What I’m Learning in Med School

Image courtesy of Arseny Togulev/Unsplash.

I was Bar Mitzvah’d in Beyt Tikkun Synagogue about 14 years ago, which was a significant moment in my life. Around that time, I remember Beyt Tikkun held high holidays at the University of San Francisco, and I particularly remember everyone dancing and singing out loud saying, “We will not be embarrassed! We will not be afraid! We will not be embarrassed, now or ever more…” I sang along and danced, and although I may have been slightly embarrassed at that time… I am not embarrassed right now! I have that spirit within me, that says we can and must be who we are.

My Bar Mitzvah was my first time reading torah. I read the parsha Yitro, or Jethro, which is most notable for God’s revelation of the 10 commandments to Moses and the Israelites at Mt. Sinai, everyone is familiar with this part of the story. But I always felt more drawn to the earlier part of the portion. Moses’ father-in-law Jethro comes to the community and sees that Moses is the arbitrator for all the people’s disputes. This is way too much work for Moses to do all by himself, and the people are waiting all day long for Moses to settle their disputes. Jethro urges Moses to divide the labor in a systematic way. Moses appoints judges of lower courts to handle the clear case disputes, while still attending himself to the more complicated disputes. Why would this accompany one of the most recognizable stories from Torah? I think it emphasizes the importance of collaboration in accomplishing large goals, such as managing the conflicts that are sure to emerge in a large population of social beings. My understanding of collaboration is that every person has super powers. Everyone has different strengths that they can bring toward a solution. Someone may be able to sing, another person may be able to 3D print a Harriet Tubman stamp so that we see a black woman on $20 bills in 2019. Another person may be able to read and understand history, or science, or the myriad social connections within their local neighborhood. We can have more than one superpower as individuals, and when we come together in with loving kindness and compassion for one another, that is when synergy takes place and Tikkun Olam  happens quickly and effectively.

For better or for worse, I have not always been able to channel that collaborative spirit, despite a growing understanding of the massive problems we face as a species. My Bar Mitzvah project in 2005 was centered on addressing Global Warming. At that time, in middle school, I brought an expert with me to my science class and we taught our understanding of global warming, something my classmates and I had never been taught in school before. We tried to communicate the magnitude of the problem and a fairly rigorous understanding of the science. And we focused on solutions at the end, such as a cap and trade program, installing more solar power or wind turbines, or being personally accountable for our individual carbon footprints by decreasing our energy consumption by washing the dishes with cold water, taking shorter showers, using public transportation, etc. At that time in my life I had personally decided never to own a car. My friends and family were encouraged that they could do something themselves to reduce our carbon emissions, but we did not pursue collective organizing or action to a great enough degree. I went on to high school and then college and got an even more advanced understanding of the science of climate change, but I did very little to organize my community around solving that problem. It always seemed like we were doing enough, being in the Bay Area or in California, we were known for being green and having great public transportation, and so after my Bar Mitzvah I became fairly disengaged with the climate movement. I decided I would become a doctor, like my mother, in order to help people struggling for a healthier life. At the end of college, my parents helped me to purchase a car, which I claimed was necessary for all the different opportunities for jobs or clinical experiences to enter into the competitive field of medicine. That was about 5 years ago that I turned back on my intention to never own a car. I have probably used about 2,000 gallons of gasoline since then, just myself, and this is a personal failure on my part to protect the climate. I take responsibility for my actions in harming our planet. I also understand it is not only my fault. There are social and economic and political structures at play that pressure people into owning cars. The public transportation in the Bay Area is what it is, but it ain’t that great. At any rate, an average American has a carbon footprint around 400 times that of an individual living in Burundi, a country within subsaharan Africa. And the healthcare system in the United States is responsible for 10% of our country’s CO2 emissions <https://www.commonwealthfund.org/blog/2018/be-high-performing-us-health-system-will-need-adapt-climate-change>. I am complicit in this and I am atoning for that today, among other things.

should mention that I am now finishing up my last of 5 years of medical school. I go to Touro University California, on Mare Island in Vallejo, where I am studying to be an Osteopathic physician. Touro is a Jewish school, which had given me an odd sense of privilege as a Jew attending a Jewish school, since now I am given the Jewish holidays off without having to ask to take time off, without needing to make up school assignments or missed classes. It’s not huge, but this is a big deal of why I have been able to join Beyt Tikkun at high holidays over the past several years.

