go mentality that we have both in medicine and just career-wise, with us kind of being this future-focused mindset of, "Oh, once I get into med school I'll start doing things," or, "Once I get into residency I'll really start doing things."

Then I don't know from your perspective, once you're in residency, maybe it's like, "Oh, once I'm an attending I'll be able to do X, Y, Z and make these changes."

And it really made me think, "Well, when do we start impacting those changes? When do we start being innovative and thinking about quality improvement and systemic changes that we can make?"

I almost think sometimes we stop ourselves from being able to really trail-blaze those things because we're always thinking about, "I'll do that once I get to this point in my career."

And one of the things that I just love about what you've been doing is you've already been starting to implement those things before you've gotten to that next big point in your life. For me as a med student, I always think, "Oh, well, I'm just a med student. There's not much I can do." And I feel like a lot of people around me might think the same way.

I just wanted to have this conversation today focused on, "Well, what can we do now as a pre-med student listening to this podcast or someone even in high school, which if you found us that's amazing, or someone who's my colleague across the country and you're also having mental breakdowns about residency and match every day?"

Gitanjali: So true. Yeah.

Lilly: Or just other residents or attendings who are listening. What are things that we can do now? And I just think that you're a great example of that.

Gitanjali: Thank you, Lilly. Well, I find that that's always such a hard question for us because it's not just that, "Oh, well, I'm just at this point in my career, and I feel like all the changes that should be made are at a point where I just don't feel like I have the power to make those changes."

But really, I think kind of the big first step for me was to recognize that I have peers that we can create a space for each other to kind of help each other and motivate each other and support each other with making these changes.

So one of my major goals as the education chief was to create that safe space. And I think that was kind of that first step of how we can make that change. I wanted to start at a very small level and create a safe space for med students and for my junior residents and for my co-residents on the wards, when we're rounding, where we have an opportunity that we can work together to name and call out things that were maybe troublesome for us and be able to debrief about that.

And then we just kind of wanted to expand that further into creating protected educational time where we do have a safe space to talk about healthcare disparities and how we can try to be actionable about it.

And so I think that was the biggest step for me, is recognizing the support that I have at this level and trying to make it meaningful for us to be able to work together and create a space for each other to make changes.

Lilly: Totally to brag about you, in so many of my interviews they'll ask about this curriculum and I always bring you up. And sometimes people know who you are, which is just really exciting.

Gitanjali:No way.

Lilly: But a lot of times they'll say, "We don't have that. We're not doing that here, and that's something we should start." And so I would love for you to tell us a little more about how you started that, and what it consists of. I guess for the listeners at home who don't know what this curriculum is, what do you do, and how does it impact the education?

Gitanjali: So this project is actually started by, when I was a second year, one of my fourth-year residents, Raeann Bourscheid, who is now an amazing stroke attending. She went to AAN and heard from Dr. Nimish Mohile, who created this curriculum through the AAN, which is a series of different modules that just goes through the history and the impact of racism within healthcare and within neurology, and how we as providers and neurologists can be better anti-racist advocates.

And so she kind of approached him and multiple other residents from different programs, and their program directors all got together to kind of work on creating this pilot implementation of the curriculum within our residency programs.

So, right now, it's multiple different programs and we've implemented it in a way that fits into our own didactic series. Here at the University of Utah, we get protected time outside of work to go through the modules and then we get together and have a discussion about them quarterly. So that's four times a year during our noon conference series, we get to talk about it.

Other programs have been doing very different things, but really the goal of it is to create a space where we can have like action items on ways that we can be better anti-racists.

What I really love about this program is that it started nationally. I'm working with other residency programs and I feel like it's something that's going to keep expanding. And I know that the modules themselves, they continuously are improving them, and making sure that it's really up to date.

So it's always fluid and it's always something that other programs can hopefully join in, because it's not like you have to create something completely new. It's just that you're creating a space for us to talk about how we can improve the system.

Lilly: And it's so cool to hear of this ripple effect that you're having, because now I feel like other residents are comfortable having these conversations with their med students, or looping in attendings and starting to have them have these conversations at an even higher level. It's just really exciting to see how much the field is opening up to these conversations.

From the med student perspective, we have some things that we want to contribute or talk about, but sometimes it just doesn't feel like that's the time or space for it.

