Race, Ethnicity, and Residency

Post #5: Action – This is our lane

See the prior posts introducing this topic, exploring the scientific myth of race, elaborating why race is still very real, and the role of implicit bias.  This discussion is not meant to be comprehensive, nor are the listed resources, but I hope it can shed some light on race, science, and racial medicine.  Please contact me with any comments or additional sources.

Of all the forms of inequality, injustice in health care is the most shocking and inhumane.

Reverend Martin Luther King, Jr., 1965
https://www.amazon.com/Martin-Luther-King-Selma-March/dp/B0722Q32VG

These words were spoken in Montgomery, Alabama at the end of the march from Selma.  Dr. King walked alongside black and white physicians he invited from the Medical Committee for Human Rights.  They were there for two primary purposes:  to give care to injured marchers and to observe to the abuse suffered.

We, too, must bear witness.  For many of us (myself included), this woefully starts with watching, reading, listening, and finally beginning to learn.  For instance – ashamedly – I just recently learned after the death of Congressman John Lewis, that Dr. King’s march was in response to one by John Lewis and others where nonviolent protestors were attacked by state troopers with clubs and tear gas; our future Congressman was severely beaten and sustained head injuries. Mr. Lewis’s march was in response to the police shooting of Jimmie Lee Jackson, a 26 year-old church deacon who was attempting to protect his mother from the nightstick of a police officer during a demonstration.

As physicians, though, it does not end with observation. Our education is purposeful – to heal.  Unequivocally, both conscious and unconscious racism worsens disease.  It leads to inequity in life and death.  We cannot heal without combating racism.     

In her book “Just Medicine” that I mentioned in the last post, Dayna Bowen Matthew borrows from Thomas Frieden’s Health Impact Pyramid [figure below] to discuss the varying ways public health efforts can impact outcomes.  Conceptually, the higher the level of the pyramid, the less public impact.  Dr. Matthew uses this figure to implore the need for lower level interventions to truly combat racial inequality in healthcare, and while I encourage reading her book to learn about it, I do not believe I give anything away by stating her plan requires changes in the medicolegal system.  Similarly, Ibram X Kendi argues that dismantling racism necessitates policy much more than personal change. Therefore, if we want to truly promote racial healing, as individuals and institutions we need to support broad and encompassing change.  We must hold our leaders accountable and elect officials that will enact antiracist policies. 

…………………………………

“Racist” and “antiracist” are like peelable name tags that are placed, and replaced based on what someone is doing or not doing, supporting or expressing in each moment.  These are not permanent tattoos.  No one becomes a racist or antiracist.  We can only strive to be one or the other.  We can unknowingly strive to be a racist.  We can knowingly strive to be an antiracist.  Like fighting an addiction, being an antiracist requires persistent self-awareness, constant self-criticism, and regular self-examination. 

Ibram X Kendi

I started this series with the intent of discussing a few steps I want to take within our program.  Admittedly, they are near the apex of the health impact pyramid above.  They also are introductory and insufficient.  But, they are tangible and accountable:  judge our program by these actions and our outcomes.

Education:  Social science literature encouragingly indicates that implicit biases are malleable.  Even though they are accumulated over a lifetime, we can counteract (although not likely fully eliminate) them with “personal, social, and situational pressures.”  With that in mind (see the pun there), I am committed to promoting regular implicit bias education in our didactic curriculum.  As a learner rather than an educator on this topic, I will lean heavily on others, and welcome any and all ideas and resources. 

The limited data on implicit bias in medical training suggests that early in training physicians are less likely to allow perceptions of race and social class to influence clinical decisions than later on.  As Dayna Bowen Matthew explains:  “Most medical schools include cultural competency training in their curricula.  However, the negative perceptions modeled by seasoned physicians, and possibly other health professionals as well, do not disappear simply because of medical school training in cultural competence … cultural competency training has little impact on the transfer of implicit biases from senior practitioners to their medical students.”  Consequently, the behavior modeled by our faculty is passed to our residents, residents to our medical students, and so on.  For educational efforts to have an impact, it must encompass our entire department, and we need to be aware the outsized role modeling behavior plays.

