Volume 9, No. 1 , Spring 2007
Volume 9, No. 1 , Spring 2007
ISSUES IN THE WORKPLACE
Renewing Trust in Regular (Allopathic) Medicine and Research
In US academic health centers, inequality reigns at many levels. At the physician level after one and a half centuries of trying, females are entering medical schools at comparable or higher percentages than males. However, males still predominate in academic health center positions of upper administration and as senior faculty. At the patient level, inequities exist in the recipients of services. Some racial and ethnic groups are highly underrepresented in the patient population, not only as recipients of health services but also as the focus of research. The purpose of this article is to uncover some of the history leading to racial inequities in patient populations, to extend the discussion to inequities in advancement opportunities for women in academic health and to provide suggestions for improvement.
Dr. Martin Luther King, Jr, remarked, “…of all forms of inequality, injustice in health is the most shocking and inhumane.”1
While the remarks of Dr. Martin Luther King, Jr testified to his dismay over the racial inequity in health care services, the remarks apply aptly to other injustices, such as the inequity of leadership opportunities and career advancement for female faculty in academic health institutions.
The chasm that separates privileged males from their female colleagues in academic medicine is similar to the chasm that has separated marginalized populations from receiving quality health services from trustworthy health providers. Some of the underrepresented, marginalized populations in the US mistrust, even fear, regular (allopathic) medicine. Even today African Americans and Native Peoples (Native Americans) are often reluctant to go to a regular doctor until the entire repertoire of home, family and neighborhood remedies has failed. Despite being severely ill, some of these people refuse, at great cost to their health, to visit a “teaching hospital”, especially one that is part of an academic health science center at which research occurs.2
Tracking down the roots of such apprehension of health services may provide a history that is parallel to the challenges of women to develop professionally and move to the highest levels in academic health careers. The path into the past uncovers interesting details in the history of medical education, research and practice in the US. For example, Elizabeth Blackwell, using ingenuity and an “E.” on her application, was assumed to be a male, and finally gained entry into Geneva College NY for medical training. She graduated as a physician in 1849.3 In the past, a number of teaching hospitals in the South used only African Americans to demonstrate differential diagnoses, treatment plans, and new surgical techniques under development.2
The building of health centers contributed to this interesting history and growing distrust of health services. When neighborhoods with concentrations of African Americans or other minorities were torn down to allow for expansion of the nearby urban teaching hospital or academic health science center, feelings of subservience, mistrust and paranoia festered. Keeping a physical distance between themselves and the invading nearby health care institutions evolved from the resultant displacement and a mistrust of those institutions’ goals and services. Embedded in the physical distance was a growing emotional distance between the majority and minority groups.2
The history of women becoming physicians is a stormy one. In the mid and late 1800s, among the few African American physicians who weathered the storms that imposed multiple barriers were some indefatigable women. The traveling National Library of Medicine/National Institutes of Health exhibit, Changing the Face of Medicine, reveals stories of many of these women.2 Some of these notable women physicians included Rebecca Lee Crumpler (graduate of New England Female Medical College), Rebecca J. Cole and Halle Tanner Dillon (both graduates of Women’s Medical College of Pennsylvania), and Susan Smith McKinney Steward (graduate of NY Medical College and Hospital for Women).1,3 Typically, in academic health education, the professionals and administrators were (and today continue to be) White (usually male), while the support personnel (e.g., people in laundry, food and custodial services) were (and continue to be) minorities.2 Not until 1970, as a result of the complaints and action of the Women’s Equity Action League against every US medical school, was there an increase in the previously imposed limit that only 5% of medical school positions in each class could be available for women.2 It took over 30 years for the percentages of female medical students to stretch from 5% to today’s more balanced ratio.Tracking further into the history of medical education, research and practice reveals a stronger basis for the distancing, fear and antipathy of many minorities toward health care, particularly in the South. In 1989, efforts to revamp a historic site, the first medical school built in Augusta, GA in 1835, led to an amazing discovery. As renovation efforts began, construction equipment unearthed thousands of bones and artifacts from the earthen floor basement of the old medical school building.4 Robert L. Blakely’s research on these bones and artifacts partially explains the basis of southern African Americans’ current fear and dread of allopathic medicine and research. The explanations unfold in a fascinating anthropological-archeological saga, Bones in the Basement, edited by Blakely and Judith M. Harrington.5
Finding the Bones
In 1989, in the process of digging in the basement to renovate the first medical school established in Augusta GA, now named the Medical College of Georgia (MCG), construction workers unearthed numerous artifacts and bones. They immediately notified the coroner’s office. The coroner contacted Dr. Karen Burns, a forensic anthropologist on the staff of the State Crime Laboratory of Georgia, a faculty of the University of Georgia, and a personal friend of mine (she always has the most interesting stories to tell!).
