The Medical Student Teaching Medicine About Structural Racism

; LaShyra T. Nolen


May 25, 2022

This transcript has been edited for clarity.

Robert A. Harrington, MD: Hi. This is Bob Harrington from Stanford University here on and Medscape Cardiology. As we often try to do, in addition to covering what I'll call the latest science in the field of cardiovascular medicine, we try to touch upon topics that are really hot in our community, trying to bring awareness to conversations that are happening in society, within the specialty, and among colleagues.

In this particular week, I'd like to talk about maybe one of the most important issues in medicine today: issues of how structural racism leads to some of the social determinants of health and results in worse health outcomes, including among individuals with cardiovascular disease for certain racial groups. For example, we know that Black men have much worse outcomes from cardiovascular disease than White men. These are the kind of topics that I want to get into with our guest today.

I have been looking forward to meeting this guest for a while since I started reading her pieces. My guest today is a Harvard Medical student, LaShyra Nolen. LaShyra also goes by "Lash," so after this intro, I will be referring to her as Lash.

She is a rising fourth-year Harvard Medical student. She is also beginning her studies for a master's degree in public policy at the Harvard Kennedy School — as if she didn't have enough to do with medical school. Importantly, she is the first Black female class president at Harvard Medical School. Something I didn't know, but many of you who are Harvard Medical School grads or who trained in the Boston programs will know, the Harvard Medical School class president serves through the duration of that class time at Harvard. She's had great sense of oversight of her class and great understanding of the medical education process.

As a background, she was born and raised in Southern California. She went to Loyola Marymount University, where she received her undergraduate degree, and then went to Spain as a Fulbright scholar. While in Spain, she focused her research on issues around obesity and diabetes, certainly in keeping with the metabolic issues in cardiovascular medicine and cardiovascular prevention. She also spent time leading conversations and teaching Spanish teenagers and young adults on topics related to health inequities, disparities, and racism.

With that as background, I'm really excited to introduce our audience today on Medscape Cardiology to Lash Nolen. Lash, thanks for joining us.

LaShyra T. Nolen: Thank you so much for having me, Bob. I'm looking forward to our conversation, and I know it's going to be very rich.

Harrington: Well, I appreciate you taking the time with all you're doing. I suspect you have less time than I do, so thank you for jumping into this.

Lash, I read a couple of pieces that you have written in the past 18 months or so. One was in The New England Journal talking about what's missing in medical education, and the other in the Huffington Post, dealing with what I found a fascinating way of framing a question: What's the answer that you really want to give when a professor that often looks like me, a White older man, asks you, "How are you doing today?'"

I'm going to try to frame some of my conversation around those and really try to get at what I'll call societal issues, institutional issues, and then individual issues regarding health inequity, disparities, and racism, and maybe try to teach our audience about some of the terminology that is important to understand.

Phrases like anti-racism — what does that mean? What should that mean for us as individuals? Let me stop, and maybe I'll ask the intro question. How did you get interested in this intersection of racism, health inequity, and medicine?

Nolen: Yeah, let's go into the foundation and how this all started. Again, thanks for having me, Bob. I'm really glad that we're going to be focusing our conversation on this important topic.

The way that this journey started for me is, as you mentioned, I grew up in Southern California. I spent my early childhood in Compton, California, and I was raised by an amazing woman, Ty Harps, who raised me as a single parent, but had a lot of support from my amazing family. My mom was the first in our family to both get her bachelor's and her master's degree.

It was really seeing her work hard and put such an emphasis on education that made me want to do the same. That was despite the fact that I had no one in my immediate family who was in medicine or the allied health fields.

I started to develop this love of medicine and science in the third grade, when I won the science fair at Amber Elementary School. From that point forward, I really was into this idea of becoming a physician, and my family believed in that dream, and they supported me in wanting to do that.

I first started to understand differences when my family moved from Compton, California, when I was 10. We moved to Rancho Cucamonga, which is a predominantly White suburb about an hour out from Compton, LA.

When I went to Rancho Cucamonga, I was suddenly the only Black girl in my class. Suddenly, there was a Trader Joe's, which I had never seen before in my life. There were no longer potholes in the streets on my way to school. I was definitely seeing how there was a differential access to food and healthy living.

That difference is when I started to think about why those things exist. I also started to pay more attention to how a lot of my family members were unfortunately losing their lives to preventable diseases. My stepfather, when I was 15 years old, died from preventable heart disease.

When I went on to college and learned about public health and the social determinants of health, it brought everything full circle because it was the differences that I saw growing up and seeing my family members be impacted by a preventable disease. I then realized that there's more to the picture that can't be solved just by looking at the science behind medicine.

You mentioned a bit about my first gap year in Spain, when I was working with Spanish youth. For my second gap year, I was in Chicago doing a year of service with AmeriCorps, and I was a health educator at a federally qualified health center there, known as Heartland Health Centers.

When I was there, I lived on the South Side of Chicago, but I worked on the North Side. Every day when I would come home from work from the North to the South Side (it was about an hour train ride), I would notice that at the Roosevelt stop — my folks from Chicago might be able to relate to this — all of the White folks would get off the train. As we continued into the South Side, everyone would be Black and Latinx. Similar to Compton vs Rancho Cucamonga, I saw those differences between the communities.