So to know that people are willing to have those conversations and just acknowledge, "Oh, yeah, that patient just made a really inappropriate remark," or, "Something that they just said was really discriminatory. Let's just talk about it. Let's check in. Let's see how you're doing," that makes such a big impact on us as students, since a lot of times we just feel like we're visitors in your space. It's really hard to know when we can speak up, and so having that empowerment really helps us.

Gitanjali: Yeah, and I think one of my goals is to continue to expand that outward too. And I think it's really great whenever we have these discussions, because we invite everyone who's on service to join us, so often that means we'll have a different med student. And even if they haven't done the module, they are invited to join our conversation. And so we always hear these different perspectives.

The most recent discussion session we had just a few weeks ago, one of the things I loved was that a couple of our attendings were actually able to join us, and that was amazing because they had their own perspective on ways that we can address things in the moment.

I had this experience with an attending that I was very uncomfortable with and I didn't know how to navigate that with that power dynamic of being a resident and knowing that I'll still have time to have to work with this attending. They just gave me some tools on, "Here's how you address somebody that does have that hierarchy over you." And I think that was one of the great things about having that conversation, is that we all have different tools that we can share with each other.

Lilly: Yeah, they always tell us about this hidden curriculum in medicine that we just dive more and more into the deeper we get.

So for those of you who are maybe in your first or second year of med school, you're learning all of the pathologies and all the diseases and all the drugs. But then once you're actually in the hospital, you realize there's also a lot of just humanism that goes into medicine and how you talk through these topics. It does impact care and how you can move forward with the people you work with and the patients that you serve. So I just think it's really awesome.

As I go through interview season and I talk to a lot of residents, a lot of them talk about burnout and just trying to get through the day-to-day of the hospital and the huge learning curve that you have going into residency. And so I really wanted you to tell us a little bit more about what drives you to do this work and what really makes you continue it.

Even myself as a med student, sometimes I feel like I sit in so many meetings and conversations with admin and I talk with my peers and sometimes we will sit there and just think, "This is really draining and this is a lot of heavy work."

Gitanjali:Totally. It really is.

Lilly: Sometimes we get tired of pushing the needle, and so I always wonder, "Where will I find that fuel when I'm an overworked resident?"

Gitanjali: Yeah, that's such a hard question too. In those moments where you're like, "Wow, is what I'm doing actually changing anyone's mind?" is so hard to get through.

And I think when I started my intern year, that was a really hard year for me. Globally, that was 2020. That was a really tough year for everyone in healthcare. But I think something that made it especially hard was I didn't know how to deal with that constant feeling of, "I feel like nobody thinks I'm supposed to be here," or things like that that you don't realize how much will impact you until you're in that actual space and that sphere of where it's affecting you so much and where it's impacting your work.

What I ultimately walked away from was I recognize that I can't change an individual's mind. There are going to always be people that maybe don't think that we're supposed to be in this space or maybe don't think that we deserve to become doctors and to serve our patients the way that we do.

But at the end of the day, I'm not doing this work because I think it's going to make my life easier. I'm doing it because there are so many people that step away from the healthcare field, and so many patients who choose not to engage in healthcare because of experiences like that. Or have really poor access to healthcare because of the way the system is in place, and just recognizing that our job is not for individuals but it's for this greater system that we can kind of just work together to break down and make it better for each other.

And I think that's what ultimately helped me kind of get through that, is that, "Yeah, it's going to be hard today, but in a few months Lilly's going to be an intern, and hopefully she won't have to experience this thing that I had experienced one time."

And there's a high school student out there that might be listening to that podcast who's wondering if being in medicine is going to be a safe space for her. But I want her to know that it will be because you and I and so many other people are trying to make it a good space for her to be in.

Lilly: I love that. It reminds me of when I was in my undergrad years and I would listen to "Bundles" and I would just think, "Wow, how do I find people like this? I wish I knew them in real life." So you can always DM me and we could be friends. But I used to always think about that.

And I remember I had a tutor when I was studying for my MCAT who when I would talk to him about my scores and how I wanted to do and we would review my application, he would say, "You're a woman and you're diverse, so no matter what you get on your MCAT, you'll be fine. I'm sure schools will take you because of those reasons."

I just remember being so flabbergasted because I was like, "Excuse me? I have worked so hard for the past four to five years of my life, and I feel like I've doubled down in so many different ways and sacrificed so much to be a competitive applicant that I don't think it should dwindle down to me being their diversity token student."

Gitanjali: Right. Exactly.

Lilly: But it's funny because I got accepted into a school that he didn't, so it's fine. Everything works out the way it's supposed to.