When I learned about this archeological find, I phoned Burns (“Kar” to her friends) about the event. She remembered the incident well. As soon as she received the coroner’s phone call, she drove immediately from her Atlanta office to the site. Her inspection led her to insist that the construction stop for a full investigation. She contacted Blakely, an anthropologist renowned for managing major digs. He happened to be teaching a course in forensic anthropology that summer at Georgia State University in Atlanta. Under his leadership an enormous team excavated almost 10,000 human bones and fragments, about 300 animal bones and about 2,000 artifacts such as old medicine bottles, scalpels and other dissection tools, microscope slides, syringes, remnants of clothing and shoes, pipettes, enamel basins, parts of a large vat, evidence of whiskey to store bodies or body tissue, and scatterings of peanut shell particles. As part of their research, the team explored the history of MCG, including the culture of medical education and practice at that time. They also interviewed elderly residents of Augusta to uncover stories passed down to them by forbears about the nature of MCG and related activities in its early days.4,5
Stepping Back into History
In the early and mid-1800s Augusta was second to Savannah as the busiest river port in the Southeast. The urban area teamed with various people: itinerants, seamen, dockworkers, slave owners (some very wealthy), the free urban poor (Whites and Blacks), indentured servants (Whites) and slaves (Blacks).5
Regular vs. Irregular Medicine
At that time, regular medicine or regular therapy by formally trained physicians involved removing poisons from the body. The poisons were thought to emanate from the air, water, decaying matter and other factors in the environment. Typical treatments fell into two basic categories: 1) heroic medicine, i.e., bleeding, blistering, and purging, and 2) regular therapy, i.e., administering cod liver oil, calomel, quinine and assorted liquids with high alcohol contents.4,5
Irregular therapy by root doctors, shamans, women who caught babies (midwives), and other people trained through various methods of apprenticeship involved homeopathic and home remedies. In homeopathic and home remedies, natural herbs, plants and liquids were used sparingly. Root doctors used popular roots and plants such as garlic, chinaberry, comfrey, mustard weed, and peach tree leaves (to soothe a fever). Other concoctions included boiled cockroaches, sheep-dung tea, mullein leaves and 3-4 glasses of wine daily (for rheumatism), and rubbing a bee sting with a chunk of fatty meat. Female and male shamans tried to match chants, drummings, and plants to an illness; some of them worked to move energies and light to heal the body and/or spirit. Though sometimes not curative, these irregular therapies of root doctors, shamans, and others probably did not lead to death as often as those of heroic and regular medicine.5-10
Location of Care
The urban wealthy received medical treatment at home. When they did not heal, they died at home and were buried on family-owned land. Others who remained ill despite home remedies were taken for medical care (usually free) to the city hospital or teaching hospitals where iatrogenic infections raged. When hospitalized ill patients died and/or no one claimed the body, the deceased often provided tissues or bodies for medical study, experimental therapies, and autopsy (usually without the patient’s or family’s permission).11
Dissection
Before 1834, the practice of dissection was illegal in the US, but physicians in allopathic training needed direct instruction about systems and structures of the human body in order to address disease. Anatomy classes included dissection. In 1834, Massachusetts became the first state to pass an anatomy act that authorized medical schools to possess and dissect a human cadaver; New York followed suit in 1854. Much later, other states began passing similar acts in the 1870s with Georgia coming on board in 1887.4-6
Procurement
To accommodate medical education at MCG before 1887, cadavers were procured in various ways. Research interviews by Blakely’s team in the early 1990s sought out any elderly whose families had dwelled in the Augusta area for generations. Some elderly Black interviewees revealed stories passed down from grandparents about activities of grave robbers, night doctors, and resurrection slaves, including “Resurrection Man.” As stories unfolded, it became clear that most of the bones found at MCG in 1989 were probably from the Cedar Grove Cemetery, the local cemetery for African Americans, with some bones probably coming from an adjacent potters’ field, a cemetery for the indigent.11,12
