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#WomenofPenn: Seeds of Inspiration Rooted in Childhood

The following post is part of a year-long online campaign highlighting #WomenofPenn. The campaign, developed by FOCUS on Women’s Health and Leadership and Penn Medicine Communications, promotes the work being done by women at Penn Medicine and aims to inspire early-career women in academic medicine through the examples of successful women role models.

Carmen Guerra, MD, MSCE

When Carmen Guerra, MD, MSCE, and Alina Mateo, MD, MS, start talking, it takes only a moment to realize that these two have a great deal in common. Guerra’s family emigrated from Honduras when she was just three years old. Mateo’s moved from the Dominican Republic to Miami when she was five. But despite moving to the United States so early in life, the glimpses of poverty, disease, and disparities they saw in their early years coupled with the challenges they faced as non-English speaking students in the U.S., made an impression that continues to drive their careers.

Even outside of their clinics and regular rotation of patients, Guerra, an associate professor of Medicine and associate director of Diversity and Community Engagement at the Abramson Cancer Center, and Mateo, an assistant professor of Endocrine and Oncologic Surgery, share a deep-seated passion for helping underserved communities to access life-saving preventive screenings, and opening doors for future generations of health care professionals.

Guerra and Mateo recently sat down to talk about barriers to access, how to help underrepresented and underserved minorities, the importance of mentorship, and always keeping patients top of mind.

Q (Mateo): In 2011, you started the first colon cancer navigation screening program, which has now reached over 500 people, and more recently the Breast Health Initiative, which provides breast cancer screenings for low-income or uninsured women city-wide. At what point did you decide to focus your efforts on preventative measures and cancer screening?

A (Guerra): It was probably my fourth year as a junior attending. I realized that I was routinely diagnosing patients who were seeing me for primary care services with cancer, and I was diagnosing patients of color at much later stages than white patients. When I asked them why they hadn’t had the colonoscopy that we’d talked about, they would say things like “I didn’t have a ride,” or “there’s a $30 prep I have to buy, and I can’t afford that.” These were issues I’d never even considered, and despite all the years of education and training, I suddenly felt completely incapable of helping my patients.

I realized that just giving the order to get a colonoscopy isn’t enough. Once I looked at this as a research question and identified the barriers, I was able to collaborate with my colleague Michael Kochman [MD, a professor of Gastroenterology] to build the colon cancer navigation program.

By the time it got off the ground, I was nearing the end of my Assistant Professorship. But, Albert Einstein once said that if he was given an hour to solve a problem, he’d spend 55 minutes thinking about the problem and five minutes thinking about solutions.

Alina Mateo, MD, MS

Q: Last fall you participated in Penn’s “Be in the Know” campaign, where faculty and staff had access to blood pressure, blood glucose, and cholesterol screenings. For those outside of the Penn community, what are some of barriers to accessing such screenings and education?

A: That’s such an important question. Recent data shows that your zip code determines how many primary care providers you have access to. The average in Philadelphia is about 1,200 patients to one provider, but in the North East and the South West areas of the city, it’s more like 3,500 patients to one provider. Those areas are like primary care deserts, and we can do better.

Even if you have access to a primary care provider, they might be so overwhelmed by their patient load that they’re in “put out fires mode” and focusing on urgent issues instead of thinking about preventive measures. I always advise individuals to ask for the preventative visits where you don’t have an agenda. Research shows that when you don’t have an urgent need, a menu pops up in the mind of a provider, and they shift their thinking to the different preventive measures indicated for a patient’s age.

Penn’s Office of Government and Community Affairs also has a website that lists all the different community events where Penn has volunteers so members of the community can see where and when they can access screenings and education in their neighborhoods.

Q: What is one major measure or focus area that we still need to work on in preventative medicine here in Philadelphia that we could adopt from other cities?

A:  I’ve seen other cities have some success in addressing the social determinants of health. It’s critical that we tackle all the issues that prevent our patients from being healthy. Things like education, transportation, food insecurity, and language are so critical to the overall health and well-being of each patient. That’s one area where I’d like to see us move forward. Hopefully that’s going to be phase two of my career — partnering more with those in the community who have an understanding of the barriers to health much more than we do sitting in our offices, and working together to improve the health and wellness of our communities.

Q: You wrote a beautiful piece in 2018 for Philadelphia magazine called “An American Tale” in which you describe coming to this country as a small child, mastering the English language, and eventually graduating from medical school. What would you say to someone who perhaps doesn’t have fluency in English and who dreams of a career in medicine, but finds it impossible to take that first step?

A: Breaking down the many siloes that exist so that everyone has an equal opportunity to pursue the career they dream about is such an important goal for me. There’s too many people who discourage our young students from even thinking about a career in medicine, and not enough people suggesting it as a possibility.

If someone doesn’t fully understand the language, what they lack in resources, they probably more than make up for in being resourceful. Use that resourcefulness to identify ways to overcome barriers. There are so many opportunities to learn English in Philadelphia, such as The Garces Foundation and Puentes de Salud, and many are offered in the evening to accommodate work schedules.

