M

edicine struggles with a chronic disease: racism.

Medical schools try to combat this disease with diversity initiatives and training in unconscious bias and cultural sensitivity. I’m about to graduate from the University of Virginia School of Medicine, so I’ve been through such programs.

They’re not enough.

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Every one of us needs to own the principles that protect us and our patients from racism and bias. That means learning to see prejudice and speaking up against it. But that is far, far easier said than done.

Again and again during my four years of training, I encountered racism and ignorance, directed either at patients or at me and other students of color. Yet it was very hard for me to speak up, even politely, because as a student, I felt I had no authority — and didn’t want to seem confrontational to senior physicians who would be writing my evaluations.

These situations made me worry for our future: How can medical professionals address the needs of a rapidly diversifying population, when we cannot address prejudice within our own community?

I did try, once, to speak up, but it didn’t end well. My first clinical rotation was in the ear, nose, and throat clinic. On my first day, I overheard the attending physician grumbling about accommodating an elderly Haitian man with limited English who had misunderstood his appointment time. “We’ll stick the med student on him,” he said. I was excited to test my skills, but I couldn’t help but feel that my seeing this patient was intended as a punishment for him — and that made me uncomfortable.

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A few hours later, when it was finally time to see this patient, the attending physician told me I had the pleasure of conducting my very first patient interview on “Amadou Diallo.”

That was not his name. The only similarity between Amadou Diallo, the young man who was shot and killed by four New York City police officers in 1999, and this elderly Haitian gentleman was their skin color. My skin color.

“That’s not his name,” I said, instinctively but respectfully.

I was pointed in the direction of the patient and clinic, and proceeded as usual.

A few weeks later when I received my clinical evaluations, I perceived some of the feedback as unkind. I couldn’t tell if the comments actually reflected my performance or if I, too, was being punished for speaking out, or maybe even for being black. It was terrifying not knowing the difference.

As my clinical training progressed, I had several opportunities to point out intolerance and injustice. I always chose amicability over advocacy. I didn’t want to jeopardize my grades and evaluations by calling attention to intolerance, so I stayed silent instead of voicing the values I believed in.

During my internal medicine rotation a few months later, a patient called me a “colored girl” three times in front of the attending physician. The doctor did not correct the patient, nor did she address the incident with me privately.

Despite all the other positive interactions I had with this teacher, her silence in this circumstance diminished my presence. I wondered if she thought of me as a “colored girl” too.

Looking back, I don’t regret my timidity. It’s what I felt I needed to do to survive. But I feel angry and frustrated that my mentors in the medical profession didn’t raise these issues themselves. Diversity and inclusion initiatives challenge bias in the abstract. Checking bias in real-time, with real people, is much more challenging.

Maybe they didn’t notice the bias. Maybe they didn’t feel it was important enough to talk about. Maybe they didn’t know how to talk about it.

They should have.

To be truly inclusive, communities must be places where everyone feels they have equal worth and where people can have honest conversations without judgement. There’s not enough of that spirit in medical school, or in the medical profession.

One more example among many: During my obstetrics and gynecology rotation, I helped perform a prenatal ultrasound on a woman wearing a Confederate flag shirt. Her husband and son watched. Both were wearing Confederate flag hats and belts.

The optics of the encounter were jarring. I wondered if my patients hated me. Again, the attending physician did not address the racially charged awkwardness of the encounter.

Although this physician was otherwise kind to me, his silence left me with a lasting impression. And too many toxic questions.

As the Brazilian educator Paulo Freire writes, “Sometimes a simple, almost insignificant gesture on the part of a teacher can have a profound formative effect on the life of a student.” All these years later, I still wonder if these physicians — my teachers — respected me. It was difficult to reconcile the compassion they showed their patients with their apathy towards me.

I needed to know if my experiences were anomalies, so I checked in with two well-respected black physicians who focus on diversity in academia. Dr. Marcus Martin, a vice president at the University of Virginia, and Dr. Eve Higginbotham, a vice dean at the University of Pennsylvania, both assured me that I wasn’t alone. In fact, they said such experiences were all too common.

“It really is over the lifetime of one’s career that you ultimately understand how to actually deal with these very difficult situations,” Higginbotham said.

Medical school often erodes aspiring doctors’ empathy, compassion, and idealism. As Harvard Medical School professor Dr. Richard Schwartzstein writes: “Typically, students enter medical school idealistic, eager to improve the human condition, and excited about becoming doctors. And then we do various things to change them.”

This is most often the byproduct of the intense pressures of academic and clinical work. As a medical student, however, I fear my heart was hardened by an extra burden, of my educators being blind to my worth as a woman of color.

As I advance in the training hierarchy and acquire students of my own, I will certainly do my best to foster inclusion. While my experience as a black medical student has made me hyperaware of racism in medicine, I know because I am human, that I have blind spots of my own.

