The Most Important Questions We Won't Answer for You

Author: 
Rhea Boyd, MD, MPH, FAAP and Nia Heard-Garris, MD, MSc, FAAP

For some, the white nationalist demonstration and tragic violence in 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 committed to the well-being of families have the opportunity to reassert their own.

As pediatricians, this is an important moment to confront intolerance in practice and, more specifically, ask vital questions about how we may perpetuate racism and oppression ourselves.


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 poor health outcomes that span generations of patients along racial lines.

Further, clinicians’ may make hurtful and dangerous assumptions about patients’ education, ability to afford care, or willingness to adhere to treatment plans based on 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 work with 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?

In the mid-1980’s, the vaccine for HIB was released and thirty years later we no longer see this disease. Because of the effectiveness of this vaccine my younger partners only know of HIB meningitis through textbooks (and some of my anecdotes).


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Some injuries
Race, or more accurately, racism is an undeniable determinant of healthcare access and quality.  "

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, how do I address it? Do I address it at all? 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 may not be toting torches, 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.


" Self-examination is hard work that requires us to be honest and uncomfortable."

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 pediatricians 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?

Self-examination is hard work that requires us to be honest and uncomfortable.  It means asking these questions over and over again, knowing nobody else can answer them for us, and remembering that silence itself is an answer.

It means 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.

The work will not cease when these questions are answered, but a daily practice of being more equitable and just is the path forward.

The views expressed in this article are those of the authors, and not necessarily those of the American Academy of Pediatrics. 

 

About the Author

Rhea Boyd, MD, FAAP, is a pediatrician, medical educator, and child and community health advocate who lives and works in the San Francisco Bay Area. She works clinically at Palo Alto Medical Foundation and teaches on structural inequality and health at medical schools and residency programs in the Bay Area. Dr. Boyd recently completed the Commonwealth Fund Mongan Minority Health Policy Fellowship at Harvard’s School of Public Health. She now serves on the Board of California Chapter 1, American Academy of Pediatrics and is an advisor to a local tech non-profit venturing to meet social needs as a means to improving child and community health. Dr. Boyd has also been active in coordinating a group of public health officials, community advocates, and funders to evaluate and address the child and public health impact of harmful police practices and policies in the Bay Area. She authors the blog Rhea.MD, where she critically engages the intersections of health and justice. She is also a member of the American Academy of Pediatrics Executive Committee on Communications and Media.

Nia Heard-Garris, MD, MSc, FAAP, is a primary care pediatrician and health services researcher within the Division of Academic General Pediatrics, Mary Ann & J. Milburn Smith Child Health Research Program at the Ann & Robert H. Lurie Children's Hospital of Chicago. A former Robert Wood Johnson Clinical Scholar, she received her medical degree from Howard University of College of Medicine and completed clinical training at Children’s National Medical Center in Washington, DC, in pediatrics and primary care. Dr. Heard-Garris’s research interests include adverse childhood experiences (ACEs); racism; racial socialization; and resilience. Through her research, she wants to help pediatricians and parents understand their role in fostering resilience in children, and in communities that support children, so they are able to overcome adverse circumstances and thrive.