Research findings from the bones unearthed at MCG indicated that many of the bones belonged to humans and had cuts suggestive of dissection procedures, e.g., false start kerfs or breakaway edges from incomplete cuts. Population records in the 1850 Census Counts from Richmond County show evidence that a disproportionate number of bones came from adult African American males. Anthropologists categorized 79% of the bones as belonging to adult African Americans vs. 21% from Euro-Americans. Of the African American bones, 79% of the bones probably came from males.12
In the early 1800s African Americans in the South were typically slaves. They believed with justification that medical experiments would be performed on them, and that they would be left to die in the hospitals and their bodies taken for autopsy and dissection. Fear of “night doctors,” who were usually medical students (or their hires) visiting acutely or severely ill people at night, kept Augusta folks away from hospitals at night for fear they would become victims of dissection.6 Despite people who held watch over the dying and the recently buried, bodies were “snatched” for medical education and training. Elderly in the Augusta area described these activities during interviews.11
Resurrection Man
Records from MCG indicated that in 1852 the Dean paid $700 for a Gullah slave, Grandison Harris. Seven MCG faculty shared ownership of Harris. Though purchased to serve as a porter, essentially Harris’ principal task was to obtain recently deceased cadavers for dissection. Sometimes he negotiated for purchases of cadavers from other locales. His reputation as “Resurrection Man” came from his skill at digging a grave, slightly opening the head of the coffin, and lifting out and placing the cadaver into a bag before loading it onto a wagon. Then he carefully arranged the grave’s surface mementos, left by mourners, so that the gravesite looked untouched.13
Harris stored the procured bodies in vats of whiskey at MCG, laid them out for dissection, cleaned the labs fastidiously after the classes and discarded used cadavers. Over time, as Harris gained expertise in dissection and anatomy, he became the laboratory teaching assistant, guiding the medical students in correct dissection procedures and the identification of anatomy. Though sometimes his activities were the subjects of jokes, he was highly respected for his skills and was often the preferred resource for medical student questions.13
During his 50 years of MCG employment Harris not only played a major role in the gross anatomy labs, he also served at academic social functions, held festive parties, and was a strong political leader in the African American community. During Reconstruction, he moved to Hamburg SC where he served as a judge. After Reconstruction ended, he returned to MCG and held the position of janitor. Though seriously underpaid by MCG, he was wealthy compared to other urban African Americans in the area. Highly literate, Harris was an elite member of the African American community with membership in the prestigious Pythians Masonic Lodge. Harris retired from MCG in 1905; he died in 1911. MCG faculty and students respected Harris while African Americans in the community highly feared him. 13
The Marginal Figure
Harris represents a marginal figure from a marginalized population, a population essential to the functioning of society but remaining on the fringes. Carlos Velez-Ibañez (1983) expands the concept of the marginal figure to more than being on the edge of a society. He purports that a marginal figure moves in two worlds, that of the majority and minority cultures. Rather than bridging both worlds, Harris was a marginal figure. He served the leaders, healers and medical academics of the dominant culture, by using the resources of the subordinate culture. In doing so, he magnified the inequality of both groups. His activities helped him and his family not only to survive but also to live a very comfortable lifestyle. At the same time he expanded the chasm between the privileged and the disadvantaged. He helped to keep the subordinate group in a subservient position and contributed markedly to their fear of academic medicine.14
In many ways, this history is repeated today in academic medicine in a different context. In considering the inequalities of opportunities afforded to males vs. females, females comprise the disadvantaged subordinate group and are often marginalized. Sometimes, a female academic rises to become a member of the power structure, e.g., becoming a chair or dean of a medical school or the provost or president of a university. Sometimes the female bridges the two groups to facilitate the entry of others from the subordinate group into the opportunities in upper administration at medical schools, universities, or corporations. Though few in numbers, these privileged women who bridge disparate groups deserve the highest accolades for their successes, bold efforts, and breakthroughs on behalf of others.
