Monica Vela, MD’93, who has faced health-care disparities as both a physician and a patient, teaches students about the issues that afflict underserved communities, inspiring many to reach out.
Monica Vela, MD’93, needs to leave soon for a talk she has delivered dozens of times. She knows the information as well as her own life story. If she forgets a detail, the thumb drive clipped to the lanyard around her neck contains her PowerPoint presentation, with data about health-care disparities and the Pritzker School of Medicine course she developed on the subject. As the daughter of Mexican immigrants who settled in Chicago's Pilsen neighborhood, where the family had limited access to medical care, Vela also has a background that adds first-person witness to the problems she describes.
Fluency with the topic and experience as a speaker does not ease Vela's anxiety. She's so nervous about addressing Rush University Medical Center's health-policy faculty that she takes a cab instead of driving herself. Rolling down the window on a humid May afternoon, she holds her hair back to let the wind cool her face. "If you'd have told me ten years ago that I'd be talking to groups of hundreds of people," Vela says, "I'd have run out of the room." Part of her still feels that urge.
Instead, half an hour later she stands at the podium at Rush's Field Auditorium, where about 50 people have gathered over sandwiches and cookies to hear her explain Pritzker's five-year-old health-care disparities curriculum. Using informational maps, Vela offers the basics about the community the University of Chicago Medical Center serves: four of the city's five poorest neighborhoods, afflicted with a wide range of public-health problems, surround Hyde Park. A dearth of health-care facilities throughout the South Side compounds those problems. Clustered dots represent the density of hospitals and clinics on the North Side; to the south, the dots become sparse—and those facilities are less accessible by public transportation. High premature-birth rates and diabetes mortality characterize the underserved neighborhoods. Many are food deserts, lacking healthy, affordable fare and contributing to the prevalence of obesity.
Since 2006 Pritzker students have learned about these issues at the beginning of medical school, taking the required health-care disparities course at the same time as anatomy. They're encouraged to develop creative solutions, but first the students have to understand the communities and individuals they're serving—and themselves.
The incoming students, Vela says, envision themselves as postracial and less susceptible than past generations to prejudices that lead to unequal care. She argues otherwise, insisting that doctors must recognize their biases when treating patients with a different cultural background, financial situation, or sexual orientation. Ignored differences can compromise communication and, by extension, a patient's quality of care.
Cultural differences color perceptions, as one assignment illustrates. Students write the first word that comes to mind when they hear "physician" and then repeat the exercise using "welfare recipient." They tend to associate physicians with altruism, intelligence, and wealth. White and male also come up often. Welfare recipients bring to mind poverty, ignorance, and helplessness. Many students think of welfare recipients as African American. "Look at how disparate these two groups are when you think of them," Vela says to the class. "How are you going to be able to walk into the room as a member of this group and treat a member of this group unless you do a lot of reflective exercise?"
That reflection requires recognizing more than racial or socioeconomic differences. "It's very easy to think along just racial lines," says third-year medical student Robert Stern, "but the health-disparities class tried very hard to recognize the range of different groups that can be affected by these issues." Sexuality as a barrier to equal care comes up in the course, for example, as well as the challenges of treating patients who do not speak English. Even bilingual students sometimes find that they have "false fluency," lacking an understanding of language nuances or cultural resistance to certain types of treatments.
From the beginning, students come up with their own ideas about how to deal with the problems. One group had a friend drop them off in the middle of a poor South Side neighborhood. Their mission: to determine how much it costs and how long it takes to reach Cook County Hospital. After two bus rides, with a one-mile walk in between, and $7.50, they arrived almost three hours later. "If you're feeling sick," Vela says, "it's going to take an awful lot to get to County Hospital."
Some projects that originate as class presentations continue long after the quarter ends, carried on by the organizers—as their intensifying medical-school schedules permit—and younger students interested in the same topics. The Pritzker Mammography Access Partnership, begun in a 2009, still helps uninsured women locate facilities that offer free mammograms. The Comer Food Project provides meals for families who can't afford food during their children's stay at the hospital. And middle-school students learn healthy eating habits from the On a Mission for Nutrition team.
