Dr. Tamika Cross was on her way to Minneapolis when a patient onboard had a medical emergency.
Dr. Cross had quickly rushed to the patient when the flight attendant called for a doctor, only to be denied the opportunity to help because the attendant was not sure Dr. Cross was an “actual physician.”
While some credit the disbelief to the fact that Dr. Cross did not immediately show her credentials, this trend is still happening across the country today. Just last year, Dr. Fatima Stanford—a Black physician, educator, researcher, and policy maker at Massachusetts General Hospital and Harvard Medical School—was heading to Boston when someone near her began having a panic attack. When she tried to help, she was barred by the flight attendants who did not trust that Dr. Stanford’s credentials were genuine, or hers.
As the racial movement spurred earlier this year by the deaths of George Floyd, Breonna Taylor, Elijah McClain, Ahmaud Arbery and others moves forward, the nation is finally beginning to see the all-too-often fatal consequences of racism and bias. What we have yet to realize, though, is the far-reaching effects that smaller microaggressions can have—especially when applied within the healthcare space.
Actually, it’s Dr. Knight
I have the unique pleasure of being a physician and the mother of a son with sickle cell anemia—sickle beta thalassemia plus, to be exact. I am no stranger to vaso-occlusive (VOC) pain crises, as a doctor, and now as a caregiver for the past eight years.
During one particularly bad episode, I was forced to take my son Jackson to the ED for additional treatment after our regular regimen of ibuprophen, bridged by acetaminophen, and finally some oxycodone failed to provide the pain relief needed.
We were received promptly according to protocol the hospital has in place for children with sickle cell disease. An IV was placed, blood was drawn for labs, and IV Morphine and IV Toradol were administered for pain.
I smiled and introduced myself to the doctor.
“Hello, Dr. Smith”
“Hello, Mom.”
I extended my hand (as this was pre-COVID-19). “Actually, it’s Dr. Knight; I am a family doc. Great to meet you.” I proceeded with a detailed history, emphasizing my previous success with treating Jackson’s pain (and some limited experience with treated sickle cell as a resident in adults). She smiled, completing her physical and said “Ok, Mom, we will get you squared away.”
And there it was—she called me Mom, again. The first time was expected, and conceptually appropriate, as many pediatricians elect to call all of their patients’ mothers “Mom.” The second time felt dismissive, and was the first sign that I would not be considered as an equal. I would not be afforded the privilege or professional courtesy of simply being called “Doctor.”
Unicorns and the Impact of Gender and Racial Bias on Physicians
Studies have shown that women in medicine are referred to less often by their professional titles than their male colleagues, which directly reflects the gender pay gap in medicine, as well as the lack of women in leadership positions in academic medicine. Pediatric medicine is no exception. In a study by Drexel University, women made up 57 percent of medical school faculty at U. S. medical schools in 2017—but only 26 percent were department chairs.
But with the discrimination faced by Dr. Cross and Dr. Stanford, perhaps our ED physician’s unwillingness to call me “doctor” wasn’t solely based on gender.
Yes, I’m about to play that card. And here’s why:
African-Americans make up roughly 13 percent of the U.S. population, while African-Americans only make up 3 percent of U.S. physicians. We are essentially unicorns. I have often had to introduce myself twice to patients and colleagues alike, before getting a nervous and still uncertain, “Oh, Dr. Knight!”. African-American female physicians are asked to validate their credentials more frequently, as we have seen with the in-flight emergencies referenced in this article’s opening.
The impact of these seemingly small microaggressions start early-on. Eleven percent of minority medical school students report that their race and/or ethnicity negatively impacts their medical school experience. Racial discrimination, prejudice, and isolation perpetuated over the course of a career leads to lack of mentorship, barriers to promotion, and—if unchecked—hostile work environments.
For me, whether the physician’s discrimination was based on gender or race (or both), the process of chipping away my dignity and self-assurance had already been begun by others years ago. And—for the record—years of these microaggressions do not automatically make one less vulnerable or “thicker-skinned.” Nevertheless, I had needed to focus my energy on getting the best care for Jackson. And in that moment, that meant smiling and nodding through the offenses.
The Dangers of a Homogenized Workforce for our Patients
As a mother, it was worth smiling and nodding if it meant my son would get the care he needed as quickly and amiably as possible. But repeated over time, many physicians experience burnout as a result of the discrimination faced in the workforce by their colleagues and patients.
