Race, Disparities & Medicine
Through no coordinated efforts on our part, three graduates from my high school arrived in New Orleans, LA to attend Xavier University of Louisiana. When I describe my experience at Xavier to other people, I describe it as the first time I could be unapologetically myself. It was so inspiring to look out on the yard on any given day and feel empowered by people who looked like me striving toward higher education and positive service toward others. Those four years became even more important when re-entering the “real world,” when remembering the support and guidance there helped during the days when I was made to feel less than or underprepared or undervalued.
The fight for equality has been ingrained into my being for as long as I can remember. My grandmother was not shy in sharing her experiences growing up and prepared me for what we now call micro-aggressions when I started elementary school. I have no doubt this part of my informal education led me to medicine and then to public health, searching for my own way to level the playing field. With the state of affairs in our country over the past months and years, I have been struggling to articulate my thoughts and feelings as it relates our country and our profession. Those feelings that range from anger to disgust to disappointment to despair.
My high school and college classmate, Ashley Harmon M.D., a psychiatrist, made an eloquent statement recently, which captured those feelings I'd been struggling to put words with:
“No one ever speaks to the complicity within the medical community that tolerates racism. Do my peers understand what it means to be called a Nig--r while providing care to patients? Do you know how it feels to be seen as subhuman and still provide excellent care? Do you understand how I have to remain silent and continue to be unbiased? Do you understand that because I am the defacto leader that I have to provide an example at all times? Do you understand how traumatizing that is? Do you know that medical schools do not teach people of color how to defend themselves? These institutions also do not teach our white peers to defend us either. Administrations look past the person and to the bottom line. Racism and bigotry scream silently down the halls of medical institutions. And we wonder why there are health disparities? The medical community has not even developed a coherent response when one of their own is harmed. How then could the medical community protect others?”
Dr. Ashley Harmon is a board certified geriatric psychiatrist, though most recently working at VA, she has worked in several different health care settings including nursing homes, assisted livings, inpatient psychiatry and emergency psychiatry. Working as an aid in an assisted living facility sparked her pathway to Psychiatry. She recounts her interaction with an elderly resident in her care. She was a God-fearing woman who never forgot her evening prayers, but she was heartbreaking because she forgot her children’s names. She could not reconcile how this praying woman could become irritable at a moment’s notice and be an adept thief that could rival any professional. They often retrieved other residents’ belongings from her purse. Dr. Harmon wanted to understand what was wrong with her brain, and why she lost her memory. It astounded her that someone’s brain was powerful enough to shape their perception of reality, and it was wonderful to learn about the person behind the illness once their symptoms resolved. She felt that through psychiatry, she would work with the young and old, including those with dementia and try to improve their quality of life.
The above Facebook post stemmed from frustration and dismay at the racial tensions and violence that were displayed in Charlottesville and the days after. White supremacists had become so emboldened that they were proudly spouting their ideas and vicious rhetoric. This event led to a reflection upon the times, in various settings in which Dr. Harmon had been called the n-word or patients of color had to manage knowing another patient was using racist language.
When dealing with emotionally unstable patients, many will adhere to social norms despite their illness. And the majority of cases where she had encountered racist language were not in the midst of psychosis or delirium. It reminded her of instances where even inside the walls of a hospital, a supposed place of healing, racial tensions could easily bubble to the surface. It is always below the surface, unspoken. If racists can proclaim their beliefs loudly in the streets, why must she remain silent in the halls of healing?
Prior to taking a sabbatical from the VA, Dr. Harmon’s team was dealing with a man who made racial slurs in front of others. Fortunately, this program had a policy in place to manage incidents like these, so there was a feeling of empowerment. This is not the norm. In other facilities, policies are not always clear and often give no recourse for those who would be aggrieved, either patients or staff. And does this not reflect on the way we deal with race in a broader context? Essentially, what we see is the policy of reprimand without consequence. This can foster a sense of helplessness which can produce apathy. There is also an ethical argument to be made about not refusing to care for those who believe differently from you. But what if those beliefs could be harmful to others?
Dr. Harmon contends that ultimately, health institutions encourage the silence because this is a difficult situation. They tend to hope it “goes away” when discharging the patient. It is also true that this is the easy way out. But the experience never truly goes away for those who are targeted by the insult. How do we protect our patients? How do we protect ourselves? Is no place sacred?
There is little in the medical literature that focuses on the experience of minority physicians and how they navigate these issues nor is there much guidance on how institutions should instruct their providers to empower themselves or their colleagues. If we are to truly address these concerns, they must first be discussed. They cannot be swept under the rug since it is indicative of a larger problem.
In medicine, we are taught you need to correctly identify the issue to address the problem. We need to broadly acknowledge that our peers and colleagues of color have experiences which can be emotionally unsafe and at times traumatizing. We should begin to document the experiences of physicians/practitioners in terms of racist interactions so that we know how prevalent this experience is. Unfortunately, this experience is quite common and often occurs at least once during the career of a practitioner of color. Once we catalog the frequency and quality of these experiences, we can begin to develop an appropriate response. Medical students should have appropriate training and enter their careers armed with tools to take care of themselves and others. Though we may not be able to refuse care to patients, we should have a coordinated and consistent response across facilities that let patients know that this behavior and rhetoric is not acceptable within healing institutions. Our brethren should be empowered alongside us so that we carry a forceful message that will scream louder than the silence of racism.
Out of sight is out of mind. Our counterparts may not actually believe that this occurs regularly and therefore think it does not warrant a coordinated response unless we have the data to prove it. We should begin to approach administrators and ask them about what policies are already in place and gauge if they are open to improving these policies and re-educating staff on how to deal with these patients. We will be the only ones to bring this issue to the forefront. We will need to be the champions not only for ourselves, but ultimately for the ones we serve.