During their third year, the final Professionalism, Communication, and Reflection module challenges students to find their meaning in medicine. They learn how to approach situations of moral distress and investigate the hidden curriculum.

Professionalism, Communication and Reflection

Stephen Berns, M.D.Since 2002, Larner’s Professionalism, Communication, and Reflection (PCR) course has served as an opportunity for preclinical medical students to reflect on their medical school experiences. The groups offer a non-judgmental environment with a small group of peers. By taking time for these reflections, says PCR Course Director and Associate Professor of Family Medicine Stephen Berns, M.D. (at right), “students learn how to develop skills in active listening, vulnerability, and how to seek support.”

Over the years, PCR has evolved with invaluable guidance from former course directors such as Yvette Pigeon, Ed.D., Dana Walrath, Ph.D., Lee Rosen, Ph.D., and Shaden Eldakar-Hein, M.D. It was Eldakar-Hein who worked with Goyal, Epstein, Dawson, Brach, and Finnie to initially link social determinants of health topics more clearly with PCR sessions. Now, this work is in the midst of its next evolutionary leap with Berns at the helm.

In January 2020, Berns became PCR course director, and in the middle of a pandemic that brought the broken pieces of the American health care system into full view, he seized on the theme of structural change and began to reconfigure PCR once again.

PCR is now delivered in five modules. “Becoming a Physician,” “Humanity,” and “Society and Medicine” are taught during the first year; “Advocacy and Social Justice” is addressed during the second year; and during their third year, students engage in the final module—“The Medical Culture and Resilience.” In the first three modules, students explore topics like self-identity, the burden of individual trauma, and the concept of implicit bias.

As they enter the second year, Berns and course professors focus primarily on advocacy, asking the students to consider questions such as “What is a physician’s role as an advocate— for their patients, their colleagues, and their communities?” and “Why should or shouldn’t social justice be taught in medical school?”

During their third year, the final PCR module challenges students to find their meaning in medicine. They learn how to approach situations of moral distress and investigate the “hidden curriculum,” which encompasses the “implicit messages about values, norms and attitudes” that students learn outside of the classroom, says Berns.

As he continues to evolve PCR, Berns says he’s committed to increased training for faculty.

“A lot of medical school faculty around the country have recognized their own shortcomings in the areas of social justice and health equity. We’re hearing them say, ‘This isn’t an area I got trained on when I was in medical school,’ and ‘I want to learn more,’” he says. “I appreciate that Larner faculty are open, eager, and curious to learn.”

Timothy Lahey, M.D., M.M.Sc.
Timothy Lahey, M.D., M.M.Sc., director of clinical ethics at UVM Medical Center and professor of medicine, with Sheridan Finnie '22

Medical Ethics

Undoing historical injustices hinges in part on open, honest discussion about the historical and cultural roots of injustice, says Timothy Lahey, M.D, M.M.Sc., professor of medicine and director of clinical ethics at UVM Medical Center. Giving medical students the opportunity to have those conversations early and often fosters an awareness that stands to help change the system.

“Understanding the social determinants of health and the incentives and history that inform them can help us identify real tools for change,” he says. “That can convert a will to fairness into a concrete plan that in fact yields it.”

Lahey seeks to foster open discussion about the social determinants of health and other ethics topics through 16 ethics sessions woven throughout the first-year Foundations of Clinical Science course. These sessions complement multiple other ways medical students can learn about social justice at Larner, from the student-run Social Medicine Theme of the Week to social justice-related sessions throughout the pre-clinical curriculum.

The weekly ethics sessions consist of pre-reading and a quiz, followed by in-class discussion. Lahey frequently links the sessions to current events, encouraging students to apply their understanding of medical ethics to an ever-changing world. For instance, during the height of the COVID-19 pandemic in the United States, Lahey added a session on resilience.

“I wanted the students to see how resilience relates intimately to ethics,” he says. “If people are feeling under fire, under-appreciated, and sleep-deprived, we know that they are much more likely to do something unethical.”

