Diversity in Medicine

It’s been about two months since I volunteered in a hospital in Brooklyn, working in an ICU taking care of patients with COVID-19. I’m back home in California now but with new perspectives, not only on the pandemic, but on those who are affected by it the most.

Courtesy Dr. Arghavan Salles

Everyone seems to have forgotten the early days of the pandemic – the time when the ICUs were overrun, we were using FEMA ventilators, and endocrinologists and psychiatrists were acting as intensivists.

Even though things are opening up and people are taking summer vacations in a seemingly amnestic state, having witnessed multiple daily deaths remains a part of my daily consciousness. As I see the case numbers climbing juxtaposed against people being out and about without masks, my anxiety level is rising.

A virus doesn’t discriminate. It can fly through the air, landing on the next available surface. If that virus is SARS-CoV-2 and that surface is a human mucosal membrane, the virus makes itself at home. It orders furniture, buys a fancy mattress and a large high definition TV, hangs art on the walls, and settles in for the long haul. It’s not going anywhere anytime soon.

Even as an equal opportunity virus, what SARS-CoV-2 has done is to hold a mirror up to the healthcare system. It has shown us what was here all along. When people first started noticing that underrepresented minorities were more likely to contract the virus and get sick from it, I heard musings that this was likely because of their preexisting health conditions. For example, commentators on cable news were quick to point out that black people are more likely than other people to have hypertension or diabetes. So doesn’t that explain why they are more affected by this virus?

That certainly is part of the story, but it doesn’t entirely explain the discrepancies we’ve seen. For example, in New York 14% of the population is black, and 25% of those who had a COVID-related death were black patients. Similarly, 19% of the population is Hispanic or Latino, and they made up 26% of COVID-related deaths. On the other hand, 55% of the population in New York is white, and white people account for only 34% of COVID-related deaths.

Working in Brooklyn, I didn’t need to be a keen observer to notice that, out of our entire unit of about 20-25 patients, there was only one patient in a 2-week period who was neither black nor Hispanic.

As others have written, there are other factors at play. I’m not sure how many of those commentators back in March stopped to think about why black patients are more likely to have hypertension and diabetes, but the chronic stress of facing racism on a daily basis surely contributes. Beyond those medical problems, minorities are more likely to live in multigenerational housing, which means that it is harder for them to isolate from others. In addition, their living quarters tend to be further from health care centers and grocery stores, which makes it harder for them to access medical care and healthy food.

As if that weren’t enough to put their health at risk, people of color are also affected by environmental racism . Factories with toxic waste are more likely to be built in or near neighborhoods filled with people of color than in other communities. On top of that, black and Hispanic people are also more likely to be under- or uninsured, meaning they often delay seeking care in order to avoid astronomic healthcare costs.

Black and Hispanic people are also more likely than others to be working in the service industry or other essential services, which means they are less likely to be able to work from home. Consequently, they have to risk more exposures to other people and the virus than do those who have the privilege of working safely from home. They also are less likely to have available paid leave and, therefore, are more likely to work while sick.

With the deck completely stacked against them, underrepresented minorities also face systemic bias and racism when interacting with the health care system. Physicians mistakenly believe black patients experience less pain than other patients, according to some research. Black mothers have significantly worse health care outcomes than do their non-black counterparts, and the infant mortality rate for Black infants is much higher as well.

Dr. Salles is a bariatric surgeon and is currently a Scholar in Residence at Stanford (Calif.) University. Find her on Twitter @arghavan_salles.

It’s been about two months since I volunteered in a hospital in Brooklyn, working in an ICU taking care of patients with COVID-19. I’m back home in California now but with new perspectives, not only on the pandemic, but on those who are affected by it the most.

Courtesy Dr. Arghavan Salles

Everyone seems to have forgotten the early days of the pandemic – the time when the ICUs were overrun, we were using FEMA ventilators, and endocrinologists and psychiatrists were acting as intensivists.

Even though things are opening up and people are taking summer vacations in a seemingly amnestic state, having witnessed multiple daily deaths remains a part of my daily consciousness. As I see the case numbers climbing juxtaposed against people being out and about without masks, my anxiety level is rising.

A virus doesn’t discriminate. It can fly through the air, landing on the next available surface. If that virus is SARS-CoV-2 and that surface is a human mucosal membrane, the virus makes itself at home. It orders furniture, buys a fancy mattress and a large high definition TV, hangs art on the walls, and settles in for the long haul. It’s not going anywhere anytime soon.

Even as an equal opportunity virus, what SARS-CoV-2 has done is to hold a mirror up to the healthcare system. It has shown us what was here all along. When people first started noticing that underrepresented minorities were more likely to contract the virus and get sick from it, I heard musings that this was likely because of their preexisting health conditions. For example, commentators on cable news were quick to point out that black people are more likely than other people to have hypertension or diabetes. So doesn’t that explain why they are more affected by this virus?

That certainly is part of the story, but it doesn’t entirely explain the discrepancies we’ve seen. For example, in New York 14% of the population is black, and 25% of those who had a COVID-related death were black patients. Similarly, 19% of the population is Hispanic or Latino, and they made up 26% of COVID-related deaths. On the other hand, 55% of the population in New York is white, and white people account for only 34% of COVID-related deaths.

Working in Brooklyn, I didn’t need to be a keen observer to notice that, out of our entire unit of about 20-25 patients, there was only one patient in a 2-week period who was neither black nor Hispanic.

As others have written, there are other factors at play. I’m not sure how many of those commentators back in March stopped to think about why black patients are more likely to have hypertension and diabetes, but the chronic stress of facing racism on a daily basis surely contributes. Beyond those medical problems, minorities are more likely to live in multigenerational housing, which means that it is harder for them to isolate from others. In addition, their living quarters tend to be further from health care centers and grocery stores, which makes it harder for them to access medical care and healthy food.

As if that weren’t enough to put their health at risk, people of color are also affected by environmental racism . Factories with toxic waste are more likely to be built in or near neighborhoods filled with people of color than in other communities. On top of that, black and Hispanic people are also more likely to be under- or uninsured, meaning they often delay seeking care in order to avoid astronomic healthcare costs.

Black and Hispanic people are also more likely than others to be working in the service industry or other essential services, which means they are less likely to be able to work from home. Consequently, they have to risk more exposures to other people and the virus than do those who have the privilege of working safely from home. They also are less likely to have available paid leave and, therefore, are more likely to work while sick.

With the deck completely stacked against them, underrepresented minorities also face systemic bias and racism when interacting with the health care system. Physicians mistakenly believe black patients experience less pain than other patients, according to some research. Black mothers have significantly worse health care outcomes than do their non-black counterparts, and the infant mortality rate for Black infants is much higher as well.

Dr. Salles is a bariatric surgeon and is currently a Scholar in Residence at Stanford (Calif.) University. Find her on Twitter @arghavan_salles.

It’s been about two months since I volunteered in a hospital in Brooklyn, working in an ICU taking care of patients with COVID-19. I’m back home in California now but with new perspectives, not only on the pandemic, but on those who are affected by it the most.

Courtesy Dr. Arghavan Salles

Everyone seems to have forgotten the early days of the pandemic – the time when the ICUs were overrun, we were using FEMA ventilators, and endocrinologists and psychiatrists were acting as intensivists.

Even though things are opening up and people are taking summer vacations in a seemingly amnestic state, having witnessed multiple daily deaths remains a part of my daily consciousness. As I see the case numbers climbing juxtaposed against people being out and about without masks, my anxiety level is rising.

A virus doesn’t discriminate. It can fly through the air, landing on the next available surface. If that virus is SARS-CoV-2 and that surface is a human mucosal membrane, the virus makes itself at home. It orders furniture, buys a fancy mattress and a large high definition TV, hangs art on the walls, and settles in for the long haul. It’s not going anywhere anytime soon.

Even as an equal opportunity virus, what SARS-CoV-2 has done is to hold a mirror up to the healthcare system. It has shown us what was here all along. When people first started noticing that underrepresented minorities were more likely to contract the virus and get sick from it, I heard musings that this was likely because of their preexisting health conditions. For example, commentators on cable news were quick to point out that black people are more likely than other people to have hypertension or diabetes. So doesn’t that explain why they are more affected by this virus?

That certainly is part of the story, but it doesn’t entirely explain the discrepancies we’ve seen. For example, in New York 14% of the population is black, and 25% of those who had a COVID-related death were black patients. Similarly, 19% of the population is Hispanic or Latino, and they made up 26% of COVID-related deaths. On the other hand, 55% of the population in New York is white, and white people account for only 34% of COVID-related deaths.

Working in Brooklyn, I didn’t need to be a keen observer to notice that, out of our entire unit of about 20-25 patients, there was only one patient in a 2-week period who was neither black nor Hispanic.

As others have written, there are other factors at play. I’m not sure how many of those commentators back in March stopped to think about why black patients are more likely to have hypertension and diabetes, but the chronic stress of facing racism on a daily basis surely contributes. Beyond those medical problems, minorities are more likely to live in multigenerational housing, which means that it is harder for them to isolate from others. In addition, their living quarters tend to be further from health care centers and grocery stores, which makes it harder for them to access medical care and healthy food.

As if that weren’t enough to put their health at risk, people of color are also affected by environmental racism . Factories with toxic waste are more likely to be built in or near neighborhoods filled with people of color than in other communities. On top of that, black and Hispanic people are also more likely to be under- or uninsured, meaning they often delay seeking care in order to avoid astronomic healthcare costs.

Black and Hispanic people are also more likely than others to be working in the service industry or other essential services, which means they are less likely to be able to work from home. Consequently, they have to risk more exposures to other people and the virus than do those who have the privilege of working safely from home. They also are less likely to have available paid leave and, therefore, are more likely to work while sick.

With the deck completely stacked against them, underrepresented minorities also face systemic bias and racism when interacting with the health care system. Physicians mistakenly believe black patients experience less pain than other patients, according to some research. Black mothers have significantly worse health care outcomes than do their non-black counterparts, and the infant mortality rate for Black infants is much higher as well.

Dr. Salles is a bariatric surgeon and is currently a Scholar in Residence at Stanford (Calif.) University. Find her on Twitter @arghavan_salles.

The Society of Hospital Medicine deplores the negative impact of racism in our nation and will always strive to remedy racial inequities in our health care system. Racism in our society cannot be ignored. Nor will SHM ignore racism’s impact on public health. SHM enthusiastically supports its members working to promote equity and reduce the adverse impact of racism. We are committed to using our platform to improve the health of patients everywhere.

SHM would like to reaffirm its long-valued dedication to diversity and inclusion. We remain committed to promoting healthy discussions and action throughout our publications, resources and member communities, as outlined by our diversity and inclusion statement.
 

SHM Diversity and Inclusion Statement

Hospitalists are charged with treating individuals at their most vulnerable moments, when being respected as a whole person is crucial to advance patients’ healing and wellness. Within our workforce, diversity is a strength in all its forms, which helps us learn about the human experience, grow as leaders, and ultimately create a respectful environment for all regardless of age, race, religion, national origin, gender identity, sexual orientation, socioeconomic status, appearance, or ability.

To this end, the Society of Hospital Medicine will work to eliminate health disparities for our patients and foster inclusive and equitable cultures across our care teams and institutions with the goal of moving medicine and humanity forward.

The Society of Hospital Medicine deplores the negative impact of racism in our nation and will always strive to remedy racial inequities in our health care system. Racism in our society cannot be ignored. Nor will SHM ignore racism’s impact on public health. SHM enthusiastically supports its members working to promote equity and reduce the adverse impact of racism. We are committed to using our platform to improve the health of patients everywhere.

SHM would like to reaffirm its long-valued dedication to diversity and inclusion. We remain committed to promoting healthy discussions and action throughout our publications, resources and member communities, as outlined by our diversity and inclusion statement.
 

SHM Diversity and Inclusion Statement

Hospitalists are charged with treating individuals at their most vulnerable moments, when being respected as a whole person is crucial to advance patients’ healing and wellness. Within our workforce, diversity is a strength in all its forms, which helps us learn about the human experience, grow as leaders, and ultimately create a respectful environment for all regardless of age, race, religion, national origin, gender identity, sexual orientation, socioeconomic status, appearance, or ability.

To this end, the Society of Hospital Medicine will work to eliminate health disparities for our patients and foster inclusive and equitable cultures across our care teams and institutions with the goal of moving medicine and humanity forward.

The Society of Hospital Medicine deplores the negative impact of racism in our nation and will always strive to remedy racial inequities in our health care system. Racism in our society cannot be ignored. Nor will SHM ignore racism’s impact on public health. SHM enthusiastically supports its members working to promote equity and reduce the adverse impact of racism. We are committed to using our platform to improve the health of patients everywhere.

SHM would like to reaffirm its long-valued dedication to diversity and inclusion. We remain committed to promoting healthy discussions and action throughout our publications, resources and member communities, as outlined by our diversity and inclusion statement.
 

SHM Diversity and Inclusion Statement

Hospitalists are charged with treating individuals at their most vulnerable moments, when being respected as a whole person is crucial to advance patients’ healing and wellness. Within our workforce, diversity is a strength in all its forms, which helps us learn about the human experience, grow as leaders, and ultimately create a respectful environment for all regardless of age, race, religion, national origin, gender identity, sexual orientation, socioeconomic status, appearance, or ability.

To this end, the Society of Hospital Medicine will work to eliminate health disparities for our patients and foster inclusive and equitable cultures across our care teams and institutions with the goal of moving medicine and humanity forward.

A “growing and disturbing” increase in suicidal behavior among black youth has quietly been underway in the United States during the past several decades, even while rates in white and Latino youth have declined, Michael A. Lindsey, PhD, MSW, MPH, declared at the virtual annual meeting of the American Association of Suicidology.

Until recently this trend remained below the radar of public awareness. That’s changing. Dr. Lindsey was coauthor of a December 2019 report to Congress prepared in collaboration with the Congressional Black Caucus entitled, “Ring the Alarm: The Crisis of Black Youth Suicide In America.” Release of the report was accompanied by submission of an omnibus bill aimed at addressing the issue comprehensively, including what Dr. Lindsey considers to be the single most important policy imperative: providing federal resources to support more and better school mental health services proportionate to student needs.

“Black youth, relative to white youth, do not receive treatment for depression, which may be a precursor issue. They’re often disconnected from mental health therapy. This is perhaps a reason why we’re seeing this uptick in suicide expression among black youth,” according to Dr. Lindsey, executive director of the McSilver Institute for Poverty Policy and Research and professor of poverty studies at New York University.

Investigators at Ohio State University analyzed youth suicide data for the years 2001-2015 obtained from the Centers for Disease Control and Prevention. They determined that black children aged 5-12 years had an 82% higher incidence of completed suicide than white children (JAMA Pediatr. 2018 Jul 1;172[7]:697-9).

This report was followed by a study of trends in suicidal behaviors among U.S. high school students during 1991-2017. The study, led by Dr. Lindsey, used data from the Youth Risk Behavior Survey covering the years 1991-2017 to document an overall 19% prevalence of thoughts about suicide, while 15% of high school students had a suicide plan. During the study years there was a 73% increase in suicide attempts among black adolescents, while rates in white and Latino teens fell by 7.5% and 11.4%, respectively (Pediatrics. 2019 Nov;144[5]:e20191187).

Dr. Lindsey cited multiple reasons for undertreatment of depression in black youth. The lack of adequate mental health services in many schools figures prominently. As a result of this situation, mental health problems in black youth are often misinterpreted as conduct problems, leading to well-documented overuse of school suspensions and expulsions.

“We tend to oversuspend and expel black kids from school for problems that are treatable. This becomes a major, major issue in the pathway from schools to prisons,” he said.

Another factor in underutilization of mental health services by black youth is the stigma involved. Many black families see mental health therapy as irrelevant. Dr. Lindsey has received grant support from the National Institute of Mental Health for development of engagement interventions that focus on stigma reduction and enhancing family support for mental health therapy in black youth. He has found that, once those barriers are lowered, therapies seem to be as effective in black youth as in other populations, despite the cultural differences.

Yet another potential explanation for the racial disparity in pediatric suicide might be that suicide may, in some cases, be more of an impulsive behavior in black youth. Dr. Lindsey presented data from a soon-to-be-published analysis of Youth Risk Behavior Survey data on nearly 5,000 adolescents with suicidal thoughts, plans, and/or attempts within the previous 12 months. About 23% had suicidal thoughts only, 37% had suicidal thoughts and a plan, another 37% had thoughts, plans, and suicide attempts, and 3% had attempts without thoughts or a plan.

Black youth were 3.7 times more likely than white youth to have attempted suicide in the absence of background suicidal thoughts and 3.3 times more likely to have attempted suicide without having suicidal thoughts and plans.

He and his coinvestigators identified a similar pattern of suicide as an impulsive behavior in youths of all races with a history of sexual assault. They were 4.2 times more likely to have attempted suicide without prior suicidal thoughts than individuals without such a history and 3.9 times more likely to have attempted suicide without thinking about it or having a plan.

“This has implications for screening and prevention; warning signs may not be present,” he said.

Dr. Lindsey reported having no financial conflicts regarding his presentation.

[email protected]

A “growing and disturbing” increase in suicidal behavior among black youth has quietly been underway in the United States during the past several decades, even while rates in white and Latino youth have declined, Michael A. Lindsey, PhD, MSW, MPH, declared at the virtual annual meeting of the American Association of Suicidology.

Until recently this trend remained below the radar of public awareness. That’s changing. Dr. Lindsey was coauthor of a December 2019 report to Congress prepared in collaboration with the Congressional Black Caucus entitled, “Ring the Alarm: The Crisis of Black Youth Suicide In America.” Release of the report was accompanied by submission of an omnibus bill aimed at addressing the issue comprehensively, including what Dr. Lindsey considers to be the single most important policy imperative: providing federal resources to support more and better school mental health services proportionate to student needs.

“Black youth, relative to white youth, do not receive treatment for depression, which may be a precursor issue. They’re often disconnected from mental health therapy. This is perhaps a reason why we’re seeing this uptick in suicide expression among black youth,” according to Dr. Lindsey, executive director of the McSilver Institute for Poverty Policy and Research and professor of poverty studies at New York University.

Investigators at Ohio State University analyzed youth suicide data for the years 2001-2015 obtained from the Centers for Disease Control and Prevention. They determined that black children aged 5-12 years had an 82% higher incidence of completed suicide than white children (JAMA Pediatr. 2018 Jul 1;172[7]:697-9).

This report was followed by a study of trends in suicidal behaviors among U.S. high school students during 1991-2017. The study, led by Dr. Lindsey, used data from the Youth Risk Behavior Survey covering the years 1991-2017 to document an overall 19% prevalence of thoughts about suicide, while 15% of high school students had a suicide plan. During the study years there was a 73% increase in suicide attempts among black adolescents, while rates in white and Latino teens fell by 7.5% and 11.4%, respectively (Pediatrics. 2019 Nov;144[5]:e20191187).

Dr. Lindsey cited multiple reasons for undertreatment of depression in black youth. The lack of adequate mental health services in many schools figures prominently. As a result of this situation, mental health problems in black youth are often misinterpreted as conduct problems, leading to well-documented overuse of school suspensions and expulsions.

“We tend to oversuspend and expel black kids from school for problems that are treatable. This becomes a major, major issue in the pathway from schools to prisons,” he said.

Another factor in underutilization of mental health services by black youth is the stigma involved. Many black families see mental health therapy as irrelevant. Dr. Lindsey has received grant support from the National Institute of Mental Health for development of engagement interventions that focus on stigma reduction and enhancing family support for mental health therapy in black youth. He has found that, once those barriers are lowered, therapies seem to be as effective in black youth as in other populations, despite the cultural differences.

Yet another potential explanation for the racial disparity in pediatric suicide might be that suicide may, in some cases, be more of an impulsive behavior in black youth. Dr. Lindsey presented data from a soon-to-be-published analysis of Youth Risk Behavior Survey data on nearly 5,000 adolescents with suicidal thoughts, plans, and/or attempts within the previous 12 months. About 23% had suicidal thoughts only, 37% had suicidal thoughts and a plan, another 37% had thoughts, plans, and suicide attempts, and 3% had attempts without thoughts or a plan.

Black youth were 3.7 times more likely than white youth to have attempted suicide in the absence of background suicidal thoughts and 3.3 times more likely to have attempted suicide without having suicidal thoughts and plans.

He and his coinvestigators identified a similar pattern of suicide as an impulsive behavior in youths of all races with a history of sexual assault. They were 4.2 times more likely to have attempted suicide without prior suicidal thoughts than individuals without such a history and 3.9 times more likely to have attempted suicide without thinking about it or having a plan.

“This has implications for screening and prevention; warning signs may not be present,” he said.

Dr. Lindsey reported having no financial conflicts regarding his presentation.

[email protected]

A “growing and disturbing” increase in suicidal behavior among black youth has quietly been underway in the United States during the past several decades, even while rates in white and Latino youth have declined, Michael A. Lindsey, PhD, MSW, MPH, declared at the virtual annual meeting of the American Association of Suicidology.

Until recently this trend remained below the radar of public awareness. That’s changing. Dr. Lindsey was coauthor of a December 2019 report to Congress prepared in collaboration with the Congressional Black Caucus entitled, “Ring the Alarm: The Crisis of Black Youth Suicide In America.” Release of the report was accompanied by submission of an omnibus bill aimed at addressing the issue comprehensively, including what Dr. Lindsey considers to be the single most important policy imperative: providing federal resources to support more and better school mental health services proportionate to student needs.

“Black youth, relative to white youth, do not receive treatment for depression, which may be a precursor issue. They’re often disconnected from mental health therapy. This is perhaps a reason why we’re seeing this uptick in suicide expression among black youth,” according to Dr. Lindsey, executive director of the McSilver Institute for Poverty Policy and Research and professor of poverty studies at New York University.

Investigators at Ohio State University analyzed youth suicide data for the years 2001-2015 obtained from the Centers for Disease Control and Prevention. They determined that black children aged 5-12 years had an 82% higher incidence of completed suicide than white children (JAMA Pediatr. 2018 Jul 1;172[7]:697-9).

This report was followed by a study of trends in suicidal behaviors among U.S. high school students during 1991-2017. The study, led by Dr. Lindsey, used data from the Youth Risk Behavior Survey covering the years 1991-2017 to document an overall 19% prevalence of thoughts about suicide, while 15% of high school students had a suicide plan. During the study years there was a 73% increase in suicide attempts among black adolescents, while rates in white and Latino teens fell by 7.5% and 11.4%, respectively (Pediatrics. 2019 Nov;144[5]:e20191187).

