Last week marked my first week as a doctor. Like thousands of my colleagues, I began intern year with a combination of enthusiasm and dread. On my first day of clinic, I woke well before dawn, full of nervous energy. I collected my precious intern paraphernalia — my stethoscope, my Pocket Medicine guide, and my crisp long white coat. I filled the pockets of my new uniform, smoothed the hems, and, as a finishing touch, began applying the pins I wore throughout medical school to the collar.
We lead babies couldn’t decipher it. It was pattern matching — something the cognitively impaired couldn’t do very well. Figure out the rules and pick the best option. If I let myself, it did feel futile.
My recent psychiatry clerkship inspired me to examine racial relations during third-year rotations. This reflection originated from a physician submitting a particularly disturbing evaluation of me. She wrote: “[The student does not] recognize and address personal limitations or behaviors that might affect their effectiveness as a physician … [The student is] defensive, rigid, intense and intrusive; unable to see nuances in human behavior that is necessary for analyses of the human psyche; lower emotional quotient than peers.” Her response left me with an open-jawed, stuporous gaze. I could not believe that she had made this kind of assessment after interacting with me in only two patient encounters for less than half a day!
“I could never be a primary care doctor,” my friend and fellow medical student says as she pops a french fry into her mouth. There are five or six of us sitting around a hospital cafeteria table, grabbing a quick lunch between our morning and afternoon lectures. “I mean, seeing fat people with diabetes and heart disease all day. It would just be so frustrating, because they did it to themselves, you know?”
As medical students, we recognize that bias in medicine is doubly damaging: it burdens our peers and it harms our patients. In the opening narratives we see both of these at play: in Micaela’s self-doubt and frustration, and in the intern’s judgment of their older, Latina patient. Such clinician bias has been increasingly shown to contribute to widespread health inequities.
Shortly before returning to the United States for the holidays from Malawi, a truck full of police and military men pulled up next to my car as I was driving and demanded my driver’s license. They claimed I was “dangerously parked” while stopped in a long queue of traffic to let my friends hop out across from a bus station and would, therefore, be fined K10,000 (approximately $18).
She just sat there and listened — what else could she do? Did he really think it was the first time she had heard this? Was the rehearsed monologue supposed to elicit some sort of epiphany? One of our pre-clinical instructors told us a story about how she went to the doctor’s office to get a refill, only to receive a 20-minute lecture about her weight by a resident. She walked out of the office both irritated and empty-handed, her refill not completed: “I know I need to lose weight!” But, at that juncture, and in that manner, she felt it simply was not the appropriate discussion.
As future physicians, understanding the consequences of absolute resource levels impact health is critical. A physician who advises a better diet to somebody without the ability to act on that advice is of little more use than the physician who prescribes an imaginary medication. However, institutes of medical education do a disservice to their students by keeping the conversation so narrow. Medical schools must begin to more fully teach how relative inequality impacts health.
As an “underrepresented minority” in medicine, my personal experiences of mistreatment while navigating the challenges of pursuing this career are mostly invisible to the rest of society, but I know that they are far from mythical or unique. In fact, my experiences harmonize perfectly with the tales of so many African-American physicians before me and even in the accounts of the students I currently mentor. Everyone asks, “Aren’t things different now for African-Americans?” Yes. But, are they better? Sadly, not exactly.
The cultural competency framework that has become the mainstay of medical education is often times employed in incredibly reductionist ways. It seems to propose that exposing physicians to homogenized, static and packaged ideas of culture will aid them in estimating patient behavior, preference or response in the clinic, thereby diminishing health care inequality. Training like this paves the way for even well-intentioned student-doctors to be explicitly ignorant under the auspices of clinical benefit. It spoils the good intent to create better patient outcomes by legitimizing the validity of stereotypes and the development of physician bias.
The images of water from Flint, Michigan water came into my mind and I lingered at the sink a few minutes too long. I became heartbroken for the children whose bodies may have been irreversibly and negatively impacted. I became enraged at a system that would prioritize saving pennies over properly protecting its citizens from preventable harm. Governor Rick Snyder, his appointed “emergency financial managers” and other leaders allowed this crisis to develop over years as they mistreated Black citizens through racist policies, violated the public trust, and endangered lives. A significantly poor and majority black city was told it was okay to use polluted water to prepare their children’s dinners. Families washed their dishes in what could be mistaken for urine. They scrubbed their pearly whites with toxins to avoid cavities.
December 10, 2015 marks the one-year anniversary of the inception of White Coats for Black Lives, a national organization of medical students that aims to eliminate racial bias and racism in the practice of medicine — as they are threats to the health and well-being of people of color.