A week after the 2016 election, I rushed to Yale Law School after class to hear one of America’s most prominent health policy experts, Dr. X, give a talk on the transformation of health care. I knew, given the political climate, he would speak on the future of the Affordable Care Act. It was an intimate setting; attendees could sit on two sofas facing one another right in front of the podium or one of several chairs around the room. All of the chairs were filled first, perhaps because most attendees were intimidated by the sofas’ proximity to this oh-so-important speaker. I had no choice but to sit on one of the sofas by the time I made it inside. As I settled in and Dr. X began his talk, I realized that I was noticeably the only Black person in the room.
After Dr. X’s discussion of sophisticated health care delivery systems, it was time for questions. Sitting right in front of him, I raised my hand … then watched him continuously pick others in the audience. The moderator, one of the law school deans, was sitting across from me, and he encouraged me to keep my hand up as he watched despair settle on my face. Finally, near the end of the Q&A session, Dr. X pointed at me. As I stated that I had two questions–just like the woman who had spoken a few turns ahead of me–he interrupted, limiting me to just one, so I managed to combine them.
His response was rude, I thought. I felt first invisible the entire time I was waiting to ask a question–first row, hand up–then hyper-visible and vulnerable as I was the only person towards whom he did not extend as much grace. I have felt both invisible and hyper-visible as a Black man in numerous casual, social and academic settings.
Now, more than halfway through my clerkship year of medical school, I have had the privilege to learn from some of the most renowned physicians and experts in this country, like Dr. X. Akin to sitting right in front of Dr. X on that sofa, I’ve been part of small teams with physicians, sometimes in close proximity for hours at a time. They’ve had to evaluate my performance, not only judging my agility with clinical skills and medical knowledge, but also judging subjective things like professionalism and attitude. It is not uncommon for medical students to be anxious in such situations: Not knowing the right time to ask a question, whether or not to laugh at a joke or even if it’s appropriate to make small talk with a senior on the team. Being a Black medical student exacerbates this situational anxiety. While I am trying to learn from and care for my patients, I always dread how many Dr. Xs I may come across as evaluators, and worry about how I will be perceived.
A study out of Yale showed that Black medical students are six times less likely than their White counterparts of similar academic caliber to be selected for membership in Alpha Omega Alpha, a process run by fellow medical students. Another study showed differences in medical student performance evaluations depending on the student’s race and gender, even after controlling for objective measures such as USMLE Step 1 scores: “White applicants were more likely than Blacks, Hispanics, and Asians to be described with adjectives like ‘exceptional,’ ‘best,’ and ‘outstanding,’ while Black applicants were more likely to be described as ‘competent.’”
It certainly isn’t the case that Dr Xs have an agenda to exclude Black students from learning experiences or to make learning more difficult for us. It is the case, however, that Black students are often either not thought of at all or thought of too much in a negative way. It feels dehumanizing, and in a learning environment, unintentional though it might be, it is particularly unfair.
In his publication “The White Space,” sociologist Elijah Anderson describes what Blacks in America experience far too often when navigating spaces historically and presently dominated by Whites. Social distance from others and limited/conditional credibility are common traits of the Black experience in a white space; this is all due to dark skin’s association with what Anderson calls the “iconic ghetto,” a mythical place ridden with poverty, danger and crime as portrayed in popular culture and media. Our skin color’s association with the iconic ghetto renders us invisible yet hyper-visible, stripping us of our intrinsic humanity. In social settings, this translates to subtle things such as people never saying hello unless I do first, peers labeling me intimidating even though I smile more than I would in Black spaces, or friends forgetting to invite me to socialize until the last minute. In academic settings, a suturing workshop leader might spend the entire workshop watching and giving advice to my White colleague sitting beside me while I, too, certainly could use either some advice or reinforcement.
This means that, in White spaces, we have to perform a dance that dissociates us from the iconic ghetto in order to earn provisional credibility. The dance for me, in these settings, means speaking a certain way, going on camping trips to make more friends, or bringing up said suturing instructor’s recent publication in a prestigious journal. All of this is a conscious effort on my part to say, ‘I’m not your uncultured, uneducated negro.’ I am more complex than the stereotypes about tall dark-skinned Black men. At times, I feel disgusted by the dance and wish I could just be still instead; I shouldn’t have to deliberately deny my attachment to parts of the “real ghetto” to be accepted where I am. However, I also know what’s at stake, so I keep dancing, knowing that the social acceptance, the credibility and other perks of the White space are conditional. All it would take is one slip-up for their presumptions to become true.
What’s special about the fast pace of clerkship year is that everyone must constantly think on their feet, so there is less time for me to perfect my dance. One week, it might be a few minutes of small talk about country music in between patients; another might be a discussion of the latest tennis news over lunch. The situational anxiety I mention above manifests in different ways for different individuals. I know there is a chance that being quiet will be perceived as not being knowledgeable, interested or engaged, so in some settings I may overcompensate. That, in turn, can be read as talking out of order, or lacking situational awareness. Such perceptions have made their way into my written evaluations. For instance, a male faculty member once wrote that he was “afraid of engaging with [me] due to [my] lack of social awareness.”
Having been in my shoes decades ago and now being one of few Black male faculty members at the medical school, a mentor’s advice was “Err on the side of being annoying, or you may be perceived as uninterested.” I am hyperaware of this possibility and am therefore doubly anxious compared to the average medical student, all other things equal. I am constantly worried about two performances: the performance of a clerkship student, and the shucking and jiving I feel obliged to engage in to assuage the fears of those around me and gain conditional acceptance.
As more studies show how negatively Black physicians and patients experience race in the hospital, discussions around bias, implicit or not, have been gaining ground in academic medicine. These discussions have been centered around what doctors can do to mitigate their biases when seeing patients or teaching trainees. The fact that a professor who is in the position to teach me and subsequently evaluate my performance admits to being afraid of engaging with me for any reason short of physical threat is terribly hurtful. It also shows how far we have to go as a field.
In order for the issues of bias in training and evaluation to be addressed adequately, attending physicians should know about these fears and how crippling they can be (well documented by the literature on stereotype threat). Physician biases might be informed by anecdotal experiences or their understanding of the iconic ghetto, and my fears, too, are biases I readily acknowledge, albeit informed by the aforementioned evidence. However, as fearful and anxious as I am, I am always excited about being part of and learning from a medical team. I want my residents and attending physicians to be aware of the elements that have so far shaped my medical school experience–a certain racial awareness, if you will–and to be as enthusiastic about teaching me as I am about learning from them.
Attending Howard University gave Max a foundation for and continues to inform how he approaches issues related to injustice. Now in medical school, he has made it one of his focal interests to learn about and contribute to progress towards health equity, nationally and globally. Through this column, he will share stories on his experience as a Black man in medicine, and insights on topics of race, class, health equity, and medical education.