“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Thursday, February 21, 2008

Sunday, February 17, 2008

Does diversity matter?



“We all should know that diversity makes for a rich tapestry, and we must understand that all the threads of the tapestry are equal in value no matter what their color.”
~Maya Angelou

I am not a poet and don't claim to have some great understanding of poetry. I do appreciate poetry and the allusions that many authors use to explain certain opinions. The Hollow Men, by T.S. Elliot, is one such poem. It makes many allusions and references to other poems and historical figures to explain his displeasure of society and war. Some believe that it is written from 5 different perspectives; each perspective representing a phase of the passing of a soul into one of death's kingdoms. This is a complex poem which requires an understanding of the time in which it was written, past history, and previous writings of both the author and other authors (such as Dante's Divine Comedy). As complex as this poem is, it is easier to understand than understanding another's perspective.

(Image Credit)
Our perspectives are formed over time. We are affected by our upbringing and experiences. There is no denying this fact. Like our musical tastes, our perspective is shaped by our initial influences and changes with our experience. Differences of perspective is one of the reasons for the emphasis on diversity. Some believe this is a repackaging of "affirmative action", but in my view it is not. Diversity is about bringing together different perspectives. I have been avoiding this topic because it is a hot button issue. Now, with our current political race placing both a African-American man vs a woman and having seen a number posts in different forms that have mentioned the topic, I felt it was time.

Before I speak about diversity, I think I have to give you my personal perspective and history. Who am I? I am the great-great grandson of a Bishop of the AME church. I am the great grandson of a former president of Wilberforce University and one of Yale's first African-American graduates. The nephew of a Yale medical school dean and a descendant of Henry O. Tanner. My parents met at a Williams and Bennington college social function. In the 60's and early 70's, my father was very involved in both SNCC and CORE. In my youth, I grew up with Afro's and dashikis. I listened to stories about Medgar Evers and other leaders in the Black power movement. Yes, I am a black man.

I am the oldest in my family. I have a total of 5 sisters, 1 by marriage and 4 half sisters. I was raised in Wilkinsburg, PA and went through the Wilkinsburg public school system. Considered one of the smart ones, I was protected by many of my friends from some of the bad influences. At age 16, my best friend had his first child; he was 15. At age 18, I had mine. At age 19, my best friend was shot in the head, because he was selling drugs in the wrong area. Needless to say, I grew up in what some would consider a "rough" area.

If you look at my family history and my environment, you may say that they were at odds. In truth, it was always understood in my family that academics was important. There was an unspoken understanding that going to college was a given, which one was the only question. You see, the competition came from within the family, not outside. My cousins class rank of 2 bettered mine by 2 positions. My other cousin's SAT score of 1580 bettered my uncle's (her father) by 20 points. I wasn't that close. Although I grew up with gangs and teenage pregnancy, my overpowering influences came from history, family history.

For me, college was initially a culture shock, but I continued to do well. I majored in Biomedical Engineering and like many times in my life, I was "the only." For some reason, may be I had vision or laps of judgment, I decided to go to medical school in the second semester of my junior year. The prerequisites were made up over the summer, and the next year I applied to medical school.

For me, medical school wasn't that hard. It was a lot of work, but nothing was nearly as hard as some of my engineering courses. My medical school resume was pretty good. As I look back, it was not as good as I thought, but still it was pretty good. Because of concerns about this "affirmative action", I chose not to state my race on my application and did not provide a picture. It may have been a stupid move, but it was a choice I made at the time because I wanted to get there on merit only. Fortunately, it didn't hurt me. You see, because of my fair complexion, people usually can't place my race. It wasn't until I was a 3rd year resident that my chairman realized I was black. That still gives me a little chuckle.

Since medical school, I have been the only black resident, fellow, and faculty member. I am different in a number of ways. You can pick any one of the many things that makes me different. Whether it be race, family history, area where I was raised, or my marriage to a British citizen, I bring something different to the mix. There are people in my field that have the similar backgrounds, but not many. Can you now see my perspective?

