In 1984, on Ralph Northam’s yearbook page at Eastern Virginia Medical School (EVMS), appeared two men dressed respectively in Blackface and in a Ku Klux Klan hood. It is unclear whether these were Halloween costumes or a real life insight into what parody “Black Culture Parties” might have been like, as also depicted in the comedy “Dear White People.” On Twitter, many asked the governor: “Are you in Blackface, or the Klansman?” Others asked “Is this really you?”, “Where did they get such a believable KKK hood as medical students?” and, perhaps most importantly, “Who let this fly by?”
This yearbook, a student-led publication, was eventually banned in 2014 because four medical students had posed in Confederate garb, a sign agreed upon by most of society as a symbol of racism. In order for this publication to have survived 29 years after the Blackface-KKK juxtaposition appeared in it, several classes of medical students must have turned a blind eye to this abhorrent depiction of racism: a sort of silent majority. They may have been disappointed by, unhappy or uncomfortable with the publication of that photo in their yearbook, but they certainly didn’t raise hell about it. This kind of inertia, whether or not Northam’s then classmates stood against racism personally, contributes to the complacency that emanates from the medical field when it comes to how much we continue to fail at addressing the lack of racial diversity within the field and bridging existing, long-standing health disparities.
When I first read that the Northam picture came from a medical school yearbook, I thought about whoever might have been his Black classmates at the time. Medical education is an intrinsically racialized experience for Black medical students. Race is often erroneously taught as biological. Through the hidden curriculum, medical students often witness subtle differences in attitudes and treatments of patients from different races, especially in disfavor of those who are Black. Black medical students are sorely underrepresented in medical school and scarcely have the opportunity to work under the supervision of Black faculty. As an anecdote, I spent 48 weeks rotating around various services in one of the largest U.S. hospitals, and I worked alongside a Black attending physician once, for nearly an hour.
In addition to these elements of the medical school experience, explicitly and implicitly racist comments coming from all types of dwellers of the school and hospital, permanent and temporary fixtures (whether pictures on the walls or the EVMS yearbook in 1984 and 2013) make the environment particularly hostile for Black trainees. A study published in the Annals of Internal Medicine in 2007 suggested how pervasive an influence race was in the work lives of Black physicians, and, 11 years later, a new study focusing on resident physicians in the Journal of the American Medical Association showed similar findings. The response to incidents perceived as racist is often minimization. Seemingly benign instances such as making fun of Black-sounding names in clinical settings (usually at the expense of patients), making light of the efforts of Black activist organizations or, like in 1984, people in Blackface and Ku Klux Klan garb appearing in the yearbook, are opportunities we have as trainees to address and hopefully right the wrongs of those around us. It costs, however, a great deal of social capital and one has to be willing to expend it.
At the institutional level, although explicit statements of commitment to diversity and inclusion in medical schools have become more mainstream, some would argue that not much has changed in practice. In fact, in some ways, things have gotten worse. Black doctors still make up only about 6% of the U.S. physician workforce; A recent report from the AAMC showed that there were fewer Black men enrolled in medical school in 2015 than in 1978. Black men have the lowest life expectancy of any major demographic group in the U.S., and we learned in the last year that having Black male doctors leads to Black men receiving more effective care.
If we traded the inertia for bold, courageous action and decision making, from the classroom and charting room to the boardrooms that make decisions about medical education and health care in the U.S., we would have a better shot at addressing health disparities. An example of such bold action could be eliminating the standardized Medical College Admission Test (MCAT) as a screening tool in favor of assessing applicants based on their backgrounds, barriers they’ve overcome and their commitment to medicine, as proposed in the Annals of Internal Medicine by Dr. Inginia Genao, an internal medicine physician at Yale University. MCAT-free medical school admission is, give or take, already happening on a small scale and deemed a successful model for institutions such as Brown University through its Program in Liberal Medical Education.
Challenging colleagues or even institutions over racist actions, policies or systems, be they intentional or not, also contributes to challenging false beliefs held about racial differences that impact our field, the health of our patients and us. For example, a 2016 study looking at racial bias and pain perception among medical students and resident physicians at the University of Virginia showed that 40% of first-year students and a quarter of residents answered that they thought Black patients had thicker skin than White patients, and half of the respondents thought that at least one of the false facts from the survey, such as Black people’s blood coagulating more quickly that White people’s, or that White people have larger brains than Black people, was possibly, probably or definitely true. These beliefs are tied to 400 years of slavery, Jim Crow and systemic racism, and most certainly to differences in quality of care received by Black patients compared to their White counterparts, noted for example, in post-operative, acute and chronic pain treatment in both adult and pediatric populations.
I am neither calling Ralph Northam, nor his classmates, racist. In fact, in an online forum of Black physicians and trainees, a participant described him as “very fair, non-judgmental, non-discriminatory, not racist.” Instead, adorning his yearbook page with images that symbolize in their own way America’s history of violence towards Black people out of humor suggests a very cavalier attitude towards a force that has continued to shape and often destroy the lives of Black people. He went on to become governor of Virginia. I’m sure many of his classmates have accrued decades of practice in medicine, and some perhaps, risen to leadership roles. The inertia of 1984 may very well continue to be a theme, now in practice and leadership.
That same inertia has been very palpable in my first three years in medicine. I wish I could say otherwise, because racism, as subtle as it can be sometimes, makes medical school more difficult to navigate than it should be; it is a serious threat to our lives and the lives of our patients. These instances of soft or bold racism absolutely have to be challenged by more than the few Black people in the room. I acknowledge that it takes courage to go against the grain and risk losing social and political capital, but it’s fundamentally the right thing to do if we are in this for a health care system that is egalitarian.
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.