On Sleeping on Couches and Diversity in Medicine S. Luckett-Gatopoulos Medicine, Science & Medicine, Society & Culture Sometimes, I Had a Bed of My Own Growing up, I spent many nights sleeping on couches, floors, and pull-outs. I shared beds with other kids or slept in sleeping bags. Sometimes I had a bed of my own, but it might be for a month, or a few months, or maybe just for a night or two. I might leave, or I might be asked to let someone else sleep there. Sometimes I had a bedroom, but often I didn’t. Once I moved to the couch because a hole opened up in my bedroom ceiling, letting the snow in. I closed the door to that room and never opened it again. I was always ready to move. The night before starting grade 8, I moved into a basement one-bedroom apartment with my father. I hadn’t seen him in months, but he showed up unannounced, and I packed my belongings into a cardboard box and a plastic bag. I picked up my cat, and left my family—my father’s ex, her toddler, and her autistic school-aged son—in my father’s busted-up van. He had slunk off months before, leaving financial and emotional destruction in his wake. The next day, my best friend waited for me in the playground, and I never showed up, because I had been withdrawn from my school and started at a new one across town. I don’t blame my parents (I see them as pretty troubled people, doing the best they could with limited resources), but my childhood was chaotic, the result of the haphazard choices they had either made or failed to make on my behalf. My adolescence had scarcely more structure or predictability as I bounced around, living now with that friend, and later with another family, buying bus tickets to visit an older boyfriend in Toronto and working jobs at a local recreation centre and a telemarketing office. I was academically talented and was fortunate to attend an alternative high school that accommodated the vagaries of my schedule and living situation. The administration allowed me to register for classes without a parental signature, which was essential to my academic success during those times when I couldn’t find my father. I was involved in synchronised swimming, which kept me on track but also necessitated constant lies about who I was living with, where, and why. I eventually left when it turned out that no one was paying the synchro bill. I kept secrets from my friends, who I didn’t want knowing that I was feeding myself on popcorn and pasta at night, the only food I could afford as a sixteen-year-old living alone. Just prior to my final year of high school, I was kicked out of my father and stepmother’s home and subsequently evicted from the place with the hole in the bedroom ceiling. I reconnected with my mother, who I hadn’t seen since I was ten. I moved in with her, my stepfather, and my toddler half-brother. Soon we were joined by another half-brother, 18 years my junior. Briefly, my younger brother joined us. There was a lot of conflict, predictably, since I was a strong-willed teenager used to making adult decisions on my own and fighting to defend my space. I didn’t share, and I didn’t know how to live peaceably with other people. I Could Not Afford to Continue Attending University Shortly, I left for university, where I floundered. I was scared and felt inadequate. Academically, I underperformed, the lack of structure and personal attention pushing my tenuous organisational skills and limited focus past the breaking point. I failed first year calculus, and barely squeaked by in physics and chemistry, achieving a first year GPA of 2.34. Financially, I was without the support of my parents, which meant that I relied on the campus food bank and emergency grants from my college that allowed me to do things like buy a winter coat and boots. I worked overnight and weekend shifts at a group home in addition to working as a research assistant to supplement my student loans and bursaries. I lied to my friends about just how bad my finances were. Just at the point when I had improved my work ethic and study skills and was carrying an annual GPA of 3.9, I realised I would have to drop out. I could not afford to continue attending university. At that point, my uncle and aunt miraculously came into my life, generously funding my education and allowing me to finish my undergraduate degree. Around this same time, I nearly failed a neuroanatomy exam. The professor, Dr. Stewart, had a policy that she meet personally with each under-performing student. It was at that meeting that she changed my life simply by asking what I planned to do with it (since I, in her words, obviously was not going to be a neuroanatomist). Up to that point, my mind had been so occupied with survival that I hadn’t seriously considered career aspirations. When she suggested medicine, I balked; there was no way to get there from where I was. Still, the seed was planted, and I thought—and talked—about it a lot in the coming months and years. People Took Chances on Me I scraped together the money to write the MCAT the first time, and it wasn’t easy. Not only was there registration to pay for, but I also had to buy a prep book. I worked in a research lab that summer and studied in the library every day after work. Then I would work out in the school gym and head home or to my serving job at Marche. Despite my studying, I scored something low in physical sciences, maybe an 8 (trust me when I tell you that your MCAT scores are completely forgotten once you’ve gotten in). I knew I would have to write again, but first I finished university and went to college for American Sign Language and Deaf Studies. I very much wanted to learn sign language, but college was also an avoidance strategy. I knew that I would have to start paying back my student loans once I was out of school, and staying in school was a way to explore a career, work (college being far less time-consuming than university), and avoid making loan payments. College wasn’t a bad idea, but I decided not to pursue schooling to be an interpreter. Instead, I finished my one-year program and applied to graduate school. When the interviewer told me that I would be rejected due to my first year marks (plus a C in second year statistics), I asked her to hold my application for a month. I then bombarded the admissions office. I sent additional letters of recommendation. I sent evidence of productivity. I even sent a letter from a statistics professor who put me through a test to prove that my statistics skills had improved. I sent an impassioned plea in which I tried to explain my personal growth and the love I had developed for