Diversity is important. Different opinions and upbringings are important. Whether it be race, gender, or social status, it is important to have a heterogeneous population of physicians. Physicians that can relate to different patient populations. Be it a small town or the inner city, people from these areas tend to return to provide care in these needed areas. Patients also like to see people who are like them providing care. It is important that we mirror our population.

As I have seen and heard many times in the past, if a majority student doesn't get a spot and a under represented minority (URM) does, they wonder if they "lost a spot" to an under qualified URM. Well, let's look at the numbers. In a recent article in the Journal of the American Academy of Orthopaedic Surgeons, Templeton et al addressed the discrepancy in the percentages of URM and women between the medical school population and the orthopaedic resident population. The opening statement of the article states this:
Women and underrepresented minorities make up smaller proportions of orthopaedic residency programs than their numbers in medical school would predict, according to our evaluation of self-reported orthopaedic residency data from 1998 and 2001, as well as information on medical students published in 2002. Based on race, ethnicity, and sex, comparisons were made between students entering and graduating from medical school and those in orthopaedic residency programs. With few exceptions, the percentages of women and underrepresented minorities were statistically significantly lower among those training in orthopaedic residency programs compared with those same groups entering and graduating from medical school. The percentage of women and minorities in orthopaedic residency programs remained constant between 1998 and 2001. Further study is necessary to determine whether fewer students of color and women apply to orthopaedic residency programs becauseof lack of interest, lack of appropriate mentoring and role models, or other factors.
When I hear or read majority students make statements in relation to URM getting spots over a qualified majority students, I laugh a little. If you look at the numbers, there are far more white males competing than any other demographic. If you take a look at the tables from this article in 1998 and 2001, the discrepancy is incredible, especially for women. Majority students occupy 78.8% of orthopaedic spots in 1998 and 76.9% in 2001. The biggest discrepancy noted in the study is with women. The percentage of women in medical school was 44.3% of students in 1998 and 47.6% in 2001 with the percentage in orthopaedic residencies being 7.6% and 9.8% respectively. These numbers are not even close to the general population.

Even our national organization AAOS has started an initiative to encourage URM and women to apply to residency programs. The AAOS realizes that this is something that needs to change and they make this statement:
As the demographic face of our nation changes, the orthopaedic community is evolving to reflect and adapt to these critical shifts in the landscape. Recognizing the value and strength inherent in our diverse population is a first step. But our larger goal remains embracing solutions and mechanisms that give all people access to and a place in our healthcare system.

These are exciting times! The world is changing. Its face grows more diverse each day. The AAOS is committed to keeping, and setting, the pace. As our population grows rapidly more diverse, our need grows significantly for physicians who reflect this diversity and are accessible to communities and individuals with unique needs. The AAOS is taking the lead to ensure all people will be served appropriately by the field of orthopaedics.

Diversity is not just for the underrepresented populations, it is also for those majority students and physicians. It brings the different perspective to a program. Many may take care of these populations, but do they understand the perspective? Whether it be understanding the differences in the Hispanic cultures, or understanding the inner-city culture, having a diverse group of physicians helps everyone become more sensitized to all of these issues.

If we go beyond the clinical setting to research, there are diseases and conditions that are specific to certain populations. Issues like gender differences in bone structure and outcomes after total knee arthroplasty have created a new line of gender specific implants. There have been a number of studies that have looked at Ethnic and Racial Disparities in Diagnosis, Treatment, and Follow-up Care and Disparities in Orthopaedic Surgical Intervention; they have noted both racial and cultural differences. Who is more likely to investigate these conditions and issues than those who could or have been directly effected by the conditions.

Understanding that our numbers are low, how can we improve the numbers? One of the biggest problems is the lack of mentors. In my education, I lacked a "like" mentor. My mentors came from my "majority" physician mentors and my family. Looking specifically academic physicians, the numbers of URM or female are few. Nationally, there are powerful people who fit these groups. Dr. Rankin will be our academy president next year. In my own field, Dr. Crawford has been a leader in the pediatric orthopaedic community for years. The problem is that, if you are a URM or female student interested in my chosen field, it is hard to find someone "like" you who can share their experiences. If I look at my own background, I don't know if I ever could have found a mentor with the same history, but I don't think that was as important as finding someone that I could have related to. Be it cultural similarities or personal history, having a mentor who I could speak frankly about my fears and insecurities would have definitely helped me along the way.

