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Protégé

BACK IN MIAMI.

“Pick up, Dr. F. Minority Affairs,” chirped Junia.

“Hi, Astrid. How can I help you?” Astrid is associate dean for minority affairs.

“Art, Joe’s in academic difficulty. They want to kick him out of school. You’ve got to help him.”

One of the things I liked best about Medishare was how the small number of Haitian-American students at our school rallied around it. Although I had a close relationship with all the Haitian-American students, it was common knowledge that Joseph was a favorite. So when Joseph’s troubles surfaced, Astrid knew to call my office. Not just me, but also Michel and André, as well as Junia, were all there for moral support. Joseph came to see us more often than the other students. I think we felt like home away from home for him. Sometimes, he wouldn’t even visit for long, just inquire as to news from Haiti from the others or drop in for a minute and ask about our project and how he could help.

According to Astrid, the problem was simply that Joseph had failed a course and then failed the makeup exam—grounds to repeat a year but not grounds for expulsion. But I knew there must be more



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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Protégé BACK IN MIAMI. “Pick up, Dr. F. Minority Affairs,” chirped Junia. “Hi, Astrid. How can I help you?” Astrid is associate dean for minority affairs. “Art, Joe’s in academic difficulty. They want to kick him out of school. You’ve got to help him.” One of the things I liked best about Medishare was how the small number of Haitian-American students at our school rallied around it. Although I had a close relationship with all the Haitian-American students, it was common knowledge that Joseph was a favorite. So when Joseph’s troubles surfaced, Astrid knew to call my office. Not just me, but also Michel and André, as well as Junia, were all there for moral support. Joseph came to see us more often than the other students. I think we felt like home away from home for him. Sometimes, he wouldn’t even visit for long, just inquire as to news from Haiti from the others or drop in for a minute and ask about our project and how he could help. According to Astrid, the problem was simply that Joseph had failed a course and then failed the makeup exam—grounds to repeat a year but not grounds for expulsion. But I knew there must be more

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti to the story. When I heard Joseph’s voice outside my office talking to Junia, I buzzed her and asked her to send him in. “What’s this all about, Joseph, and how can I help?’ “Well, I had trouble with microbiology and I had to take a makeup. The problem was, I had to take Part I of the boards before the makeup, but they didn’t want me to. I had already paid my money, and I couldn’t start the third year if I did not pass the boards. So the good news is I passed the boards, including the micro section, but the bad news is they say I flunked the makeup. So that, plus some troubles I had in the first year, means I have to leave school.” “Joseph, do you want me to intervene?” “No, Dr. F. In fact, you could be part of the problem. They want to know how a ‘marginal’ student could spend so much time volunteering in Haiti.” “Joseph, don’t let anyone ever tell you that you are ‘marginal.’ You will be a great doctor. The problems are that English is not your first language and you’re working three jobs to pay your way through school. But I don’t see what the issue is. You passed your boards. That ought to count as the makeup!” I shared all of this with Michel. “It’s like the school has put a zombie curse on poor Joseph,” I confided. “It’s a triple curse,” Michel came back. “Three strikes and you’re out: He’s poor, he’s black, and he’s Haitian.” “They’re trying to make an example of him, I know it. The whole medical education department is new, and they’re obsessed with grades and board scores. They probably didn’t expect him to pass his boards, and that’s why they didn’t want him to take the foolish test!” Mark, the new senior associate dean for medical education, was one of my former residents and one of the original collaborators on our AIDS study. Perhaps I could reason with him. “Hi, Mark. This is Art. I’m calling about Joseph.” “He’s in big trouble, Art. Don’t try to defend him. He should never have taken the boards without my permission.”

