I remember the moment I first saw a female chest X-ray. It was my own. My lecturers in the first months of medical school showed a few chest films, but I failed to recognize that the bodies all looked the same. I proudly showed my sister my clear lungs. She laughed and said, “I can see your boobs.” I looked again at mine with new eyes, taking in the dull, gray color of adipose tissue that I had never seen before. Something was missing from all the previous images I had seen: diversity.
As second years, we practiced procedures on each other to gain experience before working with patients. We did abdominal ultrasounds, yet, female medical students were discouraged from volunteering so they would not have to undress. We also placed peripheral IVs on each other. My fair-skinned classmates bragged about the visibility of their veins. Comparatively, my dark, brown skin felt like a challenge. I whispered to my partner, tongue-in-cheek, “I guess I’m preparing you for half of our patient population.”
The first years of medical school are foundational. They are often described as learning to drink from a fire hose because of the sheer speed and quantity of information dissemination. They also set expectations. Our studies are often centered around pattern recognition as a way to make sense of the vast world of medical complexity. We memorize key associations, like ulcerative colitis and primary sclerosing cholangitis. These connections are helpful memorization tools, but can also be undermined by the complexity of actual patient presentations. As a third year, I had a patient with Crohn’s disease and primary sclerosing cholangitis and remembered thinking, “She didn’t read the textbook.”
These patterns extend beyond coexisting conditions to racial and ethnic associations. While practicing USMLE questions, my friends and I quickly learned that White patients were seen as normative and typically did not receive a racial identifier in the question stem. If, however, the patient was any other race, it was mentioned immediately to trigger the reader to think about particular diseases. For example, a 3-year-old African American male presents with leg pain. Did reading that make you think of a sickle pain episode? I believe it’s because we’ve been trained to do so.
Medical education systematically ignores the diversity of medical practice during the classroom phase. Why do we only show rashes on Caucasian patients? Why do we only learn to recognize how men present with MIs? Why do we not address how obesity impacts exam findings? Medical education favors the white, thin, male patient. I’ve seen his chest X-ray, I’ve examined his abdomen, I know his symptoms, and I’ve seen his rashes. This attention to learning under “idealized” conditions does medical students a disservice. By creating a model patient, every other demographic, who collectively form the majority, become “different,” “other,” or even “difficult.”
As an African American female who has been classified as obese since high school, I am “the other” in a few respects. It only took a few weeks to hear misguided statements about a group I belong to. As a part of our doctoring course, we had a discussion about obesity. One of my classmates mentioned that he was having difficulty reconciling conflicting emotions in our anatomy class. He was frustrated that he could not see the structures he was instructed to identify on his cadaver because of her body habitus, but was grateful that she donated her body for his learning. I appreciated his honesty and respectfulness. Then, the conversation took a turn. My group preceptor offered, “Yeah, it’s hard working with fat patients. Whenever I have to scan them in the ED, I just say, ‘take them to radiology,’” with a chuckle. An awkward laugh filled the room; to join would have been a betrayal to myself and my family. I raised my hand and explained the challenges I had faced losing weight even with the privilege of a college education and family members in the healthcare field. I understood that my preceptor’s comments were symptomatic of a system that sets medical providers up to view differences as challenges, with disparaging humor as a coping mechanism. Even though 30 percent of American adults are classified as overweight, medical equipment is only designed as “one-size-fits-most.”
These systematic ways of teaching also negatively impact care. During my surgery rotation, a middle-aged, White, significantly obese man had a pannus removal and had clinical concern for severe post-operative ileus. The surgeons wanted to take him for a CT scan, but he was too large for the scanner. One resident joked about taking him to the zoo. Ultimately, arrangements were made to get him imaged, but it was too late. His bowel was perforated, and he died within days.
As a medical field, we must acknowledge that improving the care of patients from diverse populations starts with education. Medical students should be taught to identify and treat the patients who actually live in their communities, not their idealized counterparts. Instead of forcing patients to fit into one mold, we should turn moments of frustration into opportunities for empathy. No matter how challenged we our by our patients, they often face discrimination for the very same qualities. One size does not fit all, and we need a medical system that is equipped to address all patients.
Rebekah Fenton is a pediatric resident.
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