Many times, however, the academic female receives an opportunity to head up a project, to contribute resources and to accomplish goals that strengthen the resources of the dominant group, yet keeps the subservient group in their less powerful position. In other words, much like Harris’ example, women in academia become marginal figures. When they enter into leadership positions to serve the population in power but do not make the population from which they evolve become more powerful, they become marginal figures. For example, a person may accept an invitation to chair a Search Committee for a dean or vice president, yet not invite others who are junior faculty to join the Search Committee (and learn). The president or CEO of the institution may invite the female academic to head up a task force to update the institution’s bylaws or manual of policies and procedures. This leader may accept all professional opportunities for publications and presentations without acknowledging the strong contributions of other colleagues; this leader may neglect to invite junior colleagues to present reports to the power players and decision-makers of the institution. Thus the junior colleagues do not receive appropriate exposure and recognition; they miss opportunities to enrich their professional growth.
Other than the grand parties Harris hosted, not much is known about how he shared his good fortune to better others. The anecdotes that have outlived him are devoid of such messages. Not only have the stories of “Resurrection Man” lived through time and generations of people, but also these stories have crossed the borders into other southern states. And the stories carry antipathy, fear of allopathic medicine, and dread of people such as Harris who practice regular (allopathic) medicine, especially in teaching hospitals and academic health centers involved in research.11
Building Trust
Today, African Americans in the Southeast still mistrust regular medicine. Bones in the Basement reveals some of the history in the 1800s that contributed to that mistrust. African Americans as far south as Florida know stories of the “Resurrection Man”. Fear of medical treatment and research reach beyond the Southeast and permeate African Americans throughout the US because of memories about projects such as the Tuskegee Study. [The Tuskegee Study, funded by the US Public Health Service from 1932 to 1972, withheld treatment (penicillin) for over 400 African American males in order to follow the destructive course of their syphilis.15]
To unravel mistrust and build trust, physicians must educate themselves about the history of medicine and surgery related to African Americans and other minority populations. Physicians must expand their respect of others. They must deepen their empathy, cultural sensitivity and cultural competence. One approach may be to link to the respected leaders of the diverse cultural groups and partner with such leaders on projects that enhance the community. Another approach is to become involved with African Americans who are colleagues or peers on town-gown projects such as improving or developing educational resources (improving the local library or soliciting businesses to sponsor K-12 classes or classrooms) or recreational projects open to all children in the community; sponsoring arts and music events at multicultural and multigenerational health fairs; partnering with grass roots citizens to provide health education, screenings and mini-med schools in their neighborhoods; training business owners and staff at organizations such as beauty or barber shops to bring health information and educational materials to all their customers; and attending (for visibility) popular gatherings such as religious events and at popular sites such as community or senior centers. Accepting more African Americans into medical schools and upper level administration in academic settings will help to increase the comfort level of grass roots citizens regarding health services and research. By providing health providers, upper level administrators, and researchers “who look like me and know my family”, African Americans and other diverse populations may feel more connected to the providers and more trusting of services and proposed research.
To build leadership skills, academic health leaders should mentor others and open the doors to privileged information. The junior academics must learn to trust themselves, learn constantly, increase their risk-taking skills, and persevere to achieve and climb the institutional ladder. Women in academic health should be looking ahead to discover opportunities, looking abreast of themselves to assess the current picture to maintain successful growth, and looking back to remember the lessons that provided the strong rationale and foundation for continued growth. Professional seminars, fellowships, professional support groups, email networks, and professional organizations such as SELAM help strengthen strategies and the steps toward academic advancement.
Summary
The chasm that separated people in academic medicine in the 1800s at MCG from the people needing health care is similar to the chasm separating the privileged in academic medicine and the junior professionals trying to advance. Learning from history should help academics today avoid repeating inhumanity against humanity and to strengthen health education, allopathic practices, and research. The fear that arose as a result of activities such as those that occurred at MCG in the mid-1800s continues to fuel the anxiety and reluctance of southern African Americans today to seek allopathic medical treatment and to participate in research. Reading about some of the experiences of African Americans who have received inhumane medical treatment may help a medical provider understand and be more empathic in designing academic health curricula and programs that address diverse people.