But I definitely wish I would've been able to talk to people like you who could really boost me up, and instead of dismissing a lot of my identities, really helped utilize them as, "This is what's going to make you such an impactful physician," as opposed to, "These are some of the things we overlook in accepting you into the field."

Gitanjali: Yeah, exactly. It's kind of like that whole idea of erasing someone's identity so that we're all at the same level playing field. But that's not our goal here. Our goal is to recognize the fact that the thing that connects us all as humans is that we all have our individual narratives and our own ways that we've experienced and navigate through this world.

And it's so important for us to recognize that within our patients and how they navigate how challenging this healthcare system is, and how our coworkers navigate being in this field.

I think that's really what's so important for us and what ultimately paves that pathway for us to make this whole system better for each other.

Lilly: And I think as we have these conversations about ways that you can really push the needle at any stage of life . . . An example I have for me at least as a med student is seeking mentorship and making spaces for things that you're really passionate about.

So when I first started med school, I really wanted to look into refugee healthcare access. And I spent so many months emailing different departments and trying to talk to them and see who's doing research with refugees that I could just hop in on and join.

And I kept hitting roadblocks of people just not doing that work because it's really challenging work. There are a lot of different things that you need to navigate, whether it's language barriers, access, exposure to that population.

No healthcare system, no EMR really has a box that you check that identifies you as a refugee. And so you really have to know that community or know a doctor who works in that community to kind of make those connections.

And so eventually a mentor told me, "Well, you should just start a project." As a first-year medical student, you're just like, "What? I don't know how to do that."

Gitanjali: Yeah, exactly.

Lilly: And so I kind of just sat on it for a long time and I was like, "Well, I don't know how to do that." And so I ended up eventually being like, "Well, if this doesn't exist, then I guess I'll just work on building it." And I figured out how to write an IRB, which for those of you who have never heard of that, that's great. And for those of you who have, it sucks.

But you navigate that and you learn how to jump through all of the loopholes and make sure that you've gotten everything checked appropriately. And I was able to start that project and get it off the ground, interview refugees, hear their stories, and kind of figure out what they face as barriers.

And then once I was done, I didn't want that project to just die out, so I was able to talk to Ria, who's a year below me in medical school, and she was really passionate about this population too. So I was able to mentor her and then she took on the project and she presented on it and talked about at conferences.

It was really awesome to just see something that was built from the ground up as someone who's never, ever had to navigate any of those spaces before, to create something that was semi-sustainable. And I feel like a lot of the work that you've done with the curriculum is something so impactful because of the fact that long after you've graduated, it's something that can continue to happen.

Gitanjali: Yeah, totally. I think that's one of the goals of all these projects that we do, is that I think we're stepping into a space where everything just feels so new, where there's a lot of room for us to create things that are mostly out of nowhere. But one of our goals is to make it sustainable.

And I think that's also what builds this community. You jumped onto this project that I'm doing too with this curriculum, and that was so great and I was so grateful for that.

It doesn't matter where you go to residency, you are going to be somebody who is so mindful of the impact of this curriculum that you're going to want to implement it somewhere and be able to talk about it with other residents. And I think that's really great, that we're creating something that can be national and that hopefully every neurology resident will be a part of.

Lilly: It kind of leads into this other conversation about you are leaving residency . . . Well, I don't know if leaving is the right word. You're graduating.

Gitanjali: Yeah, graduating,

Lilly: You're graduating residency and that's so exciting. And with that, you'll be changing environments and roles. I'm just curious how you think all of the work that you've been doing will influence your career and the things that you're doing moving forward.

Gitanjali: So for me, I think I'm constantly in a place where I want to learn more. It's not just the work that I've done. I'm about to step into fellowship at a different program, and one of my goals in fellowship is to learn how we can continue to create these open spaces and discussions and learn about the impact of healthcare disparities and patient care.

And so I think that that's one of the biggest things, is that I never want to stop learning about ways that I can be involved and be part of making the system better.

Being able to talk to people like you, Lilly, and other med students who are stepping into the same role and who are going into residency, I hope that I can continue to be a mentor so that we could continue to work on these programs across the country and internationally and just be working together to create a better healthcare system for our patients and a better working environment for each other.

So really, the biggest thing is just continuing to be open to learn more from each other.

