fresh out of jail, now for trespassing. thoughts race
I smoke meth, crack and weed since 16, heart aches
no one ever really asked why.
I still take care of my son – shock ensues
I just go into another room. maternal instincts take over
It’s fine though; I control it with my mind. confusion arises
But I can’t see him anymore. provider lens resumes
No one asked why. emotions run high
My dad knows everything; stomach churns
he’s never tried to stop me. heart breaks
She’s just a kid, but no one asked why
Samantha Rodriguez is a fourth year medical student at Florida International University Herbert Wertheim College of Medicine. She is applying for residency in Pediatrics and enjoys yoga and gardening in her spare time.
With more time to putter in the yard during the days of the pandemic, I am discovering new ways to work with my hands (and feet) to care for the small grassy grounds surrounding our family cottage.
Using a good old-fashion reel mower, I walk at an easy pace while hand-pushing the rotating blades to their rhythmic swishing. I am alert to other living beings along the way, and stop instantly if any are noted in my path.
I’m surprised when a tiny frog jumps onto my toe. I watch a bunny nibbling a leaf. I see and hear the springy grasshoppers and winged song birds. On quite days, the sound of the surf as the tide rolls in seems like the sea is breathing.
With my enhanced attention, I notice mole tunnels and vole trails. And of course, the wild flowers, shrubs and trees, all with their unique micro-habitats.
If a neighbor happens by, we chat as I rest. Now in my second summer of planting dahlias, we share our anticipation of blooms and bouquets. Taking a simple, root-like tuber and planting it into the dark earth is a process that engenders patience – tending to the area and waiting as months pass, until a green sprout finally emerges. Even having studied the sciences, I am amazed at how a stunning flower emerges from such a seemingly mysterious process. And now we come to my first dahlia bloom of the season – a beautiful, intricately circular patterning of soft orangey glow. As I stand near admiring the blossom, I notice another being’s presence too. A large praying mantis is perched just above, seeming to honor its beauty — what an awe-inspiring pair!
The mantis, a master of the art of being motionless, teaches us the value of stillness – and the attention and closer observation skills such a practice brings. Indeed, my slowing down and ability to bring more mindfulness into my day-to-day activities has awakened so much more beauty and awe in my life, and reminds me of my interdependent relationship with Nature.
And connecting with our natural, or “other-than-human” world is showing to be beneficial to our health and well-being in many wild and wonderful ways.1,2,3,4. So inviting a bit more stillness, or ‘human-beingness’ rather than ‘human-doingness’ into our lives, will likely open our senses to the beauty and awe around us, and perhaps cultivate more joy and gratitude along the way – as it has for me.
These experiences inspired me to create a new elective for our first- and second-year UConn medical and dental students during the fall of 2020: Nature as Medicine. For our pandemic weary and virtually exhausted students, I thought a shift in environment would be refreshing. The course was thus designed with the following student learning objectives:
Directly experience & learn practices for Rewilding, esp. Forest Bathing;
Understand the physical & mental benefits that connecting with Nature has on human health & healing;
Enhance observational skills, which are fundamental to the practice of medicine & dentistry;
Learn mindful movement practices known to decrease stress/burnout, e.g. Qi Gong, mindful walking/Labyrinth;
Deepen their appreciation of the natural world;
Share their class experiences with course participants.
Offered as a daily, two-hour class, each gathering was held out doors during our schools’ one-week elective time frame. Sessions included experiential activities such as mindful walking, sensory awareness, and gentle movement as we explored the trails of local woodlands and green spaces, masked and physically distanced. We also practiced quite observation by finding a ‘sit spot’ for sitting in stillness for 15-20 minutes. Opening one’s senses, noticing any movement, and nonjudgmentally bringing attention back to the present were key parts of this practice. Our small group of twelve students were invited to share their experiences and reflections during each class via an opening ‘check-in’ and at the close of each session. In addition, some brief readings and web-based resources were offered to stimulate further curiosity and provide evidence for Nature’s benefits, e.g., the scent/exposure to pine terpenes enhances immune system function in humans.3
The results and general feedback were remarkable, with overall enhanced well-being, improved sleep, and less anxiety reported by most all students. The students also experienced first-hand the health benefits and value of human access to safe, green spaces – an important lesson as future advocates for their patients and communities. As such, I am planning to offer the elective again this spring, and look forward to continuing to evolve a Nature-based curriculum. As health professionals and educators seeking innovative ways of bridging both virtual and in-person learning opportunities, I recommend giving the nature-based learning ecosystem a try!
Mary P. Guerrera, M.D. is Professor Emeritus of Family Medicine at the University of Connecticut School of Medicine, Farmington, CT where she enjoys teaching medical students and residents.
