Caring for Ourselves,Supporting Anti-Racist Programming in Medicine

Abstract

Healthcare disparities and racism are finally being addressed in medical education. Medical schools are working to implement anti-racist programming; however, this can have a negative impact on the mental health of doctors and medical students of color. Continually hearing about people of one’s racial group suffering from inequity can have a negative personal and performance impact. Specifically, providers of color want to be a part of the anti-racist movement, but it takes a toll on their mental and emotional wellbeing in the process. Through the support of their respective institutions, it is important for these providers to prioritize self-care such as engaging in physical activity, coaching and therapy. By caring for themselves in and outside of the work environment, providers of color will be better able to fight for anti-racism in healthcare. In this essay, we discuss the importance of health disparity education, challenges in implementing successful healthcare disparity curricula, and possible solutions to support providers and trainees of color.

“Hospitals and academic medical institutions are making unbelievable efforts to address racism within their walls.”

“I thought I was going to die because no one is listening to me.” As a woman of color with many friends who are young professional women of colors, we have had tons of girl talk of late regarding our new babies. A conversation that has been omnipresent beyond the newest toy, breastfeeding, and sleepless nights revolves around the recent studies on maternal health of black women. ¹ The data show that black women, regardless of education status and income level, have more pregnancy related complications and their infants fair worse too. ² Specifically, new or expecting Black mothers are 3.5 times more likely to experience maternal mortality than new or expecting White mothers. Knowing this research, we were scared. Our fear impacted the way we perceived our miraculous moments, bringing our little ones into the world. Knowing that you and people that look like you get less or do worse is tough to grapple with as you and your family goes through healthcare, particularly when solutions are not made clear.

There is a known need to address healthcare disparity and racism in medical education. Medicine has nobly accepted the call to address structural racism. Addressing inequity is a heavy lift. We, as healthcare providers, need to balance this lift with our own health and wellness.

Inequities exist in all forms of healthcare. ³ In neurosurgery, Black patients are less likely to receive surgery, subspecialty consultations, and rehabilitation services. ⁴ Achieving equity in healthcare is a critical goal for our patients and our healthcare system.

Teaching About Racial Inequity Presents Challenges to Hospitals and Institutions

It is hard to solve racial disparities when there is lacking education around them. As an example, a 2016 poll noted that many medical students believed erroneously that Black people had different biologic pain thresholds than Whites, making Black patients less likely to receive pain medication.^5,6 More so, even though COVID-19 affected millions of people, Black people were significantly more likely to die from infection. ⁶ Yes, some causal impact was the result of extraneous socioeconomic factors, but doctors were also at fault as Black people were far less likely to be tested for COVID-19 when they presented to the emergency room with symptoms. ⁶ In addition, Black patients are less likely than White patients to be screened for different chronic diseases, such as high blood pressure, leading to undiagnosed ailments that worsen their health. ⁶ Recently, medical schools have completely overhauled their curricula to better address healthcare disparities. ⁷ For example, Duke University School of Medicine has reinvented the curriculum to emphasize “understanding the social context of health [as] a foundational skill” through the school’s newly implemented Patient First curriculum. ⁷ Likewise, University of California San Francisco School of Medicine is commencing on a 3-year expansion project to better format their anti-oppression curriculum. ⁷ Curriculum changes of this scale require enormous effort, personnel, and time.

As a neurosurgeon witnessing the enormous lifts medical schools and hospitals are undertaking to implement anti-racist programming, I have been both impressed and overwhelmed. Participating in anti-racist education and research has served as an “aha” moment for me. How can medicine solve such an enormous world problem? I realize that my colleagues and I can do the best for the patients in clinic or in the operating room; however, once we remove our white coats or scrubs, the reality of our brown skin is unchanged. These silos in which we treat patients but not the underlying racial inequities that affect them are daunting and underscore that societal ails are not well managed in hospitals.

Contrasting Lived and Learned Experiences of Racism in Medicine for Providers of Color

The feelings of exhaustion or internalized racism that result from hearing negative things about your race are real. The phenomenon of internalized racism is well-characterized by sociologists and experts in race theory. If a person of color hears and internalizes remarks about racism towards their identified racial or ethnic group, it can have a negative personal and performance impact. The education literature on stereotype threat provides conceptual evidence of this impact. For example, students of color score worse on intellectual tests after hearing negative perceptions of their racial group. ⁸ Exposure to negative perceptions of your race and association with performance leads to attrition in STEM fields. ⁹ Further, experts in racial theory argue that a concept called “racial reification,” or placing someone in an exaggerated racial group in the public eye, can be damaging to individuals of color.^10,11

As we address race and racism in medicine, providers of color may experience a tension between a desire to improve education around race and a fatigue from internalizing discouraging realities about their identified racial group. It is difficult to grapple with the idea that people that look like you get less or do worse in the healthcare system, particularly the system in which you work. It can feel impossible to rest knowing that your community is underserved.