Recruitment:  According to the most recent census estimate, 14.5% of individuals in Lexington, KY and 13.4% of the entire US population are Black.  Our department and residency program do not reflect our population.  While we intentionally recruit with racial and gender inclusion in mind, it clearly is insufficient.  Last year I wrote on the initial intent compared to the current use of USMLE scores and potential concerns with the void left if (and now when) the scoring system changes.  Given this and the disruption to the entire recruitment season as a result of COVID-19, a more holistic review process is needed.  I will advocate for systematic advances within our specialty, but also commit to intentional and rigorous changes to our program level application review process. All members of our application review and interview committees will also be required to go through implicit bias training prior to participating.

I hope those that took the time to read these posts found use in them.  I hope even more that if you are someone like me, your eyes are similarly starting to open.  This is just the beginning for our program, and I will provide updates as they come.  The changes we make, and lessons learned will influence many other aspects of our training and clinical environment.  Please reach out with any comments, concerns, or suggestions.

The good news is that racist and antiracist are not fixed identities.  We can be a racist one minute and an antiracist the next.  What we say about race, what we do about race, in each moment, determines what – not who – we are.”

Ibram X Kendi

Race, Ethnicity, and Residency

Post #4: Implicit Bias and Personal Reflection

See the prior posts introducing this topic, exploring the scientific myth of race, and elaborating why race is still very real.  This discussion is not meant to be comprehensive, nor are the listed resources, but I hope it can shed some light on race, science, and racial medicine.  Please contact me with any comments or additional sources.

“One wishes that Americans – white Americans – would read, for their own sakes, this record and stop defending themselves against it.  Only then will they be enabled to change their lives.  The fact that they have not yet been able to do this – to face their history to change their lives – hideously menaces this country.  Indeed, it menaces the entire world.”  James Baldwin, “White Man’s Guilt” in The Price of the Ticket

Collection of Dr. Samuel Morton. See Post #2. https://www.penn.museum/sites/expedition/the-samuel-george-morton-cranial-collection/

The last two posts provided examples of egregious racist acts and policies within science and broader society, and how they are intertwined and still very much with us today.  A study of medical residents in 2016 demonstrated the racial biases we carry into the hospital, which demonstrates a form of implicit bias:  “People – all people – hold some implicit biases.  A bias is a negative attitude about one group of people relative to another group of people.  However, the distinguishing feature of an implicit bias is the negative association operates unintentionally or unconsciously.”

The quote above is from the book Just Medicine: A Cure for Racial Inequality in American Health Care by Dayna Bowen Matthew.  She details the history of racial healthcare laws and policies that formed the framework for much of our inequality today, but also argues the importance of individual implicit bias at the level of the physician-patient encounter and how that influences the overall healthcare system. 

https://www.aft.org/ae/winter2015-2016/staats

If you haven’t, take the Implicit Association Test (IAT):  https://implicit.harvard.edu/implicit/.  This widely used and validated test has revealed the harm of our implicit biases in many different arenas including prosecuting attorneys in the criminal justice system, the jury selection process, employment hiring and promotion decisions, and school disciplinary actions.  Police officers with higher IAT scores (white favored implicit biases) more readily shoot unarmed Blacks than unarmed whites during video game simulations.

Healthcare workers are not exceptional and test no differently than the rest of the population.  In her book, Dr. Matthew presents “The Biased Care Model” [figure below] and details six mechanisms by which health care providers’ racial and ethnic biases contribute to disparate health outcomes.  Her argument is compelling and well worth the read.  If you remain unconvinced on the role of implicit bias in racial inequity, specifically in healthcare and explicitly at the level of the individual provider, then please consider reviewing these or other resources.

…………………………………

“When racist ideas resound, denials that those ideas are racist typically follow.  When racist policies resound, denials that those policies are racist also follow.  Denial is in the heart of racism, beating across ideologies, races, and nations.  It is beating within us.” Ibram X Kendi, “How to be an Antiracist

Even if it is not explicit, most (if not all) of us carry implicit racist biases.  That can be hard to accept, since we believe ourselves to be good and honest people.  But what I’ve tried to argue to this point is we are a product of a long history of racist ideas, policies, science, and socialization that is deeply entrenched within ourselves.  Denying this truth is harmful, but so is ignoring it.  If we believe racial equity is important in our greater profession and in our own office, then it requires constant vigilance against our own biases.  As stated by Michelle Alexander in The New Jim Crow: Mass Incarceration in the Age of Colorblindness, “This system of control depends far more on racial indifference (defined as a lack of compassion and caring about race and racial groups) than racial hostility – a feature it actually shares with its predecessors.”

The final post on this topic will explore some actionable items related to all of this, with the intent of creating accountability for our programmatic response.