I soon learned that the life expectancy drops about 20 years when you go from the North to the South Side of Chicago. That itself is a manifestation of the racism that I saw speaking to patients as a health educator.

All of this said, I think there were just these examples of systemic racism and this intersection of health that kept coming up throughout my entire life, that really culminated in why I wanted to go into medicine and gave me that health equity lens as I entered my first year of medical school.

Harrington: You've just listed so many topics that I wanted to get into with you, and you said it in a way that, I think, is going to really help our listeners think about how to frame their own learning and conversations on the topic.

One of the things that really struck me that you said was that, as you moved to another community that was predominantly White, from your younger childhood in Compton, you looked at things like access to foods — access, I suspect, to healthy foods, fruits and vegetables, and this notion of food deserts.

You also made reference to something that I often refer to, which is that your zip code is far more determinant of your health than your genetic code. Packed within that is something that the American Heart Association, for example, has been very interested in, which is how to understand structural racism, which leads to things like food deserts, access to insufficient housing, etc.

Let me ask a basic question. Explain to our audience what is meant when we say structural racism.

Nolen: Absolutely. Bob, to answer this question, I go back to a mentor and scholar who many of us look up to, and that's Dr Camara Jones. She is a phenomenal clinician and public health advocate who really helped us understand this idea of racism by breaking it down into three different categories.

The first is that we have structural racism that exists on a broad societal level. When we think about structural racism, we have to think about the fact that in 1619, when enslaved people were brought to the colony of Virginia, those individuals' interface with health was to be healthy enough to continue to do forced labor, and how that is the first relationship that Black folks came to know medicine and its purpose in their everyday lives.

From there, we can start to conceptualize all the different ways that the medical institution has been directly complicit in racism in society. We think about Marion Sims and his operating on Anarcha, Betsy, and Lucy, who were three enslaved women that he predominantly operated on to figure out the cure for vesicular vaginal fistula. Then we think about Carl Linnaeus who was a biologist who had a direct role in creating different stereotypes that were associated with different skin colors and different personality types associated with those things that persist in our understanding of different groups.

Then we think about Samuel Cartwright, who created this mental illness known as drapetomania, which was used to describe when enslaved people wanted to escape slavery. It was, once again, this idea that the medical institution wasn't these folks, who didn't have a direct role or maybe had an auxiliary role in amplifying systemic racism, but actually pushed it forward. When we think about racism on a systems level, it's how it's actually embedded in our everyday living.

Who has access to jobs? Who has access to healthcare? How do institutions play a direct role in helping further that? When we go from the societal level, we can then start to think about the racism that occurs between individuals, and that's when we think about interpersonal forms of racism.

That's kind of when we have those biases and prejudices start to play out — how we might decide that I'm going to go to the other side of the street if I see a Black person walking toward me; or when I see a person whose name is LaShyra vs Vanessa — something they might be more familiar with — I'm going to look over their application. There are so many different studies and statistics that we've seen that prove exactly that.

Then, after you think about it on an interpersonal level, then it's the individual level, when you start to think about internalized racism. If you are that person that lives on the South Side, you are that person who has an uncommon name who gets passed over for interviews, you might start to think that you have inherently done something wrong to deserve to never have access to opportunities. You start to internalize the way that society and the world have made you feel.

That's how you can think about racism. It's important to be anti-racist because you have to take action to actively fight against these systems. The author Eve Ewing, the way that she describes racism, it's almost as if you're winding up a wind-up toy, and it just goes and operates on its own. She also describes it as a merry-go-round. You don't even realize that you're on the ride until you take the active effort to get off of it.

I think that when it comes to being an ally in fighting against these forms that I've expressed, you have to actively learn about it and make tangible actions to really push against it.

Harrington: That was really well described. Thank you for taking it from the different levels.

I'll ask our readership, our listenership — whichever mode you're getting this podcast — to really take the time to look at the American College of Cardiology's documents on diversity, equity, and inclusion work, and take the time to look at Keith Churchwell's call-to-action paper on structural racism and social determinants of health as important drivers of overall cardiovascular health. Please do take a look at those.

A couple of things I want to try to unpack further. You wrote this really terrific piece in The New England Journal about how, I think you used the phrase "medical education is missing the bull's-eye." You gave a couple of examples, if I remember correctly, in your CPR training and in your dermatology class looking at Lyme disease — or maybe it was a Lyme disease class looking at skin manifestation of the disease. You make two really important points, one of which is that, "Am I only going to do CPR on White men?" When I look at the mannequins...

Nolen: Right.

Harrington: That makes you think about it. What about the woman who's pregnant? Wow, that is such a straightforward thing. Why don't we ask ourselves that?

The other was when the professor was showing pictures of Lyme disease and did not necessarily spend much time trying to figure out, looking at that punctate and the surrounding ring of Lyme, it might be easier in White skin than it is in Black skin, so can we see some examples?

Do you want to comment on that paper? Again, for our listenership, please do take a look at it. We'll make the link available on the site.

