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Left to right: Jacob Wasag, Aaron Briggs, Stephen Wang, and Subasish Bhowmik.

One Relationship at a Time, One Story at a Time

Four Geisel School of Medicine Students are Changing the Way We See Each Other

By Susan Green

In taking the Hippocratic Oath physicians pledge to do no harm. Yet many are unaware that implicit bias may affect the way they interact with their patients and unwittingly create harm. Socioeconomically disadvantaged individuals—traditionally underserved ethnic minorities and stigmatized groups—experience disproportionately higher rates of morbidity and mortality. Bias contributes to these disparities, collectively referred to as social determinants of health, and is the reason why an individual's lifespan can often be predicted by their income and zip code.

Susan Green is a senior writer for Dartmouth Medicine.

Personal bias along with the social and behavioral determinants of health are difficult to learn by reading a book and are not well explored in medical school classrooms or clinical settings, leaving medical school graduates oblivious of any unexamined attitudes they may harbor toward their patients.

Second-year medical student Aaron Briggs (DC '15, '19), who has given a lot of thought to these issues in the context of medical education, says, "If medical students are not being taught about these problems they will not be prepared or equipped to fix them when they become physicians. Some communities in this country experience rates of infant mortality that rival those seen in developing nations. These disparities are unacceptable and need to be our concern, but before we can move toward solutions we have to understand the problems."

Two months into his first year at Geisel, he conceived a way to remediate these complex problems: Beyond the Books, an experiential learning initiative to increase medical students' awarenessof these issues.

While fleshing out his idea of pairing medical students with community partners to provide basic health information—and in turn gain an understanding of the challenges their partners face—he recruited fellow student Stephen Wang ('19). Wang shares Briggs' interest in advocating for vulnerable patients, and with public health experience under his belt he understands the limitations of classroom learning around how disparity affects health outcomes.

But while enthusiastically pitching their idea to the Forward Bound Group, a support program consisting of residents and former residents of the Haven (a local homeless shelter), the two medical students received a surprising response.

"They quickly straightened us out," Briggs says. "They were not interested in the advocacy or health information we were offering. They were more interested in the opportunity to shape the next generation of physicians—of being our community professors—teaching us, and preparing us to be the kind of doctors they wanted and needed to see in the future."

By telling their stories, the Forward Bound group believed medical students would begin to understand the context of their struggles—whether with homelessness, addiction, poverty, or disability—and its affect on their health and well being; to become advocates rather than adversaries. Their desire to share was strong and was reinforced throughout subsequent conversations.

"Barriers to health are not always obvious or intuitive," Briggs says. "I had never given weekend clinic hours much thought until I heard one of my community partners say the clinic where she went to be seen was not accessible to her because her long work hours prevented her from going during the week, and there is no weekend option."

Aaron Briggs and Dr. Roshini Pinto-Powell discuss a project related to the Beyondthe Books program.

Wang tells another story—one a recovering drug addict shared with him at the Haven's warming shelter. "He was an orphan who was adopted by a foster family he grew to deeply love. In middle school he experienced inescapably intense social pressure to do drugs. Sadly, before he knew it, his life was so consumed by his addiction that his cherished foster family kicked him out because of his inability to remain sober," Wang recalls. "I was lucky that I never had to endure the circumstances that pushed him to use. Succumbing to addiction was not an act of moral weakness, but rather a decision largely made for him by the environment he grew up in."

Both Briggs and Wang believe personal connections with community partners are a powerful way to change medical students' understanding of inequality, racism, and poverty that profoundly affect the health and lives of underserved and vulnerable populations. They argue that by embracing and developing long-term relationships with those who are different, the bonds of stigma, stereotype, and implicit bias are broken. Wang affirms the importance of these connections, "When we are doctors, we will be asked by patients to provide guidance. But this guidance can be misinformed, and even harmful, if we don't understand the context oftheir lives first."

Bolstered by what they learned from their conversations, they began designing the program with Forward Bound's help. By spring of that year, like-minded students Jacob Wasag ('19) and Subasish Bhowmik ('19) had joined the cause.

"When I heard about what these guys were doing I wanted to be part of it," Wasag says. "Learning from individuals who have been neglected or who may not have had the same opportunities you had—hearing from them about the challenges they face, is the best way to effectively help them."

Bhowmik has first-hand experience with the problems Beyond the Books is trying to ameliorate. Having grown up in poverty, the program appealed to Bhowmik who says he came to medical school in order to help those living in similar circumstances, "It allows me to focus my energy and drives me to use my knowledge to help those less fortunate."