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti “But he passed them! Doesn’t that count for something?” “He’s got a big-time attitude problem—always smiling like he knows something I don’t know. Plus, his accent is so thick you can cut it with a knife. How is he going to present his patients in his third year? They’ll eat him alive on his clinical rotations.” “Mark, he got into academic difficulty because he’s working three jobs and didn’t even start learning English until he was 14. Can’t we cross the accent issue when we come to it?” I was inwardly boiling, trying to restrain myself. “Hey, it’s my job to uphold the school’s standards. This guy just doesn’t make the grade.” “I’m going to advise him to appeal.” “That’s his right.” Every student threatened with academic suspension has the right to appeal to the dean. This was Joseph’s last hope. I counseled him not to despair. The dean was a straight shooter. He was fair. When he heard the whole story, things would be set straight. Astrid and I would ask to be present. Appeal day arrived. It was strained sitting around the table in the dean’s conference room with Astrid, Mark, Joseph, and the associate dean for students, waiting for the dean to join us. Astrid and I had counseled Joseph to be himself and not be nervous, but the small beads of perspiration on his forehead and the absence of his usually irrepressible smile were foreboding. The dean entered from his office, almost like a judge entering a courtroom. After he seated himself, he looked at Astrid and me and told us we were welcome to attend the proceedings as a show of support for the student in question, but we were not allowed to speak and were not allowed to ask questions. “Uh-oh,” I thought. Mark presented the recommendation of the Promotions Committee that Joseph be dismissed, citing academic difficulty and insubordination for taking the boards when not authorized to do so.

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti The dean asked Joseph if there was anything he could say that would demonstrate that he had the capacity to meet the school’s academic standards. Just say the magic five words—Yes. I passed the boards, I thought as I stifled myself from an outburst. Joseph tried to get something out but could only stutter and stammer with his Creole accent. The dean asked Joseph if he had a plan to return to academic good standing. Again, all Joseph could do was stammer incoherently. Silence suspended the proceedings for what seemed an eternity as the dean wrote some notes and then made his pronouncement. Joseph was expelled from our school. To be reinstated, he had to make up and pass the course in question. That meant he’d lose at least a year. He also had to demonstrate his capacity to acquire biomedical knowledge by obtaining an advanced degree in one of the biomedical sciences. Finally, he had to enroll in an accent reduction class. The last Herculean task pushed me over the edge. Clearly, Mark had met with and prejudiced the dean prior to the appeal and had baited Joseph to bring out his stammering. This was worse than a zombie curse. At least if you are a zombie there’s a small hope for resurrection and escape. This was an execution. No one could possibly meet the requirements for reinstatement. The dean instructed Joseph to meet with Mark and the dean of students immediately after the meeting to review the terms of his expulsion and possible reinstatement. I passed Joseph a note telling him to come by my office after that meeting. Joseph came by later that afternoon, slumped in the chair on the other side of my desk, and buried his head in his hands and arms. “What are we going to do?” I asked. “You can’t do anything, Dr. Fournier. I have to bend to their wishes. I’ll enroll in a master’s in public health course.” “The thing that bothers me the most is that stupid accent reduction requirement. That’s really off the wall and uncalled for. That didn’t come from the dean.”

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti “Its okay, Dr. Fournier. I want to get back in school. I want to get my degree, complete my residency and go back to Haiti and make a difference.” “I have a friend of my family who’s a speech pathologist. I can ask her if she’d take your case.” “Thanks. That would be helpful. But I don’t think I can come around anymore. They don’t like it that I come to you, and they don’t like it that I’ve gone so often to Haiti.” To me Joseph’s expulsion from the school was just one example of how the curses of stereotype, blame, and conventional thinking were affecting not just our patients but the profession of medicine itself. In Joseph’s case he had been stereotyped as a poor student, blamed for taking the boards without permission, and ostracized without a fair hearing. In my opinion the school had cursed not only Joseph but also itself in the process—enslaving itself by an obsession with grades and authority. In reality, what Joseph needed was a little remediation and a scholarship! Even the dean had become ensnared in the trap of going through the motions of doing what he had to. When I was a medical student, my school was “pass-fail.” A pass-fail system discourages competitiveness among students and encourages learning for the sake of learning, not for the sake of grades. When I first came to the University of Miami, it also was a pass-fail system. However, whether because of insecurity or a desire to procure its graduates the “best possible residencies,” the University of Miami School of Medicine had evolved through the years from pass-fail, through letter grades, to now a numerical grading system. Prior to going to Haiti, I had protested the grading system as the antithesis of learning. After returning from Haiti I became even more vocal about our grading system. “We ought to be evaluating our students on the knowledge, skills, and aptitudes needed to be good doctors and give them extra credit if they volunteer for projects like our health fairs or Medishare,” I argued to the school administration. “Not on their test-taking ability or their capacity for rote memorization.” But the

