The Most Important Questions We Won’t Answer for You

By Nia Heard-Garris, MD, MSc and Rhea Boyd, MD, MPH

For some, Charlottesville was a wake-up call. As the nation considers how modern displays of anti-immigrant, anti-Semitic, and anti-Black sentiments betray our collective values, professionals have the opportunity to reassert their own.

As physicians, this is an important moment to confront intolerance in medicine and more specifically, ask vital questions about how clinicians perpetuate racism and oppression.

The Clinical Questions

Race, or more accurately, racism is an undeniable determinant of healthcare access and quality. In medicine, there is a long history of racial disparities in diagnosis, treatment and access to services. Those disparities contribute to inter-generational poor health outcomes for patients, by race. Further, clinicians’ may make hurtful and dangerous assumptions about patients’ education, ability to afford care, or willingness to adhere to treatment plans, by race. And legacies of experimentation and exploitation only exacerbate tensions between providers and communities of color. Each of these factors, individually and collectively, undermine the trust essential to patient-physician relationships and alienate patients of color in clinical environments.

Racism also shapes the professional trajectory and experience of medical students and trainees of color who must navigate patients, supervising physicians, and peers who may doubt their competency, hinder their promotion, or question their fit in certain specialties. Non-native born clinicians also face prejudice and discrimination based on accent, dress, and country of birth or training.

In all, clinicians wield an extraordinary amount of power and respect, but what good is that privilege if some are unwilling to use it to challenge racism in the very spaces they have the most influence?

So ask:

1. What type of language do I use and what assumptions do I make when I describe patients by race? Do I need to include race when presenting or discussing a patient? Or do I only include race when the patient is non-white? If so, why and how does that shape the care I provide?
2. What types of patients are even allowed to walk through my doors? Once they are there, how do staff treat them? What does that treatment communicate to patients and families about their value?
3. What types of students am I mentoring and who do I encourage to enter medicine? When my teams or my students are confronted with racism, do I address it and how? What are the ways I silently model my values or “the ideal” patient to trainees?
4. In the resident team room or doctor’s lounge, what conversations did I have after an event like Charlottesville? Or, was I silent?

The Institutional Questions

While the white nationalists’ march in Charlottesville embodies the burning ends of an older and broader American tradition, the legacy of white supremacy in medicine centers on a daily practice of ritual silence and inaction in the face of insidious racial disparities. Those disparities are the result of a history of racial exclusion from health care institutions. Institutions are not-torch-toting, but their ability to structure resources grants them the greatest power to perpetuate or eliminate racial health inequities. That power does not require the hateful voice of the emboldened few. It is enshrined in the policies on which racial hierarchies thrive.

So while verbally disavowing the public vitriol of white nationalism is important to disarm the power of white supremacy in our country, categorically examining and addressing forms of racial exclusion in our own organizations, is arguably more effective.

So ask:

1. Does my organization regularly track and report racial disparities in hiring, promotion, and leadership? And when disparities exist, are there clear and sustained paths toward equity?
2. For providers at non-profit hospitals, what percentage of my hospital’s tax-exempt savings, or community benefit funding, are actually targeted towards decreasing local racial disparities?
3. With recent evidence suggesting academic medical centers may segregate patients by insurance status, and consequently, by race, how is my hospital preventing racial segregation in patient services? Or, does my hospital reroute patients from certain neighborhoods or with certain insurance coverage to avoid caring for them altogether?
4. What questions should my institution ask to better expose the practices, policies, and operational standards that have a racially disparate impact on the patients and communities I serve?

This work is hard and requires us to be honest and uncomfortable. It requires challenging the status-quo and the “way things have always been done” even if and perhaps especially if, that way has benefited you more than others. It means confronting our language, our assumptions, our institutions, and our relationships to peers, mentees, and the communities we serve.

In the end, no one can answer these questions for you or your institution. And silence is an answer. The work now is to look yourself in the mirror and put your institution under the microscope and ask these questions and more. The work will not cease when these questions are answered, but a daily practice of being more equitable and just is the path forward.