Dr. Lindsey cited multiple reasons for undertreatment of depression in black youth. The lack of adequate mental health services in many schools figures prominently. As a result of this situation, mental health problems in black youth are often misinterpreted as conduct problems, leading to well-documented overuse of school suspensions and expulsions.

“We tend to oversuspend and expel black kids from school for problems that are treatable. This becomes a major, major issue in the pathway from schools to prisons,” he said.

Another factor in underutilization of mental health services by black youth is the stigma involved. Many black families see mental health therapy as irrelevant. Dr. Lindsey has received grant support from the National Institute of Mental Health for development of engagement interventions that focus on stigma reduction and enhancing family support for mental health therapy in black youth. He has found that, once those barriers are lowered, therapies seem to be as effective in black youth as in other populations, despite the cultural differences.

Yet another potential explanation for the racial disparity in pediatric suicide might be that suicide may, in some cases, be more of an impulsive behavior in black youth. Dr. Lindsey presented data from a soon-to-be-published analysis of Youth Risk Behavior Survey data on nearly 5,000 adolescents with suicidal thoughts, plans, and/or attempts within the previous 12 months. About 23% had suicidal thoughts only, 37% had suicidal thoughts and a plan, another 37% had thoughts, plans, and suicide attempts, and 3% had attempts without thoughts or a plan.

Black youth were 3.7 times more likely than white youth to have attempted suicide in the absence of background suicidal thoughts and 3.3 times more likely to have attempted suicide without having suicidal thoughts and plans.

He and his coinvestigators identified a similar pattern of suicide as an impulsive behavior in youths of all races with a history of sexual assault. They were 4.2 times more likely to have attempted suicide without prior suicidal thoughts than individuals without such a history and 3.9 times more likely to have attempted suicide without thinking about it or having a plan.

“This has implications for screening and prevention; warning signs may not be present,” he said.

Dr. Lindsey reported having no financial conflicts regarding his presentation.

[email protected]

I’m a black man, husband, father, son, brother, and a board-certified psychiatrist, child and adolescent psychiatry fellow, and addiction medicine fellow. I write this article as the latter, a colleague, from the former’s perspective, which you would not need to verify via Google, social media, or a badge upon meeting me.

Motortion/Getty Images

July is Minority Mental Health Awareness Month, established to bring awareness to the unique struggles that marginalized groups face concerning mental illness in the United States.

Given the events of the last few months, including a global pandemic and videotaped killings of Ahmaud Arbery and George Floyd, two unarmed black men, America’s structural racism and inequality are being challenged in historic ways. Black people are suffering. In fact, I was not surprised to learn¹ that some black families with sons have expanded the “talk” – which traditionally has focused on dealing with police officers – to include vigilantes.

Because of my extensive work with and treatment of men of color, I would like to answer a key question: “How do psychiatrists and other mental health clinicians better engage men of color? Before the “how,” let’s review the state of black men’s mental health.

According to Healthy People 2020, mental disorders are the leading cause of disability in the United States.² Among those with diagnosable mental disorders, black people are more likely than are their white counterparts to experience severe symptoms and protracted diseases. Roughly 7% of black men meet the criteria for a lifetime prevalence of major depressive disorder.³ Applying that figure to recent national population estimates means that there are 1.4 million black men currently suffering from major depression. Suicide has been on a continued uptrend among black male youth for more than 2 decades. Moreover, given the high rates of stigma and unmet need in this population, it is likely that these figures are even more dire.

Compared with other groups, black men in the United States face a disproportionate burden of preventable morbidity and mortality rates. Of all the health concerns faced by black men, mental health challenges may be among the most stigmatized.⁴ Evidence suggests that black men have more adverse life experiences than do men of other racial/ethnic groups, and consequently, experience poorer mental health.⁵ Black men experience high rates of poverty, unemployment, and underemployment, and are incarcerated at much higher rates than those of men of other racial/ethnic groups.⁶ It is notable that black male youth are often perceived as older by law enforcement, beginning as early as 10 years old, often resulting in negative interactions.⁷

Despite those challenges, black men are often expected to project strength, they are expected to minimize displays of emotion when off the field or court (i.e., “Just shut up and dribble”), and they are expected to be true versions of folk hero John Henry. This caricature of black males is used at times to validate shootings of unarmed black males (adults and youth).

Black men’s mental health should be a priority for those in the mental health field. This is particularly the case light of our field’s historical involvement in and promotion of stereotyped clinical descriptions of black men and contributing to health disparities that persist. Black men are nearly six times as likely to be diagnosed with schizophrenia as are white men. To read about holdovers from the days of targeted advertising against black protesters of the 1960s and 1970s, check out “The Protest Psychosis” (Beacon Press, 2010) by psychiatrist and anthropologist Jonathan Metzl, MD, PhD. If you go further back in psychiatric history, the late 1800s, you can learn about the devious diagnosis of drapetomania attributed to enslaved people who were seeking freedom.

Those on the front lines providing mental health services should understand black men’s mental health from an ecological perspective. Beyond the emotional burden that mental illness imposes on the individual, there are more considerable interpersonal and societal implications for the state of black men’s mental health. As such, in our full capacity like other men, black men play an essential role within families, churches, neighborhoods, and organizations.

Given our brief review, we can reconsider our question, “How do psychiatrists and mental health clinicians better engage men of color?”

I will suggest a few fundamental principles that honestly can be applied to any patient but should be strongly considered with your black male patients – given they are likely not accustomed to engaging with the health care system, let alone with a mental health clinician:

1. Create a comfortable environment. Because of stigma, persistent myths, and lack of normalcy with talking to a mental health professional, many patients, including black men, do not have a framework for a psychiatric/psychological evaluation or treatment. It would be essential to set the frame of your encounter. Evidence suggests this can improve engagement and follow-up care among black men.⁸ In addition, keep in mind that “fictive kin^”9 tend to play a major role in the transmission of culture, health promotion, and decision-making in the black community. This helps explain why barbershop initiatives¹⁰ are effective. If clinicians are able to allow black male patients to feel comfortable, the clinician, too, might become part of that fictive community and enhance the patient-provider relationship.

2. Allow for storytelling. In the age of the checklist, it can be relatively easy to lose sight that our patients, including black men, have their own narratives. Evidence suggests that physicians interrupt patients early and often. Challenge yourself to allow the patient to tell his story. In consideration of an initial evaluation, it may help to begin by first gathering sociodemographic information (i.e. housing, education, employment, family, etc.); doing so will allow the patient time to get comfortable before you assess possible psychiatric symptoms.

3. Confidentiality assurance. Many black men have a distrust for the health care profession; as such, it is vital that clinicians emphasize that their patients’ information and history will be used only to help the patient. It will be important to inform black male patients of their rights, because often in the greater society, their rights seem to be negated.

4. Be aware of nonverbal language. Given black men’s stereotyped roles in society and recognition that they are regularly perceived as threats, many black men have become adept at reading nonverbal cues (i.e., purse clutched, side comment, etc.). In doing so, clinicians must be attuned to their own nonverbal language. For example, a glance at one’s watch might be interpreted as you’re not listening. It would be better to be upfront and candid by saying something like, “I need to check the time,” rather than attempting to be stealth. Being transparent in that way will let the patient know that you will be upfront with him.

5. Be respectful. During an encounter, and in particular when discussing treatment plans, clinicians must allow the patient space to process and be involved in his care. Allowing the patient time to think through how he would want to proceed provides him a sense of personal agency and lets him know that he is capable of improving his mental wellness.

Black male patients need to feel comfortable, safe, able to trust the clinician. They must feel listened to, understood, and respected. This information might help some clinicians better understand what needs to happen between a black male patient and a nonblack clinician so the patient can feel good about his mental health engagement. To some, these recommendations might seem obvious or too simple, yet if we consider the countless reports of poor patient treatment engagement, adherence, and retention, we cannot deny the need for change. Having black male patients disclose important information during encounters could prevent poor clinical interactions that leave them feeling uncomfortable, uncertain, skeptical, disrespected, and further cynical about mental health care.

 

Dr. Simon practices at Boston Children’s Hospital. He has no disclosures.

References

1. Bunn C. After Arbery shooting, black parents are rethinking “the talk” to explain white vigilantes. NBC News. 2020 May 19.

2. U.S. Department of Health and Human Services. Office of Disease Prevention and Promotion. Healthy People 2020.

3. Ward E and Mangesha M. Am J Orthopsychiatry. 2013 Apr-Jul;83(2 0 3):386-97.

4. Holden KB et al. J Mens health. 2012 Jun 1;9(2):63-9.

5. Brown TH et al. Fam Community Health. 2015 Oct-Dec;38(4):307-18.

6. Jäggi et al. Soc Ment Health. 2016 Nov;6(3):187-296.

7. Goff PA et al. J Pers Soc Psychol. 2014;106(4):526-45.

8. Alsan M et al. National Bureau of Economic Research. NBER Working Paper No. 24787. 2018 Jun. Revised 2019 Aug.

9. Spruill IJ. J Nat Black Nurses Assoc. 2014 Dec;25(2):23-30.

10. Graham LF et al. Am J Mens Health. 2018 Sep;12(5):1307-16.

I’m a black man, husband, father, son, brother, and a board-certified psychiatrist, child and adolescent psychiatry fellow, and addiction medicine fellow. I write this article as the latter, a colleague, from the former’s perspective, which you would not need to verify via Google, social media, or a badge upon meeting me.

Motortion/Getty Images

July is Minority Mental Health Awareness Month, established to bring awareness to the unique struggles that marginalized groups face concerning mental illness in the United States.

Given the events of the last few months, including a global pandemic and videotaped killings of Ahmaud Arbery and George Floyd, two unarmed black men, America’s structural racism and inequality are being challenged in historic ways. Black people are suffering. In fact, I was not surprised to learn¹ that some black families with sons have expanded the “talk” – which traditionally has focused on dealing with police officers – to include vigilantes.

Because of my extensive work with and treatment of men of color, I would like to answer a key question: “How do psychiatrists and other mental health clinicians better engage men of color? Before the “how,” let’s review the state of black men’s mental health.

According to Healthy People 2020, mental disorders are the leading cause of disability in the United States.² Among those with diagnosable mental disorders, black people are more likely than are their white counterparts to experience severe symptoms and protracted diseases. Roughly 7% of black men meet the criteria for a lifetime prevalence of major depressive disorder.³ Applying that figure to recent national population estimates means that there are 1.4 million black men currently suffering from major depression. Suicide has been on a continued uptrend among black male youth for more than 2 decades. Moreover, given the high rates of stigma and unmet need in this population, it is likely that these figures are even more dire.

Compared with other groups, black men in the United States face a disproportionate burden of preventable morbidity and mortality rates. Of all the health concerns faced by black men, mental health challenges may be among the most stigmatized.⁴ Evidence suggests that black men have more adverse life experiences than do men of other racial/ethnic groups, and consequently, experience poorer mental health.⁵ Black men experience high rates of poverty, unemployment, and underemployment, and are incarcerated at much higher rates than those of men of other racial/ethnic groups.⁶ It is notable that black male youth are often perceived as older by law enforcement, beginning as early as 10 years old, often resulting in negative interactions.⁷

Despite those challenges, black men are often expected to project strength, they are expected to minimize displays of emotion when off the field or court (i.e., “Just shut up and dribble”), and they are expected to be true versions of folk hero John Henry. This caricature of black males is used at times to validate shootings of unarmed black males (adults and youth).

Black men’s mental health should be a priority for those in the mental health field. This is particularly the case light of our field’s historical involvement in and promotion of stereotyped clinical descriptions of black men and contributing to health disparities that persist. Black men are nearly six times as likely to be diagnosed with schizophrenia as are white men. To read about holdovers from the days of targeted advertising against black protesters of the 1960s and 1970s, check out “The Protest Psychosis” (Beacon Press, 2010) by psychiatrist and anthropologist Jonathan Metzl, MD, PhD. If you go further back in psychiatric history, the late 1800s, you can learn about the devious diagnosis of drapetomania attributed to enslaved people who were seeking freedom.

Those on the front lines providing mental health services should understand black men’s mental health from an ecological perspective. Beyond the emotional burden that mental illness imposes on the individual, there are more considerable interpersonal and societal implications for the state of black men’s mental health. As such, in our full capacity like other men, black men play an essential role within families, churches, neighborhoods, and organizations.

Given our brief review, we can reconsider our question, “How do psychiatrists and mental health clinicians better engage men of color?”

I will suggest a few fundamental principles that honestly can be applied to any patient but should be strongly considered with your black male patients – given they are likely not accustomed to engaging with the health care system, let alone with a mental health clinician:

1. Create a comfortable environment. Because of stigma, persistent myths, and lack of normalcy with talking to a mental health professional, many patients, including black men, do not have a framework for a psychiatric/psychological evaluation or treatment. It would be essential to set the frame of your encounter. Evidence suggests this can improve engagement and follow-up care among black men.⁸ In addition, keep in mind that “fictive kin^”9 tend to play a major role in the transmission of culture, health promotion, and decision-making in the black community. This helps explain why barbershop initiatives¹⁰ are effective. If clinicians are able to allow black male patients to feel comfortable, the clinician, too, might become part of that fictive community and enhance the patient-provider relationship.

2. Allow for storytelling. In the age of the checklist, it can be relatively easy to lose sight that our patients, including black men, have their own narratives. Evidence suggests that physicians interrupt patients early and often. Challenge yourself to allow the patient to tell his story. In consideration of an initial evaluation, it may help to begin by first gathering sociodemographic information (i.e. housing, education, employment, family, etc.); doing so will allow the patient time to get comfortable before you assess possible psychiatric symptoms.

3. Confidentiality assurance. Many black men have a distrust for the health care profession; as such, it is vital that clinicians emphasize that their patients’ information and history will be used only to help the patient. It will be important to inform black male patients of their rights, because often in the greater society, their rights seem to be negated.

4. Be aware of nonverbal language. Given black men’s stereotyped roles in society and recognition that they are regularly perceived as threats, many black men have become adept at reading nonverbal cues (i.e., purse clutched, side comment, etc.). In doing so, clinicians must be attuned to their own nonverbal language. For example, a glance at one’s watch might be interpreted as you’re not listening. It would be better to be upfront and candid by saying something like, “I need to check the time,” rather than attempting to be stealth. Being transparent in that way will let the patient know that you will be upfront with him.

5. Be respectful. During an encounter, and in particular when discussing treatment plans, clinicians must allow the patient space to process and be involved in his care. Allowing the patient time to think through how he would want to proceed provides him a sense of personal agency and lets him know that he is capable of improving his mental wellness.

Black male patients need to feel comfortable, safe, able to trust the clinician. They must feel listened to, understood, and respected. This information might help some clinicians better understand what needs to happen between a black male patient and a nonblack clinician so the patient can feel good about his mental health engagement. To some, these recommendations might seem obvious or too simple, yet if we consider the countless reports of poor patient treatment engagement, adherence, and retention, we cannot deny the need for change. Having black male patients disclose important information during encounters could prevent poor clinical interactions that leave them feeling uncomfortable, uncertain, skeptical, disrespected, and further cynical about mental health care.

 

Dr. Simon practices at Boston Children’s Hospital. He has no disclosures.

References

1. Bunn C. After Arbery shooting, black parents are rethinking “the talk” to explain white vigilantes. NBC News. 2020 May 19.

2. U.S. Department of Health and Human Services. Office of Disease Prevention and Promotion. Healthy People 2020.

3. Ward E and Mangesha M. Am J Orthopsychiatry. 2013 Apr-Jul;83(2 0 3):386-97.

4. Holden KB et al. J Mens health. 2012 Jun 1;9(2):63-9.

5. Brown TH et al. Fam Community Health. 2015 Oct-Dec;38(4):307-18.

6. Jäggi et al. Soc Ment Health. 2016 Nov;6(3):187-296.

7. Goff PA et al. J Pers Soc Psychol. 2014;106(4):526-45.

8. Alsan M et al. National Bureau of Economic Research. NBER Working Paper No. 24787. 2018 Jun. Revised 2019 Aug.

9. Spruill IJ. J Nat Black Nurses Assoc. 2014 Dec;25(2):23-30.

10. Graham LF et al. Am J Mens Health. 2018 Sep;12(5):1307-16.

I’m a black man, husband, father, son, brother, and a board-certified psychiatrist, child and adolescent psychiatry fellow, and addiction medicine fellow. I write this article as the latter, a colleague, from the former’s perspective, which you would not need to verify via Google, social media, or a badge upon meeting me.

Motortion/Getty Images

July is Minority Mental Health Awareness Month, established to bring awareness to the unique struggles that marginalized groups face concerning mental illness in the United States.

Given the events of the last few months, including a global pandemic and videotaped killings of Ahmaud Arbery and George Floyd, two unarmed black men, America’s structural racism and inequality are being challenged in historic ways. Black people are suffering. In fact, I was not surprised to learn¹ that some black families with sons have expanded the “talk” – which traditionally has focused on dealing with police officers – to include vigilantes.

Because of my extensive work with and treatment of men of color, I would like to answer a key question: “How do psychiatrists and other mental health clinicians better engage men of color? Before the “how,” let’s review the state of black men’s mental health.

According to Healthy People 2020, mental disorders are the leading cause of disability in the United States.² Among those with diagnosable mental disorders, black people are more likely than are their white counterparts to experience severe symptoms and protracted diseases. Roughly 7% of black men meet the criteria for a lifetime prevalence of major depressive disorder.³ Applying that figure to recent national population estimates means that there are 1.4 million black men currently suffering from major depression. Suicide has been on a continued uptrend among black male youth for more than 2 decades. Moreover, given the high rates of stigma and unmet need in this population, it is likely that these figures are even more dire.

Compared with other groups, black men in the United States face a disproportionate burden of preventable morbidity and mortality rates. Of all the health concerns faced by black men, mental health challenges may be among the most stigmatized.⁴ Evidence suggests that black men have more adverse life experiences than do men of other racial/ethnic groups, and consequently, experience poorer mental health.⁵ Black men experience high rates of poverty, unemployment, and underemployment, and are incarcerated at much higher rates than those of men of other racial/ethnic groups.⁶ It is notable that black male youth are often perceived as older by law enforcement, beginning as early as 10 years old, often resulting in negative interactions.⁷

Despite those challenges, black men are often expected to project strength, they are expected to minimize displays of emotion when off the field or court (i.e., “Just shut up and dribble”), and they are expected to be true versions of folk hero John Henry. This caricature of black males is used at times to validate shootings of unarmed black males (adults and youth).

Black men’s mental health should be a priority for those in the mental health field. This is particularly the case light of our field’s historical involvement in and promotion of stereotyped clinical descriptions of black men and contributing to health disparities that persist. Black men are nearly six times as likely to be diagnosed with schizophrenia as are white men. To read about holdovers from the days of targeted advertising against black protesters of the 1960s and 1970s, check out “The Protest Psychosis” (Beacon Press, 2010) by psychiatrist and anthropologist Jonathan Metzl, MD, PhD. If you go further back in psychiatric history, the late 1800s, you can learn about the devious diagnosis of drapetomania attributed to enslaved people who were seeking freedom.

Those on the front lines providing mental health services should understand black men’s mental health from an ecological perspective. Beyond the emotional burden that mental illness imposes on the individual, there are more considerable interpersonal and societal implications for the state of black men’s mental health. As such, in our full capacity like other men, black men play an essential role within families, churches, neighborhoods, and organizations.

Given our brief review, we can reconsider our question, “How do psychiatrists and mental health clinicians better engage men of color?”

I will suggest a few fundamental principles that honestly can be applied to any patient but should be strongly considered with your black male patients – given they are likely not accustomed to engaging with the health care system, let alone with a mental health clinician:

1. Create a comfortable environment. Because of stigma, persistent myths, and lack of normalcy with talking to a mental health professional, many patients, including black men, do not have a framework for a psychiatric/psychological evaluation or treatment. It would be essential to set the frame of your encounter. Evidence suggests this can improve engagement and follow-up care among black men.⁸ In addition, keep in mind that “fictive kin^”9 tend to play a major role in the transmission of culture, health promotion, and decision-making in the black community. This helps explain why barbershop initiatives¹⁰ are effective. If clinicians are able to allow black male patients to feel comfortable, the clinician, too, might become part of that fictive community and enhance the patient-provider relationship.

2. Allow for storytelling. In the age of the checklist, it can be relatively easy to lose sight that our patients, including black men, have their own narratives. Evidence suggests that physicians interrupt patients early and often. Challenge yourself to allow the patient to tell his story. In consideration of an initial evaluation, it may help to begin by first gathering sociodemographic information (i.e. housing, education, employment, family, etc.); doing so will allow the patient time to get comfortable before you assess possible psychiatric symptoms.

3. Confidentiality assurance. Many black men have a distrust for the health care profession; as such, it is vital that clinicians emphasize that their patients’ information and history will be used only to help the patient. It will be important to inform black male patients of their rights, because often in the greater society, their rights seem to be negated.

4. Be aware of nonverbal language. Given black men’s stereotyped roles in society and recognition that they are regularly perceived as threats, many black men have become adept at reading nonverbal cues (i.e., purse clutched, side comment, etc.). In doing so, clinicians must be attuned to their own nonverbal language. For example, a glance at one’s watch might be interpreted as you’re not listening. It would be better to be upfront and candid by saying something like, “I need to check the time,” rather than attempting to be stealth. Being transparent in that way will let the patient know that you will be upfront with him.

5. Be respectful. During an encounter, and in particular when discussing treatment plans, clinicians must allow the patient space to process and be involved in his care. Allowing the patient time to think through how he would want to proceed provides him a sense of personal agency and lets him know that he is capable of improving his mental wellness.

Black male patients need to feel comfortable, safe, able to trust the clinician. They must feel listened to, understood, and respected. This information might help some clinicians better understand what needs to happen between a black male patient and a nonblack clinician so the patient can feel good about his mental health engagement. To some, these recommendations might seem obvious or too simple, yet if we consider the countless reports of poor patient treatment engagement, adherence, and retention, we cannot deny the need for change. Having black male patients disclose important information during encounters could prevent poor clinical interactions that leave them feeling uncomfortable, uncertain, skeptical, disrespected, and further cynical about mental health care.

 

Dr. Simon practices at Boston Children’s Hospital. He has no disclosures.

References

1. Bunn C. After Arbery shooting, black parents are rethinking “the talk” to explain white vigilantes. NBC News. 2020 May 19.