To illustrate what the program is trying to accomplish, Briggs cites the work of Dr. Barry Zuckerman, a pediatrician at Boston Medical Center who discovered substandard housing conditions and food stamp termination were responsible for the high rate of childhood asthma and malnutrition he saw. "Dr. Zuckerman understood the impact adverse environmental exposures can have on health," Briggs explains. "Because of this, he was able to identify the problem and create a program to improve the living conditions of these children. We hope to prepare students so they can intervene similarly within their communities. The issue of health disparity seems overwhelming, but steps like this by individual physicians can go a long way."

This intent—supporting the development of aspiring physicians who can then serve as advocates for their patients and safeguards for the health of their communities—is what sets Beyond the Books apart from other programs.

"At Geisel, we feel strongly that to be a well rounded physician it is imperative to not only study and delve into the science of medicine, but to expand the heart and mind by acknowledging the bio psychosocial determinants of health and the tremendous disparities we know exist in our world, and in our own backyard, and to try to do something to effect change," says faculty mentor Roshini Pinto-Powell, MD, FACP, associate professor of medicine and an associate dean of students and admissions.

Pati Hernandez is a Dartmouth College lecturer whose work focuses on exploring political and social problems through the arts. She collaborated with Beyond the Books to co-host a panel discussion following the screening of a documentary featuring her undergraduate class, which connects students to people in regional correctional facilities. The panelists were all formerly incarcerated individuals.

Posing a provocative question, a panelist asked: Why do you care about me? An obvious answer is because every human being deserves respect, but her question alluded to something else.

"It was a difficult question and it made people think about why they were interested in learning this woman's story, and why this question remained with her," Wasag says. "What have we done as medical students, as a profession, and as a society that led this woman to question why anybody cared about her? What can we do to make her feel her voice is heard? It comes back to what we are trying to achieve in our program: giving people a voice who previously have not had one, and listening as intently as we can."

These are the kind of students we want to nurture and cultivate at Geisel. They had a bold idea and with hard work and determination have come up with this worthy, timely, much needed program.

The film and discussion points to the fact that when you really get to know somebody and understand their life circumstances, you learn they aren't poor, homeless, incarcerated, or addicted because they are morally weak.

At Dismas House in Hartford, VT, which provides shelter and support to men and women transitioning from incarceration to society, dinner conversations are candid and wide ranging. Bhowmik has been coordinating these student-prepared family-style meals for the eight house residents since last fall.

"Dinners helped me recognize an implicit bias I held towards people in the corrections system, and I really appreciate the opportunity to find that within myself," observes one medical student. "Hearing about the residents' families and interests is a valuable perspective adjuster."

Bhowmik says the dinners have turned into intimate conversations with the residents about their lives, "During these dinners, medical students have come to realize the house residents are not the scary people they are often portrayed to be. Once, when talking to a resident sitting beside me after dinner, we began talking about the fears we had for our families. Society would say he and I are worlds apart, but I knew there was little difference between me and the man on the other side of the couch."

Wang contends positive changes can only be made when you understand the system you are working within, otherwise you are not going to know how to help your patients. It's as simple as that.

"These are the kind of students we want to nurture and cultivate at Geisel. They had a bold idea and with hard work and determination have come up with this worthy, timely, much needed program, and have aptly named it," Pinto-Powell says. "As an associate dean of students and admissions, and as co-director of the On Doctoring course, I saw this as a win-win project for the school, the participating students, and the community. My hope is the project will continue to grow and thrive."

Student Voices

By Susan Green

Brianna Byers ('20)
Byers believes Beyond the Books provides an opportunity for her to deepen her knowledge of the ways social factors intertwine with community health.

She came to Geisel in order to become an advocate for those who are disenfranchised from resources that should be available to everyone. She says Beyond the Books provides a platform for her work.

New experiences that challenge her thinking—even if they are uncomfortable—are something she seeks. "I was attracted to the community partner idea and to the sensitive topics Beyond the Books willingly discusses," she says, "because addressing your own assumptions forces you to grow and to move forward as a human being."

And of her community partner, Byers says, "Honestly we don't talk much about medicine. I've gained some insight into what it's like to struggle with a chronic condition in a rural environment where there is limited access to resources and transportation. But most importantly we've formed a good friendship."

Lucia Joseph ('20)
"Some of our partners come through the Haven and have experienced significant economic difficulties, including homelessness, which are often compounded by serious medical issues," Joseph says (pictured above on the right).

She notes that when you listen to someone telling their story, you begin to understand why you shouldn't jump to conclusions, "I'm still shocked at the level of implicit bias in all of us.

"Mainstream society teaches us that those who are homeless or who are socioeconomically disadvantaged are in some way inferior because they haven't managed to succeed—whatever that means," she says. "The best way to break those stereotypes is to get out there and meet people. It's a gift to have my community partner share his experiences with me."

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