How a Georgetown med school student found her calling in surgery, law, and health equity

In her final year as a medical student, Francisca Finkel chose an elective rotation that is offered by few med schools: Working with lawyers to resolve non-medical issues that harm patients with cancer.

That rotation at Georgetown University’s Cancer Legal Assistance & Well-being Project transformed Finkel’s outlook as a physician.

“It was a really empowering experience and a unique clinical practice framework to be able to be on the legal side in one of these medical-legal partnerships,” said Finkel, a 2024 graduate of Georgetown’s School of Medicine and  the recipient of the Pellegrino Center for Clinical Bioethics Award. 

Cancer LAW is a medical-legal partnership between the university’s medical center, law school, and MedStar Health.

“As a medical student, you don’t always necessarily feel useful,” Finkel said. “But it was really interesting being in a situation in which we really are the experts—it’s appropriate because we know we can interpret this information and we can make compelling cases to support patients because we understand the context.”

An article about Cancer LAW is available in this issue.

Finkel is now a general surgery resident at Harbor UCLA Medical Center, where she hopes to develop an expertise in surgical oncology, or liver and trauma surgery.

“I’ve been keeping an eye on this space for what an MLP could look like in this context, or how can we expand this program so that we can get advanced social work and a legal team to really advocate for people when we can,” Finkel said.

“And that’s something that I’ll absolutely bring forward into both my residency and future practice, that awareness of the possibility of this as a solution.”

The intersection of culture and medicine is familiar terrain to Finkel, who grew up in two disparate worlds, set apart by income, race, class—and access to health care.

“My family’s pretty mixed. My mom’s side is Uruguayan American and my dad’s side is a little bit of everything truly, but predominantly Italian and Jewish,” Finkel said. “They were divorced. Growing up, I would kind of cross a door into a very different world. 

“From the perspective of someone who has gotten health care in other health systems, I think the barriers to getting your foot in the door are surprisingly high here,” Finkel said. “Everybody is frustrated by these issues at every level. We’re impacted by difficulties with, for example, people getting benefits or people getting insurance and losing their housing.”

Finkel’s lived experiences became a cornerstone of her academic pursuits in medicine, including hands-on training with Georgetown’s Cancer LAW, which provides legal services at no cost to vulnerable and marginalized communities.

“I saw how lack of access and lack of ability to communicate with people really got in the way of health. I knew that was something that I felt very strongly about coming in,” said Finkel, “And I think that was really informative in terms of helping me understand what was important for me to focus my career attention on.”

Physicians, too, experience moral distress, harm, and burnout when they are unable to help patients, especially minority and underserved patients. This is where a diverse workforce and training with an MLP comes in, Finkel said.

“We encounter issues predominantly of poverty and of lack of access in the clinic. We are in a position in which we can identify those things, but we can’t necessarily act on it,” Finkel said. “With Black patients, if they have a Black physician, if you look at broader population studies, they do better.

“People are more stubborn because, ‘Oh, I had to deal with that. Or my family, my uncle, and my friend. I’ve seen this in my community. That pisses me off,’” Finkel said. “And I think there’s something really powerful about when you get pissed off and you can channel that into a solution.

“I think that’s why it’s absolutely essential to have, not just in the physician capacity, but in the leadership capacity as well.”

Finkel spoke with Matthew Ong, senior editor of The Cancer Letter.

Matthew Ong: Thanks for taking the time to connect, Dr. Finkel, and congratulations on finishing medical school. Where were you prior to Georgetown, and what have been your areas of interest as a medical student?

Francisca Finkel: Thank you. I’m originally from Northern California, lived in the Bay Area until I was about 18, and then I went off to college at Northeastern in Boston, studied neurobiology, became very interested in medicine at that point. 

I did some research at the NIH down by DC, which drew my attention to the DC area as well as up at some of the hospitals in Boston, MGH, and Beth Israel.

