By Lucy Berrington, MS
Advocates for a meritocratic medical workplace: Ron Dunlap, MD, past president of the Society at the MMS 2017 Interim Meeting; Sharon Marable, MD, with the president of the AMA; and Carl Streed, MD, testifying at the 2017 Interim Meeting.
This is an extended version of a story that appeared in the print edition of Vital Signs.
The inclusivity of the medical profession is not a given. Anecdotally and empirically, we learn of discriminatory dynamics shaping medicine as they shape other fields. “Medicine is a microcosm of American society,” says Dr. Sharon Marable, MD, MPH, FACP, vice-chair of the MMS Committee on Diversity in Medicine. “It has its good, its bad, its blatant biases, and its unconscious biases. We carry all of that into the worksite. As physicians, we need to recognize that.”
Owning our Biases
Catching our own biases is, by definition, counterintuitive. A 2017 essay in ACEP Now, a publication of the American College of Emergency Physicians, provides a guide. “First, recognize and accept that we have biases. They help us to function and serve to protect us,” wrote Bernard L. Lopez, MD, professor and vice chair of emergency medicine and associate provost for diversity and inclusion at Thomas Jefferson University Hospital, Philadelphia:
“Research has demonstrated that bias blind spots (the ability to ‘rationally’ explain away our biases) are greater in those with higher cognitive ability (e.g., physicians). Realize that this is not easy to deal with. Explore the awkwardness and discomfort that comes along with examining our biases and how it affects our daily interactions. Engage with people who we consider ‘others’ and learn and gain experience from them. Finally, get feedback. Ask a trusted person, ‘How did I do?’ This is how we learned our profession. We became educated, sought guidance and feedback, and practiced it over and over.”
Evidence-Based Strategies
Project Implicit, founded by scientists, provides enlightening online tools for quickly measuring biases we didn’t know we had. In a 2013 analysis of physicians’ implicit bias in the Journal of General Internal Medicine, investigators identified several evidence-based strategies for reducing physicians’ bias in clinical decision-making:
- Self-awareness: Knowing they were subject to implicit bias
- Individuating: Making a conscious effort to focus on specific information about an individual rather than social categories (e.g., race or gender)
- Perspective-Taking: Making a conscious attempt to envision another person’s viewpoint
Effective Intervention
In conversations with Vital Signs, physicians emphasized the importance of their colleagues’ support. “One thing people can do is not wait for physicians of color to raise these issues. Other people need to be calling it out and talking about it,” says Vincent C. Smith, MD, MPH, a neonatologist at Beth Israel Deaconess Medical Center. “I know that when a group is composed of all people who are not people of color, the conversation is slightly different than when there are people of color present. I’ve had friends who have told me what’s said when nobody’s around, when the speaker thinks they’re in like-minded company.”
Physicians' Guide to Positive Change:
Appreciate Your Value as Active Bystanders
A physician at Brigham and Women’s Hospital described to Vital Signs how a 2015 incident during her residency, in another state, demonstrated the value of bystander interaction:
“I was a third-year resident on my last day of the rotation. The fellow and I were waiting for our new attending. He walked in and looked at me in a certain way; something about me was not agreeable to him. Within five minutes, he started to tell the story; ‘Back in my day when I was training, it was a totally different time. We had C Block and W Block.’ The fellow was from another country; he said, ‘I don’t know what you’re talking about.’ But I knew. I said, ‘You’re talking about when hospitals were segregated. There were colored wards and white wards.’ I was thinking, where is this headed?
“He said he trained in the south; ‘I remember this black woman patient. She had three beautiful daughters. They were so beautiful you couldn’t even tell they were black.’ He looked at me, a young African American woman in my white coat. He said, ‘My attending said to me, ‘They may look white, but underneath they’re still [N-word].’’’
“When I hear the N-word coming from an authority figure of power, it’s like fight or flight. I really needed to leave. I was sitting there in disbelief. I said, ‘I think you’re trying to communicate a point. Why don’t you just tell me what the chest x-ray shows.’ But I was not in a space to learn.
“Afterward, the fellow took me directly to the administrator’s office. He didn’t even tell me where we were going. He went in and said, ‘I just witnessed the most inappropriate thing I’ve ever seen in my life, directed against this resident.’ We made our report. As a result, the attending was required to take early retirement, though he continued to serve as a volunteer and have contact with residents.