2. U.S. Department of Health and Human Services. Office of Disease Prevention and Promotion. Healthy People 2020.

3. Ward E and Mangesha M. Am J Orthopsychiatry. 2013 Apr-Jul;83(2 0 3):386-97.

4. Holden KB et al. J Mens health. 2012 Jun 1;9(2):63-9.

5. Brown TH et al. Fam Community Health. 2015 Oct-Dec;38(4):307-18.

6. Jäggi et al. Soc Ment Health. 2016 Nov;6(3):187-296.

7. Goff PA et al. J Pers Soc Psychol. 2014;106(4):526-45.

8. Alsan M et al. National Bureau of Economic Research. NBER Working Paper No. 24787. 2018 Jun. Revised 2019 Aug.

9. Spruill IJ. J Nat Black Nurses Assoc. 2014 Dec;25(2):23-30.

10. Graham LF et al. Am J Mens Health. 2018 Sep;12(5):1307-16.

Editor’s Note: This transcript from the June 5 special episode of the Psychcast has been edited for clarity.

Nick Andrews: This is the Psychcast, the official podcast of MDedge Psychiatry. I am the voice of the MDedge podcasts, Nick Andrews. We are bringing this special edition of the Psychcast from MDedge in response to all of the unrest, peaceful or otherwise, in the United States in the aftermath of the shocking murder of George Floyd in late May of 2020.

Dr. Lorenzo Norris agreed to have this “after hours” discussion, believing the most appropriate response would be for us to have a real conversation about it. So welcome aboard.

Lorenzo Norris, MD: I’m happy to be here, Nick, and I’m so pleased to be talking with our guest, Dr. Brandon Newsome, a young black male psychiatrist. Dr. Newsome, sir, tell us a little about yourself and where you’re coming from.

Brandon Newsome, MD: I’m a 4th-year psychiatry resident at Boston Medical Center, so I’m about to graduate and to become a first-year fellow, as of July, at Children’s National Medical Center in Washington, D.C. I was born and raised in the South so I can talk about those experiences, and now I’ve been in the Northeast for the past 4 years.

Dr. Norris: Let’s get right into it. This is a time in our country that we’ve not seen – I shouldn’t say we, because depending on where you live in America, you have seen this and you’ve seen this multiple times.

I see a lot of myself in Dr. Newsome right now, and I am struggling with this: I’m talking to you about the same stuff I was talking about when I was a 4th-year resident. I’m talking to you about the same stuff I was talking about when I was a college student. I’m still talking about the same stuff I was talking about when I was a medical student. I’m still talking about the same things that were the impetus for the hip-hop generation regarding police brutality and violence.

We are still talking about the use of lethal force and abuse of power, particularly by police or law enforcement officers, and how that is perpetrated against African American men in particular, and the unfortunate and tragic murder of Mr. George Floyd. Dr. Newsome, tell me how you’re thinking about this. Before we even get into how our patients or our colleagues are doing, how are you doing with this?

Dr. Newsome: It’s been difficult. Like you, I’ve heard this story time and time again. I was just on a panel, having a conversation about race and policing, and I realized we had the same conversation during my first or second year of residency because there had been another death. But even though all of these unfortunate deaths are triggering us, this one is a little different for me for a few reasons. As you know, this is happening with the backdrop of the COVID-19 crisis and we’re already seeing so many people, especially from black and brown communities, dying from that.

And then I’m witnessing what happened, watching that video and thinking about all the interventions we’ve already tried. We tried body cameras, and the dude was wearing a body camera. We tried to get our police officers to be engaged, to try to check their roles, but people were there, witnessing everything, and nothing happened. An upstander was there, a white upstander, a firefighter who was telling them to check his pulse. Still nothing happened; it didn’t stop them.

I believe the backdrop of the COVID-19 crisis makes it a whole lot more painful for me and many others. I am part of a black physician email group and it’s been triggering for all of us because we all imagine that this could be me one day, especially when you think about the Amy Coopers of the world, among other things.

Dr. Norris: I completely agree. We’re dealing with loss of life due to a virus, including, [personally speaking] that of my departed grandmother Why am I bringing this up? I bring it up because, regardless of one’s socioeconomic strata or title or whatnot, particularly in the black community, this is the kind of mess we’re dealing with. We’re dealing with the stress of COVID-19 that is disproportionately affecting African Americans. We’re dealing with social isolation, we’re dealing with the economic recession and the collapse that everyone else is dealing with, and on top of that we are now dealing with another murder. But this particular murder resonates very differently because, as you said, it seemed like every single thing that could have been done was done.

You will read reports that Mr. Floyd was resisting arrest. But you look at this video; this is not a man resisting arrest. This is a man trying to say, please, you are killing me. These are other people saying the same thing. These are police officers not acting right. This is so many different things going on, and when you hear this and look at this video, you can come to no other conclusion than it is murder.

As psychiatrists, we frequently have to restrain people, and it is always understood that restraint can turn into assault extremely quickly. But in this particular case, there was no thought or concern about this man’s life or his health. There are many good police officers that do think of that, and so this was shocking. It was jarring. It was another thing piled on an already taxed black America. I was talking with my black male colleagues about this, and I think a lot of people don’t actually realize that, while there are black male psychiatrists, there are only a few of us.

Dr. Newsome: True that.

Dr. Norris: There are only so many black male physicians, period, and black male psychiatrists in particular. At different points in time we are called on to take leadership roles, and to talk, to speak on things and be a voice. Well, I have to tell you, after a while, this is pretty goddamn tiring for us to contain our disappointment, our anger, and our rage and still stay hopeful, optimistic, and still be a voice for those who are not able to speak.

Dr. Newsome: I agree that sometimes it can be tiring to have to take leadership roles and continue to talk about all these things, but I also feel that, at least for me, it gives me some sort of route to address the angst and do something with it. I believe all of us are just figuring out how to deal with these feelings that we shouldn’t have to feel because of a murder that was televised.

Dr. Norris: Thank you. For a murder that was televised; that was tweeted; that was broadbanded; that was streamed.

Now we’ve laid the framework, in terms of what we’re feeling. Let’s move on to why you and I are in this profession, and that’s our patients. What are you seeing on the front lines? What are you seeing with our patients?

Dr. Newsome: I was speaking with one of my black male patients, and he was fearful. He had been perfectly fine, even in the COVID crisis, he was doing well. But when you get this milieu of police violence, now he’s feeling this intense fear. Should I be walking alone at night? What happens if I am the one who is at the wrong place at the wrong time?

I also find that some of my nonminority patients sometimes find difficulty making sense of it. Minority individuals already know these things are happening. But some of the nonminorities are wondering how or why would something like this happen in America? This is just how America is for the black folks.

Dr. Norris: Could you elaborate on that? I always found that to be a very interesting dynamic for those who are not minorities or people of color. I will have folks in a psychotherapy session who are just bewildered by events like this. It is not the America they think they know – they are shocked that this is actually what’s going on.

Dr. Newsome: It’s all about experiences. If you didn’t grow up around a lot of minorities, you haven’t necessarily had these conversations. Even speaking for myself, sometimes I don’t want to discuss these things; you never know what you’re going to get. You might find an ally, or you might find someone who isn’t at all supportive. I think the surprise is from lack of exposure. If you don’t have to live through racism, you can most certainly have blinders on and not notice.

Dr. Norris: Can you comment on the fear you’re seeing in some folks? Can it get to the point of reactivating PTSD?

Dr. Newsome: I notice it more with black individuals, a fear that they might be the ones who may die; or with black mothers, wondering, what about my child? Is this what they are going to have to live with for the rest of their lives? Older people would say that we fought already and it’s still going on. What are the fruits of the labor we put in?

Dr. Norris: I agree with you completely. What are the fruits? You’re going to see those strong reactions. You’re going to see fear, you’re going to see anger, and you’re also going to see guilt that they could not stop this. I’m speaking particularly about some of my nonminority patients. It goes along with that confusion. This manifests in a desperate need to do something.

But here’s the problem: You don’t really know what to do because no one is educated on it. And as you said before, race is a very polarized subject. No one even likes to talk about racism because it’s so, oh my goodness. We’ve run away from it so much to the point that we can’t deal with it. Racism, whether or not you witness it, whether or not you participate in it, whether or not you are the subject of it, affects and hurts us all. We all have to start to own that. You can’t just stay siloed, because eventually, it’s going to come back and affect you.

I could easily be Mr. Floyd, but at the same time, due to my station and things of that nature, I have a certain level of privilege and autonomy. There could be a tendency to put your head under the sand, you know, look at how far we’ve come, Barack Obama. But you’ve got to say, no, we still have enormous amounts of work to do.

We’ve been talking about the patients. What have you noticed in your colleagues and how they’ve been feeling about this?

Dr. Newsome: Again, I see them feeling saddened by the events. One of the other things I’ve noticed is that some people are in environments where they have program directors and chairs who will directly condemn certain behaviors and say, “This is racist, this shouldn’t happen.” But then there are other programs that have been more silent. I’ve had people say that this is the first time that they have felt isolated in a long while.

We all participate in these physician WhatsApp groups, and according to some of the comments, people are realizing that these folks that they were just on the front lines with, fighting COVID, are perhaps not the allies that they originally thought they were, based on the things these people are saying.

Dr. Norris: Wow. It’s good that we’re talking about this from the viewpoint of two different generations. You’ve got the WhatsApp group and Google Hangouts and all that kind of good stuff, and I’m still with pagers and such. That’s interesting – the reality that folks you thought were your allies turn out not to be, because you’re bringing up difficult conversations that we don’t normally talk about.

I have noticed that some people around me have been silent because they don’t know what to say. They’re so concerned that I’m going to be offended or they’re going to hurt me or say the wrong thing, so they stay quiet. As I reflect now, this is the wrong thing to do. Own your concern. I’ve been in two large meetings now, and I’ve had multiple people whom I consider friends say, I wanted to email or text you right then and ask you how you’re doing, but I didn’t because I didn’t know what to say. I have entered meetings recently, and the meeting felt tense, and I’m thinking, what’s going on? And now I realize they did not know what to say or how to approach it.

That’s been a very interesting dynamic and tells us where we are with this. Today, for example, I was pleased to have the support of my dean’s group. I felt I had to speak out, I just had to straight out tell them. Do you want to know what I’m feeling? I’m feeling rage. I’m feeling rage. And you all have to understand that, because I have to speak for those who aren’t necessarily going to be able to express themselves. More importantly, I have to speak for myself and I’m feeling rage.

How our colleagues are processing this and how they’re thinking about this runs the gamut. But I think about people not necessarily knowing what to say or how to approach it. I absolutely agree that with the leadership, you’re going to get many different responses, and sometimes you’re left to wonder, do I have to watch what I say? But I’m definitely supported at my institution.

What else are you seeing out there in terms of your colleagues or how people think about it?

Dr. Newsome: This also spurs some folks to activism. Some have been participating in protests. There will be White Coats for Black Lives protests, among other things. So it’s spurred folks to action, and it’s also spurred folks to try to be part of a community. Of course, with the whole COVID crisis, we can’t necessarily come together, so we’ve been doing Zoom gatherings more than anything else. But it has encouraged folks to want to do that more, too, because they want to check in on their brother or their sister to make sure they are doing well, and also to be able to express what’s going on with them in a community where they know they can get validation.

Courtesy George Washington University Hospital Internal Medicine, Instagram @gtwon_medres

Dr. Norris: I’m going to push you a bit because I detect in your tone something similar to what I’m feeling. I just got the email, the White Coats For Black Lives email. But I think your feeling is similar to mine – I’ve done this before. I’ve done White Coats for Black Lives. You all may have protested. But this display in Washington, D.C., of the use of military and law enforcement to clear a public square of peaceful protesters is above and beyond the pale of anything I’ve ever seen in my life. We have to label that for the danger it is, for the threat to everything this country and the people that bled for this country stand for.

So while I’m going to participate in White Coats for Black Lives and many other things, I am looking for what is actually going to move the needle. I think the protests are great, but at this point in time I want institutions, I want money, I want lawyers, I want a systematic approach.

Dr. Newsome: I most certainly agree. Of course, the protests are really important, but depending on where you are, you have a different lens. As physicians, especially as black physicians, since there are so few of us, we have a unique opportunity to leverage that, whether that means communicating through op-eds or calling your senators and talking with them to try to move things forward.

Physicians are mobilizing. In the last few days, a physician created a Zoom event and hundreds of physicians joined to try to figure out how we can structurally fix this problem. So I most certainly believe that in this effort to address racism, we physicians will need to lend our voices and our privilege to move the needle as best we can.

Dr. Norris: Some of our colleagues in Black Psychiatrists of America have put out a press release on racism in which they propose some actions that should be taken immediately. I think this is a useful thing to talk about.

The first action: “Declare racism a public health problem and establish national goals for addressing this as a health equity issue. Give priority to addressing the issues of health care disparities, including the mental health needs of historically marginalized communities across the U.S.”

What do you think about that?

Dr. Newsome: Those are two extremely important steps. The question is: How do you make that happen?

Dr. Norris: You’re reading my mind. I love that our colleagues put that out there, but that was my next question.

Dr. Newsome: There is going to be a town hall about this and I’m hoping that we can plan how we envision this happening. I can imagine that 20 or 30 years ago there was also a fear in society that there would be episodes of police brutality. I can imagine that there were similar ideals and hopes. But I think we need to put all of our minds together and ask: How are we going to accomplish this? Is this going to be something we’re going to put our money into? Is this going to be something we’re going to get senators and legislatures onboard with to make policy?

Dr. Norris: Let me read off some of the other action points they put out. There are six of them.

“Establish a governmental multidisciplinary and ethnically diverse commission with representatives from the major health care professional associations in medicine, nursing, psychiatry, public health, psychology, social work, etc., and the faith-based community to provide recommendations to Congress regarding policies on how to best improve the health and well-being of our nation’s black citizens.”

That’s a very solid overall recommendation. My question is, doesn’t that, in some way, shape, or form already exist? Could we not put up policy statements from all of these folks regarding racism and things of that nature? I agree with what they’re saying, but part of me wonders why certain things in the current system aren’t working. That becomes the question. Are we not integrated enough? Do we not have enough cross talk? Do we not have enough money behind it? So I agree with that goal, but I would be curious if that doesn’t already exist. What are your thoughts about that, Dr. Newsome?

Dr. Newsome: I would imagine that the National Institute on Minority Mental Health and Health Disparities would have something similar. I believe one of the things you mentioned is really important. In addition to making these recommendations, we need to be looking at where these leaks are occurring that keep them from working. What is the current structure and why is it the way it is with regard to the governance?

Dr. Norris: Here is another of their action statements: “Declare ‘civic mental health’ a national priority and incorporate it into the educational curriculum from K through college, as well as in the training of local, state, and national officials, law enforcement, and the criminal justice system.”

Let me be clear, I like every single one of these action statements. I encourage everyone to participate in dialogue and discussion. You may agree with some of these, and some of them you may not, but if there is one you agree with, that you really are motivated about, that’s one that you need to explore and dig into a bit more, because it’s too big for us to handle on our own, just like racism and equality.

I’m going to tell you, I like this statement. I do like this. Obviously these are broad points, but I do like the idea of training law enforcement officers about “civic mental health.” For example, Dr. Michael Compton, who has done a lot of great work in the area of mental health and prevention, has worked with police officers to help them interact with those with mental health conditions by modulating their own emotional response. I’m very interested in these types of recommendations that particularly target law enforcement officers, and helping with that ”emotional quotient.” I’m interested in seeing how far that can spread in the country. What do you think, Dr. Newsome?

Dr. Newsome: Educating police officers about how to interact would be quite important. I believe the National Alliance on Mental Illness does some of that work, partnering with law enforcement agencies, talking about mental health and cues to look at. There also are some programs where people ride along with mental health clinicians and police officers, which I find to be really helpful. But clearly, what’s going on right now isn’t working. So I would be open to any reasonable idea.

Dr. Norris: Here’s one last action point: “Establish police community review boards with power to take action in areas of police misconduct pending formal review by the appropriate authorities. This will offer a level of empowerment when communities feel they have a voice that can be heard.”

This is where I want my focus to be, as I move forward to try to do something sustainable. To deal with police brutality and abuse of power in general, but specifically as it relates to African American men and the lethal use of force. We need to work on policies that will enable African American men to make it to court, so that every encounter with a police officer is not literally viewed as a potentially lethal encounter.

A lot of people aren’t going to like me saying that, but it’s the absolute truth. You have to think like that, as an African American male, regardless of your station, regardless of where you live, this is the reality. There are many, many good police officers out there. I have a few friends who are law enforcement officers. I work with security at the George Washington Hospital constantly. But that still does not change the fact that if I get pulled over at a traffic stop, I know precisely certain things I need to do and not do, or the encounter could end badly. By that I mean loss of life.

So I encourage anything where we can start to take a systematic look at law enforcement and empower communities to look at who is doing it right and who is doing it wrong. Information is coming out now about the man who murdered Mr. Floyd, and this was not the first time he was involved in misconduct. There were red flags; we have to start to confront this. We have to learn from every single one of these situations and grow because another one is going to happen next week, it’s just whether or not you hear about it. That’s the reality of the state of America. You may not like to hear it, but that’s just a fact.


To hear the entire conversation, go to mdedge.com/podcasts or listen wherever you find your podcasts.
 

Editor’s Note: This transcript from the June 5 special episode of the Psychcast has been edited for clarity.

Nick Andrews: This is the Psychcast, the official podcast of MDedge Psychiatry. I am the voice of the MDedge podcasts, Nick Andrews. We are bringing this special edition of the Psychcast from MDedge in response to all of the unrest, peaceful or otherwise, in the United States in the aftermath of the shocking murder of George Floyd in late May of 2020.

Dr. Lorenzo Norris agreed to have this “after hours” discussion, believing the most appropriate response would be for us to have a real conversation about it. So welcome aboard.

Lorenzo Norris, MD: I’m happy to be here, Nick, and I’m so pleased to be talking with our guest, Dr. Brandon Newsome, a young black male psychiatrist. Dr. Newsome, sir, tell us a little about yourself and where you’re coming from.

Brandon Newsome, MD: I’m a 4th-year psychiatry resident at Boston Medical Center, so I’m about to graduate and to become a first-year fellow, as of July, at Children’s National Medical Center in Washington, D.C. I was born and raised in the South so I can talk about those experiences, and now I’ve been in the Northeast for the past 4 years.

Dr. Norris: Let’s get right into it. This is a time in our country that we’ve not seen – I shouldn’t say we, because depending on where you live in America, you have seen this and you’ve seen this multiple times.

I see a lot of myself in Dr. Newsome right now, and I am struggling with this: I’m talking to you about the same stuff I was talking about when I was a 4th-year resident. I’m talking to you about the same stuff I was talking about when I was a college student. I’m still talking about the same stuff I was talking about when I was a medical student. I’m still talking about the same things that were the impetus for the hip-hop generation regarding police brutality and violence.

We are still talking about the use of lethal force and abuse of power, particularly by police or law enforcement officers, and how that is perpetrated against African American men in particular, and the unfortunate and tragic murder of Mr. George Floyd. Dr. Newsome, tell me how you’re thinking about this. Before we even get into how our patients or our colleagues are doing, how are you doing with this?

Dr. Newsome: It’s been difficult. Like you, I’ve heard this story time and time again. I was just on a panel, having a conversation about race and policing, and I realized we had the same conversation during my first or second year of residency because there had been another death. But even though all of these unfortunate deaths are triggering us, this one is a little different for me for a few reasons. As you know, this is happening with the backdrop of the COVID-19 crisis and we’re already seeing so many people, especially from black and brown communities, dying from that.

And then I’m witnessing what happened, watching that video and thinking about all the interventions we’ve already tried. We tried body cameras, and the dude was wearing a body camera. We tried to get our police officers to be engaged, to try to check their roles, but people were there, witnessing everything, and nothing happened. An upstander was there, a white upstander, a firefighter who was telling them to check his pulse. Still nothing happened; it didn’t stop them.

I believe the backdrop of the COVID-19 crisis makes it a whole lot more painful for me and many others. I am part of a black physician email group and it’s been triggering for all of us because we all imagine that this could be me one day, especially when you think about the Amy Coopers of the world, among other things.

Dr. Norris: I completely agree. We’re dealing with loss of life due to a virus, including, [personally speaking] that of my departed grandmother Why am I bringing this up? I bring it up because, regardless of one’s socioeconomic strata or title or whatnot, particularly in the black community, this is the kind of mess we’re dealing with. We’re dealing with the stress of COVID-19 that is disproportionately affecting African Americans. We’re dealing with social isolation, we’re dealing with the economic recession and the collapse that everyone else is dealing with, and on top of that we are now dealing with another murder. But this particular murder resonates very differently because, as you said, it seemed like every single thing that could have been done was done.

You will read reports that Mr. Floyd was resisting arrest. But you look at this video; this is not a man resisting arrest. This is a man trying to say, please, you are killing me. These are other people saying the same thing. These are police officers not acting right. This is so many different things going on, and when you hear this and look at this video, you can come to no other conclusion than it is murder.

As psychiatrists, we frequently have to restrain people, and it is always understood that restraint can turn into assault extremely quickly. But in this particular case, there was no thought or concern about this man’s life or his health. There are many good police officers that do think of that, and so this was shocking. It was jarring. It was another thing piled on an already taxed black America. I was talking with my black male colleagues about this, and I think a lot of people don’t actually realize that, while there are black male psychiatrists, there are only a few of us.

Dr. Newsome: True that.

Dr. Norris: There are only so many black male physicians, period, and black male psychiatrists in particular. At different points in time we are called on to take leadership roles, and to talk, to speak on things and be a voice. Well, I have to tell you, after a while, this is pretty goddamn tiring for us to contain our disappointment, our anger, and our rage and still stay hopeful, optimistic, and still be a voice for those who are not able to speak.

Dr. Newsome: I agree that sometimes it can be tiring to have to take leadership roles and continue to talk about all these things, but I also feel that, at least for me, it gives me some sort of route to address the angst and do something with it. I believe all of us are just figuring out how to deal with these feelings that we shouldn’t have to feel because of a murder that was televised.

Dr. Norris: Thank you. For a murder that was televised; that was tweeted; that was broadbanded; that was streamed.

Now we’ve laid the framework, in terms of what we’re feeling. Let’s move on to why you and I are in this profession, and that’s our patients. What are you seeing on the front lines? What are you seeing with our patients?