And when it came time to apply to medical school and I had the honor to be accepted by Georgetown, I knew that was where I wanted to do my clinical training after having lived in the city. So, having started in the midst of the pandemic, it was definitely a unique medical school experience with the first year being basically fully virtual.

But after coming back, I got really involved with the Health Justice Track, which is separate from the Cancer LAW Project. It’s a longitudinal four-year program where people engage in didactics about health justice and health inequities and develop advocacy skills. 

And so, that culminated in me doing this month-long intensive with the Cancer LAW Project as part of a capstone for them.

Other things I’ve been interested in throughout medical school, I did a fellowship in clinical bioethics, and I stayed on with the Pellegrino Center for Clinical Bioethics at Georgetown. And so, I’ve done quite a lot with them at this point, actually. But two areas of focus I think for me have been health equity and ethics.

I’d love to hear more about the structure of the Health Justice Track. So, it’s a concentration that you can work on in addition to your medical training throughout all four years?

FF: There are a few different options offered by Georgetown, and I think that’s part of the appeal of the university for sure. 

I was particularly drawn to the Health Justice Track, knowing the background that I come from. I am in part Latina and grew up in a setting in which I saw how lack of access and lack of ability to communicate with people really got in the way of health. I knew that was something that I felt very strongly about coming in.

So, I joined the track and it starts off with didactic seminars, and I will say Georgetown does, separately from this, have a very good focus on educating people about health inequities. But this is an additional didactic curriculum. 

Then, during our second year, we do a longer advocacy project working to find bills that are up in the House and Senate.

We all practice getting together and contacting our Congress people and making pitches. It was an opportunity to meet with staffers and advocate for funding for maternal health spending for Black mothers. It was the Momnibus bill from a few years back.

But going into clinical rotations following that experience, we take a little bit of a step back. There’s not really much time to be getting super involved, but part of the track is our capstone. 

So that, I chose to do with Cancer LAW, which I know was one of the inaugural programs—typically, it hadn’t been offered in the past—but Ruben [Castro, my classmate], had said very positive things and I said, “Wow, this sounds like a really great opportunity and a really enjoyable, meaningful experience.” So, I was excited to do that.

It was different. It was new. Some of the ethics work that I had done had to do with advanced care planning and complex advanced care planning. And so, when I did the Cancer LAW program, there was also a segment on advanced care planning, and it really aligned with my interests.

You mentioned that you’re Latina and you grew up looking at lack of access to care and how that informed your professional interests. What were the formative experiences that drove you to pursue health equity work?

FF: A little bit about my background. My family’s pretty mixed. My mom’s side is Uruguayan American and my dad’s side is a little bit of everything truly, but predominantly Italian and Jewish. So, there’s a wide variety of flavors in each house, and they were divorced.

Growing up, I would kind of cross a door into a very different world. I could see very starkly what access could do for people with my mother’s family being very working class, low income, and needing more support and having a different structure, and my father’s family being more affluent.

I think for maybe about 10 years, when I was a child, my mom didn’t have health insurance because she couldn’t afford it. 

And it was very interesting to see how she would navigate trying to take care of herself, versus my father, who comfortably got it through his employment and didn’t have any of those issues.

So, I think I got to see not just her experience or his experience, but the contrast between the two. And I think that was really informative in terms of helping me understand what was important for me to focus my career attention on.

My mom was born here, but even for her, it still was very inaccessible and really challenging. Adding layers of difficulty in terms of a difference in familiarity, difference in structure, it still is not easy even for folks who are native English speakers and born here.

What were your takeaways from your time with the Cancer LAW Project?

FF: It was very interesting for us as medical students, or I’ll say for myself, to see the dynamic that we experience played out from a medical perspective, where we encounter issues predominantly of poverty and of lack of access in the clinic. We are in a position in which we can identify those things, but we can’t necessarily act on it.

So, it was a really, I think, empowering experience and a unique clinical practice framework to be able to be on the legal side in one of these medical-legal partnerships, which are increasingly popping up. 