Over the years, I have learned to adapt to my different situations. As such, I am able to view things from many perspectives. I have stated in this blog previously that I have tried hard to remain humble and approachable. Today, I put myself out there as someone that medical students and residents can relate to. I believe it is important that we understand our differences. Whether it be race, gender, culture, religion, or generation, we probably have more in common than we think.

T.S. Elliot writes a poem from 5 different perspectives. Like this poem, each physician/patient interaction is seen through multiple perspectives. The perspective of the patient with all of his/her fears and past history. The perspective of the physician and his/her personal experiences, as well as previous interactions with like patients. The perspective of the nurse and other physician extenders who bring their past history and experiences to view this interaction. Ultimately, understanding our differences is what helps make these interactions better. Regardless if it makes us color blind or more culturally sensitive, diversity ultimately makes us all better physicians.

“All truths are easy to understand once they are discovered; the point is to discover them.”
~Galileo Galilei

Thursday, February 14, 2008

Valentine's Day just seems irrelevant

“Dream as if you'll live forever, live as if you'll die today.”
~James Dean

Valentines is a hallmark holiday in my mind. It is definitely not one of the majors (Christmas, Thanksgiving, Easter), and not like birthdays and anniversaries. I have begrudging participated over the years and continue to do so. I get the cards and little gifts. I have done the flower thing and bought the pretty jewelery. I say that because I am not above participating in the forced "date night." This year is a little different.

In our little town of Kirkwood, we have had a recent event that has made all of this seem quite irrelevant. About a 1/2 mile from my house sits the City Hall where I voted the Missouri primaries. Two days later, a disgruntled man stepped into that same building and shot 2 policeman, 2 city council members, 1 public works person, and the mayor. They were all killed except for the mayor. He lies in a hospital ICU in critical condition. This small suburb of St. Louis, a quiet, family oriented town, is in shock.

Tonight, as I drive home with my hallmark cards and box of chocolates, I pass children placing luminaries in the front of their houses. The streets are filled with these candle lit bags. A tribute to the fallen. Families walk the streets to observe the community's tribute. My eyes well up, and I realize that the chocolates and cards probably mean less to my family than just having my presence at home. I am sure the members of our city government said something I have said to my family many times, "I'll be right back."

To my Kirkwood family, I grieve with you.

To the families our mayor, city officials, and policy officers, I pray for you.

To my family and friends, I love you.

“Being deeply loved by someone gives you strength, while loving someone deeply gives you courage.”
~Lao Tzu

Monday, February 11, 2008

We all have our quirks ...

“The great aim of education is not knowledge, but action”
~Herbert Spencer

Looking back, residency was one of the best times of my life. Some of the experiences were priceless. I remember sitting in the resident's room and speaking with the other residents about the day. We would complain about the day. We would talk about the interesting cases that we had seen or done, what we had been accused of doing wrong (because we were always in the right), and what our upcoming plans were. Inevitably we would begin to speak about our "attending staff" and what they had said that day. We would commiserate about how we all had similar things said or done to us. I guess you could say after a while, some of the attendings became caricatures of their sayings and behaviors. If a resident would say a particular attendings "saying", we would all smile in acknowledgment. It was like an inside joke. Now, I am on the other end. I am one of the people that they mimic or mock. I guess we can't help it, we all have our quirks. It is fun to poke fun at people's eccentricities.

As an educator, it is important that you are self aware. We must understand out strengths and limits. To be effective at educating, we must understand what teaching style fits our quirks the best. I believe your teaching style should fit your personality, because the possibility of changing your general nature is slim to none. For instance, if you are not an outgoing and humorous person, you are not going to be that kind of educator. It is just a fact.

In evaluating myself, I realized I am a fire starter. Ok, that doesn't mean that I go out setting fires, but I like to look at things from the other point of view. I quite enjoy being the instigator. I do this during dinner conversations. My wife says she can see when it is coming because I get a little devilish grin. It is in my nature. I can't help it.