Dr. Newsome: I was speaking with one of my black male patients, and he was fearful. He had been perfectly fine, even in the COVID crisis, he was doing well. But when you get this milieu of police violence, now he’s feeling this intense fear. Should I be walking alone at night? What happens if I am the one who is at the wrong place at the wrong time?

I also find that some of my nonminority patients sometimes find difficulty making sense of it. Minority individuals already know these things are happening. But some of the nonminorities are wondering how or why would something like this happen in America? This is just how America is for the black folks.

Dr. Norris: Could you elaborate on that? I always found that to be a very interesting dynamic for those who are not minorities or people of color. I will have folks in a psychotherapy session who are just bewildered by events like this. It is not the America they think they know – they are shocked that this is actually what’s going on.

Dr. Newsome: It’s all about experiences. If you didn’t grow up around a lot of minorities, you haven’t necessarily had these conversations. Even speaking for myself, sometimes I don’t want to discuss these things; you never know what you’re going to get. You might find an ally, or you might find someone who isn’t at all supportive. I think the surprise is from lack of exposure. If you don’t have to live through racism, you can most certainly have blinders on and not notice.

Dr. Norris: Can you comment on the fear you’re seeing in some folks? Can it get to the point of reactivating PTSD?

Dr. Newsome: I notice it more with black individuals, a fear that they might be the ones who may die; or with black mothers, wondering, what about my child? Is this what they are going to have to live with for the rest of their lives? Older people would say that we fought already and it’s still going on. What are the fruits of the labor we put in?

Dr. Norris: I agree with you completely. What are the fruits? You’re going to see those strong reactions. You’re going to see fear, you’re going to see anger, and you’re also going to see guilt that they could not stop this. I’m speaking particularly about some of my nonminority patients. It goes along with that confusion. This manifests in a desperate need to do something.

But here’s the problem: You don’t really know what to do because no one is educated on it. And as you said before, race is a very polarized subject. No one even likes to talk about racism because it’s so, oh my goodness. We’ve run away from it so much to the point that we can’t deal with it. Racism, whether or not you witness it, whether or not you participate in it, whether or not you are the subject of it, affects and hurts us all. We all have to start to own that. You can’t just stay siloed, because eventually, it’s going to come back and affect you.

I could easily be Mr. Floyd, but at the same time, due to my station and things of that nature, I have a certain level of privilege and autonomy. There could be a tendency to put your head under the sand, you know, look at how far we’ve come, Barack Obama. But you’ve got to say, no, we still have enormous amounts of work to do.

We’ve been talking about the patients. What have you noticed in your colleagues and how they’ve been feeling about this?

Dr. Newsome: Again, I see them feeling saddened by the events. One of the other things I’ve noticed is that some people are in environments where they have program directors and chairs who will directly condemn certain behaviors and say, “This is racist, this shouldn’t happen.” But then there are other programs that have been more silent. I’ve had people say that this is the first time that they have felt isolated in a long while.

We all participate in these physician WhatsApp groups, and according to some of the comments, people are realizing that these folks that they were just on the front lines with, fighting COVID, are perhaps not the allies that they originally thought they were, based on the things these people are saying.

Dr. Norris: Wow. It’s good that we’re talking about this from the viewpoint of two different generations. You’ve got the WhatsApp group and Google Hangouts and all that kind of good stuff, and I’m still with pagers and such. That’s interesting – the reality that folks you thought were your allies turn out not to be, because you’re bringing up difficult conversations that we don’t normally talk about.

I have noticed that some people around me have been silent because they don’t know what to say. They’re so concerned that I’m going to be offended or they’re going to hurt me or say the wrong thing, so they stay quiet. As I reflect now, this is the wrong thing to do. Own your concern. I’ve been in two large meetings now, and I’ve had multiple people whom I consider friends say, I wanted to email or text you right then and ask you how you’re doing, but I didn’t because I didn’t know what to say. I have entered meetings recently, and the meeting felt tense, and I’m thinking, what’s going on? And now I realize they did not know what to say or how to approach it.

That’s been a very interesting dynamic and tells us where we are with this. Today, for example, I was pleased to have the support of my dean’s group. I felt I had to speak out, I just had to straight out tell them. Do you want to know what I’m feeling? I’m feeling rage. I’m feeling rage. And you all have to understand that, because I have to speak for those who aren’t necessarily going to be able to express themselves. More importantly, I have to speak for myself and I’m feeling rage.

How our colleagues are processing this and how they’re thinking about this runs the gamut. But I think about people not necessarily knowing what to say or how to approach it. I absolutely agree that with the leadership, you’re going to get many different responses, and sometimes you’re left to wonder, do I have to watch what I say? But I’m definitely supported at my institution.

What else are you seeing out there in terms of your colleagues or how people think about it?

Dr. Newsome: This also spurs some folks to activism. Some have been participating in protests. There will be White Coats for Black Lives protests, among other things. So it’s spurred folks to action, and it’s also spurred folks to try to be part of a community. Of course, with the whole COVID crisis, we can’t necessarily come together, so we’ve been doing Zoom gatherings more than anything else. But it has encouraged folks to want to do that more, too, because they want to check in on their brother or their sister to make sure they are doing well, and also to be able to express what’s going on with them in a community where they know they can get validation.

Courtesy George Washington University Hospital Internal Medicine, Instagram @gtwon_medres

Dr. Norris: I’m going to push you a bit because I detect in your tone something similar to what I’m feeling. I just got the email, the White Coats For Black Lives email. But I think your feeling is similar to mine – I’ve done this before. I’ve done White Coats for Black Lives. You all may have protested. But this display in Washington, D.C., of the use of military and law enforcement to clear a public square of peaceful protesters is above and beyond the pale of anything I’ve ever seen in my life. We have to label that for the danger it is, for the threat to everything this country and the people that bled for this country stand for.

So while I’m going to participate in White Coats for Black Lives and many other things, I am looking for what is actually going to move the needle. I think the protests are great, but at this point in time I want institutions, I want money, I want lawyers, I want a systematic approach.

Dr. Newsome: I most certainly agree. Of course, the protests are really important, but depending on where you are, you have a different lens. As physicians, especially as black physicians, since there are so few of us, we have a unique opportunity to leverage that, whether that means communicating through op-eds or calling your senators and talking with them to try to move things forward.

Physicians are mobilizing. In the last few days, a physician created a Zoom event and hundreds of physicians joined to try to figure out how we can structurally fix this problem. So I most certainly believe that in this effort to address racism, we physicians will need to lend our voices and our privilege to move the needle as best we can.

Dr. Norris: Some of our colleagues in Black Psychiatrists of America have put out a press release on racism in which they propose some actions that should be taken immediately. I think this is a useful thing to talk about.

The first action: “Declare racism a public health problem and establish national goals for addressing this as a health equity issue. Give priority to addressing the issues of health care disparities, including the mental health needs of historically marginalized communities across the U.S.”

What do you think about that?

Dr. Newsome: Those are two extremely important steps. The question is: How do you make that happen?

Dr. Norris: You’re reading my mind. I love that our colleagues put that out there, but that was my next question.

Dr. Newsome: There is going to be a town hall about this and I’m hoping that we can plan how we envision this happening. I can imagine that 20 or 30 years ago there was also a fear in society that there would be episodes of police brutality. I can imagine that there were similar ideals and hopes. But I think we need to put all of our minds together and ask: How are we going to accomplish this? Is this going to be something we’re going to put our money into? Is this going to be something we’re going to get senators and legislatures onboard with to make policy?

Dr. Norris: Let me read off some of the other action points they put out. There are six of them.

“Establish a governmental multidisciplinary and ethnically diverse commission with representatives from the major health care professional associations in medicine, nursing, psychiatry, public health, psychology, social work, etc., and the faith-based community to provide recommendations to Congress regarding policies on how to best improve the health and well-being of our nation’s black citizens.”

That’s a very solid overall recommendation. My question is, doesn’t that, in some way, shape, or form already exist? Could we not put up policy statements from all of these folks regarding racism and things of that nature? I agree with what they’re saying, but part of me wonders why certain things in the current system aren’t working. That becomes the question. Are we not integrated enough? Do we not have enough cross talk? Do we not have enough money behind it? So I agree with that goal, but I would be curious if that doesn’t already exist. What are your thoughts about that, Dr. Newsome?

Dr. Newsome: I would imagine that the National Institute on Minority Mental Health and Health Disparities would have something similar. I believe one of the things you mentioned is really important. In addition to making these recommendations, we need to be looking at where these leaks are occurring that keep them from working. What is the current structure and why is it the way it is with regard to the governance?

Dr. Norris: Here is another of their action statements: “Declare ‘civic mental health’ a national priority and incorporate it into the educational curriculum from K through college, as well as in the training of local, state, and national officials, law enforcement, and the criminal justice system.”

Let me be clear, I like every single one of these action statements. I encourage everyone to participate in dialogue and discussion. You may agree with some of these, and some of them you may not, but if there is one you agree with, that you really are motivated about, that’s one that you need to explore and dig into a bit more, because it’s too big for us to handle on our own, just like racism and equality.

I’m going to tell you, I like this statement. I do like this. Obviously these are broad points, but I do like the idea of training law enforcement officers about “civic mental health.” For example, Dr. Michael Compton, who has done a lot of great work in the area of mental health and prevention, has worked with police officers to help them interact with those with mental health conditions by modulating their own emotional response. I’m very interested in these types of recommendations that particularly target law enforcement officers, and helping with that ”emotional quotient.” I’m interested in seeing how far that can spread in the country. What do you think, Dr. Newsome?

Dr. Newsome: Educating police officers about how to interact would be quite important. I believe the National Alliance on Mental Illness does some of that work, partnering with law enforcement agencies, talking about mental health and cues to look at. There also are some programs where people ride along with mental health clinicians and police officers, which I find to be really helpful. But clearly, what’s going on right now isn’t working. So I would be open to any reasonable idea.

Dr. Norris: Here’s one last action point: “Establish police community review boards with power to take action in areas of police misconduct pending formal review by the appropriate authorities. This will offer a level of empowerment when communities feel they have a voice that can be heard.”

This is where I want my focus to be, as I move forward to try to do something sustainable. To deal with police brutality and abuse of power in general, but specifically as it relates to African American men and the lethal use of force. We need to work on policies that will enable African American men to make it to court, so that every encounter with a police officer is not literally viewed as a potentially lethal encounter.

A lot of people aren’t going to like me saying that, but it’s the absolute truth. You have to think like that, as an African American male, regardless of your station, regardless of where you live, this is the reality. There are many, many good police officers out there. I have a few friends who are law enforcement officers. I work with security at the George Washington Hospital constantly. But that still does not change the fact that if I get pulled over at a traffic stop, I know precisely certain things I need to do and not do, or the encounter could end badly. By that I mean loss of life.

So I encourage anything where we can start to take a systematic look at law enforcement and empower communities to look at who is doing it right and who is doing it wrong. Information is coming out now about the man who murdered Mr. Floyd, and this was not the first time he was involved in misconduct. There were red flags; we have to start to confront this. We have to learn from every single one of these situations and grow because another one is going to happen next week, it’s just whether or not you hear about it. That’s the reality of the state of America. You may not like to hear it, but that’s just a fact.


To hear the entire conversation, go to mdedge.com/podcasts or listen wherever you find your podcasts.
 

Editor’s Note: This transcript from the June 5 special episode of the Psychcast has been edited for clarity.

Nick Andrews: This is the Psychcast, the official podcast of MDedge Psychiatry. I am the voice of the MDedge podcasts, Nick Andrews. We are bringing this special edition of the Psychcast from MDedge in response to all of the unrest, peaceful or otherwise, in the United States in the aftermath of the shocking murder of George Floyd in late May of 2020.

Dr. Lorenzo Norris agreed to have this “after hours” discussion, believing the most appropriate response would be for us to have a real conversation about it. So welcome aboard.

Lorenzo Norris, MD: I’m happy to be here, Nick, and I’m so pleased to be talking with our guest, Dr. Brandon Newsome, a young black male psychiatrist. Dr. Newsome, sir, tell us a little about yourself and where you’re coming from.

Brandon Newsome, MD: I’m a 4th-year psychiatry resident at Boston Medical Center, so I’m about to graduate and to become a first-year fellow, as of July, at Children’s National Medical Center in Washington, D.C. I was born and raised in the South so I can talk about those experiences, and now I’ve been in the Northeast for the past 4 years.

Dr. Norris: Let’s get right into it. This is a time in our country that we’ve not seen – I shouldn’t say we, because depending on where you live in America, you have seen this and you’ve seen this multiple times.

I see a lot of myself in Dr. Newsome right now, and I am struggling with this: I’m talking to you about the same stuff I was talking about when I was a 4th-year resident. I’m talking to you about the same stuff I was talking about when I was a college student. I’m still talking about the same stuff I was talking about when I was a medical student. I’m still talking about the same things that were the impetus for the hip-hop generation regarding police brutality and violence.

We are still talking about the use of lethal force and abuse of power, particularly by police or law enforcement officers, and how that is perpetrated against African American men in particular, and the unfortunate and tragic murder of Mr. George Floyd. Dr. Newsome, tell me how you’re thinking about this. Before we even get into how our patients or our colleagues are doing, how are you doing with this?

Dr. Newsome: It’s been difficult. Like you, I’ve heard this story time and time again. I was just on a panel, having a conversation about race and policing, and I realized we had the same conversation during my first or second year of residency because there had been another death. But even though all of these unfortunate deaths are triggering us, this one is a little different for me for a few reasons. As you know, this is happening with the backdrop of the COVID-19 crisis and we’re already seeing so many people, especially from black and brown communities, dying from that.

And then I’m witnessing what happened, watching that video and thinking about all the interventions we’ve already tried. We tried body cameras, and the dude was wearing a body camera. We tried to get our police officers to be engaged, to try to check their roles, but people were there, witnessing everything, and nothing happened. An upstander was there, a white upstander, a firefighter who was telling them to check his pulse. Still nothing happened; it didn’t stop them.

I believe the backdrop of the COVID-19 crisis makes it a whole lot more painful for me and many others. I am part of a black physician email group and it’s been triggering for all of us because we all imagine that this could be me one day, especially when you think about the Amy Coopers of the world, among other things.

Dr. Norris: I completely agree. We’re dealing with loss of life due to a virus, including, [personally speaking] that of my departed grandmother Why am I bringing this up? I bring it up because, regardless of one’s socioeconomic strata or title or whatnot, particularly in the black community, this is the kind of mess we’re dealing with. We’re dealing with the stress of COVID-19 that is disproportionately affecting African Americans. We’re dealing with social isolation, we’re dealing with the economic recession and the collapse that everyone else is dealing with, and on top of that we are now dealing with another murder. But this particular murder resonates very differently because, as you said, it seemed like every single thing that could have been done was done.

You will read reports that Mr. Floyd was resisting arrest. But you look at this video; this is not a man resisting arrest. This is a man trying to say, please, you are killing me. These are other people saying the same thing. These are police officers not acting right. This is so many different things going on, and when you hear this and look at this video, you can come to no other conclusion than it is murder.

As psychiatrists, we frequently have to restrain people, and it is always understood that restraint can turn into assault extremely quickly. But in this particular case, there was no thought or concern about this man’s life or his health. There are many good police officers that do think of that, and so this was shocking. It was jarring. It was another thing piled on an already taxed black America. I was talking with my black male colleagues about this, and I think a lot of people don’t actually realize that, while there are black male psychiatrists, there are only a few of us.

Dr. Newsome: True that.

Dr. Norris: There are only so many black male physicians, period, and black male psychiatrists in particular. At different points in time we are called on to take leadership roles, and to talk, to speak on things and be a voice. Well, I have to tell you, after a while, this is pretty goddamn tiring for us to contain our disappointment, our anger, and our rage and still stay hopeful, optimistic, and still be a voice for those who are not able to speak.

Dr. Newsome: I agree that sometimes it can be tiring to have to take leadership roles and continue to talk about all these things, but I also feel that, at least for me, it gives me some sort of route to address the angst and do something with it. I believe all of us are just figuring out how to deal with these feelings that we shouldn’t have to feel because of a murder that was televised.

Dr. Norris: Thank you. For a murder that was televised; that was tweeted; that was broadbanded; that was streamed.

Now we’ve laid the framework, in terms of what we’re feeling. Let’s move on to why you and I are in this profession, and that’s our patients. What are you seeing on the front lines? What are you seeing with our patients?

Dr. Newsome: I was speaking with one of my black male patients, and he was fearful. He had been perfectly fine, even in the COVID crisis, he was doing well. But when you get this milieu of police violence, now he’s feeling this intense fear. Should I be walking alone at night? What happens if I am the one who is at the wrong place at the wrong time?

I also find that some of my nonminority patients sometimes find difficulty making sense of it. Minority individuals already know these things are happening. But some of the nonminorities are wondering how or why would something like this happen in America? This is just how America is for the black folks.

Dr. Norris: Could you elaborate on that? I always found that to be a very interesting dynamic for those who are not minorities or people of color. I will have folks in a psychotherapy session who are just bewildered by events like this. It is not the America they think they know – they are shocked that this is actually what’s going on.

Dr. Newsome: It’s all about experiences. If you didn’t grow up around a lot of minorities, you haven’t necessarily had these conversations. Even speaking for myself, sometimes I don’t want to discuss these things; you never know what you’re going to get. You might find an ally, or you might find someone who isn’t at all supportive. I think the surprise is from lack of exposure. If you don’t have to live through racism, you can most certainly have blinders on and not notice.

Dr. Norris: Can you comment on the fear you’re seeing in some folks? Can it get to the point of reactivating PTSD?

Dr. Newsome: I notice it more with black individuals, a fear that they might be the ones who may die; or with black mothers, wondering, what about my child? Is this what they are going to have to live with for the rest of their lives? Older people would say that we fought already and it’s still going on. What are the fruits of the labor we put in?

Dr. Norris: I agree with you completely. What are the fruits? You’re going to see those strong reactions. You’re going to see fear, you’re going to see anger, and you’re also going to see guilt that they could not stop this. I’m speaking particularly about some of my nonminority patients. It goes along with that confusion. This manifests in a desperate need to do something.

But here’s the problem: You don’t really know what to do because no one is educated on it. And as you said before, race is a very polarized subject. No one even likes to talk about racism because it’s so, oh my goodness. We’ve run away from it so much to the point that we can’t deal with it. Racism, whether or not you witness it, whether or not you participate in it, whether or not you are the subject of it, affects and hurts us all. We all have to start to own that. You can’t just stay siloed, because eventually, it’s going to come back and affect you.

I could easily be Mr. Floyd, but at the same time, due to my station and things of that nature, I have a certain level of privilege and autonomy. There could be a tendency to put your head under the sand, you know, look at how far we’ve come, Barack Obama. But you’ve got to say, no, we still have enormous amounts of work to do.

We’ve been talking about the patients. What have you noticed in your colleagues and how they’ve been feeling about this?

Dr. Newsome: Again, I see them feeling saddened by the events. One of the other things I’ve noticed is that some people are in environments where they have program directors and chairs who will directly condemn certain behaviors and say, “This is racist, this shouldn’t happen.” But then there are other programs that have been more silent. I’ve had people say that this is the first time that they have felt isolated in a long while.

We all participate in these physician WhatsApp groups, and according to some of the comments, people are realizing that these folks that they were just on the front lines with, fighting COVID, are perhaps not the allies that they originally thought they were, based on the things these people are saying.

Dr. Norris: Wow. It’s good that we’re talking about this from the viewpoint of two different generations. You’ve got the WhatsApp group and Google Hangouts and all that kind of good stuff, and I’m still with pagers and such. That’s interesting – the reality that folks you thought were your allies turn out not to be, because you’re bringing up difficult conversations that we don’t normally talk about.

I have noticed that some people around me have been silent because they don’t know what to say. They’re so concerned that I’m going to be offended or they’re going to hurt me or say the wrong thing, so they stay quiet. As I reflect now, this is the wrong thing to do. Own your concern. I’ve been in two large meetings now, and I’ve had multiple people whom I consider friends say, I wanted to email or text you right then and ask you how you’re doing, but I didn’t because I didn’t know what to say. I have entered meetings recently, and the meeting felt tense, and I’m thinking, what’s going on? And now I realize they did not know what to say or how to approach it.

That’s been a very interesting dynamic and tells us where we are with this. Today, for example, I was pleased to have the support of my dean’s group. I felt I had to speak out, I just had to straight out tell them. Do you want to know what I’m feeling? I’m feeling rage. I’m feeling rage. And you all have to understand that, because I have to speak for those who aren’t necessarily going to be able to express themselves. More importantly, I have to speak for myself and I’m feeling rage.

How our colleagues are processing this and how they’re thinking about this runs the gamut. But I think about people not necessarily knowing what to say or how to approach it. I absolutely agree that with the leadership, you’re going to get many different responses, and sometimes you’re left to wonder, do I have to watch what I say? But I’m definitely supported at my institution.

What else are you seeing out there in terms of your colleagues or how people think about it?

Dr. Newsome: This also spurs some folks to activism. Some have been participating in protests. There will be White Coats for Black Lives protests, among other things. So it’s spurred folks to action, and it’s also spurred folks to try to be part of a community. Of course, with the whole COVID crisis, we can’t necessarily come together, so we’ve been doing Zoom gatherings more than anything else. But it has encouraged folks to want to do that more, too, because they want to check in on their brother or their sister to make sure they are doing well, and also to be able to express what’s going on with them in a community where they know they can get validation.

Courtesy George Washington University Hospital Internal Medicine, Instagram @gtwon_medres

Dr. Norris: I’m going to push you a bit because I detect in your tone something similar to what I’m feeling. I just got the email, the White Coats For Black Lives email. But I think your feeling is similar to mine – I’ve done this before. I’ve done White Coats for Black Lives. You all may have protested. But this display in Washington, D.C., of the use of military and law enforcement to clear a public square of peaceful protesters is above and beyond the pale of anything I’ve ever seen in my life. We have to label that for the danger it is, for the threat to everything this country and the people that bled for this country stand for.

So while I’m going to participate in White Coats for Black Lives and many other things, I am looking for what is actually going to move the needle. I think the protests are great, but at this point in time I want institutions, I want money, I want lawyers, I want a systematic approach.

Dr. Newsome: I most certainly agree. Of course, the protests are really important, but depending on where you are, you have a different lens. As physicians, especially as black physicians, since there are so few of us, we have a unique opportunity to leverage that, whether that means communicating through op-eds or calling your senators and talking with them to try to move things forward.

