Underrepresented in Medicine Q&A

Clinical Professor Sonia Bonifacio, MD, speaks with our Division’s science writer Laura Hedli about her experiences as an underrepresented minority in academic medicine.

Laura Hedli [LH]: Can you tell me about yourself and your background and how you got to where you are today?

Sonia Bonifacio [SB]: I’m a first generation Mexican-American. My parents were immigrants from Mexico. Neither of them had more than an elementary school education. My mom met my dad here in California. It turned out that he also had a family in Mexico, so I ended up being raised by my mom and aunt in San Francisco. My mom and my aunt are two of 15 children. Those two strong women raised me. I wouldn’t have made it to where I am today without them.

I’ve never left the Bay Area, primarily because of my ties to my family because I’m an only child. At different stages where I could have left, for college, med school, residency or fellowship, I really felt the responsibility of being an only child and being close by to help them.

My mom and my aunt both did service jobs. My mom was a hotel room cleaner and my aunt worked in private homes. They used to take me with them when I was younger because there wasn’t anywhere else for me to go and I was to help them. I realized that was not the life I wanted.

LH: What propelled you to go into medicine specifically?

SB: My mom’s a very caring and empathic individual. Her heart hurts when she sees other people suffering and I am like her in that way. When I was younger, I always wanted to help things that were hurting, whether it was an animal or a person. If we went out to eat dinner, I would give my leftovers to homeless people who walked by on the streets. My mom always encouraged me to help others even when we did not have a lot ourselves.

I think the idea of what a future leader in neonatology looks like, is an area where we need to diversify and be more inclusive.

When I was in high school, I really loved science and physiology. I thought the process of a baby coming into the world was such a strange and amazing event. That’s where I decided that I probably wanted to be a pediatrician or an obstetrician.

I went to the University of San Francisco, which is a smaller Jesuit University. I had really great mentors there who encouraged me to pursue medicine. I was lucky to go to UCSF for medical school, and I also did residency and fellowship at UCSF. I was at UCSF for five years as faculty, and then I came to Stanford in 2015.

LH: What made you want to make the move to Stanford?

SB: My husband’s family is from down here in this area. We got married in my fourth year of medical school, and I added a fifth year. I had my first child, my daughter, when I was 26 years old in my last year of medical school. We actually moved down to the peninsula before I finished residency. We needed help from his parents.

My mom and my aunt moved with us for awhile to help too, when my son was born at the end of my residency. I got tired of driving back and forth from our home on the peninsula to UCSF, and I felt like my family needed me to be closer. Also, when you stay in a place for a long time, sometimes you just need a change.

LH: What was it specifically about the position at Stanford that attracted you?

SB: A lot of the work that I was doing at UCSF was about developing a neurological intensive care unit for babies. I had started that work with some of my mentors at UCSF, and then met with some of the leadership at Stanford who also, at the time, wanted to start a very similar program. I knew that Stanford had the same model of care as UCSF, in terms of wanting focus on care practices to improve neurologic outcomes. For me, that was the primary reason to come here and move a little bit away from my mentors and try to find my own niche. Just to be in a new institution—sometimes it can seem scary, but it also can open a lot of opportunities.

LH: What has it been like working in the NICU at Stanford?

SB: When I left UCSF and came to Stanford, I was a little bit hesitant at first because I was worried that the patient population at Stanford would be different than that which I was used to serving. When I was a resident and faculty member at UCSF, I was immersed in caring for a very underserved population at a public institution, one that resembled the community I grew up in. I felt really proud and honored to be able to care for those families, and to be able to care for them in a culturally appropriate way. I was really happy to find that the population that we serve in the NICU at Stanford and LPCH is very similar to the one I had been serving at UCSF. Apart from that, the NICU at Stanford is a great place to work and has been welcoming to me. We all work really hard to provide the best possible care.  

LH: Do you speak with the families at LPCH in Spanish?

SB: Oftentimes, I do. I think sometimes for me, it’s less about the language and more about the culture. When I see some of the moms that we care for, I can see my mom in them. For many, I can understand the hardships they may face.

We don’t have a lot of hope of increasing the number of underrepresented people in medicine – or any type of measure of diversity within our faculty – if we don’t start to train people in the same group.

LH: Tell me more about how you became involved with diversity, equity and inclusion (DEI) initiatives at Stanford.

SB: Two or three years ago, I was on the diversity advisory panel for medical school admissions. This was one of the first opportunities I found on campus that I felt I could contribute to and hopefully improve diversity on campus. It wasn’t until the past year or two where I started to see more DEI-dedicated initiatives at the university, school, and department level. I think that there are a lot of opportunities at Stanford to focus on DEI, and I’m just now starting to find my way. Now, I’m looking for opportunities to contribute to, whether it be within our fellowship program or Division or Department, in order to advance diversity and promote equity and justice.