It’s also important to identify both senior and peer mentors. A senior mentor is a wise person who has been through the process and can give you valuable information about how to succeed in your career, and peer mentors are people who have identified the barriers to success and how to overcome them and with whom you can share your experience. Identifying both is critical to overcoming obstacles.

Q: In “An American Tale” you quote that currently eight percent of professors at academic and medical centers are underrepresented minorities, yet 13.3 percent of the population is African-American and 17.8 percent is Latin American. Given those statistics, what can we do as medical professionals to diversify our demographics?

A: Right now we’re too focused on identifying students in college who could enter medical school. We need to reach further back and think of medicine as a pipeline that extends back to middle or elementary school. Planting the seed in a young person that they can be a doctor is a powerful thing, and because a career in medicine requires so much preparation, it’s important that students choose a high school that has rigorous scientific preparation so they have the option of enrolling in a premed program.

At Penn Medicine, we’ve done that by reaching out to high school students and allowing them to shadow us — witnessing patient care and even surgeries can open their mind to possibilities they may never have thought about.

For first-generation American students in particular, I think it can be overwhelming to think about a career in medicine given the long trajectory and financial pressures that may exist. We’re hoping to create a program here that pairs first-generation medical students and attendings with first-generation undergraduate students. The idea is that we can help students reconcile their two identities — the one they have at home, which is generally who they really are, and the one expected of them when they enter an Ivy League institution like Penn —  by providing much-needed peer support, mentorship, and role models.

If these kinds of programs work, then we need to keep expanding them because low expectations don’t help low-income communities. But if your expectations are high? Sometimes that’s all it takes to get students to think seriously about these careers that are so competitive.

Q: Is it important to have physicians who have the same geographic, ethnic, cultural, or religious background as their patients? Do you think this increases compliance in treatment?

A: Some data shows that the quality of care is the same, but some suggests patients are more likely to comply with care plans if there is racial/ethnic concordance. What might be happening in those interactions is that building trust happens a lot more naturally when you’re speaking with someone who understands you and your cultural background. Language is also important. If you can’t understand your doctor, how can you follow their recommendations?

Diversity of thought is a critical thing for medicine because physicians who have the different cultural and language perspectives are the ones who understand the barriers faced by patients of similar backgrounds and can address complex problems with more creative solutions that haven’t been tried before.

Q: Since you started practicing medicine, you have been successful in establishing programs that allow you to participate in patient care outside of a physician’s “standard or typical daily routine.” What advice would you give to a younger colleague who desires to establish a community program that reaches an audience outside of the standard inpatient/outpatient clinical setting?

A: The first thing is to make sure the community wants the solution you’re proposing. If you don’t have community buy-in, that could cause adverse effects if they see it as something that’s being imposed upon them rather than something created with community input and support. Once you have that support, then the community will bring in the stakeholders who can help solve the problem — it’s not just going to be you alone.

Also, working with doctors and staff in these communities is absolutely essential. Part of the reason why the Abramson Cancer Center has been so successful is because we have staff who were born, raised, and have worked for decades in these communities to improve health. Those folks are respected and understand their communities better than I do. Putting yourself in a humble place where you understand that you don’t always know what’s best is absolutely critical. As a physician, your role should be to make a case for a program that the community needs, whether by securing a grant to fund the initiatives and events, or convincing your unit or departments that this is critical for the health of these communities.

Q: How do you find time to balance your professional life, personal life, and physical/mental health? What advice would you give a to a physician in their early career to avoid mid-career burnout?

A: If you can’t take care of yourself, then you’re not going to be able to fully take care of those you love. I’ve always felt I have to be selfish about that, even though there’s a thousand reasons nipping at me to not do that. I start my day with exercise — which for me is so critical to my physical and mental well-being — at a time when the rest of my family is asleep. I don’t let perfection get in the way of the good. If I can’t do my usual 30 minutes on the treadmill, then even 10 will help me to feel like I did something.

Still, stress is huge. When I start to feel those moments coming, I stop and pay attention. What are the emotions that are making me feel this way? Unpacking the burnout is a critical first step, and then understanding how to move forward once you’ve identified the problem is critical. You’re probably not going to be able to do it alone, so share that with others. Have a group of people who support you and know your values so they can provide the constructive feedback that you need. But, it all starts with taking good care of yourself physically, emotionally, and psychologically.

Q: What is one thing you are most proud of that you have accomplished since graduating from medical school?

A: I would say the programs I’ve built that have screened patients for cancer at an earlier stage. I’ve worked on papers and given talks — the typical academic life — but between the two outreach programs, we’ve screened about 3,000 people now. That’s hundreds of people who hopefully won’t hear the words “you have cancer,” and they and their families won’t experience the suffering that they might have had to endure. That has been the highlight of my career and is the most fulfilling thing I’ve ever done.

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