Medical ethics is tightly tied to health equity work, says Lahey. “Ethics helps equity work have nuance by showing the full set of complex values that inform and even transcend justice. That guards against the human temptation to approach any value, including the value of fairness, too simplistically,” he says.

Web Extra
  • Read a blog post by Nikkole Turgeon ’22 and Mialovena Exume ’24 titled "The Social Justice Coalition: Breaking Ouroboros."
  • Read a blog post by Elise Prehoda ’24, Sheridan Finnie ’22 and Mialovena Exume ’24 titled "Dismantling Systemic Racism: Reflections on Medical Apartheid."
  • Read a study in BMC Medical Education by a team of Larner students and faculty titled "The design and implementation of a longitudinal social medicine curriculum at the University of Vermont’s Larner College of Medicine."

Future goals for the Social Medicine Theme of the Week include further integration of SMTW into pre-clinical and clinical training, faculty training, and assessment through student reflection and patient outcomes.

Social Medicine Theme of the Week

“Our current system is excellently equipped to deal with a faceless collection of symptoms,” says Erik Zhang ’24, “but once we begin layering in the interacting components of race, gender, mental health, language, and weight, to name a few of the big categories, in addition to the connotations and stigmas carried by each one, we lose the ability to appropriately address the issues being presented.”

It’s this understanding that motivated five Larner students to create the Social Justice Coalition in 2017. This group helped to drive creation of the formalized social medicine curriculum, which was piloted during the 2018-19 academic year. After its founding by Epstein, Dawson, Hausser, Goyal and Lynch, the social medicine curriculum continued to evolve with involvement from Class of 2022 medical students Richard Brach, Sheridan Finnie, and Nikkole Turgeon, Class of 2023’s Krisandra Kneer, and most recently, Class of 2024’s Erik Zhang and Tyler Harkness.

Within the social medicine curriculum, the student-driven Social Medicine Theme of the Week (SMTW) weaves discussions of social determinants of health throughout all courses. SMTW themes are based on the seven learning objectives of the social medicine curriculum, including topics like appraisal of the intersection of social determinants with marginalized populations’ histories, perspectives, and experiences; synthesis of the United States’ role in the “global health narrative;” and tools and strategies to advocate for lasting social change.

Themes align with relevant content taught during the preclinical foundational science courses and PCR. Examples include “The Genetic Basis of Race,” presented during the Foundations of Clinical Sciences course, when students learn about genetics and “Housing and Water,” during the Attacks and Defenses course, in which students learn about toxicology.

Although SMTW has helped raise student awareness of social determinants of health and their impact on health outcomes, the team has created a survey to gauge the level of success so far and guide further improvements to the curriculum. According to the paper that Goyal, Dawson, Epstein, Brach, and Finnie published, future goals include further integration of SMTW into pre-clinical and clinical training, faculty training, and assessment through student reflection and patient outcomes.

“Today’s system dedicates huge amounts of money, resources, and brain power to cutting-edge technology and medications, often at the expense of ground-level, socially-minded patient care,” says Harkness. “Things are changing, especially at Larner, but there needs to be a more deliberate shift in mindset for the ‘physicians of tomorrow."

Written by Michelle Bookless

Envisioning a More Equitable World

The Social Justice Coalition Book Club

The Social Justice Coalition (SJC) Book Club began as a small group of medical students in the Class of 2021 meeting to discuss historic and current injustices in health care and medicine spurred by texts such as Witches, Midwives, and Nurses by Barbara Ehrenreich, Susan Sontag’s Illness as a Metaphor, Coal by Audre Lorde, and Mary Beard’s Women and Power. After a brief hiatus, the book club resumed last summer (virtually via Zoom), as the COVID-19 pandemic and the death of George Floyd highlighted the continued racial disparities and health inequities in the U.S. This time, the group welcomed faculty, staff, and graduate students. Its goal?

“Through the reading and discussion of texts that challenge our perceptions, we are able to envision a more just and equitable world,” says Richard Brach ‘22. “This, in turn, informs our work in continuing to name and combat the racism and structural violence around us.”