I found it gave me a better understanding of my patients to be able to see what their complex social needs were on the other side, separate from their medical conditions.

I felt like it gave me an opportunity to focus on a different aspect of their experience and their struggle, and also gave us the ability to see solutions at work, with people who really care so powerfully about justice for these individuals and for equity for them.

I really was grateful to be working with and learning from people that were so committed to making this project work and helping patients address the things that were harming their health and being able to do so.

What are some examples of these issues that you can identify as a medical doctor, but you can’t necessarily act on?

FF: I think the biggest one that I saw when I was working with the Cancer LAW Project that was addressed pretty directly was a lot of housing issues—concerns about eviction, trying to fight eviction, or in some cases where housing is unsafe, unclean. That can be particularly bad for people who have asthma or allergies.

For example, a woman with a child with severe asthma, the house was full of mold and it had been a fight with the landlord. I got to go to court and watch them speak about the necessity for the cleaning of the unit. Ultimately, I believe there were orders that they have to get that done by a certain date.

It was really a relief for us because on our end, we can say, “Oh, the mold in your home is making your condition worse,” but we don’t have the power to say, “Hey, we’re going to make your landlord make this safe for you so that it’s not harming your child.”

Without access to legal support, you may not have that framework as a clinician, and neither do you have the time; right?

FF: Exactly. A lot of us come into this very optimistic. We want to save the world, but the world is complicated and we don’t have all the tools to do that. So, it’s great to meet allies who also have a similar mission to try to help people that need it.

I’ve lived in interesting places before becoming a homeowner, but I have never experienced buildings that were falling apart, with ceilings collapsing from mold and more. It was shocking to see pictures from some of the housing issues that the Cancer LAW team is handling.

FF: I know. It really is. Some things are very heavily impacted by an individual’s environment and exposures outside of their genetic makeup. Our genes are turned on and off by our relationship with our environment and the exposures that we have.

So, the idea that not only is someone affected, but maybe their offspring are affected, and their entire family line can be impacted by hardship—generational trauma in a physical sense and in an emotional sense—I think it can play out both ways, for sure.

What are some other patient stories that really stuck with you and changed your outlook on your work, and perhaps your life?

FF: I find myself very impacted by the younger patients in particular, I think, because it is so difficult to watch people close to your age range really struggle in ways that we don’t necessarily expect for our generation.

There was a young woman who had an unusual cancer diagnosis and had horrible, horrible side effects from treatment and very dramatic, debilitating complications following treatment for the cancer—which in and of itself is heartbreaking—but the deep legal battle to try to get this woman public benefits was so frustrating to watch.

Social Security?

FF: Yes. I think we’ve all worked on this one now because it’s been going on for so long. But it was interesting to me to see that our social safety nets that we have set up aren’t necessarily going to come through for some people. 

And even if you have a whole team fighting for that, that’s not necessarily going to ensure they get the support that they need.

So, I really found myself impacted by her horrible struggle and what she’s been through, and the fact that she was persistent and pursuing what legally she had the right to, I mean, having reviewed all this stuff.

It was a little bit disheartening, but again, at the same time, it was nice to see that as much as I’m a stubborn person, to see other very stubborn people say, “Well, we are not going to let this happen. We are going to keep doing whatever we can.” And that’s what everybody still is trying to do.

We get more and more frustrated the more “Nos” we hear. And so, we say, “No, no, you are not going to do this to this person. We won’t let you.”

Things get caught in a loop and then you get denied, and then all of a sudden, you’ve gone without any sort of income or support for how long, and you’re at risk of losing your home and you have cancer.

What do you think are other limitations of being a clinician, looking back at your experience, and how can clinicians augment that going forward?

FF: That’s a great question and something I feel very strongly about. I think we have a lot of things that get in our way when we’re trying to address bigger factors and people’s circumstances. 

I see health insurance and navigating people’s insurance status as one of the biggest things that gets in our way.