As the COVID-19 pandemic advanced, many rapid changes had to be made in medical education. Residency programs had to be adaptive and creative to deal with the ever-changing CDC landscape protocols to educate residents in a restrictive in-person environment.
In a matter of days, our family medicine residency clinic had to change all the in-person visits to telehealth. Video visits were something that was being tested and executed in the faculty clinic, but nothing similar was done on the residency side. At first, it was very challenging to our residents, but especially to our patients who had no idea how to use the app for the video visits. Many appointments had to be changed to telephone visits instead due to technical issues and poor literacy. However, as time went by, most of the residents, faculty and some patients started to get more familiar with the current system. Telehealth is here to stay, and I don’t think it will ever leave us. On the positive side, telehealth has now opened up opportunities for patients who previously were unable to attend their doctor’s visit.
Unfortunately, the pandemic just not affected the way we take care of patients but also negatively affected the training of residents. It led to many modifications for safety reasons within the clinics and hospitals that resulted in decreased volume of procedures, simulation laboratories, face-to-face teaching, hands-on training, and skill-based teaching activities. Elective rotations had to be canceled, reducing interpersonal connections in favor of social distancing and home isolation. The residents’ clinical skills competence in doing a physical exam weakened as they no longer have access to patients under supervision. The conventional bedside teaching where residents and faculty can ask patient questions in real-time and have essential discussions as a team had to be discontinued. Numerous residents were unable to attend conferences, complete research projects, or participate in extra-curricular activities that could help them get a competitive fellowship or their dream job.
Several residency programs at my institution had to restructure their residency training and redeploy many residents to services in need. Due to these rapid changes, the hospital shifts were at times very exhausting for the residents – not only because of the long hours and multiple days working in a row but also the constant fear of spreading the virus to a loved one. On top of all these changes having to wear personal protective equipment (PPE) all the time can be very uncomfortable. Residents many times felt a mix of anxiety, fear, emotional and physical exhaustion during these extraordinary times.
The weekly didactic teaching sessions, a crucial component of residency training, changed radically with the pandemic. All the in-person lectures moved online through platforms such as Zoom. The advantage of having the didactic session online was the ability to have everyone attend from any location and being able to invite speakers from different institutions. Virtual rounding was also implemented in countless residency programs to keep the whole medical team safe. The virtual rounds involve a pre-round done by the residents and medical students, and the attending physician would join remotely to discuss the cases with the whole team. During this time, it is an excellent opportunity for the attending physician to teach, showing research papers and PowerPoint slides about the cases that are being presented. As soon as the virtual round is ended, the attending physician would see the patients by him- or herself and resume the virtual round in the afternoon to discuss their physical exam findings and any other pertinent information from the patients or medical staff. Although there is no replacement for the face-to-face bedside teaching and observation of the resident or medical student performing the physical exam, this model is efficient, delivers substantial educational value, maximizes patient care time, and provides a safe environment to both trainees and patients.
Residency programs across the nation adopted video interviews for virtual residency recruitment. One of the advantages of virtual recruitment is the amount of money and time saved during the interview season. Not having these expenses can be a relief to the medical students and the residency program, especially as the financial crisis precipitated by the pandemic led to budget cuts for recruitment in many programs. Virtual recruitment also allows the residency program to interview more applicants as more interviewers may be available. The downside of virtual recruitment is the limited opportunities to socialize with current residents and faculty. It may also cause video fatigue if an applicant doesn’t take a break or stays uninterrupted for more than two hours in an interview.
Although these are challenging times, we were able to reconsider our current resident education and welcome ground-breaking methods while providing a high quality of care. Even though the pandemic affected residency education, several research studies show that the level of knowledge and clinical practices with virtual learning was acceptable. I believe we gained an understanding of how to integrate technology with the current teaching modality without compromising patient care. We also learned how to improve health care systems and redesign curriculums to ensure appropriate training.
In the near future, as the pandemic subsides, we will see a hybrid of these models. Learning telehealth skills along with classroom and bedside teaching, the flexibility to have lectures in person and virtual so that everyone can attend, and virtual interviews with an option for an in-person interview and visit the residency program site. These adaptations are still a work in progress, but I am hopeful that all the changes and discoveries we had this past year will positively impact medical education.
Every month I receive the evaluation comments written by fourth year students about their rotations, sites, and preceptors. I read through these looking for possible concerns around faculty development and resident development especially with regards to teaching our students. I want to make sure that if there are any trends, I am on top of them; if there any opportunities, I can quickly work to support faculty as needed.
This past Fall, I read our first evaluations since our students started back after the pandemic. I did not know what to expect. Actually, I expected negative comments to jump out at me. In the months since our faculty had last worked with students, the coronavirus pandemic had ravaged South Florida. Our affiliate hospitals were overwhelmed with COVID-19 admissions and our already busy faculty had born the burden of caring for sick patients with limited PPE. They had to attend to patient families through virtual means, and do so while working long hours. They often had to isolate from loved ones to protect them from possible illness. And there was not reprieve in site. One of our affiliates had asked community physicians to do hospital shifts to spell over-worked hospitalists. I didn’t know what students would experience as they returned to the clinical setting.
