Hello!

As representatives of TUSM's orientation committee, we welcome you to medical school. We look forward to working with you and helping you with the many and varied questions you're likely to have, especially in the next few months. We also feel as part of our education that it's important to consider the many factors which currently have an effect on our health care system. Students and faculty have come together to address this and are providing an opportunity for students to learn more about the impact of health disparities on our society. This will involve reading a book which illustrates the importance of understanding the socio-economic issues which affect access to health care and the importance of patient advocacy. The book is, The Working Poor: Invisible in America, by David K. Shipler.

During orientation, all incoming students will meet in small groups led by representatives of the second, third, and fourth year classes to discuss the book and the issues it raises about the patient-doctor relationship, our health care system, and the barriers to care which many of our patients face. We hope that by initiating an ongoing dialogue on the critical roles of health disparities and patient advocacy in medicine, Temple medical students will develop into physicians capable of providing all patients with the care they deserve.

You can purchase this book either on line or possibly in local bookstores. We look forward to hearing your opinion about it. If you have any questions, please feel free to contact mmherda@temple.edu

Sincerely,

Meagan Herda, Jarred Molitoris and Tiffany Lim

Discussion Questions for the Working Poor

1. "The profligate were the ones who stood out to Nancy [a case worker], who remembered a man requesting help to pay for prescription drugs. Pharmaceutical companies are willing to donate medicine that is nearly outdated, and she routinely worked overtime on the intricate paperwork needed to make the case in situations of particular need. But when she learned that this man had contracted to bring every available television channel into the comfort of his living room, she blew. 'I said I'm not gonna waste any time working on his $40 medicine bill if he's gonna spend $90 a month on cable.' "

Is this man getting cable irresponsible and selfish? Or is the situation more complicated than it looks? How easy is it to live life for long periods of time completely austerely? What kind of expectations for a baseline might stand in the way of upward mobility for an American who has been in the U.S. for generations, as opposed to recent immigrants--who may have come from countries where they lived without running water or electricity?

2. Chapter 9 discusses the problems and inequities of our American educational system.

"The education they are receiving doesn't open a vista on any expansion universe of possibilities. Unless they happen to find themselves in a classroom with an unusually gifted teacher, or in a home with an exceptionally visionary adult, their schooling limits them, narrows them, closes them down. If it offers a route out of the place they're in, they cannot see it. If it brings a reward, they cannot calculate it. So, as the educational machinery process them year after year, pushing them along on its conveyer belt towards graduation or less, they lose their imaginations about what can be." (239)

Shipler also writes that "the United States funds its schools largely through local property taxes, disparities between one community and the next are huge, and the poorest districts, which need the greatest services, cannot afford them." (240)

Discuss how the financing of our educational system could potentially keep the working poor from being upwardly mobile. Do programs like affirmative action make up for the shortcomings in the current system? Should efforts be more concentrated to making the system more equitable--so that inner city schools have the same access to resources found in public schools in affluent suburbs, such as after school programs, counselors, health lunches, etc?

3. Marquita's story (156) describes a vicious cycle:

Her mother is an alcoholic/addicted to drugs --> Marquita grows up with absent parents, resents parents for their addictions --> Gets pregnant the first time she has sex. Drops out of school to have the baby: "She never considered abortion, and her reasons echoed those often given by teenagers who see their babies as badges of maturity and autonomy: 'I could say to my mother, "Now I'm grown, I can do what I want to do, I can do this and that, I have some kind of little income, I have a little leverage right here.' --> Goes on welfare, poverty forces her to live in a seedy area infested with drugs --> fall into drugs

What other circumstances make the poor particularly vulnerable and traps them in a cycle of poverty? Why does Marquita get pregnant? What are the advantages of getting pregnant? How would an extensive support system prevent one from hitting "rock-bottom" as many of the people profiled in this book do?