It can be deeply, deeply frustrating because there are things that we want to do and we know are the right thing to do, but we’re unable to because their insurance won’t let them do it. 

And so, we have their best interests at heart and we know what we want to do to move forward to help them, but everybody is limited by this big organization that will or will not play ball. That’s something that I focused a lot on in some of the ethics work that I did—this idea of moral distress for us.

So, moral distress being you want to do the right thing, but there is a systemic obstacle in the way preventing you from enacting the right thing. 

For us, it’s really detrimental as well, focusing on clinician wellbeing. We want to help people, but when we can’t, it also damages us. It’s one of those things that burns people out and then ultimately leads to people in health care leaving the workforce, feeling like you’re not empowered to really stand up for people and treat them in the way you believe is right.

A friend at a safety-net hospital described it as, “You fix people. They come back in, and you fix them again. It’s just an endless cycle of people being broken.” They’re brilliant with impeccable pedigree and wanted to go on this grand journey in academic medicine, but because of this experience decided to leave and try something else.

FF: Yes, absolutely. It is sad. And I think especially in the emergency room, for example, you see a lot of that, where what really needs to be addressed is someone’s social circumstances and their housing situation in particular.

We see a lot of homelessness and people that come in who are in pretty severe mental health crisis. I think a big number of patients in the emergency department come in because of untreated social issues, and that needs to be addressed in a different setting.

There’s a lot of work at the systemic level that needs to be added in, I think, in order to help people with the root cause of their issues.

How much of that is a critique of the U.S. healthcare system, if you’ve been exposed to other healthcare systems?

FF: I’ve never worked in a health system outside of the U.S., so I can’t speak to that. But from the perspective of someone who has gotten health care in other health systems, I think the barriers to getting your foot in the door are surprisingly high here.

We make it very difficult and complicated to even get an appointment. So, I would say a good amount of that is a critique of the U.S. health system. I wish I had a solution. I hate to offer criticism without offering an alternative.

Perhaps that’s what lawyers are for.

FF: Yes, it needs to be better.

Should all cancer centers or university health systems consider creating medical-legal partnerships?

FF: I would love to see that expand. Actually, I think this is a phenomenal program, and I think that there’s absolutely space for it, particularly in places where there’s relationships with law schools, because I think there’s even more room for law student involvement as well.

So, I get really excited about that, regarding development and the increasing number of MLPs—I don’t know how quickly they’re increasing—but I know that MLPs are not uncommon, although it’s not something that we necessarily see and are aware of until we become aware of it and learn about it.

But I think the public sector, particularly, Federally Qualified Health Centers and places like that, absolutely should. And I think more universities, especially universities with law programs, should be incorporating this into their curriculum.

You mentioned that you worked on health benefits and coverage. Did you get to see how the attorneys at Cancer LAW worked to get patients their benefits or get coverage from insurance companies?

FF: Yes. I was part of the process of doing some intakes for individual patients and doing their interviews—less so on the paperwork side, fortunately—but they did let me tag along and put me in on some email chains. 

The conversations, I would listen in a little bit in terms of the back and forth. But I helped them with letters that had gone through multiple rounds of people being denied for benefits.

And it’s funny, as a medical student, you don’t always necessarily feel useful. But it was really interesting being in a situation in which we really are the experts—it’s appropriate because we know we can interpret this information and we can make compelling cases to support patients because we understand the context.

And so, I felt we were really a valuable addition to the team, and we’re able to frame things in a way that I think helped the people on the claims side get a better sense of what was actually going on with patients.

Were there cases that you observed or worked on that were successful?

FF: There were landlord-tenant court cases where I witnessed the attorneys resolve eviction cases by getting them dismissed.  

In those cases, the attorneys were able to raise housing condition defenses and also resolve ongoing issues with public benefit programs that allowed the tenants to obtain income, which allowed them to pay back any rent they owed the landlord. Yes, it worked.

So, you’ve experienced these success stories. How will this change the way you practice as a physician going forward?

