New class brings health justice to medical curriculum

On a Tuesday evening in November, Matt Eacott, a 33-year-old white male who grew up in comfortable circumstances in Avon, Conn., told a group of medical, nursing, and physician associate students about his 16 years as a drug addict. He started smoking pot at 13, and over the next four years his drug use expanded to other drugs and advanced from experimentation to habit to necessity. He racked up 19 felony arrests, spent time in 15 treatment centers, received a year-long prison sentence, stole $30,000 from his parents, forged prescriptions, and tried to kill himself. He indulged in just about every drug imaginable: marijuana, heroin, Oxycontin, Vicodin, and PCP. While high on PCP one night he heard the voice of God telling him to kill himself, smashed a wine bottle, and slashed his throat with the broken glass.

Since the beginning of his sobriety three years ago he has made it his life’s work to tell his story in hopes that it will spare others what he went through. He now works for Aware Recovery Care, a model that delivers substance abuse treatment to clients in their own homes and communities.

The students then heard from Jeannette Tetrault, M.D., HS ’05, FW ’07, director of the Yale Addiction Medicine Fellowship Program. Eacott’s story, she said, offered a lesson in how to talk to patients about substance abuse.

“It was not part of my training,” Tetrault said, speaking in a conference room at the Equity in Research and Innovation Center at Yale. There are techniques for raising such delicate issues, she told the students, and now is the time to practice them, beginning with basic questions. “Are you drinking alcohol? How much? How often? How is it affecting your life?”

Although that night’s class imparted a specific lesson, it was part of an 11-session course with a larger purpose. Its goal was to teach students in the health professions how to speak to people who come from different backgrounds and life experiences and help students develop the skills to serve as advocates for vulnerable populations. Two second-year med students, Tehreem Rehman and Robert Rock, saw a need for this type of training in the medical school curriculum, as well as more discussion of health equity. “We only had one or two sessions on health disparities,” Rehman said. “We felt a dearth of that.” With support from faculty, they designed U.S. Health Justice and offered it for the first time last fall. Their model was a global health program that had also been initiated by students and ultimately became a course of study that now offers the Certificate in Global Medicine. “We didn’t want this to be a one-time class,” said Rehman. “We really were hoping this would start momentum and get health equity in our education.”

The students’ proposal came as the medical school is launching a revised curriculum, and a key element is medicine’s responsibility to society. “We were aware of the school’s ongoing initiatives to reform the curriculum and sought to use that to our advantage,” Rehman said.

“This course fits into that goal and it would be a shame if the course wasn’t thought of as part of that goal,” said Robert Rohrbaugh, M.D. ’82, HS ’86, FW ’88, professor of psychiatry and director of the Office of International Medical Student Education, which confers the Certificate in Global Medicine.

“To function effectively and credibly as a physician in society you have to recognize that your experiences in life are very different from those of your patients,” said Forrester Lee, M.D. ’79, HS ’83, associate dean for multicultural affairs and professor of medicine. “Because of that you will carry into your clinical encounters certain biases and a lack of awareness of patients with very different backgrounds from your own. You need to have some exposure to curriculum elements during med school that sensitize you to who you are and what your limitations are, and also acquaint you with some of the issues you are likely to encounter.”

One of the problems in offering this training, said Lee, has been a lack of faculty resources. Students have opportunities to work with uninsured and underserved populations that are culturally and racially diverse, such as the student-run HAVEN Free Clinic and the Neighborhood Health Project. These, however, are all volunteer, elective activities. And, said Lee, “only a handful of faculty are actively engaged at the research level or clinically in this kind of work. The same people are called on over and over again to contribute to these kinds of efforts.”

Another supporter of the student initiative was Nancy R. Angoff, M.P.H. ’81, M.D. ’90, HS ’93, associate dean for student affairs. “It is important because our students feel it is important,” said Angoff. “They are a barometer for what change has to happen. We need to listen to them.”

Rehman and Rock’s interest in health justice arose from their early life experiences. Both come from families new to America, and both grew up in Queens, N.Y. Rehman is Pakistani-American, and Rock’s family is from Haiti.

As an undergrad at Columbia, Rehman studied access to mental health services among Pakistani Muslim women in the United States and worked in a hospital emergency room as a counselor for survivors of domestic violence and sexual assault.

Rock saw firsthand the importance of culture and language in health care as his great aunt battled uterine cancer. The matriarch of the family, she had settled in Brooklyn and “never learned a lick of English,” Rock said. Wary of the health care system, she preferred to be treated by natural healers. When she was hospitalized with late-stage cancer, Rock said, “the language barrier and the culture barrier made her connection to her providers nonexistent.”

Although they grew up just a few miles from each other, Rehman and Rock didn’t meet until they came to Yale for Second Look Weekend, which offers accepted students a chance to take another look at the medical school. Rehman was carrying a copy of Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. “On the interview trail I didn’t see that many people talking about this topic,” Rock recalled.

Once on campus, the two often discussed race and class in medicine. “That’s when the friendship really developed,” Rock said. They agreed on the need for a course that covered these issues, and surveyed other medical schools that had similar programs. “It helped us organize objectives, what topics to cover, what are the concrete skills people will get out of this,” said Rehman. “We didn’t want this to be just sit-down-and-listen-to-people-talk.”

They created a steering committee and consulted with Angoff, Lee, Rohrbaugh, Marcella Nuñez-Smith, M.D., and the Robert Wood Johnson Clinical Scholars Program. After a three-hour conversation at the Anchor Bar on College Street, Douglas Olson, M.D., HS ’10, who works in a community health center in Norwalk, agreed to serve as course director. “We really don’t have a course that focuses on these issues,” said Olson, a clinical instructor in internal medicine. “We have one on international health, but there’s a lot of stuff in this country that needs fixing.”

Over the summer the students finalized the content of the course.

“By the time I got involved,” recalled Lee, “they had an almost fully developed curriculum. It was just a matter of getting financial and administrative support.”

Then came the fall semester. Rehman and Rock worried that too few students would sign up for a non-credit elective that required that students attend every one of its 11 sessions.

“It was a big risk,” Rehman said. “What if nobody wants to take this?” More than 30 people applied.

“We didn’t even tell them that we were going to feed them,” Rock said.

In addition to classroom sessions, the course included tours of Fair Haven and the West River neighborhood led by community leaders. At the Yale Center for British Art, a curator led the class through an exhibit of 17th century British paintings on slavery that sparked a conversation on race and class issues. “It was the most genuine, meaningful discussion about the topic of race across racial lines that I have ever had in an academic setting,” Rock said.

Including students from different health professions provided an added bonus—the group included 14 medical students, four nursing students, and two students in the Physician Associate program. “The nurses have so much more experience, and a lot of them have already been immersed in the clinic. They would tell stories of the struggles they are having as providers dealing with these issues,” Rehman said.

The next step for the students is to ensure that the course continues. They are recruiting students to carry on their work next year. “My hope would be that it gets incorporated into the formal curriculum,” said Angoff, who’d like to see this training become a requirement over four years of medical school. “We have to train students to treat diverse populations.”

“The longer vision—I don’t mean 20 years from now, I mean the next couple of years—is a really wonderful vision to think about for the medical school,” said Lee. “You could come to the School of Medicine and say ’If I choose to be involved in issues of social justice, health justice, and health equity as part of my educational experience, I can do that in a very targeted way so that I have competency and skill in that area.’ ”