“That experience taught me the importance of supportive bystanders. The person targeted doesn’t know what to do; they kind of freeze. Later, in a lecture, I reported a racist comment the instructor directed at an Asian student.”
—Cianna Leatherwood, MD, fellow in rheumatology, Brigham and Women’s Hospital
When and How to Speak Up
“If you observe unconscious or blatant bias, someone not being treated justly, you should say something. Some people are comfortable enough to say it right then and there. Other people wait to pull the person aside later, go for coffee. Please don’t make believe it doesn’t exist.”
— Sharon Marable, MD, MPH, FACP, vice-chair, MMS Committee on Diversity in Medicine
“I always joke that as a cis gay white guy, I’m literally one identity away from being ‘the man,’ so I have privilege I can rest on and advocate for others. My experience is often, as a male doctor, seeing my female colleagues have derogatory comments [directed at them]; ‘Oh honey, please bring in the doctor.’ I would immediately step in and say, ‘This is your doctor right now; she is qualified and competent.’ That’s what needs to happen in every situation. I don’t know if I change people’s hearts, but I don’t hear any more derogatory comments. There have been other times when somebody says, ‘I don’t want a black doctor,’ and you say, ‘This is your doctor right now.’ I would ask that trainee if they want to see somebody else or not; I don’t want them to be exposed needlessly to this.”
—Carl Streed, MD, fellow in internal medicine, Brigham and Women’s Hospital; chair, MMS Committee on LGBT Matters
“Our unit has a significant percentage of black, Asian, and Latino providers and patients. We recently developed a promotional video. When the video was previewed, everybody in it was white. I remember sitting in the preview thinking; ‘Here we go again,’ and worrying that I have to once again be that guy pointing out this obvious, glaring thing.’ It’s funny because I know the people who made the video, and they’re aware of issues of diversity. But that still didn’t stop them from making this video and it’s not dawning on them that this video is not representative. Luckily, my boss pointed out to them, in a very educational way, that the video was not representative.”
—Vincent C. Smith, MD, MPH, neonatologist, Beth Israel Deaconess Medical Center
Establish Your Credibility Upfront
“I would tell my medical students, minorities and women, to immediately establish their credibility with their patients: Tell them that you’re a second-year resident, you’ve been training at Harvard for two years, you graduated from Georgetown Medical School, and you have this much experience [treating this condition]. Usually after the first five minutes, once they realize you’re well trained, they forget about it.”
—Ron Dunlap, MD, cardiologist, past president of the Massachusetts Medical Society
“Mentors taught me how to properly channel the situation. Inside you’re maybe a little angry because you’re being almost disrespected; on the other hand, my goal is to take care of people. That means putting personal feelings aside and trying to establish a bridge of communication, mutual understanding, and respect. The best way is through kindness and compassion. If a patient says, ‘Can you get me this or that,’ mistaking me for an assistant or nurse, I say, ‘I’m happy to get that for you, but I want you to know that I’m the medical student taking care of you.’ I say that as many times as necessary. Sometimes the interaction is very different at the end from how it started.”
—Aurian Garcia-Gonzalez, MD/PhD candidate, UMass Medical School; chapter president, Latino Medical Student Association
Seek Out Inclusive Communities
“When fellows were applying for positions, looking at medical communities around the country, I would tell them, ‘Look at the advancement of minorities at that medical school before you apply there. Look at the demographics of the community to see how likely it is you’ll be accepted. I’m not telling you not to do what you want to do, but I’m telling you to consider these factors.’”
—Ron Dunlap, MD, cardiologist, past president of the Massachusetts Medical Society
“I gravitated toward mentors who could understand me, my culture, language, and belief system. That’s the rationale for the Latino Medical Student Association: I believe I can ease other students’ transition by providing role models and mentors, including myself, who can understand, and say it gets better. The faculty of underrepresented groups is scarce.
“Then, when you get over that, you can amplify your network of mentors. Over time, I also came to realized there was so much more to diversity than just being the Latino female. I should let myself be in a diverse setting. There’s LGBTQ, disabilities, different racial and ethnic identities. Being surrounded by that spectrum — different cultures, styles of communication, belief systems, viewpoints, and personality types — is so much more enriching. I wasn’t expecting that.”
—Aurian Garcia-Gonzalez, MD/PhD candidate, UMass Medical School; chapter president, Latino Medical Student Association