I want to give a few examples of the kind of collaboration I’ve seen recently in organizing to create structural change in the community, akin to that of Moses taking his father-in-law’s advice and breaking up a big problem into smaller parts so that the community could solve it in a manageable way.

Structural change within medical school

  • In 2014, and again during my 1st year in 2015, medical students across the country, organized as White Coats for Black Lives, held “Die-Ins,” where students lay down on the concrete in their white coats for 4 ½ minutes, representing the 4 ½ hours that Michael Brown lay in the street without medical attention after being shot by the police in Ferguson, Missouri. Speakers read the names of recently killed unarmed black victims of police shootings. We called for policy changes within our schools and health systems to promote racial justice. We called for addressing the public health threat of police violence. We called for removing armed guards from hospitals and clinics. At my school, we called for hiring a full-time staff person dedicated to Diversity and Inclusion on our campus, which was an area being completely unaddressed by our school, and at that time there was perhaps 1 black medical student among our student body of approximately 500. We called for policies to promote equity in medical school admissions and grading. We organized, students spoke to each other, sent invitations via email and facebook and text, in order to get students together on the specified date and time of the rally, dressed in their white coats. We sent a few press releases to get some coverage of the event. That’s all at my school, and then you multiply these efforts by about 30 other medical schools across the country, and it becomes a huge “viral moment” where a large portion of the entire United States saw headlines and photos of medical students lying on the concrete in their white coats, standing up against police violence during those 2014 and 2015 die-ins. In the years since, we have exchanged ideas through an online publication called “The Free Radical,” where I have published a poem <https://medium.com/whitecoats4blacklives/non-native-san-franciscan-6d5cebac624e>. In an ongoing strategic and student-initiated effort, White Coats for Black Lives has published a Racial Justice Report Card, in which students at several medical schools evaluate their institutions and assign them a grade based on their approach to racial justice issues, such as having anti-racism training within the curriculum, support for underrepresented minority students and their recruitment to correct the disproportionately low enrollment of Black, Latino, Native American medical students, providing free medical care to the community through university hospitals, and more. Because of this, today, prospective medical students who are applying, as well as school administrators from medical schools across the country, are paying attention to this Racial Justice Report Card <https://whitecoats4blacklives.org/rjrc/>. We hope it can be leveraged to instill positive structural change within the larger medical education system.
  • In the fallout from the Die-In’s, our school did hire a full time Director of Student Diversity and Inclusion <http://studentservices.tu.edu/StudentDiversityandInclusion.html> as part of Student Services. We submitting a petition signed by hundreds of students and faculty, and leaned on a groundswell of student support that was expressed in meetings, in order to pressure a reluctant CEO that this was a worthy cause. Devon Lee, who was hired, is an excellent human being and incredibly talented and effective at his job, but he is underpaid and placed too low in the hierarchy to accomplish what needs to be done. This necessitates further organizing on my school campus to address ongoing injustices. Some issues we are actively organizing around today:
    • DACA Eligibility. Deferred Action for Childhood Arrivals is a temporary protection against deportation for residents who immigrated to the United States as children under 16 years old without obtaining official status, it has strict requirements such as having no criminal record — which is no easy feat in our incredibly racist criminal justice system — as well as finishing high school or an honorable discharge from military service. Several DACA recipients have graduated from medical school and are serving our communities as physicians today. Unfortunately Touro University California does not accept applications from DACA recipients. I became aware of this in Fall of 2017, when I was in Salinas on my clinical rotations at the county hospital in Monterey, Trump’s attack on DACA activated medical students across the country to take a stand to Defend DACA, and there was a huge rally at my school campus in Vallejo. The Dean of our college is photographed standing right next to the DEFEND DACA sign during this rally, but unfortunately if you go to our admissions website, it clearly states DACA applicants are not considered. This is on one hand a question of basic ethics, in terms of the extra barriers that must be overcome for someone with undocumented status to become a licensed physician in the United States these days. Medical training is grueling, there are intense personal costs for anyone in medical school, but it is true that DACA students train without a guarantee of practicing medicine after all of that, which is a question of informed consent. DACA recipients are no stranger to taking risks to pursue their dreams, and in my opinion this risk is far outweighed by the known benefits to society of graduating a physician with DACA status, who will in all likelihood go on to provide medical care to some of the most underserved communities within our country. The other factor is finances, which gets tricky because DACA recipients are not eligible for federal student loans, which most medical students use to fund their education. This begs the question, if Touro begins accepting DACA recipients, how will they afford their tuition and living expenses without access to federal student loans? The answer to this is that where there is a will, there is a way. Sure, Touro isn’t as wealthy as Harvard or Stanford, but we have highly paid executive administrators, we are part of a larger Touro College and University System (TUCS – pronounced “Tuchus”) which had an endowment of $13 million back in 2013, and currently has a student body of 18,000 students in 30 different countries, including 4 medical schools in the United States, 2 of which do accept DACA applicants. An institution of this size certainly has The means for training a few more physicians with DACA status. I believe it is currently a lack of caring for anything or anyone beyond a bottom line of profit that allows this discriminatory practice to remain in place.
    • Students have started a Structural Competency curriculum within our medical school. One of the problems with medical school is that students often have a very strong science background in the physical, chemical, and biological sciences, but often not a lot of formal exposure to the social sciences. This is problematic because the persistent health disparities of our time, which many future physicians hope to address, are largely rooted in social problems rather than purely biological ones. This curriculum teaches a critical analysis of how the social and political structures affect the health and illness of our future patients, and provides a shared vocabulary for talking about and changing these structures so that we can overcome these abhorrent health disparities.
    • One of the biggest concrete impacts that students at Touro have had in the Vallejo Community in my time as a student is publishing a letter <https://www.timesheraldonline.com/2016/11/25/touro-students-say-no-to-orcem/> opposing the creation of a cement factory in Vallejo. Vallejo is a community that has room to grow economically these days, and this cement factory would have generated industrial commerce in the area (which some people consider a good thing), but at a very high cost to the local community, and in a predominantly black neighborhood that doesn’t need more exposure to the fumes from trucks and ships for the purpose of “green cement”. Students from a few different orgs got together and published a letter in the local newspaper opposing this, and I still hear about it in the Vallejo community that the people there appreciate us speaking up on this hot political topic of that time.