Nolen: Absolutely, Bob. As I said earlier, when I came into medical school, I had this health equity lens. It was all of these life experiences that I had that really helped me conceptualize and understand the importance of always thinking about who wasn't being represented, who was not in rooms, and what I could do to make sure that I was bringing the struggles and the experiences of my community and the people that I cared about into a space like Harvard Medical School.

When we were in class, for example, learning about Borrelia burgdorferi and Lyme disease and being in the Northeast and how important it was for us to know how to recognize that bull's-eye rash, my classmate raised his hand and said, "As a Black man, I would like to know how I would recognize this in someone whose skin look like mine."

The professor didn't know how to answer that question in a very thoughtful way. That really kind of tipped me off to say, "Wow, when we don't have equitable representation of skin tone in medical education, that has a direct implication on the care we're able to provide patients of diverse backgrounds."

I think that paper was really this call to action to say, if we're going to say that we're anti-racist, if we're going to say that we care about all patients and graduating physicians and clinicians who are really committed to that work, then we need to make sure that we're having exposure to this material.

I think that was the first time that I was able to draw this line between such a clear example of how when we don't have equitable representation it leads to patient outcomes. In that paper, I talk about how Black patients are less likely to be diagnosed with early-stage Lyme disease, and the authors think it's likely because we're not learning how to recognize it earlier on in patients with darker skin tones.

We know that the thing about Lyme disease is that if you don't catch it early, it can become early disseminated, then it becomes late stage, and then you have neurologic and cardiac manifestations. I think that is a perfect example of what happens when we don't catch something early. Also, for me, that piece was about intersectionality, which is a term that was coined by Dr Kimberlé Crenshaw.

It's about when you have intersecting marginalized identities. For example, if you are a Black person, but you're also a woman, and you also have a disability, and you also are lesbian, all of those things come together to make it such that you have a difficult experience traversing and finding a way to get through life because of the way that society makes you feel and blocks you from opportunities.

When I thought about the CPR piece, it made me think about how, if you are both Black and not being able to get your Lyme disease recognized, but then you're also a woman, that means that someone might be less likely to complete CPR for you because of the nervousness that they have around not getting that training and practice.

All these things kind of come full circle. I think it's a perfect example of how it can manifest in medical education.

Harrington: Yeah. I thought it was a really terrific piece. It reminds me of conversations that I've had, in many settings, with my colleague Dr Michelle Albert, who's at UCSF and is the incoming president of the American Heart Association. Dr Albert talks often about the intersectionality of particularly being Black and being a woman, and how those things, in many cases, are not just additive but are more than additive. They really accelerate some of the health inequities and some of the way that care is delivered.

I thought the Lyme disease one was really perfect because if you just look at the endgame and say, "Oh, why is it that Black people have worse outcomes than White people with Lyme?" Well, you have to go to the beginning: How were the people that make the diagnosis being taught? Fabulous example. I suspect we could banter back and forth on this one and find many examples.

Your other example was about Band-Aids: Why aren't Band-Aids my skin color? These are just things — again, it's built into the system. That's why it's so devastating, because it's built into the system.

I know we're coming to the end of our time, and I'm going to go off script here with something that I didn't prepare you for. As I'm looking at you during this interview, I see a photograph of a woman — it looks like an older picture — over your shoulder. I suspect that somebody in our audience will know about her. Can you tell us about her?

Nolen: Yes, absolutely. The woman in this photo up here is Ida B. Wells, and she was an anti-lynching activist. She was doing work in the South and was documenting all of the forms of lynching that were happening there. Then she moved up to Chicago and did work there as well.

What was amazing about Ida B. Wells is that she was very much committed to documenting the truth and sharing the truth, and she often had to risk her life to do that. Her printing press was burned down and she often was threatened, but she was committed to doing the work.

I'm still learning so much about her, but for me, she's just this beacon of reason and someone who I really strive to be more like every day. That's why I have her picture up there — because she reminds me to stay committed to my purpose.

Harrington: Well, thank you for answering, particularly because I didn't give you a heads-up earlier.

Nolen: Absolutely.

Harrington: It's been catching my attention. Thank you for sharing that. She sounds like a remarkable woman who could serve as a beacon and a role model for all of us, as we try to make society, medicine, and cardiovascular medicine a better place.

Lash, thank you for sharing your time with us. I know how busy you are, and I appreciate your willingness to share your views, your thoughts, and your perspectives with our audience here on Medscape Cardiology.

Again, my guest today has been Lash Nolen, a rising fourth-year medical student and the first Black female to serve as class president at Harvard Medical School.

Lash, it's really been a pleasure for us here on Medscape Cardiology and

Good luck and remember to keep Stanford in mind when you're applying to residency programs because we would be a better place with your talents here. Thank you, again.

Nolen: Thank you so much, Bob. It's been a pleasure.

Robert A. Harrington, MD, is chair of medicine at Stanford University and former president of the American Heart Association. (The opinions expressed here are his and not those of the American Heart Association.) He cares deeply about the generation of evidence to guide clinical practice. He's also an over-the-top Boston Red Sox fan.

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