I will work to stay aware of tense moments. And I will always stand up for my students. I also hope I can cultivate a community where my students feel comfortable calling me out.

Until we all commit to taking action every day to foster a true spirit of inclusion, we’ll risk perpetuating racial harms and undermining the true spirit of medical professionalism. I know race relations in medicine will not change overnight, but learning to see what is hidden in plain sight will be a crucial first step.

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  • Non-Whites routinely identify as “people of color”, and this med student got in a snit because she was called a “colored” person? Give me a break.

    • Dave, I’ll top that one. The current editor of my college paper is one of these social justice warriors in the guise of student, who just wrote that white people equates to white privilege, and therefore we are unqualified to discuss racism. In reality my class of 1970, white, was hardly priviledged, but to use her language, it is us “privileged white” alumni that donate the money to run the school paper that allows her bilious rantings, but this person, like most college students these days are too obtuse to undertand such concepts.

  • Well written, and very timely as more and more diverse people are needing, directing, learning, and providing hospital based services. While its a shame that the process of desegregation is still part of our culture, its an honor and a privilege to help.
    Thank you for helping to keep this issue front and center. Until the race wound is healed for America, I believe, we won’t be able to seriously tackle any other issue.

  • Thank you Racheal! I remember seeing a photograph of a stabbing victim being wheeled into the ER. Victim was in full KKK attire with a pointy hat. The ER was a black hospital in Alabama. KKK was marching by the hospital when a clkan member was stabbed. I’m confident the doctors lived up to their Hippocratic oath most admirably. They did their job because it was not about them.

    Truth is, we are all prejudiced and racist. It’s part of human nature. Happily decent people do not act out on the racist and prejudiced views. It’s called being civilized. If anyone denies it, I bet they are afraid to take a good hard and long look into the mirror.

  • What a sad way of looking at the world. As a student of color in law school, you made the incident with the ultrasound all about you or some cause you believed in. It is not about you. Does a Muslim doctor stop what he is doing if the family are all wearing crosses? Does a Irish Catholic stop what he is doing when giving an ultrasound to an Irish Protestant? This SJW attitude that everything in life has to bow to me and my worldview is not only wrong- it fosters hate, not eliminate it. As an attorney I will defend people who hate me in their everyday life. It is not about me. The world does not revolve around you either.