These structural issues within my medical school campus are just the tip of the iceberg, but I want to talk about larger societal issues that students like me can address.

Advocacy for change at the State Level

  • When I started medical school I knew I wanted to advocate for health policy change, and I started a student chapter of PNHP, Physicians for a National Health Program, during my first year. In California, the history of the Single Payer Movement is rather complex. But I will say that our group has successfully advocated for good, but not great, incremental policy changes within the state of California as part of the California Physician Alliance. A few years ago, our advocacy helped pass SB 4 <https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160SB4>, which granted eligibility for Medi-Cal Health Coverage for youth aged 18 or younger, regardless of their documentation status, which was a positive step that helped provide free health insurance to some of the most vulnerable in our state. A current legislative bill, SB 29 <https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201920200SB29>, was originally going to extend this to all undocumented adults, but it has been modified to extend it only for adults aged 25 or younger, which is an example of cowardly incrementalism and shows that we have a lot of work to do in our state. But it would still be beneficial to hundreds if not thousands of young adults without documentation status to have access to health care, and I hope it passes. Unfortunately, the current president may start to label undocumented immigrants who access their basic human rights as a “public charge,” and use this as a reason to violently deport them from their homes. We need revolutionary changes to our policies on these issues, not incremental bandaids on a gaping wound. The safety net is severely wounded, and I have seen the ramifications of this first hand. On my rotations in Salinas, I have seen grandmothers go blind from preventable complications of diabetes due to foregone care and lack of health insurance. Amputations, babies born to mothers with untreated drug addiction, infections from lack of basic hygiene, pregnant women facing chronic stress that their partner will be deported any day now… Our understanding of chronic stress is evolving, and the Surgeon General of California, Dr. Nadine Burke-Harris <https://www.chcf.org/blog/california-surgeon-general-puts-spotlight-on-childhood-trauma/>, has championed the understanding of adverse childhood experiences or ACEs, and the physiology of chronic stress. One way to describe this in a way that makes sense to medical students is to imagine you have a difficult exam coming up, which is very relatable for medical students, who are increasingly overworked and burnt out and dealing with worsening depression and anxiety from their exams (on top of life in general) as they prepare to be healers for our communities. But imagine that you have an intense exam coming up and you’ve got to buckle down, learn that material, and perform well on the exam so that you can stay in school and get a return on your investment, and increasing debt often totalling hundreds of thousands of dollars. That is a stressful experience that happens for medical students in repetitive cycles, exam after exam, multiple 8-hour long board exams, etc. But the thing about taking an exam is that it is scheduled on a certain date, and then the exam is over. Imagine having this kind of stress, such as housing or food or water insecurity, threats of violence in your community from neighbors or from the police or from ongoing war, and never knowing if or when it will end. That is the never-ending experience of stress encountered by people living in these “underserved communities” that we claim to care about, but invest so little into.
  • I am optimistic that we are going to heal and change the world because of my spiritual renewal at Beyt Tikkun, but also because I have seen firsthand the resilience of individuals facing extreme hardship. While I was on a critical care rotation at Cedars-Sinai Medical Center, an extremely wealthy hospital system frequented by celebrities and wealthy people from all over the country, I volunteered on my days off in Tijuana during the migrant caravan crisis at the border with a group called the Refugee Health Alliance <https://refugeehealthalliance.org>. Like WC4BL, this group was organized without hierarchy, in a way that allowed people with special skills to use those