Through thoughtfully curated discussion guides and a combination of large group discussions and small break-out rooms, club members share ideas and take a deep dive into each book. In the future, members hope to incorporate additional forms of media such as documentaries, poems, and podcasts onto their “bookshelf.” All faculty, staff, medical, graduate students, and alumni of the College are welcome to join.

Here are a few of the books the club has discussed.

Fire Next Time
Review by Erik Zhang ’24

“Do I really want to be integrated into a burning house?” author James Baldwin demands in this reflection on his experience with organized religion, the individual and collective Black American experience, and the nature of justice and injustice. Caught between his own non-violent vision for Black liberation and a growing militant Black Power movement, Baldwin wrestles with the paradoxical position of strength and weakness held by the Black community in the context of white supremacy. Providing a unique perspective into the thoughts and experiences of one of America’s greatest writers and orators, The Fire Next Time serves as a key introduction for readers who are interested in understanding the dynamics fueling liberation movements of the mid-twentieth century.

Medical Apartheid
Review by Simran Kalsi ’24

In Medical Apartheid, medical ethicist Harriet A. Washington describes how an extensive history of abusive medical practices against Black Americans contributes to skepticism and distrust of the medical establishment. In explicit detail, Washington describes the persistence of racism in health care from James Marion Sims’ mistreatment of Black women in the 1800s to modern day clinical trials and surgical technology through which Black Americans are still harmed. Washington highlights the intersectionality of race, gender, and socioeconomic status. As readers, we must reckon with contextualizing our current medical practices built upon a foundation of “scientific racism.” For current and future health care professionals and researchers, Medical Apartheid is essential reading to begin to understand the history of the current racial health gap in the U.S. From this foundation, we can continue to educate ourselves and take action to rebuild trust.

Pathologies of Power

Review by Richard Brach ’22
Paul Farmer’s Pathologies of Power: Health, Human Rights, and the New War on the Poor draws connections between today’s unprecedented levels of wealth and the exploitation of the poor. While wealthy countries revel in the advances of modern science and globalization, the global poor suffer from human rights violations and die from preventable diseases that cost less than $2 per day to treat. Farmer labels our ignorance “a stain on the conscience of modern medicine and science,” and emphasizes the importance of addressing the structural violence around us. This book is an essential read for responsible healthcare professionals and should be required reading for anyone interested in global health and health equity.

Healing Resistance

Reviewed by Nikkole Turgeon ’22
Healing Resistance details author Kazu Haga’s life and training in the nonviolent legacy of Dr. Martin Luther King Jr. Haga encourages the reader to envision a path towards the “Beloved Community” Dr. King described by explaining the Six Principles of Nonviolence and how readers can take steps to incorporate them into their lives. This book should be required reading for everyone as it provides context and a framework for Kingian principles, which have historically been whitewashed and often eliminated from traditional teaching about Dr. King.

Where do we go from here

Review by Mahima Poreddy ’24
Dr. Martin Luther King Jr. dreamt of “creative dissenters” across different races who strive for racial equity and abolish poverty. Where Do We Go From Here: Chaos or Community expresses Dr. King’s revolutionary opposition against wealth inequality, the Vietnam War, and capitalism. His writing also explores the challenges of being a Black man: “To be a Negro in America is often to hope against hope. It means fighting daily a double battle—a battle against pathology within and a battle against oppression without.” Where Do We Go From Here offers a potent reminder of how ideas like alleviating poverty through providing a universal basic income have been discussed and studied for decades. For all those who strive for racial and health equity, the words of Dr. King that are often ignored by the mainstream media serve as a guide for anti-racist work today.

Red at the Bone

Reviewed by Erik Zhang ’24
Jacqueline Woodson’s multigenerational saga, Red at the Bone, is filled to the brim with poignant moments evoking both hope and despair. An ensemble of characters commands an empathetic response from any reader. Built on a scaffolding of a shared historical trauma, Woodson opens an inquiry into the most salient questions of class, gender, race, queerness, and institutions. Readers will find in Red at the Bone a deep exploration of the many facets of the Black American experience accessible only through fiction, unavailable through testimony and educational material alone.