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti school felt compelled to grade our students to the nth degree, believing that it was necessary if the school was going to compete with the best schools in the nation for the best students. The students could not help but get caught up in this obsession. For the majority, grades became the be-all and end-all of their existence. The school fueled the flames of this competitiveness by actually posting the grades of every test for all to see. Meanwhile, special students like Joseph fell through the cracks. If they failed, we blamed them for their failure, rather than asking ourselves what’s wrong with our system. Even those who succeeded in the system paid a price—medical education had become four years of a numbing, competitive, cutthroat grind, to be followed by three to five years of further “training.” So many of our students entered the system with idealism, and so many left with cynicism and burnout—medical zombies! My school’s obsession with grades was probably not that different from most medical schools in the nation. In fact, the entire profession of medicine in the United States seemed to be undergoing a process of zombification. Over the past 20 years, Medicine had shifted from a cottage industry that physicians controlled to a corporate entity in which doctors were little more than glorified assembly line workers. Medicine was no longer a profession but a business. Health care was no longer a right; it was a commodity. The precious doctor-patient relationship had been torn apart by managed care and stood on its head by malpractice issues. In response, more and more physicians were withdrawing, becoming defensive. The patients we were supposed to be serving became the enemy. Increasingly, doctors were dropping out. Older doctors were retiring early and recent graduates were choosing careers like radiology or pathology, with little patient contact, or dermatology, with little responsibility for nights and weekends and therefore few conflicts with life style. Hardly anyone was choosing a career in primary care. And in both cases, generalists and specialists, everyone seemed to be just going through the motions.

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The Zombie Curse: A Doctor’s 25-Year Journey into the Heart of the AIDS Epidemic in Haiti Making the problem worse, as I mentioned earlier, was modern medicine’s enslavement by technology. Cardiologists can no longer commit to a diagnosis of a heart murmur without an echocardiogram. Neurologists can’t diagnose a stroke without a CAT scan. The old art of medicine—talking to patients, figuring out what’s wrong, and fixing it—had died. In the process, actually caring for patients had also died. The replacement? Robotic surgery, high-tech scanners, productivity quotas for doctors, and precious little time for patients. Health care in America was becoming “The Night of the Living Dead.” Medishare had originally gone to Haiti to help the Haitian people. My first trip awoke me from my own zombie curse. It was becoming clearer and clearer to me that perhaps Haiti was helping me more than I was helping it. Perhaps experiences in places like Haiti could help some in my profession shake off the curse cast upon our profession. I had witnessed firsthand how touched our students were by the heartfelt “Mesi, ti dokte” they received from every patient after every service they performed. Medicine didn’t have to be robotic, “going through the motions,” or uncaring. There was more to being a medical student than passing exams and more to being a doctor than making money. If only our school of medicine would see it that way. The story of Joseph does, however, end on a happy note. It took him three years, but perhaps to the surprise (and consternation) of the school’s administration, he completed all of the dean’s prerequisites for reinstatement. He graduated three years ago. I cheered wildly for him when the dean handed him his diploma. He is now completing his residency in the family medicine training program here at the University of Miami. It was Joseph’s Haitianess—the dogged determination to climb one mountain after another until he reached his goal—that saved his career. If Sisyphus had been Haitian, he would have gotten that rock over the hill.