skills to help people that needed it. We went to different shelters and set up makeshift clinics that were functional, although in stark contrast to the pristine hallways and high end art lining the walls of Cedars Sinai. For example, I had one of my patients lie down on a wooden table so I could help restore balance to their autonomic nervous system using osteopathic manipulation, which helped bring calm and healing into an otherwise stressful situation. I most vividly remember the children playing at the bottom of a concrete building where we had set up one of the clinics. In the midst of an immigration crisis, kids about 7 or 8 years old knew exactly how to play, and though they may probably deal with the weight of this trauma for the rest of their lives — especially if they cross into the United States and get separated from their family — the spirit of young joy and laughter is contagious and therapeutic in ways I cannot pretend to fully understand.
  • Creating structural change is a daunting task because we are faced with such a corrupt political system with big moneyed interests writing the laws and influencing the elected officials.
  • We fought very hard in my 2nd year of medical school to pass AB 72 <https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520160AB72>, which limited surprise bills in California. This comes into play when you attempt to go to a hospital that is in-network with your insurance plan, but end up receiving services from a provider who is out-of-network, generating an exorbitant bill. AB 72 capped the cost of an unanticipated out-of-network charge. The California Medical Association was opposed to this, some of their members wanted to protect the profits from such elevated bills. This was an example of true collaboration, with entire teams of people working together to lobby in favor of protecting consumer rights. With help from the California Physician Alliance and Health Access California, I met with state legislators. I even lobbied the lobbyists of the California Medical Association, who ultimately decided against opposing the legislation. Through all of this work and effort, we were able to change the law around Surprise Bills and make a statewide impact on reducing surprise bills. But this is also just a bandaid on a gaping wound.
  • Moving forward, and same as it ever was, the most fundamental change we need in our health care system is a Single Payer Medicare For All System

When we say “Healthcare is a Human Right” in 2019, we are expressing our imagination because Human Rights aren’t protected today. People are dying because they cannot afford to pay hundreds of dollars for a vial of insulin that costs around $5 to manufacture.

Imagine if a person goes to the hospital because they are feeling sick. If it’s the first time this patient has been to this particular hospital, and if they are lucky, the hospital might contact their primary care provider’s office and receive a fax with tens or hundreds of pages of medical records. It may take hours or days to receive these records. These pages will either be printed out on paper and hole-punched into a binder, or scanned into an electronic PDF as part of their hospital record, for their doctors to review. The pages will include medication lists, test results, and written notes from their past appointments.

  • This information may contain nuggets of crucial information, but it isn’t searchable. If the care team has a specific question, they will need to read from cover-to-cover to find it. In 2019!

Our healthcare system is a catastrophe in its own right. We have the best in organ transplants and cancer therapy, but a severe primary care shortage and many people without health insurance in the first place. Around 35,000 people will die this year in the United States due to lack of health insurance <https://annals.org/aim/fullarticle/2635326/relationship-health-insurance-mortality-lack-insurance-deadly> and around 60% of bankruptcies in our country are from medical bills, and if you are admitted to the hospital, your chance of bankruptcy go way up <https://ajph.aphapublications.org/doi/10.2105/AJPH.2018.304901>.

1. Lack of universal healthcare is an egregious scourge on our society, a form of structural violence and racism that cannot be allowed to continue. Protecting healthcare as a human right is a bare minimum to fundamentally transforming our healthcare system away from corporate greed and inequity toward a system rooted in compassion that promotes health justice.