As I read, I noticed I had been holding my breath and my shoulders were tight with tension. But I didn’t need to be worried, after all. I felt my throat catch and a surge of sad happiness, probably a release of pent up emotions related to this crazy pandemic. The comments by students were amazingly positive. Over and over students spoke about the excellent, high-quality teaching provided. Students on hybrid rotations commented about the incredible learning experiences they received through virtual rounding and cases plus in-person scrubbing for surgeries. Particular patient care experiences were sometimes cited. I know those hybrid rotations were crafted quickly and with great effort in order to provide optimal learning experiences despite the pandemic. Some faculty took more students than usual yet still provided outstanding teaching and supervision. They were taking on added duties even in this situation and I imagined that they would probably write quite a few letters of recommendation in the coming months, adding further to their time demands.
There are just a few comments about faculty performance being negatively impacted by COVID-19. Still, those comments are rare. Our dean of clinical education took great care in working with sites to ensure that students would not work with patients suspected of having or diagnosed with COVID-19 and to ensure the safety of patients, students, staff, and faculty. The COVID-19 admissions slowly declined; students are only able to be in the clinical setting because the numbers were coming down. Yet, in spite of this pandemic, our faculty is giving their all to students and patients. Not only are faculty teaching during a pandemic, they are teaching well even in this different environment, providing meaningful experiences to learners while also accounting for safety.
As I continue to review the report, I am aware of the halo/horn effect and wonder if students were so grateful to be back in the clinical setting that they are providing more positive comments about faculty that they might have had there not been a pandemic-mandated pause in their clinical training. I also wonder if faculty were just so grateful to have students back that they were nostalgically reminded of the joys and wonders of teaching and passing on our wisdom and passion for patient care to those coming after us – those who will probably be our doctors one day. Whatever the reason, joyous teaching interactions leapt from the report with jubilant aplomb.
The end of the report contains students comment about the teaching they received from residents. The comments about resident teaching were just as positive and strong. I admit that I shed a few tears when I read comments about our former graduates who are now residents in multiple clinical programs and sites teaching our students in such a challenging situation.
These comments weren’t just positive. They detailed specific high-quality teaching moments. I’m so grateful to bear witness to the interpersonal connections at play with each other: patients, students, staff, residents, faculty.
These observations carried through to the personal statements of our fourth-year students applying to residency. So many students were inspired by the physicians that cared for them or their loved ones in their formative years. We are all interconnected. It may sound very “airy fairy” or New Age, but I notice this connection again and again: physicians inspiring patients to become physicians-in-training, physicians and residents teaching students who will one day become physician educators themselves, patients receiving care but actually who are educators. We are all connected and in this report I see this so clearly.
I’ve been thinking a lot lately about the interconnectivity of each person within society and on this planet. It is so clear to me during this pandemic that we as a people are only as strong as the weakest link. If just a few people are not wearing masks or are gathering together, the novel coronavirus will continue to spread. But if we follow basic guidelines, we are strong together and our unity-in-action speaks to our interconnectedness.
Medical education and patient care are intricately woven together like a tapestry with every thread contributing its own texture and color to the pattern and strength to the structure. I am so honored and grateful to witness and be a part of the beauty on the report before me, because I know that the words written are just a glimpse of the overall experience students had at their sites with their preceptors, residents, and patients.
The crux of your argument seems to be that by using a set of holistic admissions criteria, medical schools admit unqualified applicants and therefore, produce an unqualified physician workforce. However, you seem to confuse winning a competition on a single scale with being qualified. Being competitive is not the same as being qualified. 24,127 runners qualified for the Boston Marathon. Not all qualifying runners will finish at the top, or even within minutes of the most competitive athletes, but most will finish and all were qualified through a rigorous process to pursue the marathon course. The tripartite mission of medicine – education, research and patient care – is served best with attention to equity, not competition.
Dr. Wang, you falsely defined “qualified” applicants using only MCAT scores, which are incomplete metrics of an applicant’s qualifications for medical school. Aggregate national acceptance data from 2017-2020 shows that 18.1% of applicants to medical school with MCAT scores between 514-517 were not accepted. For those scoring above 517 (95th percentile) 12.2 percent were rejected by every school. Practitioners in undergraduate medical education (UME) admissions understand that assessing academic preparation and personal qualifications for medicine is complex, nuanced, and cannot be reduced to the MCAT, which has limited capacity to predict academic success (and does not predict clinical outcomes). We would no more assess cardiovascular health using only body weight than admit applicants to a profession based only on MCAT scores. There are many other factors that must be considered in context. Among these factors is the experience of racism.
