White Docs Can — and Should — Address Racism in Health Care

More than any other work I have done, creating anti-racism curricula has given me imposter syndrome and feelings of guilt, shame and fear. I've also come to realize that my discomfort is not only necessary, it is only a tiny fraction of the discomfort experienced daily by my patients and colleagues of color who have weathered a lifetime and generations of trauma in a racist society. I share my story not as an expert in anti-racism -- and not to point blame -- but as an example of how a white physician can do anti-racist work despite feeling ill-equipped, untrained and unqualified.

As a white, heterosexual, cisgender woman growing up in a middle-class family in a majority white community, I was unaware of my privilege. I attended a liberal arts university whose student body was predominantly white and wealthy. I did not experience racism, so, for me, it didn't exist.

It was not until starting medical school in Charleston, S.C., in 2007 that my illusion of racial equality started to dissolve. My Black colleagues talked about white patients who refused to allow them to participate in care. White surgery residents cracked jokes about incoming trauma victims, disparaging African American names.

A neurosurgeon commented in the OR that we should ban Muslims from entering the country because "all the terrorists are Muslim." When I pointed out that the Unabomber wasn't Muslim, he suggested I go home for the day.

I began to see the health effects of racial stress -- higher preterm delivery rates in Black women and higher rates of stroke in the area's Black population. I learned that the majority of a person's health is determined not by the health care system, but by the conditions in which they work and live.

Despite my growth during my medical school years in Charleston and work with refugees through the International Family Medicine Clinic in Charlottesville, Va., I remained ignorant of the extent to which racism shapes our lives. My initial response to the infamous Unite the Right Rally held in our community Aug. 11-12, 2017, was, "This isn't Charlottesville; these people came from outside our city."

Then I heard from colleagues, residents, patients and community members of color who experience racism every day.

It turned out this is our city. This is our country. 

Our social structures created and perpetuate racial inequities, which in turn drive egregious health disparities.

Race is a social construct, made up to describe superficial differences in appearance between people with different geographic origins. Race does not correlate with genetic difference. The false premise that there are biological differences between races (and the conclusion that the white race is therefore superior) has been used to justify endless atrocities: slavery, apartheid, segregation, eugenics, the Holocaust, genocide, forced displacement, internment, restrictive and punitive immigration policies, redlining, mass incarceration, etc.

Unfortunately, research has shown that many white people, including health care professionals, continue to harbor false biological beliefs regarding race (e.g., Black people have thicker skin, age more slowly and are less susceptible to pain).

White people have long controlled knowledge in the form of textbooks, school instruction, research, news media, legislation and more. Too often, the media we consume perpetuates false narratives of Black people as criminal and lazy, less than human. After centuries of trauma and inequitable access to resources, it should be no surprise that people of color have worse health and shorter life expectancy than whites, even when accounting for income.  

Although most of us did not choose to participate in or benefit from racism, white people find ourselves complicit in a racist society. This is in part because we don't fully understand the experiences of our Black friends and colleagues or grasp how pervasive racism remains in our society.

Thus, addressing racism is a white problem in that it was created by white people and continues to be perpetuated by white people and white institutions (even if subconsciously).

The social construct of race was created by white Europeans, our social structures were built on the false foundation of white supremacy and our entire social system continues to create racial inequity. It may not be our fault as individuals that we ended up here, but now that we are aware of the pervasive, destructive force of racism, white people need to step up; we cannot expect people of color who have endured generations of trauma to fix it alone. Being a nice person and "treating everyone the same" will not dismantle structural racism, but conscious anti-racist action will.

So how can a white doctor make a difference?

• Educate yourself.  Share your journey with other white people so that you do not burden people of color with teaching you, or with your feelings of shame or guilt (which are normal reactions to exploring your white racial identity).
• Change your definition of racism. Groups like the Ku Klux Klan are examples of overt, interpersonal racism; believing, even subconsciously, that Black people are less susceptible to pain is implicit racism (also known as implicit bias). Racism is anything that deepens the inequity between racial groups -- even if it is unintentional -- such as a policy that makes it harder for people of color to vote and school funding systems that direct more money to white schools than those with more Black and brown students. A well-intentioned person can do racist things, and striving to be anti-racist requires conscious effort.
• Do not ignore race. Although it's a false social construct, race has been made real due to the biological consequences of racism; we cannot root out racism without paying attention to race.
• It is normal to feel defensive and perhaps even guilty when confronted with your own privilege; recognize that this is a teeny, tiny taste of the pain that people of color experience every single day -- without the advantage of being able to ignore it.
• Resist the temptation to compare the hurdles you have overcome in your life to those people of color have dealt with, because they did it while also being held back by racism.

To paraphrase author and historian Ibram X. Kendi, every action you take is either racist or anti-racist; there is no such thing as a neutral action. Yes, you'll make mistakes and put your foot in your mouth, but doing nothing (thereby remaining complicit) is much worse.

Following the events of Aug. 11-12, 2017, I started educating myself about historical and present-day racism in Charlottesville. At the Society of Teachers of Family Medicine conference in spring 2018, I attended many sessions on health equity and heard a panel of residents discuss the importance of teaching about racism. Those residents were frustrated that the hard work of teaching about racism was being undertaken by residents rather than faculty and program leaders, and I decided to accept the challenge of bringing this curriculum to our residency program. 

I am fortunate to have been given a great deal of support and trust (especially from our program director, John Gazewood, M.D., M.S.P.H.) to create a longitudinal health equity curriculum for the University of Virginia Family Medicine Residency program. Our residents learn about social determinants of health, health disparities, the social structures that create and perpetuate those disparities and how to effect change. Our curriculum covers implicit bias, the history of racism in medicine, the history of racism in Charlottesville, trauma-informed care, safe space training, countering microaggressions and health in every policy.

Through the AAFP Health Equity Fellowship, I am working to expand the advocacy portion of our curriculum. Next steps include qualitative evaluation of the curriculum and publication so other residency programs can consider a similar framework.

But you don't necessarily need to build a whole curriculum to incorporate anti-racism in your work.

Be wary of stigmatizing language in your documentation. Remove the word "noncompliant" from your documentation; instead document the structural barriers your patients face in the pursuit of health. Describe the behavior rather than applying a label to your patient: "The patient is not following the treatment plan" rather than "The patient is noncompliant."

When revising or considering a new clinic or department policy, employ a Racial Equity Impact Assessment.

Critically evaluate your organization, including your clinic space:

• Do the signs and artwork communicate that you welcome diversity?
• Are people of color included in decision-making?
• Do your recruitment practices attract diverse applicants?
• Do employees of color feel welcome and included?
• Are you able to retain a diverse staff?

Earlier this summer, I participated in an AAFP Virtual Town Hall on the public health crisis of racism. In the panel, Minnesota AFP CEO Maria Huntley; Renee Crichlow, M.D., assistant professor and director of advocacy and policy at the University of Minnesota Department of Family Medicine and Community Health; faculty at the North Memorial Family Medicine Residency; and I shared our work in addressing racial health disparities and provided advice for family physicians who want to contribute to these efforts.

Striving to be anti-racist involves a steep learning curve and unpleasant emotions -- but so did medical school and residency, and this work will likely be more impactful than anything you learned in your training. Let's do this together.

Kristina Johnson, M.D., is an assistant professor at the University of Virginia Family Medicine Residency program and AAFP Health Equity Fellow.