Physicians are mobilizing. In the last few days, a physician created a Zoom event and hundreds of physicians joined to try to figure out how we can structurally fix this problem. So I most certainly believe that in this effort to address racism, we physicians will need to lend our voices and our privilege to move the needle as best we can.

Dr. Norris: Some of our colleagues in Black Psychiatrists of America have put out a press release on racism in which they propose some actions that should be taken immediately. I think this is a useful thing to talk about.

The first action: “Declare racism a public health problem and establish national goals for addressing this as a health equity issue. Give priority to addressing the issues of health care disparities, including the mental health needs of historically marginalized communities across the U.S.”

What do you think about that?

Dr. Newsome: Those are two extremely important steps. The question is: How do you make that happen?

Dr. Norris: You’re reading my mind. I love that our colleagues put that out there, but that was my next question.

Dr. Newsome: There is going to be a town hall about this and I’m hoping that we can plan how we envision this happening. I can imagine that 20 or 30 years ago there was also a fear in society that there would be episodes of police brutality. I can imagine that there were similar ideals and hopes. But I think we need to put all of our minds together and ask: How are we going to accomplish this? Is this going to be something we’re going to put our money into? Is this going to be something we’re going to get senators and legislatures onboard with to make policy?

Dr. Norris: Let me read off some of the other action points they put out. There are six of them.

“Establish a governmental multidisciplinary and ethnically diverse commission with representatives from the major health care professional associations in medicine, nursing, psychiatry, public health, psychology, social work, etc., and the faith-based community to provide recommendations to Congress regarding policies on how to best improve the health and well-being of our nation’s black citizens.”

That’s a very solid overall recommendation. My question is, doesn’t that, in some way, shape, or form already exist? Could we not put up policy statements from all of these folks regarding racism and things of that nature? I agree with what they’re saying, but part of me wonders why certain things in the current system aren’t working. That becomes the question. Are we not integrated enough? Do we not have enough cross talk? Do we not have enough money behind it? So I agree with that goal, but I would be curious if that doesn’t already exist. What are your thoughts about that, Dr. Newsome?

Dr. Newsome: I would imagine that the National Institute on Minority Mental Health and Health Disparities would have something similar. I believe one of the things you mentioned is really important. In addition to making these recommendations, we need to be looking at where these leaks are occurring that keep them from working. What is the current structure and why is it the way it is with regard to the governance?

Dr. Norris: Here is another of their action statements: “Declare ‘civic mental health’ a national priority and incorporate it into the educational curriculum from K through college, as well as in the training of local, state, and national officials, law enforcement, and the criminal justice system.”

Let me be clear, I like every single one of these action statements. I encourage everyone to participate in dialogue and discussion. You may agree with some of these, and some of them you may not, but if there is one you agree with, that you really are motivated about, that’s one that you need to explore and dig into a bit more, because it’s too big for us to handle on our own, just like racism and equality.

I’m going to tell you, I like this statement. I do like this. Obviously these are broad points, but I do like the idea of training law enforcement officers about “civic mental health.” For example, Dr. Michael Compton, who has done a lot of great work in the area of mental health and prevention, has worked with police officers to help them interact with those with mental health conditions by modulating their own emotional response. I’m very interested in these types of recommendations that particularly target law enforcement officers, and helping with that ”emotional quotient.” I’m interested in seeing how far that can spread in the country. What do you think, Dr. Newsome?

Dr. Newsome: Educating police officers about how to interact would be quite important. I believe the National Alliance on Mental Illness does some of that work, partnering with law enforcement agencies, talking about mental health and cues to look at. There also are some programs where people ride along with mental health clinicians and police officers, which I find to be really helpful. But clearly, what’s going on right now isn’t working. So I would be open to any reasonable idea.

Dr. Norris: Here’s one last action point: “Establish police community review boards with power to take action in areas of police misconduct pending formal review by the appropriate authorities. This will offer a level of empowerment when communities feel they have a voice that can be heard.”

This is where I want my focus to be, as I move forward to try to do something sustainable. To deal with police brutality and abuse of power in general, but specifically as it relates to African American men and the lethal use of force. We need to work on policies that will enable African American men to make it to court, so that every encounter with a police officer is not literally viewed as a potentially lethal encounter.

A lot of people aren’t going to like me saying that, but it’s the absolute truth. You have to think like that, as an African American male, regardless of your station, regardless of where you live, this is the reality. There are many, many good police officers out there. I have a few friends who are law enforcement officers. I work with security at the George Washington Hospital constantly. But that still does not change the fact that if I get pulled over at a traffic stop, I know precisely certain things I need to do and not do, or the encounter could end badly. By that I mean loss of life.

So I encourage anything where we can start to take a systematic look at law enforcement and empower communities to look at who is doing it right and who is doing it wrong. Information is coming out now about the man who murdered Mr. Floyd, and this was not the first time he was involved in misconduct. There were red flags; we have to start to confront this. We have to learn from every single one of these situations and grow because another one is going to happen next week, it’s just whether or not you hear about it. That’s the reality of the state of America. You may not like to hear it, but that’s just a fact.


To hear the entire conversation, go to mdedge.com/podcasts or listen wherever you find your podcasts.
 

On the Friday evening after the public execution of George Floyd, we were painfully reminded of the urgency to address the inadequate management of race, racism, and anti-blackness in medical education, residency training, and postgraduate continuing medical education.

The reminder did not originate from the rioting that was occurring in some cities, though we could feel the ground shifting beneath our feet as civic protests that began in U.S. cities spread around the globe. Instead, it occurred during a webinar we were hosting for psychiatry residents focused on techniques for eliminating blind spots in the management of race in clinical psychotherapy supervision. (Dr. Jessica Isom chaired the webinar, Dr. Flavia DeSouza and Dr. Myra Mathis comoderated, and Dr. Ebony Dennis and Dr. Constance E. Dunlap served as discussants.)

Our panel had presented an ambitious agenda that included reviewing how the disavowal of bias, race, racism, and anti-blackness contributes to ineffective psychotherapy, undermines the quality of medical care, and perpetuates mental health disparities. We spent some time exploring how unacknowledged and unexamined conscious and unconscious racial stereotypes affect interpersonal relationships, the psychotherapeutic process, and the supervisory experience. Our presentation included a clinical vignette demonstrating how racism, colorism, and anti-blackness have global impact, influencing the self-esteem, identity formation, and identity consolidation of immigrants as they grapple with the unique form of racism that exists in America. Other clinical vignettes demonstrated blind spots that were retroactively identified though omitted in supervisory discussions. We also discussed alternative interventions and interpretations of the material presented.^1-5

Because 21st-century trainees are generally psychologically astute and committed to social justice, we did two things. First, before the webinar, we provided them access to a prerecorded explanation of object relations theorist Melanie Klein’s paranoid-schizoid and depressive positions concepts, which were applied to theoretically explain the development of race, specifically the defenses used by early colonists that contributed to the development of “whiteness” and “blackness” as social constructs, and their influence on the development of the U.S. psyche. For example, as early colonists attempted to develop new and improved identities distinct from those they had in their homelands, they used enslaved black people (and other vulnerable groups) to “other.” What we mean here by othering is the process of using an other to project one’s badness into in order to relieve the self of uncomfortable aspects and feelings originating within the self. If this other accepts the projection (which is often the case with vulnerable parties), the self recognizes, that is, identifies (locates) the bad they just projected in the other, who is now experienced as a bad-other. This is projection in action. If the other accepts the projection and behaves accordingly, for example, in a manner that reflects badness, this becomes projective identification. Conversely, if the other does not accept these projections, the self (who projects) is left to cope with aspects of the self s/he might not have the capacity to manage. By capacity, we are speaking of the Bionian idea of the ability to experience an extreme emotion while also being able to think. Without the ego strength to cope with bad aspects of the self, the ego either collapses (and is unable to think) or further projection is attempted.^6-8

We have seen this latter dynamic play out repeatedly when police officers fatally shoot black citizens and then claim that they feared for their lives; these same officers have been exonerated by juries by continuing to portray the deceased victims as threatening, dangerous objects not worthy of living. We are also seeing a global movement of black and nonblack people who are in touch with a justified rage that has motivated them to return these projections by collectively protesting, and in some cases, by rioting.
 

Back to the webinar

In anticipating the residents’ curiosity, impatience, and anger about the lack of progress, the second thing we did was to show a segment from the “Black Psychoanalysts Speak” trailer. In the clip played, senior psychoanalyst Kirkland C. Vaughans, PhD, shares: “The issue of race so prompts excessive anxiety that it blocks off our ability to think.”

We showed this clip to validate the trainees’ frustrations about the difficulty the broader establishment has had with addressing this serious, longstanding public health problem. We wanted these young psychiatrists to know that there are psychoanalysts, psychiatrists, psychologists, and social workers who have been committed to this work, even though the contributions of this diverse group have curiously been omitted from education and training curricula.⁹

So, what happened? What was the painful reminder? After the formal panel presentations, a black male psychiatry resident recounted his experience in a clinical supervision meeting that had occurred several days after the murder of George Floyd. In short, a patient had shared his reactions to yet another incident of fatal police use of force and paused to ask how the resident physician, Dr. A., was doing. The question was experienced as sincere concern about the psychiatrist’s mental well-being. The resident was not sure how to answer this question since it was a matter of self-disclosure, which was a reasonable and thoughtful consideration for a seasoned clinician and, certainly, for a novice therapist. The supervisor, Dr. B., seemingly eager to move on, to not think about this, responded to the resident by saying: “Now tell me about the patient.” In other words, what had just been shared by the resident – material that featured a patient’s reaction to another killing of a black man by police and the patient’s expressed concern for his black psychiatrist, and this resident physician appropriately seeking space in supervision to process and receive guidance about how to respond – all of this was considered separate (split off from) and extraneous to the patient’s treatment and the resident’s training. This is a problem. And, unfortunately, this problem or some variation of it is not rare.

Why is this still the state of affairs when we have identified racism as a major health concern and our patients and our trainees are asking for help?
 

Rethinking a metaphor

Despite calls to action over the last 50 years to encourage medicine to effectively address race and racism, deficits remain in didactic education, clinical rotations, and supervisory experiences of trainees learning how to do psychodynamic psychotherapy.^8-10 Earlier that evening, we used the metaphor of a vehicular blind spot to capture what we believe occurs insupervision. Like drivers, supervisors generally have the ability to see. However, there are places (times) and positions (stances) that block their vision (awareness). Racism – whether institutionalized, interpersonally mediated, or internalized – also contributes to this blindness.

As is true of drivers managing a blind spot, what is required is for the drivers – the supervisors – to lean forward or reposition themselves so as to avoid collisions, maintain safety, and continue on course. We use this metaphor because it is understood that any clinician providing psychodynamic supervision to psychiatry residents, regardless of professional discipline, has the requisite skills and training.^10-13

Until May 25, we thought eliminating blind spots would be effective. But, in the aftermath of the police killing of George Floyd, our eyes have been opened.

We are encouraged by the global protests and initial actions to reform law enforcement, but we realize that medicine is in need of reform. Hiding behind the blue wall of silence is an establishment that has looked the other way while black and brown women, men, and children have come to live in fear as a result of the state-sanctioned violence that repeatedly occurs across the nation. Excessive police use of force is a public health issue of crisis magnitude. However, the house of medicine, like many other established structures in society, has colluded with the societal constructs that have supported law enforcement by remaining willfully blind, often neutral, and by refusing to make the necessary adjustments, including connecting the dots between police violence and physical and mental health.

For example, racism has never been listed even in the index of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders.¹⁴ Being the victim of police use of force is not generally regarded as an adverse childhood experience, even though communities that are heavily policed experience harassment by law enforcement on a regular basis. The 12 causes of trauma listed on the website¹⁵ of the National Child Traumatic Stress Network – bullying, community violence, complex trauma, disasters, early childhood trauma, intimate partner violence, medical trauma, physical abuse, refugee trauma, sexual abuse, terrorism and violence, and traumatic grief – do not include maltreatment, abuse, or trauma resulting from interactions with members of law enforcement. Much of the adverse childhood experiences literature focuses on white, upper middle class children and on experiences within the home. When community level experiences, such as discrimination based on race or ethnicity, are included, as in the Philadelphia ACES study,¹⁶ as many as 40% reported ACE scores of greater than 4 for community level exposures.

As psychiatrists, we recognize the psychic underpinnings and parallels between the psychic projections onto black and brown people and the actual bullets pumped into the bodies of black and brown people; there is a lurid propensity to use these others as repositories. Those who have the privilege of being protected by law enforcement and the ability to avoid being used as containers for the psychic projections and bullets of some police officers also have the privilege of compartmentalizing and looking the other way when excessive acts of force – projections and projectiles – are used on other human beings. This partly explains why the injuries and deaths of black and brown people caused by police officers’ excessive use of force have continued even though these unjustified deaths are widely televised and disseminated via various social media platforms.

Prior to the death of George Floyd on May 25, other than the American Public Health Association, the National Medical Association (NMA) was the only major medical organization to issue a call to consider police use of force as a public health issue. In its July 2016 press release, provided in the aftermath of the death of Freddie Gray while in the custody of Baltimore police officers, the NMA summarized the scope of injuries citizens sustain during “the pre-custody (commission of a crime, during a fight, chase, and apprehension, during a siege or hostage situation, or during restraint or submission), custody (soon after being admitted to jail, during interrogation, during incarceration, or legal execution), and post-custody (revenge by police or rival criminals or after reentry into the community)” periods. It is noteworthy that the scope of these injuries is comparable to those encountered in a combat zone.^17,18 According to the NMA:

“Injuries sustained by civilians at the hands of law enforcement include gunshot wounds, skull fractures, cervical spine injuries, facial fractures, broken legs, blunt trauma orbital floor fractures, laryngeal cartilage fractures, shoulder dislocations, cuts and bruises, concussions, hemorrhage, choking (positional or due to upper body holds), abdominal trauma, hemothorax, and pneumothorax. Complications of such injuries include posttraumatic brain swelling, infections following open fractures and lacerations, hydrocephalus due to blood or infection, as well as subdural and epidural hematomas and, in the most severe cases, death.”

In addition, there are multiple emotional and psychiatric sequelae of these injuries for the victims, families, upstanders, bystanders, and those viewing these images via various social media platforms. Increasingly, many are experiencing retraumatization each time a new death is reported. How do we explain that we are turning away from this as physicians and trainers of physicians? Seeing and not seeing – all of the methods used to avert one’s gaze and look the other way (to protect the psyches of nonmarginalized members of society from being disturbed and possibly traumatized) – these key defense mechanisms creep into consulting rooms and become fertile ground for the enactment described above.

Yet, there is reason to believe in change. It’s not simply because we are mental health professionals and that’s what we do. With the posting of position statements issued by major corporations and a growing number of medical organizations, many of us are experiencing a mixture of hope, anger, and sadness. Hope that widespread awareness will continue to tilt the axis of our country in a manner that opens eyes – and hearts – so that real work can be done; and anger and sadness because it has taken 400 years to receive even this level of validation.

In the meantime, we are encouraged by a joint position statement recently issued by the APA and the NMA, the first joint effort by these two medical organizations to partner and advocate for criminal justice reform. We mention this statement because the NMA has been committed to the needs of the black community since its inception in 1895, and the APA has as its mission a commitment to serve “the needs of evolving, diverse, underrepresented, and underserved patient populations” ... and the resources to do so. This is the kind of partnership that could transform words into meaningful action.^19,20

Of course, resident psychiatrist Dr. A. had begun supervision with the discussion of his dyadic experience with his patient, which is set in the context of a global coronavirus pandemic that is disproportionately affecting black and brown people. And, while his peers are marching in protest, he and his fellow trainees deserve our support as they deal with their own psychic pain and prepare to steady themselves. For these psychiatrists will be called to provide care to those who will consult them once they begin to grapple with the experiences and, in some cases, traumas that have compelled them to take action and literally risk their safety and lives while protesting.

That evening, the residents were hungry for methods to fill the gaps in their training and supervision. In some cases, we provided scripts to be taken back to supervision. For example, the following is a potential scripted response for the supervisor in the enactment described above:
 

Resident speaking to supervisor: This is a black patient who, like many others, is affected by the chronic, repeated televised images of black men killed by police. I am also a black man.

I think what I have shared is pertinent to the patient’s care and my experience as a black male psychiatrist who will need to learn how to address this in my patients who are black and for other racialized groups, as well as with whites who might have rarely been cared for by a black man. Can we discuss this?

We also anticipated that some residents would need to exercise their right to request reassignment to another supervisor. And, until we do better at listening, seeing, and deepening our understanding, outside and inside the consulting room and in supervision, more residents might need to steer around those who have the potential to undermine training and adversely affect treatment. But, as a professional medical community in crisis, do we really want to proceed in such an ad hoc fashion?
 

Dr. Dunlap is a psychiatrist and psychoanalyst, and clinical professor of psychiatry and behavioral sciences at George Washington University. She is interested in the management of “difference” – race, gender, ethnicity, and intersectionality – in dyadic relationships and group dynamics; and the impact of racism on interpersonal relationships in institutional structures. Dr. Dunlap practices in Washington and has no disclosures.

Dr. Dennis is a clinical psychologist and psychoanalyst. Her interests are in gender and ethnic diversity, health equity, and supervision and training. Dr. Dennis practices in Washington and has no disclosures.

Dr. DeSouza is a PGY-4 psychiatry resident and public psychiatry fellow in the department of psychiatry at Yale University, New Haven, Conn. Her professional interests include health services development and delivery in low- and middle-income settings, as well as the intersection of mental health and spirituality. She has no disclosures.

Dr. Isom is a staff psychiatrist at the Codman Square Health Center in Dorchester, Mass., and Boston Medical Center. Her interests include racial mental health equity and population health approaches to community psychiatry. She has no disclosures.

Dr. Mathis is an addictions fellow in the department of psychiatry at Yale University and former programwide chief resident at Yale. Her interests include the intersection of racial justice and mental health, health equity, and spirituality. She has no disclosures.

References

1. Mental Health: Culture, Race, and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md.: Substance Abuse and Mental Health Services Administration, 2001.

2. Banaji MR and Greenwald AG. Blindspot: Hidden Biases of Good People. New York: Delacorte Press, 2013.

3. Anekwe ON. Voices in Bioethics. 2014.

4. Soute BJ. The American Psychoanalyst Magazine. 2017 Winter/Spring.

5. Powell DR. J Am Psychoanal Assoc. 2019 Jan 8. doi: 10.1177/000306511881847.

6. Allen TW. The Invention of the White Race. London: Verso, 1994.

7. Klein M. Int J Psychoanal. 1946;27(pt.3-4):99-100.

8. Bion WR. (1962b). Psychoanal Q. 2013 Apr;82(2):301-10.

9. Black Psychoanalysts Speak trailer.

10. Thomas A and Sillen S. Racism and Psychiatry. New York: Brunner/Mazel, 1972.

11. Jones BE et al. Am J Psychiatry. 1970 Dec;127(6):798-803.

12. Sabshin M et al. Am J Psychiatry. 1970 Dec;126(6):787-93.

13. Medlock M et al. Am J Psychiatry. 2017 May 9. doi: 10.1176/appi.ajp-rj.2016.110206.

14. Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Arlington, Va.: American Psychiatric Association, 2013.

15. “What is Child Trauma?” The National Child Traumatic Stress Network.

16. The Philadelphia Project. Philadelphia ACE Survey.

17. “Addressing law enforcement violence as a public health issue.” Washington: American Public Health Association. 2018 Nov 13. Policy# 20811.

18. National Medical Association position statement on police use of force. NMA 2016.

19. “APA and NMA jointly condemn systemic racism in America.” 2020 Jun 16.

20. APA Strategic Plan. 2015 Mar.

On the Friday evening after the public execution of George Floyd, we were painfully reminded of the urgency to address the inadequate management of race, racism, and anti-blackness in medical education, residency training, and postgraduate continuing medical education.

The reminder did not originate from the rioting that was occurring in some cities, though we could feel the ground shifting beneath our feet as civic protests that began in U.S. cities spread around the globe. Instead, it occurred during a webinar we were hosting for psychiatry residents focused on techniques for eliminating blind spots in the management of race in clinical psychotherapy supervision. (Dr. Jessica Isom chaired the webinar, Dr. Flavia DeSouza and Dr. Myra Mathis comoderated, and Dr. Ebony Dennis and Dr. Constance E. Dunlap served as discussants.)

Our panel had presented an ambitious agenda that included reviewing how the disavowal of bias, race, racism, and anti-blackness contributes to ineffective psychotherapy, undermines the quality of medical care, and perpetuates mental health disparities. We spent some time exploring how unacknowledged and unexamined conscious and unconscious racial stereotypes affect interpersonal relationships, the psychotherapeutic process, and the supervisory experience. Our presentation included a clinical vignette demonstrating how racism, colorism, and anti-blackness have global impact, influencing the self-esteem, identity formation, and identity consolidation of immigrants as they grapple with the unique form of racism that exists in America. Other clinical vignettes demonstrated blind spots that were retroactively identified though omitted in supervisory discussions. We also discussed alternative interventions and interpretations of the material presented.^1-5

Because 21st-century trainees are generally psychologically astute and committed to social justice, we did two things. First, before the webinar, we provided them access to a prerecorded explanation of object relations theorist Melanie Klein’s paranoid-schizoid and depressive positions concepts, which were applied to theoretically explain the development of race, specifically the defenses used by early colonists that contributed to the development of “whiteness” and “blackness” as social constructs, and their influence on the development of the U.S. psyche. For example, as early colonists attempted to develop new and improved identities distinct from those they had in their homelands, they used enslaved black people (and other vulnerable groups) to “other.” What we mean here by othering is the process of using an other to project one’s badness into in order to relieve the self of uncomfortable aspects and feelings originating within the self. If this other accepts the projection (which is often the case with vulnerable parties), the self recognizes, that is, identifies (locates) the bad they just projected in the other, who is now experienced as a bad-other. This is projection in action. If the other accepts the projection and behaves accordingly, for example, in a manner that reflects badness, this becomes projective identification. Conversely, if the other does not accept these projections, the self (who projects) is left to cope with aspects of the self s/he might not have the capacity to manage. By capacity, we are speaking of the Bionian idea of the ability to experience an extreme emotion while also being able to think. Without the ego strength to cope with bad aspects of the self, the ego either collapses (and is unable to think) or further projection is attempted.^6-8

We have seen this latter dynamic play out repeatedly when police officers fatally shoot black citizens and then claim that they feared for their lives; these same officers have been exonerated by juries by continuing to portray the deceased victims as threatening, dangerous objects not worthy of living. We are also seeing a global movement of black and nonblack people who are in touch with a justified rage that has motivated them to return these projections by collectively protesting, and in some cases, by rioting.
 