Women in academic medicine and other health disciplines in the US have struggled to attain education and training. They have made inroads into health professions and have begun to overcome the barriers into academic health center leadership positions. However, inequities still exist. Leaders and providers of opportunity at all levels of academic health need to educate themselves about the disadvantaged groups, devise strategies to dissolve the chasms, and make academic health opportunities more humane, more open and more advancement-friendly to all.
Leilani Doty, PhD
University of Florida
References
© SELAM International
More Medical Schools Mean More Leadership Positions
More Medical Schools Needed: Then vs. Now
Reflecting visits to 155 US medical schools, the Flexner Report of 1910 urged high standards for admission and training, and concluded that too many medical schools and physicians existed.1 By 1930 there were only 76 medical schools, but by 1981 there was an upswing to 127.2
As predictions in the early 1990s grew stronger about the glut of physicians in the US, some medical schools closed. Now predictions are moving in the opposite direction. The baby boomers are aging, and the aging are living longer. Meanwhile, many baby boomer physicians are entering retirement.
In a 2005 report, the Association of American Medical Colleges (AAMC) urged institutions to expand medical school classes or to build new schools to increase student enrollments 30% by the year 2015. This increase would avoid an estimated 20% shortfall of physicians in 2020.3 If that shortfall occurs, patients, especially the elderly and poor, will have to wait longer, travel farther, make do with fewer medical services, and present with amplified health problems when they finally do access a physician’s care.
Start-Ups
In Arizona, California, Florida, Michigan, Pennsylvania, Texas, and Virginia, there are plans for or actual start-ups of allopathic medical schools. In The Chronicle of Higher Education Richard A. Cooper, PhD, Professor of Medicine and Senior Fellow in Health Economics at the University of Pennsylvania’s Leonard Davis Institute of Health Economics, reported knowing of “….at least 20 allopathic and osteopathic medical schools that are in various stages of development.”3
Eager to help increase the numbers of physicians in training, the AAMC is lobbying the federal government to lift its cap on the number of residency positions it supports through Medicare.3
Opportunities Opening Up in Academic Medicine
The expansion of medical schools will invariably open up new job opportunities for the under-represented in academic medicine. People from diverse backgrounds who have struggled against the barriers of tradition during their career path may now find more openings available in upper levels of administration and other leadership positions. Fueled by their passion for excellence in medical education, they should be on the alert for new positions opening up as medical training in the US expands. Newly emerging or expanding medical schools will offer the potential for many who want to elevate medical education to the highest of scientific-based ideals, and face challenges with a move into positions of greater breadth and responsibility in medical education. At the same time, academics are awakening to the importance of incorporating the values of the new generation of physicians: balanced work-family-leisure life; integration of technology to increase the efficiency, safety, and quality of medical practice; comprehensive health; creative and research-based approaches to care; strong ethics; and social responsibility that extends beyond US borders.
As a founding dean of one of the new allopathic medical schools, an individual has the opportunity to build a stellar team eager to achieve excellence in meeting the Liaison Committee on Medical Education (LCME) criteria (www.lcme.org). An aspirant from an under-represented group may now have a greater opportunity to become a health science center leader who collaborates with political and university leaders, community groups, patriarchs, matriarchs and influential grass roots citizens to bring supervised medical students and other health students into neighborhood-based clinical sites that provide culturally sensitive, comprehensive medical services and research.
