By Vanessa E. Van Doren, M.D.; Tracey L. Henry, M.D., M.P.H., M.S.
Society of General Internal Medicine, SGIM Forum, October 2020
I grew up in a die-hard liberal part of the country. As I have learned the myriad ways in which racism rears its head, I have discovered that my northeast “culture” perpetuates its own forms of racism and classism. This manifests as a dearth of Black people in leadership positions, huge racial disparities in income and life expectancy, subtle messaging about who is welcome, and condescension about “the South” and “flyover states,” often aimed at places with large Black populations. I love Boston—it is my home. I am proud of our high standard of education, social services, and low rates of uninsurance. But loving something doesn’t mean there is no room to improve.
I want to examine our collective discomfort with criticizing what we consider important parts of our identity, and few professions are more entwined with identity and ideas of self-worth than that of the physician. The long, expensive training, and the way our hours in the hospital pull time away from relationships and outside interests, make many of us feel like we are doctors before anything else. Challenging the traditions upon which our profession is built may mean challenging the framework for our whole personhood. It can call into question the value of the sacrifice we made to pursue this calling. Unsurprisingly, this often results in outrage and defensiveness. At the same time, to justify that sacrifice, it is immensely important that we do the uncomfortable work of evaluating whether our institutions are living up to their moral promise. If we can establish a culture where this introspection both is normalized and necessitates collective action, I believe that we can build that equitable system together.
Physician as Hero
Emory was my last interview because I canceled all subsequent ones after coming here. I knew this is where I wanted to be. Two things stood out to me that day. First, while every program had something to say about “diversity and inclusion,” Emory’s diverse program leadership exemplified this ideal. Second, the intense pride in resident and faculty voices when they talked about advocating for their patients at Grady—one of the country’s largest public hospitals—contrasted with awkward silences at many other programs when I inquired about care for uninsured patients.
I am now in my third year at Emory. I consistently am struck by the lengths to which my colleagues will go to care for their individual patients, but unfortunately, even our best is not enough. Inequality routinely plays out in horrific ways here: hospitalizations, evictions, deaths. The majority of patients I have watched die due to COVID-19 were Black and Brown. Even when I help someone get better in the hospital, I often discharge them back to the street or to unsafe housing or without needed supplies.
I am equally struck by how powerless we as healthcare workers feel in addressing, or even learning about, upstream causes of this inequality. In a state rife with voter suppression, where Medicaid is virtually impossible to access, and where long-standing racist policing leads to immeasurable harm, the challenges often feel insurmountable. Despite the expertise we develop through our work with marginalized patients, health policy and political advocacy make us nervous.
Much like our criminal justice system, the entire institution of medicine is steeped in the tradition of racism.1 Experimentation, without analgesia or consent, on Black bodies laid the groundwork for many modern surgeries and medications. For hundreds of years, Black people were excluded from care or only seen in poorer-quality segregated hospitals, and to a great extent de-facto segregated medical care continues today. Black patients are less likely to receive adequate pain control2 compared to white patients with the same injury. Even after controlling for income, Black patients receive consistently worse care and suffer worse outcomes.3 Somehow, these facts still are not routinely taught in medical schools.
Physician as Human
After the murders of Ahmaud Arbery and Rayshard Brooks in Georgia, Emory’s Internal Medicine leadership immediately condemned racist police violence, and many joined local demonstrations. They held a conference for the internal medicine faculty and residents to discuss both the impact of racism on our community and the importance of examining our own practices. One of our program directors talked about the day her eight-year-old son was seen as a threat because of the color of his skin. Another faculty member openly introspected about his own lack of barriers as a straight, wealthy, cis-gendered, able-bodied white man. Residents talked about microaggressions: both as victim and perpetrator.
By holding this conference, our leadership set an important standard—that we all internalize racism, and that the only way to reduce how much we perpetuate it is to unflinchingly examine and own up to our own biases. This is the first step in the continuous work of being anti-racist. Within a week, the program rolled out a Racism and Social Justice lecture series, highlighting racism and bias in medicine, the impact of microaggressions, and ways to advocate for structural change. With full program support, Emory residents have begun educating ourselves, lobbying our representatives about police reform and hate crimes legislation, promoting voter registration, joining street medic trainings, and soliciting donations to local grassroots organizations.
We are now considering long-term residency program reforms to address key questions: How can we increase diverse recruitment? What changes must we make to our core curriculum? How can we ensure that we apply the same standard of care to all our patients regardless of race or whether we see them at our private or public hospitals?
Draining the Pool Together
Our patients are neck-deep in water, and rather than burning ourselves out as we individually prop each person’s mouth above drowning-level, we need to work together to drain the pool.
Education about our country and profession’s history of racism must become a required competency interwoven throughout the medical curriculum. Only then can we begin to understand, respect, and bridge our Black patients’ distrust of the medical system as part of a comprehensive effort to provide equitable care. We must also examine how our own institutional policies and practices contribute to structural racism. If and when we identify such policies, we must change them. There can be no excuses.
Education about our complex healthcare system also must become a required competency if we are to be informed policy advocates. We need to retire the “physician as hero” narrative that lets us substitute feel-good stories about helping one patient for long-term advocacy and systemic change.
We must recruit a physician workforce that reflects our patient population, both for equitable patient care and to equalize access to positions of power. On a national level, the physician workforce remains overwhelmingly white and wealthy. While programs that implement diverse leadership and recruitment are mounting, we still have a long way to go.
We need to think about the connections between the educational debt, inhumane hours, and extreme hierarchies that define medical training and how this shapes physicians’ willingness to push for change. We all know that pushing leadership to make change could put a promotion or recommendation in jeopardy; this is a big reason that more physicians (particularly those still in training) do not speak up. Physician culture teaches us that the wisest course of action is to keep your head down, get through, and get yours. It is no surprise that as a group we are politically apathetic and unimaginative about envisioning better institutions. We must examine how often the phrase “this is the best we can do” shields those in power from discomfort or loss of their own privilege. And if our own concern for career advancement leads us to stop pushing when we feel similarly threatened, we must acknowledge that we may be doing the same thing.
Finally, allies must also start shouldering their share of the work and risk inherent in advocating for better systems. If we do not share this burden, it will continue to predominantly rest on women of color,4 adding to the barriers they already face in this field and disproportionately taking time away from career development and self-care. This is a very concrete way that allies can “give back some of their privilege.”
If we can move beyond our lone hero complexes to join together, and if we can be imaginative and brave enough to envision and advocate for something better, I believe we can build the system we all hoped to work within when we decided to become doctors.
Dr. Van Doren (Twitter: @vvd186) is a PGY-3 in the Emory University School of Medicine’s J. Willis Hurst Internal Medicine Residency program and a current participant in the Health, Equity, Advocacy, and Policy Track. Dr. Henry (Twitter: @docwithapurpose) is a general internist in the Division of General Medicine and Geriatrics at Emory University, an attending physician for the inpatient teaching services at Grady Memorial Hospital, and assistant health director and supervising attending in the Primary Care Center.
References
- Washington, HA. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. New York, N.Y.: First Anchor Books; 2006.
- Meghani SH, Byun E, Gallagher RM. Time to take stock: A meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med. 2012;13(2):150-174.
- Bridges, KM. Critical Race Theory: A Primer. St Paul, M.N.: Foundation Press; 2019.
- Grubbs, V. Diversity, equity, and inclusion that matter. NEJM. https://www.nejm.org/doi/full/10.1056/NEJMpv2022639. July 10, 2020. DOI: 10.1056/NEJMpv2022639.