To highlight the health challenges inherent in underserved neighborhoods, Vela tells her Rush audience about a boy who was amazed at a piece of fruit; he told the Pritzker students leading the after-school nutrition program that it was the first time he had seen a fresh peach.
An associate professor of medicine who became Pritzker's associate dean for multicultural affairs July 1, Vela had believed for years that care inequality needed to be addressed in medical school. She often discussed the subject with fellow U of C internist and professor Marshall Chin, who has done research on health disparities. If she could choose anything she wanted to have the biggest impact, Chin asked her, what would it be? Vela's answer: establish a health-care disparities class. "I knew right away this would be a perfect fit," Chin says. "She has just the right set of life experiences to be the leader of this course. She knows what it means to be a minority patient or a patient with limited means."
Life outside Pilsen—and even outside her own strict household—once seemed beyond Vela's imagination. From an early age she had a curiosity about the world but few opportunities to pursue her interests.
As a second grader, she remembers, Chicago Symphony Orchestra music director Georg Solti visited her school. Class preparation included learning about classical composers, which taught Vela that someone had tried to steal Mozart's music. "I thought this was a very important thing I needed to tell Georg Solti," she says. For the hour that he spoke, she kept her hand raised.
"What is it that you want?" Solti eventually said.
"Did you know somebody tried to steal Moe-zart's music?"
"Well, first of all, it's Mote-zart, and second of all, where did you hear this?"
"We heard a tape about it yesterday to get ready for you."
Solti laughed, asked for her name and address, and sent her a signed album.
"I have it to this day," Vela says. "It's so incredibly meaningful because these were the people that created a venue for me to leave this isolated community and realize there was a whole other world out there."
Awareness of that world and actually reaching it were two different things. Vela's parents, like most others she knew in the cloistered Mexican community, allowed her to leave home only to do something with educational value. Those restrictions made her eighth-grade visits to Saturday College at the University of Illinois at Chicago feel like wild freedom.
Vela and a group of friends would walk more than a mile to save bus fare. As part of the University of Illinois program, eighth graders received writing and math tutoring from college students. For Vela, it was also a lesson in ambition. "Being on that campus made us realize this was a possibility for us, that we could actually go to college," Vela says, "that we could actually list this as one of our goals."
She received a scholarship to St. Ignatius High School, funded by local physicians for students from Pilsen. But her first encounter with more privileged peers came as a shock: "I had two pairs of pants. I came home and washed one pair and put the other one on."
When a classmate teased her for choosing to study Latin—"it's not like you're going to travel to a country and speak in Latin"—Vela wondered what language the other girl had picked.
"French," she said.
"Oh, like you're going to France?"
"I'm going to France this summer."
"My jaw hit the floor," Vela says, "because I realized, that's actually possible."
She managed to work around some obstacles. To research term papers, Vela waited outside the UIC library for a group of students to enter. Trying to blend in with them, she would sneak inside and spend hours copying information from books she could not check out.
Those days fueled her first professional ambition: to be a librarian. "I wanted to be surrounded by books and smell them and enjoy reading them whenever I wanted to."
Vela carried that notion with her to the University of Illinois at Urbana–Champaign. Her parents didn't want her to go. They believed a young woman should not leave home except to get married. Before she left for college, her mother lit candles in prayer that something would stop Vela from leaving. Her father refused to drive her to the bus station. She went with a friend, riding an overnight Greyhound that arrived around dawn; they waited outside the administration building until it opened. When she visited home a month later, Vela says, her parents were relieved that her personality had not changed.
Her goals soon did, to serving neighborhoods like her own: underserved and underinsured communities, where a family doctor meant whoever could see them at Cook County Hospital, and where dental checkups were unaffordable luxuries. (By the time she first went to a dentist, at age 21 through her university's student-health service, Vela had 12 cavities.)