The anti-racist movement in medicine represents an opportunity to change the way we educate medical students to incorporate critical knowledge in healthcare disparity. Institutions have committed to anti-racist missions in an unprecedented fashion. For example, hospitals have participated in system-wide anti-racist demonstrations, held meetings to address racism in their communities within their walls, and changed metrics to include better diversity standards. ¹² While medicine cannot solve all of society’s ails, this movement is doing incredibly important work. The work institutions are doing will improve the health of communities and individuals alike.

Finding Solutions: Teaching about Health Disparities while Supporting Providers of Color

We, particularly providers of color, need to find ways to stand and serve within anti-racist missions while maintaining our wellbeing.

As we address race and racism in healthcare, we need to be mindful to embrace the humanity of students and providers of color. There are several ways to do this, and we suggest that institutions consider the following for their providers and students of color: joy, self-care, and community formation. We believe that improvement in these 3 areas will cultivate supported and peaceful mental and physical spaces.

We need to remember and value the joy in our daily lives. Witnessing a patient be treated unfairly can lead us all down a dark path. There are ways to counterbalance the difficult realities of service by tapping into positivity. ¹³ For example, Dr Karen Walrond suggests looking at your cell phone pictures to remember all the fun things that have happened to you recently. She also recommends taking a daily picture of something beautiful. Dr Bryan Sexton suggests chronicling “three good things” daily to embrace positivity and gratitude. ¹⁴ Additionally, because thoughts about racism leave everyone feeling exhausted and overwhelmed, keying into joy can help avoid feelings of despair and restore energy to do good work.

As a doctor, it is important to have different streams of happiness in our daily lives. Take, for example, my experience with the threat of disparity on maternal and fetal wellbeing. While finding joy does not change the facts of this scenario, I found comfort in discussion and even laughter with my friends. Additionally, towards the end of pregnancy, I found ways to exercise, get daily sunshine, and destress using yoga and podcasts.

Self-care can come in many forms and can help students and providers of color maintain passion and compassion while they and their institutions address race and disparity. Between the operating room, research, and finding childcare, it can feel outrageous to go get my hair done and questionable to even brush it. It’s critical to take time away from the fight to care for ourselves. Some examples of suggested self-care activities include engaging in physical activity. Committing to physical activity means committing to feeling healthy personally and has been shown to be particularly absent since the COVID-19 pandemic. ¹⁵ Additionally, coaching and therapy are key forms of self-care to address challenges and combat feelings of internalized racism.

Self-care should take place within a supportive institution. Institutions, especially now, need to support their faculty and trainees of color from recruitment through retention. For example, institutions can have designated unions or associations that cultivate community for Blacks in healthcare. ¹⁶ However, most importantly, institutions should be mindful to hear the voices of people of color without overburdening them to take on race and racism alone. ¹⁷ It is important for Blck people in healthcare to feel comfortable to voice their experience working in a predominantly White field, and it is the institutions’ role to learn and listen. To create lasting change, the racial majority within these institutions must commit to solving problems of racism and healthcare disparity.

Lastly, we can form communities to tackle race in medicine together. If medicine cannot solve society’s ails, we certainly cannot do it alone either. Bringing groups of like-minded people together to discuss key issues and share stories can help to create a supportive network and avoid feelings of isolation and despair. One example is to use the technique of narrative medicine. For example, Columbia University held a workshop on Race and Justice in which problem solving and story sharing were encouraged. It was enthusiastically supported for its creation of community and direct approach to discussing racial injustice. ¹⁸ In the future, we should consider holding these types of workshops nationally to create change on a larger scale. Additionally, it is important that institutions diversify the physician community so that it is more representative of the patient population. ¹⁹ When patients are provided for by doctors that look like them, it has been shown that they have better health outcomes and receive more equitable care. ²⁰

Embracing challenges is key to improving. The US is facing its history when it comes to healthcare disparity, and this is not easy. Hospitals and academic medical institutions are making unbelievable efforts to address racism within their walls. As we serve within these institutions and live our lives outside them, it is critical that we care for ourselves. Taking better care of ourselves will keep us in the fight to make medicine better.