Over the last few months, we have witnessed a global pandemic in which millions infected and hundreds of thousands have died. As research fellows in general internal medicine, we could not have anticipated this when our fellowship started last July. We are not far removed from our residency training and know that it has been a challenging time to be a healthcare trainee with so many of us at the forefront of the COVID-19 pandemic. We have been caring for patients who have been incredibly sick, and we are worried for our patients who are not seeking care even when they should. But the COVID-19 pandemic has not affected all communities equally: communities of color bear a disproportionate burden of the morbidity and mortality from COVID-19.
In addition, longstanding racial/ethnic disparities and structural racism have been further highlighted by recent events. The dual crises of COVID-19, with its disproportionate impact on communities of color, and the repeated police killings of unarmed Black people have exposed what many of us in medicine have long known—structural racism is a fundamental determinant of health and mortality in our country. We applaud and support those who have taken to the streets in protest, demanding dramatic change in their communities and institutions.
As general internal medicine physicians, we see the daily toll that structural racism and adverse social determinants of health take on our patients whether on the hospital wards or in the clinic. We witness the health effects of redlining and residential segregation, food deserts, substandard housing, proximity to pollution, militarized police forces, mass incarceration, and being in low-wage, essential jobs during a pandemic.1 There are times when we feel powerless as trainees, trying to partner with our patients to solve medical problems that have their roots in legacies of inequality. Despite the challenges, these clinical experiences underscore the role we have and our moral responsibility to advocate on behalf of our patients, their families, and their communities.
The recent, unjust deaths of George Floyd, Breonna Taylor, and countless others, now more than ever, illustrate how we, as physicians, must advocate for our patients. This column suggests several ways that we, as trainees in general internal medicine, can use our voices to address these social injustices, whether by educating ourselves and engaging others on the history of structural racism in our profession; participating in protests, advocacy through media, or research that translates into solutions; or working with patients to address social issues.
There is a wealth of resources on learning more about how structural racism has been a part of medicine since the beginning of its history. A few resources we suggest are Medical Apartheid by Harriet Washington,2 Praxis Podcast by Edwin Lindo,3 and the American Medical Association’s “Prioritizing Equity” video series.4 There is also a robust evidence base on interventions to reduce racial and ethnic disparities in health that we can learn from.5 Multi-level interventions that engage patients at various points during their interactions with the healthcare system, incorporating community health workers into care teams, and delivering health care in non-traditional settings such as places of worship, are a handful of examples that have been shown to improve outcomes for vulnerable communities.
Participating in Protest
As of this writing, many Student National Medical Association and White Coats for Black Lives (#wc4bl) chapters organized demonstrations on medical center campuses around the country. It was inspiring to see students leading these efforts. We need to support these efforts, use our positions in medical centers to advance their goals, and show up to local government meetings advocating for the changes needed to eliminate police violence.
Speaking up against racism can take place on various platforms, including writing an op-ed, sharing your solidarity on social media, and speaking up as an ally or bystander when you witness racist remarks or comments. Recognizing seemingly innocuous forms of structural racism, such as the continued use of race in “objective” clinical data and practice, is also part of advocacy in medicine. For example, an op-ed advocating for the removal of the eGFR for African American patients highlights one specific issue in race-based medicine.6
As research fellows with a focus on the social determinants of health and health disparities, the current moment has led us to reflect on how our work contributes to advancing equity. Systemic racism is a central force that shapes social determinants, such as residential segregation. For those in research, working alongside communities as equal and active partners to identify the structural drivers of disparities, developing studies to understand the underlying mechanisms of racism, and rigorously evaluating multilevel and structural interventions are where we can contribute.
As physicians, we can acknowledge and address the impact of social determinants of health in clinical encounters. In our day-to-day encounters with patients, we can ask patients about their social needs, in addition to their medical concerns.7
Given our shared passion for the social determinants of health, we were excited for this year’s annual meeting, themed “Just Care.” While SGIM was not able to host the annual meeting in-person, SGIM20 On-Demand is offering annual meeting content virtually. These sessions are an opportunity for us to learn and reflect on how we can all deliver more “Just Care” to patients, populations, and communities. For example, the SGIM Position Statement on “Recognizing and Addressing the Social Determinants of Health,”7 from immediate past-president, Karen B. DeSalvo, MD, MPH, MSc, and Elena Byhoff, MD, covers foundations applicable to practicing clinicians, medical educators, and researchers.
During this time of physical distancing, we miss the opportunity to re-connect with friends and to meet new ones at regional meetings, and particularly, at the Annual Meeting. Our clinical routines have changed dramatically as we spend hours on a screen or on the phone with patients in clinic. Our non-clinical days are filled with virtual gatherings with our friends and family. Even though we cannot see each other in-person, we can continue to maintain community through GIM Connect.
SGIM has been our professional home and a way for us to reach out to others who share our interests, whether that’s medical education, research, hospital medicine, or primary care. SGIM’s mission of just care for all people has truly resonated with us and has been a continued source of inspiration. We hope that SGIM will be a community for you to lean on during your training and beyond. As the associate member representatives on the SGIM Council, we want to hear from as many of you as possible. Please do not hesitate to reach out and connect with us—on GIM Connect, through e-mail, or Twitter. We hope that this column can be the start of many conversations.