Studying psychology at Illinois, she received a summer minority-research fellowship. Her mentor, Tony Waldrop, now the University of Central Florida provost, encouraged the "painfully shy" Vela to pursue her interest in research, instilling confidence and communication skills that made her "believe," she says, "that I could thrive in a science-based career."
She followed that interest to Pritzker for medical school and her internal-medicine residency. While there, she and a friend established the sort of program her health-care disparities students now develop, Medical Students for the Medically Underserved. Her initial optimism—or perhaps naiveté—inspired her to practice at St. Basil's Clinic on Western Avenue after her residency. "We were very idealistic and very excited," Vela says."I hit reality working out in the community, and I realized how resource-poor you can be."
Treating people who had little or no insurance, Vela struggled to refer them to hospitals for specialized care, which the clinic's patients often desperately needed. People would show up at St. Basil's with untreated high blood pressure and diabetes—conditions they never knew they had—or worse. "I'm talking about women walking in saying, 'I have a lump and I don't know what to do about it,'" Vela says. "Really palpable masses."
The clinic helped patients with few other options, but the economics were unsustainable and St. Basil's closed, a blow to the idealism that drew her there. Returning to the University as a clinical-skills assistant professor helped restore her optimism—a year and a half away from an academic medical center had made Vela realize how much she loved teaching during her residency.
There was a rash Vela had been dying to see. She was working at a private hospital after her residency and a patient showed up with it. "Fortunately, it was a completely benign but rare rash, and I said to the patient, 'I'll be right back.'" She went into the hallway looking for students. When she couldn't find any, Vela rounded up the nurses and said, "You have to come and see this."
The nurses were intrigued, but they had to get back to work, leaving Vela alone with her excitement. “That's when I realized," she says, "I really have to be fed by some students."
The students sustain Vela's enthusiasm, which sometimes suffers from the dispiriting experience of dealing with health-care disparities. After a group of first-year medical students presented their idea for the Comer Food Project in 2009, she thought to herself, "such a nice topic, but that's never going to happen." Too much red tape and extra responsibility for social workers and nurses would make it just another well-intentioned idea doomed amid the hospital's more pressing concerns. Yet since then the program has thrived, stocking a closet in the Comer Children's Hospital chapel. With the help of Comer chaplain Karen Hutt and staff social workers, the program now distributes food to about ten percent of families at the hospital. "They just made it happen," Vela says, presenting it as a lesson in perseverance that she learned from the students.
Stern, a Comer Food Project organizer, insists that Vela played a large role—even if it did take a while to get her e-mail response. After some initial success with about $1,000 in funding from a community organization, the program needed more to continue and to extend its reach. Stern sent Vela a note asking for advice.
Days went by. Nothing. After more than a week, Vela wrote back, asking if the students could meet with her the following day. "When we got there she had the giddiest grin on her face," Stern says. "She tells us that she's been able to get us $7,000 in funding from the hospital and the Urban Health Initiative," the medical center's program to improve care on the South Side.
For many of the student projects, Vela taps into her network of colleagues and organizations for funding and other resources. A science club at Englewood's Sherman School began when Alisha Ranadive, an incoming Pritzker student this fall, called to ask Vela's advice about developing a curriculum. They met with a Lab Schools teacher, researched what materials they would need, solicited donations, and secured a $5,000 grant from the University.
"We were psyched," Vela says, "so we sat here and ordered books the students didn't have."
Sometimes Vela stirs enthusiasm the medical students didn't know they had. "A lot of times we'll walk out of a meeting with Dr. Vela and say, 'What just happened?'" says third-year medical student Katie Raffel, who helps lead the school-nutrition project. "We'll find ourselves committing to like 12 more things. Her ability to motivate people is just incredible and why so many of these projects continue."
The projects also continue because Vela structures the course so that students follow their own interests. Although her personal history helps the issues resonate with students—"I was your patient," she tells them—Vela tries to facilitate class discussion rather than influence it. She invites experts from the University and around the country to lecture. Speakers have included Harriet Washington, the author of Medical Apartheid; SSA professor Harold Pollack, chair of the Center for Health Administration Studies; and Eric Whitaker, MD'93, the Medical Center's executive vice president for strategic affiliations and associate dean for community-based research. The class explores the social and genetic components of race, examines the racial and socioeconomic influences on conditions such as diabetes and hypertension, and illustrates how categories such as sexual orientation influence inequality in treatment. "She helps people understand and come to the lessons themselves," Chin says, "as opposed to presenting a single perspective."