Lilly: I feel like you're establishing this blueprint for us to build on, because for me, none of these things or these spaces existed, and as I went through the first three years of med school, I feel like it would've been so nice to have known you earlier. I feel like it would've helped me navigate so many of these weird, convoluted conversations and spaces much earlier on. But I'm excited to see how much impact you have on other students.

And I kind of think of that similarly transitioning from being a student to being a resident, and all I can really compare it to is just all these interviews I've been having and the questions that they ask me. It really makes you think and ponder on, "Who am I as a person, and what do I want to do in 10 years?" That's a good question.

And kind of similarly to the spaces that you're building, one thing I really acknowledged in myself is that I care a lot about community and community clinics and medical education.

And I feel like as a med student or for those of you who are in undergrad, you're in those spaces. You see them every day. You know where there are faults and where there are gaps in education or in resources. And so a lot of times, I think that we are the best people to advocate for these changes because we're the ones who are living through it.

As a resident, I'm sure that there will be things that I'll be experiencing that I'll say, "This could be done better," or, "I wish I had some type of support in X, Y, Z aspect of my residency."

And so as I'm navigating that process, I think a lot about what I want to really get out of it. I think wherever I do end up, I'm hoping to work in a community clinic or to have some type of involvement with them because I feel like they're really the foundations of these conversations that we have.

And if you're able to utilize resources and provide care to patients who have so many barriers, then you're going to do well in any environment, because I think that those are some of the hardest ones to navigate.

A lot of times in these big hospitals, we have all the resources . . . Well, not all of them, but we have all in the sense of I can get the MRI. Who knows when it'll get done? But I can order it and I don't think twice about all the medications that I'm getting for my patients.

Not taking into consideration once they go home, will they be able to even get to a pharmacy to pick them up, or will they be able to afford them, or how will they get to a follow-up visit?

And so I think community clinics really help to address how we navigate that. That's something that I definitely want to continue working with, and I know that's something that you're also super passionate about too.

Gitanjali: Yeah. And I think, like you said earlier, if we don't find those spaces, maybe that's a good opportunity for us to start them. So I think that's a lesson that I'm going to take away today, Lilly, too. If I don't find that space in fellowship or wherever I end up in my career eventually, then maybe that's a great opportunity for us to start that space.

Lilly: Yeah, seriously. Just building it from the ground up, which sounds crazy but people are doing it, and so I have faith that us and all of our listeners can be a part of that too.

Gitanjali: Exactly.

Lilly: I kind of just wanted to end off this conversation and ask for those who are listening at home, what are some ways that you feel like they would be able to learn more about being an anti-racist physician or human moving forward?

Gitanjali: Yeah, really the best way is to just kind of get started and to take the time to learn from your patients or from each other.

The reason why racism exists is because somebody, somewhere, at some point in time, decided that there is some fundamental difference between us that is important and they exploited that. And so our goal here is to redirect that narrative and to make sure that we all understand that there is something common in between all of us that kind of ties us all together as humans.

I think that there are some really great resources out there. One of the ones that I really connected to is Chimamanda Adichie. Back in the early 2000s, I think she had a TED Talk about how it's detrimental to reduce our narratives to one story. And I think that was a really great step into this world of understanding each other's stories and how that's so important in building a better healthcare system for us and for all of our patients.

And so I think just finding a resource that you really connect with moving forward is so important and so crucial to us being able to learn more and grow more.

Lilly: I love that. Yeah, just starting the conversation is really the best first step, because everyone has so many unique experiences and I learn a lot just from listening to my friends tell me about their lived experiences and just listening to those, acknowledging those.

And even if we can't change the system overnight, we can at least acknowledge the experiences that they've had. And I think that that's something that's really impactful as well.

That was amazing. Thank you so much, Gitanjali, for coming on.

Gitanjali: Thank you, Lilly. That was great. It was great to talk to you.

Lilly: And I hope our audience also loved listening to today's episode. If you have any resources that you've been using at home or books that you've been reading or other podcasts that you've been listening to that you feel like really tie in this conversation we've had today, I would love it if you all could comment it or DM it to us and we can feature it as well.

As I said earlier and as Gitanjali has been saying, this conversation doesn't just start or end here. We want you all to leave feeling really empowered to continue having these conversations, and thinking of ways that you can trail-blaze changes in whatever field or line of education you are in.

But otherwise, thank you so much, everyone, for listening to today's episode. And thank you, Gitanjali, for joining us. I hope that you all continue to listen to us wherever you podcast, and stay tuned for our next episode.