Your paper ignored structural racism, and claimed that centuries of colonization and racism, and their implications for contemporary society, vanished with the Civil Rights Act of 1964. This is tantamount to claiming lead poisoning ended when the Consumer Product Safety Commission banned lead paint in 1977. Medicine takes place within societal realities that cannot be ignored.
Racism affects different populations differently, and solutions must acknowledge these differences. As Asian Americans we face anti-Asian racism and xenophobia especially in the COVID era, but the inequalities we face are different from other forms of racism, especially anti-Black racism. Regardless of economic status, Black people must survive murderous state racism and deep structural inequalities, as they pursue educational goals. Similarly, and in different ways, Latinx, Indigenous peoples, and the diversity of Asian Americans including Southeast Asian and Filipinx Americans confront different forms of intersectional racism. Systems of oppression (e.g., racism + patriarchy + poverty) intersect to affect us in different ways. We are not all playing the same “game.” Unfortunately a uterine lottery pick predetermines resources produced by deep systems of inequalities that are heavily reproduced in access to education resources, supports, and outcomes. It would be odd if a fair admissions process could somehow simply ignore that fact.
Intersectional racism-conscious admissions
Talent is universal, opportunity is not. Many schools already employ advanced, holistic evaluation and selection methods for choosing the next generation of physicians. Affirmative action, or race-conscious admissions in education, is a critical policy and practice to advance diversity, which has been deemed necessary for robust educational benefits.
We are calling for robust praxis in intersectional, racism-conscious admissions, which affirmative action law allows. Using an admissions approach that is conscious of intersectional racism, we center everyone’s unique human dignity in evaluating their qualifications, moving beyond checking off a particular racial box to understand the totality of the applicant’s experience and talents. It does not guarantee admission for anyone. It offers a fairer, more equitable evaluation process. Only highly qualified applicants are admitted.
Equity is fundamental to medicine living up to its ideals to “do no harm” and serve all people. Black Lives Matter.
Dr. Nakae and Dr. Poon
Sunny Nakae, MSW, PhD, is a clinical associate professor of social medicine, population, and public health and Associate Dean for Student Affairs at the University of California-Riverside School of Medicine. She has previously held administrative positions at the University of Utah School of Medicine, Feinberg School of Medicine at Northwestern University, and Loyola University Chicago Stritch School of Medicine. She is the author of Premed Prep: Advice from a Medical School Admissions Dean (Rutgers University Press, 2020)
OiYan Poon, Ph.D.is an associate professor affiliate in the Department of Educational Policy Studies at the University of Illinois at Chicago. Her research focuses on how race-conscious holistic admissions works, and the racial politics of Asian Americans and affirmative action.
As Dr. W, the pathologist, ushered my peers and me in, he made sure that we were properly wearing our masks, gloves, cloth gowns, and expressions of respect. He encouraged us to speak up if we felt too nervous to walk further inside. The morgue smelled of formaldehyde and goose bumps formed on my skin as my body sensed the frigidness of the room. I was more excited than scared to watch Dr. W perform an autopsy on Ms. S, our ninety-four-year-old “patient.” As a pre-medical student at the time, little did I know how much this experience would significantly shape my understanding of the practice of medicine. And it would imprint on me an appreciation for the autopsy.Read More »
Louis Nikolis is a fourth-year medical student at the Loyola University Chicago Stritch School of Medicine, who will be applying for a residency in Physical Medicine and Rehabilitation (PM&R). During his free time, he enjoys playing basketball, traveling, writing, and practicing yoga.
When I began medical school, I signed up to volunteer with Veteran Health Partners (VHP), an organization that pairs medical students with veterans in the Recreational Control Facility (RCF) of the local Veteran Affairs (VA) Hospital. Veterans in the RCF unit have conditions ranging from spinal cord injuries to paraplegia, many of whom live there as long-term residents. As a Vietnamese-American daughter of refugees from the Vietnam War, I owed it to myself to get to know some of the honorable veterans who served.Read More »
As a public health nurse, I work in reproductive justice, prenatal and postpartum care at a Federally Qualified Health Center (FQHC) in San Francisco. I am aware that my job comes with a high responsibility as I am assessing for social and structural determinants of health as women begin their prenatal care. In the wake of COVID-19, my work has become more critical as basic needs like food, shelter, baby supplies, legal support, mental health and safety are now even higher for Latina mothers than ever before. The barriers in accessing healthcare, food and shelter that were there for Latinx patients prior to COVID-19 became even wider gaps when “Stay at Home” or “Shelter In Place” policies were first enacted in the City of San Francisco along with eight Bay Area counties even before the State of California and other states followed.Read More »