research. After a second agonising month, I was admitted. While I was in grad school, I wrote the MCAT again; this time, I still worked while studying, but registering was less of a financial hardship because of the graduate school stipend, work income, and support of my uncle and aunt. I did well and applied to medical school. I Know There are Others Out There Like Me I soon learned that the MCAT was not the only financial hurdle. Applying was expensive, and I couldn’t apply extensively because I couldn’t afford the application fees, the charges for transcripts, and all the other incidental expenses that come along with the process. But I did apply, was rejected pre-interview at a few schools, and was offered an interview at one school. I also convinced one school to interview me despite having rejected me pre-interview. I was actually accepted at that school, but chose to attend a different program. Why tell you this story? It’s embarrassing. It feels like standing naked in front of a crowd. But it’s also an important story that I hope explains my feelings about diversity in medicine. Diversity isn’t just about rural applicants, and it’s not about PhDs, either. It’s about inviting people from all walks of life to participate in providing health care FOR people from all walks of life. I know there are others out there like me. Smart and capable, these people are lost to medicine because they aren’t as lucky as I have been. I was lucky to have synchronised swimming in my life, which provided discipline, guidance, and role models. Synchro taught me that much was expected of me, and I became comfortable competing alongside others far outside my family’s income bracket. I’m lucky because I was a Scout, and learned early that I had a responsibility to myself, to my peers, and to the larger world to both achieve and give back. I learned to trust that the world was not a threatening place and that I had agency for change in my own life and in the lives of others. I’m lucky because there was an alternative school available to me, and because a guidance counsellor called me into her office and helped me apply to university. I’m lucky because a university professor picked me out of an enormous group of undergraduate students and helped me find my way. Finally, I’m lucky because I had extended family who supported me unconditionally and found a way to make university work for me financially. People took chances on me; I was swept up in a tide of people who believed in my potential. As importantly, I was buoyed by those who had the social, academic, and financial means to carry me toward my goal. There are others out there like me, but they’re not as lucky. Most have never thought of medicine as a career, or have dismissed it because they don’t know how to get from where they are now to where I am. Many come from families where education isn’t valued, and they aren’t supported in scholastic pursuits. Others are supported by family but not by a broader community, which instead conspires to keep them on the lowest rungs through institutionalised racism and classism. Some simply do not have access to the education or financial means to pursue medicine. Almost all lack concrete, positive role modelling. Even for those who have decided they want to pursue medicine, the course they chart isn’t an easy one. For some, registering for the MCAT means that they can’t feed themselves or their kids. Maybe they will lose their jobs if they take the day off work to write the test. More likely, they have learned through hard experience that the world doesn’t value their contributions, and they don’t see a point in trying just to be slapped back one more time. They’re valuable, though, and we need to figure out how to get them into medicine. When I see patients in the city I grew up in, I get them. Sure, I’m not a 52-year-old woman with chronic obstructive pulmonary disease, but I get how she got there. I’m not a 38-year-old obese man with alcoholism and poorly controlled diabetes, but I get that, too. I hear my colleagues joke about patients who come in, and others who become angry and frustrated because of the stupid decisions that bring patients to the point of poor health that we all pay for in a universal health care system. Sometimes I join them. I hear suggestions that we should limit access to the emergency department, that people should pay for their poor choices by being restricted from receiving on-going high-cost care. The uneducated, poor, and socially disadvantaged are disproportionately the brunt of the joke, and the carriers of the blame for the state of our healthcare system. That’s unfair, but I can’t blame my colleagues. Until you have slept on a park bench, it’s hard to understand the series of non-choices that brings people there. Until you have lived on plain spaghetti and popcorn, it’s hard to imagine why people can’t just eat healthier food. Medical school is full of many wonderful people who genuinely strive to contribute in a positive and meaningful way. In medical school, I met students from a variety of cultural and religious backgrounds. Some were straight, others queer. Some were parents, others still living at home. Geographically, they hailed from across Canada and beyond. Some were from rural and remote communities, others from urban centres. Yet few had experienced the barriers to good health and education that come from very low socioeconomic status. Because of that, few can relate to the poor health and very low socioeconomic status that so many of our patients experience. I don’t have a solution. I’m still learning the system, and I don’t know yet how it could be changed to give our communities more of what they need. I don’t know yet what my role is. What I do know is that things need to change. We have created a highly competitive system for admission to medical school that ensures that the most academically gifted students become physicians. This isn’t a bad thing; medical school is difficult, and medicine requires a commitment to on-going education. In short, medicine requires smarts. But that’s not all it requires. It also requires the compassion and empathy that come from experience. It demands perspective-taking. It calls upon us to be kind and non-judgmental, not just pleasant or nice. So, my brilliant colleagues, I humbly bring the question to you: How can we bring more diversity into our medical schools? How can we find not just the smart, but also those who have difficult stories, experiences, and perspectives to share? This post was originally posted on the author’s website and is reposted with the author’s permission.