Back to the webinar

In anticipating the residents’ curiosity, impatience, and anger about the lack of progress, the second thing we did was to show a segment from the “Black Psychoanalysts Speak” trailer. In the clip played, senior psychoanalyst Kirkland C. Vaughans, PhD, shares: “The issue of race so prompts excessive anxiety that it blocks off our ability to think.”

We showed this clip to validate the trainees’ frustrations about the difficulty the broader establishment has had with addressing this serious, longstanding public health problem. We wanted these young psychiatrists to know that there are psychoanalysts, psychiatrists, psychologists, and social workers who have been committed to this work, even though the contributions of this diverse group have curiously been omitted from education and training curricula.⁹

So, what happened? What was the painful reminder? After the formal panel presentations, a black male psychiatry resident recounted his experience in a clinical supervision meeting that had occurred several days after the murder of George Floyd. In short, a patient had shared his reactions to yet another incident of fatal police use of force and paused to ask how the resident physician, Dr. A., was doing. The question was experienced as sincere concern about the psychiatrist’s mental well-being. The resident was not sure how to answer this question since it was a matter of self-disclosure, which was a reasonable and thoughtful consideration for a seasoned clinician and, certainly, for a novice therapist. The supervisor, Dr. B., seemingly eager to move on, to not think about this, responded to the resident by saying: “Now tell me about the patient.” In other words, what had just been shared by the resident – material that featured a patient’s reaction to another killing of a black man by police and the patient’s expressed concern for his black psychiatrist, and this resident physician appropriately seeking space in supervision to process and receive guidance about how to respond – all of this was considered separate (split off from) and extraneous to the patient’s treatment and the resident’s training. This is a problem. And, unfortunately, this problem or some variation of it is not rare.

Why is this still the state of affairs when we have identified racism as a major health concern and our patients and our trainees are asking for help?
 

Rethinking a metaphor

Despite calls to action over the last 50 years to encourage medicine to effectively address race and racism, deficits remain in didactic education, clinical rotations, and supervisory experiences of trainees learning how to do psychodynamic psychotherapy.^8-10 Earlier that evening, we used the metaphor of a vehicular blind spot to capture what we believe occurs insupervision. Like drivers, supervisors generally have the ability to see. However, there are places (times) and positions (stances) that block their vision (awareness). Racism – whether institutionalized, interpersonally mediated, or internalized – also contributes to this blindness.

As is true of drivers managing a blind spot, what is required is for the drivers – the supervisors – to lean forward or reposition themselves so as to avoid collisions, maintain safety, and continue on course. We use this metaphor because it is understood that any clinician providing psychodynamic supervision to psychiatry residents, regardless of professional discipline, has the requisite skills and training.^10-13

Until May 25, we thought eliminating blind spots would be effective. But, in the aftermath of the police killing of George Floyd, our eyes have been opened.

We are encouraged by the global protests and initial actions to reform law enforcement, but we realize that medicine is in need of reform. Hiding behind the blue wall of silence is an establishment that has looked the other way while black and brown women, men, and children have come to live in fear as a result of the state-sanctioned violence that repeatedly occurs across the nation. Excessive police use of force is a public health issue of crisis magnitude. However, the house of medicine, like many other established structures in society, has colluded with the societal constructs that have supported law enforcement by remaining willfully blind, often neutral, and by refusing to make the necessary adjustments, including connecting the dots between police violence and physical and mental health.

For example, racism has never been listed even in the index of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders.¹⁴ Being the victim of police use of force is not generally regarded as an adverse childhood experience, even though communities that are heavily policed experience harassment by law enforcement on a regular basis. The 12 causes of trauma listed on the website¹⁵ of the National Child Traumatic Stress Network – bullying, community violence, complex trauma, disasters, early childhood trauma, intimate partner violence, medical trauma, physical abuse, refugee trauma, sexual abuse, terrorism and violence, and traumatic grief – do not include maltreatment, abuse, or trauma resulting from interactions with members of law enforcement. Much of the adverse childhood experiences literature focuses on white, upper middle class children and on experiences within the home. When community level experiences, such as discrimination based on race or ethnicity, are included, as in the Philadelphia ACES study,¹⁶ as many as 40% reported ACE scores of greater than 4 for community level exposures.

As psychiatrists, we recognize the psychic underpinnings and parallels between the psychic projections onto black and brown people and the actual bullets pumped into the bodies of black and brown people; there is a lurid propensity to use these others as repositories. Those who have the privilege of being protected by law enforcement and the ability to avoid being used as containers for the psychic projections and bullets of some police officers also have the privilege of compartmentalizing and looking the other way when excessive acts of force – projections and projectiles – are used on other human beings. This partly explains why the injuries and deaths of black and brown people caused by police officers’ excessive use of force have continued even though these unjustified deaths are widely televised and disseminated via various social media platforms.

Prior to the death of George Floyd on May 25, other than the American Public Health Association, the National Medical Association (NMA) was the only major medical organization to issue a call to consider police use of force as a public health issue. In its July 2016 press release, provided in the aftermath of the death of Freddie Gray while in the custody of Baltimore police officers, the NMA summarized the scope of injuries citizens sustain during “the pre-custody (commission of a crime, during a fight, chase, and apprehension, during a siege or hostage situation, or during restraint or submission), custody (soon after being admitted to jail, during interrogation, during incarceration, or legal execution), and post-custody (revenge by police or rival criminals or after reentry into the community)” periods. It is noteworthy that the scope of these injuries is comparable to those encountered in a combat zone.^17,18 According to the NMA:

“Injuries sustained by civilians at the hands of law enforcement include gunshot wounds, skull fractures, cervical spine injuries, facial fractures, broken legs, blunt trauma orbital floor fractures, laryngeal cartilage fractures, shoulder dislocations, cuts and bruises, concussions, hemorrhage, choking (positional or due to upper body holds), abdominal trauma, hemothorax, and pneumothorax. Complications of such injuries include posttraumatic brain swelling, infections following open fractures and lacerations, hydrocephalus due to blood or infection, as well as subdural and epidural hematomas and, in the most severe cases, death.”

In addition, there are multiple emotional and psychiatric sequelae of these injuries for the victims, families, upstanders, bystanders, and those viewing these images via various social media platforms. Increasingly, many are experiencing retraumatization each time a new death is reported. How do we explain that we are turning away from this as physicians and trainers of physicians? Seeing and not seeing – all of the methods used to avert one’s gaze and look the other way (to protect the psyches of nonmarginalized members of society from being disturbed and possibly traumatized) – these key defense mechanisms creep into consulting rooms and become fertile ground for the enactment described above.

Yet, there is reason to believe in change. It’s not simply because we are mental health professionals and that’s what we do. With the posting of position statements issued by major corporations and a growing number of medical organizations, many of us are experiencing a mixture of hope, anger, and sadness. Hope that widespread awareness will continue to tilt the axis of our country in a manner that opens eyes – and hearts – so that real work can be done; and anger and sadness because it has taken 400 years to receive even this level of validation.

In the meantime, we are encouraged by a joint position statement recently issued by the APA and the NMA, the first joint effort by these two medical organizations to partner and advocate for criminal justice reform. We mention this statement because the NMA has been committed to the needs of the black community since its inception in 1895, and the APA has as its mission a commitment to serve “the needs of evolving, diverse, underrepresented, and underserved patient populations” ... and the resources to do so. This is the kind of partnership that could transform words into meaningful action.^19,20

Of course, resident psychiatrist Dr. A. had begun supervision with the discussion of his dyadic experience with his patient, which is set in the context of a global coronavirus pandemic that is disproportionately affecting black and brown people. And, while his peers are marching in protest, he and his fellow trainees deserve our support as they deal with their own psychic pain and prepare to steady themselves. For these psychiatrists will be called to provide care to those who will consult them once they begin to grapple with the experiences and, in some cases, traumas that have compelled them to take action and literally risk their safety and lives while protesting.

That evening, the residents were hungry for methods to fill the gaps in their training and supervision. In some cases, we provided scripts to be taken back to supervision. For example, the following is a potential scripted response for the supervisor in the enactment described above:
 

Resident speaking to supervisor: This is a black patient who, like many others, is affected by the chronic, repeated televised images of black men killed by police. I am also a black man.

I think what I have shared is pertinent to the patient’s care and my experience as a black male psychiatrist who will need to learn how to address this in my patients who are black and for other racialized groups, as well as with whites who might have rarely been cared for by a black man. Can we discuss this?

We also anticipated that some residents would need to exercise their right to request reassignment to another supervisor. And, until we do better at listening, seeing, and deepening our understanding, outside and inside the consulting room and in supervision, more residents might need to steer around those who have the potential to undermine training and adversely affect treatment. But, as a professional medical community in crisis, do we really want to proceed in such an ad hoc fashion?
 

Dr. Dunlap is a psychiatrist and psychoanalyst, and clinical professor of psychiatry and behavioral sciences at George Washington University. She is interested in the management of “difference” – race, gender, ethnicity, and intersectionality – in dyadic relationships and group dynamics; and the impact of racism on interpersonal relationships in institutional structures. Dr. Dunlap practices in Washington and has no disclosures.

Dr. Dennis is a clinical psychologist and psychoanalyst. Her interests are in gender and ethnic diversity, health equity, and supervision and training. Dr. Dennis practices in Washington and has no disclosures.

Dr. DeSouza is a PGY-4 psychiatry resident and public psychiatry fellow in the department of psychiatry at Yale University, New Haven, Conn. Her professional interests include health services development and delivery in low- and middle-income settings, as well as the intersection of mental health and spirituality. She has no disclosures.

Dr. Isom is a staff psychiatrist at the Codman Square Health Center in Dorchester, Mass., and Boston Medical Center. Her interests include racial mental health equity and population health approaches to community psychiatry. She has no disclosures.

Dr. Mathis is an addictions fellow in the department of psychiatry at Yale University and former programwide chief resident at Yale. Her interests include the intersection of racial justice and mental health, health equity, and spirituality. She has no disclosures.

References

1. Mental Health: Culture, Race, and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md.: Substance Abuse and Mental Health Services Administration, 2001.

2. Banaji MR and Greenwald AG. Blindspot: Hidden Biases of Good People. New York: Delacorte Press, 2013.

3. Anekwe ON. Voices in Bioethics. 2014.

4. Soute BJ. The American Psychoanalyst Magazine. 2017 Winter/Spring.

5. Powell DR. J Am Psychoanal Assoc. 2019 Jan 8. doi: 10.1177/000306511881847.

6. Allen TW. The Invention of the White Race. London: Verso, 1994.

7. Klein M. Int J Psychoanal. 1946;27(pt.3-4):99-100.

8. Bion WR. (1962b). Psychoanal Q. 2013 Apr;82(2):301-10.

9. Black Psychoanalysts Speak trailer.

10. Thomas A and Sillen S. Racism and Psychiatry. New York: Brunner/Mazel, 1972.

11. Jones BE et al. Am J Psychiatry. 1970 Dec;127(6):798-803.

12. Sabshin M et al. Am J Psychiatry. 1970 Dec;126(6):787-93.

13. Medlock M et al. Am J Psychiatry. 2017 May 9. doi: 10.1176/appi.ajp-rj.2016.110206.

14. Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Arlington, Va.: American Psychiatric Association, 2013.

15. “What is Child Trauma?” The National Child Traumatic Stress Network.

16. The Philadelphia Project. Philadelphia ACE Survey.

17. “Addressing law enforcement violence as a public health issue.” Washington: American Public Health Association. 2018 Nov 13. Policy# 20811.

18. National Medical Association position statement on police use of force. NMA 2016.

19. “APA and NMA jointly condemn systemic racism in America.” 2020 Jun 16.

20. APA Strategic Plan. 2015 Mar.

On the Friday evening after the public execution of George Floyd, we were painfully reminded of the urgency to address the inadequate management of race, racism, and anti-blackness in medical education, residency training, and postgraduate continuing medical education.

The reminder did not originate from the rioting that was occurring in some cities, though we could feel the ground shifting beneath our feet as civic protests that began in U.S. cities spread around the globe. Instead, it occurred during a webinar we were hosting for psychiatry residents focused on techniques for eliminating blind spots in the management of race in clinical psychotherapy supervision. (Dr. Jessica Isom chaired the webinar, Dr. Flavia DeSouza and Dr. Myra Mathis comoderated, and Dr. Ebony Dennis and Dr. Constance E. Dunlap served as discussants.)

Our panel had presented an ambitious agenda that included reviewing how the disavowal of bias, race, racism, and anti-blackness contributes to ineffective psychotherapy, undermines the quality of medical care, and perpetuates mental health disparities. We spent some time exploring how unacknowledged and unexamined conscious and unconscious racial stereotypes affect interpersonal relationships, the psychotherapeutic process, and the supervisory experience. Our presentation included a clinical vignette demonstrating how racism, colorism, and anti-blackness have global impact, influencing the self-esteem, identity formation, and identity consolidation of immigrants as they grapple with the unique form of racism that exists in America. Other clinical vignettes demonstrated blind spots that were retroactively identified though omitted in supervisory discussions. We also discussed alternative interventions and interpretations of the material presented.^1-5

Because 21st-century trainees are generally psychologically astute and committed to social justice, we did two things. First, before the webinar, we provided them access to a prerecorded explanation of object relations theorist Melanie Klein’s paranoid-schizoid and depressive positions concepts, which were applied to theoretically explain the development of race, specifically the defenses used by early colonists that contributed to the development of “whiteness” and “blackness” as social constructs, and their influence on the development of the U.S. psyche. For example, as early colonists attempted to develop new and improved identities distinct from those they had in their homelands, they used enslaved black people (and other vulnerable groups) to “other.” What we mean here by othering is the process of using an other to project one’s badness into in order to relieve the self of uncomfortable aspects and feelings originating within the self. If this other accepts the projection (which is often the case with vulnerable parties), the self recognizes, that is, identifies (locates) the bad they just projected in the other, who is now experienced as a bad-other. This is projection in action. If the other accepts the projection and behaves accordingly, for example, in a manner that reflects badness, this becomes projective identification. Conversely, if the other does not accept these projections, the self (who projects) is left to cope with aspects of the self s/he might not have the capacity to manage. By capacity, we are speaking of the Bionian idea of the ability to experience an extreme emotion while also being able to think. Without the ego strength to cope with bad aspects of the self, the ego either collapses (and is unable to think) or further projection is attempted.^6-8

We have seen this latter dynamic play out repeatedly when police officers fatally shoot black citizens and then claim that they feared for their lives; these same officers have been exonerated by juries by continuing to portray the deceased victims as threatening, dangerous objects not worthy of living. We are also seeing a global movement of black and nonblack people who are in touch with a justified rage that has motivated them to return these projections by collectively protesting, and in some cases, by rioting.
 

Back to the webinar

In anticipating the residents’ curiosity, impatience, and anger about the lack of progress, the second thing we did was to show a segment from the “Black Psychoanalysts Speak” trailer. In the clip played, senior psychoanalyst Kirkland C. Vaughans, PhD, shares: “The issue of race so prompts excessive anxiety that it blocks off our ability to think.”

We showed this clip to validate the trainees’ frustrations about the difficulty the broader establishment has had with addressing this serious, longstanding public health problem. We wanted these young psychiatrists to know that there are psychoanalysts, psychiatrists, psychologists, and social workers who have been committed to this work, even though the contributions of this diverse group have curiously been omitted from education and training curricula.⁹

So, what happened? What was the painful reminder? After the formal panel presentations, a black male psychiatry resident recounted his experience in a clinical supervision meeting that had occurred several days after the murder of George Floyd. In short, a patient had shared his reactions to yet another incident of fatal police use of force and paused to ask how the resident physician, Dr. A., was doing. The question was experienced as sincere concern about the psychiatrist’s mental well-being. The resident was not sure how to answer this question since it was a matter of self-disclosure, which was a reasonable and thoughtful consideration for a seasoned clinician and, certainly, for a novice therapist. The supervisor, Dr. B., seemingly eager to move on, to not think about this, responded to the resident by saying: “Now tell me about the patient.” In other words, what had just been shared by the resident – material that featured a patient’s reaction to another killing of a black man by police and the patient’s expressed concern for his black psychiatrist, and this resident physician appropriately seeking space in supervision to process and receive guidance about how to respond – all of this was considered separate (split off from) and extraneous to the patient’s treatment and the resident’s training. This is a problem. And, unfortunately, this problem or some variation of it is not rare.

Why is this still the state of affairs when we have identified racism as a major health concern and our patients and our trainees are asking for help?
 

Rethinking a metaphor

Despite calls to action over the last 50 years to encourage medicine to effectively address race and racism, deficits remain in didactic education, clinical rotations, and supervisory experiences of trainees learning how to do psychodynamic psychotherapy.^8-10 Earlier that evening, we used the metaphor of a vehicular blind spot to capture what we believe occurs insupervision. Like drivers, supervisors generally have the ability to see. However, there are places (times) and positions (stances) that block their vision (awareness). Racism – whether institutionalized, interpersonally mediated, or internalized – also contributes to this blindness.

As is true of drivers managing a blind spot, what is required is for the drivers – the supervisors – to lean forward or reposition themselves so as to avoid collisions, maintain safety, and continue on course. We use this metaphor because it is understood that any clinician providing psychodynamic supervision to psychiatry residents, regardless of professional discipline, has the requisite skills and training.^10-13

Until May 25, we thought eliminating blind spots would be effective. But, in the aftermath of the police killing of George Floyd, our eyes have been opened.

We are encouraged by the global protests and initial actions to reform law enforcement, but we realize that medicine is in need of reform. Hiding behind the blue wall of silence is an establishment that has looked the other way while black and brown women, men, and children have come to live in fear as a result of the state-sanctioned violence that repeatedly occurs across the nation. Excessive police use of force is a public health issue of crisis magnitude. However, the house of medicine, like many other established structures in society, has colluded with the societal constructs that have supported law enforcement by remaining willfully blind, often neutral, and by refusing to make the necessary adjustments, including connecting the dots between police violence and physical and mental health.

For example, racism has never been listed even in the index of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders.¹⁴ Being the victim of police use of force is not generally regarded as an adverse childhood experience, even though communities that are heavily policed experience harassment by law enforcement on a regular basis. The 12 causes of trauma listed on the website¹⁵ of the National Child Traumatic Stress Network – bullying, community violence, complex trauma, disasters, early childhood trauma, intimate partner violence, medical trauma, physical abuse, refugee trauma, sexual abuse, terrorism and violence, and traumatic grief – do not include maltreatment, abuse, or trauma resulting from interactions with members of law enforcement. Much of the adverse childhood experiences literature focuses on white, upper middle class children and on experiences within the home. When community level experiences, such as discrimination based on race or ethnicity, are included, as in the Philadelphia ACES study,¹⁶ as many as 40% reported ACE scores of greater than 4 for community level exposures.

As psychiatrists, we recognize the psychic underpinnings and parallels between the psychic projections onto black and brown people and the actual bullets pumped into the bodies of black and brown people; there is a lurid propensity to use these others as repositories. Those who have the privilege of being protected by law enforcement and the ability to avoid being used as containers for the psychic projections and bullets of some police officers also have the privilege of compartmentalizing and looking the other way when excessive acts of force – projections and projectiles – are used on other human beings. This partly explains why the injuries and deaths of black and brown people caused by police officers’ excessive use of force have continued even though these unjustified deaths are widely televised and disseminated via various social media platforms.

Prior to the death of George Floyd on May 25, other than the American Public Health Association, the National Medical Association (NMA) was the only major medical organization to issue a call to consider police use of force as a public health issue. In its July 2016 press release, provided in the aftermath of the death of Freddie Gray while in the custody of Baltimore police officers, the NMA summarized the scope of injuries citizens sustain during “the pre-custody (commission of a crime, during a fight, chase, and apprehension, during a siege or hostage situation, or during restraint or submission), custody (soon after being admitted to jail, during interrogation, during incarceration, or legal execution), and post-custody (revenge by police or rival criminals or after reentry into the community)” periods. It is noteworthy that the scope of these injuries is comparable to those encountered in a combat zone.^17,18 According to the NMA:

“Injuries sustained by civilians at the hands of law enforcement include gunshot wounds, skull fractures, cervical spine injuries, facial fractures, broken legs, blunt trauma orbital floor fractures, laryngeal cartilage fractures, shoulder dislocations, cuts and bruises, concussions, hemorrhage, choking (positional or due to upper body holds), abdominal trauma, hemothorax, and pneumothorax. Complications of such injuries include posttraumatic brain swelling, infections following open fractures and lacerations, hydrocephalus due to blood or infection, as well as subdural and epidural hematomas and, in the most severe cases, death.”

In addition, there are multiple emotional and psychiatric sequelae of these injuries for the victims, families, upstanders, bystanders, and those viewing these images via various social media platforms. Increasingly, many are experiencing retraumatization each time a new death is reported. How do we explain that we are turning away from this as physicians and trainers of physicians? Seeing and not seeing – all of the methods used to avert one’s gaze and look the other way (to protect the psyches of nonmarginalized members of society from being disturbed and possibly traumatized) – these key defense mechanisms creep into consulting rooms and become fertile ground for the enactment described above.

Yet, there is reason to believe in change. It’s not simply because we are mental health professionals and that’s what we do. With the posting of position statements issued by major corporations and a growing number of medical organizations, many of us are experiencing a mixture of hope, anger, and sadness. Hope that widespread awareness will continue to tilt the axis of our country in a manner that opens eyes – and hearts – so that real work can be done; and anger and sadness because it has taken 400 years to receive even this level of validation.

In the meantime, we are encouraged by a joint position statement recently issued by the APA and the NMA, the first joint effort by these two medical organizations to partner and advocate for criminal justice reform. We mention this statement because the NMA has been committed to the needs of the black community since its inception in 1895, and the APA has as its mission a commitment to serve “the needs of evolving, diverse, underrepresented, and underserved patient populations” ... and the resources to do so. This is the kind of partnership that could transform words into meaningful action.^19,20

Of course, resident psychiatrist Dr. A. had begun supervision with the discussion of his dyadic experience with his patient, which is set in the context of a global coronavirus pandemic that is disproportionately affecting black and brown people. And, while his peers are marching in protest, he and his fellow trainees deserve our support as they deal with their own psychic pain and prepare to steady themselves. For these psychiatrists will be called to provide care to those who will consult them once they begin to grapple with the experiences and, in some cases, traumas that have compelled them to take action and literally risk their safety and lives while protesting.