It’s been helpful to have other members of our Division step forward and work specifically on advancing diversity. Weichen gets a lot of credit for helping to push this agenda, as well as Melissa and Valerie as leaders of the fellowship program. Currently we are working on making the fellowship selection process much more standardized while applying a DEIA [diversity, equity, inclusion and access] lens. We are trying to reduce bias in our process of application review, interviews, and ranking decisions. We want to try to stick to the merits of a person’s application as well as learn more about each applicant in terms of the road that they’ve traveled and any hardships they have had to overcome.

LH: In terms of the letters of recommendation, do you envision removing identifying information?

SB: I think that is one way of doing it. I was on a search committee at Stanford, and we did a blinded review of all the applications first and used this information to rank candidates that we wanted to interview. Once we knew who the candidates were, we committed to evaluate based on the things that they wrote and the things that they had done as opposed to any personal association we may have had with the candidate. We also had a list of interview questions in order to make sure each candidate was asked the same questions. 

LH: Are you doing this now for the upcoming cycle of interviews?

SB: We’re hoping to do this for this 2021 interview cycle, yes. The other thing that Weichen has done and presented on is looking at our data in terms of increasing underrepresented groups in medicine: What happens to those who identify as being underrepresented in terms of their trajectory through the fellowship selection process?

One of the things there’s commitment for, is trying to keep the relative percentages equal throughout the process: So, if 20 percent of the applicants identify as underrepresented in medicine, then 20 percent of the people that we interview should also be underrepresented in medicine. Then, we are thinking about our rank list in terms of how we can try to increase the number of fellows at Stanford who are underrepresented in medicine. We are making the commitment to doing that. We don’t have a lot of hope of increasing the number of underrepresented people in medicine – or any type of measure of diversity within our faculty – if we don’t start to train people in the same group.

LH: Can you talk more about what challenges there are for individuals who are underrepresented in medicine who desire to work in academia?

SB: I think there are several. First, if you don’t see anyone like you who’s doing what you’re thinking about doing, it becomes harder to have the confidence that you can do it. That’s one barrier.

Education was not prioritized for girls in my mom’s family because they lived in a small town and had a farm. The girls maybe went to elementary school. For a lot of people who are first generation, or who are underrepresented in medicine and come from a family where the educational level is not super high, they often don’t have any examples in their family in terms of people to model.

I felt: Pediatrics is fine. I can still help my community if I’m a general pediatrician. What I really struggled with was: How do I help my community as a sub-specialist? Because I didn’t at the time have any examples to follow.

I think another barrier is, often, limiting yourself in terms of the places that you go for your education. For me, it was so engrained that you don’t leave home. This is your family. You stay with your family. I’m not saying that was bad. I’m just saying when I applied to colleges, even if I had been accepted away from home, the pressure was to stay home. There were other pressures too, like financial pressures and worries. My mom didn’t want me to get into debt. And so, for me, it was about being brave enough to say: “Well, it’s not going to be your debt. It’s going to be my debt.”

And then, I think there’s self-imposed pressure once you’re in medical school. For me, I felt: Pediatrics is fine. I can still help my community if I’m a general pediatrician. What I really struggled with was: How do I help my community as a sub-specialist? Because I didn’t at the time have any examples to follow. There weren’t a lot of people doing work focused in equity and disparities, and the impact of socioeconomic status and race on outcomes. That body of work was just starting. I felt a little bit of guilt: How can I go be a sub-specialist if I went into medicine to help people like the family that I came from?

I think it’s changing, though. We have people in our own Division who are working in disparities. Within the Pediatrics Department, there’s a lot of work in disparities and social justice. The families I care for in the NICU are still just as important to me – maybe sometimes more important even – as the other work that we do to advance DEIA. I do feel like had I known all that was possible, I might have mentally struggled a little less as I was going through the different phases of asking the question: What am I going to do with my life?

LH: Within the neonatal-perinatal medicine fellowship program, where are there are other opportunities to strengthen our commitment to creating a more inclusive and diverse community?

SB: The mission of our fellowship program is to train future leaders in neonatology. I think sometimes, historically, the idea of a leader in neonatology has been a bench scientist who’s going to go on to become an NIH-funded independent investigator and get two, three, or four R01s over the first 15 years of their career. I think the idea of what a future leader in neonatology looks like, is an area where we need to diversify and be more inclusive. There are lots of types of leaders in neonatology.

Today, there is much more emphasis on education and patient-centered research, which includes clinical research, not necessarily bench research, and developing quality improvement programs. There are a lot of different areas of neonatology where we need leaders, and we don’t need to focus only on the person who’s going to become an independently-funded investigator one day.