This burnout can have a dangerous impact on both our providers, and the patients they served. Over time, race-related burnout can lead to more physicians leaving provider roles—or healthcare all together. This not only challenges our patient population by lowering the availability of provider care in general but further isolates minorities from receiving appropriate health care.
Patients often report that communication is better with a health care provider of similar background, and therefore better outcomes result. But studies also show that only 21 percent of African-American patients, and 19 percent of Hispanic patients, are actually able to meet with a provider of similar racial or ethnic background. If we continue to marginalize our providers, and people, of color, these disparities will only grow, threatening both patient satisfaction and care.
A Way Forward: Three Steps for Improving Racial Diversity and Inclusion in our Care Teams
Recent protests for greater racial equality—coupled with the disproportionate rates of COVID-19 deaths among Blacks this year—have spotlighted the prevalence of bias against African-Americans in healthcare. But what we must recognize is that protecting and elevating marginalized patients starts with making sure we create working conditions where their providers of similar backgrounds are able to practice medicine safely, and with our trust, for the benefit of others. It starts with three things:
1. Invest in Cultural Competency Training
Cultural competency education programs lead to increased patient satisfaction, improved patient health outcomes, and likely decreased health disparities. While these programs are often thought of as programs for medical students or doctors in training, there is a need to continue cultural competency training throughout the professional career of a physician.
Individuals and health care organizations alike should mandate additional training as development throughout the professional career of healthcare employees—especially those responsible for direct patient care. Ancillary staff also have a duty to be culturally competent, as any encounter—direct or indirect—affects the patient’s outcome.
2. Promote more African-Americans and other Underrepresented Minorities in Medicine
Representation matters. There is an established mistrust of the African-American community and medicine deeply rooted in this country’s history. For example, a study in Oakland in 2018 shows that 56 percent of the Black men studied were more likely to get a flu shot if offered by a Black doctor and 47 percent of Black men were more apt agree to a diabetes screening if offered by a Black doctor.
Given the current climate, this mistrust is unlikely to change soon. Therefore, we must start investing in a pipeline that supports admission of more African-Americans to medical school, increasing the number of Black doctors and other underrepresented minorities.
3. Support Women in Medicine
To conquer the gender gap, we must have opportunities for women’s advancement. We can establish mentorship programs and create space for professional development. As we see more women in positions of leadership, I hope it will end the discomfort some feel when acknowledging a fellow colleague—no matter what gender or race—as “Doctor.”
We’re here to help
African-American doctors like Dr. Cross, Dr. Stanford, and myself have dedicated our lives to helping others through providing expert medical care. But the good we can do will be barred in-part by the biases of the society in which we live—whether that’s being physically kept from helping a patient on a plane, or passed over on a promotion due to race or gender—as long as we’re stereotyped, marginalized, distrusted or ignored.
Thankfully, attitudes are changing. There is a renewed interest in studying the root causes of racism and developing effective solutions. More public and private institutions are publicly acknowledging structural racism—and developing policies to combat it. We are recognizing bias and working together to rectify it.
While the issue of implicit (or explicit) bias will not be solved overnight, with individual and corporate working cooperatively, the future looks promising.
Related Reading: Three Things I Learned Serving on ACEP’s Diversity and Inclusion Committee
Terralon C. Knight, MD is Medical Director at United Healthcare and CEO of Knight Coaching, LLC. She is a native of Mississippi and received her undergraduate degree in Biology from Tougaloo College. She obtained her medical degree from the Warren Alpert Medical School of Brown University and completed her family medicine residency at University of Texas at Houston. Dr. Knight has a passion for the underserved, with much of her career spent serving communities in the District of Columbia, Maryland and Virginia. She has been a Medical Director with United Healthcare for eight years. She enjoys traveling, photography, and family game nights with her husband and three children.
The views, thoughts, and opinions expressed in the text belong solely to the author, and not necessarily to the author's employer, organization, committee or other group or individual.
“A Physician, Not a Stereotype: The Role of Gender and Racial Implicit Bias in the Workplace” is part one of a two-part series by Dr. Knight on racial disparities in healthcare offered in collaboration with Collective Medical.