That evening, the residents were hungry for methods to fill the gaps in their training and supervision. In some cases, we provided scripts to be taken back to supervision. For example, the following is a potential scripted response for the supervisor in the enactment described above:
 

Resident speaking to supervisor: This is a black patient who, like many others, is affected by the chronic, repeated televised images of black men killed by police. I am also a black man.

I think what I have shared is pertinent to the patient’s care and my experience as a black male psychiatrist who will need to learn how to address this in my patients who are black and for other racialized groups, as well as with whites who might have rarely been cared for by a black man. Can we discuss this?

We also anticipated that some residents would need to exercise their right to request reassignment to another supervisor. And, until we do better at listening, seeing, and deepening our understanding, outside and inside the consulting room and in supervision, more residents might need to steer around those who have the potential to undermine training and adversely affect treatment. But, as a professional medical community in crisis, do we really want to proceed in such an ad hoc fashion?
 

Dr. Dunlap is a psychiatrist and psychoanalyst, and clinical professor of psychiatry and behavioral sciences at George Washington University. She is interested in the management of “difference” – race, gender, ethnicity, and intersectionality – in dyadic relationships and group dynamics; and the impact of racism on interpersonal relationships in institutional structures. Dr. Dunlap practices in Washington and has no disclosures.

Dr. Dennis is a clinical psychologist and psychoanalyst. Her interests are in gender and ethnic diversity, health equity, and supervision and training. Dr. Dennis practices in Washington and has no disclosures.

Dr. DeSouza is a PGY-4 psychiatry resident and public psychiatry fellow in the department of psychiatry at Yale University, New Haven, Conn. Her professional interests include health services development and delivery in low- and middle-income settings, as well as the intersection of mental health and spirituality. She has no disclosures.

Dr. Isom is a staff psychiatrist at the Codman Square Health Center in Dorchester, Mass., and Boston Medical Center. Her interests include racial mental health equity and population health approaches to community psychiatry. She has no disclosures.

Dr. Mathis is an addictions fellow in the department of psychiatry at Yale University and former programwide chief resident at Yale. Her interests include the intersection of racial justice and mental health, health equity, and spirituality. She has no disclosures.

References

1. Mental Health: Culture, Race, and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md.: Substance Abuse and Mental Health Services Administration, 2001.

2. Banaji MR and Greenwald AG. Blindspot: Hidden Biases of Good People. New York: Delacorte Press, 2013.

3. Anekwe ON. Voices in Bioethics. 2014.

4. Soute BJ. The American Psychoanalyst Magazine. 2017 Winter/Spring.

5. Powell DR. J Am Psychoanal Assoc. 2019 Jan 8. doi: 10.1177/000306511881847.

6. Allen TW. The Invention of the White Race. London: Verso, 1994.

7. Klein M. Int J Psychoanal. 1946;27(pt.3-4):99-100.

8. Bion WR. (1962b). Psychoanal Q. 2013 Apr;82(2):301-10.

9. Black Psychoanalysts Speak trailer.

10. Thomas A and Sillen S. Racism and Psychiatry. New York: Brunner/Mazel, 1972.

11. Jones BE et al. Am J Psychiatry. 1970 Dec;127(6):798-803.

12. Sabshin M et al. Am J Psychiatry. 1970 Dec;126(6):787-93.

13. Medlock M et al. Am J Psychiatry. 2017 May 9. doi: 10.1176/appi.ajp-rj.2016.110206.

14. Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Arlington, Va.: American Psychiatric Association, 2013.

15. “What is Child Trauma?” The National Child Traumatic Stress Network.

16. The Philadelphia Project. Philadelphia ACE Survey.

17. “Addressing law enforcement violence as a public health issue.” Washington: American Public Health Association. 2018 Nov 13. Policy# 20811.

18. National Medical Association position statement on police use of force. NMA 2016.

19. “APA and NMA jointly condemn systemic racism in America.” 2020 Jun 16.

20. APA Strategic Plan. 2015 Mar.

Prominent female physicians are handing over their social media platforms today to black female physicians as part of a campaign called #ShareTheMicNowMed.

The social media event, which will play out on both Twitter and Instagram, is an offshoot of #ShareTheMicNow, held earlier this month. For that event, more than 90 women, including A-list celebrities like Ellen DeGeneres, Julia Roberts, and Senator Elizabeth Warren, swapped accounts with women of color, such as “I’m Still Here” author Austin Channing Brown, Olympic fencer Ibtihaj Muhammad, and #MeToo founder Tarana Burke.

The physician event will feature 10 teams of two, with one physician handing over her account to her black female counterpart for the day. The takeover will allow the black physician to share her thoughts about the successes and challenges she faces as a woman of color in medicine.

“It was such an honor to be contacted by Arghavan Salles, MD, PhD, to participate in an event that has a goal of connecting like-minded women from various backgrounds to share a diverse perspective with a different audience,” Minnesota family medicine physician Jay-Sheree Allen, MD, told Medscape Medical News. “This event is not only incredibly important but timely.”

Participants say the goal of the takeovers is to amplify the reach and voice of black women in medicine while crossing boundaries and empowering others to do the same. Only about 5% of all active physicians in 2018 identified as Black or African American, according to a report by the Association of American Medical Colleges. And of those, just over a third are female, the report found.

“I think that as we hear those small numbers we often celebrate the success of those people without looking back and understanding where all of the barriers are that are limiting talented black women from entering medicine at every stage,” another campaign participant, Chicago pediatrician Rebekah Fenton, MD, told Medscape Medical News.

Allen says that, amid continuing worldwide protests over racial injustice, prompted by the death of George Floyd while in Minneapolis police custody last month, the online event is very timely and an important way to advocate for black lives and engage in a productive conversation.

Prominent female physicians are handing over their social media platforms today to black female physicians as part of a campaign called #ShareTheMicNowMed.

The social media event, which will play out on both Twitter and Instagram, is an offshoot of #ShareTheMicNow, held earlier this month. For that event, more than 90 women, including A-list celebrities like Ellen DeGeneres, Julia Roberts, and Senator Elizabeth Warren, swapped accounts with women of color, such as “I’m Still Here” author Austin Channing Brown, Olympic fencer Ibtihaj Muhammad, and #MeToo founder Tarana Burke.

The physician event will feature 10 teams of two, with one physician handing over her account to her black female counterpart for the day. The takeover will allow the black physician to share her thoughts about the successes and challenges she faces as a woman of color in medicine.

“It was such an honor to be contacted by Arghavan Salles, MD, PhD, to participate in an event that has a goal of connecting like-minded women from various backgrounds to share a diverse perspective with a different audience,” Minnesota family medicine physician Jay-Sheree Allen, MD, told Medscape Medical News. “This event is not only incredibly important but timely.”

Participants say the goal of the takeovers is to amplify the reach and voice of black women in medicine while crossing boundaries and empowering others to do the same. Only about 5% of all active physicians in 2018 identified as Black or African American, according to a report by the Association of American Medical Colleges. And of those, just over a third are female, the report found.

“I think that as we hear those small numbers we often celebrate the success of those people without looking back and understanding where all of the barriers are that are limiting talented black women from entering medicine at every stage,” another campaign participant, Chicago pediatrician Rebekah Fenton, MD, told Medscape Medical News.

Allen says that, amid continuing worldwide protests over racial injustice, prompted by the death of George Floyd while in Minneapolis police custody last month, the online event is very timely and an important way to advocate for black lives and engage in a productive conversation.

Prominent female physicians are handing over their social media platforms today to black female physicians as part of a campaign called #ShareTheMicNowMed.

The social media event, which will play out on both Twitter and Instagram, is an offshoot of #ShareTheMicNow, held earlier this month. For that event, more than 90 women, including A-list celebrities like Ellen DeGeneres, Julia Roberts, and Senator Elizabeth Warren, swapped accounts with women of color, such as “I’m Still Here” author Austin Channing Brown, Olympic fencer Ibtihaj Muhammad, and #MeToo founder Tarana Burke.

The physician event will feature 10 teams of two, with one physician handing over her account to her black female counterpart for the day. The takeover will allow the black physician to share her thoughts about the successes and challenges she faces as a woman of color in medicine.

“It was such an honor to be contacted by Arghavan Salles, MD, PhD, to participate in an event that has a goal of connecting like-minded women from various backgrounds to share a diverse perspective with a different audience,” Minnesota family medicine physician Jay-Sheree Allen, MD, told Medscape Medical News. “This event is not only incredibly important but timely.”

Participants say the goal of the takeovers is to amplify the reach and voice of black women in medicine while crossing boundaries and empowering others to do the same. Only about 5% of all active physicians in 2018 identified as Black or African American, according to a report by the Association of American Medical Colleges. And of those, just over a third are female, the report found.

“I think that as we hear those small numbers we often celebrate the success of those people without looking back and understanding where all of the barriers are that are limiting talented black women from entering medicine at every stage,” another campaign participant, Chicago pediatrician Rebekah Fenton, MD, told Medscape Medical News.

Allen says that, amid continuing worldwide protests over racial injustice, prompted by the death of George Floyd while in Minneapolis police custody last month, the online event is very timely and an important way to advocate for black lives and engage in a productive conversation.

Racism has been around for a very long time, and we still have a long way to go to eradicate it, in all of its forms. Racism can be subtle, such as not offering employment to a fully qualified candidate or lowering your level of care because of the color of a person’s skin. Also, you never know if the future will place you in the same position as that of the person you are discriminating against or excluding. Diversity through the mixture of cultures and races is what provides a richness to our communities and our country.

No matter what race we may be, we all are human and deserve to be treated and respected as such. The patient you misunderstood, feared, or dismissed could be the same person who helps you become a better physician. For instance, one of my teenage patients of Chinese descent confessed one day that she was feeling depressed, sometimes to the point of suicidal ideation. However, she was adamant that I not report this condition to her parents. From her, I learned that mental illness, such as depression, are taboo subjects in Asian cultures. This information enabled me to be more sensitive with handling this patient’s condition and treatment.

In many cities across America, people have been protesting the recent tragic death of Mr. George Floyd, an African American man killed by a white police officer. In the past few months, unfortunately, we have seen similar cases of racist acts against African Americans. Sadly, this is nothing new.

There are examples of racist acts against other racial groups as well. Since the coronavirus pandemic became global news, Asian Americans have faced a wave of intense xenophobia in the United States. Be mindful that one race suffering injustice in one country could themselves be racist against another group given the opportunity. An example of this was reported in an April 16, 2020, article in the Los Angeles Times. The events took place in Guangzhou, China. The article reported that Africans living there were harassed, targeted, and evicted from their homes in the port city following the positive COVID-19 tests of five Nigerians. Instead of imposing quarantine based on contact history, China’s response has been based on race amid the coronavirus crisis. Stories like this remind us that racism is not just black and white, but can occur by any dominant culture against the minority. To be clear, not everyone is a racist.

Fear of the unknown causes misunderstanding and weakens the relationship between a pediatrician and the patient. Instead, let us “be curious and not furious.”¹ We may look different on the outside, but inside we are all human, with feelings, desires, and dreams. An example of being misunderstood is commonly observed as others stereotype African American populations. For example, an African American mother may be described as rude, loud, and disrespectful by those in your office. Such labeling fails to take the time necessary to understand the other’s perspective, and it dismisses her. Why might she be acting this way? What false assumptions are you making? How would you react if you were frequently disrespected or dismissed? How would you react if you had to worry about being physically harmed? Your visage could appear to be angry or guarded – not exactly welcoming or pleasant. It is much easier to quickly dismiss such a patient and not be sincerely interested in what she or her child’s medical needs may be. Such a disposition only results in frustrating outcomes and the destruction of trust between a patient and the provider.

Dr. Mba Wright is a primary care pediatrician practicing in Sacramento, Calif., for more than 14 years. She has no relevant financial disclosures. Email her at [email protected].
 

Reference

^{1. “Going the Distance: Finding and Keeping Lifelong Love” (New York, N.Y.: Doubleday, 1991).}

Racism has been around for a very long time, and we still have a long way to go to eradicate it, in all of its forms. Racism can be subtle, such as not offering employment to a fully qualified candidate or lowering your level of care because of the color of a person’s skin. Also, you never know if the future will place you in the same position as that of the person you are discriminating against or excluding. Diversity through the mixture of cultures and races is what provides a richness to our communities and our country.

No matter what race we may be, we all are human and deserve to be treated and respected as such. The patient you misunderstood, feared, or dismissed could be the same person who helps you become a better physician. For instance, one of my teenage patients of Chinese descent confessed one day that she was feeling depressed, sometimes to the point of suicidal ideation. However, she was adamant that I not report this condition to her parents. From her, I learned that mental illness, such as depression, are taboo subjects in Asian cultures. This information enabled me to be more sensitive with handling this patient’s condition and treatment.

In many cities across America, people have been protesting the recent tragic death of Mr. George Floyd, an African American man killed by a white police officer. In the past few months, unfortunately, we have seen similar cases of racist acts against African Americans. Sadly, this is nothing new.

There are examples of racist acts against other racial groups as well. Since the coronavirus pandemic became global news, Asian Americans have faced a wave of intense xenophobia in the United States. Be mindful that one race suffering injustice in one country could themselves be racist against another group given the opportunity. An example of this was reported in an April 16, 2020, article in the Los Angeles Times. The events took place in Guangzhou, China. The article reported that Africans living there were harassed, targeted, and evicted from their homes in the port city following the positive COVID-19 tests of five Nigerians. Instead of imposing quarantine based on contact history, China’s response has been based on race amid the coronavirus crisis. Stories like this remind us that racism is not just black and white, but can occur by any dominant culture against the minority. To be clear, not everyone is a racist.

Fear of the unknown causes misunderstanding and weakens the relationship between a pediatrician and the patient. Instead, let us “be curious and not furious.”¹ We may look different on the outside, but inside we are all human, with feelings, desires, and dreams. An example of being misunderstood is commonly observed as others stereotype African American populations. For example, an African American mother may be described as rude, loud, and disrespectful by those in your office. Such labeling fails to take the time necessary to understand the other’s perspective, and it dismisses her. Why might she be acting this way? What false assumptions are you making? How would you react if you were frequently disrespected or dismissed? How would you react if you had to worry about being physically harmed? Your visage could appear to be angry or guarded – not exactly welcoming or pleasant. It is much easier to quickly dismiss such a patient and not be sincerely interested in what she or her child’s medical needs may be. Such a disposition only results in frustrating outcomes and the destruction of trust between a patient and the provider.

Dr. Mba Wright is a primary care pediatrician practicing in Sacramento, Calif., for more than 14 years. She has no relevant financial disclosures. Email her at [email protected].
 

Reference

^{1. “Going the Distance: Finding and Keeping Lifelong Love” (New York, N.Y.: Doubleday, 1991).}

Racism has been around for a very long time, and we still have a long way to go to eradicate it, in all of its forms. Racism can be subtle, such as not offering employment to a fully qualified candidate or lowering your level of care because of the color of a person’s skin. Also, you never know if the future will place you in the same position as that of the person you are discriminating against or excluding. Diversity through the mixture of cultures and races is what provides a richness to our communities and our country.

No matter what race we may be, we all are human and deserve to be treated and respected as such. The patient you misunderstood, feared, or dismissed could be the same person who helps you become a better physician. For instance, one of my teenage patients of Chinese descent confessed one day that she was feeling depressed, sometimes to the point of suicidal ideation. However, she was adamant that I not report this condition to her parents. From her, I learned that mental illness, such as depression, are taboo subjects in Asian cultures. This information enabled me to be more sensitive with handling this patient’s condition and treatment.

In many cities across America, people have been protesting the recent tragic death of Mr. George Floyd, an African American man killed by a white police officer. In the past few months, unfortunately, we have seen similar cases of racist acts against African Americans. Sadly, this is nothing new.

There are examples of racist acts against other racial groups as well. Since the coronavirus pandemic became global news, Asian Americans have faced a wave of intense xenophobia in the United States. Be mindful that one race suffering injustice in one country could themselves be racist against another group given the opportunity. An example of this was reported in an April 16, 2020, article in the Los Angeles Times. The events took place in Guangzhou, China. The article reported that Africans living there were harassed, targeted, and evicted from their homes in the port city following the positive COVID-19 tests of five Nigerians. Instead of imposing quarantine based on contact history, China’s response has been based on race amid the coronavirus crisis. Stories like this remind us that racism is not just black and white, but can occur by any dominant culture against the minority. To be clear, not everyone is a racist.

Fear of the unknown causes misunderstanding and weakens the relationship between a pediatrician and the patient. Instead, let us “be curious and not furious.”¹ We may look different on the outside, but inside we are all human, with feelings, desires, and dreams. An example of being misunderstood is commonly observed as others stereotype African American populations. For example, an African American mother may be described as rude, loud, and disrespectful by those in your office. Such labeling fails to take the time necessary to understand the other’s perspective, and it dismisses her. Why might she be acting this way? What false assumptions are you making? How would you react if you were frequently disrespected or dismissed? How would you react if you had to worry about being physically harmed? Your visage could appear to be angry or guarded – not exactly welcoming or pleasant. It is much easier to quickly dismiss such a patient and not be sincerely interested in what she or her child’s medical needs may be. Such a disposition only results in frustrating outcomes and the destruction of trust between a patient and the provider.

Dr. Mba Wright is a primary care pediatrician practicing in Sacramento, Calif., for more than 14 years. She has no relevant financial disclosures. Email her at [email protected].
 

Reference

^{1. “Going the Distance: Finding and Keeping Lifelong Love” (New York, N.Y.: Doubleday, 1991).}

I have an automatic preference for white people over black people. This isn’t my opinion; rather, it is my implicit bias test result. I didn’t believe it at first. Trying hard to not be biased, I took the test again and received the same outcome. My reaction – disbelief – is typical for those like me: White people who believe they are good human beings. I might be good, but that doesn’t mean I’m free of bias or exonerated from the harm being inflicted on people of color.

We’ve all watched in horror the acts of violence against blacks in the news. I was shocked and disgusted. It was easy to believe, however, that I am in no way complicit in the injustice and racism I was watching. I think I’m fair and without prejudice. I have never intentionally discriminated against someone. Wanting to help, I listened to my black colleagues, staff, and patients. What I learned made me uncomfortable.

Through all this news, I’d said little to my colleagues and friends. I cannot identify with how a black person has felt recently. What if I said the wrong thing or caused offense? The safe option is to say nothing. I learned that this is a common reaction and the least helpful. The advice from one black colleague was simple: “Just ask us.” Instead of ignoring the issue, she advised me to say: “I wonder what this experience has been like for you. Would you like to share?” And, if you mean it, to add, “I stand with you.” The latter should be followed by “What can I do to help?” Or, more powerfully, “What have I done that makes me complicit?”

Some of these conversations will be uncomfortable. If you want to help, then sit with that. Feeling uncomfortable might mean you are beginning to understand.

I also heard about the excellent book “White Fragility,” by Robin DiAngelo, PhD. In it, she argues that it is difficult for white people to talk about racism because of a tendency to react with defensiveness, guilt, and sometimes anger.

Many of the chapters in the book were easy to read because they didn’t apply to me: I don’t get angry in equity, inclusion, and diversity meetings. I don’t resent affirmative action programs. But then Dr. DiAngelo got me: I believed because I’m a good person and I have no intention of being racist, I’m absolved. Her argument was enlightening. Like all white people in the United States, I have benefited from white privilege. Yes, I’ve worked hard, but I also grew up in a white family with a college-educated father. That alone afforded me academic and financial advantages, which pushed me ahead. I’ve benefited from the status quo.

I have also failed to speak up when white friends carried on about how unnecessary affirmative action programs have become. I’ve sat with sealed lips when I’ve heard comments like “As a white male, it’s a lot harder to get into prestigious schools now.” Having no intention to harm doesn’t matter; plenty of harm is done unintentionally.

I also believed that because I have good intentions, I have no racial bias. I was wrong. The test I took online is an excellent tool to combat this blind spot. It was created by Harvard researchers and is available to everyone: Take a Test. It asks you to categorize faces as good or bad and records your tiny reaction times. Based on these and other questions, it provides feedback on your personal biases.

I was surprised that I have an implicit preference for white people over black people. That’s the point. Most of us are unaware of our biases and falsely believe we are free of them. I encourage you to take the test and learn about yourself. If the result makes you uncomfortable, then sit with it. Try not to be defensive, as I was, and accept that, even if you are a good person, you can become a better one.

Based on what I’ve learned and heard in the last few weeks, I’ve committed to a few things: To acknowledge the harm done to my black and brown colleagues and my complicity even by acts of omission. To not avoid uncomfortable feelings or uncomfortable conversations. As a leader, to use my organizational status to advocate. To stand by my partners of color not only in dramatic one-time marches but also against the everyday perpetrators of microaggressions. To create a safe space and invite my colleagues, staff, friends, and patients to share.

Standing up against racism is all our responsibility. As Dr. Martin Luther King Jr. reminds us: “In the end, we will remember not the words of our enemies, but the silence of our friends.”
 

Dr. Benabio is director of healthcare transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. He has no disclosures related to this column. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

I have an automatic preference for white people over black people. This isn’t my opinion; rather, it is my implicit bias test result. I didn’t believe it at first. Trying hard to not be biased, I took the test again and received the same outcome. My reaction – disbelief – is typical for those like me: White people who believe they are good human beings. I might be good, but that doesn’t mean I’m free of bias or exonerated from the harm being inflicted on people of color.

We’ve all watched in horror the acts of violence against blacks in the news. I was shocked and disgusted. It was easy to believe, however, that I am in no way complicit in the injustice and racism I was watching. I think I’m fair and without prejudice. I have never intentionally discriminated against someone. Wanting to help, I listened to my black colleagues, staff, and patients. What I learned made me uncomfortable.

Through all this news, I’d said little to my colleagues and friends. I cannot identify with how a black person has felt recently. What if I said the wrong thing or caused offense? The safe option is to say nothing. I learned that this is a common reaction and the least helpful. The advice from one black colleague was simple: “Just ask us.” Instead of ignoring the issue, she advised me to say: “I wonder what this experience has been like for you. Would you like to share?” And, if you mean it, to add, “I stand with you.” The latter should be followed by “What can I do to help?” Or, more powerfully, “What have I done that makes me complicit?”

