Na Tosha Gatson, MD, PhD, FAAN, is the director of the Division of Neuro-oncology with the Geisinger Neuroscience and Cancer Institutes, and the assistant dean of equity and inclusion for the Geisinger Commonwealth School of Medicine.
As the first Black person to graduate from Ohio State University’s (OSU) MD/PhD Medical Scientist Training Program in 2009, she questioned why this distinction was afforded so late. “Until 2009, despite OSU’s excellent track record for graduating diverse PhD candidates, it had not graduated a single Black dual doctorate MD/PhD candidate,” she said. “Why? What happened? I was not first to enroll, just the first to successfully complete the program.” It is Dr. Gatson’s belief and experience that our medical education system is not designed to adequately support students from diverse ethnic backgrounds “because most curricula are not designed at any level of the training to ensure social justice. The culture of medicine today reflects the educational design. It lacks a plan to combat racism, discrimination and social determinants of health despite decades of evidence (and centuries of common sense) that these issues negatively impact learners, educators and patients.”
As she thought more about “what happened,” Dr. Gatson said it became clear to her that the medical community has been “rocked to sleep” in what she calls the “other syndrome.” She challenged us to think about the reaction we might have upon opening a Christmas card and seeing a Black Santa Claus on the cover. Dr. Gatson said, “You would quickly begin to wonder who sent this to you and likely assume the sender was Black or Brown. But why? Santa Claus is a fictional character and could be any race – but Black Santa is not what we have come to expect on our Christmas cards.” Dr. Gatson argued, “It’s the same with seeing a Black person on a medical brochure. ‘Diabetes?’ ‘Sickle Cell?’ or, opening our anatomy textbooks to pages of brown skin being reflected back to view the abdominal cavity. A chapter on internal bleeding from trauma? Nope, just a regular view of the liver. I challenge anyone within 10 years of my graduating medical school class to think of a single brown-skinned character represented in the routine anatomy. It would have certainly stood out.” Dr. Gatson asserts that we have become accustomed to these imaging being of white people. She adds, “If we accept this subconsciously, then we also understand that we have been (and are being) largely taught to treat patients of European descent.” She agrees that while this might be a bit of hyperbole, she believes there is a need to exaggerate the finer points of the discussion “to impress upon the learners and educators the need to take a closer look, and then ask ‘why’?”
Dr. Gatson described the “other syndrome” as the idea that routine medicine is taught with the assumption of a “nonminority” in mind, and when the lesson calls for the “other” issues, the educator or the textbooks will take care to emphasize race at that time. She notes a practice that continues to this day with respect to standard blood laboratory results. Dr. Gatson said, “As medical students, residents and attending physicians review the creatinine labs, there is a normal range provided — and below that you might notice an asterisk denoting ‘for African American patients…’ then an actual mathematical formula follows to instruct the clinician on how to determine the other normal range for these patients!” While some labs will supply both values, that is rarely the case. Dr. Gatson said, “This is also the case for normal white blood cell count, normal blood pressure and even normal body mass index. As physicians, we make clinical decisions to treat patients based on these so-called normal levels – despite the well-established medical knowledge of the impact of various races’ normal body composition and genetics on these laboratory values.”
Dr. Gatson recalled, “When I was a medical student, I was never taught to identify dermatological manifestations of commonly taught conditions such as neurofibromatosis (NF) and tuberous sclerosis on dark-skinned tones. I never realized what I did not know until I was faced with a Black patient with NF and had to describe the exam findings. Can you imagine describing axillary freckling, café au lait spots or a ‘shagreen patch’ on a very dark complected patient?” She said she wonders whether students even realize there are “other” normal values or exam findings? “Or, do they simply know to treat based on the numbers and examination descriptors they are provided? And, if so, do any of us know who suffers and how?,” she said.
“Even more egregious,” Dr. Gatson said, “is the fact that medical students are never tested on the various mathematical formulas needed to make the proper lab conversions, nor are students responsible to know the potential clinical implications for patients prescribed therapies to ‘treat’ presumed abnormal conditions that could be quite normal for specific patient populations.These are not on the USMLE.”
She added, “There is a willful ignorance of these subtleties. This lends to a subconscious reinforcement of the ‘other syndrome’ throughout the culture of medicine.” She said she is dedicated to helping students and faculty un-learn this culture, noting, “It is important that we are all able to recognize and reject these instances of miseducation, as they are rooted in racism.”
Geisinger Commonwealth School of Medicine has appointed Dr. Gatson to lead a medical curriculum renewal sub-committee charged with decreasing racism and improving inclusivity. As the assistant dean for equity and inclusion and a thought-leader representing the Social Justice and Equity Curricular Task Force, Dr. Gatson plans to engage learners, educators and members of the community to best design and implement the necessary programs and competencies to “graduate a stronger and more culturally aware student than we matriculate.”
“To achieve true change, we have to address three streams,” Dr. Gatson said. “There is a faculty component, a student component and a curriculum (textbook, educational materials, etc.) component. We have to make sure that the focus is not just to change our students, but to change what we teach and how we teach it. The changes we are embedding into the new social justice curriculum are based on evidence as demonstrated by those institutions that have gone before us — some nearly a decade in advance.” Dr. Gatson noted that while most of the changes we are seeing with many organizations seeking to address issues of racism are “consequent and not simply subsequent to the public murder of Mr. George Floyd.” As such, Dr. Gatson warns, “There is an anticipated lag to adjusting the current standardized examinations, and students will be responsible to know more than what they will likely be tested over. But, we can no longer afford to make this information optional.”
Dr. Gatson believes that success would be measured as we produce doctors who identify injustice, mitigate outcomes based on recognizing these and practice in ways that are equitable — thus changing patient health outcomes. “The very thing we all set out to do in the first place,” she added. Dr. Gatson noted that we need students and educators alike to take issue with injustices in medicine for any reason, as we are all subject to becoming a member of marginalized population in one way or another. Dr. Gatson said, “The medical student population is the ideal personality-type to pioneer such a revolution, as they tend to object frequently and openly (and I like it). We need them to demand to be taught how to properly treat all persons, and from the many walks of life.”
In the immediate future, Dr. Gatson said her task force will integrate an interactive lecture series, community surveys, selected literature reviews and the institution of longitudinal program coaches to support student and faculty development. Her most anticipated programmatic change will be adding the peer-to-peer discussion forums where students will have a safe space to employ the “See Something, Say Something” motto to openly discuss their experiences throughout the educational reformation. The task force, comprised of a diverse array of learners, clinical and academic faculty, School of Medicine leadership and community members, has also identified a capstone community-centered research and service project which each student will be responsible to construct and execute based on the needs specific to their respective geographical service areas. “First, the learner will dedicate themselves to identifying community-specific social determinants of health. Then, they will be challenged to work on solutions designed to empower people and limit stigmatizations and discriminatory practices that hamper patient access to and delivery of quality health care,” said Dr. Gatson.
Dr. Gatson envisions the eventual progress being represented in the U.S. medical licensing examination questions and stated, “I hope this challenges textbook illustrators to reach for the brown pencil and paint brush randomly in the anatomy books. Maybe I’ll even send out some anonymous Black Santas this year,” she chuckled. “We are in a position to question everything, yet we don’t ask the questions. We can no longer feel comfortable with not knowing. It is now our time to be unreasonable. In the unadulterated words of George Bernard Shaw, ‘The reasonable man adapts himself to the world: the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man.’ Minus the patriarchal language representative of his time, let us lead with an unreasonable spirit. Let us no longer feel comfortable not knowing.”