The time has come for people with a different face, demeanor, and style to build academic excellence in medicine. One such person is Deborah German, MD, who has been setting milestones in medical education, first as the assistant and then associate dean of medical education at Duke University Medical Center (1982-98), next as the senior associate dean of medical education at Vanderbilt University School of Medicine (1999-2002), and later (2005-2006) as an AAMC Petersdorf Scholar in Residence where she studied the organizational structure and leadership of major health science center systems.4,5 Her rich administrative experiences in academic and community health settings fueled her vision and passion for her newest appointment as the Founding Dean of the new college of medicine at the University of Central Florida (UCF) in Orlando.4,5 Excited about her appointment, the UCF President John C. Hitt, PhD, described Dr. German as …”the right person to lead us into the future…” 4
Women Leaders in Professional Medical Associations
Some professional medical associations have established a track record of having a female at the helm serving as President. Founded in 1895, the National Medical Association (NMA) elected as its first female president, Edith Irby Jones, MD (1985-86), as its second female president, Vivian W. Pinn, MD (1989-90), as its third female president, Lucille C. Norville Perez, MD (2001-02), followed by L. Natalie Caroll, MD, (2002-03), and now its most recent female president (the 106th) Sandra L. Dadson, MD (2005-06).6,7
In 1982 Johanna Clevenger, MD, became the first Native American female to serve as president of the Association of American Indian Physicians (founded in 1971).7-9 Ten years later Dr. Clevenger served a second term (1992-93), followed six years later by Yvette Roubideaux, MD, MPH (1999-00), Melvina McCabe, MD (2000-01), Joy Dorscher, MD (2005-06), and most recently Susan Sloan, MD (2006-07).7-10 In 1994 Elena Rios, MD, founder of the National Hispanic Medical Association, was its first Latina president.7 The 150th president of the American Medical Association was its first woman president, Nancy W. Dickey, MD (1998-99).11,12
In dentistry the first woman president of the American Dental Association (founded in 1859) was Dr. Geraldine Morrow, elected in 1991; the second woman president (in 2005) was Dr. Kathleen Roth.13 The American Association of Dental Schools (founded in 1923 and renamed the American Dental Education Association in 2000) had Dr. Nancy Goorey as its first woman president in 1977.Almost a decade later Dr. Enid Neidle presided in 1986.14,15
Since its founding in June 1876, the AAMC governing body has been its Executive Council with a Chair (sometimes casually referred to as “president”).16 According to Marian Taliaferro, MSLS, Manager of the AAMC Reference Center and Archives in Washington, DC, the Executive Council formed the Office of (Staff) President in 1969 and appointed John AD Cooper, MD, to the position.16 He served 17 years, followed by Robert Petersdorf, MD (8 years), Jordan Cohen, MD (10 years), and now Darrell Kirch, MD.16 Since the 1980s three Executive Council Chairpersons have been women, Virginia W. Weldon, MD (1985-86), Theresa A. Bischoff, MBA, CPA (2002-03), and N. Lynn Eckhart, MD, DrPH, MPH (2004-05).One Chairperson was African American, Donald E. Wilson, MD (2003-04).16 As people from diverse backgrounds advance in positions of leadership in the AAMC, it is only a matter of time before the possibility of a diverse face and style in the AAMC leadership pipeline leads to the Office of AAMC President.
Looking for Skills in Job Listings
People in academic health interested in leadership positions should look for openings requiring skills in:
The new and expanding medical schools provide fertile ground for academics from diverse backgrounds with skills in effective financing; interaction strengths, especially negotiation skills; clear communication and decision-making skills; enthusiasm; and a positive leadership style.
Less May Be Better
Some medical schools have baulked at the recent campaign to expand medical school student positions. Instead, they have promoted increased efficiency. They have insisted that having more physicians does not mean that the underserved, especially in rural areas, will receive better medical care. They add that the trend among today’s physicians for a better balance in their career-personal-family lives may translate into more and healthier physicians, yet may not result in more physician appointment slots for patients.3
A team at Dartmouth Medical School studied effective treatment of their patients. They determined that a ratio of fewer physicians per patient actually led to an equivalent quality of care and fewer unnecessary treatments or procedures.3 As a result, they proposed that more efficient technology, such as using electronic records and medicine-dispensing computer systems, may be a better and less expensive way to increase the availability of health care services.
Such institutions also offer junior academic faculty in medicine the opportunity to multi-task, to mentor and to build auxiliary teams of additional academics who seek fellowships to gain experience in expanding administrative skills. For example, teams may test and implement efficiency designs that may be translated into best practice models. Publications on efficient practices in organizational medicine could be applied to medical schools and hospital systems.
Opportunities for Change Agents
Either way, in an expanding, new or downsizing medical school, potential opportunities are opening up for women, junior faculty, and other under-represented groups of people in academic medicine. These opportunities for strong catalysts, eager to be change agents, may make a significant difference in elevating US medical education to newer, higher standards of medical knowledge and therapeutic care. A door of opportunity that opens for anyone opens for everyone.
Leilani Doty, PhD
University of Florida
References
© SELAM International