Everything Around Us has to do with Medical Education
Adina Kalet, MD MPH
“I swore never to be silent whenever and wherever human beings endure suffering and humiliation. We must take sides. Neutrality helps the oppressor, never the victim. Silence encourages the tormentor, never the tormented.”
― Elie Wiesel
I have colleagues and friends who are afraid for their children. In the middle of a pandemic, which is hitting communities of color – particularly African American men and women – harder than other groups of Americans, colleagues who are professors of medicine and leaders of public health in elite American academic institutions, are not only worried about dying of the novel coronavirus, they fear being victims of violence because they are Black. Early in March, when the CDC recommended that citizens use bandanas and other facial coverings to prevent spread of SARS-CoV-2, Black men feared that, if they did this, they would risk being killed because they would be mistaken for criminals.
Our common experiences are horrific.
The images are spellbinding; a grinning man with his hands in his pockets kneeling on the neck of George Floyd as he dies begging for his mother; armed men in a pick-up truck heading off Amaud Arbery as he jogs down a tree-lined suburban street; the picture of a uniformed EMT, Breonna Taylor, smiling and holding a bouquet of flowers with an accompanying newspaper story about how she was killed in her home by police officers mistakenly serving a “no-knock warrant.” Images and stories like these have been accumulating in our country for hundreds of years. What is different now? Can we do the anti-racism work needed?
What does this have to do with transforming medical education? Everything.
In New York City, a woman in Central Park is asked by a man with binoculars and a cell phone to leash her dog so that it will not disturb the birds he is watching. Off-leash dogs can trounce habitat and kill birds. When she refuses, he begins recording her on his cell phone. In that recording, you see and hear the fear and outrage rising in her – she loses all reason, situational awareness and compassion. She is terrified. It is daylight in a busy park. She could walk away, leash the dog, or continue to debate dog vs. bird rights. Why does she, a white woman, feel so “fragile” that she choose to call the police, say she is being threatened, and emphasize that he is “African American”? What was she thinking? Was she thinking?
As a white woman, I search for evidence of hope among the images. There is some: Large, diverse crowds protesting peacefully across the country; police officers in San Jose and Queens “taking a knee” and walking arm in arm with anti-racism protesters; James Mattis, Marine general and former Secretary of Defense denouncing the use of the US military against Americans on American soil.
Addressing structural racism in health and education It is no surprise that studies have long confirmed the strong association between structural racism and poverty. There is now a rapidly developing literature demonstrating that health disparities are partly attributable to the weathering of the human body from the cumulative exposures to everyday racism. The accumulated stress and epigenetic phenomena, i.e. the “allostatic load,” increase the risk of cancer, stroke, heart disease, and telomere shortening, all of which are associated with premature aging and death. This “Weathering Hypothesis” was first proposed in studies exploring why the birth outcomes of African American mothers and babies from all socioeconomic strata were abysmal. If physicians and scientist hope to improve the health and well-being of the patient populations for whom they care and perform research, they must also work to address the root causes of racism.
Racism causes unnecessary academic struggle. Stereotype threat, first described by psychologist Claude Steele, is the predicament individuals face when they know the stereotypes others hold about them, and thus become anxious about confirming those stereotypes. Stereotype threat has been shown to contribute to long-standing racial and gender gaps in academic performance. In addition, students and faculty of color in medical schools across the country report experiencing unfair, unfriendly and, at times, frankly hostile environments. Medical school faculty of color are less likely to accomplish the usual academic milestones of promotion and tenure, less likely to obtain federal grants, and less likely to achieve pay equity. In addition, they pay a significant “minority tax,” providing disproportionately more formal and informal mentoring of underrepresented minority students and donating institutional service by offering to serve on committees that seek racial diversity. All members of minorities in medical schools are burdened by being “tokenized,” that is, by being expected to represent and explain their group to well-meaning members of the majority group.
Some medical schools are addressing these challenges head on and others are not. We must make sure we are fully aware and in control of our biases and embrace a moral position as allies to protect the lives of others. To be a masterful clinician, one must learn to recognize, and actively counteract a host of predictable biases or prejudiced habits of mind. If we do not, unconscious biases, ignorance, and hijacking emotions will cloud our reasoning and behavior, leading to potentially fatal diagnostic and therapeutic mistakes. People will die.
Empathy, the key to therapeutic relationships, requires perspective taking and a deep commitment to attend to others even when we are terrified, fatigued or hungry. We can teach others how to do these things, however, without a strong, internalized medical professional identity and moral clarity, it might be impossible to enact this practical wisdom consistently and “do the right thing, at the right time for the right reason.”
What does this have to do with transforming medical education? Everything.
So, right now, what do we do? We must explicitly educate ourselves toward a mature identity where doing right is consistently enacted. To the white members of the community, I say it is our job to speak up and do the hard work of active ally ship. This requires courage and conversational skills which can be learned. See the words in this issue of the Transformational Times for some ideas. This means facing what sociologist Robin DiAnglio has termed “white fragility” to describe the disbelieving defensiveness that white people exhibit particularly when they feel implicated in white supremacy. We have to be willing to have our feelings hurt, to engage in civil debate, and take action once we have some clarity.
The Kern Institute will partner with others to make sure this work happens. We need to stop making excuses for why our profession is not as diverse as our population. This is a priority because it is the right thing to do. It will ensure our healthcare workforce can best serve everyone. This will require stable funding for programs to bring young people from underrepresented groups into the pipeline and creative strategies to keep them in Milwaukee for residency training. We must examine our assumptions about admissions requirements and academic potential. Recruiting a diverse student and resident body must go hand in hand with ensuring that learners from backgrounds underrepresented in medicine feel a sense of belonging once they matriculate.
My Black colleagues fear their sons are in an impossible and depressing situation. They must depend on the rest of us to keep their children safe and healthy. I, for one, am in for this challenge. I will vote, protest peacefully, have difficult conversations with my white colleagues and friends, and aspire to have a just society where all humans flourish.
Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.
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