many medical students and residents across the country make a leap in their
training as they move into residency and fellowship positions. As a former dean
for medical education and former residency program director, the summer months
often lead me to reflect on the experience of those students and residents as
they transition to the next phase of their training. In this edition of Macy Notes, I had the pleasure and honor of speaking
with one of my former medical students, Shirlene Obuobi, MD, now a cardiology
fellow and published author of a dazzling debut novel, On Rotation.
On Rotation features a Ghanaian American medical student who is navigating her way through not only medical school, but also issues related to race and culture, family, and identity. Her book, and our conversation, shed light on some of the very real challenges faced by those who are training to become physicians, especially those who come from underrepresented backgrounds. Our discussion also delves into the way Dr. Obuobi’s art informs her clinical practice, and vice versa, and the vital role that art can play in sustaining oneself through the rigors of health professions education. The following is an excerpt of our conversation.
Holly Humphrey (HH): I would like to begin by asking how you think about art and medicine—specifically, the combination of literature, as you are now an author, and medicine. Are they related? And can you help us learn what inspires your work in both domains?
Shirlene Obuobi (SO): I love that you say the art of medicine because I do think medicine itself is an art. The art of medicine informs the more traditional types of art that I do and vice versa. There is an entire field, of course, of narrative medicine that specifically aims to take in the narratives of patients and clinicians and use them to not only understand disease states, but also to express social inequities. I lean into that.
What we do in medicine is something that is very deeply human. We see people often on their worst days and at a time when they have to entrust their bodies to us, completely, because they don’t know what’s going on. There is something very unique about that experience and very unique about training to be the person who provides that. I find myself creating a lot of content just from those interactions.
HH: On Rotation is telling the story of a medical student, who, like yourself, is from a historically underrepresented group. Could say more about your experience as a medical student—where you found the strength; what you found most challenging; and, in particular, can you give voice to what it was like to be at this largely white, fairly exclusive (in some ways) institution and how you found and expressed your voice? To what extent, if any, does that experience carry over into your art form as a writer?
SO: Being an underrepresented minority in medicine and especially at the hallowed institutions is a pretty unique experience in that we have to do what everybody else does in order to be considered worthy of being there. But we also have to do it with additional invisible challenges. Some people refer to this as the minority tax. To illustrate this: on days when my colleagues could just be studying, I would often be busy recruiting the next generation of Black and brown students, mentoring them and advocating for them. My friends who aren’t a part of a historically marginalized group had no obligation to do that. I recognize I could have just said no, but I, and many of my colleagues in my position, felt a duty to hold the door open for the next generation. And I had been mentored in the same fashion, so I felt an obligation to help others as I had been helped.
There are other aspects of being underrepresented in medicine that are harder to pin down. For example, the Ferguson protests in response to the murder of Michael Brown happened while I was in medical school. It was challenging to see recurrent images of Black people being murdered, and then have to bear witness to media rhetoric about how the victims deserved it (or, in the medical context, silence.) I think what a lot of non-Black people may not appreciate is how much of dehumanization comes in the form of never being given the benefit of the doubt, of never being allowed to make a mistake. We must always bear the full brunt of so-called consequences, going as far as being executed in the street.
I think people may not realize how many Black people truly feel like we’re one bad interaction away from being a Michael Brown, Ahmaud Arbery, or a George Floyd. I actually drew a comic a couple of years ago that talks about a frightening interaction my family had with police several years ago. We were staying at a hotel while our floors were getting redone. My siblings and I were very young, all under twelve years old, and were running up and down the halls around 9:30PM. Someone called the front desk to complain, and the next thing we knew, police were banging on our hotel door. We were escorted out. It’s something that is inconceivable now that I’m older; instead of being treated like children, we were treated like criminals.
It can be very difficult to keep up with the intense rigors of medicine on top of that emotional load. Scoring in the top percentile of your class becomes quite challenging. And on top of that, there is a pervasive sense that we are not supposed to be there, that we are taking up space that we weren’t meant to take. Because of this, there is an added sense that in order for the next generation of Black and brown students to succeed, we have to succeed. That’s a lot of pressure.
HH: You spoke about what it was like to be a medical student and be responsible, not only for your own success but for how that success would reflect on your entire community. How should institutions better manage the minority tax?
SO: From the faculty level, you have to have buy-in and have people who are invested in diversifying of the institution and in supporting careers of underrepresented minorities in medicine. Oftentimes this comes in the form of mentorship, which is something that is generally organic, but it can be guided, in my opinion. You don’t necessarily need mentors from the same background. I have mentors who are from across ethnic backgrounds and genders who have been critical to my career.
Finding those people can be very difficult for a lot of underrepresented minorities because we don’t have the experience of, “Oh, I see myself in you,” as often. Formalizing the process of connecting mentors and mentees and being a little more active in actually linking underrepresented minorities in medicine with mentors could be very helpful.