  • Higginbotham has it exactly right. It takes a lifetime. Coming from England as a child, I got huge grief for my accent, dress and unfamiliarity with American words. Then, I got beaten up by the Black kids, as we lived on the edge of their neighborhood. All people are tribal, and most have a hard time undoing their cultural training, whoever they are. Luckily, I was a soccer player with African, West Indian and Mexican teams, while having plenty of Black friends at school (and today). I could never figure out why so many people disliked others for their skin. Then I got to med school, and was shocked by the racist attitude of a lot of my peers, who were supposedly intelligent. I realized most of them came from downstate or the suburbs, and had never really known anybody non-white. It was an eye-opener. And, coming from a Jewish background, I’ve heard plenty of comments, etc., over the years, though I freely admit my skin does not instantly differentiate me from the majority, which is an order of magnitude different from your experience.
    Nevertheless, let me pass on some thoughts. Keeping one’s own counsel is often the best policy, particularly in training. One has to pick one’s battles. Medicine, unfortunately, is little different from the rest of the world, and squeaky wheels, in my own experience, don’t fare so well.
    One of my cardinal rules is, “everybody has an absolute right to be as stupid (or ignorant) as they are”. I have to adjust to them, in general, not vice-versa, because it is unlikely they will change to please me. But, my corollary is, “everyone has a story to tell”, meaning that I can’t dismiss anyone, either, no matter how much they tick me off: I will miss the “good” part of them.
    Racism is difficult to attack from the bottom of the heap, because much of it is about power in the first place. Biting one’s tongue is difficult anywhere, but it’s necessary to advancement. Now that I’m an attending, I can take people aside and tell them, “I don’t want to hear that again, OK?” I have some leverage now; not before. I agree that it is correct, however, to use it where one is able.
    But, I rarely correct patients except in extremes. They don’t come to me for a morality/PC lesson, and no doctor wins a battle with a patient. Especially these days. Also see rule 1. (But, I’ve never had a patient use the N word in reference to a staff person or trainee. I’d draw the line there, with something like, “I can’t take care of you unless you respect all my staff…Agreed?”)
    Let’s remember, though, the lady using “colored girl” has probably used it all her life. It’s her vernacular. Even though the term is reflective of a, hopefully, bygone age, she probably doesn’t consider it an insult, or use it with that specific intent. You refer to yourself as a “woman of color”, she flips it around. Is there that much difference, in the end? I’d be more irritated by the diminutive “girl”, frankly. But, I could be wrong here.
    I’d prefer it if you thought of yourself as a “doctor” pure and simple, as you have a right to be proud of the status you’ve achieved, especially over the harder road society has presented to you. No one, either through words or actions, can take that away from you.
    Where I have a good rapport with a patient, I may say to her, alone, “she’s a doctor, I’d prefer that you use that term”, but at the least, it’s best to address the incident by taking the group aside and saying ” I heard what she said and it was inappropriate, don’t let it get to you.” This supports the victim, establishes for the group my opinion, and sets an example of how to deal with incidents like this.
    Racism is an anachronism, we can agree on that. But changing the laws is only the first baby step. You are still in the vanguard of race relations, fifty years on, in part because your position exposes you to people who may never have otherwise met you. You are different, to them. And, you are held to a higher standard, which is unfair. But, you have a special responsibility in that you are paving the road for others, by your example. Is this extra burden just? No. You have enough to do. But, just as slavery, forced illiteracy, political and economic oppression has had an ongoing effect, largely unrecognized and unacknowledged, on the Black community, so has the converse social structure, essential to the above, had an impact on the White population. Illegitimi non carborundum: don’t let the bastards grind you down! Your earning power and professional status sets you apart from the majority of the population, already. You will encounter envy, jealousy, misplaced anger and racism, no matter what you do. A few people will act according to your expectations viz race, but not as many as one would like. There is no mandate that people act as you wish. See rule 1.
    For many, the Confederate flag is a cultural symbol, or a historical artifact: its underlying connection to racism does not even enter their consciousness. (And, their side lost.) Millions of White Americans went to war and died by the tens of thousands to defeat slavery. Does that not speak to the bravery and brotherhood that, somewhere, underlies the United States?
    Your attendings may be great doctors, but that does not translate into social awareness, diversity training or no. Given their age and race, many will be less sensitive than you’d like. It’s not personal. I often work in rural areas where minority staff and physicians are rare. I make a point of greeting and chatting with anyone new, so it is clear that at least I warmly welcome them, in front of the staff.
    I’m almost fluent in French. so I learned Spanish in the 90’s to be able to talk to more patients. I overhear patients calling me “gringo” before they know I understand every word. It’s not a kind expression, but I don’t let it ruin our day. I tell them I played semi-pro ball with a Mexican team with a smile, and we get down to the real business of figuring out what’s wrong.
    I feel sorry for people who, through racism, shut themselves off. I’ve had so many great experiences and met so many lovely people by making an effort to be inclusive. For one thing, my wife is Puerto Ricana, and thus my kids.
    Yes, the medical profession, as all others, has a lot to do. But change takes time and life moves slowly. Be grateful that you are attuned to this issue, as your actions will speak volumes to others.

    • I appreciate your insight into this situation. My daughter is a fourth year med student and I have a little understanding of how stressful med school is. One further thought, sometimes we are in a situation where a racist or sexist remark is made in a context where we are not expecting it (such as a patient interview). The tendency is to ignore it in the hopes that won’t happen again and we can proceed with our task. The person in charge should be prepared to make a comment either to the patient or the recipient that communicates that the remark is unacceptable. However unless you rehearse what you should say, the odds are that you will not be prepared to say anything.

  • Thank you for a very thoughtful and well-timed post. I live and work in highly diverse community; therefore, my encounters with cultural prejudice are not significant. Plus, I am white. But being bullied as a child because of my race, I cannot imagine how an adult can tolerate this kind of attitude from a patient or supervisor.
    I do understand that one has to do what one has to do in order to survive. Though, it will only prolong the injustice and won’t solve the problem.

  • This article, along with a similar article by Nurse Nacole, was something I needed. I’ve had my first major run in with racism, while being a nurse for four years, not too long ago. My supervisor and social worker basically dismissed it, saying that the patient was in their manic state. I asked to be reassigned to a different unit while the patient was there, and my request was denied. When I felt that nothing was being done, I brought it up to the executive director. I was told by my supervisor, “I thought this was done”. Fast forward to a few weeks, my supervisor sought me out to say that she was called out of her name by a POC patient. I think it was may be then, she understood where I was coming from.

    Thank you for writing this. I’ve been told that I’m too sensitive or just looking for something out of nothing. Thank you.

  • As a white male doctor (albeit with a name I’m used to having mispronounced), I can’t possibly imagine what you went through in your training.

    I’m not sure if there’s an easy way forward here. The American political climate is so fractured, even in this case where the right thing to do is clear, you can already hear the knee-jerk reactions on Fox News and so on. It’s a pity your supervisor lacked the thoughtfulness or the courage to act, nor (I assume) to even discuss it after the fact.

    The good news is that you and your country have now graduated a wise and thoughtful doctor. The thousands of patients and students that will come under your charge over the years will be the better for it. Keep your head high!

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