Some of these conversations will be uncomfortable. If you want to help, then sit with that. Feeling uncomfortable might mean you are beginning to understand.

I also heard about the excellent book “White Fragility,” by Robin DiAngelo, PhD. In it, she argues that it is difficult for white people to talk about racism because of a tendency to react with defensiveness, guilt, and sometimes anger.

Many of the chapters in the book were easy to read because they didn’t apply to me: I don’t get angry in equity, inclusion, and diversity meetings. I don’t resent affirmative action programs. But then Dr. DiAngelo got me: I believed because I’m a good person and I have no intention of being racist, I’m absolved. Her argument was enlightening. Like all white people in the United States, I have benefited from white privilege. Yes, I’ve worked hard, but I also grew up in a white family with a college-educated father. That alone afforded me academic and financial advantages, which pushed me ahead. I’ve benefited from the status quo.

I have also failed to speak up when white friends carried on about how unnecessary affirmative action programs have become. I’ve sat with sealed lips when I’ve heard comments like “As a white male, it’s a lot harder to get into prestigious schools now.” Having no intention to harm doesn’t matter; plenty of harm is done unintentionally.

I also believed that because I have good intentions, I have no racial bias. I was wrong. The test I took online is an excellent tool to combat this blind spot. It was created by Harvard researchers and is available to everyone: Take a Test. It asks you to categorize faces as good or bad and records your tiny reaction times. Based on these and other questions, it provides feedback on your personal biases.

I was surprised that I have an implicit preference for white people over black people. That’s the point. Most of us are unaware of our biases and falsely believe we are free of them. I encourage you to take the test and learn about yourself. If the result makes you uncomfortable, then sit with it. Try not to be defensive, as I was, and accept that, even if you are a good person, you can become a better one.

Based on what I’ve learned and heard in the last few weeks, I’ve committed to a few things: To acknowledge the harm done to my black and brown colleagues and my complicity even by acts of omission. To not avoid uncomfortable feelings or uncomfortable conversations. As a leader, to use my organizational status to advocate. To stand by my partners of color not only in dramatic one-time marches but also against the everyday perpetrators of microaggressions. To create a safe space and invite my colleagues, staff, friends, and patients to share.

Standing up against racism is all our responsibility. As Dr. Martin Luther King Jr. reminds us: “In the end, we will remember not the words of our enemies, but the silence of our friends.”
 

Dr. Benabio is director of healthcare transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. He has no disclosures related to this column. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

I have an automatic preference for white people over black people. This isn’t my opinion; rather, it is my implicit bias test result. I didn’t believe it at first. Trying hard to not be biased, I took the test again and received the same outcome. My reaction – disbelief – is typical for those like me: White people who believe they are good human beings. I might be good, but that doesn’t mean I’m free of bias or exonerated from the harm being inflicted on people of color.

We’ve all watched in horror the acts of violence against blacks in the news. I was shocked and disgusted. It was easy to believe, however, that I am in no way complicit in the injustice and racism I was watching. I think I’m fair and without prejudice. I have never intentionally discriminated against someone. Wanting to help, I listened to my black colleagues, staff, and patients. What I learned made me uncomfortable.

Through all this news, I’d said little to my colleagues and friends. I cannot identify with how a black person has felt recently. What if I said the wrong thing or caused offense? The safe option is to say nothing. I learned that this is a common reaction and the least helpful. The advice from one black colleague was simple: “Just ask us.” Instead of ignoring the issue, she advised me to say: “I wonder what this experience has been like for you. Would you like to share?” And, if you mean it, to add, “I stand with you.” The latter should be followed by “What can I do to help?” Or, more powerfully, “What have I done that makes me complicit?”

Some of these conversations will be uncomfortable. If you want to help, then sit with that. Feeling uncomfortable might mean you are beginning to understand.

I also heard about the excellent book “White Fragility,” by Robin DiAngelo, PhD. In it, she argues that it is difficult for white people to talk about racism because of a tendency to react with defensiveness, guilt, and sometimes anger.

Many of the chapters in the book were easy to read because they didn’t apply to me: I don’t get angry in equity, inclusion, and diversity meetings. I don’t resent affirmative action programs. But then Dr. DiAngelo got me: I believed because I’m a good person and I have no intention of being racist, I’m absolved. Her argument was enlightening. Like all white people in the United States, I have benefited from white privilege. Yes, I’ve worked hard, but I also grew up in a white family with a college-educated father. That alone afforded me academic and financial advantages, which pushed me ahead. I’ve benefited from the status quo.

I have also failed to speak up when white friends carried on about how unnecessary affirmative action programs have become. I’ve sat with sealed lips when I’ve heard comments like “As a white male, it’s a lot harder to get into prestigious schools now.” Having no intention to harm doesn’t matter; plenty of harm is done unintentionally.

I also believed that because I have good intentions, I have no racial bias. I was wrong. The test I took online is an excellent tool to combat this blind spot. It was created by Harvard researchers and is available to everyone: Take a Test. It asks you to categorize faces as good or bad and records your tiny reaction times. Based on these and other questions, it provides feedback on your personal biases.

I was surprised that I have an implicit preference for white people over black people. That’s the point. Most of us are unaware of our biases and falsely believe we are free of them. I encourage you to take the test and learn about yourself. If the result makes you uncomfortable, then sit with it. Try not to be defensive, as I was, and accept that, even if you are a good person, you can become a better one.

Based on what I’ve learned and heard in the last few weeks, I’ve committed to a few things: To acknowledge the harm done to my black and brown colleagues and my complicity even by acts of omission. To not avoid uncomfortable feelings or uncomfortable conversations. As a leader, to use my organizational status to advocate. To stand by my partners of color not only in dramatic one-time marches but also against the everyday perpetrators of microaggressions. To create a safe space and invite my colleagues, staff, friends, and patients to share.

Standing up against racism is all our responsibility. As Dr. Martin Luther King Jr. reminds us: “In the end, we will remember not the words of our enemies, but the silence of our friends.”
 

Dr. Benabio is director of healthcare transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. He has no disclosures related to this column. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

One might immediately think of the deaths of Eric Garner, George Floyd, or even the fictional character Radio Raheem from Spike Lee’s critically acclaimed film, “Do the Right Thing,” when they hear the words “I can’t breathe.” These words are a cry for help. The deaths of these unarmed black men is devastating and has led to a state of rage, palpable pain, and protest across the world.

However, in this moment, I am talking about the health inequity exposed by the COVID-19 pandemic. Whether it be acute respiratory distress syndrome (ARDS) secondary to severe COVID-19, or the subsequent hypercoagulable state of COVID-19 that leads to venous thromboembolism, many black people in this country are left breathless. Many black patients who had no employee-based health insurance also had no primary care physician to order a SARS-CoV2 PCR lab test for them. Many of these patients have preexisting conditions, such as asthma from living in redlined communities affected by environmental racism. Many grew up in food deserts, where no fresh-produce store was interested enough to set up shop in their neighborhoods. They have been eating fast food since early childhood, as a fast-food burger is still cheaper than a salad. The result is obesity, an epidemic that can lead to diabetes mellitus, hypertension that can lead to coronary artery disease, stroke, and end-stage renal disease. 

Earlier in my career, I once had a colleague gleefully tell me that all black people drank Kool-Aid while in discussion of the effects of high-sugar diets in our patients; this colleague was sure I would agree. Not all black people drink Kool-Aid. Secondary to my fear of the backlash that can come from the discomfort of “white fragility” that Robin DiAngelo describes in her New York Times bestseller by the same name, ”White Fragility: Why It’s So Hard for White People to Talk About Racism,” I refrained from expressing my own hurt, and I did not offer explicit correction. I, instead, took a serious pause. That pause, which lasted only minutes, seemed to last 400 years. It was a brief reflection of the 400 years of systemic racism seeping into everyday life. This included the circumstances that would lead to the health inequities that result in the health disparities from which many black patients suffer. It is that same systemic racism that could create two America’s in which my colleague might not have to know the historic context in which that question could be hurtful. I retorted with modified shock and a chuckle so that I could muster up enough strength to repeat what was said and leave it open for reflection. The goal was for my colleague to realize the obvious implicit bias that lingered, despite intention. The chuckle was also to cover my pain.

Whether we know it or not, we all carry some form of implicit bias, regardless of race, class, gender, ethnicity, sexual preference, or socioeconomic status. In this case, it is the same implicit bias that causes physicians to ignore some black patients when they have said that they are in pain. A groundbreaking April 2016 article in Proceedings of the National Academy of Sciences, “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs about Biological Differences Between Blacks and Whites” (doi: 10.1073/pnas.1516047113), revealed that racial disparities in pain assessment and treatment recommendations can be directly connected to the racial bias of the provider. It could be possible that this phenomenon has affected black patients who have walked into clinics and emergency departments and said, “I’m short of breath. I think that I might have coronavirus and need to be tested.” It may be that same implicit bias that has cut the air supply to a patient encounter. Instead of inquiring further, the patient might be met with minimum questions while their provider obtains their history and physical. Assumptions and blame on behavior and lack of personal responsibility secretly replace questions that could have been asked. Differentials between exacerbations and other etiologies are not explored. Could that patient have been sent home without a SARS-CoV2 polymerase chain reaction test? Well, what if the tests were in short supply? Sometimes they may have been sent home without a chest x-ray. In most cases, there are no funds to send them home with a pulse oximeter.

The act of assuming a person’s story that we consider to be one dimensional is always dangerous – and even more so during this pandemic. That person we can relate to – secondary to a cool pop culture moment, a TikTok song, or a negative stereotype – is not one dimensional. That assumption and that stereotype can make room for implicit bias. That same implicit bias is the knee on a neck of any marginalized patient. Implicit bias is the choke hold that slowly removes the light and life from a person who has a story, who has a family, and who has been an essential worker who can’t work from home. That person is telling us that they can’t breathe, but sometimes the only things seen are comorbidities through a misinformed or biased lens that suggest an assumed lack of personal responsibility. In a May 2020 New England Journal of Medicine perspective, “Racial health disparities and Covid-19” (doi: 10.1056/NEJMp2012910), Merlin Chowkwanyun, PhD, MPH, and Adolph L. Reed Jr., PhD, caution us against creating race-based explanations for presumed behavioral patterns.

Systemic racism has created the myth that the playing field has been leveled since the end of enslavement. It hasn’t. That black man, woman, or nonbinary person is telling you “I can’t breathe. I’m tired. I’m short of breath ... I have a cough ... I’m feeling weak these days, Doc.” However, implicit bias is still that knee that won’t let up. It has not let up. Communities with lower-income black and Hispanic patients have already seen local hospitals and frontline workers fight to save their lives while losing their own to COVID-19. We all witnessed the battle for scarce resources and PPE [personal protective equipment]. In contrast, some wealthy neighborhoods have occupants who most likely have access to a primary care physician and more testing centers.

As we reexamine ourselves and look at these cases of police brutality against unarmed black men, women, and children with the appropriate shame and outrage, let us reflect upon the privileges that we enjoy. Let us find our voice as we speak up for black lives. Let us look deeply into the history of medicine as it relates to black patients by reading “Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present” by Harriet A. Washington. Let us examine that painful legacy, which, while having moments of good intention, still carries the stain of indifference, racism, neglect, and even experimentation without informed consent.

Why should we do these things? Because some of our black patients have also yelled or whispered, “I can’t breathe,” and we were not always listening either.
 

Dr. Ajala is a hospitalist and associate site director for education at Grady Memorial Hospital in Atlanta. She is a member of the executive council for SHM’s Care for Vulnerable Populations special interest group.

One might immediately think of the deaths of Eric Garner, George Floyd, or even the fictional character Radio Raheem from Spike Lee’s critically acclaimed film, “Do the Right Thing,” when they hear the words “I can’t breathe.” These words are a cry for help. The deaths of these unarmed black men is devastating and has led to a state of rage, palpable pain, and protest across the world.

However, in this moment, I am talking about the health inequity exposed by the COVID-19 pandemic. Whether it be acute respiratory distress syndrome (ARDS) secondary to severe COVID-19, or the subsequent hypercoagulable state of COVID-19 that leads to venous thromboembolism, many black people in this country are left breathless. Many black patients who had no employee-based health insurance also had no primary care physician to order a SARS-CoV2 PCR lab test for them. Many of these patients have preexisting conditions, such as asthma from living in redlined communities affected by environmental racism. Many grew up in food deserts, where no fresh-produce store was interested enough to set up shop in their neighborhoods. They have been eating fast food since early childhood, as a fast-food burger is still cheaper than a salad. The result is obesity, an epidemic that can lead to diabetes mellitus, hypertension that can lead to coronary artery disease, stroke, and end-stage renal disease. 

Earlier in my career, I once had a colleague gleefully tell me that all black people drank Kool-Aid while in discussion of the effects of high-sugar diets in our patients; this colleague was sure I would agree. Not all black people drink Kool-Aid. Secondary to my fear of the backlash that can come from the discomfort of “white fragility” that Robin DiAngelo describes in her New York Times bestseller by the same name, ”White Fragility: Why It’s So Hard for White People to Talk About Racism,” I refrained from expressing my own hurt, and I did not offer explicit correction. I, instead, took a serious pause. That pause, which lasted only minutes, seemed to last 400 years. It was a brief reflection of the 400 years of systemic racism seeping into everyday life. This included the circumstances that would lead to the health inequities that result in the health disparities from which many black patients suffer. It is that same systemic racism that could create two America’s in which my colleague might not have to know the historic context in which that question could be hurtful. I retorted with modified shock and a chuckle so that I could muster up enough strength to repeat what was said and leave it open for reflection. The goal was for my colleague to realize the obvious implicit bias that lingered, despite intention. The chuckle was also to cover my pain.

Whether we know it or not, we all carry some form of implicit bias, regardless of race, class, gender, ethnicity, sexual preference, or socioeconomic status. In this case, it is the same implicit bias that causes physicians to ignore some black patients when they have said that they are in pain. A groundbreaking April 2016 article in Proceedings of the National Academy of Sciences, “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs about Biological Differences Between Blacks and Whites” (doi: 10.1073/pnas.1516047113), revealed that racial disparities in pain assessment and treatment recommendations can be directly connected to the racial bias of the provider. It could be possible that this phenomenon has affected black patients who have walked into clinics and emergency departments and said, “I’m short of breath. I think that I might have coronavirus and need to be tested.” It may be that same implicit bias that has cut the air supply to a patient encounter. Instead of inquiring further, the patient might be met with minimum questions while their provider obtains their history and physical. Assumptions and blame on behavior and lack of personal responsibility secretly replace questions that could have been asked. Differentials between exacerbations and other etiologies are not explored. Could that patient have been sent home without a SARS-CoV2 polymerase chain reaction test? Well, what if the tests were in short supply? Sometimes they may have been sent home without a chest x-ray. In most cases, there are no funds to send them home with a pulse oximeter.

The act of assuming a person’s story that we consider to be one dimensional is always dangerous – and even more so during this pandemic. That person we can relate to – secondary to a cool pop culture moment, a TikTok song, or a negative stereotype – is not one dimensional. That assumption and that stereotype can make room for implicit bias. That same implicit bias is the knee on a neck of any marginalized patient. Implicit bias is the choke hold that slowly removes the light and life from a person who has a story, who has a family, and who has been an essential worker who can’t work from home. That person is telling us that they can’t breathe, but sometimes the only things seen are comorbidities through a misinformed or biased lens that suggest an assumed lack of personal responsibility. In a May 2020 New England Journal of Medicine perspective, “Racial health disparities and Covid-19” (doi: 10.1056/NEJMp2012910), Merlin Chowkwanyun, PhD, MPH, and Adolph L. Reed Jr., PhD, caution us against creating race-based explanations for presumed behavioral patterns.

Systemic racism has created the myth that the playing field has been leveled since the end of enslavement. It hasn’t. That black man, woman, or nonbinary person is telling you “I can’t breathe. I’m tired. I’m short of breath ... I have a cough ... I’m feeling weak these days, Doc.” However, implicit bias is still that knee that won’t let up. It has not let up. Communities with lower-income black and Hispanic patients have already seen local hospitals and frontline workers fight to save their lives while losing their own to COVID-19. We all witnessed the battle for scarce resources and PPE [personal protective equipment]. In contrast, some wealthy neighborhoods have occupants who most likely have access to a primary care physician and more testing centers.

As we reexamine ourselves and look at these cases of police brutality against unarmed black men, women, and children with the appropriate shame and outrage, let us reflect upon the privileges that we enjoy. Let us find our voice as we speak up for black lives. Let us look deeply into the history of medicine as it relates to black patients by reading “Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present” by Harriet A. Washington. Let us examine that painful legacy, which, while having moments of good intention, still carries the stain of indifference, racism, neglect, and even experimentation without informed consent.

Why should we do these things? Because some of our black patients have also yelled or whispered, “I can’t breathe,” and we were not always listening either.
 

Dr. Ajala is a hospitalist and associate site director for education at Grady Memorial Hospital in Atlanta. She is a member of the executive council for SHM’s Care for Vulnerable Populations special interest group.

One might immediately think of the deaths of Eric Garner, George Floyd, or even the fictional character Radio Raheem from Spike Lee’s critically acclaimed film, “Do the Right Thing,” when they hear the words “I can’t breathe.” These words are a cry for help. The deaths of these unarmed black men is devastating and has led to a state of rage, palpable pain, and protest across the world.

However, in this moment, I am talking about the health inequity exposed by the COVID-19 pandemic. Whether it be acute respiratory distress syndrome (ARDS) secondary to severe COVID-19, or the subsequent hypercoagulable state of COVID-19 that leads to venous thromboembolism, many black people in this country are left breathless. Many black patients who had no employee-based health insurance also had no primary care physician to order a SARS-CoV2 PCR lab test for them. Many of these patients have preexisting conditions, such as asthma from living in redlined communities affected by environmental racism. Many grew up in food deserts, where no fresh-produce store was interested enough to set up shop in their neighborhoods. They have been eating fast food since early childhood, as a fast-food burger is still cheaper than a salad. The result is obesity, an epidemic that can lead to diabetes mellitus, hypertension that can lead to coronary artery disease, stroke, and end-stage renal disease. 

Earlier in my career, I once had a colleague gleefully tell me that all black people drank Kool-Aid while in discussion of the effects of high-sugar diets in our patients; this colleague was sure I would agree. Not all black people drink Kool-Aid. Secondary to my fear of the backlash that can come from the discomfort of “white fragility” that Robin DiAngelo describes in her New York Times bestseller by the same name, ”White Fragility: Why It’s So Hard for White People to Talk About Racism,” I refrained from expressing my own hurt, and I did not offer explicit correction. I, instead, took a serious pause. That pause, which lasted only minutes, seemed to last 400 years. It was a brief reflection of the 400 years of systemic racism seeping into everyday life. This included the circumstances that would lead to the health inequities that result in the health disparities from which many black patients suffer. It is that same systemic racism that could create two America’s in which my colleague might not have to know the historic context in which that question could be hurtful. I retorted with modified shock and a chuckle so that I could muster up enough strength to repeat what was said and leave it open for reflection. The goal was for my colleague to realize the obvious implicit bias that lingered, despite intention. The chuckle was also to cover my pain.

Whether we know it or not, we all carry some form of implicit bias, regardless of race, class, gender, ethnicity, sexual preference, or socioeconomic status. In this case, it is the same implicit bias that causes physicians to ignore some black patients when they have said that they are in pain. A groundbreaking April 2016 article in Proceedings of the National Academy of Sciences, “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs about Biological Differences Between Blacks and Whites” (doi: 10.1073/pnas.1516047113), revealed that racial disparities in pain assessment and treatment recommendations can be directly connected to the racial bias of the provider. It could be possible that this phenomenon has affected black patients who have walked into clinics and emergency departments and said, “I’m short of breath. I think that I might have coronavirus and need to be tested.” It may be that same implicit bias that has cut the air supply to a patient encounter. Instead of inquiring further, the patient might be met with minimum questions while their provider obtains their history and physical. Assumptions and blame on behavior and lack of personal responsibility secretly replace questions that could have been asked. Differentials between exacerbations and other etiologies are not explored. Could that patient have been sent home without a SARS-CoV2 polymerase chain reaction test? Well, what if the tests were in short supply? Sometimes they may have been sent home without a chest x-ray. In most cases, there are no funds to send them home with a pulse oximeter.

The act of assuming a person’s story that we consider to be one dimensional is always dangerous – and even more so during this pandemic. That person we can relate to – secondary to a cool pop culture moment, a TikTok song, or a negative stereotype – is not one dimensional. That assumption and that stereotype can make room for implicit bias. That same implicit bias is the knee on a neck of any marginalized patient. Implicit bias is the choke hold that slowly removes the light and life from a person who has a story, who has a family, and who has been an essential worker who can’t work from home. That person is telling us that they can’t breathe, but sometimes the only things seen are comorbidities through a misinformed or biased lens that suggest an assumed lack of personal responsibility. In a May 2020 New England Journal of Medicine perspective, “Racial health disparities and Covid-19” (doi: 10.1056/NEJMp2012910), Merlin Chowkwanyun, PhD, MPH, and Adolph L. Reed Jr., PhD, caution us against creating race-based explanations for presumed behavioral patterns.

Systemic racism has created the myth that the playing field has been leveled since the end of enslavement. It hasn’t. That black man, woman, or nonbinary person is telling you “I can’t breathe. I’m tired. I’m short of breath ... I have a cough ... I’m feeling weak these days, Doc.” However, implicit bias is still that knee that won’t let up. It has not let up. Communities with lower-income black and Hispanic patients have already seen local hospitals and frontline workers fight to save their lives while losing their own to COVID-19. We all witnessed the battle for scarce resources and PPE [personal protective equipment]. In contrast, some wealthy neighborhoods have occupants who most likely have access to a primary care physician and more testing centers.

As we reexamine ourselves and look at these cases of police brutality against unarmed black men, women, and children with the appropriate shame and outrage, let us reflect upon the privileges that we enjoy. Let us find our voice as we speak up for black lives. Let us look deeply into the history of medicine as it relates to black patients by reading “Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present” by Harriet A. Washington. Let us examine that painful legacy, which, while having moments of good intention, still carries the stain of indifference, racism, neglect, and even experimentation without informed consent.

Why should we do these things? Because some of our black patients have also yelled or whispered, “I can’t breathe,” and we were not always listening either.
 

Dr. Ajala is a hospitalist and associate site director for education at Grady Memorial Hospital in Atlanta. She is a member of the executive council for SHM’s Care for Vulnerable Populations special interest group.