One of the things I started realizing during medical school was how much mentors influenced my classmates’ success by putting them on papers or inviting them to conferences. My classmates’ mentors would advocate for them. For me to find that, I had to be so, so active about it.
In addition, assigning value to the advocacy, community, and mentorship work that underrepresented minorities often excel in is important. Currently, medicine prioritizes and celebrates test scores and research, both factors that have quite a lot to do with socioeconomic class and race, over other leadership qualities. Institutions can manage the minority tax by changing it from a tax to a boon.
HH: Not only did you begin writing this book as a medical student and then finish it as a fellow, you were also doing your residency and fellowship training during a pandemic. Can you tell us a little bit more about what it was like to be finishing a residency and then starting a demanding fellowship in the middle of a pandemic during a time before the vaccine was available?
SO: It was very emotional. I remember the first few weeks of the COVID pandemic very well. We didn’t know what was happening. We were low on PPE. People were dying. PCR tests would take a week, so we wouldn’t even know whether it was from COVID. There was widespread panic, in general.
We saw so much devastation; I still think about a lot of the patients who were lost. They were younger than I was used to. Families couldn’t come in, so you wouldn’t see the family, but you would talk to them every day. So much was unknown, so we couldn’t really tell them what to expect. Our management was changing daily. But families had to rely on us and believe in us. Miracles were far and few between; it was a dreary time.
I wrote almost all of On Rotation during that time as a way to escape. Writing was a way to process the experience, but also a way to find some kind of joy.
HH: Picking up on finding joy and a way to sustain yourself, are there more things that institutions should be doing to support and promote wellbeing from a system standpoint?
SO: There the very basic ways, such as allowing room to rest and be human and take care of ourselves. Medicine is so high intensity; we deal with intense situations and we have to make intense decisions. A lot of institutions rely on trainees as labor and push clinicians to give as much as they can. Even though most of us chose this field out of love for people, when you take away our ability to take care of ourselves, we lose empathy. I asked my (social media) followers a little while ago, “When was the last time you went to a dental appointment?” The answers were abysmal, because who has time? When can you schedule it? You have one day off, so do you choose to spend it with family or friends who you haven’t seen in forever or go to that one wedding? Honestly, the best thing that institutions can give is more time.
I also feel strongly that institutions should look at what their promotion criteria are—look at who they are keeping out by nature of that criteria. That ties back to our discussion on the minority tax.
HH: Going forward, to the extent that you can see your future, do you envision a career that will combine clinical cardiology with writing and drawing?
SO: Cardiology really doesn’t have a space like this yet. Space for narrative medicine or graphic medicine has been carved out in internal medicine, but cardiology is a male-dominated field that is very basic science and industry-heavy. And here I come bouncing in with graphic medicine and comics and books and love stories! I imagine I’m rather disruptive.
I’ve always envisioned myself in academic medicine, but quite honestly, I plan to go where I’m valued. Regardless of whether I end up practicing in an academic or private environment, I want to educate. I think that there is a lot of room for patient education through narrative and graphic medicine. Education that doesn’t feel intentional, but happens anyway. For example, On Rotation is about a medical student; it’s reflecting on medical education because I wrote it as a resident. People may start reading it because they’re interested in a coming-of-age-slash-romance novel, but they’ll finish with an in-depth glimpse into what medical education is like. My future books are very likely to talk about topics that are prevalent in cardiology; I’d like to write a book about a young woman with peripartum cardiomyopathy. We can write all the resource papers we want. We can write and review articles, and they’re going to be read within the academic community. But art is consumed by everyone. My hope is that I can be a mouthpiece that is very accessible and shine a light on the world of cardiology, the world of medicine, and teach people.
HH: It sounds to me like your art form, both graphic medicine and as a novelist, have contributed very powerfully to your own well-being. Would you like to share any final comments about that?
SO: I often say that people sacrifice themselves at the altar of medicine. What I mean by that is this: when we apply to medical school, we usually are chosen due to our diverse array of strengths and talents. But medicine is all encompassing and, in my experience, seems to demand more of us the further we get in training. And yet, it’s these same strengths and talents that give people joy, that give them an identity.
On my platform, Shirlywhirl, M.D., I often get messages from musicians who haven’t picked up their instrument in years, artists who haven’t picked up a brush, writers whose manuscript is sitting unfinished, who are inspired by the fact that I didn’t abandon my “non-medical” passions when I decided to become a doctor.
I think that one of the crucial ways that we could potentially promote physician wellness is allowing people to be who they are and grow into their strengths. Being a cartoonist and a writer is not something that is necessarily typical for a medical trainee. But I am far from the only creative who goes to medical school. I would say that a lot of us are attracted to medicine for the “art” aspect of it.
I understand their hesitation, though. Right now there is a lot of focus on particular kinds of research, at least in academia. Because of that, I’ve had to say [of my art], “No. What I do matters. It’s relevant to medicine.” I think there are a lot of other talents that are relevant to medicine—talents that can contribute to the world in big ways. Allowing people to bring their various talents to the field can make them happier and also enrich the field in lots of ways.