Usually when a resident comes to me with a plan, I like to take the opposing view point and argue that position. Even if I agree with the resident or medical students plan of care, I want to see if they have a reason. You may say that's mean. I don't know if it is, but it sure is fun. In truth, I want to see if they really understand why this is a good plan and aren't just parroting back what someone told them or what they read. I want to know that the understand enough to debate the subject. For example, a common debate I like to have with the residents is what type of graft to use for an ACL reconstruction, PROS and CONS. The resident usually fumble through this question because they usually haven't thought about it. Why do I ask it, because patients ask the same question. They need to have a good answer for why they recommend one over the other. Coming up with a plan is one thing, but being able to defend that plan is another.

I know we all have our quirks. I don't like a lot of futzing in the OR, I like foam in my casts ('cause it's cozy), and I like my coffee with cream and 1 Splenda ® (dam it). I say, "s/he's gonna love it," when I love it; and I say, "that makes me sad" or "that hurts my feelings," when I don't. If I am teaching, I want to see if the resident is actually thinking. The best way I have found to test someone's understanding of a subject is to debate of the topic. That's just how I roll. So, for now, I'll keep setting fires to see where it takes me.


“Tell me and I'll forget; show me and I may remember; involve me and I'll understand.”
~Chinese Proverb


Sunday, February 10, 2008

University Hospital Cursades ... update

Hello all. I have been working on the story line for the University Hospital Crusades. I am looking for Ideas for characteristics to give the different specialties and supporting casts. Please send me some comments on what may be interesting quirks of your or others specialties. This includes my nurse, PA, and other friends, not just physicians. It is a light hearted look at medical training. Feel free to give some suggestions.

Thank you.

Someonect

Saturday, February 2, 2008

Interviews are over ....

“The greater the difficulty, the more the glory in surmounting it.”
~Epicurus

Today was our last day of interviews. The rank list is done. The more I am involved in this process; the more I realize that it is not that scientific process. It gets difficult when you get to the last few applicants. What I have learned this year?

As I previously posted, I asked all of the applicants the same group of questions. In most of my interviews, these questions an provided the opportunity for further conversation. A couple of interviewees fell flat. I don't mean that the answered wrong or poorly, just that were flat. It is like a girl who likes a guy. She gives him every opportunity to "impress her," and he misses the cues. You know what I mean? All in all, the questions went pretty well.

For my first question, I asked, "in one sentence, tell me who you are outside of medicine?" To this question, the common themes were:
  • hard working
  • loves outdoors
  • loves being with friends and family
  • easy going
  • loves sports
Very few actually gave me a sentence. Most just gave a bunch of adjectives that described attributes that they think would be good attributes in an orthopaedic resident. For the few that gave me sentences, here are a couple I liked:
  • I am a geeky girl from the midwest.
  • I am a father, husband and friend, that loves music and the outdoors.
To the second questions, favorite book and author, I surprisingly got some interesting answers. Mostly popular authors and books. Several people enjoyed Dumas. A few like historical and biographical books. For most of them, this was not a difficult question to answer.

To the third group of questions, favorite song/album and artist/group, the answer was not as obvious. Most had multiple choices from Country to Indy rock. U2 and the Beetles where probably the overall winners. Groups like Shane and Shane were new to me. GNR and metallica were also popular choices. Lupe Fiasco and Tupac came out of no where from one application. I liked that.

Overall, I think the questions did what I wanted. They initiated conversation made most feel comfortable. I learned a non-medical side of the applicant. I got a glimpse into their psyche. It surprised me that no applicants in their review of our program prior to coming found my blog with the questions. Oh well, I tried to give a heads up.

I do think I will use these again next year. I may change them a little. May be I will ask what ringtone they would give to my phone number. Maybe they would use the Imperial March from Star Wars, like I use for all of my partners (other attendings).



One of my residents just told me he tagged my number with Pantera's Walk. That was FFT.

Pantera's - Walk


Avenged Sevenfold's - Walk cover


May be I will ask what CD's are in their car or songs on their IPOD's recent played list? Or may be I will ask what their ring tone is? I will continue to search for ways to assess an applicants past the USMLE and grades. I look forward to this next year.

“What is not started today is never finished tomorrow.”
~Johann Wolfgang von Goethe