“Why do Black lives matter?” a patient asked me. “Why can’t all lives matter?”
It was just a few weeks into my residency, and I hadn’t been expecting a patient to ask me that question. I certainly wasn’t trained to respond to it even though I, along with many of my colleagues, wore Black Lives Matter pins. The patient, who identified as white, looked at me, an Asian American physician, with curiosity.
“Was it even my place to answer?” I thought then.
Both doctors and patients can have unconscious biases that affect medical care. Yet medical education has fallen behind in teaching physicians how to initiate and continue dialogues with their patients about race and racism.
One of the many things physicians must do is ask their patients probing personal and often sensitive questions. Patients sometimes ask probing questions back, and doctors are expected to answer them honestly.
In taking a social history, which is part of an initial encounter with a patient, we learn about a person’s job, substance use, sex life, and more. Race hasn’t been a standard part of this inventory. But it should be.
In the United States, structural inequities based on race have been one of the most powerful determinants of socioeconomic status and health. People from racial minority groups are more likely to encounter limited access to safe housing, healthy food, job opportunities and education, all factors that negatively affect physical and mental health. Racial disparities are also costly. One analysis projected an economic gain of $135 billion per year if the U.S. eliminated racial disparities in health.
The main way most doctors get information about race is through the intake form patients fill out. These forms usually include a check box with the following options: white (non-Hispanic), White (Hispanic), Black, American Indian or Alaska Native, Asian, or other. This information may tell a doctor a patient’s racial identity, but it says nothing about their experience in that racial identity.
The Centers for Disease Control and Prevention has created guidelines to help clinicians take a sexual history. No such official framework exists for talking about race.
To help doctors start having these conversations with their patients, I worked with my mentor, Daniele Ölveczky, a geriatrician, hospitalist, and interim director of the Center for Diversity, Equity, and Inclusion at Beth Israel Deaconess Medical Center in Boston, to adapt guidelines from several sources. Our goal is to make asking about patients’ racial experiences a standard part of the social history.
Such conversations need to start by creating a safe space in which to have an open dialogue. Context statements like, “I want to learn more about you beyond your medical problems so I can take better care of you,” can help open the door.
Like any aspect of taking a patient’s history, the questions should start broadly, with questions like “What aspects of your background or identity are important to you?” or “Some people find that their race, religion, or culture is important for their health. Is that how you feel?”
Another important component of understanding a person’s medical experiences is by asking directly, “Have you ever experienced discrimination in the health care system? If so, was it based on skin color, accent, gender, sexual orientation, or other reason?” A “yes” answer is worth exploring, since eliciting more details can help a doctor avoid saying or doing something that could be seen as offensive.
In light of police killings of Black people and the upswing in hate crimes against Asian Americans, doctors should also address racism directly. Writing in the New England Journal of Medicine, James Lee, a psychiatry resident at the University of Washington School of Medicine, suggests that doctors ask their patients, “Are you more anxious today because of racism or do you avoid doing specific things or specific locations because of fears of discrimination?”
An exploration of race and racism isn’t just about the patient. Doctors should also reflect on their own biases and ask themselves if aspects of a patient’s appearance, ethnicity, accent, personality, or behavior might influence them in ways that lead to anything less than top-quality care.
I hadn’t thought of any of this when my patient asked me why Black lives matter. I could tell it was an important question for her, so I did my best to answer.
We talked for half an hour, discussing the centuries of oppression Black people have endured and how the deaths of George Floyd and Breonna Taylor, among the many Black lives lost to police brutality, shed light on racism and injustice. I tried to make the point that until Black lives — which historically haven’t counted — truly matter, all lives can’t matter.
The conversation wasn’t perfect, and was at times uncomfortable for me, but I chose to have it with my patient.
Engagement is really the first step. Having one-on-one conversations with patients about race and racism is part of a larger movement to tackle systemic racism in the health care system. It requires patience, as these dialogues may not finish in one sitting, but it’s crucial they happen.
Doctors need to extend social histories to include questions on racial identities and disparities. The goal is to make asking patients about race as common as asking them about smoking habits and contraception.
Some patients may not want to talk about racial identity or their experiences with racism, and that’s their prerogative. But doctors will never know who does want to talk about it unless they start the conversation. Doing that will improve care for all patients.
Minali Nigam is a first-year resident at Beth Israel Deaconess Medical Center in Boston. Her colleague and mentor, Daniele Ölveczky, a geriatrician and hospitalist at Beth Israel Deaconess Medical Center in Boston and interim physician director of its Center for Diversity Equity and Inclusion, was instrumental in creating the guidance described here.