Those lessons are not taught in such depth at most medical schools. Many offer lectures on disparities and cultural diversity as part of a broader ethics curriculum, but standalone courses are rare and often electives. Vela's health-care disparities course started that way.
Students entering in 2006 received an invitation to come a week early if they were interested in the topic. She expected to chauffeur a handful in her minivan, introducing them to the community, the facilities, and the issues. Instead more than 60 of the 105 incoming students accepted the offer. A year later, Pritzker made the weeklong disparities introduction mandatory. "That was one of the recommendations from the students themselves," says Holly Humphrey, MD'83, dean of medical education. In 2008 it expanded from a single week before classes began into a full-quarter requirement, accompanying anatomy as the first courses medical-school students take.
The timing is intentional. Chin, whose two words of encouragement—"do it"—prodded Vela to propose the class to Humphrey, invokes an old medical-school concern: the more students gain scientific knowledge, the more they lose their humanity. Standing over a cadaver in anatomy, Stern understood how that could happen. "You get into this class and spend all your time dissecting a body. It's very dehumanizing," he says. "Health-care disparities also says there are real people, real lives, that this is affecting. It's humanizing in the way that anatomy is dehumanizing." The timing is also important, Chin says, because beginning medical students tend to be committed to medicine as a mission as much as a profession. "They're fired up, they're idealistic, and this course can tap into that native passion."
Discussing the sensitive and divisive issues involved in health-care disparities—race, socioeconomics, sexual orientation—passion occasionally crosses into confrontation. During her Rush talk, Vela quotes enthusiastic student-survey responses. "This sounds very rosy and cheery," she says, yet almost every year she has been reduced to tears, vowing to her husband that she would never teach the course again. The subject simply doesn't interest some students, and others see little relevance to their future medical careers. "Dr. Vela, this is all very interesting," one student said in class, "but this community is not my community."
"It was on the tip of my tongue to say, 'Who raised you, young man?'" She resisted and considered a more thoughtful response. None came to mind. "I was actually stumped," so she asked the class to share their reactions. One student responded that any patient who walks into your clinic becomes a member of your community. Another described choosing to live on the South Side during medical school specifically to create the immersion necessary to understand the people who most needed help.
"I hit reality working out in the community," Vela says, "and I realized how resource-poor you can be."
The responses were heartening for Vela, who has since made a habit of the Socratic approach to handling hard questions. "When somebody asks—and they do—'Dr. Vela, how much equity is enough equity?' I turn to the class and ask them what they think."
A few students believe she skews the data to support her point of view, a complaint that she greets with assurance that eventually they will recognize its validity. "I tell them, 'Learn this stuff; it will come back to you even if you don't really buy into it at this point in time.'" Some of those same students have written to her two or three years later, after witnessing doctor-patient interactions that reflected the bias Vela described: "I can't believe it's actually happening in front of me."
Even for students who accept the importance of studying care inequality, third-year student Raffel admits, frustration sometimes overwhelms inspiration. "It got people a little angry: 'You're telling us all these problems. How do we fix them?' That's the question you're going to answer."
After her talk, the Rush faculty digs for more answers. They ask how she guards against increased cultural awareness actually leading to stereotyping—"African Americans do this, Latinos interact with doctors like this." Vela says the curriculum avoids any such generalizations for just that reason.
A few preface their questions with praise—"fantastic course; it sounds amazing" and "fabulous"—but she's still not at ease in front of the group. When she finishes, Vela says she could sense herself talking too fast and that the audience probably noticed her finally slow down about 15 minutes into the presentation. If she hadn't mentioned it, nobody would have known. Discussing health-care disparities, Vela delivers her message with the assurance of someone who has been there before.