2. Those with power have not acknowledged, let alone addressed, the deep problems in American healthcare. In 2016 Pres. Obama published an article <https://jamanetwork.com/journals/jama/fullarticle/2533698> in the Journal of the American Medical Association touting the success of his Affordable Care Act at reducing the uninsurance rate, but he made no mention of underinsurance, which has increased since that law passed in 2010, and affects 30% of Americans with health insurance today <https://www.commonwealthfund.org/press-release/2019/underinsured-rate-rose-2014-2018-greatest-growth-among-people-employer-health>.

Thankfully, the movement for Single Payer Medicare For All has never been stronger. Medicare currently provides health insurance for people 65 years and older. Medicare for All would remove the age restriction and cover everybody in the country. We would improve Medicare by eliminating copays and deductibles, expanding coverage to include long term care, dental, hearing, mental health. We would decrease prescription drug costs by allowing Medicare to negotiate drug prices with pharmaceutical companies, which is currently illegal! We would eliminate the for-profit insurance company for essential covered benefits, so executives would no longer earn their paycheck by denying care to patients. We would save money while protecting healthcare as a human right.

In the House, The Medicare For All Act of 2019 is called HR 1384 <https://www.congress.gov/bill/116th-congress/house-bill/1384>, and it currently has 119 co-sponsors. In the Senate, S 1129 <https://www.congress.gov/bill/116th-congress/senate-bill/1129> has 15 cosponsors. In all my years of fighting for single payer, I have never seen such institutional support for the concept within Congress. And if you talk to anyone on the streets, everyone has an idea of what Medicare for All is and could be. And it is an overwhelmingly popular concept.

What about after we get MEDICARE FOR ALL? Imagine what it would look like… Imagine that healthcare was guaranteed to everyone, and there were no restrictive networks. Imagine going to a hospital of your choosing and being asked, which doctor would you like to see? Imagine a healthcare system that respects patients…

And how do we get there? We need to center the voices of those without power…demanding our power of “we the people” back …affirming that Black Lives Matter, Muslim Lives Matter, Palestinian Lives Matter, Jewish Lives Matter, Immigrant Lives Matter, Refugee Lives Matter, …. The list goes on…

While the healthcare system generates 10% of our nation’s carbon emissions, we cannot claim to “do no harm” as the climate crisis unfolds. These issues are all connected.

Doctors are workers. Healthcare workers make up a huge number of people in our society. I am applying for residency right now and I am so excited to serve my community as a family physician and primary care doctor. I hope to join a residency that has a union. Doctors can stand up for our rights and end the structural causes of our burnout. We can’t do it alone, we need unity with our fellow healthcare workers. The hierarchy in medicine is splitting us apart. This will take a lot of work, but the bottom line is we need to treat each other like human beings.

We need to focus on HEALTH, not just healthcare, but actual HEALTH. Public Health funding in this country is abysmal. Public health professionals are underpaid and have to fight each other for grant money. We also need an emphasis on rehabilitation, healing, and restorative justice, rather than retribution and punishment and locking people up… Prisons are our country’s largest mental health institution right now <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5397789/>. That is absurd and violent.

We need a revolutionary awakening that realizes the value of love and generosity.

We need to forgive student loan debt and medical debt

We need to end our country’s imperial global domination and ongoing war crimes

We need to protect basic human rights and allow freedom of movement and citizenship

We need to come together around the Every Woman treaty <https://everywoman.org>, which is an international treaty to end violence against women, as 1 in 3 women worldwide have experienced sexual assault or intimate partner violence, 1 billion women globally lack legal protection against intimate partner violence.

We need to end our fixation on propping up existing manmade systems and refocus our purpose in life away from accumulation of money and power

It’s Yom Kippur but we can still eat the Rich, right?

OK. I have two asks of you all here today.

  1. Go to EveryWoman.org and sign the international treaty to end violence against women and girls.
  1. And come to the Single Payer Medicare For All RALLY/MARCH on Saturday, November 2. Held by National Nurses United and SNaHP (Students for a National Health Program). It will be held at U.N. Plaza just outside Civic Center BART station. The rally is 2-3pm, and then we will march down Market st to BLUE SHIELD OF CALIFORNIA HEADQUARTERS on Beale St.

See you in the streets!

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