FF: That’s a good question. I think this was a really valuable orientation to the different tools that are available to address some of the things that I can’t directly address as a physician. 

Particularly because most of my training is going to be through a county hospital, I’ve been keeping an eye on this space for what an MLP could look like in this context, or how can we expand this program so that we can get advanced social work and a legal team to really advocate for people when we can.

And that’s something that I’ll absolutely bring forward into both my residency and future practice, that awareness of the possibility of this as a solution.

What are you going to focus on in residency? Where do you see yourself in, say, five years when you’re done?

FF: I’ll still be in residency. I’m doing general surgery. I’m doing a six-year program.

Gosh, you’re not going to have a life for eight years.

FF: Yeah, I know. Could be even longer than that, I’m doing at least one research year, if not multiple. I’m interested in academic medicine.

So, things that I have stayed interested in are health equity and surgical outcomes, particularly for underserved populations. And then also ethics. 

I think the humanities perspective on the morality of medicine is really compelling. Why we need to advocate for people who are particularly vulnerable, that’s very important to me. I am interested in focusing on that with my academic time.

But following general surgery, the nice thing is it’s very open-ended what you can go into. I’m interested in a lot of things like surgical oncology, liver, trauma surgery­—which has a lot of intersections with people who have complex social needs—and then also transplant surgery, which is very different on the spectrum, but has its own very unique social and ethical conundrums.

A weird mix of metaphors, but the surgery world is your oyster.

FF: Anything except for the brain and the bones, basically.

Years from now, it’ll be fun to hear someone say, “Francisca’s a department chair, she’s got control of the budget, and she’s starting an MLP.”

FF: I think I don’t have to be a chair in order to advocate for that. And I think also, it’s one of those things where it’s a pretty compelling pitch in and of itself. 

Everybody is frustrated by these issues at every level. We’re impacted by difficulties with, for example, people getting benefits or people getting insurance and losing their housing. 

I think especially in academic centers where the focus is so much in things that are cutting edge, it’s not a hard pitch. I think it sells itself.

FF: It’s revealing about people, how they react to finding out about that kind of work. I think it maybe reflects poorly on them that that’s not a priority.

Everybody is frustrated by these issues at every level. We’re impacted by difficulties with, for example, people getting benefits or people getting insurance and losing their housing. I think especially in academic centers where the focus is so much in things that are cutting edge, it’s not a hard pitch. I think it sells itself.

How does my experience inform why I think diversity is important? Well, I think the number one thing, what we focus on in the DEI sphere when we’re having these talks is, patients do better when they feel like they can trust somebody. This has been studied pretty extensively, but outcomes are better.

For example, with Black patients, if they have a Black physician, if you look at broader population studies, they do better. And why exactly that plays out, not to editorialize, but I imagine that people are more comfortable and there’s just something a lot easier about forming a really therapeutic relationship when you feel like someone just understands you.

From the perspective of why DEI is important, I mean, I think it’s great to obviously break barriers and we need more people of color in leadership, and it’s important for the world to make sure that we’re allowing people the opportunity to progress. But the number one thing is, the patients and the patients need us, and we want the patients to do better.

That’s why we need a more diverse workforce. That’s why we need diverse voices in charge, because now, at the level where we have more physicians of color, let’s have them in leadership so that they can be helping to address policy changes. 

Because now, if we’re talking about structural issues, if we give people the opportunity to address structural issues that they’re familiar with, it also is more personal.

So, people are more stubborn because, “Oh, I had to deal with that. Or my family, my uncle, and my friend. I’ve seen this in my community. That pisses me off.” And I think there’s something really powerful about when you get pissed off and you can channel that into a solution.

I think that’s why it’s absolutely essential to have, not just in the physician capacity, but in the leadership capacity as well.

And also having people with that background who are interested in going into this work, otherwise we’d be doing more with less?

FF: Absolutely. And I think for a lot of us, it’s personal. So, there’s a push. There’s not a ton of us, but we’re pushing.